UNIVERSITY OF CALIFORNIA
CALIFORNIA COLLEGE OF MEDICINE
LIBRARY
APR 7 1970
IRVINE, CALIFORNIA
THE MEMOIRS OF A PHYSICIAN
THE MEMOIRS
OF A PHYSICIAN
TRANSLATED FROM
THE RUSSIAN OF
VIKENTY VERESSAYEV
BY SIMEON LINDEN
WITH AN INTRODUCTION AND NOTES
BY HENRY PLEASANTS, JR., M.D.
ALFRED - A ; KNOPF
NEW YORK MCMXVI
)oo
COPYRIGHT, 1916, BY
ALFRED A. KNOPF
PRINTED IN THE UNITED STATES OF AMERICA
EDITOR'S INTRODUCTION
In reviewing The Memoirs of a Physician two
important problems confront us. First: Is it
true*? Second: If it be true, should it be placed be-
fore the American public*?
Let us answer the second question first. Should
we hesitate to place anything that is true before those
who have a right to know? Assuredly not. Suc-
cess in Medicine depends to a great extent upon the
co-operation of physician and patient. If the pa-
tient remains in ignorance of the essential princi-
ples that underlie the treatment, and merely follows
blindly a course outlined because it is so ordered
the practice of medicine must savour of charlatan-
ism. Such a condition of affairs is to be deplored.
Medicine should no longer be kept what it was
in the Middle Ages a Black Art, its mysteries
known (?) only to the elect few who have studied
its text-books. The world at large has given to the
profession funds to be used in establishing hospitals,
founding medical schools, supporting asylums, di-
recting medical research, and doing a host of other
things pertaining to the advancement of the science.
It is therefore the prerogative of our profession to
vi INTRODUCTION
render an accurate account of such a trust. In this
The Memoirs of a Physician has succeeded. It
shows how earnestly and faithfully physicians have
endeavoured to prove worthy of the trust that was
imposed on them. More than that it deals with
problems that a physician is confronted with in his
daily work, it has frankly emphasized the limita-
tions of the knowledge possessed by those who should
know, and has laid bare many secrets which have
heretofore been hidden under the cloud of mystery
that has ever hung over the walls of our medical
schools.
In America many of the same problems confront
us, and the question is: Can we place these prob-
lems before the public and let them see where we
have failed to solve them made hideous mistakes?
Fortunately for us in this country conditions are not
the same as those in Russia twenty years ago.
There is less of a mystery about Medicine on this
side of the Atlantic.
Advances in science are freely discussed in the
lay press. The effort has been to educate the pub-
lic in medical matters. As a result, laws have been
enacted relating to child labour, the sale of narcotics,
sanitation, ventilation of factories, etc., and great
good has been done. Public spirited men and
women all over the country are working for the ad-
vancement of our profession. Will it alter their
view point if they know that ten or fifteen years
INTRODUCTION vii
ago certain science-mad individuals on the other side
of the Atlantic inoculated healthy children with
syphilis to prove whether or not the disease was con-
tagious in the secondary stage? No. A few sen-
sational sheets will pour out a volley of anathemas
at the profession. The Anti-vivisectionist will grab
at the facts disclosed as a hungry dog would a bone
and use those facts as they have other facts unrea-
sonably. The thoughtful man will read deeper.
He will take the problems to heart and help to solve
them; he will note the limitations of the medical pro-
fession and seek to eliminate them. Americans can
read this book and profit by it.
Let us now consider the book from another stand-
point. Is it true? Does it reflect accurately the
life and thoughts of the educated physician? In a
measure it does, but not completely. Suppose we
stand on a high mountain overlooking a broad, beau-
tiful valley. The hill-tops below us alone catch our
eye, the ravines and swamps between the hills are
invisible or appear in insignificant patches on a
superb landscape. We are impressed with the
grandeur of the scene before us. Our guide leads
us down into the valley and we find that between
the hills are the swamps and the dark ravines. The
hill-tops are no longer visible, only occasionally as
we ascend one of them we catch glimpses of others
rearing their heads above the vast stretches of
murky lowlands on all sides. It depresses us, and
viii INTRODUCTION
we long for the ascent to the heights from which
we shall again see the whole valley. So it is with
The Memoirs of a Physician. We have been
standing on the heights overlooking the Valley of
Mystery Medicine. Our guide takes us down into
the Swamps of Adversity, the Ravines of Ignorance,
the Sloughs of Despond. On all sides rise the
little Hills of Triumph whose crests when viewed
from above made the Valley beautiful, but how piti-
fully small and even ugly they seem surrounded as
they are by the vast stretches of murky lowlands.
We wish to be taken back to the mountain top, but
no, our guide leaves us still floundering in the bogs,
sorry that we came.
The author touches many raw points. He views
his profession with the eyes of a man discouraged
and disheartened. He shows us a conscience harassed
and troubled by conditions which he feels power-
less to improve. There is no physician who has
any sense of high regard for the feelings of his
fellow men, who has not experienced similar sen-
sations when he has been confronted with acute suf-
fering that he is unable to alleviate. Nearly every
physician has at one time or other seen a patient
succumb under a course of treatment that did posi-
tive harm. But the truly strong man will take such
cruel lessons as part of his education. He will take
courage from the thought that he will by reason of
such lessons be able in future not only to prevent
INTRODUCTION ix
the recurrence of such accidents, but to save the lives
of perhaps a score of others who would have perished
had the mistake not occurred.
It seems to us that the author of The Memoirs
of a Physician does not realise sufficiently the im-
portance of the physician's working with a pa-
tient rather than at him. There is not so much
empiricism in medicine as there was ten years ago.
Secrecy of methods in practice has been relegated to
the dim past. The patient of to-day, be he ever so
humble, is encouraged to study principles of treat-
ment, of hygiene, even of surgery in order that he
and his physician may work together for a common
end. Doctor and patient, in America certainly, are
drawing closer together and the results are gratify-
ing. The careful explanation to a patient as to
the danger of contracting such a disease as tubercu-
losis by living under unhygienic conditions and con-
tinuing to keep late hours carries far more weight
than a hastily written prescription for a tonic. Pa-
tients are not slow to appreciate thoroughness of
examinations or common sense in treatment.
Furthermore it is remarkable how readily the rela-
tives of persons succumbing to unusual diseases will
allow examinations of the body for the advance-
ment of science once they are tactfully impressed
with the importance of such examinations. Again,
we seldom are brought face to face with the ex-
tremes of hatred or gratitude on the part of the
x INTRODUCTION
relatives that the author dilates upon so bitterly
Perhaps the reason for this is that we have taught
our patients that the cure of a given disease lies
more within the patient himself than in the physi-
cian. The latter, if he be a wise man, bends his
energies toward conserving the patient's own resis-
tive powers rather than dosing him with "specifics."
The family of the patient are satisfied or dissatis-
fied according to the thoughtful attention given by
the doctor.
It would seem well for the reader to take these
facts into careful consideration when he thinks that
the author has left him floundering in the bog of
hopeless pessimism. Let him return to the moun-
tain overlooking the Valley of Mystery and see the
Hills of Triumph once more before him. There
they stand; the Wassermann Reaction, by which
Syphilis may be detected in the blood; Ehrlich's
Salvarsan or 606, the specific cure for the same dis-
ease; Flexner's Serum, which has saved the lives
of hundreds of children suffering from Cerebro-spi-
nal Meningitis; the typhoid bacterin, which renders
the individual immune from typhoid fever for a con-
siderable time; the fresh air treatment of tuberculo-
sis; Radium; Organo-therapy, and a host of others.
Time does not allow of the discussion of the va-
rious problems brought to light in the book which
we do not hesitate to present to the American people
whom we trust to read it carefully and thoughtfully,
INTRODUCTION xi
and after due deliberation to render our profession
their aid in solving our problems, correcting our mis-
takes and draining the Sloughs of Despond in the
Valley of Mystery.
Finally let us consider the book from another
standpoint. Conscience is its keynote. It is the re-
flection of the conscience of a philosopher who has
opened the inner doors of the hiding places of sci-
ence and is bewildered by what he has found.
There is an indescribable pathos in some of his de-
scriptions. One hears the cry of an agonised soul
for help to accomplish a task that is beyond its own
powers.
The book views the future. It apprehends a re-
volt against Science for Science and prays for Sci-
ence for Humanity alone. It shows what crimes
may be committed if science is allowed to run riot in
the course of experimentation, yet it shows too what
desperate need there is for properly conducted in-
vestigation that may lead to the alleviation of suf-
fering.
HENRY PLEASANTS, JR.
April 1st, 1916.
AUTHOR'S INTRODUCTION
Seven years ago I completed my studies at the
Faculty of Medicine. The knowledge of this fact
will prepare the reader's mind for what is to follow.
My reminiscences are not those of an old, experi-
enced physician summarising the results of his life-
long observations and reflections, having evolved
definite answers to all the complex questions of
medical science, its ethics and the exercise of its
profession. Also, they are not those of a physician
and philosopher who has deeply penetrated into the
essence of his science and completely mastered it.
I am but an average practitioner, with average
ability and average knowledge. I find myself en-
tangled in a web of contradictions, and I am utterly
powerless to solve many of the hard problems which,
importunately demanding an answer, arise before
me at every step. The only advantage I possess
lies in the fact of my not having had time to become
a pure professional, and that those impressions, to
which one involuntarily becomes inured in time,
have, in my case, still retained their freshness, their
power and their vividness. I am about to describe
my sensations on my first acquaintance with medi-
an
xiv INTRODUCTION
cine, what I expected of it, and how it actually
affected me; I will write of my first independent
steps on the high road of my professional career, of
the impressions I obtained from my practice. I
will endeavour to set down all, hiding nothing, and
I will strive to write with absolute frankness.
THE AUTHOR.
CONTENTS
CXAPTEI
EDITOR'S INTRODUCTION v
AUTHOR'S INTRODUCTION xiii
I THE FRAILTY OF THE HUMAN BODY i
II EXAMINATION AND AUTOPSY 15
III WHAT MEDICINE HAS NOT ACCOMPLISHED
AND WHAT IT HAS 34
IV THE DIFFICULTIES THAT CONFRONT THE
YOUNG PRACTITIONER 57
V YOUNG DOCTORS AND TECHNIQUE 78
VI THE ART AND INEVITABLE RISKS OF SURG-
ERY 84
VH IN MEDICINE NOTHING RISKED, NOTHING
GAINED 104
VIII MEDICINE AN ART; NOT A SCIENCE 123
IX THE QUESTION OF VIVISECTION 141
X THE UNCERTAINTY OF DIAGNOSIS 159
XI DOCTOR AND PATIENT 174
XII THE DOCTOR AND THE POOR 188
XIII MEDICINE, NATURAL SELECTION AND THE
SURVIVAL OF THE UNFIT 200
XIV MENTAL PROGRESS AND PHYSICAL DEGEN-
ERATION (RETROGRESSION) 214
XV SHAME AND THE PHYSICIAN 228
XVI WHEN THE PATIENT DIES 241
XVII "THE PROFESSIONAL MANNER" 256
xv
CONTENTS
CHAPTER PACK
XVIII DOCTORS AND MONEY 267
XIX DOCTORS AND THE LAW 285
XX THE MARKET FOR DOCTORS 299
XXI THE DOCTOR'S STRUGGLE 306
APPENDIX A (Editor's Notes) 314
APPENDIX B (Experiments on Living Men and Women) 332
AUTHOR'S POSTSCRIPT 367
THE MEMOIRS OF A PHYSICIAN
THE MEMOIRS OF A
PHYSICIAN
CHAPTER I
THE FRAILTY OF THE HUMAN BODY
1 STUDIED with diligence while at the Gym-
nasium and was considered a good scholar, but
in common with the majority of my fellows, I held
the curriculum of my school in the greatest con-
tempt. Those studies oppressed me as an irksome
and distasteful burden, in itself lacking all personal
interest, but, for some reason, essential for me to
carry. What did I care about the date of canonisa-
tion of some obscure Byzantine Saint, the parentage
of Otto the Great or the passive conjugation of
persuadeo tibi? The advance of my mental de-
velopment was quite independent of my school, and
it was outside school hours that I accumulated the
knowledge of those facts which interested me. But
all this underwent a sharp change as soon as I be-
came a student at the University. The first two
years at the Faculty of Medicine are devoted to
theoretical study of the various branches of natural
2 THE MEMOIRS OF A PHYSICIAN
science: chemistry, physics, botany, zoology and
physiology. I was entirely carried away by these
subjects so new and so important to me was the
information they imparted. All the phenomena
which surrounded me and rilled me, which I con-
templated before with the eyes of a savage, now
became plain and comprehensible; and I was sur-
prised that I should have lived to the age of twenty
without any knowledge of, or interest in, those facts.
Every day, every lecture brought new "discoveries"
in their wake and I was astounded to learn, for in-
stance, that the meat I ate in the form of beef-steaks
and cutlets was that mysterious matter called
"muscle," which hitherto my imagination had
vaguely pictured as balls of greyish thread ; formerly
I thought that solid food left the stomach for the
intestines, and the fluid for the kidneys; it appeared
to me that in breathing my chest expanded because
some inexplicable force introduced the outside air;
I was cognisant of the laws of conservation of mat-
ter and energy, but in my heart of hearts did not
believe in them. Afterwards I made the discovery
that most so-called educated people retained no less
childish conceptions in regard to all that lay within
their vision, and were not discomfited by the fact.
They will blush for shame if unable to name the
century of Louis XIV., but are not in the least
disconcerted when it comes to displaying their
ignorance as to the process of asphyxiation or the
FRAILTY OF THE HUMAN BODY 3
reasons for the luminosity of phosphorus placed in
the dark.
In regard to anatomy, one often has to hear of
the unpleasant and repulsive side of its study, owing
to the necessity of dissecting and preparing dead
bodies. Certainly, many of my comrades took some
time to become accustomed to the sight of 'the
anatomical theatre, filled with mutilated corpses with
glassy eyes, grinning teeth, and claw-like fingers;
one of them even had to repudiate medicine, and
take up another branch of learning; he began to
have hallucinations to his disordered imagination
at night his room seemed to fill with corpses, and
from every corner bleeding limbs crawled towards
his bed.
For my part I very soon became familiarised with
the corpses and used to sit for hours engrossed, heart
and soul, in their preparation, which laid all the
secrets of the human body open before me. For
seven or eight months I devoted myself entirely to
the study of anatomy, and for the time being my
views on mankind became wonderfully simple.
When walking in the street watching a pedestrian
in front of me, I saw in him but an animated corpse ;
now his glutaeus maximus would contract, then his
quadriceps femoris; that swelling of the neck de-
noted a strong development of the sternocleidomas-
toideus muscle. If he dropped his walking stick and
bent down to lift it up, I knew that the musculi
4 THE MEMOIRS OF A PHYSICIAN
recti abdominalis had contracted, drawing his thorax
down towards the pelvis. People who were near
and dear to me seemed to assume a dual quality:
that young girl for instance there is so much
originality and attractiveness about her! When in
her presence I feel happy and light of heart, but
at the same time all that goes to make her is well
known to me, and there is really nothing extraordi-
nary about her: her brain is corrugated by the same
convolutions, such as I have seen upon hundreds
of brains; her muscles are permeated through and
through with fat which makes the dissection of
feminine corpses such an unpleasant task ; in a word,
there is really nothing in her either attractive or
suggestive of poetry.
But I was even more powerfully impressed by
the method which reigned in this new knowledge,
than by what that knowledge offered me in itself.
It led one forward carefully, with circumspection,
but without wavering, without leaving the most
insignificant detail unverified or uncontrolled at
every step with the most painstaking severity by
experiment and observation; and what had once
been passed was passed finally, without there being
the slightest chance of the necessity arising for
the retracing of one's steps. This method was
all the more fascinating because it had nothing in
common with the class-room rules of abstract logic;
it was the necessary outcome of the very matter in
FRAILTY OF THE HUMAN BODY $
hand. Every fact, every explanation of a fact
seemed to exemplify the golden words of Bacon:
Non fingendum aut excogitandum^ sed inveniendum,
quid natura facial aut ferat. No need even to know
of the existence of logic science itself would force
one to acquire its method more effectually than the
most exhaustive treatise on methods! It educated
one's mind in such a manner as to make all devia-
tion from its straight path a sheer impossibility.
With the closing of the last term of my second
year, these theoretical studies came to an end. I
passed my intermediary examination, and our
clinical work then began.
The whole character of the knowledge to be ac-
quired underwent a radical change. Instead of ab-
stract science, living man came to the fore; the
theories of inflammation, microscopical preparations
of tumours and bacteria, gave place to real wounds
and sores. An endless procession of sick, maimed
and suffering humanity began to pass before one's
eyes. Slight cases are not admitted to the Uni-
versity hospitals; and here the sufferings were real
and grave. Their abundance and variety had a
benumbing effect on me; I was struck by the im-
mensity of existing suffering, at the great multi-
tude and variety of the different forms of the most
refined, incredible tortures prepared for us by nature
torments, the very sight of which made one's soul
sick.
6 THE MEMOIRS OF A PHYSICIAN
Soon after the commencement of our clinical
studies, a market gardener with lock-jaw was
brought into the senior students' ward. We went
to look at him. Stillness reigned in the big room.
The sufferer was a thick set and muscular sun-
tanned working man of gigantic stature; bathed in
sweat, with lips distorted from the hideous agony,
with rolling eyes, he lay on his back. At the slight-
est noise when a tram bell rang in the street below
or a door slammed, the sick man began to bend
out slowly: the nape of his neck was drawn down,
his jaw convulsively locked together, until the teeth
cracked audibly, and a terrible, prolonged convul-
sion of the dorsal muscles lifted the body from
the bed, while a large moist spot of perspiration
gradually spread over his pillow away from his
head. A fortnight before, while he was at work
bare-footed amongst his vegetable beds, a splinter
entered his big toe; that insignificant particle of
wood had been the cause of what I now saw before
me.
The mere fact of the existence of such frightful
sufferings was not the most terrible side to the ques-
tion; the ease with which they could be acquired,
and the absence of guarantee against them for the
healthiest of men, were what appalled.
A fortnight ago any one would have envied that
very same gardener his splendid health and phy-
sique. A strapping young ostler, in passing across
FRAILTY OF THE HUMAN BODY 7
his stable-yard, slipped and struck his back against
a trough. For six years up to this date he has been
in our clinic; his legs hang lifeless as wisps of
straw, he cannot move them, and he passes water
and evacuates unconsciously. Helpless as a babe
in arms, there he lies on his back for days, months,
years, lies until he develops bed-sores, and there
is no hope of his ever regaining a particle of his
former vigour. ... A government clerk with in-
flammation of the ischiatic nerve, goaded to mad-
ness by his sufferings, yells at the professor:
"Oh, you miserable quacks! Kill me, for God's
sake, kill me, that is all I beg of you !"
One fine summer's evening he had rested on the
dewy grass.
Every moment and at every step we are warned
of all manner of dangers; to defend ourselves were
in vain because they are too varied, flight is useless
because they are everywhere. Even when we are
in a state of health, our organism is not quiescent;
in swallowing, in breathing, billions of bacilli find
an entrance into our bodies; the most deadly
poisons are generated without intermission; un-
noticed all our vital powers wage remorseless war
with injurious substances and influences, and we
dare not for a moment consider ourselves safe-
guarded against the possibility of our internal forces
proving inadequate in this endless struggle. And
when this happens, our cause is lost; a small abrasion
8 THE MEMOIRS OF A PHYSICIAN
develops into erysipelas or a phlegmon, or causes
blood-poisoning; a slight bruise results in the for-
mation of cancer or sarcoma; a trifling attack of
bronchitis contracted through exposure to a draught,
ends in consumption. . . . Ideal and exceptional
circumstances of existence would be required to
make sickness a "chance" occurrence; as things stand
at present all suffer from disease: the poor because
of their want, the rich owing to their superfluity;
workers because their strength is overtaxed, drones
by reason of their idleness; the careless as a result
of their carelessness, the cautious because of their
over-caution.
Decay lies hidden in man from the tenderest age,
his body begins to decompose before it has even had
time to complete its development. In Boston the
mouths of four thousand school children were ex-
amined and it was found that healthy teeth, espe-
cially in children of over ten years of age, were an
exception. In Bavaria only three children were
found to have perfectly sound teeth out of a total
of five hundred pupils of the elementary schools
that were examined. Dr. Babes dissected one hun-
dred infantile corpses, and in the case of seventy-
four he found tubercle bacilli in the bronchial
glands ; all those children had died of non-tubercular
diseases. Children wake with "sleepy" suppurat-
ing eyes; from childhood we all begin to suffer from
chronic nasal catarrh and cannot dispense with a
FRAILTY OF THE HUMAN BODY 9
pocket handkerchief; for a healthy man a pocket
handkerchief is superfluous, but this simple truth
will astonish most people. As for women who have
reached the age of puberty, they are normally and
physiologically condemned to be ill for several days
each month.
I began to regard the people surrounding me
with a new and strange feeling, and I was more and
more struck by the rarity in their midst of healthy
individuals; nearly every one of them had some
ailment. To me the world began to assume the
aspect of one gigantic infirmary: normal man was
sick man; the healthy person merely represented a
happy freak, a sharp deviation from the normal;
this fact was ever becoming more plain. When I
first entered upon the theoretical study of obstetrics
and commenced the perusal of my text-book, I re-
mained engrossed in it that whole night, unable to
withdraw my attention from the subject. The pic-
ture of the "normal," the "physiological" process
of parturition unfolded itself before me like an op-
pressive and feverish nightmare. . . .
I remember the first confinement at which I was
present, as if it had occurred but yesterday.
"Tut, tut, ma'am, try and bear it quietly!" the
assistant house-surgeon remarked in the calmest of
voices.
The night dragged out endlessly. The labouring
woman had long abandoned all efforts at self-con-
10 THE MEMOIRS OF A PHYSICIAN
trol; her moans filled the ward, while she sobbed,
trembled and clasped her clenched hands ; her groans
could be heard in the passages and were lost far
away in the great building. After an unusually
painful access of the throes, catching hold of the
assistant's hand, pale, with a face racked by the
agony, she looked at him with a piteous and be-
seeching glance.
"Doctor, tell me, shall I die 4 ?" she asked in mortal
fear.
In the morning her husband, agitated and nerv-
ous, came to the hospital, to inquire after his wife's
condition. I regarded him with a feeling of odium ;
this was his second child; therefore he knew that
his wife had to go through this torment, and still
he remained undeterred by the knowledge. . . .
"This was an easy case of confinement, and of
small interest," remarked the surgeon.
All this was "normal" too. And civilisation
could not be held responsible for having made child-
birth more difficult: women always gave birth in
torment and the ancients were struck by this strange
phenomenon and could only explain it as the curse
of God.
Such impressions as the above weighed the soul
down and, following each other without intermis-
sion, intensified the general sombre colouring of
everything around me.
One night I woke up. I had dreamt of being
FRAILTY OF THE HUMAN BODY 11
run over by a carriage while traversing a narrow
and dark alley; the pole struck me in the side, and
pneumothorax had supervened. I sat up in bed.
The pale night stared me in the face through the
window, a cricket kept up its monotonous chirping
behind the stove; somewhere in the house I could
hear my landlady's sick child crying fitfully. All
that I had seen and brooded over of late came home
to me with a sudden clearness, and I was appalled
to see how utterly human life lacks all protection
against extraneous chances, and on what a slender
thread man's health depends. If only it were pos-
sible to keep one's health! with such a reserve no
trials could have any real terrors. Its loss meant
loss of one's all; without health there could be no
freedom, no independence, a man becomes the slave
of those who surround him, of his environment; it is
the highest and most inestimable of all blessings and
it is so difficult to retain it! To try and do so were
to consecrate one's whole existence, all one's
strength, to the attainment of the one object; but
how ridiculous, how insulting to one's self-esteem,
were such an aim in life! And after all, it would
be of small avail, even if we were to live to that
sole end! Supposing that we were ever on our
guard; loss of adaptability would result. And
wherein ought our precautions lie*? We are ab-
solutely ignorant of the origin of cancer, sarcoma,
a multitude of nervous affections, diabetes, the
12 THE MEMOIRS OF A PHYSICIAN
majority of the painful diseases which attack the
skin, and so on.
It is quite within the bounds of possibility, no
matter how careful I may be in the interval, that a
year hence you will find me struck down by pemphigo
foliaceo^ a disease which causes the skin to blister;
these blisters burst, lay the subcutaneous surface
bare and heal no more, so that the sufferer, deprived
of his skin, can neither lie down nor sit up, for the
slightest touch causes burning agony. Very likely
you will call me ridiculous! But remember that
the man with pem'phigo foliaceo^ whom I saw in the
clinic the other day, was hale and hearty and free
from misgivings half a year ago! We are not as-
sured of a single hour of health. At the same time
we all want to live, to live and be happy and this
is denied us. ... And why does love exist with
all its poetry and bliss"? Why should there be such
a thing as love if it causes so much torment 4 ? Can
it be that "love" is not a cruel mockery of love, if
a man has it in him to cause the woman he adores
such sufferings as I had witnessed in the lying-in
hospital *? Suffering, suffering without end, in every
shape and form it is thus that the essence of the
entire life of the human organism may be summed
up.
Such was the gist of my cheerless reverie during
the small hours of the morning. I had not long to
wait before I had a personal experience which seemed
FRAILTY OF THE HUMAN BODY 13
to bear out the above. A small mole under my left
arm-pit, without any apparent cause, suddenly began
to increase in size and become painful. I was afraid
to believe the evidence of my senses, but it grew and
grew, and hurt me more every day. At last the
swelling attained the size of a hazel-nut. There
was no room for further doubt: the mole had de-
veloped into a sarcoma, that terrible melano sarcoma
which generally originates from innocent-looking
beauty spots. I went to attend the consulting hours
of our professor of surgery, feeling as if I were
about to have a final interview with the hangman.
"Professor, I believe ... I have a sarcoma of
the arm," I said in an unsteady voice.
The professor scrutinised me attentively.
"Are you a medical student of the third course^"
"Yes."
"Show me your sarcoma!"
I undressed. The professor removed the growth
by severing its narrow stem with a pair of scissors.
"Your sleeve had merely irritated the mole, noth-
ing more. Take your sarcoma with you as a keep-
sake!" he said, smiling good-naturedly and hand-
ing me a small fleshy pellet.
I went away happy, although much ashamed, and
I felt abashed at my childish apprehensiveness.
But soon afterwards I began to notice that something
abnormal was taking place within me : I experienced
a general lassitude and distaste for work, I lost my
14 THE MEMOIRS OF A PHYSICIAN
appetite and I constantly suffered from thirst. I
lost flesh too, and every now and then abscesses
formed on different parts of my body ; I passed water
very abundantly; I tested it for sugar it contained
none. All these symptoms pointed to diabetes in-
sipidus. In deep dejection I perused the chapter
devoted to that disease in StrumpelPs text-book:
"The causes of diabetes insipidus still remain quite
obscure. . . . Most sufferers are either young or
of middle age, men are somewhat more subject to
the disease than women. . . . The relationship be-
tween this disease and diabetes proper is obvious,
and the one has been known to pass into the
other. . . . The disease may continue for years and
even decades, and cures are extremely rare. . . ."
I went to our professor of therapeutics. With-
out telling him of my fears, I simply detailed my
symptoms. As I proceeded the professor's brows
contracted more and more.
He cut me short.
"You suppose that you have diabetes insipidus.
It is very praise-worthy that you should have studied
Strumpell so painstakingly; you have not omitted a
single symptom. I hope you will be as well up in
the subject when the examinations come round.
Smoke less, eat more, take more exercise and leave
off thinking of diabetes."
CHAPTER II
EXAMINATION AND AUTOPSY
WE were now obliged to study the sufferings
of living men ; but at first it was not so much
the sight of these, as the fact of our having to make
them the subject of study, that was the most dis-
tressing. Let me illustrate my meaning: a patient
with a dislocated shoulder is affected by heart
disease; chloroform cannot be administered, and the
shoulder is reset without ancesthetic; the hospital at-
tendants hold the patient tightly, he struggles and
screams from pain; at the same time one has to
give one's full attention to the professor's manipula-
tions in returning the limb to its proper position,
one must remain deaf to the cries of the man being
operated upon, blind to the agonised contortions of
his tortured body, one has to choke down one's feel-
ings of sympathy, and control one's agitation. This
was very difficult until one got used to such scenes,
attention invariably becoming divided; it was con-
stantly necessary to repeat to oneself: "I am per-
fectly well, it is not I but another person who is
being hurt."
Torrents of blood during operations, the groans
of labouring women, the convulsions of patients
with lock-jaw in the beginning all these jarred
upon the nerves badly, and interfered with one's
work. Habit had to be acquired.
However, this habit comes sooner than might be
thought, and I know no case of a medical student,
who had once got over the dissecting of corpses,
leaving the field of medicine because he could not
get used to the sound of groans and the sight of
blood. And Heaven be , praised that this should
be so, because, without a doubt, such comparative
"hardening" is both essential and desirable.
However, the study of medicine on the living
patient has another side, in dealing with which we
are Confronted by what is infinitely more complex
and painful, where there is far more room for ques-
tion and doubt. We learn from the patient; to
enable us to do so, the doors of the clinics are
thrown open to the sick; at the same time, refusal
to submit to examination by the professor or students
is met with prompt expulsion of the obstreperous
one. Are these examinations and demonstrations,
however, a matter of such indifference to the patient?
Of course, every effort is made to spare his or
her feelings. But, unfortunately, it is not always
feasible to do so; certain limits have to be passed:
if, for instance, the patient is suffering from some
rare and instructive disease, or else if there be a
EXAMINATION AND AUTOPSY 17
dearth of clinical material which is frequently the
case, not only in small university towns, but even in
the capitals. This is what we learn from Professor
Eichwald's report, read at a conference of the
Medico-Chirurgical Academy (of St. Petersburg) :
"In the late seventies the I. Therapeutic Section
of the Clinical Hospital simultaneously served the
students of the III. and V. courses, and also the
female students, for the purposes of practice, which
arrangement was, of course, a great hardship upon
the patients. The latter not only complained of
these practical studies on numerous occasions, as-
cribing to the above their slow recovery, but not
infrequently left the clinic for this reason."
In general, however, one must confess that such
cases are exceptional. When the patient is subject
to examinations for the purposes of study, it is usual
to adhere strictly to the rule that the latter should
have no detrimental effect upon his health. But
the matter does not only lie in the evasion of direct
physical harm to the sufferer, for there is a moral
side to the question. A semi-dark ward during our
evening round, seems to arise before my eyes; we
students, stethoscope in hand, stand around the
house-physician who demonstrates amphorical res-
piration upon one of the patients. The latter, a
cotton-mill hand, is in the last stages of consump-
tion. Terribly wasted, his youthful face is slightly
cyanotic ; he breathes rapidly and superficially, while
i8 THE MEMOIRS OF A PHYSICIAN
his eyes are turned to the ceiling with an expression
of intense inward suffering.
"If you will apply your stethoscope to the
patient's chest," explains the house-physician, "and
at the same time strike the mallet upon the plexi-
meter close by, you will hear a clear metallic, so
called 'amphorical resonance.' . . . Here, col-
league," he continues, turning to a student, and
then, addressing the patient, "Sit up" . . . and so
on.
Serving the purposes of study and the object of
coldly impersonal explanations, such lonesome suf-
fering stands out glaringly. Even if it strikes no
one else, the sufferer at least fee.ls the incongruity
acutely.
All examinations unconnected with those neces-
sitated by their treatment, have a particularly de-
pressing effect on the bad cases at the same time,
from an instructional point of view, the latter present
most value. The intensity of this aversion for such
examinations is best exemplified by the fact that
even those with the slenderest means decline to go
to the clinics; although, apart from the described
discomfort, they are better cared for in every re-
spect in these infirmaries than would be possible
elsewhere.
In 1878 the Medico-Chirurgical Academy nomi-
nated a commission for the devising of some means
whereby the number of patients in its hospital might
EXAMINATION AND AUTOPSY 19
be increased. The Commission, among other meas-
ures, recommended adding to the number of free
beds.
"The reserving of beds for paying patients," it
declared, "is inexpedient, because people with means
do not go to the clinics, apprehensive of being in-
convenienced by the students' examinations." In
1880 the academical authorities again petitioned the
government for powers to increase the number of
free beds, pointing out that those reserved for pay-
ing patients remained unoccupied almost through-
out the year. 1
Of course the free beds will never be vacant
all-powerful Mother Want will see to that. ... I
not infrequently hear it said, that although all these
examinations and practical demonstrations may be
distasteful to the patient, on the other hand, he
enjoys exemplary nursing gratis. Quite true: but
wealthy people enjoy exemplary nursing without
being subject to all this. The question often oc-
curred to me: What would medical science do if
all were wealthy? Probably it would find itself
in a tight place. In any case, even now, efforts to
shield patients from these examinations with an
instructional purpose, have been made. In 1893,
for instance, the working classes of Berlin boycotted
the Charite hospital; amongst the demands formu-
1 In America private buildings connected with general hospitals
where the patient receives the utmost privacy are greatly in de-
mand.
20 THE MEMOIRS OF A PHYSICIAN
lated by those who joined the movement was the
following: "absolute freedom shall be given the
patients in acquiescing or declining to allow of their
being used for the purposes of instruction." If the
patients enjoyed such liberty everywhere, many and
many of them would say: "Leave me in peace. I
understand that this is necessary to science, but I
am too ill to take science into consideration."
The patient dies. The same rules which demand
that he should readily submit himself to be examined
by the students, also require obligatory autopsy in
the case of the bodies of those who die in the Uni-
versity hospitals.
Every morning in the lobby and at the main
entrance of each clinic, a crowd of women may be
noticed for hours together, on the lookout for the
house-surgeon or physician. When he passes, they
intercept him and implore that the remains of child,
husband or parent be given up for burial. Some-
times the most heart-rending scenes are enacted.
Naturally, a categorical refusal meets all such re-
quests. Having failed to gain her point from the
house-surgeon, the petitioner goes further, impor-
tunes all those in authority, finally gets at the pro-
fessor and supplicates him on bended knees not to
have the deceased dissected.
"Why, his malady was a well-known one oh,
why should you continue to worry him after death?"
Of course, here again, she meets with the same
EXAMINATION AND AUTOPSY 21
refusal : it is absolutely necessary to perform autopsy
on those who die; without that, clinical study be-
comes senseless. But to the mother, the autopsy
of her child is no less terrible than its death; even
educated people are very unwilling to give their
consent to a post-mortem examination of their dear
dead, while for the ignorant poor the former assumes
the shape of something absolutely horrible. I have
seen a female factory hand earning 40 kopecks a
day, try to press a three-rouble note on the acting
house-physician, in the vain hope of saving, by this
bribe, her dead child from "desecration." Of
course, such an attitude towards autopsy is but the
result of prejudice, but notwithstanding this the
grief of the mother remains unaltered.
Once, during the summer, I was present at the
post-mortem of a little girl who had died of croupous
pneumonia. Most of my fellow-students had left
for the vacation; the only persons present were the
house-physician on duty and myself. The attend-
ant, a black-bearded man of gigantic stature, opened
the body and took out the internal organs. The
dead reposed upon the table with head thrown back,
her blood-besmeared abdominal region yawning
open; on the white marble, in pools of blood, lay the
removed vitals. The house-physician was dissecting
the right lung with a knife, on a small wooden
slab.
"What are you doing*?" suddenly gasped a chok-
22
ing voice from the threshold. A man with a small
red beard, dressed in a pea-jacket, with a deathly
pale face, distorted with horror, stood in the door-
way. It was the little girl's father, a journey-man
cobbler; he was on his way to the mortuary, to
enquire when the deceased might be laid out, and
blundered into the dissecting-room instead.
"What are you doing here, you brigands?" he
yelled, shaking all over and staring at us with wide
open eyes. The knife remained paralysed in the
anatomist's hand.
"Now then, what's your business here"? Be off!"
said the attendant, recovering himself and approach-
ing the intruder.
"So this is where you cut our children up, is it?"
he cried with a kind of sobbing howl, stamping his
feet and shaking his clenched fists; "what have you
done to my little girl?"
He made a run towards us. The attendant seized
him under the armpits from behind and wrenched
him away; the man caught hold of the door-post and
yelled for help. . . .
At last the attendant managed to push him into
the passage and locked the door from the inside.
The cobbler persisted in his efforts to force an en-
trance for a long time, crying for help the while,
until the house-physician lost patience, summoned
the porters from the window and had him removed
from the premises,
EXAMINATION AND AUTOPSY 23
If another child of that man's falls sick, he will
ruin himself in nursing it at home, will allow it to
die without proper aid, but will never consent to
take 'it to the clinic: the desecration of his precious
dead were too high a price to pay for the advantage
of hospital nursing.
By the way, the right to dissect the bodies of
patients that die within their walls has not only
been annexed by the University infirmaries, but by
all the hospitals, and quite illegally too: for the law
gives them no such powers. According to the law,
in the ordinary hospitals autopsy is obligatory only
when required for the purposes of judicial investiga-
tion; and yet I don't know of a single hospital
where the deceased's body, in accordance with his
relatives' wishes, would be delivered to them with-
out autopsy being previously performed. 2 The
relatives of such patients do not, however, suspect
that they have the right to demand the above.
The post-mortem examination of each patient that
succumbs is extremely important to every doctor,
even in the case of the most "common" diseases:
it shows him his mistakes and the way to evade
them in future, accustoms him to attentive and all-
round examination of his patient, enables him to
obtain a clear and detailed anatomical presentment
2 In America it is impossible to perform an autopsy without the
consent of the family of the deceased. But in some hospitals rela-
tives are required to sign blank forms giving permission for the
autopsy in the event of death.
24 THE MEMOIRS OF A PHYSICIAN
of every illness. Without autopsy the making of a
good physician is impossible, without it medical
science cannot advance and perfect itself.
It is absolutely indispensable that all should
understand this as clearly as possible and willingly
consent to the autopsy of their relatives' bodies.
For the present, the public mind has not yet grasped
this truth; and hospitals attain their ends by dis-
secting the dead in opposition to the wishes of
friends and relatives. The latter humiliate them-
selves, go down on their knees before the doctors,
try to bribe them all in vain. For fear of a post-
mortem examination in the event of death, the
friends of the patient do all they can to prevent his
being taken to the hospital, and he often perishes at
home through lack of proper attendance, or owing to
ignorant nursing.
At the hospital in which I subsequently worked
the following episode had taken place: there was a
typhoid patient, a little boy five years old ; symptoms
of perforated intestine appeared. In such cases ab-
solute quiet is of the last importance, but the mother
suddenly made known her wish to take the child
home, refusing to listen to all remonstrances. "He's
bound to die. Better that he should die at home,
for then he won't be cut up," she said. The house-
physician was compelled to give the woman her
way, the boy succumbing en route. . . . This case
gave rise to considerable comment amongst the
EXAMINATION AND AUTOPSY 25
hospital-staff; of course, the profound ignorance and
senseless barbarity of the Russian lower-classes was
referred to, the right of the house-physician to per-
mit the boy's removal was called in question, as well
as his moral and judicial responsibility for the child's
death. But the main interest of the case lies else-
where : how great must the mother's fear of autopsy
have been, if she was prepared to risk her offspring's
life to escape it ! The house-physician was of course
neither an "ignoramus" nor a "brute," but that the
simplest, and one would think, the most natural
solution of the problem, never entered his head, is
characteristic: he might have given the mother a
solemn assurance that if the child died it would not
be dissected.
But those who have to suffer most from the neces-
sity which compels us to study medicine on the
living, are the women who lie in the clinics. My
recollections connected with this phase of the ques-
tion are especially painful, because I have to blush
for myself. But there is no help for it, as I have
pledged myself to write all.
A young woman suffering from pleurisy mounted
the professor's dais accompanied by the two students
appointed to watch her case. Having read her "his-
tory," one of the students stepped up and touched
the shawl which enveloped the patient's shoulders,
thereby intimating that she was to undress. The
blood mounted to my face: this was my first ex-
26 THE MEMOIRS OF A PHYSICIAN
perience of the demonstration of a young female
patient. She took off her shawl and bodice and
lowered her chemise as far as her waist; her face
was serene and proud.
Then commenced the usual auscultations and
soundings. I sat there, hot all over, trying not to
look at the patient; I felt as if the looks of all my
comrades were turned my way; when I lifted my
eyes, the same proud, cold, beautiful face bent over
her pale bosom, met them, it seemed as if those
strange male hands were not feeling her body.
When we rose, my glance encountered that of my
neighbour, a fellow-student and almost a stranger to
me; in some inexplicable way we read the same
thoughts in each other's eyes and exchanging an
angry stare, turned aside quickly.
Was there any voluptuous feeling in me when the
patient stripped beneath my eyes'? There was, but
very little; the fear of such a feeling predominated.
But later on, when at home, the recollection of
that experience acquired a delicately voluptuous
tint and I reflected with a secret pleasure, that in
the future I should often be the witness of such
scenes.
And of course there were many similar occur-
rences. I especially well remember one patient,
Anna Gratshoff by name, a young girl of eighteen,
of rare beauty. She had heart disease with a very
characteristic prsesystolic murmur; the professor
EXAMINATION AND AUTOPSY 27
advised us to sound her frequently. When one ap-
proached, she submissively and deftly threw off her
night-shift and sat up in bed, bared to the waist,
while we auscultated her in turn. I tried to look
upon her with the eyes of a physician, but could not
help observing that she had handsome shoulders and
a beautiful breast, and the fact of my comrades
taking an exaggerated interest in the prsesystolic
murmur did not escape my notice, making me feel
ashamed that this should be so. I could not help
suffering on behalf of the girl, the more so, because
I was conscious of the impurity of our glances.
What power was it that forced her to strip before
us? Would not all this have a lasting and deroga-
tory effect upon her in future 1 ? I conjectured, try-
ing to read upon her pretty, almost childish face, the
whole story of her sojourn in our clinic, to imagine
her indignation, when forced to appear naked before
all for the first time, and how she had resigned her-
self to the inevitable, because her people were too
poor to nurse her at home, and how she got used to
her position little by little. . . .
Once during an out-patient day of our professor
of syphilology, a young woman came, with a note
from her doctor, in which the professor was begged
to determine whether the rash the patient had was
of syphilitic origin or not.
"Let us see the rash!" said the professor. She
showed her hand.
28 THE MEMOIRS OF A PHYSICIAN
"Oh, that's nothing. Healed forunculi. Any-
where else?"
"On the chest," faltered the patient, "but it isn't
a bit different."
"Let us see it."
"But it is exactly the same there, nothing to
show," persisted the patient, blushing.
"Any way, please show us your rash: we are very
inquisitive!" remarked the orofessor with a humor-
ous smile.
After demurring considerably the patient took off
her bodice.
"Oh, that's also a mere trifle! Anywhere else?
Tell your doctor that there is nothing serious the
matter."
I Meanwhile the assistant had drawn down the
patient's chemise from behind and examined her
back.
"Serguei Ivanovitch, look here!" he said in an
undertone.
, The professor complied.
"Ah ... a! That is very different!" he re-
marked. "Undress entirely retire behind that
screen. . . . Next!"
The patient reluctantly did as bidden. The pro-
fessor examined several patients.
"Ah, yes! And the other patient, has she un-
dressed?" he asked at last.
The assistant went behind the screen. She stood
29
fully attired and was crying. He made her strip to
her chemise. Placing the patient on a lounge they
began to examine her; she was examined at length
in a detail revolting to the lay-person.
"You may put your things on 1 ." the professor
said at last, and turning to us, while drying his
hands after having carefully washed them, remarked :
"It is difficult to say anything definite for the pres-
ent, gentlemen. There, my dear," to the woman,
"come again in about a week."
The patient was already dressed. She stood
breathing heavily, gazing motionlessly at the floor
with unseeing, wide-open eyes.
"No, I won't !" she answered in a trembling voice
and, turning on her heel, rapidly quitted the room.
"What was the matter with her, I wonder 1 ?" asked
the professor in a surprised tone, glancing round.
The same evening a young lady-student friend
came in to see me. I described the scene of the
morning.
"Yes, it's very hard!" she said, "but after all,
what's to be done? One can't learn in any other
way. We must reconcile ourselves to such occur-
rences."
"Quite true. But answer me this; if you had to
undergo anything of the kind only try and realise
things clearly would you come to us*?"
She was silent for a moment.
"No, I wouldn't. . . . For nothing in the
30 THE MEMOIRS OF A PHYSICIAN
world!" she smiled apologetically "I would rather
die !" with a shiver.
And mark you she deeply venerated science and
understood thoroughly that "one couldn't learn in
any other way." The other woman understood
nothing of such questions; all she knew was that
she had not the means to pay for a private consulta-
tion and that she was burdened with three children.
It is the harsh hand of necessity which drives the
poor to the clinics, to the profit of science and the
medical schools. Unable to find the money, they
have to pay for their treatment with their bodies.
. . . But for many the price is too high, and they
prefer to die unsuccoured. This is what the cele-
brated German gynaecologist Hoffmeier says:
"Teaching in clinics for women is made more diffi-
cult than that anywhere else, through the natural
shame of women and their perfectly comprehensible
aversion to demonstration in the presence of students.
According to my experience, I think that in small
towns it would hardly be possible to conduct a
gynaecological clinic if all patients, without excep-
tion, were not chloroformed for the purposes of
examination. At the same time, examinations con-
ducted by an inexperienced hand are often exceed-
ingly painful, and examination by a large number
of students is unpleasant in the highest degree. For
this reason, in most clinics for women, the patients
are demonstrated and examined under an anaesthetic.
EXAMINATION AND AUTOPSY 31
"Least feasible of all is the teaching of practical
gynaecological out-patients relief work, at any rate
in small towns. He who desires to obtain real
knowledge in this branch, must personally examine
the patients. And this is what the latter dislike
most. The fear of such examinations in the pres-
ence of students especially by the students them-
selves in our country at any rate often proves
more 'powerful than the Patients' -dressing need for
help."
In the abstract such niceness may appear foolish;
the students are practically doctors and bashful-
ness in the presence of one's medical adviser is out
of place. But the whole aspect of the case changes
when you put yourself in the patient's position.
We men are naturally less modest than women,
nevertheless I can vouch for myself that I would
never consent to be led out perfectly naked beneath
the eyes of a hundred women, or tolerate these
women to feel me all over, examine me minutely,
question me about everything, stopping at nothing.
Thus, I came to see that although this niceness may
be unreasonable, nevertheless it ought to be taken
very much into consideration. Still, the axiom re-
mains "it is impossible to study in any other way."
In the Middle Ages medical study went no further
than theoretical lectures, in which the works of the
Arabian and ancient physicians were commented
upon ; for the practical schooling of the students did
32 THE MEMOIRS OF A PHYSICIAN
not enter into the programme of the universities of
those days. According to Pirogoff, 3 as recently as
the late "forties," in some of the out-of-the-way
German universities "bleeding was taught on pieces
of soap, and amputation on turnips." Fortunately
for medicine and the sick, those times have vanished
forever, and to sigh for them were criminal, be-
cause nowhere can the lack of practical preparation
work so much harm as in the physician's art. And
practical preparation is, I repeat, impossible, with-
out the accompaniment of all that has just been
described.
There we stumble against one of those contra-
dictions which we are destined to encounter so often
as we proceed: we, the representatives of the most
humane of the sciences, are compelled to trample the
most elementary humanity under foot. Availing
itself of the inability of the poor to pay for medical
aid, our school takes advantage of their need and
converts the sick into dummies to be used for the
purpose of study, ruthlessly setting at nought
woman's shame, adding to the sorrow of the be-
reaved mother by "desecrating" her dead child, etc.
But there is no middle course: no patient would
ever consent to serve the cause of science of his own
free will!
I am quite at a loss to suggest any practicable
8 Pirogoff was one of Russia's most celebrated surgeons. TRANS-
LATOR.
EXAMINATION AND AUTOPSY 33
way out of this dilemma; all I know is, that we
cannot do without medicine, and that no other way
of acquiring knowledge is possible. At the same
time I must confess that if want were to force my
wife, or sister, into the position of the unhappy
patient who consulted the professor of syphilology,
I would cry out that I did not care a fig for all the
schools of medicine in the world and that no one
was given the right to degrade the feelings of his
fellow-creatures, merely because they chanced to
be poor.
CHAPTER III
WHAT MEDICINE HAS NOT ACCOMPLISHED AND
WHAT IT HAS
DURING my third year, about a fortnight after
the term had begun, I was present for the first
time at an autopsy. The body of a woman of
forty, wasted to a skeleton, lay on a marble table.
The professor of pathological anatomy, a leathern
apron tied round him, was drawing on a pair of
rubber gloves, cracking jokes the while; at his side
stood one of his colleagues a surgeon, in whose
clinic the woman had died dressed in a white gown.
The benches encircling the dissecting table in the
amphitheatre were crowded with students.
It was obvious that the surgeon was not at his
ease; he pulled at his moustache nervously and his
eyes roamed over the serried ranks of students with
an assumed expression of boredom; when the pro-
fessor of pathology made a joke, he hastened to
smile pleasantly; altogether his manner towards the
pathologist was that of a school-boy before his ex-
aminer; he seemed anxious to ingratiate himself with
the other. As I gazed upon him, it struck me as
strange that this should be the same awe-inspiring
34
MEDICINE'S ACHIEVEMENT 35
N , who comported himself with such Olympian
majesty in his clinic.
"So she died of peritonitis*?" shortly inquired the
professor of pathology.
"Yes."
"Was she operated upon*?"
"Yes, she was."
"Humph !" grunted the pathologist, slightly lift-
ing his brows, and commenced the autopsy. The
prosector made a long incision in the skin from the
chin to the symphisis pubis. The pathologist care-
fully opened the abdominal cavity and began to
examine the inflamed peritoneum and the glued
intestines. In his clinic, the day before, the surgeon
had expressed to us his opinion as to the cause of
the patient's death: the tumour which he had in-
tended to remove was found to adhere extensively
to the intestines; probably, while disengaging these
adhesions, the intestine sustained a slight injury,
which resulted in purulent inflammation of the peri-
toneum. This supposition was confirmed by the
post-mortem examination. The pathologist sought
out the wounded part and removed a section of the
intestine with a small abrasion: this he handed the
students on a plate, for examination. While we
scrutinised the sinister little wound, surrounded by
a film of pus, curiously, the surgeon frowned and
worried his moustache. I followed his movements
with concentrated and malicious attention : here was
36 THE MEMOIRS OF A PHYSICIAN
the tribunal before which all their sins and mistakes
were mercilessly exposed and punished! That
woman applied to him for aid and, thanks to his
intervention, she now lay before us a corpse; it were
interesting to learn whether her relatives knew this,
whether the operator had seen fit to explain the
cause of her death to them 4 ?
The autopsy was at an end. In his description
of the case the pathologist declared that peritonitis
had undoubtedly been caused by the wounding of
the intestine, but owing to the mass of adhesions
and ligatures of the growth, it was extremely diffi-
cult to notice the scratch, and that in such compli-
cated operations the best surgeons could not be
guaranteed against untoward accidents.
The two professors then warmly shook hands and
departed, the students crowding out of the building
in their wake.
That first experience of a post-mortem examina-
tion left a strange and painful impression behind it.
"Peritonitis was caused by a wound to the intestine;
it is difficult to notice such an abrasion ; unfortunate
accidents happen to the best surgeons." How very
simple it all sounded! One might be led to think
that the whole question concerned an experiment in
chemistry which had fallen flat, its mere want of
success being the most important consideration.
The reasons for the miscarriage were stated with
complete sang froid, the person responsible, even if
MEDICINE'S ACHIEVEMENT 37
he were agitated, experiencing uneasiness merely be-
cause his amour fropre was at stake. ... In real-
ity, however, it was a matter which concerned the
destruction of a human life, no more nor less, a mat-
ter which involved something incomparably more
terrible in its import. And the inevitable question
arose: how dared such an operator continue to pur-
sue his vocation*? A physician whose duty it is to
heal, kills his patient ! Such a crying contradiction
was inadmissible and at the same time it seemed to
pass unnoticed.
I felt as if I had suddenly found myself in a
school of augurs.
We students were future augurs no need to be
squeamish in our presence and therefore we were
introduced, without more ado, to the seamy side of
our business. The lay mind might rebel at the
existence of such a reverse to the medal; we, how-
ever, had to accustom ourselves to view matters in
a "broader" light. . . .
The further I penetrated into medicine, the more
that impression of my first autopsy grew upon me.
In the clinics, at the theoretical lectures at the post-
mortems, in the text-books it was the same every-
where. Side by side with that brilliant medicine
of the foot-boards, which heals and resurrects, and
for the sake of which I had taken up its study,
another medicine slowly revealed itself to me a
helpless, impotent, erring and false science, which
38 THE MEMOIRS OF A PHYSICIAN
undertook the treatment of diseases which it could
not identify, painstakingly diagnosed illnesses which
it could not cure.
In the text-books I often came across descriptions
of diseases winding up with the following remark:
"The diagnosis of this disease is only possible on the
dissecting table" as if such timely enlightenment
could do any one any good! Perhaps a child with
tubercular pyo-pneumothorax would be shown us;
emaciated and shrunken, with protruding bones and
a bluish face, it would sit there breathing rapidly.
When laid upon its back it would commence to
cough as if about to render up its soul. The pro-
fessor with serious mien, as if performing an act of
the greatest importance, would localise the region
of condensation, determine the extent of the trans-
position of the mediastinum, etc., while I followed
his movements, sneering covertly to see all the trou-
ble he took over his examinations, only to state in
the end, that the patient's case was hopeless and
that we were powerless to cure him. What sense
was there in his diagnosis'? Never mind how subtle
the latter might be, after all it was but equivalent
to Mqliere's pithy words, "They will tell you in
Latin that your daughter is ill" ("Le medecin mal-
gre lui"). All this is pitiful and ludicrous. I
recalled Mephistopheles' definition of the spirit of
medicine :
MEDICINE'S ACHIEVEMENT 39
Der Geist der Medicin ist leicht zu f assen :
Ihr durchstudiert die gross und kleine Welt,
Um es am Ende geh'n zu lassen
Wie's Gott gefallt. 1
In the treatment of diseases I was always struck
by the extreme instability and indefinite character
of their symptoms, the large number of remedies
offered against every ill and, at the same time, at
the utter uncertainty of their efficacy. Let me
quote an extract from StrumpelFs well-known text-
book: "Up to the present the treatment of
aneurism of the aorta gives very doubtful results;
nevertheless, in every case, we have the right to try
the effect of either one or the other of the remedies
recommended." . . . "To prevent recurring fits of
angina fectoris" we find in the same work:
"Many remedies are recommended: arsenic, sul-
phate of zinc, nitrate of silver, bromide potassium,
quinine, etc. No harm can be done if we try any
one of these remedies, but one should not promise
oneself any sure success." And so on ad infinitum.
"One may try this or that. . . . No harm can be
done by essaying this. . . . Some have greatly ap-
proved of the following. . . . To give so-and-so a
trial were not a bad idea." ... I came to the uni-
1 It is easy to grasp the spirit of medicine:
You carefully study the great and lesser world
To allow things in the end to take the course
It pleaseth God.
40 THE MEMOIRS OF A PHYSICIAN
versity to be taught how to cure the sick, and I was
asked to "try" this or that drug; and, mark you,
without any guarantee of success !
Not a day passed without my learning some new
facts which still further undermined my respect for,
and faith in medicine. Pharmacology introduced
us to a whole series of remedies, known to be utterly
ineffective, and nevertheless recommended their use.
If the nature of the patient's disease is not as yet
clear to me I must await further developments be-
fore being enabled to diagnose it definitely. Or
else, if it be incurable, I am told that "one cannot
allow the patient to go without medicines." In
such cases it is customary to prescribe neutral reme-
dies; there is a special term for the latter: ut aliquid
fiat (an abbreviation for ut aliquid videatur}.
This trick is practised so as to make the patient
think that something is being done for him.
Our professor would enlarge upon such matters
in the most serious and unemotional manner. I
looked him in the face with internal laughter and
thought: "Now really, aren't you an augur*?
Wouldn't we laugh like augurs, if we could see our
patient anxiously glancing at the clock, afraid to
be ten minutes late with his weak mixture of acidu-
lated syrup?"
Soon the existence in medicine of a fairly large
assortment of very instructive so-called "special
terms" became known to me. "To diagnose ex
MEDICINE'S ACHIEVEMENT 41
juvantibus* according to what can help," for in-
stance! You prescribe a certain course of treat-
ment, and if the above proves efficacious, you
conclude that the patient is suffering from such and
such a disease; thus the second step is taken before
the first has been made, and the whole science of
medicine turned upside down; the patient's illness
being unknown, he is treated in a given way, so as
to ascertain according to the result obtained, whether
he ought to have been thus treated.
I became more and more impregnated with a
species of absolute medical nihilism, that nihilism
which is so characteristic of all "half-knowers." It
seemed to me that I had now penetrated to the core
of medicine, having at least grasped the fact that it
possessed but two or three efficacious remedies, the
rest being ut aliquid fiat; that with its pitiful and
imperfect means of diagnosis, it blundered in the
dark, pretending to wisdom. When talking on the
subject with the laity, I smiled knowingly and said
that to confess frankly, "all our doctoring was
merely humbug."
The question arises as to why the foregoing
should have been instrumental in my arriving at
such sweeping and final conclusions'? I think that
the foundation for such an opinion was based upon
the following popular foible, which I also uncon-
sciously shared: "You are a physician, therefore
1 In America termed "The Therapeutic Test."
42 THE MEMOIRS OF A PHYSICIAN
you ought to be able to recognise and cure every
ill; if, however, you are powerless to do so, it fol-
lows that you must be a quack."
Because medicine could not accomplish all, I held
it up to derision, shutting my eyes to its positive
achievements and declining to take into considera-
tion the actual means at our science's disposal and
their limitations. The attitude of the great un-
thinking majority towards medicine is identical
with the above. ... In 1893, a "cardiac polypus
discovered by chance at a post-mortem examina-
tion," was displayed among the pathologico-ana-
tomical specimens on show at the Hygienic
Exhibition held in St. Petersburg. That polypus
greatly amused a writer in a certain important
newspaper of the metropolis: "See how clever our
doctors are ! An edifying sort of a 'chance' find !"
Such was his theme. The same Hygienic Exhibi-
tion which furnished such rich proof of what medi-
cine could do, was non-existent to the writer of the
"leaderette" ; of all the wealth of material it offered,
he only had eyes for that solitary polypus, and ac-
cordingly indiscriminately loaded both doctors and
medicine with his ridicule and contempt, without
caring to find out whether it were possible to locate
such a growth during life. Nothing should be im-
possible to the physician; this is the standpoint held
by the masses. And at that period I judged in the
same way.
MEDICINE'S ACHIEVEMENT 43
But a certain episode wrought a complete change
in me. A woman of about fifty was admitted to
our clinic. She had a large swelling on the left
side of the abdomen. I was appointed to watch her
case. It devolved upon me to examine the patient,
define her illness and record its course; when the
patient was demonstrated before the students, it
was my duty to give the history of her complaint,
acquaint my audience with the results of my exami-
nations and state my diagnosis. After this the pro-
fessor would point out my mistakes and omissions,
himself minutely examine the patient and finally
make known his own opinion.
My patient's swelling occupied the entire left
half of her ventral regions from the hypochondrium
to the osiliacum. What was the nature of the
swelling 4 ? From which of her organs did it origi-
nate? Neither my questionings nor my examina-
tions availed to furnish me with any more or less
approximate indications; it was just as easy to sus-
pect cystic tumour of the ovarium, echinococcus of
the spleen, hydronephrosis or cancer of the pancreas.
I ransacked every text-book I could lay hands on,
and this is what I found in them :
"It is very easy to confound echinococcus of the
kidneys with hydronephrosis; we have also fre-
quently discovered soft sarcomatous tumours 'of the
kidneys when we had been sure that we were dealing
with hydronephrosis" (Tillman's Special Surgery'),
44 THE MEMOIRS OF A PHYSICIAN
"Cancer of the kidneys is often mistaken for
retroperitoneal tumours; tumour of the ovarium or
of the spleen, for large abscesses in the pelvic region,
etc." (Strumpell).
"In cases of cystoma of the ovarium 1 very un-
pleasant mistakes in diagnosis are made. The
distinguishing of cystic tumour of the ovarium, as
differentiated from hydronephrosis, is one of the
most dangerous of rocks; because, if hydronephrosis
be extensive, superficial examination furnishes an
identical picture with the first named affection;
thanks to this, such diagnostical mistakes are far
from rare" (Schroeder's Gynacology).
"The clinical symptoms of cancer of the pancreas
are rarely sufficiently clear for a true diagnosis"
(Strumpell).
In a frame of mind both sceptical and hostile
towards medicine, a contemptuous sneer curling my
lip, I perused these confessions of impotence and
incompetence. It seemed almost as if I were
pleased at being unable to make head or tail of my
case; for was I to blame because our "science" (save
the mark!) proved powerless to furnish me with
anything approaching a reliable clue to the truth*?
The statement of the bare fact that my patient had
a swelling in the abdominal region was the only one
I could conscientiously make. The role of a char-
latan being distasteful, I refused to choose at ran-
* Cystoma ovarii 01- cy*tpraa of the ovary.
MEDICINE'S ACHIEVEMENT 45
dom and boldly declare in favour of hydronephrosis,
knowing full well that sarcoma, echinococcus or
anything else, were just as likely.
The day for the demonstration of my patient
arrived. She was brought into the lecturing-room
on a stretcher and I was called to her side. I read
her "anamnesis" and described the results of my
examinations.
"And what is your diagnosis'?" asked the pro-
fessor.
"I don't know," I answered sulkily.
"Well, approximately*?"
I silently shrugged my shoulders.
"I certainly agree that the case is by no means a
simple one," said the professor, and proceeded to
interrogate the patient himself.
He began by allowing her to give her own ac-
count of her illness. I based all my subsequent
investigations upon it; the professor, on the other
hand, took her recital into consideration very little.
When she had done, he began to question her very
carefully and minutely on the state of her health
prior to her present malady; upon its commence-
ment, asked her all about her functions during her
sickness. Thanks to this skilful catechism alone,
things assumed quite a new aspect; instead of a
chaotic array of symptoms, a complete presentment
of the diseased organism's life unfolded itself before
us, in all its deflections from the normal. Next,
46 THE MEMOIRS OF A PHYSICIAN
the professor examined the patient's swelling, lay-
ing great stress upon its consistency, noted whether
it was displaced by respiration or had any connec-
tion with the womb, determined its position in rela-
tion to the colon, etc. And at last the professor
began his deductions. He approached them slowly
and warily, as a blind man groping his way along
the edge of a precipice; he did not leave the smallest
symptoms without attentive and searching consid-
eration; to explain the most insignificant symptom,
which I never would have noticed, he turned the
whole tremendous arsenal of anatomy, physiology
and pathology upside down; he himself met every
contradiction and obscure point half way, and passed
on only after completely clearing the matter up.
. . . And when, finally, he arrived at his diagnosis
of "soft cancer of the left kidney" after having
sifted all the evidence, his verdict was obviously the
logical outcome of the foregoing.
I listened dumfounded and enraptured: how
petty and childish my own investigations and all my
scepticism appeared to me now! The tangled and
obscure tableau, which it seemed to me impossible
to unravel, had become crystal-clear and perfectly
comprehensible and this was merely due to the
professor not having deemed any trifle unworthy of
attention.
A week later the patient died. Again, as of
yore, the corpse lay upon the dissecting table, once
MEDICINE'S ACHIEVEMENT 47
more the students crowded around the same pro-
fessors, following the autopsy with strained atten-
tion. The pathologist extracted from the abdomen
of the deceased a tumour the size of a human head,
and after careful examination pronounced it to be
medullary cancer (soft cancer) of the left kidney.
I can hardly describe the feeling of enthusiastic
pride in science which welled up within me on
hearing those words. While looking at the soft
crimson mass, that lay upon a wooden dish, I sud-
denly called to mind our country bailiff, Vlass
a fiery hater of medicine and doctors. "How are
the doctors to know what goes on inside me? Can
they see through one*?" he used to ask with a scorn-
ful snort. Yes, it was just a case of "seeing
through one." . . .
From that day forward, my attitude towards
medicine underwent a radical change. On com-
mencing its study I expected it to accomplish every-
thing; seeing that medicine could not do all, I con-
cluded that it could do nothing. Now, however,
I saw how much it could still do, and that "much"
filled me with reliance in, and respect for, that
science I had so recently despised from the bottom
of my soul.
A patient lies before me ; he is feverish and com-
plains of pains in the side; on auscultation the
deadened sound shows that in one part of the thorax
the air contained by the lungs has given place to
48 THE MEMOIRS OF A PHYSICIAN
morbid secretion; but the question arises whether
it is located in the lung proper or the pleural space.
I place my hand on the patient's chest and make
him loudly say "ninety-nine." The vibration of
the thorax on the affected side is weakened, this
circumstance telling me as plainly as if I could see
all with my own eyes that the secretion is located in
the pleural sac not in the lung. Another patient
has paralysis of the left leg; I strike the sinews of
the knee with my mallet his leg leaps up violently ;
this shows that the affection does not lie in the
peripheral nerves, but somewhere above their start-
ing-point in the spinal marrow; but where *? I care-
fully ascertain whether the skin has retained its
sensitiveness, whether the other limbs are affected,
whether the functions of the cerebral nerves are
in order, etc. and can at last say with complete
certainty that the affection which has called forth
paralysis of the left leg is located in the cortex of
the central convolution of the right cerebral hemi-
sphere, near the sinciput. What stupendous pre-
paratory work of centuries was necessary to evolve
such seemingly simple methods of examination ; how
much power of observation, genius, laborious re-
search and knowledge must have been expended!
Truly the conquests of science are vast!
By sounding a diseased heart it is possible to tell
which of the four valves is defective in its action,
and determine the cause thereof; by employing cor-
MEDICINE'S ACHIEVEMENT 49
responding mirrors, we are able to examine the
inside of the eye, the nose and gullet, the larynx,
vagina, even the bladder and stomach. Invisible,
mysterious and obscure "infection" has been ex-
plained; we can now cultivate it in test-tubes, in
its pure form, and investigate its properties beneath
the microscope.
In midwifery the whole complicated mechanism
of child-birth has been studied with almost mathe-
matical precision, and no matter what the child's
position, we know exactly which artificial manipula-
tions ought to be recoursed to for assisting the nat-
ural process of delivery. . . . We cauterise the
nasal conchils of a child with white-hot metal, after
having made them insensible to pain through the
agency of cocaine: the living flesh hisses and
crackles, a smell of burned meat is wafted through
the air, while the child sits still smiling, contentedly
purling the smoke from its nostrils.
But it is impossible to enumerate all. Of course,
much, very much still remains to be done, but this
is merely a question of time. We cannot guess
how far science may go. Why, a few years past the
very idea of actually seeing through the human body
would have struck one as an absurdity; now, how-
ever, thanks to Roentgen, that absurdity has crys-
tallised into fact. Forty years ago 2 three-fourths
of those operated upon died of septic infection:
3 This is a conservative estimate,
50 THE MEMOIRS OF A PHYSICIAN
pyaemia was the curse of surgery, against which the
skill of the operator was helpless. "I positively do
not know what to say of that terrible curse of
surgical practice," wrote Pirogoff, in 1854, despair-
ingly; "all is enigmatic about it: its origin and de-
velopment. So far, it is as incurable as cancer."
"When looking back upon the cemeteries," he writes
elsewhere, "where lie buried all those who have been
infected in the hospitals, I do not know what to
wonder at more: the stoicism of the surgeons, who
continue to devise new operations, or the confidence
which hospitals continue to enjoy amongst the
public." Then Lister appeared upon the scene, in-
troducing antiseptic treatment; this gave place to
the still more perfect aseptic method and the sur-
geon, ceasing to be the slave of septic infection, be-
came its master; nowadays if a patient dies of it
after an operation, the operator is to blame, not
science.
If so much has already been done, what may not
science attain to in the future! The bright vistas
which were revealed before my gaze filled me with
buoyant gladness, for I felt that the true road had
been found and there was no swerving aside from
it. Natura parendo vindtur nature is conquered
by him who obeys her; and when all her laws were
fathomed, man would become her lord and master!
The present-day one-sided methods of treatment
would disappear along with the artificial prevention
MEDICINE'S ACHIEVEMENT 51
of disease: man would have learned to develop and
render invincible the curative forces of his own
organisms, he would have no need to fear infection
or colds, spectacles and dental surgery would be-
come unnecessary, headaches and neurasthenia ceas-
ing to be known. Man would be strong, happy and
healthy, and would be born of strong and healthy
women, the latter knowing neither the surgeon's
forceps, chloroform, nor secale cornutum.
But although my fascination grew, I could not
help being struck at the tremendous cycle of subjects
embraced by the study of medicine, and this circum-
stance disconcerted me not a little. My head spun
round at the mass of new, totally divergent infor-
mation to be assimilated which, however, it was
impossible to dispense with. We were busy from
morning till evening, we had no time to read up
in medicine, let alone outside subjects. We were
in a sort of fever, flitting from clinic to clinic,
from lecture to lecture, from laboratory to labora-
tory, in a kind of delirium. As in a rapidly revolv-
ing kaleidoscope a great procession of the most dis-
similar subjects passed before us: dissection of the
knee-joint, lectures on the properties of digitalis, the
incoherent ravings of a paralytic patient, the ap-
plication of accoucheur's forceps, the position oc-
cupied by Sydenham in medical literature, the prob-
ing of the lachrymal canal, the methods of colour-
ing Loeffler's bacilli, the location of the subclavian
52 THE MEMOIRS OF A PHYSICIAN
artery, massage, the symptoms of death from as-
phyxiation, ringworm, the various existing systems
of ventilation, the theory of chlorosis, our laws on
prostitution, etc., etc., were all jumbled up together.
All this was absorbed mechanically, undigested.
The desire to reflect on the information acquired, to
linger upon this or that subject, succumbed beneath
the pressure of that endless torrent of new facts.
All that could be done was to store the latter up
as mechanically, seeking comfort from the thought,
"Later on, when I have more leisure, I will think all
over and put everything straight." But the im-
pressions obtained gradually became obliterated, the
questions which arose at the time were forgotten
and their interest was lost; the assimilation of
knowledge was thus rendered superficial and school-
boyish.
During our entire academic course we hardly ever
had the chance of thinking or acting independently.
Our professors skilfully performed the most difficult
operations in our presence, unravelled those compli-
cated and tangled riddles which are called patients
before us, while we ... looked on and hearkened.
Everything seemed to be so simple, harmonious and
obvious. But whenever I had to deal with a patient
on my own initiative, as would occasionally happen,
something invariably turned up to nonplus me com-
pletely. At first this hardly worried me, for was
I not a student, who knew but little as yet, and to
MEDICINE'S ACHIEVEMENT 53
whom the necessary knowledge and experience
would come later on? Time passed, however, and
my knowledge had increased, I had completed my
fifth year, the final examinations were in progress
while I continued to feel as helpless as ever,
clumsy and incompetent, incapable of taking the
smallest independent step. At the same time I
could see that I was in no way behind my comrades ;
on the contrary, I stood above the majority. . . .
What sort of physicians would we become'?
Our final examination lasted for about four
months. 3 These examinations are especially diffi-
cult at the Faculty of Medicine, owing to the over-
whelming number of subjects required. During
the terms I worked a great deal, and I was endowed
with fair capacity; nevertheless, one was forced to
read from ten to twelve hours daily, as long as the
examinations continued. The amount of knowl-
edge demanded of us was tremendous, at least three-
fourths being ballast, which the memory discarded
as soon as the tests were passed. Add to this, that
most professors see nothing beyond their own par-
ticular branch of science and rarely rise above their
narrow specialities. One of my comrades failed
in anatomy because he did not know whether the
duodenum was covered with peritoneum or not a
question of great interest to the anatomist, doubt-
3 In America examinations occur at the end of each academic
year and last approximately one week,
54 THE MEMOIRS OF A PHYSICIAN
lessly, but without the slightest importance for a
doctor.
It was necessary to be able to enumerate the
names of several dozen surrogates of milk, although
every one of them was to us but an empty sound;
it was indispensable to have all the chemical re-
actions of atropin at one's finger's ends, although
we had not experimented upon a single one of them
ourselves. . . .
But most important of all was to know the in-
dividual hobbies and foibles of each examiner
hobbies which were often wonderfully absurd.
The student who had neglected to acquaint him-
self with them was sure of being "plucked." The
favourite question of one of the professors was as
follows: "If we administer an enema to a certain
animal, the water will flow from its mouth. Pray,
name that animal." The professor of general thera-
pathy put the following question to me: "What
is the difference between pouring a spoon of cold
water over one's head and swallowing it*?" The
professor of dermatology gave the student who told
him that leprosy was contagious a bad mark; the
professor of general surgery marked down the stu-
dent who gave the opposite answer.
In a word, success or failure depended entirely
upon the personality and character of the examiner :
a "kind" professor passed into the profession the
student who proposed to give a three-months-old in-
MEDICINE'S ACHIEVEMENT 55
fant five drops of opium; while a strict professor
"ploughed" the luckless one who was ignorant of
the action of narceinum an insignificant com-
ponent of that very same drug.
This system of purely school-boy tests turns them
into a monstrous farce, which is as little sensible
as wise. Instead of the real knowledge essential
to every doctor, an incredible jumble is required,
which it is possible to retain in one's memory only
as long as the examinations last.
It was Virchow's dream once upon a time that
doctors should be subjected to renewed examinations
at given intervals; as things stand at present, such
a scheme, however reasonable in its idea, were im-
practicable: all examinations are so organised that
only youths with fresh and elastic memories are
capable of passing them, neither experience nor solid
knowledge of medical science being essential.
The above fact is impressed upon one with special
force in the case of the "Doctor's" examination;
the qualifications for this test are practically identi-
cal with those for the "Surgeon's" degree, only more
comprehensive. Queer things result from such a
state of affairs. I know an old physician, distin-
guished both as a practitioner and a scientific worker
through his researches. To be eligible for the post
of chief physician of a hospital he must bear the
title of "Doctor"; but age renders him incapable
of "cramming" in all the scholastic wisdom required
.56 THE MEMOIRS OF A PHYSICIAN
thereto and he remains a "Surgeon." On the
other hand, many of my comrades men of scant
knowledge and less experience immediately after
obtaining their "Surgeon's" diplomas, with their
memories still fully stocked, applied themselves to
the task of passing their "Doctor's" examinations
and experienced no difficulty in winning that learned
degree.
Such a degradation of scholastic honours is only
possible in medicine; a mathematician or historian,
who has not lost touch with his subject, can obtain
his "Doctor" at any moment of his career, if so
inclined. If, however, you were to subject, after
the lapse of five years, a fully-fledged doctor of
medicine to the same ordeal, without previous warn-
ing, he would fail ignominiously. I make bold to
assert that not a single eminent physician living
would be able to pass his examinations a second time
without laborious preparation unless his inquisi-
tors showed leniency in consideration of past serv-
ices; i.e. were to require a real knowledge of medi-
cine not the acquisition by rote of endless minutiae
of no value whatever to any one.
4 There is only one medical degree in the United States, i.e.
M.D. (Doctor of Medicine). Recently there has been another de-
gree conferred upon men who are surgeons in well known hos-
pitals. This is the F.A.C.S. (Fellow Am. College of Surgeons).
CHAPTER IV
THE DIFFICULTIES THAT CONFRONT THE YOUNG
PRACTITIONER
OUR final examinations terminated, we as-
sembled in the University hall to sign our
oaths and receive our diplomas. The latter were
embellished with the Imperial arms and the great
University seal, and bore witness to our having suc-
cessfully passed all tests, both practical and theo-
retical, the Faculty of Medicine declaring us worthy
of the degree of Surgeon, "with all^the rights and
privileges appertaining to that calling according to
the law."
I bade good-bye to our Alma Mater in a de-
pressed and unhappy frame of mind. The vague
misgivings which had begun to assail me as my uni-
versity career drew to its close, at last assumed
definite shape and confronted me in all their naked-
ness. I, whose entire mental stock consisted of a
chaotic accumulation of fragmentary, undigested,
and unassimilated information, I, who had hitherto
only looked on and listened to others and never
acted independently, who was ignorant of the most
elementary practical knowledge had suddenly at-
tained the dignity of physician and patients might
57
58 THE MEMOIRS OF A PHYSICIAN
apply to me at any moment ! In the name of good-
ness, what could I do for them?
All my comrades experienced the same feelings
as myself. We looked with bitter envy upon the
happy few who had been retained in the clinics as
assistant house-physicians. For they later would
continue to learn, working under the superintend-
ence of experienced and skilled professors, not at
their own risk. While the rest of us we had to
start in life forthwith as independent medical men,
not only enjoying the "rights and privileges," but
also bearing the duties and responsibilities which
the law imposed upon us "in accordance with our
calling!"
A few of my comrades were fortunate enough to
obtain hospital appointments elsewhere, others
entered the service of the "Zemstvos"; but those
who remained including myself failed to secure
any such positions, and the only thing left us was
to try and gain our bread by private practice.
Accordingly, I took up my residence in a small
governmental town of middle Russia. I arrived
upon the scene at a particularly propitious moment;
a short time previously the doctor, who lived on
the outskirts of the township, and had worked up
a fair practice, died. I took lodgings in the same
district, put up my brass plate with the legend:
"Dr ," and began to wait for patients.
I awaited them, and at the same time I dreaded
THE YOUNG PRACTITIONER 59
their advent. Every pull at the bell made my
heart beat in a panic; each time that it turned out
that no patient had called, I sighed with a feeling
of relief. Would I be able to diagnose, would I
be capable of prescribing the right treatment? My
store of information was neither so large, nor was
I so well at home in what I possessed, to feel certain
of being able to apply it impromptu. All well and
good if the patient's case was not too urgent and
he could be allowed to wait : after prescribing some-
thing neutral, I would look up my text-books at
home and ascertain the right thing to be done. But
what if I were called to an emergency case? It is
just this sort of case that beginners are generally
summoned to. ... What would I do then?
There is a book by a certain Dr. L. Blau, called
"Diagnostics and Therapeutics in cases showing
Alarming Symptoms." I got it and transcribed its
main contents into my pocket memoranda, supple-
menting this conspectus from my text-books. I
grouped the different diseases in accordance with
their symptoms; for instance, dyspnoea: (i) croup;
(2) pseudo-croup; (3) oedema of the glottis; (4)
spasm of the larynx; (5) bronchial asthma; (6)
congestion of the lungs; (7) croupous pneumonia;
(8) uremic asthma; (9) pleurisy; (10) pneumo-
thorax. Each disease in turn was accompanied by
an enumeration of its symptoms and the correspond-
ing treatment. This note-book did me yeoman
60 THE MEMOIRS OF A PHYSICIAN
service and I could not dispense with it for a long
time afterwards about two years. When sum-
moned to the bedside of a patient, I would unclasp
my trusty friend under the pretext of taking notes,
seek out the disease most resembling the patient's,
and prescribe accordingly.
I was the only medical man in the part of the
town where I lived, and little by little the patients
began to arrive. ... I soon worked up a practice
amongst the local townspeople which could be con-
sidered very fair for a beginner.
Among others I attended the wife of a certain
shoemaker, a woman of about thirty, suffering from
dysentery. All went well and the patient was on
the way to recovery, when one morning she began
to complain of violent pains in the right side of
her stomach. Her husband immediately ran to
fetch me. I examined the patient. Pressure
caused diffused pain throughout the abdominal
region, while that of the liver was so tender that
she could not bear the slightest touch; the stomach,
lungs and heart were in good order and the tempera-
ture was normal.
What could the matter be *? I mentally reviewed
all the different diseases of the liver I knew of and
could not fix upon a single one. It was the most
natural thing in the world to connect this new com-
plication with the original trouble; in cases of
dysentery, abscesses of the liver sometimes form;
THE YOUNG PRACTITIONER 61
but in the present instance the normal temperature
seemed to negative such a supposition. Having
injected some morphia, I went home entirely
baffled.
However, towards evening the temperature went
up to 104 Fahrenheit, violent rigours setting in,
the patient's respiration became somewhat laboured
and the pains in the side increased in severity. All
my doubts vanished: an abscess resulting from
dysentery must have formed in the sick woman's
liver, while the shortness of breath was accounted
for by the pressure exercised upon the lung through
the swelling of the first-mentioned organ. I was
really pleased with myself for the shrewdness of my
diagnosis.
But once the patient had an abscess, an operation
became imperative (a very easy thing to say in a
clinic). I advised the husband to place his wife
in hospital; I told him that the situation was ex-
tremely grave, that his wife had an abscess in her
vitals, and that if it ruptured internally, death was
inevitable. He hesitated for some time, but finally
allowed himself to be persuaded.
Two days later, on calling at the hospital to en-
quire after the sufferer's condition, I was astounded
to hear that the real mischief was croupous pneu-
monia ! I could hardly believe my ears. . . . The
house-physician conducted me to her ward and
showed me my late patient.
62 THE MEMOIRS OF A PHYSICIAN
I then recollected that at the time it did not even
occur to me to ask whether she had a cough; I had
not even repeated my auscultation of her lungs, so
pleased was I to hear of the rigours and fever which
I unhesitatingly accepted as an indisputable con-
firmation of my diagnosis. Truly, the thought had
flitted through my mind that it would do no harm
to sound the lungs once more; but the patient
screamed so at every movement, that I simply did
not dare examine her.
"But her abdomen is very tender," I ventured, in
confusion.
"Yes, there is a slight pain in the liver," answered
the doctor, "although the right pleura causes her
much more discomfort."
I persisted, touching her stomach almost imper-
ceptibly, at which the patient screamed aloud. The
house-physician then started chatting with her, en-
quiring about the previous night, gradually sink-
ing his whole hand into her stomach in the mean-
while, without the sufferer so much as noticing his
action.
"Now then, my good woman, sit up !" he ordered.
"Oh, I can't."
"Tut, tut, nonsense ! Sit up."
And she obeyed. We could then sound her at
leisure : it was a most typical case of croupous pneu-
monia.
THE YOUNG PRACTITIONER 63
How could I have conducted my previous ex-
aminations so superficially and carelessly 4 ?
It was absolutely indispensable to examine every
patient from head to foot, no matter what he might
be suffering from all our professors never wearied
of repeating the above; this was sufficiently dinned
into our ears, and at an examination I would
have adduced endless corroborative examples. But
theory is one thing, practice another. It struck
me as absurd to proceed with the examination of a
patient's eyes, nose and heels, because he or she com-
plained of indigestion. In these matters the only
real teacher is personal experience theory is help-
less to force us to accept the truth. In the clinics,
unfortunately, we could not acquire that experience.
Further, it was characteristic, that in diagnosing,
I invariably fixed upon the rarest of all the diseases
which might be suspected. The case just described
was by no means unique in my practice: I would
take colic of the bowels for the beginning of peri-
tonitis, a simple case of piles assumed the aspect of
cancer of the rectum, and so on.
My acquaintance with everyday illness was very
limited the first diseases which occurred to me
were those serious, rare and "interesting" cases to
which I had become accustomed in the lecture-room.
Nevertheless, in the distinguishing of diseases I
was still more or less sure of my ground; while in
64 THE MEMOIRS OF A PHYSICIAN
college, diagnoses used to be made in our presence,
although we took but very little part in them; still
we saw enough. But I was quite at sea when it
came to predicting the course that each patient's
illness would take, and I was entirely ignorant of
the action of the different curative remedies pre-
scribed by me, being solely acquainted with them
through the text-books. At the university it was
considered very satisfactory if the same patient were
demonstrated before us four or five times. During
my whole student life I only had the opportunity of
following from beginning to end the maladies of ten
or fifteen patients, when appointed by the professor
to watch their cases. Such a small number is just
about as good as none at all.
One day, about a couple of months after settling
down in practice, I was requested to call on the wife
of a certain cloth manufacturer; this was the first
occasion upon which I was asked to a wealthy
patient. So far my clientele had been made up of
mechanics, small shopkeepers, petty officials, and
so on.
"Have you been in practice long*?" was the first
question my patient, a young and intellectual look-
ing lady of about thirty, asked.
Ashamed to tell a lie, although longing to say
"Two years," I answered truthfully.
"Well, I am very glad!" was the satisfied re-
joinder. "That means that you are abreast of the
THE YOUNG PRACTITIONER 6$
times; to be candid, I feel much greater confidence
in young doctors than in all these 'celebrities' : the
latter have forgotten everything, and merely try to
hypnotise us with their reputations."
The patient was suffering from acute rheumatism
of the joints as it chanced, one of those complaints
for which medicine possesses an efficacious specific
remedy in the shape of salicylic acid. No case could
have been more favourable for a first debut.
"Will her illness last for long, doctor?" the
patient's husband asked in the hall.
"N no!" I answered. "The pains ought to be-
come less every day and her condition will improve,
only see that the medicine is taken regularly."
A few days later the following note reached me:
"Sir! not only is my wife no better, but she feels
much worse. Be so kind as to call."
I came. At first the patient's right knee and left
foot had been affected ; now she felt pains in the left
shoulder joint and left knee in addition. I was
greeted with a cold and unfriendly stare.
"Why, doctor, you told me that I should be well
soon," she said, "but I get worse and worse. Oh!
such terrible pains. My God! I never imagined
that such sufferings were possible !"
So much for my sodium salicylate that sure
specific !
I silently began to remove the cotton-wool im-
pregnated with an ointment of vaseline and chloro-
66 THE MEMOIRS OF A PHYSICIAN
form, in which were enveloped the affected joints.
"I wonder whether it is the ointment which has
that putrid smell, or whether I am beginning to
decompose while still alive!" the patient ejaculated
capriciously. "If I am to die, let me die; I don't
care! But why should I be made to suffer so*?"
"Compose yourself, madam! How can you lose
heart in that way!" I remonstrated. "There can
be no question of dying, you will soon be quite
well."
"Oh, yes, you say so to console me. And shall
I continue to suffer like this for long 1 ?"
I vouchsafed an evasive answer and promised to
call on the morrow.
Next day the pain had considerably subsided, the
temperature had fallen, my patient looked bright
and cheery. She warmly shook me by the hand.
"I believe I am getting better at last!" she said.
"Confess, doctor, that I have been a horrid
nuisance. My husband took me to task and I am
ashamed of my impatience. Tell me, can I now
hope that things will begin to mend at last*?"
"Certainly! You expected the salicylic powders
to work like magic, which was impossible. They
may not take effect as promptly as one might wish,
but their action is sure. Mind you keep on taking
them."
"But they make me perspire very much; last
night I had to change my chemise three times."
THE YOUNG PRACTITIONER 67
"Have you felt any buzzing in the ears?"
"No."
"Then continue the powders, unless you want the
rheumatism to become acute once more."
"Oh, no, no!" she laughed. "I would rather
change my things a dozen times."
Next day I called again. My patient did not
stir when I entered the room. However, at last she
unwillingly turned her head in my direction; her
face was drawn and there were dark circles beneath
her eyes.
"My right shoulder has begun to ache, doctor,"
she slowly said, eyeing me with hatred. "I couldn't
sleep the whole of last night for the pain, although
I have been taking your salicylic powders religiously.
I suppose this comes as a surprise*?"
Alas, she was right there! Perhaps it had been
a mistake to promise a rapid recovery from the be-
ginning: my text-books made the reservation that
salicylic acid was sometimes inefficacious in the case
of rheumatism; but I never suspected that once it
had begun to work, its action could be suddenly
arrested without visible cause. The books were
schematic perforce, and it was only natural that I,
who had to rely upon them exclusively, should be
no different.
On taking my leave, I was not asked to call again.
However wounded I might have felt at this slight,
nevertheless, in my inmost soul, I was glad to be rid
of my capricious patient, for she had worried and
harassed me exceedingly.
Generally speaking, there was little to cheer me
in my practice at large. I was chronically in a
terribly nervous state. Although, goodness knows,
I had appraised my medical knowledge at a very
humble figure, when it came to the point I found
that even my modest estimation had been too high.
I was on the verge of giving up in despair, for nearly
every case disclosed to me more and more plainly all
the depth of my ignorance, my utter unpreparedness
and incompetence. My abstract bookish wisdom,
which had not stood the test of experience, prepared
constant pitfalls. Actual life could not adapt itself
to the stiff and unpliable moulds furnished by my
erudition which, on the other hand, I was incapable
of rendering more elastic. So often did I err in my
diagnoses and prognostications, that I was ashamed
to look my patients in the face. When asked
whether the medicine prescribed would be palatable,
I was unable to answer: it generally happened that
I had never set eyes on it before, much less tasted it.
The bare idea of being summoned to a complicated
case of child-birth threw me into a cold sweat: while
at the university, I had only assisted at five confine-
ments, and the only thing I knew well in midwifery
was the great danger arising from unskilled assist-
ance.
To me the life and the soul of the patient were a
THE YOUNG PRACTITIONER 69
closed book; we used to visit the clinical wards in
the guise of "young gentlemen," passing ten or
fifteen minutes at the bedside of each patient; we
barely had time to give their diseases the necessary
attention; as for the suffering man, he remained an
entirely unknown quantity.
But why should I dwell upon such subtleties as
the psychology of the patient 4 ? The simplest things
constantly found me wanting. It was mortifying
to discover that I lacked that knowledge and ad-
dress which every nurse possesses. When ordering
an enema or poultice, I was in constant fear of being
asked how they should be applied. As students,
we were never instructed in such "trivial" details:
that was the hospital attendant's or the nurse's work,
the doctor merely issuing his orders. Having
neither hospital attendants nor nurses to do my
bidding now, I was compelled to give instructions
personally to those who asked for them. The
larger and more "serious" text-books had to be laid
aside; their place was taken by such works as
"Nursing," by Billroth, a primer written for Sisters
of Mercy. And I, who had artistically amputated
a corpse's knee according to Sabaneeff's method,
when passing my final examinations, now conscien-
tiously studied the methods of lifting a weak patient
up in bed and the technique of blistering.
Not far from where I lived resided an old doctor,
Ivan Semenovitch N. by name, who had retired
70 THE MEMOIRS OF A PHYSICIAN
from practice on account of old age. If ever these
pages should meet his eye, may he once more accept
my warm gratitude for the kind sympathy he showed
me during that trying period of my career ! I used
to unbosom myself to him about my perplexities
and mistakes, would ask his advice on all knotty
questions, and even dragged him about with me to
see my patients. With purely paternal responsive-
ness, Ivan Semenovitch was ever ready to come to
my assistance with his knowledge and experience,
or to help me in any other way that lay within his
power. And every time that we stood together at
the bedside of a patient he calm, confident and
resourceful, I helpless and timid, the fact that we
should be considered each other's equals and pos-
sess the same diplomas, struck me as a crying incon-
gruity.
One of my patients, a grocer in a small way, was
suffering from a very severe attack of typhoid fever,
complicated by mumps of the right gland. Early
one morning the tradesman's wife urgently sum-
moned me through the errand boy : her husband had
become much worse during the night and was suf-
focating.
I found the patient in a semi-comatose state : his
respiration was stertorous and thick, as if something
were compressing his throat; at every breath his
hypochondrium was deeply drawn in; a film of
dried slime of a brownish hue covered his teeth and
THE YOUNG PRACTITIONER 71
the edges of his lips, while the pulse was very feeble.
Owing to the swelling of the glands, the patient
could not properly open his mouth, which prevented
my examining his throat. Under the pretext of
fetching my syringe to inject some camphor, I
hastened home, and sat down to study those chap-
ters of my text-books which dealt with typhoid.
That difficulty in breathing had to be accounted
for, and the only thing indicated by my authorities
was oedema of the glottis, owing to inflammation
of the arytenoid cartilage. In such a contingency
my note-book ordered the following treatment:
"energetic laxatives, swallowing of small lumps of
ice; if neither take effect, immediate tracheotomy."
I went back to my patient, injected some camphor
subcutaneously, ordered ice, and sent to the chemists
for one of the most powerful purgatives known,
colocynth.
I came again a few hours later. Notwithstand-
ing colocynth having taken effect, the patient's
breathing had become still more laboured. Tra-
cheotomy alone remained. I went for Ivan
Semenovitch. He attentively listened to what I
had to say and merely shook his grey head. A mo-
ment later we were driving away together.
On examining the patient, Ivan Semenovitch
made him sit up, filled an indiarubber bulb with
warm water, and introducing the mouthpiece be-
tween the patient's teeth, syringed out his mouth;
72 THE MEMOIRS OF A PHYSICIAN
a lot of sticky and oozy slime came out. The pa-
tient sat coughing and spluttering while Ivan Se-
menovitch energetically continued his syringings; I
marvelled that he should have no fear of the patient
choking. Each time more and more of the stuff
came out. I was amazed to see what an incredible
quantity of slime could be contained in the mouth
of a single man.
"Now then, cough it up, spit it out!" repeated
Ivan Semenovitch loudly and imperiously. And
the patient came round, blowing and spluttering.
His breathing was quite free by now. "To think
that I had prescribed colocynth," I muttered in dire
confusion, when we left the sick-room.
"Oh, oh, oh!" said Ivan Semenovitch, shaking
his head, "and the patient so weak too ! It doesn't
take long to kill a man that way, and what the
dickens was there to suggest such treatment?
When a man lies unconscious and can hardly swal-
low, it's the most natural thing in the world for a
lot of muck to collect in his mouth."
Of course, the books never hinted at the possi-
bility of such "complications" in typhoid, because
they could not foresee every minute contingency.
My dejection was profound: I was so stupid and
unresourceful that I would never make a doctor;
my competence went no further than that of a com-
mon hospital attendant only able to act according
to cut-and-dried routine. Now my despair strikes
THE YOUNG PRACTITIONER 73
me as ludicrous: as students, the necessity of in-
dividualising in each case was constantly being im-
pressed upon us, but the faculty could only be
acquired through time and experience.
But, at the period described, things appeared in
a very different light.
Thanks to what incredible misunderstanding had
I become possessed of my medical certificate*?
Every day this question arose before me with more
and more insistence; for my right to call myself a
doctor merely on the strength of that document
misgave me not a little, while life cried with ever
growing emphasis : "No, you have no such right !"
At last a thing came to pass, the bare recollection
of which plunges me into sadness and horror.
On the very outskirts of our town, in a tumble-
down cottage, dwelt a widowed washerwoman with
her three children. Two of these died in hospital
of scarlet fever, and soon after their death, her only
remaining child a gaunt, ugly boy of about eight
years of age sickened. His mother decided to
nurse him at home, unable to bring herself to send
him to hospital. She applied to me. Her boy had
the fever in a very bad form: he was delirious and
tossed about restlessly; his temperature was 105
Fahrenheit, and his pulse could hardly be felt.
After having examined the patient, I told the mother
that his recovery was very doubtful. The poor
washerwoman fell on her knees before me.
74 THE MEMOIRS OF A PHYSICIAN
"Oh, sir, save him ! He is the only one left me !
I was rearing him to be a support and comfort to
me in my old age. I will pay you all I can, I will
wash for you for nothing as long as I live!"
The boy's life hung in the balance for a week.
At last the fever abated, the rash grew faint, the
patient began to recover; and that sickly boy, with
ugly peeling face and apathetic stare, became dear
to me. His happy mother thanked me raptur-
ously.
A few days later the patient's fever returned, and
the right submaxillary gland became swollen and
painful. The swelling increased day by day. For
the moment no danger threatened; if the worst came
to the worst, suppuration might set in and an ab-
scess form. Still, I relished the possibility of such
a complication very little. If an abscess formed,
it would have to be opened; the incision would
have to be made in the neck, which contains a great
number of veins and arteries. I was afraid that
if I severed some important vessel by accident, I
should be unable to stop the haemorrhage. Hitherto
I had never touched the living flesh with my knife.
Of course I had seen the most complicated and diffi-
cult operations performed, but now, left to my own
devices, I was afraid of the slitting of an ordinary
gathering !
In the first stages of inflammation of the gland?,
treatment with grey ointment is very beneficial;
THE YOUNG PRACTITIONER 75
when applied in time it often arrests the inflamma-
tion before suppuration has had time to set in. Ac-
cordingly, I made up my mind to treat my patient
with the mercurial ointment.
The swelling was very painful and therefore I
rubbed the stuff in very lightly at first. Next day
the boy looked brighter, ceased to complain, his
temperature went down; he smiled and asked for
food. The glands were much less tender. I re-
peated my application of the salve, this time rub-
bing it in more vigorously. His mother almost wor-
shipped the ground I trod and bitterly regretted
that I had not attended her other children; she was
sure I would have saved them.
On coming to see the patient next day, I found
that an abrupt change for the worse had taken place.
The boy lay on his back with his head bent to one
side and moaned continuously; in the right supra-
clavicular fossa, below the original swelling, a large
new one stood out red and angry. I went pale and
began to examine my patient with throbbing heart.
The thermometer registered 103 Fahrenheit the
right elbow-joint was swollen and so painful that it
could not bear the slightest touch.
The mother, although much alarmed, followed
my movements with confidence and hope. ... I
went away utterly wretched. No need to break my
head it was as clear as day : my massage had driven
the pus all over the boy's system, general blood-
76 THE MEMOIRS OF A PHYSICIAN
poisoning had set in, and he was doomed to a cer-
tainty.
All day I roamed about the streets aimlessly,
plunged into a state of numb stupor: I could think
of nothing, and my soul was gripped by a feeling
of horror and despair. Every now and then the
thought: "Why, I have killed a human being!"
stood out in my consciousness with merciless vivid-
ness. Self-delusion was out of the question; things
could not have been plainer if I had deliberately cut
the boy's throat with my own hand.
The patient lingered for over a week; every day
new and new abscesses formed in his joints, in his
liver, in his kidneys. . . . He suffered unspeakably,
and all that could be done was to inject morphia.
I came to see him several times daily. When I
entered the room, I was greeted by the suffering
eyes and the drawn and darkened face of the child;
with clenched teeth, he groaned pitifully without
intermission. His mother already knew that there
was no hope.
At last, one evening, when I entered the hovel,
I saw my patient laid out on the table. 1 All was
over. . . . With a strange feeling of tortured curi-
osity I approached the corpse. The setting sun illu-
minated the wax-like pinched features of the boy.
His face wore an expression of sorrowful reverie,
1 In Russia it is customary to lay the dead out on a table cov-
ered with a white cloth. TRANSLATOR.
THE YOUNG PRACTITIONER 77
and his eyebrows were contracted. While I, who
gazed upon him, was his murderer. . . .
The bereaved mother sobbed in a corner. Dusty
cobwebs hung from the bare walls of that miserable
abode, the dirty earthen floor smelt of damp, all was
cold, cold and empty. With a lump rising in my
throat I went up to the mother and essayed to con-
sole her.
Half an hour later, as I was on the point of tak-
ing my departure, the washerwoman opened her box
and offered me a greasy three-rouble-note.
"Take it, sir ... for your trouble," she said.
"Oh, how you tried to save him, may our Mother
in Heaven bless you!"
I declined the fee. We stood together in the
semi-dark passage.
"It was God's will !" I murmured, looking away.
"His holy will. He knows best," she answered,
and once more her lips began to tremble and her
sobs broke forth afresh. "Oh, thank you, thank
you, sir, for having been so good to my boy !" . . .
And she tried to kiss my hand, still crying, thank-
ing me for my kindness and consideration. . . .
No! I would throw everything up, renounce all
and go to St. Petersburg to study further, even if I
starved in the attempt.
CHAPTER V
YOUNG DOCTORS AND TECHNIQUE
ON my arrival in St. Petersburg I registered for
the courses at the Helena Clinical Institute.
That institution is specially intended for medical
men who are anxious to perfect themselves further.
After a brief attendance, however, it was borne upon
me that I would derive but little from those courses,
for the system was identical with that existing at
the University; once more we were allowed to look
on ad infinitum and there the matter ended. I con-
sidered that I had done so quite sufficiently as it
was. These lectures are very useful to doctors who
have already been long in practice and accumulated
many cjuestions demanding an answer; but for us
beginners they were of small value : we chiefly stood
in need of hospital work under the direction of ex-
perienced mentors.
I began to hunt for a suitable position. I would
have been satisfied with the wretchedest pay, for
my ambition did not go beyond what would suffice
to keep me in bread and cheese and from sleeping
on the doorstep for I had no private means what-
ever.
I visited all the hospitals in turn, interviewed
78
YOUNG DOCTORS AND TECHNIQUE 79
all the chief-physicians; they received me with cold
nonchalant civility, invariably informing me with
a superior smile that there were no vacancies, ex-
plaining further that I was mistaken in thinking it
were possible to obtain a salaried hospital appoint-
ment for the mere asking. Soon I myself under-
stood plainly how naive such hopes had been.
In every hospital dozens of doctors work gratis;
those who aspire to the beggarly pay of house-
physician must wait from five to ten years; the ma-
jority do not even expect anything of the kind, and
give their services in exchange for that which their
colleges ought, but have failed, to supply. Various
corporations avail themselves widely of the advan-
tages to themselves resulting from such a state of
affairs, especially our municipalities, which accord-
ingly exploit the faculty to an incredible extent.
It is not the same everywhere, however. The
Copenhagen municipality helps to serve the ends of
medical education by liberally distributing appoint-
ments amongst young doctors in the city hospitals,
at the same time cutting down the term of service
to two years, so as to make room for fresh candi-
dates. Throughout France the municipal hospitals
likewise act in the same liberal spirit. While in
1894 one f the members of the Town Council of
St. Petersburg proposed that the salaries of the
physicians of the municipal hospitals be entirely
withdrawn, because there would always be a suffi-
cient number of applicants content to give their
services gratis. "Doctors," he declared, "ought to
be glad of being given mere access to the hospitals."
I gave up all hope of obtaining a salaried posi-
tion and entered myself at one of the hospitals as a
"Supernumerary." I often found myself in the
greatest want: in the evening I used to trim the
"fringes" of my trousers and mend the rents in my
boots with black thread ; I used to envy my patients
when ordering them extras, because I myself sub-
sisted mainly on bread and cheap sausage. During
those hard times I experienced and came to under-
stand a phenomenon which was formerly quite be-
yond my comprehension how one could take to
drink through hunger.
At that period, whenever I passed a public-house,
it had an irresistible attraction for me; at such mo-
ments I used to think that it was the height of bliss
to step up to the brilliantly illuminated bar, cov-
ered with tempting "zakouskas," and to toss off a
glass or so of vodka; strange to say, half-starved
as I was, the spirits attracted me more than the eat-
ables, although I was never a dipsomaniac. When
I had a rouble in my pocket, I could not resist the
temptation, and got drunk. Never before or after,
when I was properly nourished, did vodka have any
fascinations.
There was a great deal of work at the Infirmary,
and it was plain to me that my labour was simply
.YOUNG DOCTORS AND TECHNIQUE 81
indispensable to the hospital; the amiability ex-
tended to me, whereby I was "allowed" to perform
my duties, being of the same order as the philan-
thropy of the contractor who "gives bread" to his
workmen, only with this difference: the bare per-
mission to work was all the pay I received for my
services. When I returned home dead beat and
broken, after a sleepless vigil, and cogitated pro-
foundly as to the most nourishing dinner that could
be procured .for eight kopecks (4 cents), I used to
be seized with rage and despair: to think that in
return for this drudgery I could not even claim the
right to be decently fed! And I would begin to
repent having thrown up my practice and come to
St. Petersburg. Billroth says that only a doctor
without a drop of conscience can permit himself
without more-a-do to make use of the rights which
his diploma gives him. But who were to blame?
Not we! It was the public's fault that we had no
other alternative open to us so let them pay the
piper! I thought vindictively.
In addition to my regular hospital duties, I con-
tinued to attend certain lectures at the Clinical
Institute and also worked in other hospitals. And
everywhere the scant consideration given to our
doctor's diplomas, "with all the rights and privileges
appertaining to that calling according to the law,"
by the medical world, became more and more ap-
parent.
82 THE MEMOIRS OF A PHYSICIAN
At our hospital every prescription I wrote, every
diagnosis I made, was strictly controlled by our
chief house-physician for many a day. Everywhere
I was only allowed to prescribe for the patients and
to operate upon them independently, after the au-
thorities had become convinced in person of my
competence they ignored my certificates. At the
Nadejdensky Lying-in Hospital a doctor, desirous
of studying midwifery, for the first three months is
only allowed to examine the patients and to be pres-
ent at the operations; only at the close of this pro-
bationary term, on passing his "colloquium," is he
admitted to operate in person, under the supervision
of the resident-surgeon on duty. . . . Could con-
tempt for our "rights" go further? My certificate
declares me to be a fully qualified physician; the
law compels me, under pain of dire penalties, to
respond to the first summons of midwife in a diffi-
cult confinement case, while here I am not trusted
with the easiest child-bed, and it must be admitted
with entire justification.
"I demand," wrote the well-known German sur-
geon Langenbeck in 1874, "that every doctor called
to the battle-field should possess the technique of
operations as perfectly as a fighting soldier wields
his weapons." . . .
After all, who would think of sending into battle
soldiers who had never held rifle in hand and had
only seen others shoot? And, nevertheless, doctors
YOUNG DOCTORS AND TECHNIQUE 83
not only go to the battle-field, but enter upon life,
in the guise of clumsy recruits unable to handle
their arms.
The medical press of all countries exhausts itself
in its clamour for reform, which should render such
a crying contradiction impossible, but unavailingly.
How is this 4 ? I am absolutely at a loss to suggest
any explanation. Whose interests would suffer,
were the fact clearly established that practical
preparation is absolutely essential, if doctors are to
perform their duties conscientiously? Of course not
those of society, no more than of the faculty, which
is ever repeating to the public: "Pray understand
that we learn upon you, that we obtain experience
at the expense of your lives and healths!"
CHAPTER VI
THE ART AND INEVITABLE RISKS OF SURGERY
I WORKED indefatigably at our hospital, and
under the direction of my erder colleagues,
gained experience by degrees.
So far as that experience concerned prescribing
and treatment, things were fairly simple and went
smoothly enough; I prescribed or gave my orders,
and if I made a mistake, a senior comrade pointed
out the fact and I rectified my error. But matters
assumed a very different complexion when it became
necessary to attain either technical or operative skill.
Mere instruction did not suffice here: however ex-
perienced my mentor, that skill had to be acquired
by me personally. Only he who has the habit, can
operate with confidence and composure. But how
is this proficiency to be obtained if you have not
operated previously, were it even with faltering and
unsteady hand*?
In the middle of the late eighties the American
surgeon O'Dwyer invented a new method of treat-
ment for stricture of the larynx, threatening danger
to children suffering from croup. Formerly, in
such emergencies, it was usual to perform trache-
otomy: the windpipe of the patient was opened in
84
SURGERY ITS RISKS 85
front and a metal tube introduced into the orifice.
Instead of this sanguinary operation, so terrible to
the relatives of the patient and requiring chloro-
form and the assistance of several doctors, O'Dwyer
proposed his own method, which consisted of the
following: the operator inserts his left index into
the child's mouth, catches the epiglottis, and with
his right hand introduces, by means of a special in-
strument, a metal tube with an enlarged head which
he guides along his left finger into the child's larynx.
The tube is left there; its enlarged head reposes
upon the vocal cords and prevents it from slipping
into the windpipe; when required no further, it is
removed from the throat. This operation is known
under the name of "intubation," and by means of
it the most wonderful results are often attained, as-
phyxiation being immediately arrested. In diph-
theria cases it is employed more and more, displacing
tracheotomy, which is only resorted to now-a-days
upon those comparatively rare occasions when intu-
bation fails to answer.
As already stated, this salutary operation is both
simple and painless . . . when performed by a
skilled hand. Prolonged habit is necessary for the
introduction of the tube into the larynx of scream-
ing and frightened children smoothly and without
hitch.
In our diphtheria ward I worked under the direc-
tion of a colleague, Stratonoff by name. I had seen
86 THE MEMOIRS OF A PHYSICIAN
him perform intubation dozens of times and fre-
quently practised it myself upon corpse and dummy.
At last Stratonoff allowed me to try my skill on a
living child. The latter was a chubby little boy of
three, with sweet blue eyes. He tossed about his
cot fitfully, gasping for air, and his face was livid.
They brought him into the operating room, where
he was placed on a lounge and his arms pinioned.
Stratonoff opened his mouth by means of a dilator,
and a Sister of Mercy held the boy's head. I began
to introduce the instrument. The small and soft
larynx of the child jumped and throbbed beneath
my fingers and I could not make sure of its position.
At last I thought that I had found the entrance to
the larynx; I began to introduce the tube; however,
it was stopped by something and would not budge.
I pushed harder, but the tube would not move.
"Steady! I say, don't press, you can gain noth-
ing by employing force," remarked Stratonoff.
"Lift the handle a bit and slip the tube in without
any effort whatever."
Taking the intubator out, I began to introduce it
afresh; for a long time I continued to fumble about
in the child's throat with the end of the tube; at
last it found its way in and I removed the director.
The tortured and breathless child immediately spat
the tube out, together with some bloody saliva.
"You had inserted the tube into the gullet, not
the windpipe," said Stratonoff. "First locate the
SURGERY ITS RISKS 87
epiglottis, firmly press it forward, retain it in that
position and introduce the tube when the child sighs.
The main thing is to employ no force !"
Red and perspiring, I took breath and again pro-
ceeded with the operation, trying not to look at the
protruding and agonised eyes of the child. Its
larynx had become swollen and I found it still more
difficult to be sure of my whereabouts. Once more
the end of the tube was obstructed by something and
I could not resist the impulse to try and surmount
the obstacle by violence.
"No, I can't!" I declared at last, frowning, and
removed the guide.
Stratonoff took the intubator and rapidly put it
into the child's mouth; the boy struggled, his eyes
starting, his breathing was arrested for a second;
Stratonoff pressed the screw and deftly removed
the director. The characteristic blowing sound of
breathing through a tube became audible; the child
coughed, trying to eject the foreign body.
"No, my fine fellow, you don't this time!" said
Stratonoff, smiling and pinching the child's cheek.
Five minutes later, the little fellow was fast asleep*
breathing freely and regularly.
A difficult time dawned for me. It was abso-
lutely necessary that I should master intubation; at
the same time, all demonstrations and explanations
availed nothing, and my previous practice on the
dummy and corpse proved to be of small value. It
88 THE MEMOIRS OF A PHYSICIAN
was only after a week of failure that I managed to
introduce the tube successfully; and for long after-
wards, when about to intubate, I lacked the convic-
tion that I would be successful.
It would happen sometimes that after having tor-
tured the child and myself as well, in the end I had
to send for the house-surgeon, who performed the
operation for me.
All this was terribly hard, but I had no choice.
The operation was so obviously useful and salutary.
... I am conscious of this especially now that those
painful experiences are things of the past, and that
I can undertake to perform intubation at any mo-
ment and under any circumstances. Quite recently,
while on night duty, I had to perform it upon a
little girl of five; the day before, the tube had been
inserted, but she had coughed it out. She was car-
ried into the operating room and I began to prepare
my instruments. The little girl sat on the nurse's
knees, pale, with drops of sweat on her forehead and
an expression of that terrible depression which is
peculiar to those who are struggling for air. At the
sight of the instruments, her dull eyes brightened
slightly; she opened her mouth and kept stilh evi-
dently following my movements with timid and ex-
pectant hope. My heart contracted with a sweet
spasm of joy. Rapidly and dexterously, delighting
in my own skill, I introduced the tube into the little
sufferer's larynx. The little girl raised herself and
SURGERY ITS RISKS 89
sat up on the sofa, taking in the air with full and
greedy breaths; her cheeks regained their colour
and her eyes sparkled with happiness.
"That's right! You can breathe easier now,
can't you*?" I asked.
She silently nodded.
"Now then, dear, say 'Thank you' to the doctor,"
put in the nurse.
"Thank you!" came the grateful whispered
answer.
On returning to my room and lying down, I
remained awake for a long time. The darkness
seemed to re-echo that weak lisping "Thank you,"
and the happy childish face rose up before me again
and again. Yes, such moments soften the recollec-
tion of the hard road which it is necessary for us to
traverse and in a measure reconcile us to actuality;
without the bitter there could not be the sweet.
But still, those first ones who had to suffer for the
others' sake what cared they for the benefits to the
latter, purchased at the price of their own martyr-
dom?
Alas, this suffering is incalculable. How many
ruined lives lie in the wake of every doctor!
"Our progress is over mountains of corpses,"
sadly confesses Billroth in one of his private letters.
Most vivid of all stands out the recollection of
my first and only tracheotomy; that experience will
ever haunt me as a ghastly nightmare. I had often
90 THE MEMOIRS OF A PHYSICIAN
assisted at the operation, when carried out by my
colleagues, and had on numerous occasions per-
formed it myself upon the dead.
Finally, the day arrived for me to try my hand
on a living girl; in her case intubation had ceased
to help. One of the doctors administered chloro-
form, while Stratonoff acted as my assistant, ready
to come to my aid at any moment.
With the first incision I made in the white and
plump throat of the little girl, I felt that I was
powerless to control the agitation that possessed me :
my hands trembled visibly.
"Keep cool, all goes well," Stratonoff said quietly,
carefully seizing the fascia covered with blood with
his forceps.
"Retractors! There is the thyroid gland, detach
the fascia, proceed with a blunt edge ! There, that's
right."
At last I reached the windpipe with my probe,
hurriedly tearing aside the loose tissue and parting
the black, swelling veins.
"Have a care, don't press so," said Stratonoff.
"Why, man, you'll break all the cartilages of the
trachea at that rate! Don't hurry!"
The smooth gristly rings of the windpipe moved
regularly beneath my fingers with the child's respi-
ration; I fixed it with a retractor and made an
incision; the air began to whistle faintly through
the aperture.
SURGERY ITS RISKS 91
"Dilator!"
I introduced the latter into the incision. . . .
Thank God, it would soon be over ! But that char-
acteristic hissing sound, which shows that the air
has free egress, was absent.
"You have missed the right opening; you have
introduced the dilator into the mediastinum!" sud-
denly exclaimed Stratonoff nervously. I pulled the
instrument out and, with fingers trembling from
excitement, inserted it a second time, going astray
once more. I was losing my head fast. The deep
funnel-shaped wound kept filling with blood, which
a Sister of Mercy promptly soaked up with wads of
cotton-wool; the blood frothed at the bottom of the
wound from the air which escaped through the dis-
sected trachea; the incision itself was hideous and
jagged, while a little lower down yawned the aper-
ture caused by my clumsy introduction of the di-
lator. The Sister of Mercy stood by with suffering
face, and the nurse holding the little girl's legs bent
her head low, so as not to see. . . .
Stratonoff took the dilator from me and began to
insert it himself. For a long time he had great
difficulty in locating my incision, but finally suc-
ceeded : a hissing noise resounded and a fit of cough-
ing expelled drops of bloody slime. Introducing
the canula, Stratonoff bent down and began to suck
the blood out of the windpipe.
"Colleague, it is self-evident and needs no expla-
92 THE MEMOIRS OF A PHYSICIAN
nation," he said, when the operation was over, "the
incision ought to be made in the very middle of
the trachea, while you somehow managed to make
it at the side. And why on earth did you make
such a long cut*?"
"Why!" Upon the corpses my incisions were
of the proper length and situated exactly in the
middle of the windpipe.
The child developed diphtheria of the wound.
The dressing had to be changed twice a day, the
temperature keeping at 104 Fahrenheit. The tube
would not hold firm in the tremendous suppurating
funnel-shaped wound; it became necessary to stop
it tight with gauze, but even then the canula kept
its position badly. StratonofT used to do the dress-
ing. On removing it one day, we found that part
of the trachea had become mortified a most un-
fortunate complication. Deprived of its support,
when introduced into the incision the tube pressed
against the posterior wall of the windpipe, and the
child began to suffocate. Stratonoff placed the
canula in its proper position and propped it round
carefully with gauze and cotton-wool. The little
girl lay with dilated and suffering eyes, trying to
struggle from the nurse's grasp, kicking out franti-
cally with her legs; her face was puckered up from
crying, but no sound could be heard: when trache-
otomy is performed, the air from the lungs escapes
through the canula without reaching the vocal cords
SURGERY ITS RISKS 93
and the patient is absolutely dumb. The process of
dressing was very painful, but the weak state of the
patient's heart forbade chloroform.
At last Stratonoff completed his task; the little
girl sat up; Stratonoff scrutinised her narrowly.
"Breathing is still unsatisfactory," he said, knit-
ting his brows, and again began to readjust the
tube.
The child's face ceased to pucker; she sat still,
as if in deep thought, and motionlessly gazed into
the distance, over our heads. Suddenly a strange,
feeble, irregular grating sound became audible. . . .
The child was grinding its teeth with convulsively
set jaws.
"Deary darling, bear it a little longer, it won't
hurt any more in a minute!" said Stratonoff in an
agonised voice, tenderly stroking her cheek.
But the fixed stare of the poor mite never relaxed
and she continued to grind her teeth rapidly; her
whole mouth grated, as if she were crunching a piece
of sugar; it was a horrible sound, and my fancy
pictured her teeth reduced to a powder and her
mouth filled with a mass of bone-splinters. . . .
Three days later she died. I swore never again
to attempt tracheotomy.
But what did I gain thereby*? My comrades,
who had commenced work simultaneously with my-
self and who were no less tender-hearted, can now
save the life of a fellow creature, where I must stand
94 THE MEMOIRS OF A PHYSICIAN
idly by, helpless to assist. About eighteen months
after my first and last tracheotomy, while I was on
duty, a workman suffering from syphilitic stricture
of the larynx was brought to our hospital. The
contraction had been gradually developing during a
whole month, and for the last day or two the patient
had hardly been able to breathe. Wasted and hag-
gard, with his thin hair dishevelled, and a bluish
earthy complexion, he sat clutching his chest, breath-
ing with a heavy, rattling noise.
I sent for my colleague the assistant hous-
surgeon, and ordered the patient's removal to the
operating room.
The surgeon made a rapid examination.
"We shall have to perform an operation, cut your
throat open," he said.
"All right, all right! . . . Only be quick about
it, for God's sake," the patient muttered in deathly
trouble, nodding jerkily.
While the instruments were being prepared, he
was given oxygen to inhale.
"Now lie down!"
The patient crossed himself and, supported by the
assistants, clambered on to the operating table.
While we washed his neck, he continued to inhale
oxygen. I wanted to take away the tube, but he
held on to it supplicatingly.
"Only a little more, let me breathe the 'air* a
little longer!" he whispered huskily.
SURGERY ITS RISKS 95
"You've had enough! You'll be easy in a mo-
ment!" said my comrade. "Shut your eyes."
The suffering man once more crossed himself and
closed his eyes tightly.
The operation was performed under cocaine.,
After one or two incisions, I parted the edges of the
wound with my hook-retractors, the surgeon opened
the cricoid cartilage and fragments of bloody
phlegm flew out of the slit with the usual fit of
coughing. My comrade introduced the canula and
bound the wound up.
"It's all over!" he announced. The patient got
up, taking greedy and deep breaths; his face ex-
panded into an endlessly happy and perplexed
smile, and he shook his head with astonishment.
"Eh, haven't we fixed you up smartly, my
friend*?" laughed the surgeon. All around were
laughing, the nurses, Sisters of Mercy, the attend-
ants. . . .
In the meanwhile the patient, smiling as before,
in happy bewilderment, whispered something in-
audible and kept on shaking his head, lost in admi-
ration for the wonderful resources of our science.
Next day I visited the ward where he lay, to
see how he was getting on. He greeted me with
the same silly and pleased grin.
"How goes it?" I asked.
He nodded his head and made a comprehensive
gesture, to show how comfortable he felt. . . .
96 THE MEMOIRS OF A PHYSICIAN
I went away with a heavy heart : I could not have
saved him. If my colleague had not been at hand,
that man must have perished.
No, all my oaths were nonsensical ! It could not
be helped! What Billroth said was true: "our
progress is over mountains of corpses." There was
no other way. We had to study on, undeterred by
failure. . . . But that grinding of the little girl's
teeth resounded in my ears and I felt, with de-
spair, that I could not, / could not; that my hand
would never again be lifted for such another opera-
tion.
By what should one be guided under the circum-
stances'? Because I had run away, it did not mean
that the problem had been solved. Personally, I
might choose such a course, but what if all were to
follow suit 1 ? A certain old doctor, who was chief
of the surgical division of the Hospital of ,
used to tell me of the pangs he suffered when allow-
ing a young doctor to operate. "Of course, I can't
forbid it they too must learn ; but how can I tran-
quilly look on, expecting every moment to see him
blunder in the most damnable way with his knife?"
And he used to take away his junior's knife and
complete the operation himself.
Of course, this sort of thing is very conscientious,
but . . . but from others, from doctors who had
been under him, I heard that it was not worth while
working in my friend's division: he was a good
SURGERY ITS RISKS 97
surgeon certainly, but it was impossible to learn
anything of him. There is nothing strange in this.
A surgeon who is so careful of his patients cannot
be a good teacher. Here is another illustration of
the fact. A certain Russian doctor and traveller
relates his impressions of the great Lister, the in-
ventor of the antiseptic method: "Lister takes the
interests of his patients too near to heart and places
his moral responsibility in regard to each of those
upon whom he operates too high. Lister, accord-
ingly, rarely trusts his assistants with the binding
of arteries and, as a rule, he performs personally all
that is connected with the direct treatment of his
patients. Thanks to this, his junior assistants lack
operative skill." If the individual interests of each
patient are to be held paramount, of course this is
the only way to treat the matter. The same trav-
eller Professor A. S. Tauber, in giving his impres-
sions of the German clinics, remarks:
"A great difference is noticeable in the subsequent
progress of the wounds, when amputation has been
performed by the experienced hand of the professor
and when by his young assistants the latter often
bruise the tissues, crush the nerves, sever the muscles
too short off or else lay the arterial vessels bare of
their adventitise (external coat of the artery) too
high, all of which steps prevent rapid healing of
the stump."
But is it necessary to cite further proofs of such
98 THE MEMOIRS OF A PHYSICIAN
an obvious truth as that, which tells us that with-
out experience it is impossible to become a skilled
operator? How remedy such a situation? From
the doctor's point of view, it may be possible to
resign oneself to the inevitable, with the reflection,
that "such is fate there is no alternative!" But
when I think of the patient about to submit himself
to the knife of the surgical novice, on the point of
performing his first operation, I find that such argu-
ments cease to satisfy me, I am conscious that there
must be another way out of the labyrinth, which
ought to be discovered at any cost.
In the late "thirties" such a way out of the diffi-
culty was proposed by the eminent French physiolo-
gist Magendie. The latter was of the opinion that
a good surgeon of the anatomical theatre was not
necessarily a good operator. Until he had acquired
the faculty of operating with confidence he might
expect at any moment to make the grossest mistakes ;
and yet, although it ought to have been there from
the very beginning, if only the surgeon's education
had been better directed, that faculty could only be
attained through long practice. The chief fault
lay with the contemporary methods of teaching,
prevailing in the medical schools. The students
passed directly from dead nature to the living, and
were compelled to gain experience at the expense of
humanity, at the cost of the lives of their fellow-
creatures. Apart from man, there were creatures,
SURGERY ITS RISKS 99
whose lives were less precious, and upon which it
were permissible to perform initial experiments.
Magendie expressed the wish, that in addition to
the usual medical education, skill in operating upon
living animals should be required of all physicians;
for he who had familiarised himself with the above
kind of operation, could afford to laugh at those
difficulties which baffled so many surgeons of the
day.
There is nothing to prevent Magendie's advice
being followed; nevertheless, so far, it has not been
put into practice. When inventing some new op-
eration, the surgeon generally performs it on ani-
mals first. But so far as my knowledge goes,
nowhere in the world is experience in operating on
living animals held as a necessary qualification,
previous to the young surgeon being allowed to
operate on living man. As things now stand, our
surgical novices are even inexpert in operating on
the dead let alone the living body.
In the "thirties," the surgeon who studied anat-
omy invited derision. This is what Diffenbach, a
German professor of surgery, said of the young
French surgeon Velpeau: "He is a kind of
anatomical surgeon." "In Diffenbach's opinion,"
remarks Pirogoff, "that was the worst possible re-
commendation for a surgeon."
So much for the "thirties" ; but let me quote once
more from Prof. A. S. Tauber, whom I have al-
ioo THE MEMOIRS OF A PHYSICIAN
ready had occasion to mention. Speaking of mod-
em surgery, he says: "In Germany, it is usual for
the junior assistants in surgical clinics to learn
upon the living, not upon the dead. No one will
dispute that the warm blood flowing beneath the
strokes of the knife, or the contractions of the living
muscles during operations, develop in the young
surgeon intrepidity, presence of mind and confi-
dence, but, on the other hand, I believe that there
can be no doubt, that such practising of the inex-
perienced hand in operations upon living man is
inhumane and generally at variance with the aims
of the physician."
It appears to me that only the most strict and
systematic application of the rule recommended by
Magendie would save the patient to a certain de-
gree at least from the necessity of paying with
his blood, and even with his life, for the education
of skilled surgeons, but not entirely. For how
determine the precise moment when a surgeon has
become sufficiently expert? Where draw the line*?
In 1873 when in his prime and at the apogee of
his fame, Billroth wrote to one of his old friends, a
lady, thus: "I have many patients whom I have
operated upon and still more upon whom it will
be necessary to do so; they occupy all my thoughts
year by year, their numbers increase, and the burden
grows heavier and heavier. An hour ago I left the
side of an excellent woman upon whom I had op-
SURGERY ITS RISKS 101
crated yesterday a terrible operation. . . . With
what a look did she gaze upon me this evening!
'Will I live*?' I hope that she will live, but our
art is so imperfect ! I wish I had a century of ever-
increasing knowledge and experience behind me,
perhaps then I might accomplish something. But
as things are now our progress moves rather slowly
and it is so difficult to transmit to another that little
which one has attained oneself! The one that
receives must accomplish the most important him-
self."
Surgery is an art, and as such, demands, above
all else, creative power, and reconciles itself least of
all to cut and dried standards. Where standards
exist there are no mistakes, where creative power
comes into play errors are possible at every mo-
ment. A long apprenticeship of such mistakes and
false strokes evolves the master, and as before, his
road lies over "Mountains of corpses." . . .
While still a young "decent" (lecturer) of sur-
gery, the same Billroth wrote to his master Baum
about a certain patient, whom he had subjected to
forcible extension of the leg three times in the course
of the same week, without suspecting that the
capitulum of the tibia was broken. "The effect of
the extension upon the inflamed parts naturally
turned out extremely harmful; mortification super-
vened, followed by death. . . . That case was very
instructive to me because, like many others, it taught
102 THE MEMOIRS OF A PHYSICIAN
me what not to do. But of course, this is entre
nous."
The English surgeon, Sir James Paget, Bart.,
tells us of a like case in his own practice: "A
young man had a tumour removed from deep in the
back of his thigh, and at the end of the operation
I know not whether by myself or some one else, a
broad strip of plaster was put round the thigh com-
pletely encircling it, and over that for some further
means of security, a bandage. Next day the limb
was swollen, but apparently not much more than it
might have been swollen from ordinary inflamma-
tion following an operation. But the day after the
limb was swollen much more; and the day after
that, there was acute inflammation of all cellular
tissue about the wound ; and then came haemorrhage ;
and then the man sank and died. The sole cause of
his death was the strip of plaster which was put
round his limb and not removed for two days.
From that time to this I think no one ever saw me
put a strip of plaster round a limb unless spirally.
Small as such a thing may seem in the act of dress-
ing, it cost that man his life."
A vivid picture of the process necessary for the
development of experience is given by Pirogofl in
his "Annals of the Dorpath Surgical Clinic," which
were published in German towards the close of the
1 See "Clinical Lectures and Essays": "Calamities in Surgery"
(Clinical lecture, 1868; chapter ii. p. 51).
SURGERY ITS RISKS 103
"thirties" and in their day caused a great sensation.
With the frankness of genius he recounts in these
confessions of a practical surgeon, all the mistakes
and miscarriages for which he was responsible, while
in charge of the University Hospital.
That, which others only venture to mention in
private letters entre nous, was published in the face
of the whole world to the great confusion and
scandal of all. The lurid picture painted by him
was shocking in the extreme.
Yes, once more, all this is entirely unavoidable;
there is no other way. Things will have to remain
as they are : the torments of conscience must become
silent in the presence of the inevitable. And, never-
theless, I myself would on no account, of my own
free will, consent to become the victim of that in-
evitability, nor has any victim ever wished to repeat'
his experience.
Countless is the number of such cursed problems
in this terrible science of ours, in the pursuit of
which it is impossible to step without stumbling
against living man!
CHAPTER VII
IN MEDICINE NOTHING RISKED NOTHING GAINED
IN 1888 Professor Petrescu of Bucharest proposed
that croupous pneumonia should be treated with
very large doses of digitalis (tenfold of that cus-
tomary). According to his observations, which ex-
tended over a number of years, when this treatment
was employed the death-rate dropped from 20-30%
to 3%, the disease was arrested instantly and van-
ished "as at the wave of the magician's wand."
Petrescu's paper on his treatment, read before the
Parisian Academy of Medicine, attracted general
attention the results published were really most
striking. Other doctors adapted it and in most
cases were very pleased with the results obtained.
At that time I had the pneumonia ward of our
Infirmary under my care. Fascinated by the above
communications, I decided, with the permission of
the chief house-physician, to try Petrescu's method.
Only a little while before I had read an article,
which appeared in Bot kin's Hospital Gazette, by
Dr. Rechtsamer, dealing on the subject. Although
the author regarded Petrescu's hopes as somewhat
exaggerated, still he did not deny that the recovery
104
MEDICINE MUST RISK TO GAIN 105
of certain of his patients could only be ascribed to
the new treatment. In his opinion, it was recom-
mendable as a last remedy in grave cases affecting
old people and drunkards. "In none of my own
cases could I put a patient's death down to digitalis
poisoning," so the article ended.
An old house-plasterer, who had been suffering
from pneumonia for two days, was brought to my
ward; his entire right lung was involved through
and through, he breathed rapidly, groaned and
tossed about; his wife told me that he had been a
hard drinker from childhood. This was a suitable
case and I prescribed digitalis according to Petrescu.
In the act of signing my prescription I paused,
involuntarily struck by its extraordinary appear-
ance. It ran thus:
"R p Inf. fol. Digitalis ex 8.0 (!): 200.0
D.S. every hour (!) a tablespoonful."
This means a decoction of eight grammes of digi-
talis in two hundred grammes of water, while the
notes of exclamation were required by law for the
benefit of the dispenser: in common practice,
the greatest quantity of digitalis leaf, which may
be administered to the human being in the course of
the twenty-four hours, is put down at 0.6 grammes ;
those notes of exclamation showed the chemist, that
in prescribing my monstrous dose, I had not been
guilty of a clerical error, but acted quite consciously.
106 THE MEMOIRS OF A PHYSICIAN
I perused my prescription again and again. Those
notes of exclamation stared at me provokingly, al-
most insolently, as if saying: "Yes, you dare not
give a man more than six decimals of digitalis un-
less to poison him be your intent, while you order
thirteen times that amount!"
When I left the hospital the notes of exclamation
in my prescription still haunted me. I recalled Dr.
Rechtsamer's words: "In none of my cases could
I put a patient's death down to digitalis poisoning;"
but what would I do, if the sad necessity of "putting
a patient's death down to digitalis poisoning," were
reserved for me? Had I not dashed off those elo-
quent notes of exclamation with my own hand*?
Next day the patient was worse; he stared at me
dully with glassy eyes, the tip of his nose had as-
sumed a bluish tinge, his pulse, continuing rapid,
was fluctuating now. Was this in consequence of,
or notwithstanding the digitalis? The patient's
heart was weak and these phenomena might be as-
cribed to the course of the disease, which the digitalis
had been powerless to stem. But, on the other
hand what if this were owing to the drug? I did
my best to suppress such reflections : why, many had
tested the remedy and found it to be efficacious
and beneficial. So I renewed my prescription.
Two days later the old man died. The weakness
of the heart had ever been on the increase, accom-
panied towards the end by deafness. I stumbled
MEDICINE MUST RISK TO GAIN 107
up against his wife at the gates of the hospital; she
was in the act of leaving the mortuary chapel, mum-
bling to herself, her face and swollen eyes almost
hidden by her shawl. With an indefinable sensa-
tion of shame and fear I read the deceased's clinical
register over again: a minute description of his ill-
ness continued from day to day, showing its gradual
aggravation, the prescriptions with their glaring
notes of exclamation, and in conclusion a laconic
footnote by the doctor on duty: "The patient died
at 2 A.M."
Now I was at a loss to account for the mental
aberration which had prompted me to prescribe such
bold and unverified treatment. Possibly the old
man would have died in any case, but could I under-
take to affirm that his death had not been caused
by that monstrous amount of powerfully acting
digitalis, introduced by me into his system? And
at a time, too, when all the forces of his organism
were required for combating his disease.
Soon afterwards I read an article in the Physician
by Dr. Rubel, who, after carefully studying his own
experiments, those of Petrescu and of the latter's
disciples and partisans, proved irrefutably that
"Petrescu's treatment is obviously injurious and in
many cases threatens the patient's life; it only re-
mains to advise its complete discontinuation."
And I registered a vow in future only to employ
those remedies upon my patients, which had stood
io8 THE MEMOIRS OF A PHYSICIAN
ample test and left no room for doubt as to their
effects. The closer I became acquainted with cur-
rent medical literature, the firmer did this decision
become. An appalling state of affairs was revealed
to me. Each number of every medical journal
contained communications on dozens of new reme-
dies; and thus it went on, from week to week, from
month to month ; a gigantic, insane and endless tor-
rent, which bewildered the eyes: new doses, new
medicines, new methods of introducing them, new
operations and dozens, nay hundreds of human
lives lost and healths ruined. Some of these inno-
vations, like bubbles on the frothing surface of a
torrent, leaped up and immediately burst, leaving
behind one or two corpses.
Thus, for instance, in 1888 Dr. Rosenbusch pub-
lished an article in which he advocated the injection
of a solution of creosote into the lung tissue of con-
sumptives, which, according to his assurances, gave
the best results. Dr. Stakhewicz tried to apply this
method of treatment upon two of his patients; the
results speak for themselves: "The cough of the
first patient increased after the injection, and the
destruction of the left apex, into which the injection
had been made, proceeded with much greater rapidity
than before. Blood appeared in the sputum of the
other patient immediately after the injection and
next day an abundant haemorrhage supervened."
And creosote injections disappeared from the stage.
MEDICINE MUST RISK TO GAIN 109
Professor Mehring caused animals to inhale
pental and arrived at the conviction that it would
be a very good anaesthetic. This was followed by
Dr. Hollaender experimenting upon his patients
with the drug, and he obtained brilliant results with
it. At the Congress of Naturalists and Physicians,
held at Halle during September, 1891, he expressed
himself rapturously in favour of pental. He de-
clared that it had proved itself to be the best extant
anaesthetic for short operations, thanks to the cer-
tainty of its action, the absence of disagreeable
after-effects for the patient, and its entire freedom
from danger; pental had no ill-effects either upon
the cardial functions or those of respiration. So
pental became the fashion. Six months passed.
Then Dr. Haegler made the following communica-
tion: a strong man, to whom he had administered
the anaesthetic, developed dyspnoea and cyanosis,
which were finally succeeded by cessation of respira-
tion ; only the most energetic means of revival saved
his life. Two months more passed, and a lady died
at Olmiitz, after inhaling pental while having a
tooth drawn. About the same time the British
Journal of Dentistry published the following fact:
a young woman of thirty-three, suffering from tooth-
ache, died after inhaling ten drops of the drug.
Dr. Breier nearly lost a healthy little girl, whose
respiration and pulse ceased through inhaling pental.
Two of Dr. Sick's patients died from its effects
no THE MEMOIRS OF A PHYSICIAN
one a strong and vigorous man, the other a young
girl suffering from hip-disease, but otherwise sound
and healthy. Hardly a year and a half had elapsed
since Hollaender's first communication saw the light,
when Professor Gurlt read a paper at a congress of
German surgeons, in which he gave comparative
statistics of the mortality from different anaesthetics.
Supported by overwhelming statistical evidence, he
showed that while ether, laughing-gas, brom. aetyl
and chloroform produced one death in thousands,
pental gave one death for each 199 cases. Profes-
sor Gurlt concluded his report with the very sen-
sible remark, that in view of the data so far obtained
it became necessary positively to warn the faculty
against the employment of pental. And the ill-
omened compound vanished as swiftly as it had ap-
peared.
Has any one forgotten the triumphal flourish of
trumpets which announced the advent of Koch's
tuberculine, and its unfortunate exit*? Thousands
of tuberculous patients were injected with the cele-
brated lymph at the time. While two years later,
it became clear beyond doubt that nothing but mis-
chief could result from its use. 1
Such is the history of a few of those new remedies
which have, upon closer acquaintance, proved them-
selves to be worthless. However, the fate of others
1 The failure of Koch's tuberculine was due to ill-judged em-
ployment in unskilled hands.
MEDICINE MUST RISK TO GAIN 111
was very different: they emerged from trial, their
position assured and recognised by all, with their
indications and counter-indications strictly denned.
But even then, a heavy toll in human life and health
had to be paid.
A peculiar illness is frequently met with amongst
the inhabitants of mountainous districts goitre
(struma), when the thyroid gland, located about the
lower part of the throat, becomes enlarged. One of
the methods for treating goitre was the complete
eradication of the organ. This operation gave very
encouraging results : the patients left hospital in per-
fect health and their deprivation of the thyroid
gland seemingly had no evil effects. But in 1883
Professor Kocher of Berne published an article in
which he communicated the following: he had per-
formed complete extirpation for struma in thirty-
four cases and was very pleased with the results ob-
tained. But one day a medical friend told the
Professor of a girl under his treatment, upon whom
Kocher had performed the above-mentioned opera-
tion nine years previously, and advised the eminent
surgeon to examine her now. The tableau was a
striking one. The patient had a younger sister ; nine
years before both were so much alike that they were
often mistaken for each other. "In the course of
those nine years," Kocher tells us, "the younger sis-
ter developed into a blooming and pretty girl; the
one operated upon remained stunted and has the
112 THE MEMOIRS OF A PHYSICIAN
repulsive appearance of a semi-idiot." Such a reve-
lation prompted Kocher to enquire into the fate of
all those he had operated upon for this peculiar dis-
ease. In the case of the twenty-eight patients who
had undergone but partial removal of the thyroid
gland, all were found to be quite healthy; of the
eighteen who had been entirely deprived of that
organ, only two remained in health; the rest had
developed a peculiar complexity of symptoms, thus
characterised by Kocher: "the retention of growth,
the large head, knobby nose,-thick lips, clumsy body,
unwieldiness of tongue and thought, accompanied
by excessive muscular development all these un-
doubtedly point to the close relationship of the de-
scribed disease to idiocy and cretinism." Mark you,
the growth caused but little inconvenience to many
of those operated upon, and practically, the opera-
tion merely had the aesthetic in view ; the result, how-
ever, was idiocy. 1 Later the close connection be-
tween the above symptoms and the removal of the
thyroid gland the opinion held by Professor
Kocher was disputed; but, nevertheless, nowadays
no surgeon would ever venture to perform complete
extirpation, unless the disease of the gland threat-
ened the patient with unavoidable death.
In 1884, Koller introduced into general use one
of the most precious remedies which medicine pos-
1 The failure of the operation for the complete removal of the
thyroid was due to the fact that the para thyroid glands were also
removed.
MEDICINE MUST RISK TO GAIN 113
sesses cocaine ideal for local anaesthesia. Two
years later, Professor Kolomnin of St. Petersburg,
while about to operate upon a woman, introduced
into her rectum a solution of the alkaloid. Sud-
denly the patient went blue in the face, convulsions
seized her, and half an hour afterwards she expired
with all the symptoms of cocaine-poisoning. Profes-
sor Kolomnin went home, locked himself up in his
study and blew out his brains.
In the reperusal at the present day of the different
communications made on the employment of cocaine
during the first few years after its introduction, one
is struck by the excessiveness of the doses prescribed :
for example, Professor Kolomnin introduced about a
gramme and a half of the drug into his patient's
system, and such doses were not exceptional in those
days; Huseman considered that the fatal dose for
an adult must be "very large." The bitter experi-
ence of Kolomnin, as well as others, has taught us
that, on the contrary, the amount necessary is very
small; that it is dangerous to introduce more than
six-hundredths of a gramme of the alkaloid into the
human body; which quantity is twenty- five times
less than what the unfortunate Kolomnin admin-
istered to his patient.
Towards the close of the "eighties," Professor
Kast introduced sulphonal as an excellent and harm-
less soporific. Other doctors began to experiment
with the drug and found it was really a "harmless
114 THE MEMOIRS OF A PHYSICIAN
hypnotic which does not evoke any accessory ef-
fects" (Oestreicher). But barely three months
after the appearance of Professor Kast's article, Dr.
Schmei informed the medical world that two
grammes, given to an old man suffering from arterio-
sclerosis and subject to fits of angina pectoris, "were
terrible in their effect : shortly after taking the pow-
der a most acute attack of suffocation set in and
all night long these attacks followed each other at
intervals of a few minutes." Dr. Schmei accord-
ingly counselled circumspection, when prescribing
sulphonal in cases of angina pectoris and arterio-
sclerosis. Further observations showed that it
should be administered with great precautions in
cases of extreme ansemia, emphysema of the lungs,
acute melancholia and morphinism; and further,
that it is not safe to take it for a lengthened period
without break.
What was the price paid for this information?
In the course of five years following the first in-
troduction of the drug, Professor Lepine aggre-
gated the total number of fatal cases of sulphonal
poisoning, which appeared in the medical press, at
sixteen. . . .
Yes, certainly the deduction to be drawn from the
above was obvious enough. I was never to employ
a remedy which had not been thoroughly tested be-
forehand, or threatened my patient with the slightest
risk.
MEDICINE MUST RISK TO GAIN 115
About three years ago, I attended a certain lady
school-teacher suffering from phthisis. Just then
the news arrived that Robert Koch, who had con-
tinued to work upon his discredited tuberculine, had
improved and was once more employing it. My
patient consulted me as to the advisability of her
subjecting herself to treatment with the "purified"
lymph.
"Better wait a bit," I answered. "First let the
superiority of the new stuff over the old be es-
tablished!"
I had acted quite conscientiously, but could not
help wondering at whose cost would the right answer
be arrived at*? Somewhere, far away and beyond
my ken, the matter would be threshed out by ex-
periment upon the invalid, and if it proved a suc-
cess . . . why, I would avail myself of the result
and apply the new treatment to my own patients, as
I now employed such invaluable remedies as sul-
phonal and cocaine. But again, what would hap-
pen if all doctors regarded matters in the same way
as myself?
We still know very little of the human organism
and of the laws which govern it. In making use of
a new medicament, the physician can only foretell its
action more or less approximately. It may turn out
beneficial ; however, even if it were to work nothing
but harm, astonishment would be out of place; the
game being played in the dark, it stands to reason
Ii6 THE MEMOIRS OF A PHYSICIAN
that one should be prepared for all eventualities.
The chances of such surprises are limited to a certain
extent, thanks to the possibility of previously trying
the drugs on animals; this is a great help. But,
nevertheless, the organisms of animals differ greatly
from that of man, and we cannot draw unimpeach-
able inferences from these experiments. So man is
approached, although it is a secret to no one that
the remedy's efficacy beneficial or the reverse is
but a matter of pure conjecture; a greater or lesser
risk is always present. Expectations may often be
deceived, and what is more, in many cases this does
not at once become apparent: clinical observation
is laborious and complicated. Not infrequently the
action of the compound misleads one for a long time,
the favourable impression it created turning out
afterwards to have been merely due to self-sugges-
tion on the observer's part.
Because medicine did not hesitate to follow this
path, wrought with constant risks, upon which it
was forced to blunder in the dark, falling into error
over and over again, and then renouncing its mis-
takes, it gained most of those victories in which its
pride is fully justified. Without risks being taken,
no progress would have been made the whole his-
tory of medical science stands to prove this.
During the first half of the nineteenth century,
women were treated internally for tumour of the
ovarium. The experiments made for the removal
MEDICINE MUST RISK TO GAIN 117
of these growths by surgical means the dissection
of the abdomen (ovariotomy) ended so disas-
trously, that if I had been writing these confessions
fifty years ago, I would have adduced ovariotomy as
an example of unpardonable experiment upon the
human being. At that time there lived in England
a young surgeon, Spencer Wells by name. He had
had occasion to assist at ovariotomy, and his im-
pressions tended to show "that ovariotomy was not
a justifiable operation." Soon after, he took part
in the Crimean War, in the capacity of surgeon; he
saw many wounds in the abdomen and had followed
many such cases. He remarks : "When I returned
to London in 1856 I was certainly much less afraid
than before of abdominal wounds." He now be-
lieved that ovariotomy ought to give good results,
if the operation be properly carried out. At the
same time, it was held in such universal distrust that
in medical circles it had been dubbed "murderous,"
and the Crown lawyers openly declared that sur-
geons guilty of it ought to be prosecuted. Notwith-
standing this, Spencer Wells decided to chance the
risks as soon as occasion presented itself. He had
not long to wait, and performed his first ovariotomy.
The patient died. "I think," wrote Spencer Wells,
"it would be difficult to imagine a position more
disheartening than that in which I was placed when
making my trials of ovariotomy. The first attempt
was a complete failure, and strengthened not only
li8 THE MEMOIRS OF A PHYSICIAN
in the minds of others, but in my own mind, the fear
that I might be entering upon a path which would
lead rather to unenviable notoriety than to a sound
professional reputation. Everything was against
the venture. The medical press had denounced the
operation, both in principle and practice, in the
strongest terms. At the medical societies, the
speakers of the highest authority had condemned it
most emphatically." Still, undaunted, Spencer
Wells continued to operate, with ever-increasing suc-
cess. Opinion began to veer round little by little.
Finally in 1864 "ovariotomy was very generally
accepted as a legitimate operation and was, not long
afterwards, cited as a triumph of modern surgery."
It was in the "eighties" that Spencer Wells thus
spoke covered with world-wide glory, one of the
benefactors of humanity, thanks to whom the lives
of tens of thousands of women had been saved.
Who will dare to reproach him in his temerity'?
No one sits in judgment upon the conqueror.
A few years ago, when Behring introduced his
anti-diphtherial serum, Professor Pouriege, in draw-
ing attention to the unscientific way in which his
experiments had been conducted, laid stress upon
the hardihood required for the injecting of children
with the diphtherial anti-toxin, without being quite
sure as to the possible results.
However that may have been, the serum proved
highly beneficial (at least, thus it would appear
MEDICINE MUST RISK TO GAIN 119
so far), and we can only be grateful to its discoverer.
It would enter no one's head to enquire too closely
whether Behring could have nerved himself to use
his own child for a first experiment.
When, in his old age, Pirogoff developed cancer
of the upper jaw, Dr. Vivodtseff, who attended him,
begged Billroth to operate upon the great veteran
of Russian surgery. But on mastering the circum-
stances of the case, Billroth found that he dared
not take the risks. "I am no more the fearless and
bold operator you used to know in Zurich," he wrote
to Vivodtseff. "Now, when an operation seems in-
dicated, I always ask myself the following question :
'Would I submit to the operation I wish to perform
upon the patient*?' ' Must we infer that Billroth
used to perform operations on his patients which he
would not permit in his case? Certainly. Other-
wise we would not possess that series of brilliant new
operations which we owe to him.
So to act up to the motto, "only employ what
has been tested," which I had chosen for my own,
was not so simple and plain as had seemed at first
glance. As long as I applied the rule to myself
I found it to answer admirably and to be the only
admissible one; but when I tried to imagine all
adopting it, I saw that such a mode of action would
not only lead to the undoing of medicine, but to an
absolute absurdity. "You say," wrote the French
surgeon, Pean, recently deceased, "you say, that it
120 THE MEMOIRS OF A PHYSICIAN
is only permissible to apply to man remedies which
have been previously tried on man; but such a con-
tention contradicts itself; if medicine were to fol-
low it, to its misfortune, it would condemn itself to
the purest empiricism, to the most dogmatic tradi-
tion. Experiments upon animals would only serve
the purposes of speculative research; great benefit
would accrue to veterinary medicine, of course,
through these experiments, but human medicine
would be unable to utilise them."
In effect, what would medicine turn into then?
If new untried remedies could be used, it would
be impossible to renounce the methods already
tested; the doctor who did not treat syphilis with
mercury would be no less in the wrong, according
to such a standpoint, than the one who employed
some untried remedy for the same disease ; it requires
as much courage to discard the old, as to introduce
the new. At the same time, the history of medi-
cine tends to show that our science of to-day, not-
withstanding all its positive acquisitions, has been
enriched to use Magendie's expression chiefly
through its losses.
The inevitable result would not be far to seek:
practical medicine would become petrified until that
distant date when science had attained to a perfect
understanding of the human organism, the action of
each new remedy proposed being foreseen in all its
effects. But in the meanwhile, on every side we
MEDICINE MUST RISK TO GAIN 121
hear humanity cry: "Help us, why do you not do
more to help us 1 ?"
My position became highly anomalous. My as-
pirations did not seem to rise above the one desire
not to do the patient who sought my aid any harm.
At first glance such a rule would appear to be quite
elementary, requiring no further explanation; at the
same time, its systematic application would condemn
me to complete inactivity, render me utterly inca-
pable. Living man obstructs every path I would
take. If I were to turn back I might perhaps pre-
serve my peace of mind, but would be no nearer the
truth. And it is the same in all.
How define the limits of the permissible? I
leave some one else to give the answer. And it is
just at the present time that these questions have be-
come especially acute. The creation of bacteriology
was the crowning achievement of a great epoch of
capital discoveries in the province of medicine, and
a temporary lull has fallen. And as always hap-
pens at such times, empiricism rears its head and
practice is inundated with a sea of all sorts of rem-
edies. Without end and without a pause, the most
varied new chemical substances are offered to us
anesin, cosaprin, golocain, criofin, midrol, and thou-
sands of others; every thinkable bacterial toxin and
anti-toxin is injected into the patient, as well as
extracts from every imaginable animal organ; all
manner of operations are being invented both san-
122 THE MEMOIRS OF A PHYSICIAN
guinary and bloodless. Perhaps much of value will
remain behind, when this whirlwind has passed over
us; but the heart sinks at the thought of the price it
will be bought with and one pities sick humanity,
which, like a moth attracted by the flame, hurries
onward towards its own destruction, often against
the advice of us doctors.
One day, soon after my arrival in St. Petersburg,
I had occasion to visit an aged aunt, the widow of
a general officer. She began to regale me with an
account of her numerous complaints palpitations,
heart-burn, nervous tics, insomnia and the like.
"My doctor has prescribed a new medicine to help
me to sleep. The very latest! I suppose you don't
know it yet. . . . How do they call it*? Chlo-ra-
lose. . . . Not hydrate of chloral, that acts upon
the heart this is quite harmless; an improved
chloral."
She rose and fetched me a smart box of tabloids,
ordered for her by a fashionable physician, and, with
every sign of satisfaction, showed me the prescrip-
tion.
"Poor, poor thing!" I thought.
CHAPTER VIII
MEDICINE AN ART; NOT A SCIENCE
ON the eve of completing my studies at the Uni-
versity I gloried in medicine and my faith in it
was unbounded. Its scientific acquisitions were im-
mense ; a great deal of the human organism had been
placed within our reach and was perfectly under-
stood ; in time no mysteries would remain for us, and
the way to the attainment of our goal was sure. It
was with such a perfectly definite conception of
medicine, that I began practice. But here, at the
outset, I stumbled up against living man, and all my
preconceived views underwent a rude shock. "We
do not yet know the functions of this organ . . .
the action of such-and-such a remedy is not under-
stood by us yet . . . the causes of such-and-such a
disease are unknown" I read. What did Science's
great conquests avail, if we were surrounded by such
immeasurable horizons, where all was still obscure
and unexplained? What do I understand of the
patient's condition if I do not understand all, and
how am I to approach him*? The works of a time-
piece are incomparably more simple than the human
123
124 THE MEMOIRS OF A PHYSICIAN
organism, yet can I undertake to repair a watch un-
less I am familiar with its every part, down to the
most insignificant cog-wheel?
As on my first introduction to medicine, I was
once more struck by its endless imperfection of diag-
nosis and the unreliability and precariousness of all
its indications. Only with this difference: formerly
I was filled with a deep contempt for "those" who
had created such a poor science; while now its im-
perfections stood out before me as natural and in-
evitable, which was all the more sad, because they
affected human existence.
Confronted by the mysterious, inaccessible living
organism of which I understood so little, how could
I determine what living forces governed it, what
were the infinitely refined processes which were cease-
lessly in operation within it"? What was the es-
sence of the action of those medicines which we em-
ployed, wherein lay the secret of the germination
and development of disease? In the human organ-
ism Koch's bacilli call forth consumption; Loef-
fler's which are so similar in outward appearance
cause diphtheria. What was the explanation?
I inject a solution of apomorphin beneath the pa-
tient's skin : it circulates through his or her body in-
differently, but on coming into contact with an
emetic centre, causes nausea; I am not even vouch-
safed a hint as to the chemical affinities of the nerve-
cells of these centres and apomorphin, which on com-
MEDICINE AN ART
ing into contact with each other, call forth vomiting.
A young girl, suffering from migraine, applies to me.
What is migraine? When the fit is upon her, the
patient's forehead becomes cold, the pupils dilate;
the girl is ansemic; all this tends to show that her
migraine results from the irritation of the sympa-
thetic nerve, in consequence of general poverty in
blood. An excellent explanation, forsooth! For
why, and in what way, does anaemia call forth irri-
tation of the sympathetic nerve in this case?
Wherein lie, and what do the curative forces of the
organism, which battle with the disorder, consist in
those forces which I seek to strengthen? What
is the effect of that phenacetin and caffein which I
prescribe upon the spasm of the sympathetic nerve,
or of the iron in cases of anaemia? Thus it comes
to pass that the patient applies to me for relief,
which I undertake to give her and which, perhaps,
I may be successful in affording and at the same
time I understand nothing of her complaint and of
the way in which my physic will do her good.
I lack so much as a distant idea of the typical
processes, common to all human organisms; and at
the same time each and every patient rises up before
me in all the wealth and variety of his individual
peculiarities and deflections from the normal aver-
age. What can I know of these ? Two apparently
perfectly healthy people may get wet feet: the one
catches a cold in the head, the other develops acute
126 THE MEMOIRS OF A PHYSICIAN
rheumatism of the joints; why"? . . . The highest
dose of morphia is three centigrammes : an adult and
far from weak female patient received an injection
of five /^////grammes of the hypnotic and died; for
the explanation of such facts a special word exists in
medicine "idiosyncrasy," but that word gives me
no clue to the detection of such cases beforehand.
. . . The maximal quantity of chloral that may be
taken during the twenty- four hours, is five grammes :
recently a Dr. Davis communicated that a patient,
suffering from toothache, took sixty grammes of
chloral in the course of three days, without any in-
jury to health; in other words, he absorbed twenty
grammes in the twenty-four hours; and I have no
reason for doubting the truth of the statement. If
the author had written 160 instead of 60 I also
could not give him the lie direct so limited is our
knowledge of man in his peculiarities.
What means am I provided with by science for
penetrating the veil which envelops the living organ-
ism, for the discovery of its ills? Of course some-
thing is vouchsafed me. For instance, a patient
may be feverish, complain of pains in the joint, his
spleen and liver are enlarged. I take a drop of his
blood and examine it beneath the microscope : in the
midst of the blood corpuscles fine spiral creatures
rapidly wriggle about; these are the spirals of
relapsing fever, and I diagnose accordingly with
absolute assurance. If science gave me equally re-
MEDICINE AN ART 127
liable means for the distinguishing of all illnesses
and of all the peculiarities of each individual sys-
tem I should feel that I had something at least to go
upon. But in the overwhelming majority of cases
there is nothing of the kind present. I must draw
my inferences from the most trivial data, although
my patient's life and health may depend upon my
diagnosis. . . .
I was one day called in to attend an old maid of
about fifty, the owner of a small house in an un-
fashionable suburb of St. Petersburg. She lived in
three small, low-ceilinged rooms hung with holy
pictures and lamps, with an old friend of her child-
hood, crabbed, yellow and bony as herself, as sole
companion. The patient, who was of very nervous
and hysterical aspect, complained of palpitations and
pains in the chest; every day, at about five o'clock,
she experienced great shortness of breath and what
seemed to be difficulty in swallowing.
"Don't you feel as if you had a ball in your
throat when you swallow?" I asked, having in my
mind that well-known symptom of hysteria globus
l hystericus.
"Yes, yes, that's just how I feel !" exclaimed my
patient.
The most careful examination of both heart and
lungs showed them to be sound; it was plain that
this was a case of hysteria. I prescribed accord-
ingly.
128 THE MEMOIRS OF A PHYSICIAN
"But, doctor, do you think that I may die sud-
denly*?" she asked.
She then told me that she intended leaving the
house to her friend, as otherwise that small property
would pass into the hands of the only legal heir, her
brother, a rascal and a scamp who had fraternally
borrowed all her money without security, in all
about six hundred pounds, and now declined to re-
turn it.
"What a strange question to ask ! Who is to pre-
vent you from making your will?" I remarked.
"There is no immediate danger, but one never knows
what may not happen! You may as soon get run
over by a tram-car in the street. Of course it's al-
ways best to make one's will in good time."
"You are right, quite right!" she murmured
thoughtfully. "As soon as I am better I'll go to
the notaire"
This was at three o'clock. And at five, two hours
later, her companion rushed into my room sobbing,
and told me that her friend was dead: while in the
act of rising from dinner, she suddenly staggered,
went white, the blood gushed from her mouth and
she fell down a corpse.
"Oh, why, why didn't you tell us, doctor 1 ?" the
poor woman kept on repeating, weeping, gasping
and striking her side frenziedly with her clenched
fist. "I shall have to go begging now, the wretch
will turn me into the street !"
MEDICINE AN ART 129
Now that it was too late, I understood; the diffi-
culty in swallowing towards evening (after dinner),
which I explained as globus hystericus, was caused
by the swelling of an aneurism, in consequence of in-
creased pressure of the blood after partaking of food.
. . . But what good could such a late diagnosis do?
In such cases I used to give way to rage and de-
spair: what value could a science, that left me so
blind and helpless, have? Why, I felt like a crim-
inal and dared not face this unfortunate woman I
had made a pauper and at the same time, who
could lay the blame at my door?
And this feeling recurred the oftener as time went
by. Even when my diagnosis appeared to me to be
clearly indicated, as in the case just described, actu-
ality constantly showed me to be in the wrong;
and oftener still, I stood before the patient com-
pletely nonplussed from the outset: how was I to
draw any conclusion from the misty and obscure
indications with which his case furnished me"? And
for whole nights I would pace up and down my room
pondering upon the data, piecing them together, and
never arriving at any definite conclusion. When
ultimately I did diagnose, I could never shake off
the haunting thought: "What if my guess be
wrong? How am I to verify its correctness?"
And to think that I had to live my life through, be-
neath the depressing weight of such constant uncer-
tainty !
130 THE MEMOIRS OF A PHYSICIAN
But assuming that I had diagnosed the disease
aright, I now had to treat it. What guarantee does
science give me that the remedies it recommends
are really efficacious and to the point*? The action
of most of them is in the highest degree obscure to
us, and the indications to their application are most
empirically set down through clinical observation.
We already know, however, how unstable and de-
ceiving clinical observation is. A given remedy acts
excellently according to the unanimous testimony of
the profession, and in a year or two it is thrown
overboard as useless or even injurious. Koch's
tuberculine lorded it for two years they saw with
their own eyes what a "brilliant" effect it had in
combating tuberculosis !
In that infinitely complicated and obscure process
of which the life of the diseased organism consists,
thousands of factors are active the incalculable
malignant effects of the disease in question, the pa-
tient's surroundings, all the innumerable forms taken
by the curative and resisting forces inherent in the
human body and to all these is added a thousand-
and-first influence in the shape of the remedy pre-
scribed by the physician. How to determine what
its concise action may be*? The ancient Grecian
physician Chrysippus forbade food to the fever-
stricken, Diocippus allowed them no drink, Sylvius
made them sweat, Broussais bled them until they
MEDICINE AN ART 131
fainted, Currie placed them in cold baths and each
considered his method to be the most efficacious.
The physicians of the Middle Ages considered that
the employment of salves made from human dung
was a very good remedy for cancer. During the
eighteenth century the lancing of the gums used to
be repeated dozens of times upon infants to ease
their teething, it was even practised upon mites ten
days old; as late as 1842, Underwood recommended
the slitting of the gums right round, and insisted on
the incision being deep, to the very teeth, alleging
that "no injury to the latter need be feared." . . .
All this was very beneficial, according to the doctor's
opinion! . . .
I entered practice with a definite store of thera-
peutic knowledge, with which my university had
furnished me. What employment was I to give it?
Clearly I ought to apply it practically with cool
confidence. But no sooner did I try to do so, than
disenchantment set in. Decoction of senega is rec-
ommended for provoking cough, when it is neces-
sary to free the lungs from the loose phlegm filling
them. When I prescribed the leaf I used to try to
detect its action, but not in a solitary instance did I
feel justified in declaring that the physic had con-
duced to the increase of the patient's expectoration
by a single drop. . . . Perhaps iron would be pre-
scribed in cases of anaemia, but even when the pa-
132 THE MEMOIRS OF A PHYSICIAN
tient got better, I could never be sure that the im-
provement in his or her condition was in the slight-
est measure due to the tonic administered.
In fact, I was expected to believe, on hearsay,
that those, and many other remedies, acted exactly
in the way described such was the logical con-
clusion to be drawn. But science itself precluded
such faith by unceasingly undermining it. Ex-
amples are not far to seek. One of the drugs most
frequently given to phthisical patients, is creosote
and its derivatives. At the same time voices, grow-
ing ever more and more persistent, declare that creo-
sote is not of the slightest use, that it is merely a kind
of hall-mark for the consumptive. The funda-
mental rule of diet in typhoid requires that the pa-
tient be fed exclusively on liquid food; but now the
tide has turned, and a current of opinion, ever-in-
creasing in volume, declares that by so doing we pur-
poselessly starve the sufferer. 1 Arsenic is held to be
an invaluable remedy for many skin diseases,
anaemia, malaria; suddenly a medical journal of
reputation publishes the following remarks:
"What is most remarkable in the history of arsenic,
is the fact that it never lost its popularity amongst
doctors, murderers and horse-dealers. . . . Doctors
ought at last to understand, that arsenic gives then
1 To-day the patient is not fed exclusively a milk diet but is given
almost everything fed to a normal person except meat. This feed-
ing is in such quantities that the patient gains in weight rather than
loses.
MEDICINE AN ART 133
too little to warrant such eternal veneration. The
survival of the arsenic myth is the shame of our
therapeutics."
In the beginning, such unlocked for criticisms
simply bewildered me. What was I to believe?
And the conviction grew upon me, that I ought to
believe nothing, ought to accept nothing unchal-
lenged, ought to suspect all, discard all, and only
take back what my personal experience had shown
me to be efficacious. But in that case, where did the
medical experience of centuries come in, what value
could it have*?
A certain young doctor asked the great Syden-
ham, the "English Hippocrates," what books it was
necessary to read to become a good physician.
"Read 'Don Quixote,' my friend," answered Sy-
denham. "It is a very good book and I often re-
peruse it."
But this is awful ! This means that there can be
no tradition, no pre-emption of observation; "Learn
to study life without any prejudice, and each of you
learn from the beginning!"
Since Sydenham gave utterance to his pithy re-
mark, more than two centuries have passed. Medi-
cine has made gigantic strides, it has become in many
respects a science; but tremendous vistas still exist,
in which Cervantes, Shakespeare and Tolstoi, who
have no relationship whatever to medicine, remain
the best teachers.
134 THE MEMOIRS OF A PHYSICIAN
But once forced to distrust the experience of
others, dared I believe my own? Supposing that
I had, through personal experiment, become con-
vinced of the efficacy of a given remedy ; how was I
to say how it acted, and why it acted thus? So
long as its action was not fully explained to my
mind, there was nothing to guarantee that my sub-
jective impression was not an optical illusion. All
my previous scientific training protested against such
a crude and empirical mode of procedure, against
such groping about with shut eyes. But the op-
pressiveness of this state of affairs made itself felt,
by contrast, most acutely of all when I left the un-
stable and oozy ground of empiricism and emerged
once more upon the firm road of science. In ab-
dominal surgery there is always danger of septic in-
fection of the peritoneum; but I know what to do
to avert it: if I employ instruments that have been
boiled, if I carefully disinfect my hands previous to
operating, infection cannot take place. The proper
concave glasses must help the short-sighted indi-
vidual. A dislocated elbow, if there be no compli-
cations, must return to its socket, if the proper
manipulations be resorted to. In all such cases,
pre-emption is indispensable to the practitioner; one
has to read anc 1 know something besides "Don
Quixote." Of course, both error and progress are
possible in this sphere as well as elsewhere ; but mis-
takes will result either from my insufficient training
MEDICINE AN ART 135
or inexperience progress will be made by improv-
ing the older methods, not by repudiating them.
The future of our science is brilliant and indubitable.
Its attainments, up to the present time, serve to
demonstrate what it will arrive at in times to come :
complete understanding of the normal and diseased
organism, of the individual peculiarities of each
separate unit, a complete grasp of the action of every
remedy employed these achievements will go to
build up its foundations.
"When physiology," says Claude Bernard, "shall
have given all that we have a right to expect of it,
it will have become transformed into medicine,
which will then be a theoretical science; and from
this theory will be deduced, as in other sciences, the
necessary adaptations, i.e. applied practical medi-
cine."
But, alas, how immeasurably far removed are we
still from such an age! And this reflection led to
the ever more frequent recurrence of the question:
Until we arrive so far, what sense can there be in
the practice of medicine at all*? Wherein lies the
raison d'etre of this game at blind-man's-buff?
Why should society be deceived by a make-believe
"medical science'"? Let homoeopathists and their
kind devote themselves to that sort of thing they
who would compress the endless varieties of the
life-processes into one or two dogmatic formula!
Our task can only be one to work for the future,
136 THE MEMOIRS OF A PHYSICIAN
to try to know and conquer life in all its complexity
and breadth. In regard to the present, we can but
repeat the words of Averroes, an Arab writer of the
Middle Ages: "An honest man may derive pleas-
ure from the theory of the physician's art, but his
conscience will never allow him to pass on to medical
practice, however vast be his knowledge."
I sought solace from this thought each time that
I felt the impenetrable darkness in which I was
forced to work, owing to the imperfection of my
science, oppressing me too heavily. I perfectly well
understood that the idea was preposterous: the un-
systematic and doubting medicine of to-day no doubt
leaves much to be desired, but still it is of incal-
culably greater practical utility than all the systems
ever evolved by the human brain alone, or crude em-
pirical generalisations. Also, it is conscience which
prevents the physician from compelling the sick to
seek the aid of quacks and falling into the grasp of
the homceopathists, various pastors Kneip and other
charlatans. I must confess here, that I was ever be-
coming more and more convinced, in my inner con-
sciousness, of my utter personal disqualification for
the profession of a doctor, and that, in betrothing
myself to medicine, I had lacked the most distant
conception of that standard to which every physician
must come up. And it was with the above sophisms
as to the unfitness of the science of the day that I
sought to stifle this terrible thought.
MEDICINE AN ART 137
Thanks to the shortcomings of theoretical medi-
cine, as it stands at the present day, practical
medicine can only be an art, not a science. To pre-
cisely understand the significance of the above, it is
necessary to experience in person all that this in-
volves. Had I not examined the patient, who died
of aneurism, most conscientiously, applying all that
science demanded from me, to fall into gross error
nevertheless*? Had a born physician been in my
place, he would have diagnosed rightly : his peculiar
creative faculty would have discovered a mass of
impalpable symptoms which had escaped me;
through sub-conscious inspiration he would have thus
filled the void left by the absence of clearer indi-
cations, guessing what I was incapable of divining.
Only a man thus gifted can answer to the require-
ments of the ideal doctor, for talent is as necessary
here as it is to produce the true poet, artist or
musician.
Whereas I had imagined, when entering myself
at the Faculty of Medicine, that it was possible to
learn that art. ... I fondly believed that a certain
level of knowledge and a certain degree of mental
development were all that I required; that these
qualifications would enable me to master medicine
in the same way as any applied science, such, for
example, as chemical analysis.
When medicine shall have become a science in the
completest sense of the word, single, universal and
138 THE MEMOIRS OF A PHYSICIAN
infallible, its acquisition by the average man will be
possible. But at present it is as far beyond our
powers to learn medicine, i.e. the healing art, as to
become poets or actors at will. There are shoals of
excellent theorists, genuinely "scientific" medical
men, who are not worth a brass farthing in actual
practice.
But why should I have been entirely ignorant of
all this, when embarking on my studies'? Why was
I possessed of such a cloudy and perverted concep-
tion in general of what awaited me? . . . How very
simply everything came to pass! We handed in
our papers and certificates, were entered as students
of the Medical Faculty, and the professors com-
menced their lectures forthwith. And not one of
our preceptors opened our eyes for us as to the fu-
ture, no one explained what awaited us in our life's
work. l
While we ourselves imagined everything to be so
simple and so obvious! You examined the patient
and said: he (or she) suffers from such-and-such a
disease; he (or she) must take this or that, and such-
and-such treatment must be applied! The scales
had now fallen from my eyes, but the knowledge of
my mistake was bought at the price of seven of the
best years of my life.
I was utterly dispirited. Half-heartedly,. I still
continued in my duties, laughing bitterly in my soul
at the patients who were simple enough to apply to
MEDICINE AN ART 139
me for aid : they also thought, as I had done before
them, that he who had completed a course of study
at the Medical Faculty was a doctor. They knew
not that there were as few physicians in the world as
there were poets, that the ordinary human doctor was
an absurdity, while science remained in its present
state. And why should I continue in bondage to
this folly? I ought to get out! Anything rather
than remain in the false and criminal role of an im-
postor !
For two years this state of affairs dragged on.
Then little by little came humility.
It was true that science gave me less than I had
anticipated, and that I was no genius. But would
I be in the right if I renounced my diploma*? If,
at a given moment, art were to lack a Tolstoi or a
Beethoven, we could dispense with them; but the
suffering cannot wait; tens of thousands of Bee-
thovens and Tolstois would be necessary for the
satisfying of all their wants. And of course they
would never be forthcoming.
Things being so, were we average doctors so
utterly useless? For after all, if we regard the
matter in the abstract, science has added much to
its possessions at the expense of art, and year by
year its conquests extend. And in the province
of science, at least, we are masters. Even in the
rest of 'medicine we can be useful and accomplish
much on condition of rigid adherence to the old
THE MEMOIRS OF A PHYSICIAN
maxim, "primum non nocere" This must be our
first consideration. And in the next place we must
once and for all discard the notion that our work
consists in careless and unquestioning obedience to
the mandates of science. We must fully realise
how complex and responsible the work before us is,
must study each patient with an unrelaxed conscious-
ness of the novelty of his disease, work unceasingly
at self-improvement, never resting or pausing in our
quest for the truth.
All this is terribly hard and many may faint be-
neath the burden; but as long as I find strength to
bear it honestly, I have the right to remain at my
post.
CHAPTER IX
THE QUESTION OF VIVISECTION
IN those days of doubt and disillusion, I found
special solace in scientific work. Here, in pure
science, one had no need to grope about in obscur-
ity; it was possible to institute complete control over
one's every step, to verify each result obtained; here
reigned supreme those severe scientific methods
which medical practice set so contemptuously at
nought. "Better to add one tiny brick to the edi-
fice of the great medical science of the future,"
thought I, "than to carry water in a sieve by
striving to accomplish what is beyond my under-
standing."
Among other things, I pursued researches as to
the part played by the spleen in resisting infectious
diseases. Two monkeys of the Macacus species
were purchased by our laboratory, for inoculation
with relapsing fever. During the three weeks they
remained with us, before the commencement of our
experiments, I had time to become greatly attached
to them, especially to the male specimen, whom we
had named "Stepka."
Whenever I entered the laboratory, he used to
rush up to the front bars of his roomy cage, in ex-
141
142 THE MEMOIRS OF A PHYSICIAN
pectation of a present of sugar. After having fed
my pets, I used to let them out. The female
"Jilda" was more timid; she would run about the
floor clumsily, looking round at me in fear. If I
made a slight movement' she would turn and fly
back to the cage. Stepka, however, treated me
quite as a familiar chum. As soon as I sat down,
he would immediately clamber on to my knees and
begin to search my pockets, eyebrows lifted and his
large close-set eyes peering forth with comical seri-
ousness. Pulling my percussional mallet from my
breast pocket, he would set up a surprised cry, his
eyes open wide, and then commence to examine the
bright instrument with minute curiosity.
After having gazed his fill, Stepka would drop
the hammer on to the floor, and with the same mel-
ancholy seriousness, as if performing a necessary,
but very tiresome task, proceed with his search of
my person. Carefully taking me by the beard, he
would remove my glasses with his thin brown
fingers. . . . But all this soon palls on him.
Stepka climbs up on to my shoulder, sighs, looks
about him, then, espying a corked phial, of a sudden
quick as a dart springs on to the table his
favourite amusement is the uncorking of bottles.
Stepka quickly and neatly draws the stopper, stows
it away in his cheek-pouch, and tries to escape to
the ceiling via the blinds : he knows that I will de-
prive him of his prize. I capture him half-way.
THE QUESTION OF VIVISECTION 143
"Tsi-tsi-tsi !" he chatters with displeasure, draw-
ing in his head, screwing up his eyes and trying to
get away. I possess myself of his play-thing.
Stepka contemplates the scene sorrowfully. Sud-
denly his eyes brighten; he jumps on to the window-
sill and begins to chatter excitedly. Outside a cab
is drawn up in the street ; Stepka cranes his neck, and
stares at the horse with insatiable inquisitiveness.
I stroke him, but he removes my hand impatiently
with his own little paw, settles down more comfort-
ably and continues to scrutinise the horse. A dog
runs across the street. Stepka is all alert, the fur
on his neck and back bristling up, his eyes become
restless, and he again commences his chattering,
greatly excited, and peers first through one pane,
then through another. The dog runs away.
Stepka scampers across the long table, upsetting
glasses, and follows the dog out of sight, from win-
dow to window.
One might have passed whole hours in the rascal's
company without being bored. I felt that a bond
of common sympathy united us, and that we had
arrived at mutual understanding.
I did not like the idea of cutting out his spleen
myself, and a comrade performed the task for me.
When the wound healed, I inoculated Stepka with
typhoid. When I entered the laboratory now,
Stepka no longer rushed to the bars as of yore ; weak
and ruffled, he sat motionless in his cage, staring at
144 THE MEMOIRS OF A PHYSICIAN
me with strange darkened eyes; every day he got
worse; when he essayed to climb on to his perch,
his hands failed him, he lost his hold and fell to the
bottom of his dwelling. Finally, he became too
weak to rise at all; wasted, he lay still with grin-
ning teeth, and moaned hoarsely. And it was be-
fore my eyes that Stepka died.
An obscure martyr to science, he lay a corpse be-
fore me. I gazed upon that pitiful little body,
upon that pretty nai've little face, from which the
death-agony even had been powerless to efface its
customary serio-comic expression, and experienced
a most unpleasant feeling. To tell the truth, at
heart I was a little ashamed of myself. When I
recalled all his engaging little tricks and funny ways,
I could not drive away certain vague misgivings as
to whether my crime had been, after all, so very
many times less grave than if it had been per-
petrated upon a child 4 ? Such sentimentality, in re-
gard to the lower animals, strikes you as ridiculous*?
But are the criteria of sentimentality so very hard
and fast and immutable*? Two thousand years ago
how loudly would a Roman Patrician have laughed
at the sentimental person who expressed indignation
at his casting a slave, guilty of breaking a vase, to
the murense. In his eyes a slave was a "lower ani-
mal" too.
Descartes looked upon animals as simple auto-
mata, animated but soulless bodies; according to
THE QUESTION OF VIVISECTION 145
his opinion, there existed in them exclusively cor-
poreal, purely sub-conscious manifestations of those
emotions which we call spiritual. Malebranche
held the same views. "Animals," he said, "eat
without pleasure, cry without experiencing pain;
they desire nothing and know nothing."
Is it possible to accept such statements as these
nowadays? Leaving ordinary everyday observa-
tion, which cries aloud against such a blind theory,
out of the question, how can we, the followers of the
principles of evolution in natural science, acquiesce
with the above?
The only possible view to take seems to be that
expressed by Huxley, who held that the great doc-
trine of continuity did not permit us to suppose that
anything in nature could spring into existence spon-
taneously and without antecessors, without going
through a process of gradual transformation, and
that there could be no disputing that the lower verte-
brate animals possessed in a less developed form that
part of the brain which we have every reason to
believe to be the organ of our consciousness. And
therefore, that it was highly probable that the lower
animals possessed consciousness in proportion to the
development of their organ of consciousness, ex-
periencing, in more or less definite form, the same
emotions as we do ourselves. Once this is so, once
it be true that we are not divided by the rigid line
which we once imagined to exist, is such sentimen-
146 THE MEMOIRS OF A PHYSICIAN
tality so ludicrous, are these twinges of conscience,
which we experience when we make animals suffer,
so false*? For the sensation I experienced was very
much akin to the pricks of conscience. One of my
colleagues, a surgeon, was investigating the pecul-
iarities of abdominal wounds inflicted by fire-arms;
he sought to discover whether it were best to adopt
a waiting policy, or to proceed immediately to oper-
ate. His method was to discharge a revolver into
the stomachs of dogs, tied to boards, a few yards
away; then he either performed laparotomy imme-
diately, or else allowed his canine victims to remain
without operation. On entering his laboratory, one
was struck by the din of groans, barking and yelp-
ing, that filled the room; some of the dogs were in
their death throes, others lay still, whining feebly.
When I looked upon them, I did not feel merely
pained, as I used to in the beginning, when contem-
plating the sufferings of men under operations; the
sensation I experienced, when gazing upon the elo-
quent eyes of those dying dogs, ennobled by suffer-
ing and almost human in their expressiveness, was
that of malaise and shame. At such moments I
understood the mood of Pirogoff when an old
man.
"In my younger days," we read in his posthumous
memoirs, "I was pitiless to suffering."
"One day, as I remember, this indifference to the
agony of animals undergoing vivisection struck me
THE QUESTION OF VIVISECTION 147
with such force, that with my knife still in my hand,
I involuntarily exclaimed, turning to the comrade
who was assisting me : 'Why, at this rate one might
cut a man's throat.'
"Yes, much can be said in favour of and against
vivisection. There can be no doubt that it is an
important aid to science. . . . But science does not
entirely fill the life of man; the enthusiasm of youth
and the ripeness of manhood pass and another period
of life ensues, and with it an inner call for introspec-
tion; and it is then that the recollection of the vio-
lence used upon, the tortures inflicted on and the
sufferings caused, another creature, commence to pull
at one's heart-strings involuntarily. It seems to
have been the same with the great Haller; so it was
with me, I must confess, and in these latter years I
would never be able to bring myself to perform the
same cruel experiments upon animals which at one
time I carried out so zealously and with such non-
chalance."
None of this can be denied. Mais que faire?
To renounce vivisection were to place the future of
medicine in jeopardy, to condemn us doctors forever
to the uncertain and barren paths of clinical obser-
vation.
It is necessary to grasp fully the tremendous im-
portance of vivisection for science, to be able to
understand that there is but one way out of the
dilemma that of stifling the reproaches of con-
148 THE MEMOIRS OF A PHYSICIAN
science, of choking down pity and closing one's eyes
to the living agony of the animals sacrificed.
A violent agitation has been conducted in Western
Europe, for several decades, against vivisection, and
of late the campaign has been taken up in Russia
too. The anti-vivisectionists base their propaganda
upon an assumption diametrically opposed to the
principle I have just laid down: they aver that vivi-
section is entirely unnecessary to science.
But who are these persons who have taken upon
themselves the task of proving this assertion of
theirs? Clergymen, society ladies, statesmen, per-
sons entirely unassociated with science; they seek to
refute Virchow, Bernard, Pasteur, Robert Koch and
other colossuses, who carry science forward upon
their broad shoulders. What a gigantic absurdity!
Profound study and knowledge are necessary for
mastering the methods of science. How can the
uninitiated take upon themselves to judge in such
matters'? That they themselves should be uncon-
scious of this contradiction is impossible, and it is
easy to understand with what joy they acclaim those
savants who express themselves in sympathy with
the movement. A while ago, the anti-vivisectionists
made much of Lawson Tait, a very eminent practi-
cal surgeon, and of an entirely obscure as far as the
scientific world is concerned medical man, Charles
Bell Taylor. On November i6th, 1892, the above
mentioned Charles Bell Taylor, F.R.C.S.E. and
THE QUESTION OF VIVISECTION 149
M.D. Edin., delivered an address before the Medico-
Surgical Society of Nottingham, in condemnation of
vivisection. The address was circulated amongst
our anti-vivisectionists in a rather ungrammatical
translation, as a supplement to the Novoye Vremja
newspaper.
While reading this speech, one is aghast at the
mass of wilful misrepresentations with which it
teems, and the question involuntarily arises: can a
doctrine, which employs such brazen-faced methods
of public deception, have any vitality in it 4 ? Bol-
stered up by his authority as a specialist, and confi-
dent in the utter ignorance of his audience, Bell
Taylor stops at nothing. "It is true," he declares,
"that Harvey was a vivisector, but it is not true that
he discovered the circulation of the blood by means
of vivisection ; on the contrary, so long as he confined
his attention to vivisection he was continually
wading through blood, agony and torture, only to
arrive at doubt, uncertainty and contradiction."
Proceeding, Bell Taylor quotes Harvey's words:
" 'I was led to distrust the existing belief of the
course of blood by considering the arrangement of
the valves of the veins' " (which, of course could
only be studied on the dead body, adds the orator).
"It was plain that the common doctrine that the
blood moved to and fro in the veins outward from
the heart and back again was incompatible with the
fact of the direction of the valves, which are so
150 THE MEMOIRS OF A PHYSICIAN
placed that the blood could only move in one direc-
tion."
(We must here remark, that Harvey's celebrated
treatise on the circulation of the blood consists almost
entirely of descriptions of his experiments upon liv-
ing animals; we quote the headings of several chap-
ters of his treatise :
Chap. II. "Ex vivorum dissectione qualis sit
cordis motus"
Chap. III. "Arteriarum motus qualis ex vivorum
dissectione"
Chap. IV. "Motus cordis et auriculorum qualis
ex vivorum dissectione" Etc.) 1
"Koch's inoculations with tubercle," continues
Bell Taylor, "which were adopted from experiments
upon animals, have led to death from initial fever,
the infection of the whole system of patients, who
merely suffered from localised disease, and to failure
and terrible disappointment to patients subjected to
it." (It will be remembered that the address was
delivered towards the close of 1892, when there was
hardly any one left to defend Koch's tuberculine;
but Bell Taylor was discreetly silent on the fact that
it was through vivisection that Koch discovered the
tubercle bacillus, and that bacteriology, in its en-
tirety, was created, thanks to vivisection.)
1 See Exercitatio anatomica de motu cordis et sagulnis in anl-
malibus. Auctore Gulielmo Harveo. Lugduni Batavorum. 1737.
THE QUESTION OF VIVISECTION 151
And so on ad infinitum; his every assertion was
either a direct untruth, or a gross distortion of actual
fact. In the notes furnished below, the reader will
find a few more typical samples of anti-vivisectionist
literature ; the latter are culled at random from Eng-
lish tracts and pamphlets, which are everywhere
being circulated in thousands by the "Anti-vivisec-
tion Society." 2
Vivisection is indispensable to medical science
2 "... We have to consider the claims of vivisection to practical
results," says Dr. Stephen F. Smith in a paper read before the Na-
tional Individualist Club. "There appear to have been some. For
example, an American doctor shaved the fur from some animals and
placed them in a freezing temperature. They caught cold. We
learn from that to wear warm clothing in winter. Frogs have been
placed in boiling water. They endeavour to escape, showing that
pain is caused. We learn that we should avoid bathing in boiling
water, . . . etc. But here, as far as I can ascertain, the practical
result ceases. . . ." (See "Vivisection, An Independent Medical
View," by Dr. Stephen F. Smith, page 8, London, 1898.)
Agitators from the ranks of the laity adduce other arguments to
prove the uselessness of vivisection. "Vivisection is the arch-enemy
of science, whose teaching has ever been that Nature is one in es-
sence, and that her laws are harmonious and not contradictory; but
if her laws are not contradictory, how can it possibly be that what is
morally wrong should be scientifically right; that what is cruel and
unjust should eventually lead us to peace and health? . . ." (See
p. 6, "The Sanctuary of Mercy," by Mrs. Mona Caird, 1899.) And
this is what is said in the country of Darwin! . . . Sometimes God
is substituted for Nature. "I believe that the great Orderer of all
things is a Righteous, Holy, Merciful God ; and such a God could
not (I say it with all reverence), could not possibly have made His
world as that man should be obliged to seek for the remedies of his
diseases by tormenting His humbler creatures. I think it is a
blasphemous idea that such should be God's appointment."
Thus spoke Miss Cobbe, upon the occasion of the formation of the
Welsh Section of the British Union for the Abolition of Vivisection
in 1898. (See "Vivisection Explained," p. 6.) ... And so on
ad inf.
152 THE MEMOIRS OF A PHYSICIAN
only ignorant, or very unprincipled, people can deny
this. The foregoing chapters have shown how
manifold is the necessity of vivisection in our
science.
Previous experiment on animals furnishes at least
a partial guarantee that a murderous dose of a new
drug will not be administered to the patient, that
the surgeon will not attempt an operation without
previous experience. Further, it is no mere co-
incidence that criminal experiments on men have
been perpetrated most frequently in the province pf
venereal disease from which the lower animals are
entirely immune. But most important of all is the
fact, that without vivisection we are entirely de-
barred from understanding and grasping the living
organism. Let us take up any branch of physiology
or pathology and we shall see that nearly everything
of any importance has been discovered through ex-
periment upon animals. In 1883, in answer to
pressure brought to bear on the Prussian Govern-
ment by anti-vivisectionist agitators, the former ap-
plied to the medical faculties of the universities
throughout the country, with enquiries as to how far
vivisection was really necessary.
An eminent German physiologist, for an answer,
sent the Government Herrmann's "Handbook on
Physiology," having previously struck out all those
facts which it would have been impossible to es-
tablish without recourse to vivisection. According
153
to the German newspapers, "Herrmann's book,
thanks to such annotations, acquired the appearance
of a Russian newspaper after it had passed through
the censor's hands; more text was crossed out than
left untouched."
It is impossible to understand and know the living
organism without vivisection; and without its com-
plete and manifold comprehension, the supreme end
of medicine the succouring of the sick would be
unreliable and fallacious. In 1895 the well-known
physiologist, Prof. T. P. Pavloff, exhibited before
an assembly of one of the medical societies of St.
Petersburg, a dog whose nervus vagus had been
severed; thanks to his experiments upon this dog,
Pavloff had been enabled to decide several highly
important questions dealing with the physiology of
digestion. A writer in the Novoye Vremja vehe-
mently attacked the professor for his experiments.
"By whom was it required, and to what end neces-
sary, to sever the dog's nervus vagus? 1 Has actual
life ever furnished a case which could have sug-
gested the experiment to the disciples of science?
This is an extremely sad example of vivisectionist
zeal of the worst and most unscientific kind. . . .
This is a case, so to speak, of science for science's
sake. . . . When we contemplate these fine artifices
resulting from the straining and unnatural ingenious-
ness of the vivisector brotherhood, in juxtaposition
with the fact that most people die of ordinary colds,
154 THE MEMOIRS OF A PHYSICIAN
which the doctors are unable to cure, the raptures
of medical societies over an experiment with the
nervus vagus, savour uncommonly of sarcasm. . . .
They do not know how to cure or understand the
simplest diseases, and at the same time this vivi-
sectionist enthusiasm is assuming threatening dimen-
sions, and the unwisdom and the heartlessness of
the sapient butchers who stand at its forefront fills
us with disgust."
This is a typical argument of the man in the
street. "Why study the organism in all its func-
tions if one cannot cure a 'simple' cold*?" Yes, we
persevere in these researches for the sake of learning
how to cure a "simple" cold (which, by the way,
is far from being simple) ! "This is science for
the sake of science." . . . Science is only then sci-
ence when its pursuit is unfettered by any conditions
qf direct practical utility. Electricity remained for
a long time but a "curious natural phenomenon," de-
void of all practical importance. If Grey, Galvani,
Faraday, and a host of less distinguished investi-
gators, had not been guided by the principle of
"science for the sake of science," we should at the
present day have neither telegraph, telephone, Ront-
gen Rays, nor electro-motors. The chemist Chev-
reuil, out of a thirst for knowledge purely scientific,
discovered the components of fatty substances
which resulted in the manufacture of stearine candles.
However, we must give them their due; far from
THE QUESTION OF VIVISECTION 155
all the anti-vivisectionists base their opinions upon
such crude and ignorant tenets as these just ad-
duced. A number of them seek to base the whole
question upon foundations of pure principle; thus,
for instance, the English anti-vivisectionist Henry
S. Salt, author of "Animals' Rights considered in
Relation to Social Progress," says : "Let us assume
that the progress of Surgical Science is assisted by
the experiments of the vivisector. What then"?
Before rushing to the conclusion that vivisection is
justifiable on that account, a wise man will take into
full consideration the other the moral side of the
question the hideous injustice of torturing an inno-
cent animal." This is the only possible and fitting
position for the anti-vivisectionist to take up:
whether science can dispense with vivisection or not
does not concern him; animals are made to suffer,
and that settles everything. The question is plainly
put and there can be no room for any equivocation.
I repeat, that we ought not to ridicule the preten-
sions of the anti-vivisectionists the sufferings of
animals are truly horrible and sympathy with
them is not sentimentality; but we must bear in
mind that there is no "way round" where the build-
ing up of scientific medicine its goal the healing
of mankind is at stake.
In Western Europe the enemies of vivisection
have already obtained considerable restrictions of its
freedom. The Cruelty to Animals Act passed by
156 THE MEMOIRS OF A PHYSICIAN
the British Parliament in 1876 may be considered
the most important of such legislative measures.
According to this Act, only those who have obtained
a special licence thereto, have the right to experi-
ment on living animals (which authorisation, by the
way, is liable to be withdrawn at any moment). In
1885 the Austrian Minister of Public Education
issued certain regulations, according to which "ex-
periments on living animals may only be conducted
in the interests of serious investigation and only in
exceptional cases of the most pressing need."
In Denmark permission for vivisection is necessary
from the Minister of Justice (!). All such laws
create a most bizarre impression. To whom will
such licences be granted? Naturally to eminent
savants. But let us go back into history a little.
In the late seventies, in the obscure little German
town of Wollstein, a then entirely unknown doctor,
Robert Koch by name, through his experiments
upon animals, most minutely studies the biology of
the bacillus of anthrax and, thanks to these in-
vestigations, opens up broad prospects for the newly-
born and extremely important science of bacteriol-
ogy. It is very unlikely that that obscure provincial
doctor would have been able to obtain the necessary
licence. . . . To go into the question further, who
is to decide which experiments are "necessary" to
science and which are not? The Minister of
Justice *?. The idea is preposterous! The learned
THE QUESTION OF VIVISECTION 157
faculties'? But who does not know that academical
erudition is almost invariably a staunch adherent to
routine? When Helmholz discovered his law of
conservation of energy, the Academy of Sciences
he has told us so himself dismissed his work as
one consisting of "senseless and vacuous reasonings."
His investigations on the rapidity of transmission of
the nervous current were also greeted by the scepti-
cal smiles of those who then stood at the head of
physiology.
Has the anti-vivisectionist agitation any chance
of success in the future? I think that its success
has been hitherto due solely to the ignorance of the
public, and that in proportion to the lessening of
that ignorance it will fall further and further in
popular estimation.
The Cruelty to Animals Act was passed by the
British Parliament in August, 1876. A most auspi-
cious date ! It was just at that time that the Turks
were enacting their atrocities in Bulgaria, encouraged
by the friendly non-interference of Great Britain.
Is it possible that the frogs and guinea-pigs experi-
mented upon in the laboratories were more precious
and dear to the members of Britain's parliament,
than the Bulgarian women and children outraged
and slaughtered by the Bashibouzouki ? Of course
not. The explanation is far simpler: Parliament
saw that intervention in Bulgaria's cause was un-
profitable to England, but it did not realise the
158 THE MEMOIRS OF A PHYSICIAN
unprofitableness of placing difficulties in the way of
vivisection. For when nothing seems to threaten his
interests, man finds it easy to be upright and humane.
. . . Russian life furnishes us with still more vivid
examples of such seeming inconsistency. . . .
When men comprehend what they sacrifice in
depriving science of the right of vivisection, the anti-
vivisectionist agitation will be doomed to a natural
death. At one of the anti-vivisectionist Congresses,
the Bishop of Manchester, Dr. Moorehouse, declared
that he would "rather die a hundred times than save
his life by such infernal experiments" as those in-
flicted upon vivisected animals. Only the most in-
significant minority of men are capable of such con-
scious self-sacrifice.
CHAPTER X
THE UNCERTAINTY OF DIAGNOSIS
WHATEVER be the physician's limitations, the
health and life of man are entrusted to his
custody.
As the reader will recall to mind, as far back as
the closing years of my University studies, the slip-
pery, hard and dangerous way, which the imperfec-
tions of our science foredoomed us to tread, was
disclosed before me. One day our Professor of
Gynaecology entered the lecturing theatre with
sombre face, evidently upset about something.
"Gentlemen!" he said, "you remember the woman
suffering from endometritis, whom I demonstrated
before you ten days ago, and upon whom I performed
in your presence erosion of the uterus. Yesterday
she died of septic infection of the peritoneum. . . ."
The professor minutely detailed before us the
progress of the disease and the results of the post-
mortem examination. Apart from the abnormal
development of the mucous membrane, for the re-
moval of which curetting had been resorted to, it
turned out that in the thickness of the uterus a so-
called myoma was in existence a muscular tumour.
160 THE MEMOIRS OF A PHYSICIAN
Erosion of the uterus, in the presence of myoma, is
accompanied by grave danger, because mortification
readily sets in, followed by purulent decomposition.
In the present instance, the most careful inspection
of the uterus disclosed nothing to lead one to suspect
the presence of a myoma. Curetting was per-
formed which resulted in the patient's death.
"Thus, Gentlemen," continued the professor,
"there can be no doubt that the patient's death was
caused by our operation; without it she might have
continued to live for years and years, although not
without suffering. . . . Unfortunately our science
is not omnipotent. It is well-nigh impossible to
foresee such sad eventualities and we must be always
prepared for them. To guard against such errors,
Schultze recommends "
The professor spoke on for a long time, but I had
ceased to pay attention to him. His words seemed to
have hurled me from those skies whither my raptur-
ous enthusiasm in the progress of medicine had re-
cently transported me. Our professor, I mused, was
a specialist of European reputation, with talents rec-
ognised by all, and nevertheless he was not certain of
avoiding such terrible mistakes. How would it
fare with me, one of the herd, in future*? And for
the first time that future loomed up before me
scowling and ominous. I felt disconcerted and
crushed by the immensity of the responsibilities that
awaited me later on. Everywhere I found confirma-
UNCERTAINTY OF DIAGNOSIS 161
tion of the vastness of this responsibility. Taking
up a copy of the Therapeutic News one day, I
chanced upon the following lines:
"Binz communicates a case of abortion that took
place after five doses of natrium salicylicum, each
one gramme, had been administered. Arraigned in
court, the physician who had prescribed the medicine
was acquitted, on the ground that cases such as the
above had not as yet been published, although, as is
well known, the employment of natrium salicylicum
is largely practised."
This paragraph came under my notice accidentally
I might as easily have passed it by unread; how-
ever that might have been, henceforth, if anything
of the kind were to happen to me, I should have no
excuse: a precedent had already been established.
... I had to know all, remember all, be able to do
everything, no one enquiring whether the strength
of a single man were adequate to such a task !
But my buoyancy of spirit soon returned. So
long as I remained at the University, no responsi-
bility weighed me down. But when, as a full-
fledged doctor, I took up practice and became cog-
nisant of the limitations of my powers, in actual life,
I began to feel myself in the position of a guide
whose duty it is to conduct people through the night
along the slippery and crumbling edge of a precipice :
they trust in me and do not even suspect that they
are on the brink of an abyss, while I am ever in a
tremble, lest one of them should miss his footing and
topple over into space.
Often, when I had diagnosed a patient's com-
plaint, I positively could not make up my mind to
start treatment, and availed myself of the first pos-
sible pretext to abandon the case.
One day, at the outset of my practice, a woman
suffering from tape-worm came to me. The best
and most efficacious remedy against tape-worm is
extract of male fern. I refreshed my memory by
looking the matter up in my text-books, and read
the following: "The remedy (i.e. extract of male
fern) lost much of its old reputation, because it was
administered in too small doses. . . . But in pre-
scribing, great circumspection must be exercised:
large doses may have a poisonous effect." Thus
I was enjoined to exercise "great circumspection"
in prescribing the only efficacious quantity, which
should not be "too small." Under these conditions,
how on earth was I to exercise caution 4 ? I told my
patient that I could not treat her and that she had
better apply to another medical man.
She opened her eyes wide.
"I will pay you," she said.
"Oh, no, you misunderstand me. You see. . . .
One must give the business in hand one's undivided
attention, and at present I lack the necessary
leisure. . . ."
The woman shrugged her shoulders and went
UNCERTAINTY OF DIAGNOSIS 163
away. In the beginning I experienced the same
fears in the presence of nearly all of my patients,
and my apprehensiveness was further increased
through the sense of my undoubted inexperience:
it suffices us to recall the case of the washerwoman's
son.
But as time slipped by, habit developed little by
little; I ceased to be afraid of every little thing and
my self-reliance grew. I no longer suffered vain
tortures at the thought of all manner of complica-
tions every time I prescribed for a patient. But
nevertheless that sword of Damocles the possibility
of an "unfortunate accident," always kept me in a
state of nervous tension.
One never knows beforehand whence to expect,
and where to look for, those terrible "unfortunate
accidents." I remember how one day we had to
perform dissection of the elbow in the case of a
young girl of sixteen. I was to administer the
anaesthetic. And no sooner had I placed the
chloroform mask over her face, hardly had she drawn
breath one single inhalation of the anaesthetic
than her visage went blue, her eyes became fixed and
her pulse vanished; the most energetic measures of
re-animation proved unavailing; a minute before
she spoke, was agitated, her eyes shone with fear
and life and now she was a corpse ! In accordance
with the parents' wish, an official post-mortem
examination of the deceased was held: all her
164 THE MEMOIRS OF A PHYSICIAN
internal organs were found perfectly sound as
examination, previous to the administering of chloro-
form, had shown; notwithstanding all this death
had resulted from that terrible "idiosyncrasy" which
is the surgeon's bane and which it is impossible to
foresee. And the poor child's parents removed the
body, showering curses upon us.
I passed last summer in an out-of-the-way village
of central Russia. One day I was asked to visit a
neighbouring land-owner. I declined to do so point-
blank, for, worn out by over-work, I sought but one
thing complete rest to see no more suffering faces,
to find relief for my over-wrought nerves. It was
quite enough when the peasants applied to me, for I
had not the heart to turn them away.
But in the end, of course, I had to go. The
patient was a quiet, charming old man, a retired
lieutenant-colonel of the army, with white, tobacco-
stained moustache; he suffered from cirrhosis of the
liver and dropsy.
"I don't expect to get well, Doctor," droned the
old fellow in his slow, deep voice. "Time I quitted
the scene one ought to show a sense of decency.
But there's such a lot of water in my belly just
look at it quite a hay-stack I can hardly breathe.
My doctor taps me every month, but he's away just
now. ... So I took the liberty of bothering you.
I have all the necessary instruments in the house."
In such cases a special instrument, a so-called
UNCERTAINTY OF DIAGNOSIS 165
trocar, is used for the tapping of the liquid; it con-
sists of a fine straight metal tube containing a keen-
pointed stiletto. The abdominal walls are pierced
by means of the trocar, the stiletto is withdrawn
and the fluid escapes through the tube. This opera-
tion is entirely without danger : if the instrument be
introduced in the right way, no wounding of the in-
testines is possible. I let the liquid out.
A month later the old man sent for me again.
Once more I made the puncture: this time the fluid
was weakly tinted with blood; probably a small
vein had been pierced. Out of precaution I re-
mained with the invalid for an hour or so, but could
detect nothing to arouse anxiety. Early next morn-
ing I was suddenly summoned to the patient. Dur-
ing the night a rapid change for the worse in the old
man's condition had taken place; he lay in bed
motionless, deathly pale, with waxen face and barely
stirring pulse. There were all the symptoms of an
abundant internal haemorrhage. While I was
busied in preparing a physiological saline solution
for a subcutaneous injection, the patient died. It
was hard to say what had really happened. I was
not allowed to perform autopsy; the most likely
thing of all was, that the sharp point of the trocar
had penetrated an abnormally developed and senilely
degenerated branch of the epigastric artery, which
was located in an unusual position, and that during
the night some sharp movement of the patient's, or
166 THE MEMOIRS OF A PHYSICIAN
a fit of coughing, had increased the flow of blood,
which had been but insignificant at first.
His relatives ascribed the old man's death to the
natural course of his illness. I hated to keep silent
on the subject, I would have liked to tell them the
truth, to explain everything but what end could
my frankness have served*? So I drove off home,
without enlightening them.
Quiet, joyous morning lay over the dewy fields,
the sky resounded with the thrills of the lark, the
trunks of the slender birches stood out white against
the delicate green of the woods so pure, so serene.
. . . Was it possible that nowhere and never was I
destined to share in that happy untroubled restful-
ness?
In his "Lectures on Calamities in Surgery," Sir
James Paget, Bart., remarks: "I venture to say
that there is no surgeon in large practice, no surgeon
to a large hospital, who has not once or more in the
course of his life shortened patients' lives when he
was making attempts either to prolong them or to
make them happier. And this, you will observe, is
not merely the case with capital operations. When
a patient submits to a capital operation, it is always
in order to remedy something that will render his
life either very miserable or very short; and to escape
such distress, it is quite fair that a man should
seriously risk his life. But these calamities occur,
however rarely, in comparatively trivial cases, when
UNCERTAINTY OF DIAGNOSIS 167
the operation is not done for any consideration of
prolonging life, but, it may be, of making life some-
what happier, or somewhat more useful, as in the
amputation of a finger, the tapping of an ovarian
cyst, the tapping of a hydrocele, the division of a
cervix uteri. ... I have known deaths from all
of these, and if you were to go over the whole list of
so-called minor operations, you would find that every
surgeon of much experience has either had in his
own practice, or known in that of others, one or
more cases of each that have proved fatal. If any
man will remove with the knife, in a hundred
instances, cysts from the scalp, I will venture to
say that he will have one or two deaths. If any
man will take in succession an equal number of
cases of ligation of haemorrhoids, the probability is
that he will have one or two deaths." . . .
Nothing can save us from this.
A catastrophe may overwhelm you at any moment
and ruin you for life. In 1884, Dr. Spitzer, a
Viennese physician, attended a girl of fourteen,
whose fingers had been frost-bitten; he prescribed
collodion with iodine and gave directions that it
should be applied to the frost-bitten parts; the
child's little finger mortified and had to be ampu-
tated. The patient's mother sued Dr. Spitzer.
The defendant was mulcted in damages to the
amount of 650 Guldens, condemned by the Court to
a fine of 200 more and, in addition, deprived of his
168 THE MEMOIRS OF A PHYSICIAN
right of practice. The papers savagely attacked
Spitzer, showering him with gibes and loading him
with ridicule. This aroused great excitement in the
medical world. Spitzer had no grounds whatever
to expect that the application of innocent collodion
with iodine could have such a destructive action.
The defendant appealed to the Senate. The opinion
of the Medical Faculty was called into request.
Relying upon a report dealing with the subject
drawn up by the eminent surgeon, Professor Albert,
the Faculty unanimously declared itself as follows:
"The application of collodion-with-iodine-ointment,
as employed by Dr. Spitzer, did not result in
gangrene in a series of experiments especially con-
ducted by the Faculty. Neither science nor litera-
ture furnish us with any indications pointing to the
danger of employing the above remedy in general,
and in cases such as that under consideration in par-
ticular. Therefore no grounds exist for accusing
Dr. Spitzer of incompetence."
But Spitzer stood in no further need of this
acquittal^ On the very day that the Faculty's
verdict was made public, his body was recovered
from the Danube: he had drowned himself, unable
to support the weight of this universal condemnation.
Expect mercy of no one in such circumstances!
A doctor must be a god, infallible, superior to doubt,
to whom all is clear and all is possible. And woe
to him if it be otherwise, if he make a mistake, even
UNCERTAINTY OF DIAGNOSIS 169
though it were humanly impossible not to err. . . .
About fifteen years ago a "feuilleton" writer in the
Petersburg Gazette gave wide publicity to the fol-
lowing "revolting" case that took place in the surgi-
cal clinic of Professor Kolomnin. A boy, Kharito-
noff by name, "with a pain in the hip-joint," was
brought by his parents to the hospital; while being
examined by the assistant house-surgeon, Dr. T. (the
name was given in full), this is what took place:
"T. requested Kharitonoff to jump on his injured
leg; the patient declined to do so, assuring the worthy
medico that he could not stand on the affected limb.
But the ^Esculapius gave no heed to the wretched
youth's words and, with the assistance of those pres-
ent, made him jump. He did. A terrible cry rang
out and the unhappy boy fell into the arms of his
executioners: the bone had broken short off at the
hip." The patient developed sarcoma "with fright-
ful rapidity" and died "owing to the fault of his
torturers."
Dr. T. explained the true circumstances of the
affair in a letter to the editor. The boy complained
of pains in the joint, but there were no external
indications of any such affection; but there was
reason to suspect tuberculosis of the hip-joint. The
patient Kharitonoff could stand on the disease leg.
"I asked the patient to stand on the affected leg and
to jump slightly. This test, in cases of hip-disease
in its initial stages, when all other symptoms are
170 THE MEMOIRS OF A PHYSICIAN
absent, betrays the presence of the disease by a slight
pain in the joint." Fracture resulted. Such frac-
tures belong to the category of so-called spontaneous
fractures. As it afterwards transpired, the boy was
suffering from sarcoma of the bone-marrow; it had
corroded the bone from the inside and destroyed
its normal hardness; the first violent movement
sufficed to cause fracture; it would have occurred in
any case, whether at the hospital or on the patient's
way home. "To diagnose such disease, when the
tumour itself cannot be found, is difficult in the high-
est degree, and sometimes positively impossible. 1 ''
We may here add that the disease just described be-
longs to the number of very rare affections, as com-
pared with coxitis, which is exceedingly prevalent.
Dr. T.'s explanation called forth further con-
tumely on the "feuilletonist's" part. "Do you not
find it most wonderful !" he wrote. "A spontaneous
fracture! ... Is not this the apogee of untoward
coincidence, especially for us lay folks, whose lot it
is to hear for the first time of spontaneous, self-
acting, automatic fractures of arms and legs'? Only
these extraordinary cases enable us to appraise science
at its true valuation, and move us to bitter tears at
our own ignorance. . . . What are the uninitiated
to do"? Of course not argue with science ! All that
remains us is to hide our diminished heads in the
glorious presence of science and to assure ourselves
UNCERTAINTY OF DIAGNOSIS 171
without delay (through violent contact with any
hard object), quaking the while, that this species of
treacherous spontaneous fracture has not singled us
out unawares as its victims." And for an entire
week Dr. T. ran the gauntlet of universal newspaper
ridicule.
It is easy enough for outsiders to wax indignant
at such mistakes of the faculty. The tragedy of
our position lies therein, that were such a case to
present itself to any of us the day following, we
should be in duty bound to act in exactly the same
manner as just described. Of course the choice of a
much easier course were open ; no external symptoms
of injury to the joint are in evidence; there is a way
of finding out whether the trouble be tubercular; but
what if the affection proved to be sarcoma of the
bone and a fracture were to result 1 ? Truly, sarcoma
of the bone is so rare that an ordinary doctor is
liable to come across it three or four times during
his entire practice ; it is no less true that if treatment
of the tubercular joint be taken in hand without
delay, every hope exists for a complete and durable
cure ; but nevertheless . . . nevertheless, better steer
clear of rocks; better let the patient return home
and come again when undoubted external symptoms
have made their appearance. . . . The coward who
would act thus were unworthy of the name of
doctor !
-1 7 2 THE MEMOIRS OF A PHYSICIAN
The views on medicine held by society are very
erroneous here lies the main reason of the public's
unjust attitude towards the profession. Society
ought to familiarise itself with the scope of the
powers vested in the physician, and not blame him
for that which is the result of the imperfection of
medical science. If we were once to arrive so far,
the demands on doctors would be lowered to a rea-
sonable level.
However, on reflection, I doubt somewhat that
this would happen. Feeling lacks logic and declines
to countenance it. This was confirmed quite re-
cently by personal experience. My wife was
brought to bed, and labour being very difficult, an
operation had become necessary. All the accidents
that might be possible under the circumstances sud-
denly loomed up before me with cruel vividness.
"We must operate," the accoucheur said to me
with the utmost sang froid, in his everyday tone.
How could he speak of such a thing so coolly?
Why, he knew how numerous were the hazards which
threaten the mother during these operations; allow-
ing even that such occurrences were rare, still they
existed and were possible. Yes, I felt that he ought
to clearly realise what the loss of my Natasha would
mean to me, he ought to be absolutely sure of per-
forming the operation successfully. Otherwise the
whole thing was too terrible to contemplate. And
there could be no excuse for him, neither for him nor
UNCERTAINTY OF DIAGNOSIS 173
for science, if he failed. No, he dared not fail! I
was entirely carried away by this feeling and all the
reasonings of my intellect and knowledge were
powerless to affect me in the least.
CHAPTER XI
DOCTOR AND PATIENT
1HAVE already had frequent occasion to remark
upon the strong distrust of the Dublic mind
towards medicine and doctors.
Since time immemorial doctors have been the
favourite butt for caricature, epigram and anecdote.
The healthy speak of medicine and the faculty with
a smile, the infirm who have not derived benefit
from its ministrations criticise it with unmeasured
hatred. These sneers and this distrust disconcerted
me a great deal while I was a novice. I felt that,
at the bottom, both were well-merited, for there was
no denying that our science contained much of which
we well might be ashamed. Under the influence of
this feeling, in moments of expansiveness, I occasion-
ally felt inclined to ventilate my poor opinion of,
and contemptuous attitude towards, medicine.
One evening while staying in the country, I was
returning home from a stroll, when a peasant woman
came up and begged me to examine her and give
her some physic. I entered her cottage, accom-
panied by my cousin. The woman complained of
heart-burn, flatulency and vertigo, whenever she
174
DOCTOR AND PATIENT 175
stooped. So I examined her and told the good
woman to come round later on for some drops that
I would give her.
"What was the matter*?" asked my cousin, when
we had left.
"How do I know*?" was my smiling rejoinder.
"Now, that's funny! The assurance of your
manner led me to believe that you saw what was
the matter at a glance."
"I'll examine her again in a day or two perhaps
then I will be able to tell what ails her."
"Dear, dear me ! So much for your science !"
"Oh, yes, our science is pretty exact, as you see,
isn't it*?" I remarked. And I started on a recital
of numerous cases which demonstrated further this
"exactness" and illustrated the nai've way in which
patients looked up to us doctors.
This was by no means the only occasion upon
which I spoke of medicine in the same strain. Still,
notwithstanding the undoubted truth of what I said,
those conversations invariably left me with a feeling
of shame. Whenever I gave voice to such senti-
ments, for the time being I adopted the standpoint
of my listener in my appraisement of the facts, but
quand meme, at bottom my attitude towards medi-
cine was both earnest and full of reverence. Clearly
a deep misunderstanding underlay this. Medicine
does not justify all the expectations that are placed
upon it, and it is derided and discredited in conse-
176 THE MEMOIRS OF A PHYSICIAN
quence. But are such expectations either just or
legitimate? A science dealing with the cure of dis-
ease, which we style medicine, is supposed to exist;
those who have studied it are expected to recognise
at a glance and to cure all illnesses forthwith and
without fail. If they cannot do this, either they
must be incompetent, or else their science is a fraud
and a delusion. Nothing could be more natural
and, at the same time, more mistaken, than such a
view. A science answering more or less to the ideal
of perfection and completeness, whose business it
were to cure disease, is non-existent. Such as it is,
medicine is confronted by the human organism in its
endlessly complex and involved life; we have ar-
rived at understanding much of that life, but, at the
same time, each new discovery unravels further
before us its miraculous intricacy. Many diseases
develop in the system through dark paths that we
can but ill follow; obscure and intangible are the
combative powers of the human body ; no means are
known by which these forces can be sustained ; there
are other diseases more or less intelligible; but time
out of number they run their course so secretly that
science, with all the means at its disposal, is power-
less to detect them. Does this signify that doctors
are superfluous and that their science is utterly bank-
rupt? But we must not forget that, on the other
hand, there is much else that is actually within their
ken; the field where the physician can dispense con-
DOCTOR AND PATIENT 177
crcte help is sufficiently vast. No doubt he is often
powerless to give relief, but a doctor alone is com-
petent to judge of this not the patient. Even
when in the presence of such a case, the physician is
invaluable were it but for the reason that he real-
ises the complexity of the morbid process, whereas
neither the patient nor his entourage are able to un-
derstand it.
People lack even the faintest idea either of the
life-processes of their bodies or the powers and
remedies at the command of medical science.
From this spring the great majority of such mis-
understandings; here lies the cause both of blind
faith in the omnipotence of medicine and of the blind
disbelief in its efficaciousness. Both lead to equally
disastrous results. All manner of popular medical
books and pamphlets are disseminated amongst the
public. Every family, pretending to more or less
education, invariably possesses a medicine chest, and
before the doctor is called, the patient is sure to have
been consecutively dosed with castor oil, quinine or
salicylic acid. If people possessed a reasonable
understanding of elementary medical science, instead
of blind faith, nothing of the kind would be possible.
It would then be recognised that every new patient
represented a novel and unique illness, highly com-
plicated and involved, which even a doctor, with all
his knowledge, often finds it difficult to understand
fully.
178 THE MEMOIRS OF A PHYSICIAN
Suppose that a member of the family be consti-
pated he is given castor oil. Would any one dare
venture upon such treatment if he or she so much as
suspected that sometimes a man may be killed by this
means; that occasionally, for example in cases of
saturnine colic, constipation cannot be relieved by
castor oil, but only by ... opium?
The exaggerated demands made of medicine,
founded upon an ignorant belief in its omnipotence,
are the physician's bane and fetter him hand and
foot. A patient ill with typhoid suffers from high
fever, splitting headaches, night sweats; he is op-
pressed by delirium; these must be fought against
with great precautions, natural remedies being
chiefly recoursed to; but tell the patient that he must
suffer, bathed in perspiration and tormented by hal-
lucinations, he will turn from you and apply to a
medical man who will not stint him in quinine,
phenacetin and chloral. He says: "What doctor
is this who does not alleviate the patient's pain*?"
No matter that this assuagement is bought at the
price of the patient's strength : let the permanent ruin
of his constitution be the result, let him lose for all
days the power to combat disease independently; his
pain was soothed, and that sufficed in itself. The
most miserable patients in this respect are various
"exalted personages" impatient and spoilt, who
blame the doctor for the slightest malaise, even when
it is impossible to remove it, This explains why
DOCTOR AND PATIENT 179
many doctors, of whom their colleagues speak with
contempt, and to whom no medical man in his right
senses would ever dream of applying, enjoy the great-
est popularity with a certain section of the public.
People say that a doctor is a doctor who is able to
ease pain and cure diseases with facile confidence;
but actuality contradicts such an idea at every step,
and those who had hitherto blindly believed in
medicine, cast themselves into the other extreme.
Suppose that the patient suffers from a curable
complaint, but one requiring long and systematic
treatment; a week or two pass by without any
appreciable improvement, and the patient throws
over his medical adviser and applies to a quack.
There are certain protracted diseases for which no
efficacious remedies exist for instance, whooping-
cough; the doctor who has been requested to treat
this illness in a family for the first time, may rest
assured that his services will never again be in
demand in that quarter. All that the physician can
do is to keep an eye on the hygienic conditions,
and be on the alert to meet any possible complica-
tions; and it requires either deep and tried confidence
in the doctor, or else full understanding, to become
reconciled to his passive role.
But the richest soil of all for the flourishing of
this negation of medicine, is furnished by the pro-
fession's mistakes. A doctor diagnoses a disease as
typhoid, while autopsy discloses general tubercular
180 THE MEMOIRS OF A PHYSICIAN
infection shame upon the faculty! although the
clinical picture of both is often identical. I number
among my acquaintances a man who has suffered
for three years from severe pains in the knee: one
doctor diagnosed tuberculosis, another syphilis, a
third the gout; and neither of the three afforded
him any relief.
Of course, this only shows that very often the
manifestations of a disease are so obscure and vague,
that we have to depend on chance alone for hitting
upon the right diagnosis. But personal experience
is all to the individual, and my friend says : "Your
profession is as necessary to mankind as a neck-tie;
although entirely useless, conventional decency re-
quires that the civilised man should wear one. Ac-
cordingly, he uncomplainingly spends money on
cravats, and those who earn their living by making
them imagine that they are performing useful
work. . . ."
"I confess to you, Doctor, that I entirely dis-
believe in your medicine," a lady remarked to me
the other day.
She disbelieves in medicine. . . . But she is abso-
lutely ignorant of the subject! How can one be-
lieve or disbelieve in the importance of what one
knows nothing about?
A great deal of what I have said in the foregoing
chapters may breed scepticism in persons whose
faith in medicine had hitherto been blind. I ex-
DOCTOR AND PATIENT 181
perienced this scepticism myself, and lived it down.
Now, knowing all, I exclaim with conviction: "I
believe in medicine !" I believe in it, in the face of
its limitations. How could my attitude be other,
when every day of my life my training enables me
to save my fellow-creatures from death, when hourly
I see how those who renounce medicine compass
their own ruin?
"I don't believe in your medicine!" says my lady
friend. Perhaps it were as well to go to the root
of the matter and find out what she really does
believe in!
That it is possible to stop whooping-cough in a
couple of days, or that the timely application of
atropin, in certain ocular affections, can preserve
a man's sight 1 ? Neither in a couple of days nor a
couple of weeks is it possible to stay the natural
course of whooping-cough, but a few drops of atropin
may save a man from blindness, and he who "dis-
believes" in such truths is on the same mental plane
as the sceptic who is incredulous that there should be
parts of the world where the peasants speak French.
A man suffers for long years from asthma: I
cauterise his nasal conchils and he becomes well,
happy in the consciousness of his health. A boy is
slow and inattentive, lacks memory: I remove his
hypertrophic tonsils, and mental transfiguration
results. A child is exhausted by diarrhoea; without
any medicine, simply by regulating its diet and the
hours of its meals, I bring it back to plump health
and high spirits. Often my knowledge enables me
to ward off a serious illness by the timely prescrip-
tion of the most trivial dose of physic, the applica-
tion of the simplest treatment. And the more
profound the popular ignorance, the more vividly
does the importance of my knowledge stand out.
In those difficult and involved cases which required
the expenditure of a large amount of mental and
nervous force, the enjoyment of the sweets of
triumph was especially keen, and one fully realised
the absurdity of the idea that it would have been
possible to accomplish anything without scientific
training. . . . No, I repeat that I believe in medi-
cine, and I deeply pity those who do not.
The jeers at its expense are born of its deriders'
ignorance. Still, there is no denying that in many
cases we are impotent, ignorant, and even dangerous,
although the fault is not ours; but it is just this
seeming contradiction which breeds unbelief in our
science and gives rise for this ridicule of ourselves.
These jeers and this distrust being unjustified and
unreasonable, the question naturally arose: what
should my attitude be towards my patients'? Of
course, honesty in my dealings with them should be
my first consideration. It was just because we our-
selves withhold from them the true extent of the
knowledge at our command that the hostile and
ironical feeling towards ourselves, which we invari-
DOCTOR AND PATIENT 183
ably arouse, is made possible. One of Tolstoy's
chief artistic merits lies in his strikingly human and
earnest treatment of every one of the types he paints ;
he makes but one a notable exception to this rule
when he deals with doctors; Tolstoy cannot
describe them without irritation and an almost
Turgenev-like wink to the reader. Evidently there
is something, an indefinable "something" which
prejudices us in all eyes. And I fancied that it
must be this cloaking of ourselves in a kind of
nebulous mantle of mystery, the exaggerated con-
fidence and expectation that we excite towards our-
selves. Plainly this had to be remedied. But life
lost no time in upsetting such a notion. Things
could not be changed. Here is an example. I
attended a certain government clerk, suffering from
typhoid; he was constipated, his abdomen was
greatly distended. I prescribed calomel in the usual
laxative dose and with all the customary precautions.
"Doctor, some sort of complication has set in in
my husband's mouth," his wife said to me, when I
paid my next call.
The patient complained of an abundant secretion
of saliva, his gums were red and swollen, his mouth
emitting a disgusting odour; everything indicated
the typical symptoms of a slight mercurial poisoning
caused by the calomel I had prescribed. No reason
existed for the slightest self -accusation. I had
taken absolutely every measure of precaution.
184 THE MEMOIRS OF A PHYSICIAN
What could I say? Was I to tell them that tak-
ing my medicine was the cause 4 ? Nothing could
have been more idiotic. For I would merely have
shattered my patient's confidence, no useful end
being attained thereby, and in future he would an-
ticipate some catastrophe from my every prescrip-
tion. So I wisely held my peace, evading the eye
of the patient's wife, and listened to her remarks
upon the wonderful variety of complications in
typhoid with unruffled composure.
Another time I was called to attend a child that
had suddenly been taken ill; it was feverish but
made no complaints, nor were there any definite
symptoms present; nothing could be done until
further developments showed themselves. I did not
care to prescribe ut aliquid fiat, so I told the mother
that certain general hygienic measures should be
taken, but that no medicines were necessary. The
child developed meningitis and died, the mother
bitterly blaming me for its death, because I had not
"stopped" its illness in time.
Again, could I "be honest" with incurables? In
their case it is ever necessary to play the hypocrite,
and to lie; one has to tax one's ingenuity again and
again in making up all sorts of fictions, so as to
sustain the sufferer's drooping spirits. The patient
is conscious of the deception at least to a certain
extent and regards the doctor with sentiments of
indignation he would like to relegate medicine to
DOCTOR AND PATIENT 185
the blackest depths of hell. . . . How should one
comport oneself under the circumstances'? ... In
such matters the ancient medicine of India was sin-
cere and cruelly frank: it only busied itself with
hopeful cases; the incurable had no right to its min-
istrations; his relatives conducted him to the banks
of the Ganges, filled his nostrils and mouth with
the sacred mud and cast him into the river. . . .
The invalid loses his temper when the doctor does
not tell him the truth. Oh! all that he wants to
know is the truth ! At first I was na'ive and youth-
fully direct enough to acquiesce when the patient
was persistent; only little by little did I realise
what was really meant, when he desired to know
the truth, declaring that he did not fear death.
The real interpretation of such words was to be
read thus: "If there be no hope, lie to me with
skill, that I should not doubt the truth of your
words for a moment."
It is necessary in medical practice to be an actor
everywhere and at every step. This is of the last
importance because disease is not only cured by
medicines and special treatment, but by the patient's
spirits as well; a cheerful and hopeful mood is an
immensely powerful factor in the struggle against
sickness, and its importance cannot be over-esti-
mated. The patients whom I attended habitually,
who warmly believed in me and would summon me
from the other end of the town, derived much
i86 THE MEMOIRS OF A PHYSICIAN
greater benefit from my treatment than those who
applied for the first time; and in the beginning this
was a source of surprise, for I merely saw an amus-
ing coincidence in the fact. It was only by degrees
that it dawned upon me that this was no sport of
chance, that I was really powerfully reinforced by
the confidence I had won : the energy of both patient
and his entourage was wonderfully buoyed up
thereby. The sick stand in pressing need of this
faith, detecting with fine instinct any note of doubt
or vacillation in the doctor's voice.
And in the sick-room a deportment breathing calm
confidence came to me as a second nature; I issued
my orders in an authoritative tone, brooking no
contradiction, although a thousand doubts might be
assailing me internally.
"Wouldn't it be better to try ?" queries the
sceptical patient.
"I must beg you to do exactly as I tell you," I
remark categorically. "Only on this condition can
I treat your case." And my whole tone implies
that I am in possession of supreme knowledge, to
doubt which would be a gratuitous insult.
Do not think that it is sufficient to win this con-
fidence once; the struggle for its maintenance must
be unceasing. The patient's illness is prolonged;
one must keep a sharp eye on his psychical state as
well as on that of his relatives; at the first sign of
their losing heart, it is necessary if only in out-
DOCTOR AND PATIENT 187
ward appearances to change the treatment, pre-
scribe some new mixture, change the dose; one has
to take a thousand trivialities into account, straining
all the powers of one's imagination, finely studying
the character and taking stock of the mental devel-
opment of the sufferer and those about him. What
I had originally imagined to be the work of the
doctor, the pedantic carrying-out of the cut-and-
dried ordinations of medicine, proved to be very
remote indeed from all this. A Turkish physician
of the people, a hadja, prescribes for his patient,
hangs numerous amulets and finally blows upon
him; everything depends upon the last act: only a
hadja endowed with a "good breath" can treat the
sick. The same "good breath" is required of the
bond fide doctor too* He may be gifted with a
magnificent talent of discrimination, be capable of
discerning the finest details of the action of his pre-
scriptions and all this will avail him nothing, if
he lacks the qualities necessary for the conquest and
subjugation of the patient's soul. Of course, there
are truly educated patients who do not stand in need
of this "good breath," who set a higher value upon
talent and knowledge and do not fear the naked
truth. But such patients are as rare amongst men
as genius itself.
CHAPTER XII
THE DOCTOR AND THE POOR
IT took me a long time for my mental focus to
adjust itself to view the powers vested in medi-
cine in their true proportions and to recognise the
limitations of the latter. When in the presence of
a patient to whom I was powerless to give relief, I
used to feel distressed and ashamed; standing before
me, sullen and despairing, he was a living incarna-
tion of heavy reproach to that science which I rep-
resented. And again and again maledictions would
rise up in my breast at the impotence of this science.
". . . Was hab' ich
. . . Wcnn ich nicht alles habe." *
To this one I could bring relief, this one was be-
yond my aid; nevertheless all of them flocked to
me, all burned with the same desire to get well, all,
with equal right, expected salvation at my hands.
The cries of despairing anguish that fill the intimate
correspondence of the mightiest representatives of
the profession are very human and intelligible.
And the greater the man, the more acutely is he
i "What have I, if I have not all?"
1 88
THE DOCTOR AND THE POOR 189
made to feel his own helplessness. "Out of all my
work, my lectures alone interest me and retain their
life," wrote Botkin 2 to his friend Dr. Belogolovy.
"The rest I drag along as a man on the towing path
drags his rope, prescribing a mass of superfluous
medicines. This is no empty phrase, and will help
you to understand why my practical work in my
polyclinic oppresses me so. Having a tremendous
number of chronic cases under my observation, I
have begun to realise with sadness how impotent
our therapeutic remedies are. Hardly a polyclinic
passes without the bitter reflection : 'why had I taken
money from half the patients and put them to the
further expense of buying one or other of our phar-
maceutical remedies, which, after affording relief
for four and twenty hours, would work no appre-
ciable change in their condition 1 ?' Forgive me for
this hypochondria, but this was my day for private
consultations, and I am under the fresh impression
of my fruitless work."
Billroth wrote some verses, not intended for pub-
lication, which he sent to his friend the celebrated
composer Brahms. It is difficult to render in trans-
lation the power and poetry of this fragment:
"Ich kann's nicht mehr ertragen,
Wic mich die Mensehen taglich, stundlich qualen,
Wie sie Unmogliches von mir begehren !
2 One of Russia's greatest physicians of the latter half of the
nineteenth century (deceased). TRANSLATOR.
190 THE MEMOIRS OF A PHYSICIAN
Weil ich ein wenig tiefer wohl als andere
In die Natur geheimstes Wesen drang,
So meinen sie, ich konnte gleich den GSttern
Durch Wunder Leiden nehmen, Gliick erzaubern,
Und bin doch nur ein Mensch wie andere mehr.
Ach, wiisstet Ihr, wie's in mir wallet, siedet,
Und wie mein Herz den Schlag zuriicke halt,
Wenn ich statt Heilung mit unsicheren Worten
Kaum Trost kann spenden den Verloren. . . .
. . . Was soil denn aus mir werden?
Aus mir, den viel bewunderten, hiilflosen Mann ?" 3
But one had to humble oneself gradually in the
presence of this impotence: the inevitable always
carries a kind of reconciliation; for, after all said
and done, science gave us considerable powers,
which allowed us to accomplish much. But what
I could not reconcile myself to and what shook my
satisfaction in my life's work, was the utter ficti-
tiousness of these powers in the face of modern
reality.
Medicine is a science devoted to the healing of
8 "I cannot bear this longer
When people daily, hourly torment me,
When they demand the impossible of me !
Because I have penetrated a little further than others
Into the most secret depths of nature,
They believe that, god-like,
I can by miracle relieve their suffering, conjure happiness,
While I am but a man, just as others.
Oh, if you but knew how everything wells up and seethes within
me,
And how my heart-pulse falters,
When, instead of healing, with broken words
I am barely able to dispense comfort to the lost ones . . .
What will become of me,
Of me a helpless man, the object of so much wonder?"
THE DOCTOR AND THE POOR 191
mankind. So much was to be inferred from our
books and our studies at the University. But life
proved conclusively that medicine was, as a matter
of fact, a science dealing with the treatment of the
wealthy and leisured. As far as the rest were con-
cerned, it was but a theoretical abstraction, which
told us how one might cure people, if they were rich
and free. What I was compelled to offer them, in
the absence of these conditions, was no more nor less
than the most brazen profanation of the healing art.
At rare intervals on holidays, a small boy an
apprentice from a neighbouring cobbler's shop,
attends my consulting hours. His face has the
greenish-pale hue of mildewed plaster and he suf-
fers from vertigo and fainting fits. I often pass the
workshop where he toils its windows open upon
the street. Whether it be at six o'clock in the
morning or at eleven at night, I never fail to see
the cropped head of this poor child bending over
a boot, and around him other green-complexioned,
emaciated apprentices and boys; a small petroleum
lamp feebly burns above their heads, and through
the open window rolls forth a thick nauseating
stench that turns the stomach. I have to treat
poor little Ivan the apprentice. I ought to come
and tear him away from that dark, noisome kennel,
take him out of town and let him run about the
fields in the hot sunshine, inhaling the soft country
breezes: his lungs would expand, his heart grow
192 THE MEMOIRS OF A PHYSICIAN
strong and his blood turn warm and red. Whereas,
even the dusty streets of the metropolis see him
only on those rare occasions when his employer
sends him on an errand to a customer; even on holi-
days he is allowed no exercise, for his master locks
him in the workshop together with the other boys,
so as to keep them out of mischief. . . . All I can
do is to prescribe some iron and arsenic for the poor
lad, and derive what comfort I may from the re-
flection that still I am "doing something" for him.
A washerwoman suffering from eczema of the
hands comes to me, or else a drayman with hernia,
or a consumptive weaver; I prescribe salves, pills
and powders all round and, myself ashamed of the
farce I am keeping up, tell them in deprecatory
tones that the chief conditions necessary for their
recovery are as follows: that the washerwoman
should not wet her hands, that the drayman should
not strain himself by lifting weights, and that the
weaver should keep out of dusty places. They sigh,
thank me for my ointments and powders, and ex-
plain that they cannot give up their occupations
because they must eat.
At such moments I am consumed with shame for
myself and the science I serve, for the puling little-
ness to which it is condemned when brought into
operation.
In the country, a peasant suffering from great
shortness of breath came to me one day. I found
193
his left lung to be affected by croupous inflamma-
tion through and through. I was amazed that he
should have been able to reach me, and told him
that he mnst go to bed immediately on his return
home, and keep there.
"Why, sir, how can I*?" It was his turn to show
amazement. "Don't you know what season this
is? These are busy times, the harvest has to be
gathered in. The Lord has sent us fine weather
and you tell me to lie in bed! Why, don't you
know what that would mean? No, no! You just
be kind and give me some drops to ease my chest."
"But don't you understand, no drops will do you
any good if you go to work! This is no joking
matter you may die!"
"The Lord is merciful, why should I die? I'll
get over it somehow. Any way, I can't possibly
stay a-bed; we live for the whole year on the work
of these three weeks." With my mixture in his
pocket and his scythe over his shoulder, he trudged
off to his field and reaped his rye till evening, then
lay down under his hedge and died of anasarca of
the lungs.
Ruthless, gigantic and resistless in its passionless
sway, life ceaselessly does its blind, cruel work, while
somewhere, far below, at its feet, the puny science
called medicine potters about, evolving its hygienic
and therapeutic "Standards."
We have before us the human system with all its
194 TH E MEMOIRS OF A PHYSICIAN
organic wealth and diversity, demanding broad and
unfettered scope for its functions; while the mission
of life would appear to centre in a gruesome experi-
ment of what this organism would come to if placed
in the most impossible conditions. Some people
are condemned to everlasting walking and standing
about without rest; their soles flatten, their legs
swell, the veins on their calves become strained and
gradually develop into unhealing ulcers. Others
are compelled to lead a sedentary life; their backs
become crooked, liver and lungs compressed, bleed-
ing piles appear in the rectum. Miners have to toil
all day long on their hands and knees in the dark,
close galleries of coal pits; the blowers at glass
manufactories only work with their lungs, which
they convert into bellows. There are no unnatural
movements or positions in which people are not com-
pelled to pass their days, there are no poisons which
they are not forced to inhale, there are no circum-
stances of existence which life does not compel them
to adopt.
I have just returned from visiting a broken-down
cigarette-maker; she dwells in the corner of a tene-
ment room a squalid, low-ceilinged hutch, seven
paces long by six broad. Sixteen human creatures
make it their home. To remain in this abode for
ten or fifteen minutes is torture to me; the room
lacks air this is no figure of speech the lamp,
THE DOCTOR AND THE POOR 195
which is properly trimmed and lit, smokes and gut-
ters there is insufficient oxygen to allow of a
bright flame; the oppressive, moist, almost sticky
atmosphere is impregnated with the foetid odour of
infantile excrements, twist and petroleum.
The waxen, strangely inanimate faces of the chil-
dren peer at me out of the corners of the room ; they
are pigeon-chested, their teeth are crooked, their
limbs rickety; while their large eyes betray no trace
of that liveliness and merriment that is "natural"
to childhood.
In fact, on becoming a doctor, I quite lost my
bearings as to what was really right and proper in
the human race. Was it natural that a tired person
should want to sleep? No! A hospital nurse, a
teacher, a journalistic drudge, worn out and broken;
they cannot go to sleep without swallowing a dose
of bromide potassium. Ought a person who had
long remained without food experience a craving
for it? No, certainly not ! He finds himself com-
pelled to resort to an artificial appetizer just as
if he were a surfeited glutton. This phenomenon
struck me particularly amongst the majority of fac-
tory hands and artisans.
"You work all day, the machinery throbs, the
floor beneath your feet wobbles like a live thing.
. . . Well, you get so dog-tired that you haven't
the heart for your victuals. You only just seem to
196 THE MEMOIRS OF A PHYSICIAN
want a good draught of kvass. 4 But kvass can't
give you any strength it merely fills up your belly
that's all. Vodka is the only thing that helps
us out; after a little glass, well you want to
eat."
For several years I have attended the employees
of a certain printing firm, and during all that time
I never came across an old compositor. There is
no old age, there are no grey hairs in that trade
the lead dust drives them all into an early grave.
Life conducts its experiments upon man and
mockingly places at our disposal the results obtained
for further investigation. We study the subject
and obtain a very clear understanding of the effects
on man of chronic phosphorus, lead or mercurial
poisoning; the influence of insufficient light, air and
exercise upon the growth of children is also made
plain to us; we learn that only nine out of every
hundred weavers attain the age of forty, that only
six per cent, of the women employed in the textile
industry live to the same age. . . . Also, we be-
come acquainted with the fact that in Russia, owing
to the arduous nature of their agricultural work, the
physiological life peculiar to women is entirely sus-
pended in the peasant woman during the summer
months; that seamstresses and female students often
degenerate in a few years into anaemic, sickly
4 Kvass = a Russian national non-alcoholic beverage made of
malt. TRANSLATOR.
THE DOCTOR AND THE POOR 197
creatures. And we shall learn much more as time
passes. . . .
What could our medicine do under the circum-
stances'? What value could be placed upon those
pitiful palliatives with which it seeks to patch up
all that so disfigures our life? . . .
Great suffering mankind hangs upon the cross,
his hands and feet are transfixed by cruel nails, and
medicine bathes the ensanguined wounds with arnica
and applies aromatic poultices.
It is powerless to accomplish more. No science
can exist that could teach us how to heal sores with
the iron still rankling in them; it cannot go beyond
showing that humanity must live otherwise, that
first of all the nails must be drawn from the lacera-
tions.
Villerme's investigations, conducted in the late
"twenties," showed that half the children of the
Mulhausen weavers died before reaching the age of
fifteen months. Villerme persuaded the mill-owner
Dollfus to allow his female mill-hands to remain at
home for six weeks after confinement, retaining
their full wages the while; this measure proved suf-
ficient in itself to lower the infantile mortality by
fifty per cent, without any extraneous medical aid.
One thing was ever becoming clearer and more
incontestable in my eyes: that medicine can do no
more than point out those conditions which alone
make possible a healthy existence and the cure of
198 THE MEMOIRS OF A PHYSICIAN
disease. Therefore, a physician if he be a phy-
sician and not a mummified medical functionary
must first of all strive to remove those conditions
which at present render his work both senseless and
barren; he must be a public worker in the broadest
sense of the term; he must not only prescribe, but
he must strive and seek to discover the means for
carrying his directions out of theory into actuality.
And the need for undelayed action is all the more
imperative, because time does not wait and life is
rapidly carrying humanity towards the brink of a
dark abyss. The numbers of the "unbalanced,"
physically unfit, and hereditary drunkards are ever
on the increase, the halt, blind, deaf and stammer-
ing are ever multiplying.
The best criterion, for an estimation of the physi-
cal condition of the people, is furnished by the per-
centage of conscripts eligible as soldiers in those
countries where military service is obligatory and
we see that, year by year, this number is falling off
everywhere, like a barometrical column before a
storm. In Austria, for instance, in 1870 the num-
ber of those who came up to the standard was
twenty-six per cent., in 1875 eighteen per cent., in
1880 fourteen per cent. This is degeneration with
a vengeance, which can almost be grasped by the
hands, so to speak! One of our anthropologists
ventures upon a prophecy as to the future, and his
words have the ring of cruel truth about them
THE DOCTOR AND THE POOR 199
they are not a mere empty phantasmagoria. "The
ideal of a harmonious social order, with its interests
at one, may not be realised, owing to the degenera-
tion of humanity. A centralised feudo-industrial
system will establish itself, in which the popular
masses will be relegated, in somewhat modified
form, to the position of the helots of ancient Sparta,
organically adapted to such a state, owing to their
own degeneration."
CHAPTER XIII
MEDICINE, NATURAL SELECTION AND THE
SURVIVAL OF THE UNFIT
BUT I will suppose, for the sake of argument,
that social conditions have undergone a radical
change. Every one is placed in a position to fol-
low all the dictates of hygiene; we doctors are
enabled to offer each patient all that medical science
requires. Would our work be so sure to prove of
indisputable benefit free from contradictions'?
Already we have to hear more and more often
the cry raised amongst doctors and anthropologists,
that medicine is terribly one-sided and that its use-
fulness to mankind is open to grave question.
"Medicine benefits the individual at the expense of
the type." Mother Nature is prodigal and care-
less: she casts numberless creatures upon the world",
not caring much as to the perfection of each speci-
men; the task of weeding out and destroying the
unsuccessful and unfit is left to merciless life. And
it is here that medicine appears upon the scene and
strains all its energies to frustrate this work.
A woman in child-bed may have narrow hips and
she cannot give birth ; she and her child must perish ;
200
MEDICINE; NATURAL SELECTION 201
medicine steps in and saves both, and thus enables
women with bad, narrow hips, unadapted for child-
birth, to multiply. The higher the infantile death-
rate, which medicine so energetically combats, the
surer is the next generation of being purged of all
weakly and sickly organisms. The syphilitic, tu-
berculous, rickety, mentally infirm and nervous in-
dividuals, cured through the good offices of medicine,
breed and produce a puny and nervous degenerated
posterity. All these weaklings who, although they
have been preserved, are rotten to the core, mix and
cross with the healthy and thus conduce to the rapid
degeneration of the race in general. And every
new success of medicine will accelerate this down-
ward progress of deterioration.
Before his death Darwin had solid grounds for
imparting to Wallace his despondent views on the
future of humanity, owing to natural selection and
survival of the fittest having no room in modern
civilisation.
This spectre of universal degeneration is so real
and glaring that it gives us food for serious and
deep reflection. Many have made this knotty prob-
lem the subject of profound thought, and the most
far-reaching reformatory projects are mooted for
averting the danger. Proposals have been put for-
ward that "all philanthropy" should be eradicated
from human society and humanity transformed into
a kind of vast stud-farm under the supreme direc-
202 THE MEMOIRS OF A PHYSICIAN
tion of anthropo-technical physicians. It is not
difficult to invent schemes of a like nature at one's
study table: "The Happiness of Humanity" as-
sumes such majestic and real proportions, while
living individuals, transformed into dumb ciphers,
are so easily amenable to addition and subtraction!
. . . But after all, perhaps the essence of life is
concentrated in the individual consciousness of the
unit, and outside this sphere the rest fades into in-
significance. To the lasting honour of humanity
be it said, that the praiseworthy instinct to break
down the walls of already existing stables shows
itself to be ever in the ascendent, and men give no
indications of wanting to build up fresh prison
walls. . . . Nevertheless the fact remains: natural
selection is on the wane, while medicine is always as-
sisting this process, giving absolutely nothing in
exchange.
The consequences of the disappearance of selec-
tion, as just roughly indicated, do not stop here, but
are much deeper and more far-reaching.
By long and untiring effort, the type of modern
man, more or less adapted to his environments, was
evolved. But these environments do not remain
inert on the contrary, they undergo constant
fundamental changes, which are compassed with
ever increasing rapidity. On the other hand, the
human organism has ceased to keep pace with them,
in the sense of developing new and positive quali-
MEDICINE; NATURAL SELECTION 203
ties. In former times teeth were necessary for the
reducing of hard and tough food of moderate tem-
perature. Nowadays man consumes soft foods,
either very hot or very cold. This kind of nutri-
ment requires an entirely new dental apparatus
the old serves its purpose no more. The appalling
number of bad teeth that we see in civilised com-
munities speaks for this. Wild tribes which are
devoid of all culture possess powerfully developed
jaws and strong and healthy teeth. The semi-civi-
lised peoples show a percentage of between five and
twenty-five with decayed teeth, whereas 80 per cent,
of the population of highly cultured communities
are affected by dental corrosion. 1
Pray give this your full attention: the living or-
ganism in a state of rot and corruption in the living
man! There is nothing exceptional about this
on the contrary, such is the rule with but insignifi-
cant deviations. Either man must return to his
former food, or else, evolve new teeth ! How does
medicine act in the meanwhile*? It cleans, fills and
treats these teeth and does all it can to fortify those
1 Researches instituted to ascertain the condition of the teeth of
the female pupils being educated in the schools of the Russian Impe-
rial Humane Society, showed how gigantic were the strides made by
dental decay, with the advance of age. The pupils were divided
into three groups according to age: (i) from 8-12, (2) from 12-16,
(3) from 16-20. The first group showed that 79 per cent, had
spoilt teeth, each girl averaging three bad ones; the second dis-
closed 87 per cent., with an average of 4.5 bad ones for each; in
the third group there were 92 per cent, an average of 5.9 bad
teeth being constated.
204 THE MEMOIRS OF A PHYSICIAN
remaining intact, which will, in their turn, go, be-
cause they cannot help it.
Formerly man required his eyes chiefly for long
distance vision, and they entirely answered their
purpose. Conditions of life have undergone a
change, the organ has to meet the requirement for
more work at close quarters; a new organ must evolve
itself, equally efficient for long vision and short
focus work. But medicine accommodatingly sup-
plies the short-sighted eye with a lens thus the
unserviceable organ is made serviceable by purely
extraneous devices. The number of the myopic is
constantly on the increase, and all that remains to us
is to thank the Lord that there will ever be sufficient
glass to provide all with spectacles.
The fact that the human organism does not ac-
quire those positive qualities which are essential to
the changed conditions of life, is thus made plain.
But worse is to follow : the human organism shows a
serious tendency to lose those it already possesses.
Medicine, in the pursuit of its aims, threatens to do
humanity a very poor service in this direction too.
What is modern medicine's ideal*? It lies in the
stamping out of every disease in its inception, or
better still in not admitting it into the system at
all. For instance, surgery insistently demands that
the most insignificant scratch or cut should immedi-
ately be subjected to careful antiseptic treatment.
In each separate case this may answer very well,
MEDICINE; NATURAL SELECTION 205
but if applied habitually and universally, the system
will entirely lose its powers of independent struggle
with infection ! At the present day a vast accumu-
lation of observation has established the fact that
savages easily recover, without any special treat-
ment, from wounds that would kill the European,
notwithstanding the most careful nursing.
Then, again, let us take infectious diseases in gen-
eral. The human system shows far greater powers
of resistance in regard to complaints that are pecul-
iar to a given district and a given nationality, than
towards diseases hitherto unknown. Amongst sav-
ages scarlet fever and measles carry away half the
population at a sweep. Numerous as is the number
of Polynesian aborigines exterminated by arms, the
"white sickness" (phthisis) has claimed far more
numerous victims.
"Who killed your father? Who killed your
mother?"
"The white sickness!"
A Polynesian woman, entering into relations with
a white, invariably falls victim to consumption; this
is not all she infects her native lovers as well. If
an Australian aboriginal passes a few days in a
European town of New Holland, he contracts con-
sumption (according to Krjlvitsky).
On the other hand, the European as easily suc-
cumbs to tropical malaria, yellow fever and tropi-
cal dysentery. WTiat would the result be if all
206 THE MEMOIRS OF A PHYSICIAN
infectious diseases were destroyed by science in the
germ? Entirely strange to them, man would fall
their victim swiftly and surely, if chance deprived
him of his accustomed protection. Finally he would
lose every vestige of independence, not daring to
stray a yard from the protecting wing of medicine.
I recently came across an article containing the fol-
lowing reflections on the aims of medicine: "It
will only then be possible to safeguard the system
from that varied multitude of poisons that are con-
stantly being introduced by different microbes, when
one universal antitoxin for all these shall have been
discovered. This desideratum once attained, we
should merely have to inject daily into our blood a
fixed amount of the antitoxic fluid and thus antici-
pate the malignant effects of the poisons which the
micro-organic world daily introduces into our bodies.
At present, unfortunately, there are not the slightest
grounds for believing in the realisation of such rosy
hopes."
Is not this awful ! To be forced to inject a dose
of universal antitoxin beneath your skin every day
of your life, when rising! And if you forget to
you perish because the first stray bacillus will be
sufficient to give your poor organism, which has lost
all capacity of self-protection, its coup de grace.
The science called hygiene tells us that we should
not sleep between window and stove: the draught
caused by the difference of temperature of the cold
MEDICINE; NATURAL SELECTION 207
window panes and the warm stove might give us a
cold. Hygiene warns us against hard out-door
work on cold winter days, as our deep inspirations
conduce to the violent cooling of the lungs, which
might result in a chill. But, pray, why does not a
crow become enrheumed through sleeping in the bit-
ing autumn wind; why do not the reindeer, that
madly gallop over the frozen tundra at a freezing
temperature of forty degrees below zero, contract
pneumonia? The crows and the reindeer that
caught cold died off, thus purifying the species of
unadapted units, while we have no right to leave
the weak human creature to the mercy of the laws
of survival of the fittest. No one will say a word
against this. But medicine should strive and make
those weak creatures strong. Unfortunately, it re-
verses the process, makes the strong weak and seeks
to turn all men into pitiful, helpless beings, tied to
its apron-strings.
However, it is a matter for deep congratulation
that, of late, science shows indications of choosing
other paths, which bid fair to lead us in the future
to much that is consolatory. In this respect the
experiments in artificial immunisation of man are
especially noteworthy. Although, as yet, not con-
clusively proven, it is very probable that the essence
of the action of such immunisation lies in the train-
ing of the organic forces in the independent struggle
with those microbes and poisons which force their
208 THE MEMOIRS OF A PHYSICIAN
way into the system. If this really be so, we have
to deal with a vast revolution of the very founda-
tions of medicine: instead of hastening to rid him
of the disease that has already taken root, medicine
will convert man into a combatant himself, able to
deal with the dangers menacing him. Here we
have before us an illustration of one of those meth-
ods whereby medicine, without claiming any vic-
tims, may arrive at leading civilised humanity to
the same desideratum which savage communities
attain through survival of the fittest, at the price of
great waste of life.
The dreams of to-day will be the reality of to-
morrow; science preserves within itself much latent
and, to itself, unknown energy; and we have the
right to expect that the science of the future will
find more ways than one for the achievement of the
same object as that pursued by nature but in a
manner reconciling the interests of the individual
and the type.
To what extent and within what limits this will
prove feasible, remains to be seen we cannot con-
jecture beforehand. But this, the true anthropo-
technic will have many problems to solve prob-
lems both wide-reaching and knotty perhaps insol-
uble, but none the less burning.
"All that leaves the hands of Nature is perfect."
Rousseau's celebrated dictum has long been ex-
ploded, in respect to man no less than to nature's
MEDICINE; NATURAL SELECTION 209
other creations. The present day has overtaken the
human animal in an evolutionary stage: still re-
taining numberless defects, in some respects he is
insufficiently developed, while many organs repre-
sent atrophied relics of a bygone age. Every whit
as if man had been suddenly snatched, unfinished
and incomplete, from Nature's laboratory, while the
process of his shaping was in full swing.
For example, at the commencement of the colon
is located the short c&cum, or blind intestine, whereas
in our zoological ancestors it existed in the form of
a large and necessary organ, still surviving as such
in the herbivorous animals of to-day. Ceasing to
serve any useful purpose in man, this organ did not,
however, disappear, but transformed itself into a
long, narrow, worm-like outgrowth appending to
the ccKcum. Not only does this obsolete survival
serve no useful purpose, but its presence is a source
of positive danger to man; the pips, seeds and such
like contained in the chyme, frequently find their
way into this cul-de-sac and cause serious, and often,
fatal inflammation of the vermiform process (ap-
pendicitis}.
Pursuing our investigations further, we see that
the disposition of man's vitals has not as yet finally
adapted itself to his upright carriage. We should
clearly realise how violently this change of carriage
must needs have affected the distribution and extent
of the stresses exercised upon our various organs,
210 THE MEMOIRS OF A PHYSICIAN
and we shall easily understand that their task of
accommodating themselves to the changed condi-
tions was far from light. Without enumerating
all the defects resulting from this, I need only draw
attention to one of the most important: nearly half
of all the female complaints known are caused by
various displacements of the womb. At the same
time a large proportion of these displacements
would never occur, and the rest would be cured with
much greater ease, if women walked on all fours.
Even as a temporary measure the so-called genu-
pectoral position (a la vaclie), introduced by
Marion Sims, is invaluable in gynaecology and
obstetrics: some gynecologists hail Marion Sim's
discovery as "the turning-point in the history of
gynsecology."
Making women the subject of our special atten-
tion, we stumble upon such a mass of the most
grave physiological contradictions and defects in
her organisation, that the mind absolutely declines
to acquiesce in their being proper and "normal."
The definition of woman as "an animal naturally
weak and sickly, only enjoying occasional bright
periods of health which show up against a back-
ground of uninterrupted disease," is no less sad than
true. The healthiest of women the most pains-
taking research furnishes conclusive proof to this
effect is periodically unmistakably ill. And it is
impossible to explain such an anomaly otherwise
MEDICINE; NATURAL SELECTION 211
than by assuming it to be the result of a transmi-
gratory stage towards another, more perfect state.
Maternity furnishes a repetition of the same story:
the female in woman is ever becoming less pro-
nounced there being nothing "unnatural" in this,
because she too possesses a brain with all its broad
and mighty calls. At the same time she cannot,
without radically changing her nature, renounce
love with its accompaniment of uninterrupted ma-
ternity, which saps the strength of woman in its
bloom. Two demands, equally potent and legiti-
mate, come into collision; but as long as the organ-
ism remains as it is, there is no help for it.
Metschnikoff points out another crying contradic-
tion one dealing with the sexual instinct. A child
is altogether unfit for propagation, yet the sexual
instinct is so far individualised that the child is
enabled to abuse it. The growth of the hip-bones
in a young girl, on completion of which she becomes
ripe for maternity, is only achieved at the age of
twenty, 2 while pubescence comes at sixteen. In
consequence of this, the three moments which ought
to coincide that of the awakening of the sexual
instinct, its satisfaction and the function of repro-
duction, are separated from each other by periods
of several years. A girl may experience the desire
2 Statistical data fully bear out Metschnikoff's contentions: ac-
cording to Bertillon, the death-rate amongst spinsters of the ages
from 15-20 amounts to 7 per cent., whereas that of married women
of the same age is as high as 50 per cent.
212 THE MEMOIRS OF A PHYSICIAN
to be a wife at ten, she can only become one at six-
teen, while she may only be a mother at twenty !
"It is worthy of note," remarks Metschnikoff,
"that such perversions of the natural instincts as
suicide, infanticide, etc., i.e., just those so-called
'unnatural' actions, are numbered among the most
characteristic peculiarities of man. May not this
point to the fact that these actions are part and
parcel of our nature and, therefore, worthy of the
most serious attention *? It may be affirmed that the
genus Homo Sapiens belongs to the number of those
which have not as yet fully arrived at stability and
are not fully adapted to the conditions of existence."
The unfitness of man for the conditions of his
existence is glaringly exemplified by the dispro-
portionate weakness of his nervous system. In this
respect he lags badly behind his times. Actuality
places a heightened demand on his nervous powers,
requires an increased mental expenditure ; our nerves
are unequal to such intensive work and resort to
stimulants, artificially quickening the nervous en-
ergy, results. Moralists may essay to shame us for
recoursing to such remedies, medicine may point out
the "unnaturalness" of introducing nicotine, thein,
alcohol and like poisons into our systems.
But "unnaturalness" is a very elastic idea. By
themselves many stimulants, such as tobacco, spirits,
beer, etc., are horrid to the taste and their action
upon the unaccustomed person is extremely unpleas-
MEDICINE; NATURAL SELECTION 213
ant. Why, then, should every one of these excit-
ants spread from its birth-place all over the world
so victoriously and with such lightning rapidity, and
the "uncorrupted" nature of man fall its victim so
readily? It is the human organism, which has been
left behind in the world's onward progress, that is
abnormal; it is unnatural that man should be
compelled to draw upon his surroundings for that
strength which ought to be self-contained !
One way or another, sooner or later, the human
organism must arrive at a state of stability and har-
mony between its cravings and its functions. The
attainment of this end cannot fail to become the su-
preme goal of science, because therein lies the funda-
mental condition of human happiness. For these
eternal throes, this everlasting self-distortion must
finally cease and mankind awaken to a broad and
untrammelled life, free to satisfy all its needs, when
the very thought of such phenomena as "unnatural
cravings" will appear grotesquely impossible.
CHAPTER XIV
IT was shown in the foregoing chapter that it still
remains for the human organism to emerge from
its evolutionary stage and arrive at final complete-
ness in harmony with existing conditions. But how
are we to foresee the form this adaptation will take !
The hawk soaring at a dizzy height distinguishes
the lark cowering to the ground and is adapted to
the circumstances of its existence; so is the blind
mole burrowing in the earth. What is man destined
to the freedom of the hawk or the slavery of the
mole*? Is he fated to improve and perfect his ex-
isting faculties or to lose them?
Thanks to his intellectual superiority, man eman-
cipates himself ever more and more from the yoke
of external nature, is ever adding to his independ-
ence and gathering more strength in his struggle
with nature's forces. He protects and shelters him-
self from the cold by means of clothing and habita-
tions, he converts the coarse foods provided by
nature into easily assimilated nutriment, he substi-
tutes the greater muscular power of animals for
his own, makes mighty steam and electricity his
servants.
Culture has swiftly wrought many improvements
314
PROGRESS AND DEGENERATION
in our life and made possible such conditions of
existence, which would be utterly precluded under
the sway of elemental nature. In its onward prog-
ress it also promises to place the comforts that are
now the privilege of the fortunate few, within the
reach of the masses, at no distant date.
The end to the domination of nature over man is
in sight. . . . But have we really such good reason
for jubilation*? The soft waves of culture have
enfolded us in their embrace and carry us forward,
without allowing us to see whither we are speeding;
we surrender ourselves to these waves and do not
perceive how all the treasures we possess are, one
by one, engulfed. Not only does this fact escape
our notice we wilfully ignore it : for all our atten-
tion is exclusively centred upon our most prized
jewel our intellect, which lures us on to the bright
realm of perfect civilisation." But when we
reckon up all that we have lost already, and make
a mental calculation of what we are about to part
with so blithely, cold fear grips the heart and the
dark menace of some new form of human slavery
looms up ominously, over-clouding the bright, far-
off vistas of our imaginations. Professor Gruber's
measurements show that the length of the alimen-
tary canal of the European increases appreciably
from S.W. to N.E. Its greatest length is encoun-
tered in Northern Germany, and especially in Rus-
sia. This is accounted for by the fact that the
216 THE MEMOIRS OF A PHYSICIAN
inhabitants of Northeastern Europe subsist on less
digestible food than those of the Southwest. Such
observations encourage the physiologist in entertain-
ing "bright hopes" for the gradual corporeal regen-
eration and "perfecting" of man, thanks to a rational
diet. By absorbing for many generations concen-
trated chemical compounds, which would become
transformed into blood in their entirety, without
requiring any previous preparation by the digestive
juices, the human system would free itself, to a great
extent, from the burden represented by the digestive
organs, while the saving in constructive tissue and
of the material formerly expended upon the up-
keeping of their living energy, would go to reinforce
the nobler higher organs (Setschenoff 1 ).
For the sake of the "nobler higher organs," the
reduction of the vegetative apparatus of the human
body to zero is hailed as the ideal desideratum of
the organism of the future. Herbert Spencer goes
further and expresses satisfaction at civilised man's
loss of those qualities which are typical of the
savage, viz., fineness of the physical senses, keen
perception, skill in arms, etc.
In his "Principles of Sociology" (vol. i, p. 89)
he remarks: ". . . in virtue of a general antago-
nism between the activities of the simpler faculties
and the activities of the more complex faculties,
1 Professor of Physiology at the Imperial University of Moscow,
and a savant of wide reputation. TRANSLATOR.
PROGRESS AND DEGENERATION 217
it results that this dominance of the lower intellec-
tual life hinders the higher intellectual life. In
proportion as the mental energies go out in restless
and multitudinous perception, they, cannot go out in
calm and deliberate thought."
Civilisation energetically and successfully goes
out to meet such ideals half-way. Our olfactory
organ has become quite rudimentary; the sensibility
of the cutaneous nerves to variations of temperature
and their faculty of regulating the calorification of
the body has become appreciably lessened; the
glandular tissue of the female breast is becoming
atrophied; considerable weakening of sexual energy
is noticeable; the bones are becoming smaller, the
first and the floating ribs show a tendency to dis-
appear; the wisdom teeth have become rudimentary
organs and are entirely lacked by forty-two per cent,
of Europeans; it is prophesied that the double molars
will follow suit; the intestinal duct is ever growing
briefer and the army of the bald ever increasing.
When reading about savages and their powers of
endurance, the subtlety of their external senses, I
am seized with bitter envy; I find it impossible to
reconcile myself to the thought that it is necessary
and inevitable that we should lose all these! The
Guiana native will tell you the number of men,
women and children who have passed along a forest
path, while the utmost that the white can do is
to faintly distinguish a few confused footprints.
218 THE MEMOIRS OF A PHYSICIAN
When Kommerson, the naturalist, arrived amongst
the Society Islanders, accompanied by his servant,
the natives sniffed, smelt the latter over and de-
clared that he was a woman, not a man at all : and
so it was, for Jeanne Bare, his sweetheart, accom-
panied him in his circumnavigation disguised as his
valet. The Bushman can starve for several days,
running, while, on the other hand, he can procure
food where the European would die of hunger.
The Bedouin in the desert sustains himself for a day
with a couple of gulps of water and two handfuls
of parched meal slightly moistened. While others
shiver from cold, the Arab sleeps barefoot beneath
an open tent, reposing no less peacefully upon the
burning sand in the full blaze of the mid-day sun.
While visiting Tierra del Fuego, Darwin saw a
woman with a suckling babe approach the ship out
of sheer curiosity, while the falling snow melted
upon the naked bodies of both child and mother. It
was also whilst among the Tierra-del-Fuegans that
the great naturalist and his companions felt chilled
while sitting, well wrapped up, next a bright camp-
fire, whereas the naked aboriginals sweated pro-
fusely, although remaining a good distance from the
blaze.
The Yakouts 2 are called the "Iron People" be-
cause of their insensibility to cold, the naked chil-
dren of Esquimaux and Tschouktshi 3 run out of
2 A Siberian aboriginal tribe. 3 Ibid. TRANSLATOR.
PROGRESS AND DEGENERATION 219
their warm dwellings into the cold, with the ther-
mometer often as low as 40 Fahr. . . .
These people are as strange to us civilised folks
as the inhabitants of another planet, and in our very
conceptions of health we have nothing in common
with them. Our hyper-civilised man walks over a
dewy lawn barefoot and contracts a cold, a night
passed beneath the open sky cripples him for life,
a twenty-miles' walk results in synovitis.
And we consider ourselves healthy notwithstand-
ing! Thanks to gloves, our hands will soon be-
come as sensitive to cold as are our feet, and
the expression "to get wet hands" will acquire the
same meaning as "getting wet feet" at the present
day.
And the Lord alone knows what the coming age
has in store, what gifts and conveniences are being
prepared for us in civilisation's laboratory ! In the
same way as ordinary plain food is no more con-
sidered a suitable diet for us, so, in the future, will
natural air become "irrational," being too rare and
impure for our small and delicate lungs. Man will
carry an apparatus filled with concentrated, pure
oxygen about with him, inhaling it through a little
tube; and if his apparatus suddenly goes wrong,
will perish from suffocation in the free air of heaven,
exactly like a stranded fish. Thanks to improve-
ments in the optical line, the human eye will be able
to discern a gnat at ten miles' range, to see through
220 THE MEMOIRS OF A PHYSICIAN
solid earth and stone walls, itself a counterpart to
our modern olfactory apparatus transformed into
a rudimentary and inflamed organ, in daily need of
syringing, rinsing and cleaning. At present we live
in a state of chronic intoxication ; wine, tobacco, tea,
etc., losing their stimulating properties, humanity
will pass on to new and more potent poisons.
Fecundation will be accomplished artificially as
being too gross for man, the amorous instinct finding
satisfaction in voluptuous embraces and other irri-
tants, without the accompaniment of "filth," as
described by Huysmans in his book "La-bas."
Perhaps even things will go still further. Profes-
sor Eilenburg cites one of the latest German writers,
Hermann Bahr, who dreams of an "extra-sexual
sensuality and the substitution of more refined nerves
for the low erotic organs." According to his opin-
ion, the twentieth century is destined to make the
"Great discovery of a third sex mid-way between
man and woman, standing in no need of either male
or female apparatus, because this new sex will unite
in its brain, all the faculties of the opposite sexes,
and after long probation, will have learned to sub-
stitute the imaginary for the real."
Pray admire this "ideal being" freed from all the
vegetative and animal functions of the organism!
In his celebrated story "The War of the Worlds,"
Wells painted the Martian's portrait with insuffi-
cient vigour. In reality the creature must have
PROGRESS AND DEGENERATION 221
been far more mighty, helpless and repulsive than
the being described by the novelist.
Science cannot remain blind to the retrogression
of the glorious human image before culture an
image created by a long and difficult process of evo-
lution. But it takes refuge in the reflection that
man could not otherwise have developed his mind in
the required degree. As already mentioned, Spen-
cer actually evinces satisfaction that this intellect
should have become purblind and half deaf, thus
placed beyond the disturbing influences of "restless
and multitudinous perception." Wiedersheim, the
eminent authority on comparative anatomy, declares
that, by developing his brain, man completely made
good the loss of a long array of useful organic ap-
pliances. These had to be sacrificed to forward the
cause of cerebral development, which has made man
what he now is Homo Sapiens.
But this remains to be proved! Evidence must
be forthcoming to show that the brain really stands
in need of such sacrifices and, what is still more
important, that they cannot be obviated in future.
If cerebral development was hitherto purchased at
the body's expense, it by no means follows that all
other ways to further advancement are closed. We
view our past losses with equanimity: it matters
little, after all, that we cannot eat other than easily
digestible, pappy food, that we must envelop our
delicate, shivering bodies in warm wraps, stand in
dread of chills, use spectacles, clean our teeth and
rinse our mouths for fear of offensive breath, etc!
The length of the human intestinal canal exceeds
that of the body by six times; would we be much
happier if, instead, it were like a sheep's twenty-
eight times as long 1 ? If in lieu of one, man pos-
sessed four stomachs like a ruminant? When all is
said and done, "Der Mensch ist was er isst," a man
is what he eats. And there would not be much to
rejoice about if he were turned into a dull, cud-
chewing brute, whose entire energy was absorbed by
the digestive process.
If man were to discard clothing, this would neces-
sitate a tremendous expenditure of energy on the
part of the system to increase our caloric out-put,
and there are really no grounds for envying the
glacial flea, which lives and multiplies upon the ice.
No one will argue against such a contention. Of
course I am far from wishing man to become a
ruminant or a glacial flea. But no more does it
follow that his ideal should be an animated brain
specimen solely able to exist in a hermetically
sealed glass case! Cultured man does not mind
saddling his nose with spectacles, losing his muscles,
refusing "heavy" food; but he would be horrified at
the prospect of never parting with a phial of con-
centrated oxygen, of covering up his face and hands
indoors, having to insert olfactory discs into his nos-
trils and speaking trumpets into his ears!
PROGRESS AND DEGENERATION 223
Here is the whole matter in a nutshell: while
availing ourselves of the advantages offered by civi-
lisation, we must preserve the closest communion
with nature ; in developing various new and positive
qualities in our organisms, made possible by our
civilisation, we must be jealous of our old character-
istics; their attainment has been won at too great
a cost, while nothing could be easier than to lose
them. Grant intellect full scope for its advance-
ment but let us have strong thews, keen organs of
sense, an active frame and a hardened system too,
that we may lead a natural, wholesome life at one
with nature, and not merely content ourselves with
resting in its lap in the garb of effete summer
visitors.
Only the body's free and many-sided existence in
all the variety of its functions and multiplicity of
the impressions furnished by the brain, can impart
a wide and energetic life to the brain itself.
"Thy body is thy greater mind, multiplicity with
a single consciousness, peace and war, the herd and
the shepherd."
"Thy lesser reason is thy body's tool, oh my
brother; that little tool, that toy of thy greater
mind thou callest thy spirit."
Thus spoke Nietzsche's Zarothustra, addressing
those who "despise the body." . . . The closer the
acquaintance with the soul of the so-called "intel-
lectual" man, the less attractive and satisfying does
224 THE MEMOIRS OF A PHYSICIAN
that "lesser reason," which has disowned the
"greater mind," stand out before us.
And, at the same time, there can be no doubt
that social evolution dooms this greater mind to
annihilation; at any rate there is nothing to lead us
to expect that things will improve in this respect in
the near future. The promise of the future social
emancipation of man is embodied in the great city,
and only such speculations as those indulged in by
Bellamy have any real foundation.
This future, so bright from the social point of
view, is hopelessly sinister and poor as far as the
life of the organism itself is concerned; everything
will tend to make physical labour superfluous and
bodily idleness will result, fat will take the place of
muscle, we shall lead an unretrospective, vegetative
existence, being deprived of broad horizons and
strangers to nature. . . .
Medicine may be as insistent as it pleases in
pointing out to man the necessity of an all-round
physical training all its injunctions, as far as the
adult is concerned, will be effectually nullified by
the existing conditions, as they are set at nought by
the cultured classes of to-day. To become strong
and vigorous the adult must work with sinews and
muscles, not merely exercise the latter. It is no
great hardship to throw away daily two or three
minutes cleaning the teeth for hygienic considera-
tions, but it would be unspeakably dreary and
225
repugnant to waste several hours per diem over
senseless and unproductive gymnastics. Here lies
the chief reason of the intellectual person's bodily
flabbiness, and not at all in his lack of appreciation
of the benefits accruing from a good physique. Per-
sonal experience convinced me of this.
In this respect I was brought up under exception-
ally favourable conditions. Each summer, up to
the close of my University career, I passed in the
country, living the life of a simple labourer. From
morn till eve I ploughed, mowed, harvested and
felled timber. And how well do I know the bliss
of that hearty, healthy fatigue in every muscle, that
is born of hard work in the open, when colds have
no terrors; how well do I remember my ravenous
appetite and sound sleep. Even now, when I am
able to tear myself away from town, I fly to the
country, again taking up scythe and axe; returning
to St. Petersburg with horny hands, a rejuvenated
body, a thirsty and joyful love of life. I am not
theorising. My whole being cries to me that the
soul stands in need of energetic life of the body,
and in its absence my depression of spirits becomes
almost ridiculous. I passed last summer in rustic
surroundings as usual : one night, about a fortnight
after my return to town, I woke from a paroxysm
of weeping; some dream had plunged my soul into
terrible sadness. I tried to recollect my vision
at first in vain finally succeeding. I saw myself
226 THE MEMOIRS OF A PHYSICIAN
standing at the edge of the forest, axe in hand; at
my feet lay two birch-trees just felled by me; grey
clouds straggled athwart the sky and a fresh and
bracing wind fanned my face. Nothing more.
But my heaviness of heart remained, and the same
feeling of depression gripped it: as if a glimpse of
heaven had just been granted me, to be followed
by a sad awakening to reality; my summer's dream
was a thing of the past. . . . My limbs were suf-
fused with an irritating, restless sensation, as if
yearning for work; a dull light, reflected from the
street lamps, played upon the ceiling of my bed-
room, while the everlasting, muffled, vibrating
rumble of the unsleeping city floated through the
windows.
And nevertheless, when in town, I cannot help
living the life of a brain-worker pure and simple.
At first I try to resist, take dumb-bell exercise, do
gymnastics, go for long walks; but my patience is
short-lived, it succumbs beneath the boredom and
senselessness of it all. And if, in times to come,
our inherent craving for labour will only find outlet
in sport, lawn tennis, cricket, gymnastics, etc., all
the remonstrances of medicine and of our reason
itself will prove utterly powerless against the ennui
of such "work."
Dostoievsky, in his "Letters from the House of
the Dead," describing enforced convict labour in
Siberia, says: "If it were desired to crush and
PROGRESS AND DEGENERATION 227
utterly abase man, to inflict upon him the most
awful punishment, that the most terrible murderer
would quail before and fear in anticipation, all that
would be required were to impart the character of
perfect, complete uselessness and senselessness to his
work. If, for instance, the convict were forced to
pour water from tub to tub, while another was given
sand to pound in a mortar, and so on, I think that
the prisoner would strangle himself after a few
days, or else commit a thousand crimes, so as to
escape this horrible degradation and suffering, even
at the cost of his life."
Small wonder then if the man of the future kicks
all these absurd tubs aside.
Thus life says: "Thou strong men with power-
ful thews, sharp eyes and keen ears, hardy and self-
sufficient in thy independence, I have no use for such
as thou, that are doomed to extinction." . . .
But the new man, who is to take his place, what
promise of happiness does he hold out*?
CHAPTER XV
SHAME AND THE PHYSICIAN
ONE day a peasant woman from our village
came to ask me to see her daughter who was ill.
On entering their cottage I was struck by the
sour and indescribably disgusting stench pervading
the air just the sort of smell as emanated from a
gully where offal is cast. Lying upon one of the
low broad benches running round the room, covered
with a sheep-skin coat, was a girl of seventeen with
pale and wasted features.
"Where do you feel the pain 1 ?" I asked.
She grew very red and made no response, merely
staring at me in a frightened way.
"Oh, Doctor deary, she's a-bed with an illness a
maid might well be ashamed to show," whined the
old woman.
"What nonsense! You mustn't be ashamed of
your doctor! Let me see what's the matter."
I went up to the girl. Her face suddenly as-
sumed a wooden expression of submission, while a
pair of dull and scared eyes stared at me mutely.
"Turn round, Annie, let him have a look!"
228
SHAME AND THE PHYSICIAN 229
coaxed the mother, removing the sheep-skin. "The
doctor will see what ails you, please God he'll do
you good and you'll be well."
With the same imbecile eyes and with a concen-
trated, frightened passiveness, the girl turned on her
side and lifted her rude linen shift, which was stiff
as bark from dried pus. I grew faint from the un-
bearable odour and from the sight I saw. Her
entire left thigh, from waist to knee, was one great
bluish-red swelling, corroded by sores and abscesses
the size of a fist, covered with stinking, decomposing
matter.
"Why didn't you send for me before*? Why,
I've been here for the last six weeks!" I cried.
"Oh, deary Doctor, she was ashamed, poor lass,"
sighed the old woman. "She's been ill more than
a month; she thought it would pass by itself, God
willing; first of all it was just such a little spot. . . .
Says I: 'Annie, there's a doctor come to stay with
the Squire, all pray for him for the good he does
go and show him your leg.' 'Oh no, mammy, I'm
ashamed.' ... Of course, she's a maid and fool-
ish. . . . And this is what we've come to!"
I hastened home to fetch my instruments and
bandaging materials. . . . My God, how grotesque !
Aid was to be had for the asking for the past month
but a clownish, monstrous feeling prevented her
from availing herself of it, and only now, at the
eleventh hour, had she screwed up courage to cross
230 THE MEMOIRS OF A PHYSICIAN
this boundary now that it was too late, per-
haps. . . .
Such cases are very common. How many com-
plaints are neglected by women through this shame,
how many obstructions placed in the way of the
doctor's diagnosis and subsequent treatment ! How
much mental suffering has a woman to pass through
when forced to overstep her shame! Even now
before me arises, as in the life, the flurried face of
the girl, with its suddenly assumed expression of
vacuity, and her scared submissive eyes; she must
have gone through much, before she felt compelled
to waive her maidenly shame and apply to me.
When we are subjected frequently to the same
impressions we become accustomed to them. Never-
theless, whenever a female patient unrobes in my
presence with slightly heightened colour and an al-
most imperceptible tremor, I wonder whether I
have any true conception of what her soul is going
through at this moment?
In "Anna Karenina" there is a painful scene.
"The celebrated doctor," writes Tolstoy, "a very
handsome and not as yet an old man, demanded
an examination of Kitty. He seemed to insist
with special pleasure, that maidenly shame was a
relic of barbaric times and that nothing could be
more natural than that a man, still in his prime,
should feel over a young and bared girl. It was
necessary to submit. , , . After an attentive exam-
SHAME AND THE PHYSICIAN 231
ination and auscultation of the patient, who was
flurried and stupefied from shame, the celebrated
doctor having carefully washed his hands, stood in
the drawing-room conversing with the prince. . . .
Her mother went to Kitty in the drawing-room.
Thin and flushed, with a peculiar brightness of the
eyes, owing to the shame she had lately borne,
Kitty stood in the middle of the room. When the
doctor entered, her face flamed up and her eyes
filled with tears."
Patients gradually develop habit for such exam-
inations; but it is only attained at the cost of the
painful shattering of the spiritual ideology nurtured
from childhood. By no means do all pass through
the mill unscathed. I remember once experiencing
something akin to fear at the sight of the terrible
denudation that such a shattering may occasionally
cause in the soul of a woman. I was a student at
the time and on my way to a cholera-stricken dis-
trict in the province of Ekaterinoslav. At Khar-
koff, about 10 P.M., a young ladylike woman got
into our car; she had a sympathetic and pretty face
with clear nai've eyes. We entered into conver-
sation. On hearing that I was a medical student
she told me that she had been to Kharkoff for
the sake of undergoing special treatment, and forth-
with launched into a description of her malady:
a victim to dysmenorrhcea for the last four years,
she had consulted various professors; one diagnosed
232 THE MEMOIRS OF A PHYSICIAN
anteflezion of the uterus ; another, constriction of the
colon; a month ago division of the colon had been
performed upon her. Gazing at me through the
gloom of the car with limpid and serene eyes, she
described the symptoms of her complaint and told
me how it had commenced; she initiated me into
the most intimate details of her sexual and married
life, there was nothing before which she showed
any hesitation; and all this unnecessarily, with
no end in view, even without any questions on my
part! I listened dumfounded: how many revolt-
ing manipulations and inquisitions must it have
been her lot to submit to, how long and sys-
tematically must she have been forced to trample
upon her woman's modesty, that this voluntary and
aimless baring of herself before the first chance
acquaintance should have become possible!
But if this same shame of woman bore another
character such outraging of her sensibilities, and
the resulting spiritual devastation, would not be
possible. In St. Petersburg once I had to attend
a lady student. Everything indicated typhoid; the
spleen could be felt through her chemise, but it was
necessary to bare her middle, that I might see the
roseola. I hesitated for a moment even now it
pains me to proffer such requests.
"Ah! you want me to lift my nightgown 7" the
girl asked quite naturally, guessing what was re-
quired.
SHAME AND THE PHYSICIAN 233
She did so. And this, which is often so agonising,
shameful and hard, proved wonderfully easy and
simple ! I can hardly tell you what a sympathetic
aspect this serious-faced girl, with her clever and
calm eyes, acquired on the instant. ... I saw that
to her what had happened contained neither offence
nor torture, because she was cultured in the true
sense. But although this baring of herself at my
request was performed with such ready and un-
conscious simplicity, I am convinced that, casually
met in a railway carriage, she would never have told
me anything like that other one.
What is shameful for the human being and what
is not shameful?
There are certain tribes that are ashamed to clothe
themselves. When the missionaries distributed
clothes to the Indians of the Orinoco River, to cover
their bodies with, the women either threw them away
or hid them, saying: "We do not clothe ourselves
because we are ashamed." While in Brazil, Wal-
lace once found in a hut several women who were
absolutely naked, but not in the least abashed by
the circumstance. One of them was provided with
a "saia" or kind of petticoat, which she occasionally
donned; Wallace tells us that it was when she had
it on that she showed almost the same shame as
would a civilised woman if surprised without that
article of apparel.
What is shameful? We judge from a standpoint
234 THE MEMOIRS OF A PHYSICIAN
that we have acquired through the complex agency
of the most varied and, often, entirely chance,
causes. Those who are more bashful than ourselves
and those who are less so, excite the same con-
descending smile of pity at their "want of culture."
Modesty forbids the oriental woman to expose her
face to the male gaze ; a Russian peasant woman re-
gards it as a shame to appear in public with bare
head; the provincial ladies described by Gogol
thought it bad manners to say "I have blown my
nose," substituting "I have made use of my pocket-
handkerchief, I have eased my nose." All this pro-
vokes our laughter, and we are genuinely perplexed
as to why it should be indecent to show one's face
or hair, or to talk about blowing our noses. But
why does not a woman, who is ashamed to bare her
knee or middle before a man, excite our ridicule.
How is it that the most modest girl does not con-
sider it indecent to expose the upper half of her
breast at a ball, whereas, stripped to the waist, she
would be called a brazen hussy? Why do we not
feel shocked at the sight of a man who appears in
the presence of women with uncovered beard and
moustache for these are undoubtedly the secondary
attributes of the male? There is no harm in saying
"I have blown my nose," but the mention of certain
other physiological functions, equally unaesthetic it
is true, but no less natural, is forbidden. In con-
sequence of this, when in each other's presence,
SHAME AND THE PHYSICIAN 235
members of the opposite sexes subject themselves to
torment, frequently courting serious illness by not
daring to betray any sign of wanting to perform that
without which, as all know, we cannot exist.
Our whole up-bringing is directed to the one end
of making us regard our bodies as something to be
ashamed of; we are taught to consider a whole series
of the most legitimate functions of our organisms,
pre-ordained by nature, not otherwise than with
shame; obscoenum est dicere, facere non obscoenum
thus Cicero sums the matter up.
With the first glimmer of consciousness, the child
commences to receive persevering instructions that it
should be ashamed of such-and-such functions and
of certain portions of its body: the pure nature of
the child is for a long time unable to grasp the mean-
ing of these lessons ; but the efforts of its preceptors
do not relax, and at last it commences to realise the
iniquity of its physical life. This goes on for sev-
eral years.
When the time arrives, the mystery of his or her
origin is unveiled before the budding man or woman ;
and thanks to their early training, the secret as-
sumes the aspect of filth from beginning to end, un-
speakably shocking and revolting in its unexpected-
ness. In some the thought of the legitimacy of such
incredible depravity calls forth a voluptuous feel-
ing; it plunges others into despair. The anguished
sobs of the young girl, who recoils at the revelation
236 THE MEMOIRS OF A PHYSICIAN
of the impurity of life, vowing never to marry, her
love rudely trampled into the mire these are ele-
ments for a most serious and painful drama, which,
at the same time, strikes one with its unnaturalness.
But how were anything else possible"? Rousseau
demanded that parents and preceptors should them-
selves explain all to their children and charges, not
leave the task to the unclean tongues of menials and
school-fellows. But this would not make the slight-
est difference: the child's education renders it in-
capable of seeing these things in any other than the
most revolting light that of horrible and shameless
foulness, no matter how "purely" you put things
before it!
Still, all this by no means implies that shame
itself is actually no more than a survival of bar-
barity, as Tolstoy's "celebrated doctor" would have
it! Shame that instinct which protects our in-
timate life from the stranger's gaze, that feeling
which makes it impossible for the human being to
give himself or herself up to the casual female or
male, is no remnant of the barbaric age, but a
precious acquisition of culture.
However, such pudency by no means excludes an
earnest and frank attitude towards the human body
and its life. Bourget, in his "Profils Perdus" has
a striking sketch, in which he describes a highly
educated young Russian girl; a rather shallow
disciple of the "Science of love" is utterly non-
SHAME AND THE PHYSICIAN 237
plussed by her: she discusses with him, "in terms of
scientific materialism," the subjects of conception,
maternity, etc., with the utmost freedom, "whilst,
at the same time, no man's lips had ever so much as
touched her hand!" . . .
Modesty, severe and chaste, does not even pre-
clude nudity. Buffon says: "We are neither
sufficiently depraved nor sufficiently innocent to go
about naked." Is this just? Savages are no more
immoral than we, the fables about their innocence
have long been exploded; at the same time, many
of them go about unclothed and their nakedness
does not deprave them: they are used to it that is
all. More than this, as we have already seen, tribes
exist that are actually ashamed to dress. Exactly
as the custom to clothe one's body may go hand in
hand with the most profound corruption, so can
habitual nakedness be associated with the severest
chastity. The Tierra-del-Fuegan women go about
stark naked, without being in the least embarrassed
by the fact; however, when they felt the lecherous
glances of the European sailors rest upon them, they
blushed and hastened to hide themselves; probably
a fully-attired European woman would flush in the
same way, on encountering the look of a Brazilian
or Orinoco Indian.
It is solely a matter of what we are used to. If
it were only considered improper to uncover the
little finger, the exposure of that part would have a
238 THE MEMOIRS OF A PHYSICIAN
more potent effect upon representatives of the op-
posite sex than that of any other. With us nearly
the whole of the body is jealously concealed by
clothing. The noble, pure and beautiful human
body is thus turned into an allurement for perfectly
definite ends: forbidden and inaccessible to the eye
of the other sex, it is only disclosed on specific oc-
casions, intensifying the voluptuousness of these
moments and imparting to them an added zest.
Habitual nakedness would deal the first and severest
blow of all to the voluptuary. 1 We can admire a
draped beauty without experiencing any special
feeling, but our up-bringing has rendered us inca-
pable of looking purely upon the nude body of a
living woman even were her form to rival the
Venus of Milo in its perfection of shape.
We are ashamed of our body and do not respect
it; all our efforts are directed at ornamenting it at
the price of its complete disfigurement. Special
albums entitled "Le Nu" are annually published in
Paris, being collections of photo-engravings from all
the pictures depicting the nude, exhibited during the
1 In the "Klassische Walpurgisnacht," Mephistopheles felt himself
an utter stranger: "Fasst alles nackt, nur hie und da behemdet," he
grumbled discontentedly, "Zwar sind auch wir von Herzen un-
austandig, Doch das Antike find' ich zu lebendig." . . .
In another place, he remarks:
"Was hat man an den nackten Heiden?
Ich Hebe mir was auszukleiden,
Wenn man doch einmal lieben soil."
That refined voluptuary, Maupassant, lingered with special relish
over scenes describing the process of undressing.
SHAME AND THE PHYSICIAN 239
current year at the art galleries. A glance through
such an album is sufficient to frighten one, yes,
actually fill one with lively apprehension for the
future of mankind the mere sight of those soft,
flabby female figures with gigantic fat posteriors,
compressed sides and rudimentary, prematurely
pendant breasts! Unless to speculate as to the cri-
teria which will in the future determine the limits of
pudicity, but one thing is beyond doubt the man
will treat nature and her ordinances with ever grow-
ing respect, ceasing to blush because he has a body
which lives in accordance with its appointed laws.
But this happy epoch is probably still very remote.
In dealing with the soul of woman at present, medi-
cine must exercise great gentleness and delicacy.
Until recently the stronger sex monopolised medi-
cine, and women with the most intimate maladies
had to apply to men for aid. Who will ever cal-
culate the vast amount of misery and outraged sen-
sibility this involves, count the number of women
who have perished because they could not force
themselves to disclose their sufferings to a man*?
We men are exempted from such trials, also being
less particular in this respect. Nevertheless, some
strange things happen.
In 1883, during the session of a certain Zemstvo,
two of its members tried to get through a proposal
making medically-qualified women ineligible as dis-
trict doctors, "because," explained the worthies,
240 THE MEMOIRS OF A PHYSICIAN
"male syphilitic patients are ashamed to apply to
female physicians." This is quite intelligible to us :
not one of us suffering from any more or less intimate
complaint would willingly accept treatment at the
hands of a woman. But would those excellent
members have had the hardihood to aver that women
felt differently in the matter"? If so, they were
guilty of gross mendacity. The reports of the doc-
tors in the employ of our Zemstvos constantly draw
attention to the reluctance displayed by the peasant
women, and especially girls, in availing themselves
of medical aid.
At the present day, fortunately, medical training
is placed within the reach of women; this is a
tremendous boon to the whole sex without distinc-
tion, not only to Mussulmen women, as the cham-
pions of medical education for women are pleased to
point out. It is a gigantic gain to science itself.
For only woman will be able to understand and
make her own the obscure and terribly involved life
of the female organism in its physical and psychical
entirety; for men this knowledge will ever remain,
at best, incomplete and vague.
CHAPTER XVI
WHEN THE PATIENT DIES
ABOUT eighteen months after my arrival in
St. Petersburg, I was called in to attend the
sick baby of an engine-driver. The family occupied
a room on the fifth floor, at the top of a dirty and
malodorous staircase. The engine-driver's three-
year-old boy had an abscess in one of his tonsils; the
child was rickety, thin and pale; it struggled and
bit at the spoon, so that I had no little difficulty
in examining its throat. I prescribed appropriate
treatment. The father, a tall and shaggy man with
a red beard, wanted to pay me when I was about
to leave; the room was wretched and squalid and
there were a lot of children about, so I declined to
take his money. He respectfully saw me to the
door and thanked me.
For the next two days the child continued fev-
erish, the swelling in the throat increased and
respiration grew difficult. I spoke to the parents
and proposed to lance the gathering.
" How's that*? Do you mean that you will cut
him inside*?" asked the mother apprehensively and
suspiciously.
242 THE MEMOIRS OF A PHYSICIAN
I explained that the operation was quite safe.
"No then! I won't allow it!" she declared
with shrill decision, and my remonstrances and ex-
planations were unavailing.
"I think that the Lord knows best," said the
father. "If God wills it the boy will die, even if
you do slit the gathering. Besides, he's too weak to
stand an operation, anyway."
I said no more, but began to syringe the child's
throat.
"Why, he opens his mouth himself now," re-
marked the father sadly.
"The abscess will probably burst to-day," I said.
"See that the child doesn't choke in his sleep from
the matter. If he's very bad, send for me."
I went into the kitchen. The father sprang after
me, and begari helping me on with my coat.
"I don't know, Mr. Doctor, how to thank you.
We shall be your debtors, in a manner of speaking,
for life!"
When I came round again next day, the bell was
answered by the engine-driver's wife; her eyes were
red, her face was pale, she cast a hard look at me,
and withdrew to the kitchen-range without a word.
"Well, and how is your son?" I queried. No
answer came. She did not turn round even.
"Dying," muttered an old woman from a corner
of the room.
I took my overcoat off, and stepped into the
WHEN THE PATIENT DIES 243
dwelling-room. The father sat on the edge of the
bed, with the pallid child lying on his lap. He
glanced at me in a cold and apathetic way.
"It's beyond me how he lived till morning," he
answered sulkily. "He'll be dead by mid-day."
I felt the little patient's pulse.
"The matter came out of his nose and mouth all
night long," continued the father. "Sometimes he
was nearly suffocated went blue, and turned his
eyes up; the wife would begin to cry and shake him
and he'd come round a bit."
"Bring him to the window, I want to look at his
throat," I ordered.
"What's the good of tormenting him any more 1 ?"
the mother angrily broke in just then. "Leave him
in peace!"
"Fie!" I cried. "Your child gets a little worse
and you lose all hope and do nothing: let it die!
Why, he isn't really so ill at all !"
The swelling in the throat had considerably sub-
sided, but the boy was greatly exhausted, and very
weak. I told the parents that he was doing very
well indeed, and would soon be all right.
"Lord grant it !" remarked the engine-driver with
a sceptical sneer. "7 don't think you'll find him
alive when you come to-morrow."
I wrote out a prescription, explained how the
medicine was to be administered, and rose to go.
"Good-bye!"
244 THE MEMOIRS OF A PHYSICIAN
The father hardly vouchsafed me an answer, and
no one saw me to the door.
I left them, deeply indignant. Of course their
grief was perfectly legitimate and comprehensible:
but what had I done to merit such treatment?
They saw how much trouble I gave myself on their
behalf and not a spark of gratitude ! There used
to be a time when in my dreams I pictured things
very differently: the patient died, but his relatives
had seen how warmly and disinterestedly I minis-
tered to him in his sickness, and regarded me with
love and gratitude.
"I'm not wanted so much the better ! I won't
call again," I decided.
Next day I had to bring all my will-power into
play to force myself to visit my little patient.
While in the act of ringing I trembled with indigna-
tion, in anticipation of further proofs of the sense-
less, undeserved hatred of those people whom I was
doing all in my power to assist.
I was admitted by the mother rosy, happy;
after a momentary hesitation she seized my hand
and warmly wrung it. I was surprised to see what
a nice and comely face she had I never noticed
the fact before. The child was getting on very well,
looked cheerful and asked for food. I left, fol-
lowed by the fervent thanks of both parents.
This case was the first to show me that if you
are expected to save the life of a dear one, and you
WHEN THE PATIENT DIES 245:
disappoint such hopes, you will never be forgiven,
no matter how great your pains may have been.
I attended the young wife of a certain merchant,
Starikoff by name, suffering from diphtheria. Her
husband, a round, rubicund little man with a good-
natured face and small yellow moustache, used to
drive round himself with his thorough-bred "trotter"
to fetch me. His fussy, counter-jumper's attentions
embarrassed and amused me at the same time. He
stood at my elbow when I got into the sledge, then
arranged my fur coat about my knees, and having
made me comfortable, would seat himself on the
very edge of the cushions. The patient was stricken
down with a very serious, so-called phlegmonous
form of the disease, and hovered on the brink of
death for several days; at last, however, she began
to recover. But there was still danger to be feared
from paralysis following on diphtheria.
One morning I was rung up at four o'clock by
my patient's husband. He told me that his wife
had suddenly been seized with sickness and violent
pains in the stomach. We drove off without delay.
A blizzard was raging outside, and the light sledge
sped swiftly through the deserted streets.
"What a lot of trouble we do give you, Doctor!"
began my companion apologetically. "Just think
of hauling you out at such an hour and in such
weather too, depriving you of your sleep!"
The sufferer was in a very bad way; she com-
246 THE MEMOIRS OF A PHYSICIAN
plained of drawing pains in the chest and stomach,
her face was white with that indescribable pallor
which does not even require a very practised eye
to tell the doctor that heart failure is rapidly and
irresistibly drawing near. I, accordingly, warned
the husband of the imminence of the danger. After
staying three hours with the patient I left her to
visit another serious case that could not wait. An
experienced trained nurse replaced me at Mme.
Starikoff' s bedside.
In an hour and a half I returned. The husband,
with altered face and inflamed eyes, came out to
meet me. He paused on the threshold of the draw-
ing-room, and deliberately put his hands beneath
his coat-tails.
"Got anything nice to tell us?" he asked in tones
of contemptuous familiarity.
"How is Maria Ivanovna*?"
"Maria Ivanovna, is it 1 ?" he repeated in drawling
accents.
"Why, yes."
He remained silent for a moment.
"She died comfortably half an hour ago!" sneered
Mr. Starikoff, scanning me with hatred. "Good-
day!'' And, abruptly turning on his heel, he dis-
appeared in the drawing-room, where the deceased's
relatives were assembling.
My memory refuses to recognise the same man
in these two personifications of Mr. Starikoff; the
WHEN THE PATIENT DIES 247
one fussily attentive, obsequious, hanging on my
words, the other distant, hostile, provoking in his
offensive familiarity of manner, with red eyes burn-
ing with hatred. Oh, how such people do hate!
Their hatred knows no bounds. In former times,
on like occasions, short was the doctor's shift.
"A certain outlandish physician, Anthony by
name," we read in the ancient Moscovite chronicles,
"doctored Prince Karakoutsh, but took his life with
poisonous herbs because he mocked. Whereas the
Great Prince Johann III. delivered him to the son
of Karakoutsh, who tortured him and then held him
up to ransom. Whereas the Great Prince did not
allow this to be done but ordered his killing; and
they led him in the winter to the Moskva River,
and beneath a bridge slaughtered him with a knife,
like a sheep."
According to the laws of the Westgoths, if a
doctor's patient died, the former was immediately
handed over to the relatives of the deceased, "that
they might do what they pleased with him." And
even nowadays, many and many sigh because these
cheerful customs have gone out of fashion. About
fifteen years ago a Russian landowner, a certain
Herken, lost his daughter whom one Dr. Svintsinsky,
in the employ of the Zemstvo, had attended. Ac-
cording to the provincial newspapers, the be-
reaved parent handed the Assembly of the Zemstvo
a deposition, in which he stated that Dr. Svintsinsky
248 THE MEMOIRS OF A PHYSICIAN
was more ignorant of medicine than a common hos-
pital attendant, and that the entire population of
the district were dissatisfied with him because of his
"lack of knowledge and attention." A commission
of enquiry was nominated. Herken's plaint was
found to be a gross libel, and the Assembly passed
a unanimous resolution expressing gratitude to Dr.
Svintsinsky for his "upright and beneficial labours."
Towards the end of 1883 the Novorossisky Tele-
graph newspaper, published in Odessa, printed a
letter by a certain Beliakoff, under the following
sensational headline:
MY SON HAS BEEN MURDERED.
(A father's extraordinary obituary notice on his son.)
"Yes, Mr. Editor!" wrote Beliakoff, "My only
son, Socrates, was scientifically murdered in Kher-
son, at the stroke of 10 P.M., on the 28th of No-
vember, through the agency of a local operator called
Petrovsky." . . .
And in a lengthy "feuilleton" Beliakoff pro-
ceeded to describe in minute detail how his child
had been taken ill with diphtheria, how faultily the
doctors attended it, and how the affection extended
to the larynx, thanks to their neglect. With the
conscientiousness of an examining magistrate he
quoted all the doctors' orders and prescriptions, as
evidence for the prosecution, and thereby clearly
WHEN THE PATIENT DIES 249
although unwittingly proved to all competent per-
sons that there was nothing to find cavil at. The
child was in a very bad way. One of the doctors
declared the case hopeless and left. The father
implored that his child should be saved. It was
then that Dr. Herschelmann, who had remained,
proposed the last expedient an operation. During
the latter, which was performed by Dr. Petrovsky,
the child died. As will be seen from the writer's
own testimony, the case was a very bad one, the
end being possible at any moment; but Beliakoff,
who was entirely incompetent to judge, declared that
the operator had simply "murdered" his son. 1
"Ought the operation to have been performed,"
queried Beliakoff, "the illness having lasted for six
days? Competent persons (?) say that when
diphtheria has run its course for so long without
complications and the patient still breathes there
can be no need for an operation" (this is absolute
nonsense). "Finally, was Dr. Herschelmann's
treatment right? Had he employed all the reme-
dies possible to save the patient? In my opinion
Dr. Herschelmann treated the affair too super-
ficially. . . . After this hunt up a paragraph in our
1 In consequence of a formal petition lodged by the father, the
child's body was exhumed and a post-mortem examination held in
the presence of the examining magistrate and four experts; it was
clearly established that the cause of the deceased's death was as-
phyxiation by diphtherial membrane, the operation itself having
been performed irreproachably.
250 THE MEMOIRS OF A PHYSICIAN
penal code that would meet the case, and justly in-
flict a terrible penalty upon the person guilty of
Socrates' death, and thus avenge our grief !"
Of course, no paragraph of any penal code could
have appeased Beliakoff. Now, if the laws of the
Westgoths were in force, no doubt the fond parent
would have devised a penalty fully avenging his
loss! The thirst for a sanguinary expiatory offer-
ing to the shade of the dear departed, at any cost,
is very strong in man.
In the beginning, this hatred which I had to face
tortured me acutely. I turned red and suffered
agonies whenever I chanced to meet in the street
any one connected with a defunct patient, and saw
the former hastily look away, so as not to bow to
me. Little by little becoming inured to such a
state of affairs, I began to be aware of an unlooked-
for phenomenon.
Not far from where I lived resided a lady proof-
reader, a certain Mme. Dekanoff, whose son, a pupil
of the Gymnasium, suddenly fell ill. I was recom-
mended to her by one of my patients and she asked
me to call. She lived in a small flat with her two
children the sick boy and her grown-up daughter
Katerina Alexandrovna, a prepossessing girl with an
attractive and spirituelle face a student of medi-
cine. It was evident that both mother and daugh-
ter worshipped the boy. I found him to be suffer-
WHEN THE PATIENT DIES 251
ing from croupous pneumonia. The mother, a thin
and nervous woman with restless, psychopathic eyes,
was overwhelmed.
"Doctor, tell me, is it very dangerous 1 ? Will he
die?"
I replied that it was impossible to say anything
at present, that the crisis would set in in five or six
days. And then began a most trying time for me.
Neither mother nor daughter could for a moment
allow the thought that their darling might die;
they were ready to do anything to save him. I had
to visit the patient three times a day; this was en-
tirely unnecessary, but I was overborne by their per-
sistency.
"Doctor, oh, he is not dying, surely*?" the mother
would ask in a horrified and strangled voice. "Oh,
my dear Doctor! I am off my head, forgive me.
. . . What was it I wanted to say? . . . Oh, yes,
you'll do all you can? You will save my Vladi-
mir?"
On the fourth day Katerina Alexandrovna took
me aside; she was much agitated and bit her lips,
seeking to control herself.
"Don't take it amiss, but might I speak to you
as to a private person. . . . Your treatment strikes
me as being too commonplace: baths, codeine, cup-
ping, ice-packs to the head. . . . Now you've pre-
scribed digitalis." . . .
252 THE MEMOIRS OF A PHYSICIAN
"If you think so, please take matters into your
own hands I will obey your commands," I coldly
responded.
"Oh, no, I know nothing," she hastily exclaimed.
"But I want something out of the common to be
done that would save our Vladimir for certain.
Mother will go out of her mind if he dies."
"You had better find another doctor; I am doing
all that I think necessary."
"Oh, you misunderstand me again. . . . Forgive
me, I don't know what I am saying myself!" she
finally broke off nervously.
They had hired an experienced professional nurse
to attend their patient. Nevertheless, hardly a
night passed without my being rung up by the
younger of the two ladies; the servant would for-
ward an urgent message :
"Vladimir is worse, he is delirious and groaning,
please come round."
And I dressed and went without demur. But
sometimes my patience failed me.
"Were you sent by the nurse or did you yourself
consider my presence necessary*?" I would ask
gruffly.
Her dark eyes flashing with indignation, on such
occasions Katerina Alexandrovna could barely con-
trol herself, seeing how I valued my rest.
"I fancy a mere Sister of Mercy is no doctor and
incompetent to judge."
WHEN THE PATIENT DIES 253
Saying no more, I would enter the sick-room.
The boy is delirious, tosses about fitfully, his breath-
ing is rapid, but the pulse good and there is no need
to alter anything. The nurse sits at the window
in a huff. I silently go into the hall.
"What's to be done*?" asks Katerina Alexan-
drovna. "His pulse is growing faint."
"Continue treatment as hitherto. The pulse is
excellent," I answer moodily, and close the door
behind me. And on my way home I reflect that if
I had to attend such a patient daily for a year, my
constitution, no matter how robust, would be utterly
worn out.
Next day the boy feels better and his sister's eyes
gaze upon me affectionately and caressingly.
In fact, without seeing the patient, I always un-
erringly guessed how he was by the expression of
Katerina Alexandrovna's eyes when she opened the
front door; if he were worse, her face breathed ill-
concealed dislike ; if he were better, her eyes beamed
upon me with infinite tenderness.
The crisis was very stormy. For two days the
boy hovered between life and death. During that
period I was hardly outside the Dekanoffs' flat.
Twice I held consultations. The mother looked
quite crazed.
"Doctor, save him! . . . Doctor!" And tightly
clutching my elbow with her bony fingers, she peered
fixedly into my face with eyes that were both piteous
254 THE MEMOIRS OF A PHYSICIAN
and supplicatory, and at the same time terrible and
full of hatred; as if she sought to make me fathom
the abyss of anguish his death would plunge her
into.
The boy, with bluish and motionless face,
breathed hurriedly and thickly, his pulse was hardly
perceptible. I completed my auscultation and lift-
ing my head, caught the hungry look of the dis-
tracted, awful eyes of the mother.
The patient survived the crisis and rallied. Two
days later he was out of danger. Mother and
daughter came to my house to express their thanks.
Oh, Lord, what gratitude was theirs.
"Doctor, darling! Our dearest friend!" the
mother kept on repeating in ecstasies. "Can you
realise what you have done for me*? . . . No, you
cannot! Oh, God, how can I express myself 1 ?
When I die I will think of you alone! I have
vowed it to Our Lady of Sorrow. . . . Oh, what
can I do to thank you sufficiently, I am under a life-
long obligation to you. Doctor, forgive me." . . .
And she tried to seize my hand to kiss it.
Katerina Alexandrovna, her profound and beautiful
eyes streaming, clasped my hand in both of hers.
While I I looked at both these women, trans-
figured by this ecstatic gratitude, and seemed to de-
tect a vanishing reflection of that hatred which had
gleamed in those same eyes three days ago.
They departed, I resumed the book which their
WHEN THE PATIENT DIES 255
advent had made me lay aside. And suddenly it
struck me how cold all their thanks had left me; it
was as if a tiresome tempest of words, empty as
chaff, had passed over my soul, not one of them
finding its way to my heart. Was this myself who
had once upon a time imagined that such moments
as those were our reward, the "bright rays of light"
which illuminated the sombre and hard life of the
physician*? "What bright rays were these*?"
Undying hatred would have been my reward for the
same pains and strenuous desire to save the boy
if he had died.
Gradually I grew accustomed to that hatred and
became indifferent. And as an unexpected con-
sequence of this, complete coldness to gratitude fol-
lowed of its own accord.
And the conviction took ever deeper and deeper
root that in general it was first of all necessary to
develop in oneself a profound and utter indifference
to the feelings of the patient. Otherwise, despair
and grief would drive one mad twenty times over.
CHAPTER XVII
"THE PROFESSIONAL MANNER"
VERILY, we must steel our hearts and rise su-
perior to suffering, despair and hatred, con-
templating each patient as an irresponsible being,
powerless to deal us any insult. Secure in the
armour of such a philosophy, I will go dispassion-
ately to the engine-driver I spoke of in the forego-
ing chapter, and the thought of his unjust hatred will
be powerless to make me falter on the threshold.
"Indifference, indifference!" This was the watch-
word I ever repeated to myself. But oh ! how hard
it was to acquire !
I recently attended the young wife of a civil-
service functionary. Her husband, with a nervous
and intellectual face and queer thin voice, informed
me in a panic that his wife was very ill probably
with diphtheria. Examination, however, showed it
to be merely a case of ulcerated sore throat.
"It isn't dangerous, is it?" queried the husband.
"No. Very probably it will be over in a day or
two, although it is possible that an abscess may
form."
256
"THE PROFESSIONAL MANNER" 257
Two days later a gathering actually did appear
in the left tonsil.
"Why should an abscess begin to form*?" enquired
the husband.
Why! As if any one could answer such a ques-
tion.
Both husband and wife showed me the confiding
and charming trust that is so stimulating and is
so valued by the doctor. My every direction was
carried out to the letter, almost religiously. For
five days the patient was in great pain and hardly
able to open her mouth or swallow. After I had
incised the swelling several times, it subsided and
the patient began to recover rapidly ; however, some
muscular pain still remained on either side of the
neck and I applied myself to massage the affected
parts softly.
"How delicately and gently you do everything!"
the patient said with a blushing smile. "Really I
wouldn't mind being ill always to be attended by
you."
I used to remain to coffee every day, in com-
pliance with their kindly insistent invitations, often
chatting with them for an hour on end. I expe-
rienced great pleasure in the friendly and almost
affectionate way this couple treated me.
Two days later the patient began to feel pains in
the right side of her throat and her temperature went
up again.
258 THE MEMOIRS OF A PHYSICIAN
"What can it be?" asked the alarmed husband.
"Probably a gathering is forming in the right
tonsil too."
"Oh, dear! Another!" moaned the lady, drop-
ping her hands on her lap.
Her husband opened his eyes wide.
"But why should this happen?" he enquired with
astonishment. "We seem to have done all that
could be done!"
I explained the impossibility of stemming the
natural course of the malady.
"Oh, my poor little girl !" he exclaimed nerv-
ously. "So we must go through it all once more !"
And I plainly detected in his tone a note of anger
directed against myself.
The abscess ripened with provoking slowness,
notwithstanding my lancing it twice. Once more
the patient's throat swelled and swallowing became
difficult. I noticed the daily increasing coldness of
both husband and wife, and the thickening of an
atmosphere of genuine detestation of myself. I
now experienced an unpleasant feeling whenever I
called. I was pained when I had to examine the
silent patient and issue my orders the husband
trying not to look me in the face while I spoke.
At the same time their former kindly manner
towards me gave place to a species of exaggerated
and punctilious politeness; their distrust and an-
tipathy could be plainly felt, although concealed
"THE PROFESSIONAL MANNER" 259
beneath a veneer of civility, which did not give me
a chance of coming to an understanding and throw-
ing up the case. At bottom, there was not even any
real distrust; I was merely the personification and
accompaniment of the tiresome illness that had ex-
hausted our patience all round, and as such, had be-
come hateful and odious.
At last the patient got well. Superficially our
parting was very cordial, but when, a week later,
I encountered the husband in the lobby of the
theatre, his countenance suddenly assumed a pre-
occupied expression, and, averting his face, he rap-
idly passed by, pretending not to have seen me.
Yes, we must harden our hearts and not let such
treatment hurt us, because it is part and parcel of
our vocation. But frequently, especially when deal-
ing with incurable chronic cases, all the force of
habit, all the efforts of one's will, cannot stand up
before the wild onslaughts of the despairing invalid's
fierce hatred for his doctor. It is the doctor's high-
est bliss to get rid of such a patient, but often, all
his detestation notwithstanding, the latter will cling
to his medical adviser with tenacity, declining to be
shaken off. A few years ago the following affair
took place in Italy, not far from Milan. Dr.
Franchesco Bertola attended a certain consumptive
cobbler in the last stages of the disease. Seeing
his condition ever growing worse, the tradesman
lost all patience and began to abuse his physician
260 THE MEMOIRS OF A PHYSICIAN
every time the latter called, cursing him for a quack,
an ass, an ignoramus, etc. Assuring himself of the
irradicable hatred of the man, Dr. Bertola declined
to treat him further. His decision threw the cob-
bler into a frenzy. Waylaying the doctor next day
in the street, he asked: "Will you resume your at-
tendance of my case or not?" and on receiving
a negative answer, thrust a butcher's knife into the
doctor's stomach. The unfortunate man fell down
mortally wounded, the assassin sinking to the ground
simultaneously, blood gushing from his mouth.
The murderer and his victim were immediately
picked up and conveyed to the same hospital, where
they both died.
A doctor's life is made up of moments of terrible
nervous tension, which almost without intermission
beat at his heart like sledge-hammers. A sudden
turn for the worse in a convalescent patient, an in-
curable who cries for relief, the impending death of a
patient, the ever present possibility of an untoward
accident or mistake, finally, the whole atmosphere
of suffering- and sorrow that surrounds one all
these hold the soul in an everlasting thraldom of ill-
defined, unappeasable alarm. We are not always
conscious of this mental condition. But perhaps a
red-letter day dawns when all goes smoothly: no
deaths, the patients are all getting on well, you are
treated with cordiality and only then does the
resulting sensation of deep relief and restfulness sud-
"THE PROFESSIONAL MANNER" 261
denly bring home the realisation of that terrible state
of nervous strain that you habitually live in.
There are times when the powers to continue
such a life are entirely exhausted and you are seized
with such depression that only one thought remains
to turn your back on all and flee far from the
madding crowd and feel, if only for a time, free
and at peace.
Man cannot always live at such a pace and I
am beginning to develop certain salutary habits. I
no longer feel the sting of my patients' hate and
injustice as of yore, my heart is not cut to the quick
by their sufferings and the sight of their helpless-
ness. Serious cases are especially instructive to a
doctor; formerly I could not grasp how it was that
my hospital colleagues were so eager to take over
the wards with "interesting" bad cases; I, on the
contrary, did my best to eschew such invalids. I
was pained at the sight of their shrivelled bodies
with scaling flesh and polluted blood, to meet their
gaze mutely praying for the assuagement of their
torment while I could do so little for them.
Time brought habit.
Small wonder that I should be gradually evolving
an attitude towards my patients which is a thing
entirely apart: I am kind and considerate towards
them, trying to give their needs my full attention,
conscientiously doing all I can for them; but "out
of sight, out of mind." At home, in the circle of
262 THE MEMOIRS OF A PHYSICIAN
my friends, I chat and laugh: if I am called to a
patient, I go, do what has to be done, perhaps com-
fort the mother weeping over her dying son; but on
my return I at once resume my former humour, and
the shadow of the past does not obtrude itself on
the present. To me the "patient," with whom I
have to deal professionally, has nothing in common
with any ordinary sick person. However, leaving
intimate friends out of the question, it suffices for
such a sick person to be a mere acquaintance, and
I am capable of sharing his sufferings; but in my
official capacity this faculty is ever becoming more
and more atrophied, so much so, indeed, that I can
fully understand a friend of mine, a surgeon (the
most humane of men), who asks the patient, shriek-
ing beneath his knife, with perfectly genuine as-
tonishment: "Funny man, why make such a row*?"
I also understand how Pirogoff, with his respon-
sive and sensitive heart, could have been guilty of
the revolting sally he mentions in his memoirs.
"Only once in all my practice did I make such a
gross mistake in my examination of a patient, that
on performing lythotomy, I could find no stones in
the bladder. This was in the case of a timid and
God-fearing old man; greatly vexed at my false
stroke I was indelicate enough to send the exhausted
patient to the devil repeatedly. 'You have no fear
of God,' he said in a languid, supplicating voice,
"THE PROFESSIONAL MANNER" 263
'if you invoke the unclean evil spirit when only the
name of the Lord can alleviate my anguish !' '
It is a strange peculiarity of the human heart
that it should so often become hardened in a definite
and, frequently, very narrow groove, remaining in
other respects unchanged. Formerly such things
were beyond my understanding ; now, however, I am
convinced that a gaoler or executioner is capable
of warmly responding to all that is good, if only it
lies beyond his professional sphere.
In dealing with my patients I am not guided by
my immediate feelings, but by the promptings of my
reason. This gives me breathing space. But
when personally I come across the same attitude in
others, I cannot help experiencing a feeling of in-
dignation.
My sister arrived in my house from the provinces ;
she had been a municipal school-teacher, but was
forced to resign two years previously, owing to ill-
health: overwork had completely exhausted her
nervous system, and her weakness was such that she
lay in bed for days and nights, the peal of a bell
called forth convulsions, she could not sleep at all
and had become embittered, irritable and trivial.
Two years' nursing had done her no good, so, as a
last hope, she decided to see a specialist of the
metropolis. I did not recognise her, she had grown
so thin and pale, her eyes had become large, bluish
264 THE MEMOIRS OF A PHYSICIAN
circles were pencilled round them and they burned
with a strange nervous lustre.
Formerly so full of energy and thirst for work,
now she was lackadaisical and apathetic. I took her
to see a celebrated neuropathologist.
We had long to wait, for his consul ting- room was
thronged. At last we were shown into his study.
The professor, with a merry face, upon which in-
difference was writ large, began to interrogate my
sister; he nodded his head at each answer and said:
"Very good!" Then he sat down to write out a
prescription.
"Can I hope for a cure 9" asked my sister, and
her voice caught.
"Oh, of course, of course!" came the genial re-
joinder. "Thousands suffer from the same com-
plaint, of course you'll get well! We'll order you
baths twice a week, then." . . .
I was experiencing a feeling of ever-increasing dis-
like for the merry, nonchalant face, and that tone,
with which it is customary to address little children.
He did not know that there was tragedy in the air:
six months earlier, on entering my sister's room by
chance, her mother had wrenched from her grasp a
phial of morphia, with which she was on the point of
poisoning herself, not wanting to drag out the exist-
ence of a useless parasite. . . . And we had to listen
to this odious tone, accompanied by that no less
"THE PROFESSIONAL MANNER" 265
odious freedom of manner, that so plainly denoted
how little this drama concerned the outsider.
My sister stood silent and big tears coursed down
her cheeks unheeded; proud, she was angry to be
unable to suppress them and they fell all the faster.
Her great grief had been vulgarised and belittled
for were there not thousands such as she"? and the
magnitude of her affliction struck no one. ... To
think that she had anticipated such great things
from the interview !
"Tut, tut, young lady! That will never do!"
exclaimed the professor at the sight of her weeping.
"Dear, dear, dear, what a shame! Crying! Com-
pose yourself, compose yourself."
And once more his entire manner proclaimed that
the professor daily saw dozens of such hysterical
patients, and that, for him, these tears were but
drops of saline fluid secreted from the lachrymal
glands by shaky nerves.
We left in silence, and silently took our place in
our cab. My sister bent forward, buried her face in
her muff, and suddenly broke into sobs, vainly and
angrily trying to smother them.
"I won't take any of his foolish medicines!" she
cried, tore out his prescription and reduced it to
shreds. I did not protest; in my heart I felt like
her, having lost all faith in the efficacy of the treat-
ment prescribed by that nonchalant, self-complacent
266 THE MEMOIRS* OF A PHYSICIAN
man, who cared so little for the afflictions of his fel-
low-creatures.
And that same evening I thought: "Where
then shall I discover the true line of demarcation be-
tween patient and physician which will make exist-
ence possible to both, and shall I always be able to
keep to that line?
CHAPTER XVIII
DOCTORS AND MONEY
ONE night I heard my bell pulled violently.
The servant informed me that I was begged to
visit a patient. A tall pimple-faced young man,
wearing the cap of a post-office clerk, stood in the
hall.
"Doctor, please come at once to see a lady who
has suddenly been taken ill!" he burst forth in an
agitated voice. "She's dying. . . . It's quite near
by just round the corner." . . .
I hastily dressed and we started off together.
"What has happened to your patient? Has she
been ill long*?" I asked my companion.
He shrugged his shoulders in perplexity.
"I simply can't understand it ! My God ! She's
the wife of a fellow employee and I am their paying
guest. Last night they returned home from seeing
some friends, and she laughed and joked. While
a short time ago her husband woke me up, saying
that she was dying, and sent me after you. I'm
quite at a loss to say how it all happened !"
We climbed up to the fourth floor along a dark
and steep staircase, lighting our way with matches.
267
268 THE MEMOIRS OF A PHYSICIAN
My guide rang sharply. A dark young man with
a small black beard, in his shirt sleeves, opened the
door.
"Doctor. For God's sake!" he sobbed, "quick!"
He led me into a bedroom. Upon a broad double
bed, with her head bent towards the wall, lay the
motionless form of a young woman. I felt her
pulse: her hand was cold and limp, there was no
flutter in her wrist; I turned the young woman
on to her back, lifted her eyelids, sounded her
heart. She was dead. I slowly straightened my-
self.
"Well?" asked the husband.
I shrugged my shoulders regretfully.
"Dead!" he cried in a choking voice, and sud-
denly, staring at me with fixed and protruding eyes,
began to sob quickly and jerkily, with a queer, bark-
ing sound. It seemed as if his eyes had become
rooted into me and he continued to shake and sob in
the same strange, jerky fashion.
"Try to calm yourself. . . . Nothing can be
done!" I said, placing my hand on his arm. He
sank heavily into a chair, and swaying his body to
and fro, seized his head in his hands. A young girl
clad in a night-jacket and worsted petticoat, who
had been standing by the chest of drawers, began to
cry audibly.
The dead was growing cold. Young and beauti-
ful, draped in a laced nightgown, she lay upon the
DOCTORS AND MONEY 269
bed among the crumpled sheets which still seemed
to retain their warmth.
"How did it all take place*?" I asked.
"She was quite well !" the husband cried stri-
dently. "We returned home from a party yester-
day. I woke up in the night and saw her lying on
her side. I touched her shoulder, she was cold and
did not move. Oh, God, God, God !" he repeated,
pulling his hair. "Oh, oh, oh! what does it all
mean?"
My companion shook his head in pitying depreca-
tion.
"There now, old man! Serge! We can't help
it now !" he remonstrated in a sad and supplicating
voice. "It's God's will! You remember the
Tsheprakoffs, the same thing happened to them ; we
are helpless before the Lord's will."
"But oh! Only a minute or so ago. Na-
astenka! Nastia! . . ."
The girl dressed and went out to send the house-
porter for the mother of the deceased. The friend
continued to console the young widower. There
was nothing further for me to do, so I rose to go.
The husband seemed to wake up.
"One moment, Doctor, just one moment, pray!'
he said hurriedly.
And continuing to sob, he hastened to open a
drawer of the bureau and, after rummaging about a
little, handed me three roubles.
270 THE MEMOIRS OF A PHYSICIAN
"If you please, no!" I said with a frown, putting
his hand from me.
"But, Doctor, how is this? Why not*? No, no,
please." I had to accept the fee. I returned home
feeling both pained and offended; those three rou-
bles burned my pocket: what a harsh, brutal disso-
nance they were in the presence of this terrible
bereavement ! I pictured my wife dying before my
eyes in the same way and could not imagine myself
hunting for a few miserable coins to pay the doctor !
Even if we were angels, this necessity of paying for
our services at moments when one would look to see
the whole world stand still for grief, were sufficient
in itself to breed sentiments of animosity and ab-
horrence towards us medical men. I experienced
these on contemplating my role in the abstract.
Oh, that money! What a time it took me to
become more or less used to these payments ! Your
every step is marked by a rouble, the ring of the
rouble ever intrudes itself between you and suffering
man. What complications does it not cause, how
often it interferes with one's work and ties one's
hands. . . .
I was especially weighed down in the beginning
by the very system which governs the appraisement
of the services rendered by the physician. We are
paid for treatment, no matter whether we cure or
not. In the present state of our science no other
DOCTORS AND MONEY 271
arrangement were feasible, but, nevertheless, it
struck me as grotesque and absurd that payment
should be made for work that had accomplished
no useful end. About three years ago a certain
French doctor of Lyons treated a lady with in-
trauterine injections of iodine; the patient getting
no better, her husband, a rich man, instead of dis-
charging his doctor's bill, sued him for 10,000 francs
damages for the alleged injury done his wife's
health. The Court found for the defendant and
condemned the plaintiff to pay the doctor six hun-
dred francs for his attendance, "because the phy-
sician had employed a remedy sanctioned by science,
and was not therefore responsible for the inefficacy
of his treatment."
But then, again, wherein lies the guilt of the
patient who applies to the physician for aid and is
obliged to pay him for the questionable pleasure of
undergoing a course of inefficacious treatment ac-
cording to the methods "sanctioned by science'"?
Sganarelle, in Moliere's "Le Medicin Malgre
lui," remarks: "Je trouve que c'est le metier le
meilleur de tous (i.e. medicine) car, soit qu'on fasse
bien, ou soit qu'on fasse mal, ou est toujours paye de
meme sorte. La mechante besogne ne retombe
jamais sur notre dos, et nous taillons comme il nous
plait sur PetofTe ou nous travaillons. Un cordon-
nier, en faisant des souliers, ne saurait gater un
272 THE MEMOIRS OF A PHYSICIAN
morceau de cuir qu'il n'en paye les pots casses, mais
ici Ton peut gater un homme sans qu'il en coute
rien." x
There is much mordant truth in these words,
spoken by Sganarelle, as in Moliere's remarks on
doctors in general. Only that there is really no
cause for merriment: we have before us once more
one of those involved and painful incongruities with
which the physician's work is so monotonously re-
plete.
The Lyonnais tribunal found that the doctor
accused had "employed a remedy sanctioned by
science and was not therefore responsible for the
inefficacy of his treatment." Moliere ironically
remarks through the lips of the soubrette Toinette
(see "Le malade imaginaire") :
"Cela est plaisant! ils sont bien impertinents de
vouloir que vous autres messieurs, vous les gueris-
siez! Vous n'etes point aupres d'eux pour cela;
vous n'y etes que pour recevoir vos pensions et leur
ordonner des remedes: c'est a eux a guerir s'ils
peuvent." 2 And we medical men are compelled in
1 "I find that it (i.e. medicine) is the best trade of all, because
whether you do your work well or ill, you are paid the same. Fail-
ure is never visited on our backs and we cut the material upon
which we are working as we please. If a cobbler, in making a
pair of shoes, spoils a p : ece of leather, he must pay for the damage,
while here one may spoil a man without its costing anything."
2 "This is pleasant! they are very impertinent to wish you, other
gentlemen, to cure them! You do not attend them for that purpose;
you are only there to receive your fees and to prescribe remedies:
their affair to get well, if they can!"
DOCTORS AND MONEY 273
all seriousness to give the same answer that Moliere's
caricatured doctor Diafoirus made to Toinette:
"Cela est vrai. On n'est oblige qu'a traiter les gens
dans les formes." ("That is true. One is only
obliged to treat people according to the forms.")
Exactly we are obliged to treat patients in ac-
cordance with the rules of science. And no fault
of ours that these should be so imperfect. If a
physician were only paid for successful treatment,
he would not waste time in undertaking that of any
more or less serious case, there being no guarantee
for a cure.
When I started on my medical career, every fee I
received made me feel most unhappy. This money
seemed a stain on my noble vocation, and its accept-
ance lowered me in my own estimation. It struck
me as incredible that the doctors of Western Europe
should have arrived at the cynicism of sending bills
to their patients. 3 A bill for medical attendance!
Just as if a doctor were a tradesman and his minis-
trations to the patient could be assessed in guineas,
francs or marks, as so much grocery! Like Vol-
taire's ideal doctor, I never pocketed a fee without
regret and availed myself of every excuse for de-
clining it. During the first two years of my life in
8 In Russia it is customary to pay the doctor upon each visit ;
etiquette requires that his fee should be handed to him in as unob-
trusive a manner (generally in the act of shaking hands) as pos-
sible, every one paying according to his means. One may accept
the average fee paid to the family doctor, by people in the middle
station of life, at three roubles (about $1.50). TRANSLATOR.
274 THE MEMOIRS OF A PHYSICIAN
St. Petersburg I hired a room in a family. My
landlady often sought my professional advice and
at first invariably handed me my fee.
"Please don't mention it! It is quite unneces-
sary!" I would exclaim in an offended voice, and
forced the money back into her palm.
Hiding a smile, she returned it to her pocket,
while I left her airy, cosy bedroom for my own dark
and narrow den next the kitchen, and resumed my
copying at 1 5 kopecks, or about eight cents per page,
of some technical specification or other, to eke out
my rent.
In ancient Russia the monkish physicians of those
days took no money for their ministrations. In my
opinion, the same principle ought to be the key-note
of the high office of every doctor. Pay is but a sad
necessity, and the less the pecuniary question ob-
trudes itself in the physician's and patient's relations
the better; for it frequently places both parties on a
false footing, often simply tying the physician's
hands. Suppose the patient improves, but still re-
mains weak and needs careful watching; his friends
politely intimate that he being better, thank God,
there is no need for my further attendance, and that
they hope that I will be so kind as to call should he
grow worse again. Of course I ought to say, "I
must still continue in attendance for you are in-
competent to judge as to when the patient may stand
in need of my aid,"
DOCTORS AND MONEY 275
But this would also mean "continue to pay me
for my visits." So you do not give the only answer
proper under the circumstances and leave the patient
to his fate.
When I read in the newspapers of a doctor suing
his patient in court for fees due, I blushed for a
profession numbering such persons in its ranks; I
vividly pictured the plaintiff as a greedy skinflint
to whom human suffering merely represents so many
pounds, shillings and pence. Why had he chosen
the profession of a doctor*? He were better suited
to become a merchant, a contractor or a pawnbroker.
Then the turmoil of life closed over my head. I
became more intimately acquainted with the rela-
tions subsisting between faculty and laity, came to
know my comrades better. And, by degrees, my
former views underwent considerable modification.
One of my colleagues was a specialist for massage.
For two years he had been in constant attendance
upon a rich merchant's family. The merchant, who
was highly educated and quite the gentleman, owed
my friend about two hundred roubles. Half a year
passed. Being hard pressed for money, my comrade
wrote a polite note to the man of commerce, beg-
ging for a settlement. The merchant brought the
money round in person, apologising profusely.
"Pray excuse me, Doctor! It was so awkward
of me to have kept you waiting so long. You know
all my time has been taken up with urgent affairs,
276 THE MEMOIRS OF A PHYSICIAN
it is sometimes possible to forget! Please forgive
me I am much to blame !"
But all the while he addressed my friend as
"Doctor" not in the more genial Russian way of
Christian name and patronymic, and took the great-
est pains to express himself with that excessive
civility which masks a feeling of aversion.
And from that time forward my colleague saw no
more of him. Of course the merchant did not con-
sider it bad form to present bills for payment and
accounts for settlement, in the ordinary way of busi-
ness; but a doctor, a doctor who mixed money up
with his vocation. . . . Such a doctor, in his eyes,
did not stand at the summit of his profession.
The behaviour of the merchant impressed me
considerably and gave food for deep thought. Un-
becoming and senseless, it was nevertheless founded
upon that high ideal of the physician which I also
shared. In the merchant's opinion, a doctor should
be ashamed of what? Of the circumstance that
he also had to eat and clothe himself that he also
requires payment for his services!
We ought to give our entire energy to society
gratis but who are these disinterested and self-
abnegating people themselves, who consider that
they have the right to demand this sacrifice of us*?
I emphatically assert that a doctor has no less
right to claim what is due to him, than a journey-
man and need feel no shame therein ! Let him do
DOCTORS AND MONEY 277
so openly and in the face of all men, instead of
covertly pocketing his fee, as if it were a shameful
and illegal bribe ! Just because the world has seen
a few bright examples of self -sacrificing and dis-
interested physicians, it wishes all doctors to be
philanthropists. No doubt such an arrangement
would be highly desirable, but still better if society
were entirely made up of ideal people! The aver-
age doctor is also an ordinary average man, and to
apply a higher standard to him than the thousand
were unjust. If he declines to toil without reward,
what right have those, who place a very shrewd and
nice value upon their own efforts, to brand him as
mercenary?
Not so very long ago Mr. "M. G." told the read-
ers of the Son of the Fatherland newspaper about
an acquaintance who was anxious to have a certain
doctor who had sued him for his fee shown up.
"Why didn't you pay him?" asked the journalist.
"Well, you know, summer was coming on, I had
to think about the sea-side, summer things for the
children, and the like." . . .
Such is the reverse of the medal called society's
high ideal of the true doctor! He must be a disin-
terested champion well, and we, plain mortals, can
go to the sea-side and take our holidays at his ex-
pense. A colleague told me the following story:
"A lady called on me with the request to see her
son, who was ill, I went and was shown into a
278 THE MEMOIRS OF A PHYSICIAN
small but very cosy and pretty flat; her son, a
schoolboy, was down with typhoid. I enquired
whether she had taken any one else's advice pre-
viously. The mother made a disdainful grimace.
'Oh, yes, Dr. was in attendance. . . . Please
tell me, Doctor, why there are so many heartless and
sordid men in your profession 4 ? This Dr.
came to see Basil once. When I asked him to come
a second time, he said there was no necessity, as he
knew what was the matter and could prescribe what
was required at a distance, without a personal in-
terview.' . . .
"Agreeing with her that this was not at all nice,
I examined the boy, gave all necessary directions
and was about to leave. The mother saw me to the
door, thanked me and . . . that was all ! Shook
hands, said, 'Thank you so much' and there the
matter ended. Three days later she came again to
call me to her son.
"I said that I knew all about his malady and
could write out a prescription without seeing him.
"The lady took the prescription,- rose, boiling
with indignation, and left without saying 'Good-
day.' "
Of course this lady afterwards enlarged with heat
and at length upon the rapacity of "our doctors."
The way in which such people, fully convinced of
their own righteousness, circulate their stories, is
quite extraordinary no less than the sympathetic
DOCTORS AND MONEY 279
listening the public gives them. In No. 248 of the
Riga Messenger for 1892, the following letter to the
editor was published:
"On the 2 1st of September of this year, I asked
Dr. to my house to see my daughter who was
ill. After remaining ten minutes with the patient
Dr. left, promising to call again next day.
He was paid one rouble for his visit (fifty cents).
Half an hour after his departure my daughter re-
ceived his visiting card with the following inscrip-
tion : 'Madam ! In view of your not being in any
danger I advise you to apply in future to a doctor
living nearer you. I do not visit patients for less
than three roubles and do not receive them in my
house for less than two. Yours respectfully,
(Signed) L. Gordon. Dr. would do well,
when advertising himself in the newspapers, to sub-
join a scale of his charges. At any rate he would
not then be disappointed in his calculations.
(Signed) A. Ivanoff."
In an answering letter, Dr. wrote as fol-
lows: "The value of a doctor's services cannot on
each occasion be adequately appraised by a fee
fixed for once and for all. A sleepless night passed
at the bedside of a poverty-stricken patient is always
rewarded by the consciousness of a duty fulfilled;
in attending the wealthy, a doctor is justified in ex-
pecting pecuniary remuneration porportionate to the
trouble taken.
280 THE MEMOIRS OF A PHYSICIAN
"Undoubtedly a doctor has many sacred duties
to perform towards his brothers; but, at the same
time, certain obligations towards the physician de-
volve upon the patient or his friends. ... I will
now pass on to a case in my practice. On September
2 1st of the current year I was requested to come
'immediately' to see a patient living in Kurmanoff
Street, in the Moscow 'Vorstadt,' which I did as soon
as I possibly could. I remained at the patient's bed-
side exactly as long as I considered the case required,
not hurrying in the slightest. On returning home
I paid the cabman, whose fare swallowed the larger
half of my honorarium. It is perfectly true that
I was not satisfied with the remnant of my rouble
fee that was left me. In view of the minuteness of
the treatment the chronic malady of the patient
would have entailed, I decided to make known to
her my terms, which she was at liberty to accept or
reject."
This case is very characteristic. Mr. Ivanoff
mark you, a man of means makes a doctor come
to his house "immediately" from the other end of
such a large city as Riga, and remunerates him for
the time he has lost with thirty or forty kopecks
(15 to 20 cents). Not content with this, he pil-
lories the unhappy physician, not himself, on a
charge of rapacity. A newspaper prints the letter
and its readers cry the doctors down. . . .
On the strength of his belonging to the medical
DOCTORS AND MONEY 281
profession, the everyday doctor does more good and
displays more disinterestedness than other people.
Let us suppose that the bread-winner of a family
lies dangerously ill, starvation stares his wife and
children in the face the doctor attends the sick man
gratis. Without a doubt, no person pretending
more or less to decency would exact payment under
those circumstances. The difference lies in that the
laymen -would not take money, while the physician
actually does not; and although it may not strike us
at first sight, this distinction is, nevertheless, very
great. For the ordinary average mortal a good ac-
tion is something out of the common and very rare
for the average doctor it is part of the day's work.
Most doctors have free consulting hours for the poor;
in most towns the hospitals have their "Out-patient
relief" days, when the needy can obtain medical ad-
vice for nothing, and there is never a lack of medical
men volunteering their services gratis. According
to calculations made by Professor Sikorsky, the chief
hospitals of Kiev (those of the Red Cross, the
Pokrovsky Sisterhood, etc.) dispensed, during 1895,
more than 138,000 free consultations. If each of
these be valued at twenty-five kopecks (i.e., about
12 cents), and if we allow that all private consul-
tations both at the doctors' and at the patients'
homes were charged for, it will nevertheless be
found that the donations to the poor of the two hun-
dred odd medical men resident in Kiev annually
282 THE MEMOIRS OF A PHYSICIAN
amounts to about thirty-five thousand roubles (i.e.
roughly $17,500). How much a year do you give
away in alms, reader?
If members of all professions, lawyers, civil
functionaries, manufacturers, landowners, mer-
chants, in the exercise of their respective vocations,
did as much for the poor as we doctors do, the whole
question of providing for the destitute would, to a
certain extent, lose its acuteness. In actuality doc-
tors are expected to be disinterested, while as for
the rest the rest may content themselves with ex-
acting this virtue from the medical faculty.
About twenty years ago Kiev was the scene of the
following affair. A certain Dr. Protsenko was
called to a patient whom he examined, but on learn-
ing that the sick man could not afford a fee, took
his departure without prescribing.
The doctor was prosecuted and condemned to a
fine and a month's arrest in the guard-room. 4 A
numerous public that filled the court greeted the
sentence with applause.
Every one will allow that Dr. Protsenko's act was
despicable; but the psychology of the public, which
so warmly approved of the sentence and afterwards
complacently went home, also presents considerable
interest. In dispersing, it discussed the hard-
hearted rapacity of doctors in general, but it never
4 This is the mildest form of incarceration, after "domiciliary ar-
rest," existing in Russia, and does not leave the same stigma as
ordinary imprisonment in gaol. TRANSLATOR.
DOCTORS AND MONEY 283
for a moment entertained the thought of coming to
the aid of the poor fellow who had been the cause
of Protsenko's condemnation, with so much as a
penny. I will suppose that that poor man was
given to logical and consequential thought. He
goes up to one of the public and says :
"As you have just heard, the fact that I am poor
and did not have the wherewithal to pay my doctor
was established in court without any room for
doubt; you will have no difficulty in guessing that
I not only stand in need of medical attendance, but
also require food: further my children are starv-
ing too. So just hand over two or three roubles."
"First of all, my friend, if you use that tone, I
will give you nothing," answers the gentleman
addressed, rather taken aback by such sans gene.
"However, if you ask me politely, I may perhaps
give you five kopecks for the salvation of my soul;
take them and pray for "
"No, I don't beg, but I demand, and not the gift
of a paltry five kopecks, but at least a couple of
roubles. A doctor's fee amounts to about that
much, and you have just seen what was done to one
of them for declining to help me (why, you your-
self applauded his conviction!). If you don't fork
out those roubles, I'll see you put into the dock too."
The outraged gentleman of course calls a police-
man and gives the impudent rascal in charge, the
public warmly sympathising with such a proceeding.
284 THE MEMOIRS OF A PHYSICIAN
At the police station the luckless one discovers that
logical thought does not always pay, that a doctor
may be locked up for his lack of charity, whereas
the rest of the community enjoy the undisputed
right of disposing of their purses and time according
to their tastes. For declining to succour a man
dying of starvation they only have their own con-
sciences to "square," and provided these be tough
enough, find it possible to carry their heads proudly,
in the enjoyment of universal esteem.
CHAPTER XIX
DOCTORS AND THE LAW
(THE PHYSICIAN IN RUSSIA)
* 4 ^" I MiE first duty of every physician is to be
JL humane and on all occasions to stand ready
to afford active assistance to people of all classes
suffering from illness. Therefore every physician
is bound to come to the assistance of such patients
as summon him. Whosoever fails to comply here-
with without being able to show special legitimate
impediment thereto, is liable, for such neglect and
disrespect for suffering humanity, to a fine not ex-
ceeding one hundred roubles and to arrest lasting
from seven days to three months."
So proclaimed! Article 81 of the Medical Statutes
and Articles 872 and 1522 of the Russian Penal
Code. It were vain to ransack the Body of Laws
of the Russian Empire for any other instances in
which people are legally obliged to be "humane"
and which appoint penalties for "disrespect for suf-
fering humanity." Such legal demands are only
presented to doctors. But is it possible that human
suffering begins and ends in sudden illness, which
alone demands immediate succour*? The homeless
285
286 THE MEMOIRS OF A PHYSICIAN
waif may freeze to death on the steps of an unten-
anted house, may die of hunger before the windows
of a baker's shop and the law will serenely des-
patch the body to the mortuary of the nearest police
station, contenting itself with a statement as to the
cause of death. The owners of house or bakery
have nothing to fear; it is no business of theirs to
be philanthropic and to display respect for the suf-
ferings of their fellows. But if a doctor, worn out
by his day's work and a sleepless night, declines to
go to a patient, the law appears upon the scene and
casts the "inhuman" physician in gaol.
It is impermissible to leave those suddenly taken
ill without succour. If doctors were allowed to
decline a summons, it might be impossible to obtain
help in a moment of emergency. We will suppose
that a dear one of ours is in imminent and deadly
peril. We fly for the doctor; he meets us in the
hall, with his mouth full of beefsteak, and coolly
says: "I am at supper and will afterwards go to
bed; it is too late try elsewhere." In another
place we are told that the doctor is out; in a third,
that he is at cards and disinclined to come. While
we are hunting about the town for assistance, the
patient dies, although timely aid might have saved
him. Ought not these doctors be held responsible
for his death and do they not merit imprisonment?
If we applied the same logic to the owners of
untenanted houses and bakers they would have to
DOCTORS AND THE LAW 287
be considered responsible for the homeless state of
the destitute and the hunger of the starving. Only
children can settle social problems in such an off-
hand and short-sighted fashion. People should not
be suffered to die of hunger, or to freeze to death,
in the public streets; but it lies with society, as a
body, to organise relief and not to throw the re-
sponsibility upon the shoulders of individual land-
lords merely because they have unoccupied houses,
and upon bakers because bread happens to be their
article of commerce. The poor man should not be
allowed to die without medical aid, it ought not to
be possible for people to fail in their searches for a
doctor at night, but society should itself provide for
such contingencies, organising a body of doctors for
night duty and supporting a special medical staff
for ministering to the poor. In England, France
and Germany the laws obliging medical men to ap-
pear at the patient's first call and to attend the poor
gratis have long been repealed.
In its egoism our society is undesirous of burden-
ing itself with superfluous cares; it transfers their
entire weight from its own shoulders to those of
single individuals and severely punishes the latter
when they decline to carry the burden imposed upon
them. The injustice of such a state of affairs
strikes one forcibly; but as it is profitable to society,
it remains unnoticed, and is wilfully ignored. And
after having shirked its plain duties, society is filled
288 THE MEMOIRS OF A PHYSICIAN
with noble indignation when those upon whom it
has shifted their weight carry them out with insuffi-
cient alacrity. The result is an incredible state of
affairs: people seem to lose their understanding of
the simplest things, the bare discussion of which
were something to be ashamed of; and one asks
oneself in perplexity how is it conceivable that
moral blindness should be capable of reaching such
extremes'?
For instance this is what A. P ff wrote in the
Novoye Vremya (No. 8098) :
"Can one's teeth ache at night or on holidays'?
It would appear that they cannot, judging from what
I am told by the person who has complained to me.
We often blame the doctors when at night they
flatly decline to go to a patient, or do so with
reluctance; while the majority of dentists, upon the
strength of some incomprehensible custom, enjoy a
kind of special privilege to rest on holidays and not
to allow themselves to be disturbed at night. The
patient applied to several dentists and was unable to
see any of them."
The above paragraph is transcribed by me with
perfect accuracy; it positively contained the expres-
sions: "a kind of special privilege" and "incompre-
hensible custom." In regard to any other toiler,
would the tongue of the same A. P ff dare turn
to frame the opinion, that to rest on holidays and
not to allow oneself to be disturbed at night is an
DOCTORS AND THE LAW 289
incomprehensible custom? In regard to his own
person, it is hardly likely that A. P ff would
consider such a custom as so very incomprehensible.
I had a college comrade named Petroff. Upon
taking his degree he entered the service of the
Zemstvo as physician in an out-of-the-way district
of one of the Eastern provinces, and I lost sight of
him.
A couple of years ago the newspapers, first those
of the provinces, afterwards those of Moscow and
St. Petersburg as well, published a revolting case,
the hero of which, so it happened, was this comrade
of mine.
In the village of N , so wrote the papers, the
elder of the commune was taken ill after eating
some putrid fish. He sent to the neighbouring
hamlet for the Zemstvo doctor, Petroff. Petroff
despatched his dispenser instead of coming himself.
The patient became worse and worse. He sent for
the doctor a second time, but it was the dispenser
who arrived on this occasion as well. The elder
died towards morning. It transpired that Dr.
Petroff had been dead drunk that night. The
Zemstvo immediately dismissed him from its service.
For about two months Petroff's name did not leave
the columns of the papers and became notorious
throughout Russia.
Six months later I encountered Petroff in my
house in St. Petersburg; he had arrived to seek a
290 THE MEMOIRS OF A PHYSICIAN
place, and looked me up. Sunburnt and uncouth,
in a starched shirt front, to which he was unaccus-
tomed, Petroff sat before me with his shaggy head
bowed low and told me how it all happened.
"It was just as the papers described, that's true
enough. A fair was being held at the time; the
out-patient work on days like that is tremendous, I
had to attend to about two hundred cases you'll
understand what that means; while the night before
I had been summoned to Stsheglovo to attend a
confinement, and returned home just in time for tak-
ing over my out-patient duty, and was only able to
swallow a glass of tea. It so happened that a few
friends visited the fair. We sat down to cards that
evening and then started drinking. It can't be de-
nied a good deal was drunk. . . .
"Week after week, month after month pass by
in the self-same way; you're pulled to pieces from
all sides, and every now and again you feel so down
in the mouth you'd rather die than go on at the same
gait. I know that when such a spell overtakes me
it happens five or six times in the year I have
to give myself a shake up, have a good drink, so as
to see hell- and after that you're as fresh as paint
and feel braced up once more. . . . Well, I got
home. And I was called to a patient 'dying/
Sinner that I am, I couldn't go the hospital
attendant would have had to heave me on to the
cart. , , , Well . . . and sx> it happened," . . .
DOCTORS AND THE LAW 291
And he relapsed into silence.
"You don't know, old man, what service in the
Zemstvo means. You have to be on good terms with
every one, you are dependent on every one. Pa-
tients come whenever they please during the day
or at night: how turn them away*? Or else, some
peasant may take you in on his way to have his
horse shod: 'Can't you come round, a woman is
dying in the village*?' You have a five versts'
drive and ask: 'Where's the patient*?' 'Oh, she's
just gone off to reap rye.' . . . My district is fifty
versts * across, with a dispensary at either end, and
I must visit each twice a month; the devil knows
how you sleep and eat. So it goes on, from day to
day, without holidays, without a break. At home
your son's down with scarlet fever, while off you
must go. . . . Extremely hard work." . . .
Once more he relapsed into thought, his hands
resting on his knees.
"Extremely hard work," he repeated and pulled
up. "The papers wrote : 'Dr. Petroff was drunk !'
Quite true, I was drunk and that was very wrong.
Every one has the right to be indignant. But they
themselves why, ninety-nine out of a hundred of
them aren't averse to a drink, have been drunk more
than once and don't blame themselves for it. Only
they can't understand how a man, who isn't given
a moment of his life to call his own, can feel some-
1 A verst = about two-thirds of a mile. TRANSLATOR.
292 THE MEMOIRS OF A PHYSICIAN
times. . . . And oh, how hard that is, old man, the
Lord preserve one from such a fate."
I will permit myself to introduce the reader to
yet another newspaper notice.
"At present St. Petersburg may be called 'help-
less,' " wrote in July, 1898, the chronicler of the
St. Petersburg Gazette, V. P. "In the course of the
last week I thrice had occasion to convince myself
that during the summer the inhabitants of the me-
tropolis are entirely deprived of medical aid. Dur-
ing the summer, the native of Petersburg dares not
fall ill, otherwise he may find himself in an awk-
ward fix; he runs the risk of not being able to get a
doctor." After describing how he and some of his
friends searched in vain throughout St. Petersburg
for a medical man, Mr. V. P. concludes his notice
by propounding the following "very interesting
question of principle" : "Have physicians the right
to neglect their duties towards their patients in the
way they do at present 1 ? Are doctors absolutely
free agents who may do what they like with their
time, according to their personal inclinations'? In
brief, do they serve society or not 4 ?"
These questions are interesting, forsooth. . . .
Do doctors serve society or not 1 ? Every kind of
service pre-supposes at least some sort of mutuality
of obligation. Doctors leave St. Petersburg foj the
summer; some to rest after their arduous winter's
work, others because it is no easy matter to earn
DOCTORS AND THE LAW 293
one's living by practice in the emptied city. They
should remain in town, because they may be re-
quired by V. P. and his friends and because they
turn up their noses at the hospitals (which work
during the summer) and at the municipal physi-
cians. Well, and supposing V. P. and his friends
remain in good health will they see that the ex-
penses of the doctors remaining in town on their
behalf are paid?
Certainly not ! Let them live as they please, but
let them be ever ready to attend at any moment to
the needs of V. P. !
The value of this notice by the chronicler of the
St. Petersburg Gazette lies in the nai've coarseness
and straightforwardness with which it gives expres-
sion to the views predominating amongst the public
as to the legitimacy and necessity of reducing the
faculty to a state of serfdom.
"Are doctors absolutely free agents who may do
what they like with their time, according to their
personal inclinations^" The question does not re-
fer to physicians holding special fixed appointments,
who, by accepting the advantages of an assured
position which their appointments offer them,
thereby naturally relinquish their "absolute free-
dom" ; it refers to the faculty at large, in its dealing
with persons who do not consider themselves bound
down by any corresponding obligations whatever.
They follow the physician's every step with terrible,
294 THE MEMOIRS OF A PHYSICIAN
unflinching and merciless vigilance: "Serve soci-
ety, be a hero and a champion, never dare avail
yourself of the 'incomprehensible custom' of resting;
and when you are worn out or when you perish in
harness, it is no business of ours." 2
A short time ago we buried our comrade Dr.
Stratonoff. A week previously he had performed
tracheotomy in a private house, and while sucking
the diphtherial membrane out of the incision in the
windpipe, contracted diphtheria himself. He died
while young, strong and energetic, and his death
was terrible in its rapidity and unexpectedness.
His coffin stood in the chapel, covered with un-
necessary wreaths. The air was pervaded with the
fragrance of incense, the last notes of the "Eternal
Memory" died away beneath the vaulted roof, while
the rush and roar of the city was wafted in through
the windows. We stood round the bier
2 During session of the Assembly of the Zemstvo of St. Peters-
burg, the executive of that administrative body proposed that a sub-
sidy be granted to two medical health officers and a dispenser,
who had contracted typhoid while in performance of their duties.
Member P. P. Durnovo violently opposed this motion. No one, he
declared, was insured against infection, while doctors, in view of
the very character of their work, were in duty bound to run such
risks to their healths. If a doctor died one might grant his family
assistance, but in the present case he had merely been taken ill.
Of the nine medical health officers of the province, at least
one would be down with typhoid, or some other disease, every year;
was it possible that in every such instance the Zemstvo ought to hold
itself bound to provide pecuniary assistance? // the Zemst-ro were
to distribute grants so lavishly, doctors would contract typhoid on
purpose. To the credit of the St. Petersburg Zemstvo Mr. Dur-
novo's declarations elicited the unanimous protest of the Assembly.
DOCTORS AND THE LAW 295
"And silently gazed on the face of the dead,
Immersed in sad thought of the morrow." . . .
He left a widow and orphans : but neither his fate
nor theirs was any one's concern. All indifferent,
the city beyond the windows of the chapel kept up
its noisy bustle; one might have thought that even
were all its streets strewn with dead bodies, it would
continue to lead the same self-centred busy life,
without distinguishing corpse from cobble-stone. . . .
"Do our doctors serve society or not 9 "
According to Dr. Grebenshtshikoff's calculations,
37 per cent, of our doctors in general die of infec-
tious diseases, the latter accounting for sixty -per
cent, of the deaths occurring amongst physicians
serving in the Zemstvos.
In 1892, half of all the Zemstvo doctors who
died that year succumbed to typhoid. Professor
Sikorsky investigated the question of suicide in the
Russian medical fraternity, availing himself of of-
ficial data. He found that "within the age limits
of 25-35 years suicide accounted for almost 10 per
cent, of the normal death-rate, i.e. at this age,
amongst doctors, one death out of every ten was
self-inflicted." This number is so appalling that
we can hardly credit it. But another investigator,
Dr. Grebenshtshikoff, arrived at almost the same
results, although utilising entirely different mate-
rial and working independently of Professor Si-
korsky. According to his statistics, during 1889-
296 THE MEMOIRS OF A PHYSICIAN
1892, amongst all doctors, suicide accounted for 3.4
per cent, of their deaths, while over ten '-per cent, of
al\ the Zemstvo doctors died by their own hand.
Professor Sikorsky then proceeds to compare his
data with those dealing with the other professions,
both in Russia and Western Europe. It turned out
that in the matter of suicide the Russian faculty
"enjoyed the sad distinction of occupying the first
place in the world."
The following circumstance is most remarkable:
one might be led to suppose that no one, bent on
self-destruction, would find it so easy to choose a
painless mode of death as a doctor. But in reality
it turns out that in the case of medical men the
more agonising methods of self -despatch figure most
frequently: poisoning by strychnine, sulphuric or
carbolic acid, piercing of the heart with a trocar, etc.
"Evidently," remarks Professor Sikorsky, "a con-
siderable deadening of the instinct of self-preserva-
tion made the mode of death a matter of indifference
to these unhappy colleagues of ours, so long as they
attained their end."
Yes, our doctors "serve society," and their servi-
tude is not of the lightest or most serene order.
And this is the fate which awaits those doctors who
have "completed their term of service to society."
In Russia we have a medical subsidiary fund, in-
augurated by Professor J. A. Tshistovitch. Before
me lie the printed minutes of the sittings of the
DOCTORS AND THE LAW 297
executive committee of the Society for 1896. I
adduce two extracts from the above.
"The petition of one of the members of the fund,
M. A. Vissotsky, in which he requested that a pen-
sion be awarded him in view of his entire destitution
and incapacity to continue in practice, owing to ill-
health, was reported upon. Mr. Vissotsky, aged
59, is a former municipal physician of Ashin, has
no means, receives no Government pension, has no
relatives who could give him a home, is incapable
of gaining his livelihood by work, and stands in
need of nursing, owing to his suffering from ad-
vanced heart disease and paralysis of the left side.
A pension of 300 roubles (about $150) awarded.
"The petition of the female physician K. F.
Lantveroff, soliciting the grant of a subsidy of 200
roubles, in view of her very straightened pecuniary
situation, due to her suffering from chronic malaria
and extreme ansemia, developed after an attack of
typhus contracted in the service of the Zemstvo,
reported upon. Professor V. A. Manassein and Dr.
D. N. Jbankoff certified Mme. Lantveroff's dis-
tressed situation, and the necessity of her being
provided with the means to pay for her medical
treatment, board and lodging. Two hundred rou-
bles granted."
The above fund is one of mutual assistance and
is sustained by the annual subscriptions of its mem-
bers, who alone have a claim upon its assist-
298 THE MEMOIRS OF A PHYSICIAN
ance. Of course society, which doctors serve, has
nothing to do with this fund, nor does it desire to.
"You may fall victims to infection, you may cripple
yourselves in working for us, but once fallen in the
ranks, you may help yourselves as best you can."
The dimensions of the grants allowed speak for
themselves, and show what aid the fund is capable
of according its members.
CHAPTER XX
THE MARKET FOR DOCTORS
AMONGST others, the following thesis figures
in V. K. Anrep's doctor's dissertation: "The
petty police officers, dvorniks l and janitors of St.
Petersburg are better paid than the physicians in its
service." This statement is not in the least exag-
gerated. The house-physicians in the hospitals of
many of our towns receive 45-50 roubles a month;
only quite recently those of St. Petersburg had their
salaries advanced to 75 roubles. Our municipal
doctors, while burdened with a mass of the most
varied duties, only receive 200 roubles (roughly
$100) a year. According to a census made by
Grebenshtshikoff, 16 per cent, of our doctors en-
dowed with fixed appointments receive less than
600 roubles a year, 62 per cent, no more than 1200
roubles.
The opinion is very prevalent that salaried doc-
tors can easily eke out their miserable stipends by
private practice, and this furnishes an explanation
as to the reason why these appointments are so badly
paid. But the first condition necessary for private
1 Dyornik = house porter.-^TRANSLATOH.
300 THE MEMOIRS OF A PHYSICIAN
practice is the free disposal of one's time ; this, how-
ever, must necessarily unfavourably affect the nor-
mal discharge of one's official duties, and woe to
the doctor who displays negligence in his capacity
of a paid Servant of Society: he becomes the object
of universal obloquy, people forgetting that they
themselves designated private practice as a sub-
sidiary source of income. Also the latter is very
small contrary to prevailing opinion: according to
the researches of the statistician just quoted, in the
case of 77 per cent, of all (Russian) doctors (in-
cluding those without official status), the income
derived from private practice does not exceed 1000
roubles r per annum. Few of the liberal professions
can boast worse remuneration.
Our medical market has long been glutted, the
supply considerably exceeding the demand. This
leads to competition amongst doctors, the least esti-
mable members of the faculty stopping before no
means for depriving a rival of a patient; when
asked to call, such doctors commence by criticising
their predecessor's prescriptions, declaring "that it
wouldn't take long to kill the patient that way."
The advertising columns of our newspapers are
covered with such men's advertisements, their names
becoming as well known as those of certain soap and
cocoa manufacturers. The more adroit push them-
selves before the notice of the public through news-
paper articles and interviews with accounts of the
THE MARKET FOR DOCTORS 301
brilliant operations performed by them, cures ob-
tained, etc. On the other hand, not a few doctors,
having assured themselves of the difficulties lying in
their way and the precariousness of their profession,
take up some other occupation; the number of the
latter seems to be ever increasing. During recent
years, accounts have appeared in the newspapers
from time to time, describing how doctors commit-
ted suicide owing to their being in absolute desti-
tution; instances are known of fully qualified
medical men accepting situations as dispensers and
hospital orderlies, contenting themselves with the
wages of these humble positions.
Even people of comparative education sometimes
express the opinion that the reason why so many
doctors find themselves in a distressed position lies
in their gravitation towards cities. These persons
will say: "We have about twenty thousand doc-
tors, while the population of Russia is 128,000,000.
How can there be a question of over-production*?
Doctors dislike going to out-of-the-way parts of the
country, and insist upon dwelling in centres of cul-
ture ; obviously a glut in the market of those centres
must result! But the above phenomenon is purely
artificial: doctors starve in these centres, while the
rural population perishes and degenerates without
knowing medical succour. We have too few medi-
cal men, not too many of them, and every effort
should be made to increase their numbers."
302 THE MEMOIRS OF A PHYSICIAN
It is quite true that the rural population is perish-
ing and degenerating without medical succour.
But is it possible that the reason thereof lies in a
dearth of medical men 1 ? Half the population of
Russia goes about shod in bark shoes is it possible
that this is because we lack cobblers'? You may
increase the numbers of cobblers ad infinitum, with
the only result that the cobblers will be reduced to
wearing bark shoes themselves, while all those who
wore them formerly will continue to do so.
Doctors are far from being possessed of such a
strange taste as to prefer starvation in cities to bread
in the back-blocks. There are always shoals of ap-
plicants for the most out-of-the-way situations of
the Zemstvos, with the most pitiful pay: for in-
stance, in 1883 (see The Physician), seventy-six
applications were filed for one vacancy of Zemstvo
physician in the Kniaguinensky district; while an-
other, in the district of Kashin, was competed for
by ninety-two medical men. The crux of the mat-
ter does not lie in the physician's horror of burying
himself in some remote rural district, but in the fact
that our village is hopelessly poor and incapable of
paying a doctor for his ministrations. The late
eighties give us not a few examples of experiments
of free practice in the country; the names of Sitshu-
goff and Tairoff and others will still be fresh in the
memory of all. But these experiments merely
proved that men, inspired by an idea, can manage
THE MARKET FOR DOCTORS 303
to eke out a livelihood somehow, even in the coun-
try, without extraneous assistance. However, that
is not the question at all; the question is, can an
average medical man, not a knight-errant, but an
ordinary worker, exist in the country, relying on his
profession alone 1 ? Any one who is but slightly ac-
quainted with the conditions of our rural life will
agree that its poverty and lack of culture entirely
shut off the ordinary practitioner.
The material position of doctors is ever becoming
worse. And now woman enters the lists as a new
rival much desired, and at the same time most
formidable. As everywhere, where she enters into
competition with man being satisfied with less pay
for the same amount of work she lowers the aver-
age level of prosperity. Data furnished by Dr.
Grebenshtshikoff show that the mean salary (in Rus-
sia) of male doctors in the public service amounts
to 1161 roubles, while that of the female physician
is only 833 roubles. With the increase of the
number of medically qualified women, there can be
no doubt that the average earnings of the doctors
will ever become less.
Such a state of affairs does not subsist in Russia
alone. In Western Europe the physician's plight is
still more distressed. Everywhere we see a vast
army of medical men without work and without
money, ready to accept anything. Eight years ago
the Hospital Fund of Budapest made known that
304 THE MEMOIRS OF A PHYSICIAN
it would pay its doctors forty kreuzers (about 12
cents) for each visit to a patient; notwithstanding
the scantiness of the pay, shoals of applicants, eager
to accept these terms, put in an appearance. More
than half of the doctors residing in Berlin barely
earn 150 marks (circa $37) a month; the doctors
of Vienna do not turn their nose up at twenty
kreuzers fees. Henri Beranget, in an article on the
"Intellectual Proletariat of France," says that no
less than half of the Parisian doctors cannot even
claim to be in circumstances placing them beyond
the pinch of want; while the majority of that half
are in an abject condition of destitution, in the full-
est sense of the word, many members of the profes-
sion frequently seeking the shelter of doss-houses
for the night. In the provinces barely five thousand
out of ten earn a decent livelihood.
In Western Europe innumerable doctors are un-
able to find anything to do, but of course the reason
does not lie in society's being sufficiently provided
with medical aid already for there, as in Russia, for
the vast majority of the population, the ministrations
of medicine are still an unattainable luxury. This
is but a partial manifestation of those amazing
incongruencies which, like the roots of an oak im-
bedded in the soil, deeply penetrate into the very
foundations of modern existence. Countless tons
of grain and meat rot without finding a market,
while next door, thousands of human beings die 'of
THE MARKET FOR DOCTORS 305
starvation for want of work; blood is lavishly ex-
pended in the conquest of far-away markets for dis-
posing of our silks and velvets, while the people
employed in their production go about in cotton
rags.
CHAPTER XXI
THE DOCTOR'S STRUGGLE
THE other day I was called at an early hour to
see a patient in one of the suburbs of St.
Petersburg.
That night sleep had long eluded me, for I was
suffused by a strange sensation : my head was heavy
and dull, something in my breast vibrated tremu-
lously and I felt as if all my nerves were the taut
strings of some instrument; the distant reverbera-
tion of a locomotive whistle at the railway station,
the cracking of the wall paper, made me start pain-
fully with fluttering heart. After taking some
potassium bromide I at last dozed off, only to be
roused an hour later.
It was barely light. I took a cab and rumbled
off through the dark, empty streets. Through the
light mist heralding the dawn, sullenly vibrated the
"buzzers" of various works and factories; it was
both cold and damp; here and there lights winked
sleepily in the windows. I experienced a vague
feeling of void, and apprehension crept into my
heart. Recalling my condition of the previous
evening and noting my present broken-down state,
it was borne upon me with horror that I was ill,
THE DOCTOR'S STRUGGLE 307
seriously, unmistakably ill! For the last twenty-
four months I had noticed that my nerves were ever
becoming more and more unstrung, but only now
did I plainly see what I had come to.
I had been a doctor for seven years. How had I
lived them 4 ? They had been a cruel mockery from
beginning to end; my impotence ever flaunted in
my face, the tension on my nerves never being re-
laxed for a moment, merciless life ceaselessly play-
ing its harsh tunes upon them. To pass through
the ordeal unscathed, an iron constitution and tre-
mendous nervous energy were necessary, the con-
ditions of life being such as to undermine the most
robust. I knew no such things as holidays, and
could never be sure of enjoying undisturbed rest; I
might be called away at any moment from my meals
or from my sleep, and kept from home for hours,
no one giving my powers of endurance a thought.
Year by year one becomes more and more of a
physical wreck and a neurasthenic creature, every-
thing going by the board joy and love of life
worse the very capacity for sympathy and warm
responsiveness. And at the same time I knew very
well that these nobler qualities were not entirely
dead a short spell of life in normal human en-
vironment sufficed to regenerate the soul and one
felt that it was still very full of latent strength and
love.
How did I live*? After waiting for five years I
308 THE MEMOIRS OF A PHYSICIAN
had at last obtained an appointment worth seventy-
five roubles a month ; this, plus the uncertain income
derived from private practice, had to support me
and my wife with our two children. Such questions
as that of buying a new winter overcoat, the pur-
chase of fuel or the hire of a nurse, were knotty
problems which entailed a lot of painful mental
labour and sometimes necessitated visits to the pawn-
broker's.
My school-fellows had chosen various paths in
life some were engineers, others tax collectors or
excise officials, business men, etc.; for work which
allowed of their leading a tranquil and undisturbed
existence they received salaries that were beyond
my dreams. I was even deprived of domestic joys,
forbidden the pleasure of carelessly caressing my
children, because I could not thrust away the thought
that perhaps I might be giving them scarlet fever
or the smallpox, etc., with which I came into daily
contact.
The great city, enveloped in morning fog, passed
in review before me: high buildings, sombre and
silent, jostled each other, appearing to be immersed
in cheerless reverie. Here was that Moloch that
claimed all my strength, health, and my very life!
At the same time the consciousness of that terrible
monster's utter obliviousness of my individuality
was appalling. . . . And I was powerless to do
otherwise than bow my head before it that city
THE DOCTOR'S STRUGGLE 309
which took away my all and gave me nothing in
return.
Absurd delusion to imagine that it were possible
for me to excite its pity; equally ridiculous to ex-
pect that anything could be gained by drawing at-
tention to the unjust treatment meted out to our-
selves. Only he who fights can claim a hearing.
The only thing remaining is for us doctors to band
together and fight this monster with united forces
shoulder to shoulder, and by strength of arms carve
for ourselves a happier and freer destiny.
While turning these matters over in my mind I
had not noticed how we had left the main thorough-
fares and were now driving along a suburban road.
The roadside ditches were overgrown with coarse
yellow grass, and a wooden sidewalk, wet with dew,
stretched away on either side in monotonous per-
spective. Dense black smoke welled out of the fac-
tory chimneys and spread itself in a dark, suffocating
mantle above the housetops. My Jehu pulled up in
front of an ugly, yellowish-brown tenement house.
I ascended to the second floor by some dark and
steep stairs, and rang. In a small room a pale man
of about thirty, dressed in a blue blouse, sat at a
table; his blond beard and moustache were blotched
with red, while on the floor next him stood an earth-
enware basin full of pinkish water, in which floated
dark clots of blood. A young woman, bathed in
tears, was breaking ice with a chopper.
310 THE MEMOIRS OF A PHYSICIAN
"Please excuse me, Doctor, for bothering you!"
said the man, rapidly rising and stretching out his
hand. "It's the usual thing consumption and
I've just had a haemorrhage. It was my wife who
insisted on sending for a doctor." . . .
I cut him short.
"First of all lie down and don't talk! You
shouldn't say a word. And don't be excited, it
isn't at all dangerous."
"Am I excited?" he asked in surprise, and with
a shrug of his shoulders, sat himself down on the
bed.
I had him undressed and carefully applied my
stethoscope to his chest. With his handsome head
thrown back and biting his thin ensanguined lips, he
lay still with half-closed eyes, gazing up at the ceil-
ing.
"What is your husband's profession?" I asked the
young woman, on completing my examination.
She was sitting at the table with wet cheeks, follow-
ing my movements sorrowfully.
"He's a copper foundryman employed in the
works. Oh, Lord, Lord, to think that he
should only have lasted till he was thirty ! He used
to be so strong ! . . . The copper fumes have eaten
out his chest !"
And she leaned her breast against the table con-
vulsed with sobs.
"Don't take on so, Kitty ! It's not so bad as all
THE DOCTOR'S STRUGGLE 311
that," the foundryman murmured impatiently and
at the same time kindly. "You heard what the doc-
tor said. . . . People live to be fifty with such
haemorrhages. . . . Isn't it so 4 ?" he asked, turning
to me.
"Yes, of course! . . . Only don't talk, but lie
still. Sometimes people quite get over it."
He lay quiet, merely nodding his approval. I
sat down to write a prescription.
"My God, how soon his life broke him down!"
the woman went on with a shivering sigh. "I will
tell you how it is, sir, he doesn't take a bit of care
of himself; you should hear what a life he led!
On coming home from work he'd take up his books
at once, or else be hurrying about on business. . . .
He wasn't given the strength of two men!"
The patient was seized with a fit of coughing,
bent forward and spat out a large clot of blood.
"That'll do! Don't talk so much!" he said to
his wife in an undertone, on regaining his breath.
I remained for about half an hour with the pa-
tient, trying to console and calm his wife. The
room was a poor one, but all testified to its owner's
tastes. A heap of books were piled in a corner,
books were strewn over the chest of drawers and
lay upon the sewing-machine, and their covers bore
names that were dear and precious to me.
I went out and drove off. It was quite light by
now; the mist had lifted from the ground and was
312 THE MEMOIRS OF A PHYSICIAN
ascending heavenwards in moist, grey clouds; be-
tween their rifts one caught glimpses of a clear,
sunny sky. The streets still retained their still-
ness, but already smoke issued from the chimney-
pots and people could be seen in the windows; the
footprints of early pedestrians marked the dewy
wooden footpath. I recalled the humour in winch
I had started out from home and gazed upon the
selfsame surroundings that coarse yellow grass
about the roadside ditches, the tall houses and
was struck by its exceeding triviality it seemed
entirely foreign to me; not that I felt ashamed
merely I was unable to account for having let my-
self go in such a way.
We must combine and fight the good fight quite
so! But who are "We"? We doctors'? Of
course we may try to better the position of our cor-
poration, perfect co-operation and the like. But a
struggle, a struggle all-embracing and deep-reach-
ing, is impossible if the emblem on our standard be
a brass farthing. Our lot is a hard one, but how
immeasurably more wretched is that of a vast num-
ber of our humbler brethren! In some parts of
Russia the workmen employed in the matting indus-
try are hired on condition of their not begging in
the public streets; it is quite common for girls to
prostitute themselves to the foremen in order to get
work to do. ...
No doubt it would be very nice if we doctors
THE DOCTOR'S STRUGGLE 313
received the same emoluments as engineers, if we
could work without overtaxing our strength and
without thought for the morrow. But easier said
than done. A physician in the employ of the
Zemstvo receives beggar's pay, but the village can-
not create meat and wine for him out of its own
crust of black bread.
The remuneration of the physician is very low
as a rule, nevertheless, not only for the poor man,
even for the person of average means, medical treat-
ment is ruinous. All this tends to show that an-
other way out of the labyrinth must be found.
Ours should not be the fight of a legion forming
an integral part of a great army, but, rather, that
of a handful of individuals whose efforts are directed
against all who surround them, and are, for that
reason, senseless and condemned to failure. Oh,
why should this truth be so difficult for us to under-
stand, for us who have been nurtured on noble ideas,
before whom education has unfolded "broad hori-
zons"; while those who have been placed at a dis-
advantage from birth and were compelled to conquer
every foot of their ground, have long ago grasped
the fact?
Yes, there is another way. That only way lies in
the realisation that we are but a small part of one
gigantic integral whole, that our own brighter future
is indissolubly bound up with the advancement and
prosperity of that great whole in its entirety.
APPENDIX A
(Editor's Notes to the Foregoing Chapters)
CHAPTER I
THE FRAILTY OF THE HUMAN BODY
In this chapter the author has touched on experi-
ences that are well known to every medical student.
The years in the medical school are devoted to the
study of cases that are unusual and are sent to the
medical school hospitals for treatment that they can-
not get at home. As a consequence the student be-
comes more familiar with them than he does with
the more common disorders and he is apt to view
every case during the first year or two of his practice
as probably being some rare disorder. It would be
of great value if a three months' apprenticeship with
a practitioner could be incorporated into the curricu-
lum of our medical schools.
CHAPTER II
EXAMINATION AND AUTOPSY
The problem of whether or not to allow students
to examine patients admitted to the charity wards
of the large hospitals is a very complex one. That
it is necessary in the education of the student to ob-
314
EDITOR'S NOTES 315
serve patients closely is beyond question; that the
recovery of such patients is at times hampered by
such examination is in many cases perfectly true.
If such examinations are conducted tactfully and
carefully the mental strain is lessened. It resolves
itself, therefore, into a matter of great care and
judgment on the part of the professors in the medi-
cal schools to teach the students how to make such
examinations without causing distress to the patient.
In a vast majority of cases a thorough, serious and
minute examination by the students is welcomed
by even the most ignorant patients. Personal at-
tention and sincere interest is always appreciated
and the examinations become agreeable rather than
unpleasant. In the present day the clinical work
done by the student himself on the case under his
observation yields, in many instances, a wealth of
information that is of material assistance in secur-
ing a satisfactory diagnosis of the case. It is be-
coming more and more unusual in America to have
patients raise much objection to going to a medical
school hospital on account of being subjected to
examination by students. It is still rarer to find
after their return that they have anything but praise
for the careful work that has been done. The
whole matter resolves itself into a question of tact-
ful management and sincere interest on the part of
both teacher and student. When this is secured the
question of examination is negligible. In the per-
3i6 THE MEMOIRS OF A PHYSICIAN
formance of autopsies on the bodies of patients, a
much greater problem presents itself, but in such
matters also the exercise of tact and consideration
carries great weight. There are certain hospitals
which require permission for an autopsy in the event
of a patient's death to be signed by relatives before
the patient is admitted to the wards. In most other
hospitals, however, permission is only obtained from
the relatives after death and it is surprising how
seldom objection is raised. The request is presented
tactfully and the family are made to realise that the
life of some other sufferer may be saved by the
knowledge derived from the autopsy. Regarding
the examination of patients particularly female
patients in clinics the problem is distinctly more
complex. Such examinations cannot be ignored
and their importance, particularly in the case of the
most sensitive individuals, can hardly be over-
estimated. Extremely frequently patients are sent
to university hospitals by the physicians in their
own towns because these physicians have been unable
to make the necessary examinations. Often it is
discovered in the course of a very complete and
minute study of a case that some simple, trifling
detail is the cause of immense misery and suffering.
For this reason the discomfort of a seemingly prying
examination is a necessary evil. Fortunately at the
present time there are clinical tests that can be made
without the patient's knowledge and which elimi-
EDITOR'S NOTES 317
nate the necessity for certain cross questioning that
is painful alike to physician and patient. In fact,
it is generally found that the statements made by
a patient regarding his or her condition are in the
majority of cases hopelessly incorrect, and the im-
portant details may be secured in a conversation of
a few minutes, the real details being left to the
laboratory.
CHAPTER III
WHAT MEDICINE HAS NOT ACCOMPLISHED AND
WHAT IT HAS
In this chapter the author adopts a bitter atti-
tude that is scarcely fair. "To diagnose ex-juvanti-
bus" has been termed in America "The Therapeutic
Test" and has passed almost out of existence within
the past few years, although it is still found in the
country where clinical laboratory work is difficult
to obtain. In the author's description of his exam-
inations of patients with soft cancer of the kidney,
it would seem to the careful reader that he had
allowed his contempt for the science to interfere
with his work. His awakening in the latter half of
the chapter to the possibilities in medical diagnosis
seems belated.
When he deals with the deficiency of the present
system of examinations in the medical schools he
touches a very vital point and his criticism is well
3i8 THE MEMOIRS OF A PHYSICIAN
taken. Improvement along this line has been very
great in the past ten years. Students in the large
university hospitals are credited little on the result
of the final examination in any subject. Their
daily work in the laboratory and in the "Ward
Class," their general attitude of mind toward their
work is taken into more serious consideration. In
addition to this a new system has sprung up recently
in the form of Quiz Classes conducted by instructors
outside of the regular hours. In these classes prac-
tical work is gone over again and again and funda-
mental principles are grounded so thoroughly that
the students find the final examination a mere mat-
ter of form.
CHAPTER IV
DIFFICULTIES THAT CONFRONT THE PRACTITIONER
In this chapter the author shows how hope-
lessly unfitted for the practice of medicine is the
recent graduate from the medical school. No one
knows this incompetence better than the doctor
himself and this knowledge increases his diffidence,
and decreases what little respect the possession of
a degree gives him in the eyes of the world. The
world famous surgeon Marion Sims, in his book,
"The Story of My Life," reviews his own experi-
ences in the early practice of medicine that are so
parallel with those of the author of "The Memoirs
EDITOR'S NOTES 319
of a Physician" that they should be read in con-
junction with this book.
In commenting upon the mistake in diagnosis of
the case of pneumonia it may be said that there is
scarcely a physician who has not had similar hu-
miliating experiences, although one must remember
that such a mistake is easily made where the pneu-
monia begins in the central portion of the lung and
the physical signs of consolidation are not in evi-
dence until late in the course of the disease. Pa-
tients have been not infrequently operated upon for
appendicitis when the trouble was in reality pneu-
monia. The case of rheumatism described presents
an interesting medical problem in itself. Within
the past ten years this disease has become separated
from the general category of acute infections and
regarded more as a poisoning of the system from
some focus probably obscure, and the treatment of
it to-day is aimed at the removal of such a focus
rather than the relief of symptoms through the giv-
ing of drugs. It would seem that the author of the
Memoirs had little cause to reproach himself for
the failure of this line of treatment at the time he
practised medicine. The description of the old
doctor coming to the rescue in the case of Typhoid
Fever is admirable as it shows one of the triumphs
of practical experience over theory. The cause of
general Sepsis following Scarlet Fever is worthy of
comment but reflects less discredit on the author
320 THE MEMOIRS OF A PHYSICIAN
than he seems to suggest. It seems improbable that
he did as much harm in the application of the oint-
ment to the swollen glands as he allows us to believe.
CHAPTER V
YOUNG DOCTORS AND TECHNIC
This chapter reflects an amount of perseverance
and singleness of purpose on the part of the young
physician that is remarkable. Here as in other
points of his narrative he shows such deep appre-
ciation of his responsibilities that the reader cannot
but be impressed.
CHAPTER VI
SURGERY, ITS RISKS AVOIDABLE AND INEVITABLE
One can scarcely read this chapter without realis-
ing two things : First of all, the dangers of surgery
in the hands of men unqualified for that branch of
the medical profession, and, secondly, the triumphs
of surgery in skilful hands. Glancing over the
chapter, one is impressed with the fact that the
author was never adapted mentally or physically
for the practice of surgery. His thoughtful intro-
spective mind predisposed towards hesitancy, and
his overdeveloped conscience stir his nerves into
such a state of confusion that he is unable to carry
out even minor operations successfully. In the past
EDITOR'S NOTES 321
lew years the practice of medicine and surgery are
becoming more and more separate and wiser men
of the profession are leaving their operative work
to those best qualified to handle it. This is a sensi-
ble measure and it is probable that within a few
years no man will be allowed to practice surgery
unless he is possessed of a separate and distinct de-
gree in addition to his regular medical certificate.
As regards the problem of allowing young surgeons
to gain their experiences on patients a great deal
must be said pro and con. The teachings of the
medical schools of the present day are for the most
part so thorough and students have such unlimited
opportunities for watching the operations that the
ground work of their surgical knowledge is fairly
complete. In addition to this a year's service as resi-
dent in a hospital is compulsory. During this time
they are allowed to assist at operations and later
operate under the directions of the surgeon. After
this if the young man decides to take up surgery
as a specialty he practically gives up all thought of
making a living for several years and devotes his
time to dispensary work and in being assistant to
a surgeon in some large hospital. As his experience
increases, his confidence in his own ability increases,
and he is able at the end of seven to ten years to
take up surgical work by himself. The necessity
for an utterly inexperienced man to take the re-
sponsibility of operating on a patient is obviated,
322 THE MEMOIRS OF A PHYSICIAN
CHAPTER VII
IN MEDICINE NOTHING RISKED, NOTHING GAINED
Here the author deals with a problem that is
ever present. In the majority of cases, however,
the trial of a new remedy is first preceded by a
fundamental knowledge of certain facts that indi-
cate what the value of that remedy would be under
certain conditions. Next it is warily tried where
other measures have failed and its results are
carefully judged. Here as elsewhere laboratory
analyses give their important clues as to its value,
and it is adopted by the profession only after most
careful and painstaking research. It is interesting
in this regard to note the fact that as our clinical
knowledge of the action of drugs increases, the num-
ber of drugs used decreases. In other words, we
have come to find out that drugs such as we used
ten years ago have so little real value that their
administration has been almost abandoned. The
real triumph of modern medicine has come to be the
fostering of the patient's own resistance to disease
and supplementing the bodily resources by measures
which can help the individual to throw off the in-
fection. Drugs are playing a more and more sec-
ondary part. Pneumonia is treated by fresh air,
easily assimilated food, appropriate . stimulation,
The same is true of almost every infection. A few
EDITOR'S NOTES 323
"specifics" are used, such as Quinine in Malaria and
the like. The laboratory shows us that evidence of
the disease disappears from the blood after the in-
gestion of the drug. Particularly in children's dis-
ease is the use of drugs becoming more and more
obsolete. Certain pediatrists boast that their thera-
peutics in children's diseases consist of appropriate
diet, castor oil, plenty of sleep and a rectal tube.
Regarding the operation for goitre it is a well known
fact that the failure of this operation was due to
the removal of the Para Thyroids. Since these
have been left intact the operation has been more
successful.
CHAPTER IX
MEDICINE AN ART, NOT A SCIENCE
In this chapter the author takes a distinctly pessi-
mistic view of the medical science and it seems as
if he had missed some of the most important details
of his studies. He calls attention to the various
changes in treatment that have taken place over a
period of years and scoffs at them, but he seems to
lose sight of the fact that each of these probably
accomplished a great deal when administered in
given cases. The fact that none of them were alto-
gether satisfactory simply emphasises the fact that
medicine is not an exact science and it is the untir-
ing, incessant study of the individual and adapta-
324 THE MEMOIRS OF A PHYSICIAN
tion of a given course of therapeutics to individual
cases that accomplishes any good.
CHAPTER X
THE QUESTION OF VIVISECTION
Here the author deals with one of the most
mooted questions in the profession. How far hu-
man beings have the right to perform experiments
on living animals is a matter that must be consid-
ered very carefully. Certain it is that no thought-
ful, truly Christian man, whether he be a scientist
or not, would cause an animal suffering. Stories
reach our ears of vivisection that are too horrible to
be admitted. If they be in a measure true, then
law should step in and prevent their recurrence.
However, in the present day, vivisection in the
medical schools is mainly confined to the inocula-
tion of guinea pigs and rabbits and operations upon
animals under ether or chloroform anaesthesia, and
under the same aseptic precautions as would be em-
ployed in actual operations upon human beings. If
there was at one time a disregard of the feelings of
dumb animals, those who have had opportunity to
observe the work in modern medical schools cannot
but realise that such is not the case at the present
time. The tendency now is to eliminate experi-
ments upon animals by students except under the
close direction of instructors. The anti-vivisection-
EDITOR'S NOTES 325
ists have much on their side of the problem; prob-
ably too much has been done in the past to cause
suffering among animals. On the other hand it is
not altogether reasonable to place the life of a mis-
erable street dog above that of a human being.
There is no question but that infinite value has come
from vivisection; perhaps it has been abused, but in
the progress of the world such abuses will be done
away with. As regards the inoculation of animals
with disease, let it be said that the nervous system
of animals such as guinea pigs, rabbits, and rats is
not highly organised and it is extremely improbable
that such inoculations cause much suffering. The
value of this animal inoculation has been shown be-
yond a shadow of a doubt in the lessening of the
death rate of Diphtheria to such an extent that the
disease is no longer held in the dread that it once
was. The same is true of Tetanus (Lock-jaw),
Meningitis and other diseases. It is no more rea-
sonable to have vivisection absolutely abolished
than it is to have slaughter houses forbidden by law.
The problem concerns us more how vivisection
should be practised, rather than whether or not it
should exist.
CHAPTER XI
THE UNCERTAINTY OF DIAGNOSIS
Here the author deals with the hideous mistakes
that are the nightmare of the profession. Until our
326 THE MEMOIRS OF A PHYSICIAN
science becomes an exact science we shall ever be
confronted with them. The best we can hope to
do is to subject our patients to the most careful ex-
aminations that are possible in order to lessen the
number of our errors.
CHAPTER XII
DOCTOR AND PATIENT
The author touches on a sore point when he deals
with the ignorance of most persons with ordinary
medical subjects. If we are to develop the science
of medicine as it should be developed the public at
large should know more than it does about the prin-
ciples that underlie it. The time is passed when
the doctor could be considered a sort of a magician
who casts a spell over the malady. The further we
go in the study of the ills of the human body the
more we realise how simple are some of the princi-
ples of diet, hygiene and sanitation, and how easily
they can be understood by persons of ordinary in-
telligence. There are very few principles of medi-
cine that cannot be explained in simple terms.
There are things which could be taught in our public
schools which would undoubtedly tend toward the
rearing of a healthier, saner race. If these princi-
ples were taught there would be less overcrowding
of factories, streets would be kept clean, water sup-
EDITOR'S NOTES 327
plies would be kept free of pollution, contagious
diseases would soon be unusual.
CHAPTER XIII
THE DOCTOR AND THE POOR
This is a social problem to be met by the public
at large. Social service workers connected with the
large hospitals have done a wonderful amount of
good in teaching the poor how to live on slender
incomes and how to carry out the directions of the
attending physician. As time goes on the public
will understand that squalor and filth and disease
in one quarter of a city menaces the health and pros-
perity of another quarter, and steps will be taken to
keep such conditions from even existing.
CHAPTER XIV
MEDICINE, NATURAL SELECTION AND THE
SURVIVAL OF THE UNFIT
The author takes an attitude than man is retro-
gressing rather than advancing in physical condi-
tion. The logic of his argument is not clear. He
has allowed himself to wander into a maze of pos-
sibilities that are not within the bounds of reason.
Perhaps the practice of medicine in some instances
does strive towards the survival of the unfit, but can
we not see many instances all around us of puny
328 THE MEMOIRS OF A PHYSICIAN
children who a score of years ago would have died
miserably, but are now reared to healthy manhood
and womanhood by reason of the correction of
physical deformities. Are not the children of these
puny specimens frequently the most healthy in a
given community 4 ? Undoubtedly so. The science
of medicine is advancing along the lines of common
sense, teaching people how to live that they may be
healthy. It is striving toward the attainment of
the goal where medicine itself will cease to have any
cause for existence. The summit of our hopes as
practitioners of medicine will be reached when our
services are no longer required.
CHAPTER XV
MENTAL PROGRESS AND PHYSICAL DEGENERATION
There is hardly any comment necessary upon this
chapter. Mental progress must always go hand in
hand with physical ability. No man can continue
mental work without sufficient physical vigour to
supply food in the form of blood and tissue to his
brain. It is true that a man's brain is more highly
organised than that of an animal and that generally
speaking a human being is the weakest of animals
physically, yet it is undoubtedly true that with com-
paratively little difficulty man may train himself
physically so that he is able to perform feats of en-
durance that cannot be equalled by any other animal.
EDITOR'S NOTES 329
A trained runner can tire out a horse or a dog or
even a deer by reason of his highly developed nerv-
ous system. A man can bring his body under con-
trol and use it to better advantage than any other
animal. Whether he does this or not rests with
the individual himself. It does not require genera-
tions for man to adapt himself to surrounding con-
ditions. He can live where other animals cannot;
he can stand extremes of cold and heat that other
animals cannot; in short, he is probably the most
adaptable animal that exists in the world. Do
these facts suggest retrogression or progress 1 ?
CHAPTER XVI
SHAME AND THE PHYSICIAN
The author has probably purposely overdrawn his
pictures, and, while worthy of consideration, this
does not seem to be one of the vital problems that
concern the profession.
CHAPTER XVII
WHEN THE PATIENT DIES
Such harrowing scenes as are here depicted hap-
pen as a result of ignorance pure and simple. When
the public is educated as to what a physician is try-
ing to do and is able to judge his merits or demerits,
such occurrences will be rare. Physicians of the
330 THE MEMOIRS OF A PHYSICIAN
present day do not meet with such problems as often
as they did in the past, extremes of gratitude and
hate, as has been said before, are unusual. The
recovery of a patient under a doctor's care is not
considered miraculous unless the physician has ac-
tually done something that is phenomenal by reason
of his skill in handling a knife or pulmotor. Credit
is given to him more on account of his personal at-
tention and unfailing interest than on his book
knowledge.
CHAPTER XVIII
THE PROFESSIONAL MANNER
Indifference is not as necessary as the author would
lead us to believe; on the contrary, fellow feeling,
cheerfulness and singleness of purpose are more im-
portant; encouragement and frankness are always
appreciated and evenness of temper is essential.
CHAPTER XIX
DOCTORS AND MONEY
Here is one of the vital problems of medicine.
The author has dealt with it clearly. Once a
famous specialist was asked to describe the profes-
sion of medicine. He said, "It is one of the grand-
est professions in the world but a horrible business."
Physicians are under paid and wrongly so, but this
EDITOR'S NOTES 331
is due to a lack of understanding as to what their
ability means. It seems exorbitant for a doctor to
charge five dollars for a personal interview lasting
a few minutes, but if physicians are to exist they
must have the means wherewith to live, and the
expense of medical education is enormous. There
is scarcely a physician who does not feel that he
would prefer to eliminate the necessity to charge his
patients for his services. The personal element in
the practice of medicine is so essential and yet so
sacred that it can scarcely be placed on a mercenary
basis. The simplest plan of meeting this great
question would be to have every individual required
by law to withhold a certain per cent of his income,
no matter how small it might be, and turn this over
to a properly appointed official or bureau. This
officer in turn should use it in recompensing the
physician who attends the family of the man upon
presentation of an itemised account of the services
rendered on a definite basis of specific charges. In
this way the pecuniary matters which now hamper
both physician and patient would become negligible
and there would be no tendency on the part of the
patient to avoid payment and no hesitancy in send-
ing for a physician at the proper time. The details
of such an arrangement could be worked out by a
properly appointed commission, and such a system
would work great good besides eliminating the ques-
tion of how much to charge the individual.
APPENDIX B
(This is Chapter VIII of the original Russian.
For fairly obvious reasons it has seemed wisest to
print it as an appendix in this version.)
EXPERIMENTS ON LIVING MEN AND WOMEN
For the nonce I will take leave of those tangled
and difficult problems, which I am at a loss to
solve, and in the face of which I must confess utter
helplessness. I will now occupy myself with a ques-
tion to which but one answer is possible, and that a
perfectly straight one. It deals with gross and en-
tirely conscious disregard for that consideration
which is due to the human being.
I approach the subject with regret, but it is im-
possible to pass it by.
"A certain Dr. Koch," we read in the Russian
medical paper, Physician, "has published a pam-
phlet, entitled, 'Aerztliche Versuche an lebenden
Menschen' ('Medical Experiments on Living Man'),
than which nothing were better calculated to further
undermine the respect for, and confidence of the
laity in, our profession. The author essays to prove
that 'vivisection has long crossed the thresholds of
our hospitals' in other words, that experiments
similar to those conducted upon the lower animals
EXPERIMENTS ON MAN 333
in the laboratory, are practised on living man in our
infirmaries. As might have been expected, Koch's
book was immediately seized upon by different feu-
illeton writers and newspaper chroniclers. It were
highly desirable that our German colleagues should
not leave a single one of Dr. Koch's 'facts' without
searching inquiry and explanation, as it is only pos-
sible by this means to nullify the effect of his
book." l
I have not read the above-mentioned pamphlet,
and do not know how far the "facts" mentioned by
Dr. Koch merit the ironical inverted commas which
the editor of the Physician had seen fit to place them
in. But unfortunately there is much substantial
truth even in the title of Dr. Koch's booklet alone.
In proof of the above it would be easy enough to
adduce a very long array of facts facts of such
a nature, too, that they could not be bracketed in
inverted commas, for this simple reason they are
substantiated in black and white by the perpetrators
themselves.
As we proceed, I shall point out the original
sources of my information with every possible care,
that the reader may verify my statements.
I shall restrict myself to the venereal diseases.
Notwithstanding the delicacy of the subject, I was
compelled in my choice to single out the above,
because they furnish us with the greatest wealth
1 See The Physician, 1893, P- 96-
334 THE MEMOIRS OF A PHYSICIAN
of the facts I wish to draw public attention to. For
venereal complaints are the exclusive lot of man,
and not a single one of them can be transmitted to
the lower animals. 1 Owing to this, many questions
which, in other branches of medicine, find their an-
swer in experiments on animals, can, in venerology,
only be decided through human inoculation, and
venerologists have not hesitated to take the plunge :
crime stains every step made by their science.
As is well known, three varieties of venereal dis-
ease exist: gonorrhoea, soft ulcer and syphilis. I
shall commence with the first named.
The specific micro-organism of gonorrhoea was
discovered by Neisser in 1879. H IS experiments,
conducted with exemplary care, tended to prove,
with a considerable degree of probability, that the
gonococcus he had discovered was the specific agent
of that disease. But in bacteriology the proof posi-
tive of the specific quality of any micro-organism
is only absolute when obtained through inoculation;
if, on inoculating an animal with a pure culture of
the micro-organism, we call forth a given disease,
this fact proves that the above micro-organism is the
specific agent of the latter. Unfortunately, not a
single animal, as we already know, is liable to gonor-
rhoea. Either the discovery had to remain doubtful,
or else it was necessary to inoculate man. For him-
self, Neisser chose the first alternative.
1 It has been possible to infect monkeys with syphilis.
EXPERIMENTS ON MAN 335
His followers were not so nicely conscientious.
The first to inoculate man with gonococcus was Dr.
Max Bockhart, assistant to Professor Rinecker.
"Geheimrath von Rinecker," writes Bockhart,
"held the view, that the discovery of the causes of
venereal disease was only possible through the in-
oculation of human beings." 2 Acting upon the sug-
gestion of his patron, Bockhart inoculated a patient
suffering from creeping paralysis in its last stages
with a pure culture of gonococcus: a few months
previously the patient had lost his sense of feeling
and his death was awaited very shortly.
The inoculation proved successful, but the dis-
charge was very insignificant. To increase it, the
patient was given half a litre of beer. "The suc-
cess was brilliant," writes Bockhart; "the dis-
charge became very copious. . . . Ten days after
inoculation the patient died of a paralytic fit. Au-
topsy showed acute gonorrhoeic inflammation of the
urethra and bladder, with incipient kidney mortifi-
cation, and a large number of abscesses in the left
kidney; numerous gonococci were found in the pus
taken from these abscesses." 3
The methods of pure culture employed by Bock-
hart were very crude, and his experiment had but
small scientific value. The first undoubtedly pure
2 "Beitrag zur Aetiologie desHarnrohren trippers": Vierteljahr-
schr. fur Dermatol. und Syphilis, 1883, p. 7.
3 Beitrag zur Aetiologie des Harnrohrentrippers": Vierteljahr-
schr. filr Dermatol. und Syphilis, 1883, pp. 7-10.
336 THE MEMOIRS OF A PHYSICIAN
culture of gonococcus was obtained by Ernst Bumm. 4
To prove that it was the specific agent, Bumm, by
means of a platinum wire, introduced the culture
into a woman's urethra, which had been found per-
fectly healthy after repeated examinations. Typ-
ical urethritis developed which required six weeks
for its cure (op. cit. p. 147). Studying the various
peculiarities of his cultures, Bumm inoculated his
gonococcus upon another woman in the same man-
ner, obtaining an identical result (p. 150). Here
we must note that, more than twenty years pre-
viously, Noeggerath proved how serious and painful
were the effects especially in the case of women,
following so-called "innocent" gonorrhoea, which
the ignorant even now speak of with a smirk, al-
though science has long ceased to have any doubts
on the matter whatever. This is what such an au-
thoritative specialist in these matters as Neisser, of
whom we have already had occasion to speak, de-
clares: "I do not hesitate to state that in its after
effects, gonorrhoea is an incomparably more dan-
gerous (ungleich Schlimmer) disease than syphilis,
and I think that all, especially gynecologists, will
agree with me." 5 Bumm himself declares, in the
preface to his work, that "gonorrhoeic infection is
4 E. Bumm, "Die Micro-organismus der gonorrhosichen Schleim-
hauterkrankheiten." 2. Ausg. Wiesbaden, 1887.
5 Prof. Al. Neisser, "Ueber die Nothwendigkeit von Spezialklin-
iken fur Haut-und Venerische-Kranke" : Klinisches Jahrb., Bd. ii.
p. 199.
EXPERIMENTS ON MAN 337
one of the most important causes of painful and
serious affections of the sexual organs" 6 ; which
knowledge did not, however, deter him from subject-
ing two of his patients to such a risk. It is true that,
according to his accounts, "every measure of pre-
caution (?) against infection of the sexual organs"
was taken, but such precautions are extremely unre-
liable. We may further add that even gonorrhceic
affection of the urethra alone is sufficient to cause
the most painful complications later.
The next step in the culture of the gonococcus
was made by Dr. Ernst Wertheim, 7 who succeeded
in obtaining a pure culture on plates. "To prove
conclusively," writes Wertheim, "that the colonies
growing on the plates were really those of Neisser's
gonococci, it was naturally necessary to perform
inoculation upon the urethra of man." Wertheim
inoculated four paralytic patients with his culture
and also a certain S. (an idiot of thirty-three).
"Fairly abundant discharge was still noticeable in S.
two months after inoculation." Wertheim made
no further experiments "owing to lack of suitable
material." 9
6 Op. cit., p. iv.
7 Provisional report in the Deutsche med. Wochenschrift, 1891,
No. 50 ("Reinziichtung des Gonococcus Neisser mittels des Plat-
tenverfahrens"). Detailed description in Archiv fur Gynaecologie,
Bd. 42 (1892): "Die ascendirende Gonorrhoe beim Weibe."
8 Archiv, pp. 17, 28, 33-34, 37, 39.
9 I < \vill here draw attention to the fact of Wertheim having in-
jected pure culture of gonococcus into his own body each time
with positive results.
338 THE MEMOIRS OF A PHYSICIAN
Wertheim's methods were verified by other in-
vestigators. Gebhard 10 was successful in his inocu-
lation of Wertheim's culture upon human beings
(no details are given on his work). The experi-
ments of Karl Menge also furnished positive results :
he inoculated a woman suffering from a vesico-
vaginal carcinomatous fistula, with gonococcus; it
was he also, who inoculated a woman, suffering
from tumour on the brain, with gonorrhoea, two days
before her death. 11
But especially comprehensive were the experi-
ments of Finger, Ghon and Schlangenhaufen. 12
They inoculated fourteen patients, all of them hope-
less cases, chiefly consumptives, who mostly died
from three to eight days after inoculation. "Ex-
tremely valuable histological material was furnished
by the patient F. D., 21, who died three days after
inoculation. Taking into consideration," remarked
the joint authors, "the short duration of the process,
which lasted but three days, one is surprised at its
intensity, which caused such deep histological
changes."
Gonorrhoea is one of the commonest causes of
inflammation of the eyes in newly-born infants.
Many investigators studied the relationship of gon-
10 "Der Gonococcus-Neisser auf der Platte u. in Reincultur" :
Berlin, kiln. Woch., No. n, p. 258.
11 "Ein Beitrag zur Kultur des Gonococcus": Centralblatt fur
Gynaecologie, 1893, No. 8.
12 "Zur Biologic des Gonococcus": Archiv fur Dermatologie und
Syphilis, Bd. 28, 1894, pp. 304-306, 317-324.
EXPERIMENTS ON MAN 339
ococcus to eye-disease in newly-born children. E.
Fraenkel inoculated the eyes of infants, which could
not have lived in any case, with the inflammatory
secretions of gonorrhceic patients. One of the
infants lived for ten days after inoculation, de-
veloping typical purulent inflammation of the
eyes. 13
Tischendorff inoculated the eyes of atrophic chil-
dren with gonorrhceic discharge of little girls suf-
fering from that disease: purulent inflammation,
with characteristic gonococci, was the result. 14
Kroner inoculated six adult blind persons with the
muco-purulent discharge of pregnant and oarturient
women (with negative results). 15
Such is the very incomplete history of gonorrhoea
from the standpoint which interests us. I now
ought to pass on to the inoculation of soft ulcer
(ulcus molle), but I need not tarry for the purpose:
firstly, because such inoculations are comparatively
harmless in their after-effects the investigator
merely inoculates the patient's shoulder, thigh or
abdomen with the ulcer and heals it a week or so
later; that sort of thing is a "mere nothing" to the
patient, for is not the living skin of man "the most
18 "Bericht iiber eine bei Kindern beobachtete Endemic infec-
tioser Kolpitis": Virchovfs Archiv, Bd. 99, Heft 2 (1885), pp. 263-
264.
i* "Verhandlungen der 57 Versammlung deutscher Naturforscher
u. Aerzte in Magdeburg, 1884'': Archiv filr Gynaecologie, Bd. 25
(1885), p. 114.
15 Ibid., p. 113.
340 THE MEMOIRS OF A PHYSICIAN
natural nutritive milieu for the micro-organism of
soft ulcer*?" to quote Dr. Spitschka. 16
Secondly, the sum total of the above inoculations
is so great, that one would have to devote several
printed sheets to their description. Suffice it there-
fore to mention the names of Hunter, Ricord, Na-
deau, Roller., Buzenet, Cuillerier, Lindwurm, de
Luca, Mannino, W. Beck, Strauss, Hubbenet,
Baerensprung, Ducre, Kraefting, Spitschka, and
many, many others.
So we pass on to syphilis. Without going far
back into antiquity, I shall give an account of the
history of that disease dating from the times of
the celebrated French syphilologist, Philippe Ricord.
Ricord cleared up many obscure problems of his
specialty and entirely reconstructed the science of
venerology. But, of course, he did not escape error.
One of his most lamentable mistakes was the affirma-
tion that syphilis was not contagious in its second-
ary stage. This mistake was due to the fact that
while Ricord performed endless inoculations upon
venereal patients, he never ventured to experiment
upon the healthy. 17 Let us see how this fallacy was
set right.
16 "Zur Aetiologie des Schankerbulo" : Archiv fiir Dermal, und
Syphilis (1894). Bd. 28, p. 32.
17 Rinecker, referring to this fact, very justly remarks: "It is
hard to understand why Ricord condemned the inoculation of
the healthy so absolutely; taking into consideration the vast num-
ber of his experiments, he could not have remained in ignorance
of the fact, that the inoculation of the sick is not infrequently
EXPERIMENTS ON MAN 341
One of the first to express himself in favour of
secondary syphilis being contagious was the Dublin
physician, William Wallace, in his highly instruc-
tive "Lectures on Cutaneous and Venereal Disease."
These Lectures are remarkable for the classical
shamelessness with which their author tells us of his
criminal experiments in inoculating healthy people
with syphilis.
"The operation of inoculation," says he, "I per-
formed in one of three ways: firstly, by making a
puncture with a lancet and applying the matter of
either an ulcer or the condylomata to the wound;
secondly, by removing the cuticle with the ointment
of cantharides and applying lint immersed in matter
to the denuded surface; or else, thirdly, by removing
the cuticle from a small extent of surface with the
finger covered by a towel, and by applying the mat-
ter to the surface of the cutis thus exposed. The
results were similar." 18
In his subsequent lectures, he gives a detailed ac-
count of his inoculations performed upon five healthy
individuals from 19 to 35 years of age. All de-
veloped characteristic syphilis. 19
In his twenty-second lecture Wallace declared
dangerous to the latter." The sum-total of Ricord's gonorrhoeic
inoculations, as well as those of syphilis and soft ulcer, amounted
to seven hundred.
18 W. Wallace, "Lectures on Cutaneous and Venereal Diseases":
The Lancet for 1835-36, vol. ii. p. 132.
19 "Clinical Lectures on Venereal Diseases": The Lancet, 1836-
1837, vol. ii. pp. 535, 536, 538, 620, 621,
342
that the facts above mentioned were "only a portion,
yes, a very small portion of those of a similar kind
which I could adduce." 20 In his twenty-third he
again lays stress on the circumstance that the ex-
periments described were only a small part of those
he had conducted. 21
"Is it permissible to expect more convincing proofs
of the contagiousness of the secondary stage of
syphilis?" queries Dr. Schnepf, 22 writing on the sub-
ject of these experiments. "No further experiments
on the healthy are required. Wallace's make them
entirely superfluous. The problem is solved, sci-
ence desires no more victims ; all the worse for those
who close their eyes to this fact."
But the orgy was only about to commence. . . .
In 1851 the "remarkable epoch-making" experi-
ments of Waller were published. This is how he
described them:
"First experiment: Durst, a boy of 12, registra-
tion number 1396, suffered for a number of years
from sores on the head. Otherwise quite healthy,
never had rash or scrofula. As his disease required
his detention in hospital for several months, and as
he had not suffered from syphilis in the past, I
found him to be very suitable for inoculation, which
20 Ibid., p. 539.
^Ibid., p. 615.
22 "De la contagion des accidents consecutifs de la syphilis":
Annales des maladies de la peau et du syphilis. Publ. par A.
Cazenave. Vol. iv., 1851-52, p. 44.
EXPERIMENTS ON MAN 343
was performed on August 6th. The skin of the
right thigh was incised and the pus taken from a
syphilitic patient introduced into the fresh and
slightly bleeding wounds. I rubbed the matter into
the abrasions with a spatula, then I rubbed the scari-
fied surface with lint soaked in the same matter, and
having covered it with the same lint, applied a band-
age." About the beginning of October the child
developed a typical syphilitic rash. 23
"Second experiment: Friedrich, 15, registration
number 5676, suffered for the last seven years from
lupus of the right cheek and the chin. Up to now
the patient had not had syphilis and was therefore
eligible for inoculation. This was performed on
July 27th. I introduced the blood of a syphilitic
woman into fresh incisions made on the left thigh
and then dressed the wounds with lint soaked in the
same blood." About the beginning of October the
success of the inoculation was beyond a doubt. 24
"I showed both patients expressly to the director
of the hospital, Riedel," adds Waller, "to the head
physicians of the hospital (Boehm and others), to
many of the city physicians, to several professors
(Jackisch, Kubik, Oppolzer, Dietrich and others),
to almost all the hospital physicians of the city and
to many foreigners. All unanimously substantiated
23 Waller, "Die Contagiositat der secondaren Syphilis": Viertel-
jahrschr. fiir d. prakt. Heilkunde. Prag. 1851, Bd. I. (xxix), pp.
124-126.
z *lbid., pp. 126-128.
344 THE MEMOIRS OF A PHYSICIAN
the accuracy of my diagnosis of the syphilitic rash
and declared themselves ready, if necessary, to step
forward as witnesses of the reality of the results of
my inoculations."
Is not this a complete and accurate . . . criminal
report? All the details of the "case" are communi-
cated, the victims are indicated and the witnesses
cited name by name. ... If the public prosecutor
had peeped into this province, he would have found
his task wonderfully simplified.
Waller's were the signal for general and universal
experiments for the verification of the contagious-
ness of secondary syphilis.
In March, 1852, Professor Rinecker inoculated a
boy of 12, suffering from incurable St. Vitus' dance,
with the pus taken from a syphilitic patient. After
the lapse of a month the inoculated part developed
infiltration and induration. There were no con-
stitutional symptoms in this case. 25
In 1855, at a convocation of Pfalz doctors, while
the contagiousness of secondary syphilis was under
discussion (in connection with Waller's experi-
ments), the assembly was acquainted by its secre-
tary with the contents of a communication received
from an absent colleague.
25 "Ueber die Ansteckungsfahigkeit der constitutionellen Syphilis":
V erhandlungen der pfiys. medic. Geselbschaft in Wurzburg, Bd. III.
(1852), p. 391. In the clinic of the same Prof. Rinecker two
physicians, Drs. Warneri of Lausanne and W. P., consented to be
inoculated and both developed syphilis.
EXPERIMENTS ON MAN 345
"A peculiar coincidence made it possible for the
above-mentioned colleague to carry out experiments
in connection with the contagiousness of secondary
syphilis, without infringing the laws of humanity."
These experiments consisted of the following. 28
The discharge of flat moist condylomata and the
secretion of the fissures of a female syphilitic patient,
were inoculated upon eleven persons three women
of 17, 20 and 25 years of age respectively, and eight
men of ages varying from 18 to 28 years. All de-
veloped syphilis. The pus of syphilitic ulcers was
used for inoculating three women of 24, 26 and 35
years of age respectively. All three developed syph-
ilis. Sores on the feet of six patients were smeared
with blood taken from a syphilitic patient; three of
the above contracted syphilis. The blood of a
syphilitic patient was introduced into the wounds
left after wet cupping of three persons. There was
no result. 27
Thus twenty -three persons were inoculated ; seven-
teen of these developed syphilis; and it was found
possible to do all this "without infringing the laws
of humanity!" Truly, a wonderful coincidence!
As we proceed, we shall see that such "coincidences"
are not rare in syphilology. . . . The identity of
the author of these experiments never transpired;
26 Ib'ld.
2T "Auszuge aus den Protocollen des Vereins pfalzischer Aerzte
vom Jahre 1855": Aerztllche Intellegenzblatt, 1856, No. 35, pp. 425,
426.
346 THE MEMOIRS OF A PHYSICIAN
he found it best to keep his infamous name forever
in the' dark, and he is known in science to this day
as the "Anonimus of Pfalz."
The same question of the contagiousness of sec-
ondary syphilis was the subject of the researches of
Professor H. von Hubbenet. Among others, he
made the following experiments:
1. "F. Susikoff, medical orderly, 20 years of age,
in February, 1852, underwent inoculation with
mucous papulse of a syphilitic patient, while in
blooming health. I blistered his left thigh, and,
after thus removing the cuticle, transferred the mat-
ter of the mucous papule, by means of a spatula, to
the raw surface, and applied lint dressing impreg-
nated with the same secretion. . . . Roseolse ap-
peared on his chest and abdomen in five weeks.
From that moment the syphilitic affection made
rapid progress. I kept the patient in this condition
for a week longer, to enable me to demonstrate him
before as large a number of physicians as possible,
and thus allow them to assure themselves of the
actuality of the fact. At last I applied the mer-
curial treatment, and the patient was cured in three
months."
2. "Private Timothy Maximoff, 33, admitted to
the surgical clinic on January 13th, 1858, suffer-
ing from an inveterate fistula of the urethra. As ac-
cording to every calculation the patient was to re-
main in hospital for a considerable period, and there
EXPERIMENTS ON MAN 347
was thus sufficient time at our disposal to await
results, this case struck me as being a suitable one
for experiment. On March 14th, inoculation with
the matter taken from the ulcerated tonsils of Pri-
vate Nesteroff was performed. . . . By May 22nd
characteristic roseols. . . . Mercurial treatment
started on June 2nd, and in six weeks the patient
was cured." 28
Commenting upon these descriptions, Professor
V. A. Manassein expresses himself as follows : "We
do not know what to be more amazed at: the cold-
blooded way in which the experimenter allows syph-
ilis to develop more acutely for the purposes of
clearer illustration and 'so as to show the patient to
a larger number of physicians'; or at that logic of
the superior, which permits him to subject a sub-
ordinate to the dangers of a serious and, not infre-
quently, fatal disease, without so much as obtaining
his consent thereto! I should very much like to
know whether Professor Hubbenet would inoculate
his own son with syphilis, even were he to ac-
I * 9Q
quiesce!
Professor von Hubbenet concludes his article with
the following words : "I consider it necessary to re-
mark that, having carried out a multitude of ineffec-
tive experiments on sick persons, I was perfectly con-
vinced that, in the case of the healthy, I would meet
28 Prof. H. v. Hubbenet, "Observations and Experiments in Syph-
ilis": The Medical-Military Journal, Part 77 (1860), pp. 423-427.
OT "Lectures on General Therapeutics," Part i. St. P. 1879, p. 66,
348 THE MEMOIRS OF A PHYSICIAN
with the same lack of success: this conviction alone
made it possible for me to proceed with these dan-
gerous experiments." Needless to say that a pro-
fessor and specialist could not have been ignorant
of Waller's successful inoculations. Besides, Prof.
Hubbenet performed his first successful inoculation
in 1852, while his last dates 1858. Are we to be-
lieve that in 1858 the professor proceeded with his
inoculations full of the same "conviction" ?
The publication of these observations, continues
Hubbenet, "will perhaps restrain others, even with
such a sceptical nature as my own, from making
further experiments, often leading to the complete
wrecking of the lives of the persons subjected to
them. It would add considerably to my peace of
mind in respect to the victims' fate, if these experi-
ments were to spread the conviction that the second-
ary stage is contagious. If they lead to the estab-
lishing of such an important truth, the sufferings of
a few individuals were not too high a price to be
paid by mankind for the attainment of such a truly
beneficial and practical result."
If that is the case, it is hard to understand why
Professor Hubbenet did not inoculate himself with
syphilis. Perhaps, after all, such a price would
have been too high to pay even "in the cause of hu-
manity."
In 1858 the French Government applied to the
Parisian Medical Academy for elucidation on the
EXPERIMENTS ON MAN 349
still contested question of the contagiousness of sec-
ondary syphilis. A commission was nominated and
Dr. Gibert was appointed as its referee. Among
other things, he stated that with a view to clear this
question up, Dr. Auzias-Turenne had inoculated two
adult patients suffering from lupus, and that both
developed syphilis.
The referee himself inoculated two patients, also
suffering from lupus, and in both cases he obtained
syphilis. 30
Gibert's report gave rise to stormy and lengthy
debates in the Academy; Ricord, who had hitherto
obstinately denied the contagiousness of secondary
syphilis, notwithstanding overwhelming confirma-
tory evidence, entered the lists with great heat, but
was compelled, in the end, to confess his mistake,
and went over to the opposite camp.
Thus the most powerful and authoritative op-
ponent of the new view taken by science was van-
quished. But, nevertheless, experiments, now ab-
solutely unwarrantable, went on and on. ... In
1859 Guyenot inoculated T. B. B., a boy of ten,
suffering from sores of the head, with the secretions
of syphilitic plaques, and obtained syphilis. 31
In the same year Professor Baerensprung success-
30 Bulletin de I'Academie Imperiale de Mededne, Tome xxiv.
Paris. 1858-1859, pp. 888-890.
31 "Nouveau fait d'inoculation d'accidents Syphil. Secondaires" :
Gaz. hebdomad, de med. et de chirurgie, 1859, No. 15. Guyenot was
terribly punished for his experiment: the Tribunal of Correction of
Lyons condemned him to a fine of one hundred francs!
350 THE MEMOIRS OF A PHYSICIAN
fully inoculated Bertha B., a girl of eighteen, with
syphilitic pus. It was also he who inoculated the
prostitute Marie G. with the secretions of hard
chancre. 32
Prof. Lindwurm, in 1860-1861, inoculated five
women lying in his hospital, aged 18, 19, 30, 45
and 71 years respectively, with syphilis. We quote
the description of the last of these experiments:
"Mary E., aged 71 years, suffering for many years
from an extensive and deep ulcer in the forehead.
Both sinera frontalia, thanks to the destruction of
the front walls, are open; the bottom of the ulcer
is covered deeply with granulations, through which
the probe easily reaches the bone, and, in places,
traverses the latter. ... On May 27th, 1861, the
blood of a syphilitic patient was injected subcutane-
ously between the shoulder blades." The patient
developed syphilis. 33
According to Zeissel, Dr. Rosnerom, acting under
Prof. Hebra's directions, made the following experi-
ments: "(1) The secretion of a flat condyloma,
located on the breast of a certain wet-nurse, was
inoculated upon a patient of 50, suffering from
acute itch." Syphilis. (2) A wet-nurse, suffering
from innocuous syphilis, was inoculated in the fore-
82 "Mitteilungen aus der Klinik fur syphil. Kranke." Annalen
des Charite-Krankenhauses, Bd. IX. Heft i (1860), pp. 167, 168.
33 "Uber die Verschiedenheit der syphilischen Krankheiten":
Wurzburger medicinische Zeitschrift, Bd. III. pp. 146-148, 174
(1862).
EXPERIMENTS ON MAN 351
arm with chancrous pus. This woman, impregnated
with syphilis, developed characteristic pustules.
The pus of the latter was used to inoculate a certain
leprous patient, who had not previously suffered
from syphilis. . . . This inoculation also was suc-
cessful." 34
Dr. Puche inoculated a patient lying at the Ho-
pital du Midi) in the ventral regions, with the secre-
tion of an indurated ulcer of a syphilitic patient,
but without results. Three weeks later Puche in-
oculated his victim with the matter of another
syphilitic. This time the experiment was crowned
with success : the patient contracted syphilis. 30
To settle the question once and for all whether a
person who had once had syphilis could contract it
again, Prof. Vidal de Cassi made the following ex-
periments. "M., age 37." (Had been cured of
syphilis, entered hospital with paralysis of the lower
extremities, formerly employed in a tannery and
afterwards as a watchman.) "The patient began
to recover but wished to remain in hospital for a
certain time longer, in expectation of a government
post. In January, 1852, small blisters were applied
to each thigh because of the inactivity of the blad-
der; when the skin was removed, the wounds were
dressed with lint soaked in matter taken from the
34 Herrmann Zeissel, "Guide to the Study of General Syphilis."
St. Petersburg, 1866, page 29.
35 Henry Lee, "Hunterian Lectures on Syphilis": The Lancet,
1875, vol. ii. p. 122.
352 THE MEMOIRS OF A PHYSICIAN
mucous papules of another patient. This inocula-
tion was barren of results. Later I proposed that
the experiment should be repeated. On April 12th,
1852, when the patient began to complain of diffi-
culty in breathing, blisters were applied to the upper
parts of his arms; these were dressed on April 13th
with lint saturated in the pus of the mucous papules
of another patient. April 15th, the wounds on each
arm had become covered with a greyish membrane,
suppuration very copious and of disgusting odour;
lint saturated with the same pus as previously was
freshly applied to the wounds," etc. 36 Vidal was
very dissatisfied with the squeamishness of those
savants who did not venture upon such experiments.
"Unfortunately," he remarks, "the cleverest of
syphilologists, who could be of the greatest serv-
ice to science thanks to their logic and clinical ob-
servations, regard experiment as immoral, and neg-
lect it accordingly." 37
Is syphilis contagious in the tertiary stage 4 ? The
majority of the experiments conducted tend to nega-
tive contagiousness. Didet inoculated healthy per-
sons with the blood of syphilitic patients in the third
stage without result. 38 Finger performed more than
thirty inoculations with the secretions of gummata
38 Prof. A. Vidal, "On Venereal Disease." Transl. from the
French, St. Petersburg, 1857, pp. 560-561.
37 Prof. A. Vidal, "On Venereal Disease."" Transl. from the
French. St. Petersburg, 1857, p. 31.
38 Gaz. Med. de Paris, 1846. Cited from Lancereaux: "The
Study of Syphilis," p. 607.
EXPERIMENTS ON MAN 353
and periostitse upon ten healthy, i.e. non-syphilitic
subjects. 39
A long series of experiments were conducted by
different scientists for the purpose of discovering
whether the normal and pathological, but non-spe-
cific, secretions of the syphilitic patient in the sec-
ond stage were contagious. Thus Basse inoculated
the skin of a healthy person with gonorrhoeic pus
taken from a syphilitic patient, with negative re-
sult. 40 Prof. V. M. Tarnovsky was more fortunate.
"In the winter of 1863," he tells us, "in the Kalinkin
Hospital, after eighteen ( !) attempts, I was enabled
to inoculate a woman, suffering from warty growths,
who had had syphilis, with the mucous-purulent se-
cretion of another patient" (a syphilitic woman).
Typical syphilis developed. 41
It was in the same Kalinkin Hospital that Pro-
fessor Tarnovsky conducted a series of experiments
for the purpose of verifying Cuillerier's assertion
that soft ulcer cannot be transmitted through un-
ruptured mucous membrane. . . . "More than this,"
writes the professor, "in 1868-1869 I decided to
experiment in the same manner with the discharge
of hard chancre and that of the subsequent stages
of syphilis. In the case of two female patients who
39 E. Finger, "Die Syphilis und die venerische Krankheiten."
Wien, 1886, p. 7.
40 Rollet's speech at the Congress held at Lyons in 1864. Gaz.
hebd., 1864, p. 706.
41 V. M. Tarnovsky, "Course of Venereal Diseases," St. Peters-
burg, 1870, p. 67.
354 THE MEMOIRS OF A PHYSICIAN
had never had syphilis and absolutely lacked the
slightest abrasions in their valvulse . . . the secre-
tion of indurated chancre and mucous papules was
introduced into the vagina of each." Syphilis did
not supervene. 42 By the way, the same Prof. Tar-
novsky, testing Langleber's preservative fluid, made
the two following experiments: the "secretion of
indurated chancre in the one case, and that of moist
mucous papules in the other, was transferred upon
the inner surface of the upper arm of a healthy
patient, where the cuticle had been previously erased
with a lancet. The infectious matter was left in
contact with the raw surface from five to ten min-
utes, after which it was rubbed with the preservative
fluid. In neither case did syphilitic symptoms
supervene." 43
In the spring of 1897, Professor Tarnovsky was
superannuated and quitted his chair at the Military
Medical Academy. His valedictory lecture was de-
voted to ... medical ethics. The professor must
have given expression to high-minded and noble
sentiments, for the students accorded him a loud
ovation.
Can syphilis be transferred through the agency of
the secretions of the soft ulcer of a syphilitic pa-
tient? A. G. Gay, lecturer (now professor) of the
Ibid., p. 64.
43 E. Lancereaux, "The Study of Syphilis." Translated into the
Russian under the editorship of Prof. V. M. Tarnovsky. St. Peters-
burg, 1876, p. 669. See Editor's note,
EXPERIMENTS ON MAN 355
Kazan University, essayed to clear this question up
by experiment. "The experiment was performed
upon a woman suffering from Norwegian leprosy
who had never had syphilis and who gave her con-
sent for the experiment" (sic!). The result was
negative. 44
The results of four inoculations by Rieger, con-
ducted by him in Rinecker's clinic, were also nega-
tive in their result. Biedenkapp's 45 experiments
were more successful. . . . Ah, no! I crave his
pardon; one of those magic "coincidences" quite
improbable in everyday life, but which, as we know,
occasionally crop up in syphilidology came to his
aid.
"First case: A young girl, admitted October Qth,
1862, suffering from blenorrhcea of the vagina and
the urethra, inoculated herself, by means of a needle,
with chancrous virus taken from the artificial ulcers
of a female patient who was under treatment for
syphilidisation. . . . Two ulcers formed, which
were not accompanied by constitutional syphilis."
"Second case: A young girl suffering from ec-
zema of the forearms, but who had never had any
venereal affection, inoculated herself out of mischief : ,
similarly to the preceding patient ', with 18 (eight-
een ! ) chancres ; to these were added 1 2 more, inocu-
44 "Diary of the Physicians' Society of Kazan," 1881, p. 12.
45 See Bumler's "Syphilis" in the "Guide to Special Pathology
and Terapathy," by Zierassen. Rus. translation. Vol. III. Part i.
p. 84. Kharkoff, 1886.
356 THE MEMOIRS OF A PHYSICIAN
lated as a test, with pus from the original pustules,
as the cause of their origin was not at first known."
The patient developed syphilis. 46
For the sake of ascertaining whether the milk of
women suffering from syphilis was infectious, Par-
dowa inoculated four healthy wet-nurses with the
milk taken from a syphilitic patient; in each case
the result was negative. 47
The same question was the subject of Dr. R.
Voss' research. In the Kalinkin Hospital he in-
oculated three prostitutes, "having obtained their
consent" with the milk of a syphilitic patient.
First experiment: P. A., aged thirteen, a peas-
ant from the Province of Novgorod ; had had syphi-
lis, but was cured. On September 25th, 1875, the
milk of a syphilitic patient was injected into her
back. The only result was an abscess the size of
a "small fist."
Second experiment: Natalie K., age fifteen,
had taken up prostitution but recently. Admitted
with urethritis and vaginitis. Milk of a syphilitic
patient injected. No result.
Third experiment: Lubov U., age sixteen, a
prostitute; admitted into hospital suffering from
urethritis; never had syphilis. September 2yth, a
full Pravaz syringe of milk from a syphilitic patient
46 See Bumler's "Syphilis" in the "Guide to Special Pathology and
Terapathy," by Zierassen. Rus. translation. Vol. III. Part i. p.
84. Kharkoff, 1886.
47 Lancereaux, p. 614.
EXPERIMENTS ON MAN 357
injected beneath the left shoulder blade. The girl
developed syphilis**
Dr. Voss, as also Prof. Gay, assures us that his
victims gave their consent to these experiments. Is
this mockery? The eldest of the girls was but six-
teen years of age ! Even if their consent had really
been obtained, did these children know what they
were agreeing to, could any importance have been
attached to their acquiescence*?
This will suffice. I have mentioned far from all
the facts at my disposal, dealing with the inocula-
tion of syphilis upon man. But even those I have
adduced seem to me to prove convincingly enough
that these experiments are by no means exceptional
or chance occurrences 49 : they are conducted sys-
tematically, they are described with the greatest
sang froid, without fear of being condemned by
public opinion, as if it were but a matter concerning
dogs and rabbits. In conclusion, I will only quote
a few more experiments from other spheres of medi-
cine. Although the latter are comparatively rarer
(thanks to the possibility of experimenting upon
animals), nevertheless their absolute number is more
than sufficient.
While investigating the channels of human infec-
48 "1st die Syphilis durch Milch ubertragbar ?" St. Petersburger
med. Wochenschrtft, 1876, No. 23. In the original all three girli
were named in full.
49 This was true enough at the time this book was written (1900)
but is no longer so.
358 THE MEMOIRS OF A PHYSICIAN
tion with worms, Professor Grass! and Calandruccio
administered a pill, containing the germs of ascaris,
to a boy of seven, who had not hitherto suffered
from worms : in the course of three months the child
evacuated 143 ascaris of lengths varying from 18
to 23 centimetres each. 50
At the medical congress held in Halle, Professor
Epstein communicated the results of his experiments
in the same direction : the germs of ascaris were ad-
ministered to three children in their food, and in
three months their excrements contained the ova of
this parasite. 51
Studying diabetes and anxious to know more of
the changes made by the disease in the liver, Pro-
fessors Frerichs and Erlach punctured this organism
with a trocar, in the cases of various patients. "On
removal of the stiletto, the tube of the trocar was
generally found to contain a few drops of blood
with liver cells and occasionally a more or less large
sausage-shaped piece of the liver itself." 52
Dr. Fehleisen, who discovered the micro-organism
of erysipelas, inoculated an old woman of 58, suf-
fering from multitudinous fibro-sarcoma of the skin,
with a culture of his streptococci, with positive re-
sults. "On the sixth day after inoculation a
60 Prof . B. Grassi, "Trichocephalus u. Ascarisentwicklung":
Centralbl. filr Bacterial, u. Paras., 1887, Bd. I. p. 131.
61 The Physician, St. Petersburg, 1891, p. 972.
82 Prof. Th. v. Freichs, "Uber den Diabetes." Berlin, 1884, p.
27*.
EXPERIMENTS ON MAN 359
threatening collapse of the patient's strength set
in, which necessitated the employment of stimu-
lants." 53
After this Fehleisen inoculated six more patients
who suffered from lupus and various tumours, with
erysipelas. 54
In March, 1887, a woman, suffering from cancer
of the mammary gland, applied to the surgeon,
Eugen Hahn, of Berlin. The performance of an
operation was impossible. "Not wishing to divulge
before the patient the hopelessness of her condition
by declining to operate upon her, and so as to re-
lieve and reassure her by the psychical illusion of
having performed the operation," Dr. Hahn re-
moved a portion of the tumour of the patient's
diseased breast and . . . transplanted it into the
other healthy one; the inoculation was success-
ful. 55
53 Dr. Fehleisen, "Die Aetiologie des Erysipels." Berlin, 1883,
pp. 21-23.
64 Op. cit. p. 29. Essaying to vindicate his experiments, Dr.
Fehleisen makes mention of the alleged beneficial action of erysipe-
las in cases of malignant tumours and lupus, as observed by certain
savants. He mentions his experiments on a man of twenty, who
suffered from lupus for the last twelve years and had erysipelas
many times. What were Fehleisen's grounds for expecting that ery-
sipelas, inoculated by him, should heal a patient that had many times
been attacked by that disease without deriving any benefit from it?
"Desirous of discovering whether an individual, after having had
the disease, retains immunity for a certain length of time," Fehlei-
sen inoculated a little girl of eight for the second time with
erysipelas.
65 E. Hahn, "Ueber Transplantation der carcin. Haul." Berlin,
kiln. Woch, 1888, No. ^^.,
360 THE MEMOIRS OF A PHYSICIAN
Thus the very important fact that it was possible
to inoculate cancer was definitely proved.
Subsequently Professor Bergmann successfully
repeated Dr. Harm's experiment, and an anonymous
surgeon did likewise, sending his communication on
the subject to the Parisian professor Cornil.
Dr. N. A. Finn studied the question of the infec-
tiousness of typhoid fever in one of the military
hospitals of the Caucasus. Following his instruc-
tions, assistant house-physician Artemovitch injected
the blood of typhoid patients subcutaneously into
the systems of seventeen healthy soldiers. Not one
of those inoculated contracted the disease; "only ten
of them developed ordinary abscesses at the places
of puncture." In addition, twenty-eight young and
healthy soldiers were placed by Dr. Finn in the same
ward with typhoid patients. They lay in hospital
in the vicinity of the sick, "for four or five days,
the beds being moved close together, and sometimes
they were covered with the blankets of the typhoid
patients." 56
During December, 1887, Dr. Stickler read a pa-
per before the Academy of Medicine of New York
on preventive inoculation against scarlet fever. He
had observed that persons who had contracted hoof
and other kindred diseases from the lower animals,
became immune to scarlet fever. To verify his ob-
50 The minutes of the meetings of the Imperial Caucasian Medical
Society for 1878-1879, No. 8, p. 107. Drs. Finn and Artemovitch
also injected the blood of typhoid patients into their own systems.
EXPERIMENTS ON MAN 361
serrations, Stickler inoculated children with the
blood of sick horses and cows. After this he placed
the children on bedding which had been in the use
of scarlet fever patients and made them inhale the
air exhaled by the latter; these children numbered
twenty. Stickler also injected the blood of scarlet
fever patients into the systems of the twenty chil-
dren. Of their number several did not take the
fever at all, the rest developed it in very mild form;
there were no serious cases. 57
Professor Roberts Bartholow of Ohio, U. S. A.,
attended a female patient, the posterior part of
whose cerebrum had become exposed, owing to can-
cer of the cranial integuments. The professor took
advantage of this rare case for the purpose of con-
ducting a series of experiments of electric irritation
of his patient's brain. Galvanic irritation of the
dura mater proved to be painless, while faradic cur-
rent caused muscular contraction throughout the
opposite side of the body. After this he "passed
an isolated needle into the left posterior lobe; the
other isolated needle was placed in contact with the
dura mater. When the circuit was closed, muscu-
lar contractions of the right upper and lower ex-
tremities ensued; faint but visible contractions of
57 Summary of Stickler's paper, as it appeared in one of the Amer-
ican medical journals. The Centralblatt fur Bacteriologie u.
Parasitenkunde, Bd. IV., 1888, p. 369, remarks: "The results ob-
tained are, in any case, sufficiently important to encourage further
research in the same direction."
362 THE MEMOIRS OF A PHYSICIAN
the left orbicularis palpebrarum and dilation of the
pupils also ensued. Notwithstanding the very evi-
dent pain from which she suffered, she smiled as if
amused."
The same experiment was repeated upon the right
cerebral hemisphere. "When the needle entered
the brain substance she complained of acute pain in
the neck. In order to develop more decided reac-
tions, the strength of the current was increased.
When communication was made with the needles,
her countenance exhibited great distress, and she be-
gan to cry. Her eyes became fixed, with pupils
widely dilated, lips blue, and she frothed at the
mouth. She lost consciousness and was violently
convulsed on the left side. The convulsion lasted
five minutes, and was succeeded by coma. She re-
turned to consciousness in twenty minutes from the
beginning of the attack." After the lapse of a cer-
tain time the experiment was repeated once more
with a weaker current, and three days later her con-
dition was decidedly worse. In the evening she
"had a convulsive seizure, lasting about five min-
utes. After this attack she relapsed into profound
unconsciousness and was found to be completely
paralysed on the right side."
The unfortunate woman died soon afterwards.
According to Professor Bartholow's opinion her
death was caused by the original disease. 58
58 See British Medical Journal, 1874, vol. i. p. 687. In review-
EXPERIMENTS ON MAN 363
"So this is how the doctors treat those patients
who place their health in the hands of the faculty!"
some readers will exclaim, on finishing this chapter.
Such a deduction were entirely mistaken. The ex-
istence of a few hundred doctors, to whom the sick
are merely so many objects for experiment, does not
justify the branding of the entire profession. As a
parallel, I might bring forward a no less array of
facts, which would show that, in the past, doctors
have conducted and continue to do so now no
less dangerous experiments upon their own persons.
Thus, PettenkofTer's and Emerich's experiments are
still fresh in the memory of all: both swallowed
pure cultures of cholera bacilli, after having had the
acids of the stomach neutralised with soda. This
was repeated by Professor Metschnikoff, Drs. Has-
ing the above communication which appeared in an American con-
temporary, the British Medical Journal censured the author for
his experiments. Bartholow wrote a letter to the editor, in which
he sought to vindicate his action by remarking that his patient
was bound to die very soon and that she had agreed to the ex-
periments, which, according to his opinion, presented no danger.
"Notwithstanding my sanguine expectation that small isolated
needle electrodes could be introduced without injury into the cere-
bral substance," wrote the professor, "I now know that I was mis-
taken. To repeat such experiments with the knowledge we now
have that injury will be done by them, would be in the highest de-
gree criminal. I can only now express my regret that facts which I
hoped would further, in some slight degree, the progress of knowl-
edge, were obtained at the expense of some injury to the patient."
According to the journal's opinion, this letter was "one which is
likely to disarm further criticism," and the editor found it both sin-
cere and worthy of the author's profession, and even . . . humane
(p. 728). All this was said without a trace of irony. On the
whole, however, Bartholow's experiments aroused the indignation of
the entire medical press.
364 THE MEMOIRS OF A PHYSICIAN
terlick and Latapie. Drs. Borgioni, 59 Warneri, 60
and Lindemann, 01 and many others, inoculated them-
selves with syphilis; young and healthy, in the name
of Science, they faced experiments which crippled
and ruined their entire lives. To conclude that the
entire medical body is made up of heroes, because a
few devoted men martyred themselves in the name
59 On Feb. 6th, 1862, Prof. Pellizzari inoculated Drs. Borgioni,
Rosi and Passigli with the blood of a syphilitic patient after they
had "courageously given themselves up to be experimented upon,
notwithstanding the professor's remonstrances." The inoculation
of Dr. Borgioni was successful: two months after it had been per-
formed he began to suffer from nocturnal headaches, general rash
appeared, as well as swelling of the glands; ten days later the
primary ulcers on the hands began to heal, and it was only then
that Dr. Borgioni submitted to mercurial treatment (Gaz. hebdom.
1862, No. 22, pp. 349-350).
60 Verhandlungen der pfiys. med. Gesellschaft in Wurzburg, Bd.
iii. (1852), p. 391. Article by Prof. Rinecker.
61 Being interested in the different questions of syphilidology, Dr.
Lindemann made the following experiment upon his own person.
In the course of two months he inoculated himself upon the hands
with soft ulcer, at intervals of five days; three months later he
inoculated himself with the secretions of a syphilitic patient and de-
veloped the disease. Seventeen days after the appearance of the
papular eruption, Lindemann again began to inoculate himself with
chancres of varying malignity. The commission appointed by the
Medical Academy of Paris to examine Dr. Lindemann, reported
upon his condition through the medium of its referee, Dr. Beguin, in
the following terms: "Both arms (from shoulder to palm) are cov-
ered with sores; many of the ulcers are confluent, they are sur-
rounded by acute and painful inflammation; suppuration is very
abundant; the bottom of most of the ulcers is of a greyish hue; to
sum up, all these injuries to use a surgical term have a very bad
aspect. The whole body is covered with an abundant eruption of
syphilitic papules. Dr. Lindemann is full of courage and confidence
and expressed his intention of at least applying himself to the regu-
lar treatment of his disease, which has become inveterate and
serious." (Bulletin de I'Academie Nationale de medtcine, Tome
xvii, Paris, 1851-1852, pp. 879-885),
EXPERIMENTS ON MAN 365
of Science, were as erroneous as to write all doctors
down brutes, callous of their patients' interest, in
consequence of the comparative few having con-
ducted criminal experiments as described. But the
latter establish one thing beyond all vestige of a
doubt and that is the shameful indifference with
which the medical world contemplates such atroci-
ties. For this martyrology of the unhappy patients
offered up as victims to science was not compiled by
any underhand means the culprits publicly blaz-
oned their own infamy in black and white. One
would suppose that the mere fact of publication of
such experiments would make their repetition ut-
terly impossible, the first to attempt anything of the
kind being cast forever from the medical corpora-
tion! But, unfortunately, this is not so. With
heads proudly erect, these bizarre disciples of science
proceed upon their way without encountering any
effective opposition, either from their colleagues or
the medical press. Of all the organs of the latter, I
know of only one which stoutly and energetically
protests against every experiment on the living hu-
man creature and that is the Russian journal
Physician, which was edited until recently by Prof.
Manassein, lately deceased. Upon the pages of
that journal, notices such as the following are al-
ways in evidence: "Once more impermissible ex-
periments!" "We are utterly at a loss to under-
stand how doctors can permit themselves to perform
366 THE MEMOIRS OF A PHYSICIAN
such experiments!" "Must we really wait until
the public prosecutor takes upon himself the task of
indicating the line where legitimate experiment
stops and the criminal commences*?" "Is it not
time for doctors to unite and rise up in revolt against
such experiments, no matter how instructive they
may be?"
Emphatically, yes!
It is time, high time! But the moment has also
arrived for society to take its own measures of self-
protection against those zealots of science who have
ceased to distinguish between their brothers and
guinea-pigs, without waiting for the faculty to
emerge from its lethargy.
AUTHOR'S POSTSCRIPT
"Is it possible that there is no voice in your mother's heart,
which forbids you to destroy your son's ideals ?"
"But what will then become of truth?"
"What will then become of ideals'?"
"Oh ! ideals, ideals ! . . ."
IBSEN : "Ghosts."
THESE "Memoirs" have brought down upon
me a storm of indignation emanating from a
certain section of my readers. How could I have
the hardihood to expose with such unreserved can-
dour in the press and before the laity all that a doc-
tor has to go through? What could my aim have
been in so doing 1 ? Ought I not to have known that
a great distrust in medicine and in doctors exists
in the public mind as it is*? Such an exposure as
that furnished by my "Memoirs" could only serve
to strengthen this distrust. The cheap news-
papers, which constantly run the doctors down,
would pounce with glee upon the material I had
provided, to make use of it for the furtherance of
their own obscure ends. Rumours might reach the
lower strata of society the ignorant masses and
estrange them from medicine, in the assistance of
which they stand in such pressing need. The au-
thor himself a medical man ought to have
367
368 THE MEMOIRS OF A PHYSICIAN
realised what he was about, when thus starting to
undermine the confidence of the public toward both
doctors and medicine.
This outburst of indignation struck me as very
significant. All of us fear the truth so much, we
are so little conscious of its necessity, that it suffices
to lay bare its smallest corner and people begin to
feel uneasy. "Why 4 ? What good can it do 4 ?
What will the uninitiated say*? What construction
will they put upon the truth, as offered them'?"
From the moment of my matriculating at the
University Medical School, and more especially,
of my taking up practice, one by one all manner
of questions began to arise before me, each more
complicated and more difficult than its predecessor.
I sought their answer in my medical books and in
the medical press and found it nowhere. Medical
ethics were elaborating, painstakingly and . pe-
dantically, a tiny circle of petty questions dealing
with the rules which regulate the attitude of doc-
tors towards their patients and towards each other.
But all the problems which confronted me hardly
existed for them. Why"? . . . Was it really neces-
sary to be endowed with extraordinary perspicacity
and sensitiveness to be able to note and raise the
questions which I touch upon in my "Memoirs"?
Why, every medical man is assailed by them, they
torment every doctor who has not yet retired into
the shell created by affluence or the ease of an as-
AUTHOR'S POSTSCRIPT 369
sured position. Why then does no one discuss
them, why should each be compelled to seek their
answer single-handed?
It seems to me that there can be but one ex-
planation: all fear that if such questions be stirred
up and made the subject of open discussion, the pub-
lic's confidence in the profession might suffer. Ac-
cordingly, an impenetrable veil is cast upon the most
serious and burning problems of the physician's art,
and they are studiously ignored as if entirely non-
existent. And in the meanwhile this systematic
hushing-up has worked much evil and continues to
do so. Thanks to it there is an absence of that
which is most important of all of an all-pervading
atmosphere pregnant with the consciousness that
these problems still remain unsolved, and that their
clearing up is of the most pressing necessity.
These questions are settled in solitude and in secret,
this way or that. Often they find the wrong an-
swer, and more often still, are stifled without any
answer being given them at all. I have had oc-
casion to hear contentions of such a nature put for-
ward by my colleagues, in regard to my "Memoirs,"
that I simply cannot bring myself to quote
them so extraordinarily grotesque and profession-
ally egoistical are they; and nevertheless I have had
to listen to them from many quarters. " I think that
such objections could only have been generated from
that dense, voiceless murk, in which the mind only
370 THE MEMOIRS OF A PHYSICIAN
begins to quicken when it stumbles right up againsc
a question; and under these circumstances, it is vain
to expect the embracing of a problem with anything
like breadth of grasp.
Others have queried: "If you considered it
necessary to raise these questions, why did you not
make use of the medical press, why did you lay bare
your doubts before the lay-mind'? The lay-mind is
incapable, in any case, of finding an answer to them.
Moreover, it ought to remain in ignorance of the
very existence of such questions !"
In the Middle Ages a certain physician of Worms,
Rosslin by name, published a medical work in Ger-
man, not in Latin as was the custom in those days.
Thoroughly conscious of the enormity of such a
"profanation" of his science, he excused himself be-
fore his readers in his preface, and earnestly begged
them to keep his book well under lock and key, "to
prevent its falling into the hands of the uninitiated,
that thus pearls should not be cast before swine."
These times have long passed into oblivion. The
professional press makes exclusive use of the idiom
of the country it belongs to, the idiom understood
by, and intelligible to, every "uninitiated" person.
It would not have altered matters one jot even if I
had put my "Memoirs" into less popular lan-
guage and published them in a professional pe-
riodical in any case the press at large would not
have failed to extract and make all that was. "in-
AUTHOR'S POSTSCRIPT 371
teresting" general property. Only it would have
been enabled to serve the facts according to its own
tastes and illuminate them in its own way per-
haps inaccurately and ignorantly.
Anyhow, the kernel of the nut lies elsewhere:
why should the man in the street remain ignorant
of those questions'? To whom and by whom was
the right given to play guardian to him? By all
means let judges, school-masters, literati, lawyers,
engineers and police inspectors publish their
memoirs !
If I were told that, as an outsider, I ought not to
be introduced to the hidden aspects of the profes-
sions enumerated, I would answer that not being a
child, I was fully competent to judge for myself of
what was good for me and what was not. "On
learning the truth the lay-person may lose his or her
confidence in medicine and its exponents." . . .
How strange that that old, old rotten fallacy should
still be countenanced the stifling of publicity for
fear of the truth shaking established authority!
As if it were possible to create a box strong enough
to keep Truth a voiceless captive! You may use
the stoutest iron bars to bind your box with, but it
will start at every seam and joint, and the truth will
ooze out distorted, mutilated, disjointed, irritating
in its incompleteness, and, for that reason, leading
one to suspect the very worst. Doctors carefully
guard the public from all that may shake its faith
372 THE MEMOIRS OF A PHYSICIAN
in medicine, and, pray, what is the result"? Is the
confidence of the public very great'? Is not the
public ever on the alert to seize upon the most
grotesque gossip regarding the faculty, does it not
proffer the most absurd accusations and demands'?
At certain times, in serious cases, it is occasionally
necessary to deceive the patient for his own good;
but society at large is not an invalid, and momen-
tary mendacity should not be elevated into an eter-
nal principle.
One of the two: either the truth can lessen our
faith in medicine and doctors, because medicine is
in itself unworthy of our confidence in that case
the truth is beneficial (nothing is more harmful
nor causes so much disillusion as exaggerated faith
in anything). Or else, the truth is capable of shak-
ing faith in doctors because it exposes the seamy
side of their profession, which can be, but is not,
remedied in that case the truth is indispensable;
for if the dark sides were obliterated, confidence
would spring up once more. But until this is ac-
complished, complete faith were out of place. And
here I repeat once more what I have already said
in my "Memoirs": that personally I would never
apply to a doctor fresh from the student's bench,
would not submit myself to a surgeon who was
about to perform his first operation, would not allow
my child to take a new, little-known medicine, nor
would I permit of its being inoculated with syphilis.
AUTHOR'S POSTSCRIPT 373
And I believe that no other doctor, in his
turn, would act differently. Once this fact is es-
tablished, how dare one hide all this from the "out-
sider," how dare one leave him to face that which
the "initiated" would most sensibly decline*?
It is perfectly true that the lay-public is not in a
position to find the true answer to these problems.
But it has every right to demand that a solution be
discovered, and its interest in these questions is per-
fectly legitimate; they concern the public too closely.
Further still the public discussion of these ques-
tions is, in my opinion, the only guarantee of their
being satisfactorily answered. If this task were left
to doctors alone, they might easily err, to a greater
or lesser degree, in the direction of one-sidedness.
,Yet another accusation is levelled against me. A
certain much-read medical journal affirms that I
"generalise single facts of medical practice in an un-
justifiable manner," and that "for some unknown
reason" I permit myself "undoubted exaggerations
and lay my paints on too thickly." Of course, such
an accusation calls for the most serious considera-
tion; but unfortunately, it is not formulated with
any further preciseness, and therefore a rejoinder
becomes a rather difficult task.
That such accusations would be made against me
I foresaw from the very beginning, and it was for
this reason that I took pains to supply my text with
abundant and exhaustive quotations, which appeared
374 THE MEMOIRS OF A PHYSICIAN
to me to be sufficiently characteristic and convincing
to the direct detriment of the literary merit of my
essay. As a matter of fact, I have even been re-
proached by the general press of "going into too
great detail," and am told that my "Memoirs"
occasionally "assume the character of a professional
article in a medical journal." If I do not adduce
further substantiation of the correctness of my
"Generalisations," this, at any rate, can in no case
be put down to a lack of the necessary material.
THE AUTHOR.
THE END
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Smidovich, Vikentyy
Memoirs of a physician
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1916
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