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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 
 
COPYRIGHT, 1916, BY 
 ALFRED A. KNOPF 
 
 PRINTED IN THE UNITED STATES Qf AMERICA 
 
EDITOR'S INTRODUCTION 
 
 In reviewing The Memoirs of a Fhysician 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 . 
 . . . . J 
 
 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- 
 
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 
 
 CHAFTEK rAGX 
 
 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 
 
 VII 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 
 
 35V 
 
CONTENTS 
 
 CHAPTER PAGE 
 
 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 
 
 I 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 
 persuade tihi? 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 filled 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- 
 toid eus 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 ahdominalis 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 5 
 
 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 da3^s, 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: — 
 
 *'0h, you miserable quacks I Kill me, for God's 
 sake, kill me, that is all I beg of you I" 
 
 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 "ph3^siological" 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- 
 
lo 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*?" 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 ii 
 
 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 
 foUaceo^ 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 pemfhigo foUaceo^ 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? 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 )^ou 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 Strumpell's 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 ansesthetic; 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." 
 
i6 THE MEMOIRS OF A PHYSICIAN 
 
 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 feels 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.^ 
 
 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- 
 
 ^ 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 factor}^ 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 THE MEMOIRS OF A PHYSICIAN 
 
 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 iists; "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.^ The 
 relatives of such patients do not, however, suspect 
 that the)^ 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 fivG 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^ — 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 foruncuU, 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. 
 
 P 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, 
 t. The assistant went behind the screen. She stood 
 
EXAMINATION AND AUTOPSY 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!" 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 I" she answered in a trembling voice 
 and, turning on her heel, rapidly quitted the room. 
 
 "What was the matter with her, I wonder?" 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 fou 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 I" — 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 g)ni2ecologist 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 
 helpr ' 
 
 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,^ 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 PirogoflF 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 syphilolog}% 
 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. 
 I 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? 
 
 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 propre 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 Moliere's pithy words, "They will tell you in 
 Latin that your daughter is ill" ("L^ medecin tnal- 
 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 fassen : 
 Ihr durchstudiert die gross und kleine Welt, 
 Um es am Ende geh'n zu lassen 
 Wie's Gott gefallt.^ 
 
 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 Strumpell's 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 pectoris^''' 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 he 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 
 
 juvantihus^ 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"? From which of her organs did it origi- 
 nated 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 ^ 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 GyncBCology), 
 
 "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 I) 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- 
 
 1 Cystoma ovarii or cystoma of x^% Qvary. 
 
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 I 
 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 
 puffing 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 ^ three-fourths 
 of those operated upon died of septic infection: 
 
 2 This is a conservative estimate. 
 
50 THE MEMOIRS OF A PHYSICIAN 
 
 pysemia 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 Pirogoif, 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 vincitur — nature is conquered 
 by him who obeys her; and when all her laws were 
 fathomed, man would become her lord and master I 
 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 sec ale 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,^ 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 
 tl:V 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. 
 
 * 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 
 em.bellished 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 I 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^M 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, dyspncea: (1) 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 
 
6o 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'? 
 
 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 I 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'?" 
 
 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 begim 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 surprised" 
 
 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 
 
68 THE MEMOIRS OF A PHYSICIAN 
 
 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 fnan^ he remained an 
 entirely unknown quantity. 
 
 But why should I dwell upon such subtleties as 
 the psychology of the patient? 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 S5^mpathy he showed 
 me during that trying period of my career I 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 I" 
 
 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 I 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 glands, 
 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.^ 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, 
 
 ^ 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 comer. 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" 
 
 I declined the fee. We stood together in the 
 semi-dark passage. 
 
 "It was God's will I" 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 I" . . . 
 
 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 questions 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 of 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- 
 
8o THE MEMOIRS OF A PHYSICIAN 
 
 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 I 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 — 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 niore 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*? 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 elder 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 8^ 
 
 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 nothr 
 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 I" 
 
 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" 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 perfonPx 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 still, 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 I" 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 I" 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 
 fimnel-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 I" 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. Stratonoff 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 I" 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 comirades, 
 who had commenced work sim.ultaneously 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 I" 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, I 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? 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 adventitiae (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- 
 
lOo THE MEMOIRS OF A PHYSICIAN 
 
 ready had occasion to mention. Speaking of mod- 
 ern 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 loi 
 
 erated 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 I 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 "docent" (lecturer) of sur- 
 gery, the sam^e 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 Pirogoff in 
 his "Annals of the Dorpath Surgical Clinic," which 
 were published in German towards the close of the 
 
 ^ 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 I 
 
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 Botkin'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 
 tpssed about; his wife told me that he had been a 
 Kird 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: — 
 
 "RP 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. 
 
i66 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 v/as 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 
 
id8 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 hsemorrhage 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 
 anesthetic 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 tlie 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 — 
 
110 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 ansesthetics. 
 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 igg 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.^ 
 
 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 
 
 ^ The failure of Koch's tuberculine was due to ill-judged em- 
 ployment in unskilled hands. 
 
MEDICINE MUST RISK TO GAIN in 
 
 was very different: they emerged from trial, their 
 position assured and recognised by all, with their 
 indications and counter-indications strictly defined. 
 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 twent)^-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 sesthetic in view ; the result, how- 
 ever, was idiocy.^ 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- 
 
 ^ 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 ansesthesia. 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 furttier, 
 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 Lcpine aggre- 
 gated the total number of fatal cases of sulphonal 
 poisoning, which appeared in the medical press, at 
 sixteen. . . . 
 
 Yes, ccrtaiftly 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- 
 perim^ent 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 v/riting 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 3^oung 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 
 
ii8 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, Pirogoif 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?" 
 
 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" 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 125 
 
 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 ansemia 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 ansemia'? 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 ;;7///2grammes 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 
 ^hystericus, 
 
 "Yes, yes, that's just how I feel I" 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. 
 
 "\^niat 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 I" 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*?" the 
 poor woman kept on repeating, weeping, gasping 
 and striking her side frenzledly 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 I 
 
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 points 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 ansemia, but even when the pa- 
 
132 THE MEMOIRS OF A PHYSICIAN 
 
 tient got better, I could never be sure that the im- 
 provement in nis 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.^ 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 
 
 ^ 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 I" 
 
 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 and knov/ 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 formulae! 
 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 homoeopathists, 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 symiptoms v/hich 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. 
 
 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 
 
 mc 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 I Anything rather 
 than remain in the false and criminal role of an im- 
 postor I 
 
 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 
 
140 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 OP 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 hi5 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 I" 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 naive 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? 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 knov/ 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*? 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 commion 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 Ms experiments upon liv- 
 ing animals; we quote the headings of several chap- 
 ters of his treatise : — 
 
 Chap. II. "£x vivorum dissectione qualis sit 
 
 cordis motus^ 
 Chap. III. ''Arteriarum motus qualis ex vivorum 
 
 dissectione.^^ 
 Chap. IV. '''Motus cordis et auriculorum qualis 
 
 ex vivorum dissectione T Etc.) ^ 
 
 ''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.) 
 
 ^ See Exercitatio anatomica de motu cordis et saguinis in ani- 
 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." ^ 
 
 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 tnf. 
 
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 of 
 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 
 Physiolog}^" having previously struck out all those 
 facts which it would have been impossible to es- 
 tablish without recourse to vivisection. According 
 
THE QUESTION OF VIVISECTION 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 ^ Has actual 
 life ever furnished a ease 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 
 erf 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 ^^^ 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 tlie 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- 
 ^rofitahle 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 
 Gynsecology 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. 
 
 iS9 
 
i6o 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 I 
 
 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 
 
i62 THE MEMOIRS OF A PHYSICIAN 
 
 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^ 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 
 ansesthetic. And no sooner had I placed the 
 chloroform mask over her face, hardly had she drawn 
 breath— one single inhalation of the ansesthetic — 
 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 
 
i64 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 
 
i66 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 
 
i68 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 JCharitonoff 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 ^sculapius 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^' 
 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 I" 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 hound 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? 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 I 
 
172 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 
 
 I HAVE 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 17^ 
 
 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 I 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 I" 
 
 "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 naive way in which 
 patients looked up to us doctors. 
 
 This was by no m^eans 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 
 
 Crete 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 m_edicine 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 
 m.eans; 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 S5^stematic 
 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 
 efBcacious 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 mxcdicine, is furnished by the pro- 
 fession's mistakes. A doctor diagnoses a disease as 
 typhoid, while autopsy discloses general tubercular 
 
i8o 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 I" 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? 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 diarrhcea; without 
 any medicine, simply by regulating its diet and the 
 
i82 THE MEMOIRS OF A PHYSICIAN 
 
 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. 
 
l84 THE MEMOIRS OF A PHYSICIAN 
 
 What could I say? Was I to tell them that tak- 
 ing my medicine was the cause"? 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 I At first I was naive 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 PHYSiaAN 
 
 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 
 sceptipal patient. 
 
 '1 must b,eg 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 hirti 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 
 . . . Wenn 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 
 
 1 "What have I, if I have not all?" 
 
 l88 
 
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 ^ 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 *?' 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, 
 Wie mich die Mensehen taglich, stiindlich qualen, 
 Wie sie Unmogliches von mir begehren ! 
 
 2 One of Russia's greatest physicians of the latter half of the 
 nineteenth century (deceased). — ^Translator. 
 
iQo 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 Gottern 
 Durch Wunder Leiden nehmen, Gluck 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 zurucke halt, 
 t 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 ?" * 
 
 * 
 
 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 
 
 * "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 
 
THE DOCTOR AND THE POOR 193 
 
 his left lung to be affected by croupous inflamma- 
 tion through and through. I v/as amazed that he 
 should have been able to reach me, and told him 
 that he must 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 I 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"? Pll 
 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 THE 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.* 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 v/ith 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 ansemic, sickly 
 
 ^ 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 v/as 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. v. 
 
 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 hum.anity 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.^ 
 
 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 I 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 $2 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 I 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. Num^erous 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 I" 
 
 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 Krjivitsky). 
 
 On the other hand, the European as easily suc- 
 cumbs to tropical malaria, yellow fever and tropi- 
 cal dysentery. What would the result be if all 
 
2o6 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 
 
2o8 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 cczcum^ 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 c cecum. 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. 
 
:2io THE MEMOIRS OF A PHYSICIAN 
 
 and we shall easily understand that their ta^ 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 vache)^ introduced by 
 Marion Sims, is invaluable in gynaecology and 
 obstetrics: some gynaecologists hail Marion Sim's 
 discovery as "the turning-point in the history of 
 gynaecology." 
 
 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,^ 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 
 
 MENTAL PROGRESS AND PHYSICAL DEGENERATION 
 
 I 
 
 T 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 I 
 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 
 
 214 
 
PROGRESS AND DEGENERATION 215 
 
 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 
 
2i6 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 ^). 
 
 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, 
 
 ^ 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. 
 
2i8 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 ^ are called the "Iron People" be- 
 cause of their insensibility to cold, the naked chil- 
 dren of Esquimaux and Tschouktshi ^ run out of 
 
 2 A Siberian aboriginal tribe. ^ /^;^, — 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 suh^ 
 stitute the imaginary for the realT^ 
 
 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 
 
222 THE MEMOIRS OF A PHYSICIAN 
 
 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? 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 I 
 
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 
 
PROGRESS AND DEGENERATION 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 
 m_orn 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 fromx tub to tub, while another was given 
 sand to pound in a mortar, and so on, I think that 
 the prisoner w^ould 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 
 
 jNE day a peasant v/oman 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'?" 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 I 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 iist, 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" 
 
 I hastened home to fetch my instruments and 
 bandaging materials. . . . My God, how grotesque I 
 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 
 flurpied 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 scattering 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 naive 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 dysmenorrhoea for the last four years, 
 she had consulted various professors; one diagnosed 
 
232 THE MEMOIRS OF A PHYSICIAN 
 
 anteflexion 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 
 roseolse. I hesitated for a moment — even now it 
 pains me to proffer such requests. 
 
 *'Ah! you want me to lift my nightgown*?" 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 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 
 m.e anything like that otJier 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." \\Tiile 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 unsesthetic 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, facer e non ohscoenum 
 —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, \m- 
 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 t±ie 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 I 
 
 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 I 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 gf 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 I" . . . 
 
 Modesty, severe and chaste, does not even pre- 
 clude nudity. Buffon says: "We are neither 
 sufRciently 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, v\^hen 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.^ 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 liebe 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. 
 
 24X 
 
242 THE MEMOIRS OF A PHYSICIAN 
 
 I explained that the operation was quite safe. 
 
 "No then! I won't allow it I" — 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 began 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^" 
 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. "I 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 I 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 I" 
 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?" 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 I 
 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.^ 
 
 "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 
 
 ^ 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 fiat with her two 
 children — the sick boy and her grown-up daughter 
 Katerina Alexandrovna, a prepossessing girl with an 
 attractive and spifituelle 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 2^1 
 
 ing from croupous pneumonia. The mother, a thin 
 and nervous woman with restless, psychopathic eyes, 
 was overwhelmed. 
 
 "Doctor, tell me, is it very dangerous? 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 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 I" 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 f4ncy a mere Sister of Mercy is no doctor and 
 incompetent to judge." 
 
WHEN THE PATIENT DIES 2^3 
 
 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 treatm.ent 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 m.e 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? 
 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 I" 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." 
 
 J?56 
 
"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 
 vp 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 
 
26o 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 I' " 
 
 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 consulting-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?" 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 di^g out the exist- 
 ence of a useless parasite. . . . And wc had to listen 
 to this odious tone, accompanied by that no less 
 
"THE PROFESSIONAL MANNER" 26^ 
 
 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 I 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 muif, 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 I" 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 I 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 I" 
 
 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 I" 
 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 I" 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" 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 i3 
 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 
 mcilleur de tous {i.e. medicine) car, soit qu'on fasse 
 bien, ou soit qu'on fasse mal, ou est tou jours paye de 
 meme sorte. La mechante besogne ne retombe 
 jamais sur notre dos, et nous taillons comme il nous 
 plait sur I'etoffe ou nous travaillons. Un cordon- 
 nier, en faisant des souliers, ne saurait gater un 
 
:^72 THE MEMOIRS OF A PHYSICIAN 
 
 morceau de cuir qu'il n'en paye les pots casses, mais 
 ici I'on peut gater un homme sans qu'il en coute 
 rien." ^ 
 
 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 plaisanti 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." ^ 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.^ 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 I 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 
 
 3 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 
 statioo^ 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"? 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 21st 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 I 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. 
 
28o 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.^ 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 
 
 * 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) 
 
 ^^rip^HE first duty of every physician is to be 
 X 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 proclaimeth 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 
 
 Novo ye 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 ix\ St. Petersburg; he had arrived to seek a 
 
290 THE MEMOIRS OF A PHYSICIAN 
 
 place, and looked me up. Sunburnt and uncoudi, 
 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 so 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 vou 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- 
 
 J"- 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^ 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'?" 
 
 These questions are interesting, forsooth. . . . 
 Do doctors serve society or not? Every kind of 
 service pre-supposes at least some sort of mutuality 
 of obligation. Doctors leave St. Petersburg for 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 naive 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." ^ 
 
 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 Zemstvo <vjere 
 to distribute grants so lavishly, doctors ivould contract typhoid on 
 purpose. To the credit of the St. Petersburg Zemstvo Mr. Dur- 
 novo's declarations elicited the unanimous protest pf 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'?'"' 
 
 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 
 all 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 "xorldT 
 
 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 
 iPx V. K. Anrep's doctor's dissertation : "The 
 petty police officers, dvorniks ^ 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 Dvornik = house porter. — ^Translator. 
 
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 7/ per cent, of all (Russian) doctors (in- 
 cluding those without official status), the income 
 derived from private practice does not exceed 1000 
 roubles '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 I 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*? 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 Fhysician), seventy-six 
 applications were filed for one vacancy of 2^mstvo 
 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? 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, 
 
 30^ 
 
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^ 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 
 
3o8 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 hsemorrhage. 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 
 
 thatj" 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*?" he asked, turning 
 to me. 
 
 ''Yes, of course I , . , 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 I 
 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 I" 
 
 The patient was seized with a fit of coughing, 
 bent forward and spat out a large clot of blood. 
 
 'That'll do I Don't talk so much I" 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 which 
 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 examxination 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 
 questiQii 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'3 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. 
 J* 
 
 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 3^7 
 
 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? 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? 
 
 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, Fhysician^ "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 tQ those conducted upon the lower ammals 
 
 33« 
 
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." \ 
 
 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 Fhysician 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 
 
 ^ See The Physician, 1893, p. 906. 
 
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/ 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. His 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." ^ 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." ^ 
 
 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 Aetlologie desHarnrohren trippers": Vierteljahr- 
 schr. fur Dermatol, und Syphilis, 1883, p. 7. 
 
 ^Beitrag zur Aetlologie des Karnrohrentrippers": Vierteljahr- 
 schr. fiir Dermatol, und Syphilis, 1883, PP* 7-10. 
 
336 THE MEMOIRS OF A PHYSICIAN 
 
 culture of gonocoecus was obtained by Ernst Bumm.* 
 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 
 gonocoecus 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 gynaecologists^ will 
 agree with meT ^ Bumm himself declares, in the 
 preface to his work, that "gonorrhoeic infection is 
 
 * E. Bumm, "Die Micro-organismus der gonorrhosichen Schleim- 
 hauterkrankheiten." 2. Ausg. Wiesbaden, 1887. 
 
 5 Prof. Al. Neisser, *'Ueber die Nothwendigkeit von Spezialklin- 
 iken fiir 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" ^ ; 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 gonorrhoeic 
 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,''^ 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." ^ 
 
 ^ op. cit., p. iv. 
 
 ■^ Provisional report in the Deutsche tned. Wochenschrift, 1891, 
 No. 50 ("Reinziichtung des Gonococcus Neisser mittels des Plat- 
 tenverfahrens"). Detailed description in Archiv fur Gynaecologies 
 Bd. 42 (1892): "Die ascendirende Gonorrhoe beim Weibe." 
 
 ^Archiv, pp. 17, 28, 33-34, 37, 39. 
 
 ^I^will 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 ^^ 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. ^^ 
 
 But especially comprehensive were the experi- 
 ments of Finger, Ghon and Schlangenhaufen.^^ 
 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, klin. Woch., No. ii, p. 258. 
 
 11 "Ein Beitrag zur Kultur des Gonococcus": Centralblatt fur 
 Gynaecologie, 1893, No. 8. 
 
 12 "Zur Biologic des Gonococcus" : Archiv fur Dermatologte 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 gonorrhoeic patients. One of the 
 infants lived for ten days after inoculation, de- 
 veloping typical purulent inflammation of the 
 eyes.^^ 
 
 Tischendorfl inoculated the eyes of atrophic chil- 
 dren with gonorrhoeic discharge of little girls suf- 
 fering from that disease: purulent inflammation, 
 with characteristic gonococci, was the result. ^^ 
 Kroner inoculated six adult blind persons with the 
 muco-purulent discharge of pregnant and parturient 
 women (with negative results). ^^ 
 
 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 
 
 ^3 "Berlcht iiber cine bei Kindern beobachtete Enderaie infec- 
 tioser Kolpitis": Firchoiu's Archiv, Bd. 99, Heft 2 (1885), pp. 263- 
 264. 
 
 ^* "Verhandlungen der 57 Versammlung deutscher Naturforschei* 
 u. Aerzte in Magdeburg, 1884": Archiv fur Gynaecologie, Bd. 25 
 (1885), p. 114. 
 
 '^^ Ibid., p. 113. 
 
340 THE MEMOIRS OF A PHYSICIAN 
 
 natural nutritive milieu for the micro-organism of 
 soft ulcer ^" to quote Dr. Spitschka/^ 
 
 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, Rollet, 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. ^"^ Let us see how this fallacy was 
 set right. 
 
 1^ "Zur Aetiologie des Schankerbulo" : Archiv fiir Dermat. und 
 Syphilis (1894). Bd. 28, p. 32. 
 
 1''^ 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 cantJiarides 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 hiat- 
 ter to the surface of the cutis thus exposed. The 
 results were similar." ^* 
 
 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.^^ 
 
 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. 
 
 i^W. Wallace, "Lectures on Cutaneous and Venereal Diseases": 
 The Lancet for 1835-36, vol. ii. p. 132. 
 
 18 "Clinical Lectures on Venereal Diseases": The Lancet, 1836- 
 X837, vol. ii. pp. 535, 536, 538, 620, (>2i. 
 
342 THE MEMOIRS OF A PHYSICIAN 
 
 that the facts above mentioned were "only a portion, 
 yes, a very small portion of those of a similar kind 
 which I could adduce." ^^ 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.^^ 
 
 "Is it permissible to expect more convincing proofs 
 of the contagiousness of the secondary stage of 
 syphilis?" queries Dr. Schnepf,^^ 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 
 
 ^^Ibid., p. 539- 
 
 ^^Ibid., p. 615. 
 
 22 <'De la contagion des accidents consecutifs de la syphilis": 
 Annales des maladies de la feau 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.^^ 
 
 "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.^^ 
 
 *T 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. 
 
 ^^Ibid., pp. 126-12?. 
 
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.^^ 
 
 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": 
 Fer hand lung en der phys. 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.^^ 
 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 1 7, 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.^^ 
 
 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 Ibid. 
 
 27 "Ausziige aus den Protocollen des Vereins pfalzlscher Aerzte 
 vom Jahre 1855": Aerztliche Intellegenzhlatt, 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 roseolse. . . . Mercurial treatment 
 started on June 2nd, and in six weeks the patient 
 was cured." ^^ 
 
 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 I should very much like to 
 know whether Professor Hubbenet would inoculate 
 his own son with syphilis, even were he to ac- 
 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 (i860), pp. 423-427. 
 3^ "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.^^ 
 
 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.^^ 
 
 In the same year Professor Baerensprung success- 
 
 ^^ Bulletin de V Academic Imperiale de Medecine, 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 incx:ulated 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.^^ 
 
 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.^^ 
 
 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- 
 
 32 "Mittellungen aus der Klinik fiir syphil. Kranke." Annalen 
 des Charite-Krankenhauses, Bd. IX. Heft i (i860), pp. 167, i68. 
 
 33 "Uber die Verschiedenheit der syphilischen Krankheiten": 
 Wiirzburger 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." '' 
 
 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.^^ 
 
 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 
 
 ^* 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. 123. 
 
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 I2th, 
 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.^^ 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." ^^ 
 
 Is syphilis contagious in the tertiary stage? 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.^^ Finger performed more than 
 thirty inoculations with the secretions of gummata 
 
 3«Prof. A. Vldal, "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. 
 
 ^^ Gaz. Med, de Paris, 1846. Cited from Lancereaux: "The 
 Study of Syphilis," p. 607. 
 
EXPERIMENTS ON MAN 353 
 
 and periostitae upon ten healthy, i.e. non-syphilitic 
 subjects.^^ 
 
 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.^ ^ Profe V. M. Tarnovsky was more fortunate. 
 "In the winter of 1863," he tells us, "in the Kalinkin 
 Hospital, after eighteen ( I) 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.^ ^ 
 
 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 
 
 ^^ E. Finger, "Die Syphilis und die venerische Krankheiten." 
 Wien, 1886, p. 7. 
 
 *° Rollet's speech at the Congress held at Lyons in 1864. Gaz. 
 held., 1864, p. 706. 
 
 *i 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.^ ^ 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." ^^ 
 
 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 
 
 *2 Ibid., p. 64. 
 
 *^ E. Lancereaux, "The Study of Syphilis." Translated Into the 
 Russian under the editorship of Prof. V. M. Tairnovsky. St, Peters- 
 burg, X876, 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 
 
 44 
 negative. 
 
 The results of four inoculations by Rieger, con- 
 ducted by him in Rinecker's clinic, were also nega- 
 tive in their result. Biedenkapp's *^ 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 9th, 
 1862, suffering from blenorrhoea 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 mischiefs 
 similarly to the preceding patient^ with 18 (eight- 
 een ! ) chancres ; to these were added 1 2 more, inocu- 
 
 "** "Diary of the Physicians' Society of Kazan," i88i, p. 12. 
 
 *5 See Bumler's "Syphilis" in the "Guide to Special Pathology 
 and Terapathy," by Ziemssen. 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.^^ 
 
 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.^'^ 
 
 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 27th, a 
 full Pravaz syringe of milk from a syphilitic patient 
 
 *^ See Bumler's "Syphilis" in the "Guide to Special Pathology and 
 Terapathy," by Ziemssen. Rus. translation. Vol. III. Part i. p. 
 84. Kharkoff, 1886. 
 
 ■*'^ 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*^: 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- 
 ts <'Ist die Syphilis durch Milch ubertragbar ?" 5"/. Petershurger 
 med. Wochenschrift, 1876, No. 23. In the original all three girls 
 were named in full. 
 
 *9This 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 Grassi 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.^^ 
 
 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.^ ^ 
 
 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." ^^ 
 
 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 
 
 ^50 Prof. B. Grassi, "Trichocephalus u. Ascarlsentwicklung": 
 Centralbl. fur Bacteriol. u. Paras., 1887, Bd. I. p. 131. 
 
 81 The Physician. St. Petersburg, 1891, p. 972. 
 
 82 Prof. Th. V. Freichs, "Ubcr den Diabetes." Berlin, 1884, p. 
 272. 
 
EXPERIMENTS ON MAN 359 
 
 threatening collapse of the patient's strength set 
 in, which necessitated the employment of stimu- 
 lants." "' 
 
 After this Fehleisen inoculated six more patients 
 who suffered from lupus and various tumours, with 
 erysipelas.^^ 
 
 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.^^ 
 
 ^^ Dr. Fehleisen, "Die Aetiologie des Erysipels." Berlin, 1883, 
 pp. 21-23. 
 
 ^* 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. 
 
 55 E. Hahn, "Ueber Transplantation der carcin. Haut." Berlin, 
 kiln, Woch, 1888, No. 21, 
 
36o 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. Hahn'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." ^^ 
 
 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- 
 
 5« 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 oivn systems. 
 
EXPERIMENTS ON MAN 361 
 
 servations, 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.^"^ 
 
 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 
 
 ^■^ Summary of Stickler's paper, as it appeared in one of the Amer- 
 ican medical journals. The Centralblatt fiir 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 PHYSiaAN 
 
 t±ie 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.^^ 
 
 ^^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 I" 
 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, Pettenkoffer'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. Ras- 
 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,^^ Warneri,®^ 
 and Lindemann,^^ 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. hehdom. 
 1862, No. 22, pp. 349-350)- 
 
 ^0 Verhandlungen der phys. 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 VAcademie Nationale de medecine, 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 experimicnts 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 I" ''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 truths" ' 
 
 "What will then become of ideals *?" 
 "Oh I 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? 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"? What good can it do*? 
 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 I" 
 
 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 "ia- 
 
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-m.asters, 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 v/as 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 I 
 As if it were possible to create a box strong enough 
 to keep Truth a voiceless captive I 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 declined 
 
 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. 
 
 lYet 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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