Medicine: The Sick and the Heartsick

Out last week was an unusual medical book, Nervousness, Indigestion and Pain (Hoeber; $5), an authoritative treatise which Dr. Walter C. Alvarez directs toward young physicians, but which will be as eagerly read by laymen as by doctors. Its 471 pages include some of the ideas the famed gastroenterologist summarized in his recent hints to busy doctors in the Journal of the A.M.A. (TIME, Aug. 16)—and many more. All are calculated to help doctors make accurate diagnoses and limit treatment to what will actually help. Emphasis is on ways of knowing when a patient has no organic disease at all but a “functional” disorder “arising in the brain.”

Dr. Alvarez has already written one medical bestseller, Nervous Indigestion. Laymen like his cheerful, chatty style, free from scientific doubletalk, full of Aesopic richness of anecdote, character sketches in which many a reader may recognize himself. Sample anecdotes:

>”That the currents in the digestive tract can be reversed by worry was well shown by a nervous young woman who one day received a menacing letter from the income-tax collector. This so frightened her that . . . she took to her bed and vomited day & night for a week. She stopped only when . . . I went to the Custom House and appeased Uncle Samuel with $3.85. . . .”

>”I remember a worrisome young man who, one day, came back from the roentgenoscopic room wringing his hands and trembling with fear. It is all up with me.’ he said. ‘The X-ray man said I have a hopeless cancer of the stomach.’ Knowing that the roentgenologist would never have said such a thing, I asked, ‘Just what did he say?’ and the answer was that on dismissing him, the roentgenologist said to an assistant, ‘N.P.’ In Mayo Clinic cipher this meant ‘no plates,’ and indicated that the roentgenologist was so satisfied with the normal appearance of the stomach on the roentgenoscopic screen [fluoroscope] that he did not see any sense in making films. But to the patient, … it meant ‘nothing possible’; in other words, that the situation was hopeless.”

>”When the examination [of a young farmer] failed to reveal anything, I said to him, ‘If I were to tell you that you have no ulcer or cancer, and that there is no reason to expect one in the future, and if I were to assure you that this ache is due only to a little arthritis around your spine which may bother you off & on for years without bringing you to any bad end, what would you do?’ His answer delighted me. He said, ‘I’d say, to hell with it!’ And off he went happy and . . . cured.”

Advice to Patients. The troubles of about one-fourth of Dr. Alvarez’ patients are “functional” disorders (caused usually by overtiredness, “nervous storms,” sometimes insanity); the rest of his cases are organic. But some patients with well-marked organic disease are suffering not so much from it as from “functional” malady —one woman had five or six organic diseases but the real cause of her trouble was that her husband, tired of her fussiness, had got himself a cheerful mistress. Says Dr. Alvarez: “I knew of no medicine or operation to cure this.”

Far from scorning sufferers whose organs are normal, Dr. Alvarez knows from his own experience (gained chiefly during a long convalescence from influenza in 1918) that “functional” aches & pains may be just as debilitating as organic disease. These patients he treats with sympathetic advice, sometimes works cures by getting them to adopt calmer ways of thinking and living.

His liking for people, especially patients (most of his are women), appears throughout the book. He likes them even though nearly 40 years of listening to troubles have given him such a comprehensive view of human frailty that he can guess many sins a patient is too shy to reveal. Here & there a sharp comment appears: “As I often say to women, the greatest trouble with them as a sex is their pettiness and their inability usually to differentiate what is really important from what is inconsequential.”

Advice to Doctors. The book’s advice to young doctors makes good sense: 1) take the time to get a good, complete history of the patient’s illnesses; 2) do not write down anything likely to embarrass the patient; 3) unearth, if possible, the patient’s real reason for seeing a doctor; 4) take a good look at each patient; size him up; 5) never get angry with a patient and never give him the lie direct—”the patient is always right”; 6) do not put too much faith in laboratory tests nor order unnecessary ones—a laboratory girl’s report has caused many a needless operation which a careful physical examination or even a glance at the patient would have prevented; 7) some patients, the “constitutional inadequates,” are victims of an “ineradicable disease” and there is no use spending your time and their money trying to make them healthy; 8) always tell a patient the truth (avoiding, if possible, the word “cancer”); 9) dismiss pigheaded, stupid patients who will not take advice while they are still friendly; 10) do not let it break your morale when you make a diagnostic mistake—”I just say to myself that I did the best I knew how.”