Circumstantial Evidence by David R. Trevithick GEORGE CASTLETON had not been long in the field before he came to know that the successful practice of medicine depends upon more than the possession of a technical knowledge of one's profession. Beyond the most that any institution could teach even the thoroughly conscientious there was the matter of proper psychology in application. This subtle matter was what he couldn't comprehend. It is not that George was a failure. He had established a certain following that allowed him to keep the wolf howling in minor key. Practical people who had had his ministrations in instances where positive symptoms made diagnosis easy and treatment conventional were highly pleased with his colorless but reassuring profficiency. When the affliction allowed him to be positive, he was positive, positive in the solid way that the afflicted enjoy; but when there were complications, George was confused. And patients don't like confusion in those appointed to shield them from the grave. People who were troubled in body became troubled in mind when they perceived that George seemed tangled in a medical wilderness. When he found it necessary to beat time, his methods were according to the best traditions of his profession, but his manner was faulty. Confusion took refuge in a timid sort of frankness that was construed as incompetence. When trouble did not reveal at once its true nature he would say, "Symptoms are so complicated that positive diagnosis is just now impossible. Until matters become more definite, we had better adopt some general measures." Then he would make conventional tests and prescribe some innocuous ointment or pale tablespoonful-three-times-a-day liquid. If there was not immediate happy response to his ineffectuals, the patient became hysterical over the supposed nearness of death and called in a consultant who usually arrived just when certain treatment could be employed. Those unhappy coincidences made George look like a veterinarian with a junior college diploma. The simple farm folk among whom he practiced refused to allow education any quarter. Learning to them was a mighty and mysterious discovery of truth that made hesitation impossible. Clear-cut decisions were inevitable where knowledge was applied by one who had an awesome title. If there were no decisions, there must be no knowledge. George often drove in to the state capital, a city of more than a hundred thousand, when it was necessary for him to replenish his kit with those things that make up a doctor's general equipment. One of his restocking expeditions he made on the third day after he had taken a case involving a melancholy middle-aged bachelor who had been brought to his bed by a complication of internal aches and pains. George believed that there was nothing seriously wrong with his patient, but the man would not have it that Death was not gesturing. Though he got no worse, his trouble refused to reveal positive symptoms, and he was becoming restive over George's timid administration of ineffectuals. At the Prescription Drug George placed an order for gauze and bandages and antiseptics and prescription bases and general-purpose compounds. He had not finished when someone spoke to him. It was Dr. Henry Allan, a specialist in internal medicine who had established an enviable reputation and built up in-the capital city a lucrative practice. George knew him as a capable, self-confident, personable man. His professional knowledge was great, his methods legitimate, and his psycho-analytical abilities remarkable. After the conventional preliminaries they came naturally to their profession. "I'm getting a toehold," replied George to Allan's question: "Maybe I'll find a place for both feet after a while. I haven't had many deaths that could be avoided. But then people over my way are a healthy lot and don't page EIGHT get much wrong with them. Except for colds and bruises, about the only affliction is too many years." Allan laughed. "The great fault there, I should say, is an economic one. Colds and bruises get well without much attention, and folks don't pay much for helping them to die when all the parts wear out at once. You ought to move in here or to some still larger place where people seem more conscious of the demands of our profession and feed themselves on other than farm and garden stuff. City people are slower to get away. Some of them come down with fancy complications that take months to find and years to treat." "That's why I should stay in the country," said George. "The conventional troubles are my field. When I come up against complications I am lost." "We all are," said Allan. "Only we don't admit it. The best men I know prescribe most any kind of harmless shake-well-before using treatment until they can be certain enough of their ground to take a definite course. No man ever practiced medicine successfully who did not beat time." "I give colored water too when I am baffled," replied George. "But my patients seem to realize that it is colored water. They lose confidence in me. Right now I am going to lose a case that won't help my reputation any if it doesn't soon pass from the patent medicine stage one direction or the other." He explained with great seriousness the circumstances and symptoms involved in his bachelor-patient problem. Allen smiled at his naivite. "I know where your trouble is," he said. "You are bothered with an acute attack of beginner's sincerity. You're not dictatorial enough. People don't want you to guess them well. They want to be commanded. If you prescribe baking soda you must do it with the same authority that you would declare the necessity of a brain operation. The religious taking of soda must seem the only solution. This story will demonstrate what I mean. "A year ago I had a case showing so many conflicting symptoms that I was quite bewildered. It was no society doctor affair. A woman about sixty was taken to bed with alarming fluctuations of temperature. She showed a general body rash and vomited violently. I saw possibilities of malaria, trichinosis, scarlet fever in fact a score of fevers and poisons. I made some tests which showed nothing and prescribed aspirin in capsule form, hoping that her trouble would soon reveal itself by a positive symptom that I could translate. In the afternoon of her second day in bed I called on her and found no development that would help me. While I sat by the bed trying to find something new to say that she must do or not do, I saw some orange peelings on a plate nearby. I pretended to be greatly irritated and charged her with disobeying my orders. Though I had not told her not to eat oranges, I said that I had pointed out specifically on my first visit the dangers of citrus acid for one in her condition. I declared that she could not hope to get well if she disregarded my commands. She was convinced that I knew what I was doing. A second blood test revealed her trouble, and I got under way with proper treatment." George returned with enthusiasm to his melancholy patient. He made a conventional inspection with impressive briskness and great determination. The man was puzzled and George was puzzled too. He knew no better than before what to do. But he was determined that no one would ever again be conscious of his distress. He helped himself to a drink of water in the kitchen and stood looking at the sick man, apparently in deep thought. Then he saw something under the bed that pointed the way out of his confusion. "It is as I thought," he said, his voice heavy with professional displeasure. "You have disobeyed my orders concerning your diet. I told you that you must not eat meat. How in the world can you hope to get well when you eat horse flesh?" The man was aghast. "Horseflesh?" he asked, as though his trouble had suddenly centered in his ears. "Yes," declared George. "There's the saddle under your bed." page NINE