A Little Book of Doctors' Rules III. . . For Oslerian Clinicians.: New Revised Edition by Clifton Meador
My rating: 5 of 5 stars

This is, strictly speaking, not a book of rules, rather a set of guidelines and principles of clinical practice. These apply equally to the raw intern or to the hoary old practitioner and all physicians in between. Hippocrates and Osler are outdated to a large extent.

Here are some Oslerian aphorisms:
• Medicine is learned by the bedside and not in the classroom. Let not your conception of disease come from words heard in the lecture room or read from the book. See, and then reason and compare and control. But see first.
• Live neither in the past nor in the future but let each day’s work absorb your entire energies and satisfy your widest ambition.
• The good physician treats the disease; the great physician treats the patient who has the disease.
• The value of experience is not in seeing much, but in seeing wisely.
• The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head. Often the best part of your work will have nothing to do with potions and powders, but with the exercise of an influence of the strong upon the weak, of the righteous upon the wicked, of the wise upon the foolish.
• We are here to add what we can to life, not to get what we can from life.
• To study the phenomenon of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all
• I have three personal ideals. One, to do the day’s work well and not to bother about tomorrow…The second ideal has been to act the Golden Rule, as far as in me lay, toward my professional brethren and toward the patients committed to my care. And the third has been to cultivate such a measure of equanimity as would enable me to bear success with humility, the affection of my friends without pride, and to be ready when the day of sorrow and grief came to meet it with the courage befitting a man.

These, in contrast, are the aphorisms of Hippocrates:
• We should rather purge upward in summer, and downward in winter.
• Pains seated above the diaphragm indicate purging upward, and those below it, downward.
• Dysentery, if it commences with black bile, is mortal.
• In all cases whatever, bilious discharges cease if deafness supervenes, and in all cases deafness ceases when bilious discharges supervene.
• If a person labouring under a fever, without any swelling in the fauces, be seized with a sense of suffocation suddenly, it is a mortal symptom.
• Sweats, in febrile diseases, are favourable, if they set in on the third, fifth, seventh, ninth, eleventh, fourteenth, seventeenth, twenty-first, twenty-seventh, and thirty-fourth day, for these sweats prove a crisis to the disease; but sweats not occurring thus, indicate pain, a protracted disease, and relapses.
• When the hypochondriac region is affected with meteorism and borborygmi, should pain of the loins supervene, the bowels get into a loose and watery state, unless there be an eruption of flatus or a copious evacuation of urine. These things occur in fevers.
• Blood or pus in the urine indicates ulceration either of the kidneys or of the bladder.
• When small fleshy substances like hairs are discharged along with thick urine, these substances come from the kidneys.
• Spasm supervening on a wound is fatal.
• A convulsion, or hiccup, supervening on a copious discharge of blood is bad.
• If a drunken person suddenly loses his speech, he will die convulsed, unless fever come on, or he recover his speech at the time when the consequences of a debauch pass off.
• Persons disposed to jaundice are not very subject to flatulence.
• When a person has been cured of chronic haemorrhoids, unless one be left, there is danger of dropsy or phthisis supervening……………

This book is so valuable because the author reminds doctors that they are treating a person, not a disease. With that in mind, he stresses the importance of listening to the patient, observing him, and even touching him. First, listen for clues: "Most patients can tell you why they got sick. . . Let a patient ramble for least 5 minutes when you first see them. You will learn a lot." Then, be sure you are facing the patient. "Learn to watch people's faces and eyes. Learn to watch their lower lip and then the upper lip." Finally, "Always examine the part that hurts. Put your hand on the area." Then, based on what he has heard, seen and felt, the doctor is able to begin ordering tests – but not a battery of tests: "Use laboratory tests like a rifle, not a shotgun." Over-testing can lead to over-treating.

The author says, “My fascination has always been more with the nature of the practice of medicine than with its actual practice. I have often wondered what it is that constitutes the real stuff of the practice of medicine. What are its essential elements? What is it we do that is helpful? What do we do that is harmful? Is there a way to codify and describe these necessary elements? Can we tease out the unspoken and unwritten rules by which we operate, and which determine our behaviour and make us physicians? Can we begin to explore the hazy art of the practice of medicine in some systematic way? Can we create a science of the art of the practice of medicine?”

The book codifies simple but essential guidelines which should have been taught in Medical College or learned through experience.

For example,
• Learn to listen for the “life narrative” of the patient. Diseases tend to arise from the “lived life” of the patient.
• Sit down when you talk with patients. Don’t talk with patients with your hand on the door.
• Always examine the part that hurts. Put your hand on the area.
• Touch the patient, even if you only shake hands or feel the pulse, especially with seniors. But not with paranoids.
• When you are listening to a patient, do not do anything else. Just listen.

A book that should be read and reread.


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