For the harried practitioner seeking a direct route from a presenting symptom to a specific diagnosis, there was French's Index of Differential Diagnosis [5], a sturdy, well-constructed compendium that has survived to the present day [6] and has spurred the publication of at least a dozen similarly oriented texts. For details on treatment, the no-nonsense physician consulted Hare's Textbook of Practical Therapeutics [7], which had already undergone 11 revisions by 1905.

For me, however, the piece de resistance is Cabot's Differential Diagnosis [8, 9]. A mint-condition copy of this two-volume work was given to me by a friend in trade for an early Polaroid Land camera. I was delighted. Here was an opportunity to be transported back into the medical world of 1911-1914, as reported by Richard Clarke Cabot (1868-1939), perhaps the outstanding clinician of his day. I decided that the journey would be well worth taking.

The Format

Cabot tells us that his volumes constitute "an attempt to study medicine from the point of view of the presenting symptom ..." [10], and each chapter is devoted to a nonspecific symptom or symptom complex. Gathered under these headings are 702 cases, each of which is listed in the Table of contents with a specific diagnosis. The initial history, physical findings (frequently illustrated by abnormalities of palpation, percussion, or auscultation overlaid on a photograph of a unisex torso), and laboratory findings (rudimentary by our standards) are recorded, along with a summary of the patient's course. Each case presentation is followed by a discussion of the differential diagnosis and a section titled "Outcome," which covers the final diagnosis and treatment. Occasionally, the diagnosis remains uncertain; this is not surprising because Cabot comfortably "chose no cases in which the diagnosis was obvious ..." [11].

Cabot's format was adapted from the "method of case teaching long used at the Harvard Law School, first described by W.B. Cannon ..." [12]. It is the ancestor of the time-honored Clinical-Pathological Conference (once known, familiarly, as "Cabot cases") preserved each week in uninterrupted continuity in The New England Journal of Medicine. Cabot's work, unlike French's text, was not intended to provide concise descriptions but rather to "give ... practice in thinking" [12]. Here, he struck a receptive chord: The first volume of his book went through three editions and was reprinted nine times. Not to be outdone, contemporaries published similar compilations of case histories in surgery, neurology, and pediatrics [13-15].

These case studies make fascinating reading for medical historians, but they are of limited interest for today's practitioners in search of focused answers to specific questions. Indeed, I question whether the original purchaser of my volumes spent much time with them. They show no signs of wear, and, while rifling through the pages, I discovered that leaflets advertising other contemporary publications had not been disturbed. (These leaflets provide a reminder of the inexorable march of inflation: De Lee's New Obstetrics, which comprised 1060 pages and 913 illustrations, 150 in color, cost $8.00.)

The Author

Cabot was an indefatigable worker whose interests extended far beyond the care of huge numbers of patients. He published an analysis of 697 cases of pernicious anemia [16]; even more impressive, he stated offhandedly, "I examined 3000 ... necropsy records, searching for lesions ordinarily supposed to produce diarrhea ..." [17].

Cabot also distinguished himself in other ways. His experience in the Outpatient Clinics of the Massachusetts General Hospital, where he saw "about 30 patients a day or 3000 in my [annual] 4 months service ..." [18], made him aware of the effect of poverty and neglect on his patients' health. Indeed, he became a prime mover for the establishment of social work as a recognized profession, and he was so alienated by what he saw as the callous attitudes of his peers that in 1920, he abandoned full-time medical practice to teach medical ethics [19]. Speaking of the sorry lot of housewives, he describes a 37-year-old homemaker who tolerated a 4.5-kg uterine tumor for 8 years [20].

"That a patient who has but 1.9 million red cells should patiently continue to do the whole work for her husband and 6 children is a type of familiar heroism to which, despite its familiarity, I cannot forbear to elude."

Understandably, our hero was not immune from pronouncements that have not weathered the test of time. The most dramatic evidence of Cabot's clouded crystal ball lies in his assurances to the heavy smoker: "I may here confess that I have seldom, if ever, been convinced that excess in tobacco is, in itself, the cause of any serious symptom, whether cardiac, digestive or nervous" [21]. In addition, Cabot astutely skirted the pitfalls inherent in the mind-body dichotomy. On the one hand, to jump to the conclusion that a patient's symptoms are solely of emotional origin may have dire consequences. There are "dangers lurking in the diagnosis of ‘hysteria’ ..." and such "blind spots in our diagnostic retina ..." must be avoided [22]. On the other hand, patients with primary emotional problems are also at risk. Cabot says of a patient with multiple symptoms: "she has also suffered many things from many physicians, as nervous sufferers are unfortunately apt to do ..." [23].

At the Bedside

In reading case studies devoted to the analysis of difficult diagnostic problems in 1911 to 1914, it is not surprising to learn that syphilis, tuberculosis, and emotional disturbances (often labeled as hysteria) were by far the most common of the wide range of diseases seen. In general, I was pleased to discover how neatly diagnoses were established despite the limitations imposed by constricted laboratory support. Physicians were adept in percussing widened retromanubrial dullness and enlarged cardiac borders. They could also identify succession splashes and changes in whispered voice sounds, talents no longer prized in the age of magnetic resonance imaging.

The road to the establishment of a diagnosis differed not at all in principle from that which we follow today; the focus on thinking about a patient's problems has not changed. Great emphasis was placed on the history and physical examination despite the emergence of chest and abdominal roentgenography. It is a testament to my early training that I came upon only one unfamiliar physical sign: "The tongue is bat shaped-widest at the tip. It is protruded very far and during this act the anterior pillars of the fauces are drawn forward." This intriguing finding reflected Cabot's interest in psychosomatic linkages. It occurs because the patient "has usually been in the habit of looking at his tongue in the mirror ... [providing] a certain inkling of a patient's mental condition" [24].

Although he did not give it a name, Cabot provided an excellent description of sleep apnea. His notion of pathogenesis has a naive charm: "The respiratory center goes to sleep and allows the respiratory act to become almost suspended. The patient then awakes with a horrible gasp" [25]. Similarly, Cabot described a patient who had a goiter for more than 30 years [26]. The tumor "was about the size of a hen's egg, situated in the median line, smooth, rounded, not tender, moving with the larynx on swallowing." This is a precise description of a thyroglossal duct cyst, although it was not designated as such. Regardless, Cabot knew how to treat it; he spoke of the finding as being "really negative" and ignored it.

I found it interesting to review the therapeutic options available in 1912. Although alert physicians were aware of the new direction that psychotherapy had taken, "what Freud calls ‘psycho-analysis’ ..." [27], treatment for emotional disturbances remained superficial. A patient with hysterical paralysis "was given a severe scolding and the arm was raised and the fingers were bent and straightened again by force for about 5 minutes in spite of his shrieks and protestations ..." [28], and clinicians were not above rousing a patient in hysterical coma with a pail of water [29].

Practitioners had available to them a limited number of specific therapies, such as arsphenamine for syphilis [30] and thyroid extract for hypothyroidism [31], and some procedures that were quite sophisticated. For example, an ingenious if somewhat medieval treatment, an early precursor of modern endometrial ablation [32], was applied to patients with menorrhagia. "Under gas and ether ... a jet of hot steam was introduced into the uterus, the vagina being protected by a continuous stream of cold salt solution ..." [33].

In reviewing these cases, I looked forward to the discovery of not-yet-described diseases. In one example, a 31-year-old housekeeper had recurrent kidney stones and was troubled by repeated episodes of nausea and vomiting, polyuria, and anorexia [34]. This patient surely had hypercalcemia, probably due to primary hyperparathyroidism, which was described for the first time some 15 years after publication of Cabot's book. The existence in these volumes of not-yet-described disorders may suggest to the reader that the books are a mine of "first" descriptions. Perhaps they are, but without attempting a count, I think that more diseases have been subtracted from than added to our diagnostic pantheon since Cabot's time.

Judgmental Observations

During the course of my otherwise pleasant excursion, I found myself unable to ignore an unsettling question: Did Cabot harbor unsavory prejudices against minorities, or were his sweeping generalizations merely reasonable conclusions educed by a fair-minded physician with wide clinical experience?

In his preface to the chapters on pain, we come upon some shockingly bald statements, such as "We know that certain races-for example, the Chinese-are much less sensitive than others to pain in that they exhibit far less evidence of ‘shock’ after a bullet wound or disembowelment ..." [35]. Furthermore, "though women are generally believed to be more highly organized and more sensitive than men, it is a well known fact that they bear pain, especially prolonged pain, better than men ..." [36]. (After my stupefaction abated, I searched for evidence to support these contentions. As far as I know, no studies indicate that the pain thresholds of Chinese persons differ from those of other persons. As for women, they may have lower pain thresholds than men do [37] and are hardly stoics [38]).

It must be said, however, that Cabot readily distinguished between women's sensitivity to pain and their sensibilities. He showed a nice sense of decorum in discussing a maneuver to assist in abdominal palpation. He recommended "immersing the patient in a bath as hot as he can bear ..." and then added in a thoughtful footnote that "women can be protected by making the water opaque with soap suds ..." [39].

Some of Cabot's judgments may ring true; for example, "ladies do not faint as they used to" [40] and "sailors are notoriously apt to have syphilis" [41]; others have lost, with the passage of time, whatever validity they may have had. For example, "Of course it is perfectly possible for hysteria to exist in an Irish laborer of 27 but such a coincidence is certainly infrequent ..." [42] and "A young Italian laborer does not stay in bed for 3 weeks for the fun of it ..." [43].

Lastly, Cabot seemed much taken with the notion that the Jews of Boston around 1912 were, by and large, neurotic. On one occasion, he went so far as to state that "weakness and loss of weight with headache and digestive symptoms are complained of by innumerable Jewesses of this age [34 years] without our being able to discover any more definite cause than self-starvation and a psychoneurotic condition ..." [44]. After this bombardment, it was heartening to learn that the manifold neuroses of Jews did not include promiscuity: "gonorrhea ... [is] very rare in the young, unmarried Russian Jewesses of Boston ..." [45].

Without question, Cabot knew that he was guilty of unacceptable stereotyping and, with extraordinary candor, he acknowledged his prejudices [18].

"The chances are ten to one that I shall look out of my eyes and see, not Abraham Cohen but a Jew. I do not see this man at all. I merge him into the hazy background of the average Jew. Perhaps, if I am a little less blind than usual today; I may hear what he says instead of what I expect him to say."

Thus spoke Richard Cabot, the Boston Brahmin born into a caste structure described in the famous toast, "And this is good old Boston, the home of the bean and the cod, where the Lowells speak to the Cabots and the Cabots speak only to God." He acknowledged his bias against Irish, Italian, and Jewish immigrants with their foreign personalities and customs, and he also recognized that his stereotyping was medically misleading and ethically reprehensible. Furthermore, he had none of the virulent xenophobia and anti-Semitism that contaminated much of smug east coast society in his day. On the contrary, he successfully fought a continuing battle against the medical establishment to provide social services for aspirants to the American dream.

Conclusions

Cabot's two volumes reveal that at the turn of the century, well-trained physicians excelled in the art and science of bedside medicine. In many ways, the performances of these physicians would shame modern academicians, whose clinical examinations are increasingly perfunctory. Although their exemplar, Richard Clarke Cabot, recognized the central role that science had come to play in medical practice, he never subscribed to the popular dogma that the new science of medicine would resolve all clinical problems. Indeed, those of today's advocates of holistic medicine who rail against medical orthodoxy would do well to study Cabot's Differential Diagnosis.