The Light Within the Darkness
DR. ELLIOTT DOBSON is the pseudonym of a physician who is practicing today and who began to lose his eyesight in his thirty-third year. Now in total darkness, a specialist in the field of internal medicine, he handles his large practice, teaches at one of our leading medical schools, and serves as a staff member in a large metropolitan hospital. His article is drawn from the book When Doctors Are Patients, edited by Max Pinner, M.D., and Benjamin F. Miller, M.D., which Norton will publish in April. Other chapters, by Dr. Fredric Wertham and the late Dr. Abraham Myerson, will appear in subsequent issues of the Atlantic.
by DR. ELLIOTT DOBSON
1
THE doctor’s office was on 59th Street, and as we came out on the sidewalk we could see that the green of Central Park was beginning to be tinged with faint brown under the hot blue sky of mid-July. We went to R um pel mayors for lunch and afterward took a taxi to the hospital. Riding uptown, I can remember seeing a. sign above a shoe store. The letters were large, black upon a white background, and surrounded by a scintillating halo. They spelled out the words “Thom McAn,” and they were the last I was ever to read. The next day I was operated upon for retinal detachment. Despite the efforts of an able surgeon the operation was a failure, and since that day twelve years ago I have been totally blind.
When my world thus came tumbling down about my ears, I was forty years old, with a wife and two small sons, aged six and eight years. I had been engaged in the practice and teaching of internal medicine for fifteen years and had attained the rank of assistant professor of clinical medicine in a large metropolitan school. At the age of five, I had been found to be a high myope with astigmatism and ocular muscle imbalance. Like many myopes I was an avid reader with a retentive, photographic memory. Despite my visual handicap I was able to participate in sports, such as baseball and football, to a limited extent. My myopia increased sharply during adolescence, and by the time I was twenty-two years of age it had reached 12 diopters. During succeeding years, likewise, the imbalance of my ocular muscles and my astigmatism gradually became worse. When I was thirty-two I suffered a large retinal tear in the macula of my left eye. The consensus of my ophthalmological consultants was against surgical repair, and for the next seven years I lived and worked with slowly failing monocular vision.
There is no need here to recount the thoughts, the desperate dwindling hopes, the slow surrender to grim inevitable truth of one who watches the dark curtain slowly descend, nor does it seem fitting to transcribe that black despair which twists the heart when the silent severance from light is made complete. These things, portrayed by abler pens than mine, seem to me to lie too deep for plucking forth. Suffice it to say that the storm was somehow weathered through.
The facts being squarely faced, it became necessary to take stock and to make a decision. The inventory showed among my assets some pearls of great price. Chief among these stood my wife, herself a physician and gifted with intelligence, optimism, and energy. Without her loyalty and her gay, courageous heart, a dark way would have been darker indeed. Her ability to achieve a career for herself, while maintaining to the fullest the role of wife and mother, and giving encouragement, guidance, and support to me in a hundred ways, represents in itself a most noteworthy accomplishment. Next in importance stood the encouragement and support of my friends and colleagues, and the coöperation of my associates and superiors in the medical school and hospital. Fortunate also was the happy accident of my training in a special field where the benefit of vision is more dispensable than in most.
With these considerations in mind only one decision was possible: to pick up the pieces and to carry on. Through the kindness of hospital and academic authorities I have been able to concentrate my activities in the teaching hospital of our medical school. My work has continued to include private consultation practice, the direction of a special outpatient clinic, and clinical teaching in the form of bedside conferences, ward rounds, and clinical lectures. I visit patients in consultation in their homes or other hospitals, sit on various hospital committees, contribute occasional articles to the medical literature, and present, papers from time to time before local or national medical organizations. My office and hospital practice is carried on with the aid of an assistant.
For various reasons I have failed to utilize several facilities for the blind. I have not attempted to learn Braille. This doubtless is due in large part to intrinsic inertia (a euphemism for pure laziness); to the ineptitude of a middle-aged set of reflexes; to the fact that much of my reading material is of necessity technical and not available in Braille; and in large measure to the availability of other sources of cultural and recreational reading. The Talking Books, made possible through the combined efforts of a government project and the American Foundation for the Blind, have filled a great need with the wide variety of literature which they supply. Radio has its obvious niche and, along with periodicals and newspapers read to me by members of my family, helps to keep me abreast of current developments. Much of my spare time is of necessity devoted to current medical literature and the preparation of lectures. In this I have enjoyed the services of a neighbor, a skilled reader versed in medical literature, the widow of a distinguished colleague and friend.
Two other potential advantages have likewise not been realized. The availability of stenographic assistance and technical recording facilities has abetted my disinclination to learn a touch system of typewriting (doubtless another manifestation of intrinsic inertia). I have not acquired a Seeing Eye dog largely because most of my time is spent indoors within the hospital and office. The problem of physical exercise has been solved in part by cross-country walking and calisthenics.
2
WHAT of the practice of medicine without benefit of vision? The effectiveness of the properly integrated use of palpation, an attentive ear, and a keen olfactory sense is indeed remarkable. The auditory impression of the length of stride and of the level from which the spoken voice emanates gives a useful estimate regarding the height of the patient. The quality of the voice tells me much about the personality and emotional tension. The quality imparted by swelling of the upper respiratory mucous membranes or by motor impairment of the laryngeal mechanism is often characteristic. I have been able correctly to suspect the presence of acromegaly and of myxedema from the patient’s voice. The vocal quality imparted by tumors in the nasopharynx, or by uvular paralysis or weakness, is sometimes diagnostic — as is the stridor associated with recurrent laryngeal paralysis or with intrathoracic pressure exerted upon the trachea or bronchi.
The uses of palpation are manifold and obvious. The patient’s general habitus, his state of nutrition and of muscular tone and development, the presence of atrophy, and conformation of the skull, the physiognomy, the texture of the skin, can be ascertained by touch. Also, the character and distribution of the hair, exophthalmos, edema, the presence of tumors, adenopathy, goiter, vascular pulsation, ascites, hernias, lesions of the nails, tremors, enlargement of abdominal viscera — all these things and many more are readily revealed to the exploring hand of the sightless examiner.
Likewise the value of olfactory impressions is considerable. The fresh alcoholic aroma which surrounds the diurnal drinker or the stale smell of last, night’s drinking bout may reveal much. I once astonished a patient, after we had exchanged a few words of int roduction, by remarking that all I knew of him at the moment was that be bad lived in New York, probably Brooklyn, and that he was a heavy smoker of cigars. He pleaded guilty to both these soft impeachments. The answers of course lay in his characteristic accent and in the equally characteristic odor of cigar tobacco which hung about him. The quality of a woman’s perfume and cosmetics, or the lack of them, may be revealing. The odors of disease require but little comment. Uromia, acetonemia., and sometimes intestinal obstruction all impart a characteristic quality to the breath of the patient. Clinicians of an older generation, lacking the diagnostic refinements of today, were obliged to rely more upon their senses, and I have heard them describe the smell of typhoid fever, smallpox, and other infectious diseases. I cannot vouch for the accuracy of these observations from my own experience.
Diagnosis — absolute or tentative — and a plan for further study or treatment thus crystallize from correlation of several components. The fundamental importance of a carefully detailed history seems too obvious for comment. Yet despite the emphasis placed upon it in curricula, and the recent renaissance of interest in the personal relationship between patient and physician, this art remains largely undeveloped among medical students and young physicians. A major hindrance to the procurement of a history in office and clinic practice is hurry. It is of prime importance that the patient be put at ease and be made to feel that he has plenty of time to tell his story to a sympathetic listener. It is admittedly sometimes difficult to reconcile such an attitude with the inevitable pressure of the clay’s work; but once this relationship is established, impressions of great value regarding the fundamental origin of the patient’s complaints can often be obtained.
A careful history having been extracted and digested, those parts of the physical examination which are dependent upon the examiner’s vision, such as the patient’s color, the Ocular findings, the appearance of the skin, teeth, mouth, tongue, throat, and so forth, are completed by my assistant and I then proceed with my own part of the examination. After properly correlating the information thus obtained, I am able with the aid of a rather highly visual imagination to form an impression of the patient and his diagnostic problem, which is usually, I think, pretty close to that which would be gained by a sighted physician. It may be understood that I am obliged to depend more than the average internist upon the services of special consultants— the dermatologist, the ophthalmologist, the otolaryngologist, the electrocardiographer, and the fluoroscopist.
The personal relationship between the patient and the blind physician deserves some comment. I am sure that many persons who would otherwise have consulted me have not done so, many doubtless because they hesitate to entrust themselves to one who cannot see, and some perhaps because of an understandable Philistinic complex which leads to the avoidance of affliction. Most of the patients who come to see me know that I am blind, and I see to it that the few who do not are soon tactfully made aware of the truth.
I have occasionally been amused by patients who were not aware of my visual handicap asking whether I would personally perform a recommended surgical operation. The situation once understood, there is very likely to develop a sympatheticrelationship between the patient and myself, which I think is often deeper and stronger than that which exists between the ordinary doctor and his patient. There often follows a relaxation of mental reservation and a letting down of emotional barriers, a freedom of eommunication which is of inestimable value in many instances both to the patient and to me. This is of particular advantage in the recognition and management of the numerous functional and emotional disturbances which form so large’ and important a part of the practice of internal medicine. I have often thought that, blindness might actually he at times an advantage to the psychiatrist. There are, I believe, a few blind psychiatrists practicing at this time; and while I have not had the privilege of discussing this point with any one of them, I trust that I may one day be able to do so.
Most of the teaching in which I engage consists of clinical lectures to undergraduate and graduate groups and bedside clinical conferences with small groups of undergraduate students. The preparation of lectures requires usually two to three hours for each hour of teaching and calls for the memorizing of a detailed outline. The problem of adjusting lectures to the passage of time has been solved by the use of a repeater watch or a Braille type watch. My bedside conferences are based largely on the Socratic method and, as they consist largely of “spot” teaching, do not permit detailed preparation beyond a preliminary review of the general problem presented by the patient.
I am sometimes asked whether in my opinion a blind person could successfully complete the required courses in a modern medical school. I am sure that under present conditions this would be an impossibility. Notable among blind physicians in this country was the late Dr. Robert Babcock of Chicago, and in Ireland Dr. Moorhead of Dublin. However, with the exception of Babcock, all of the blind physicians with whose careers I am familiar suffered their loss of vision after completing their medical education. Babcock, who lost his vision in boyhood, completed his education while totally blind. His accomplishments are outstanding.
3
WHAT are the uses of my adversity? These may be catalogued as of the body, the; mind, and the spirit. Chief among the physical advantages which have accrued to me I would place the development of my auditory sense. There is a widespread belief among the laity that the blind are likely to be endowed with a compensatory increase in acuteness of hearing. This is not true. There is, of course, no physiological reason why blindness should be followed by an increase in auditory acuity. From my own experience, however, I am convinced that, largely as a result, of necessity, the blind are able to develop to a high degree their latent ability to interpret and orient the significance of sounds. One learns to do perforce what one must do.
A keen awareness of many of the details of the life which is going on around and about us is possible to those who know how to use their ears to interpret what they hear. Thus, as I sit dictating these lines in my bedroom on a quiet midsummer morning, I am aware of many things. From the kitchen I can hear and smell the pleasant preparations for lunch; in the upstairs sitting room I can hear the metallic snip of my mother’s scissors as she mends the torn I ro users of her oldest grandson; in the field behind the back hedge a carpenter is hammering away. A soft wet wind laden with the promise of rain gently stirs the elm trees in the front yard. The milkman’s electric truck whirs to a quiet stop in front of the house; I hear him dismount, and, rattling his bottles, walk up the gravel drive toward the kitchen door. A family of robins quarrel noisily in the garden; overhead hangs a crow with raucous irritated cries. Across the street the neighbor’s children scold their dachshund; and from the distant highway comes the muffled interrupted roar of the midmorning traffic’s strain.
I have learned to distinguish the individual characteristics of voices and speech which permit me to identify most of my friends after only a few words have been spoken. Aided by occasional brief descriptions of scene and action, I am able quite readily to follow plays on the stage or screen from dialogue alone. One minor accomplishment, has interested me a good deal. I am somehow able to detect the proximity of a wall when I get within two or three feet of it. The most obvious explanation lies in the variation of reflected sound. Yet I have on occasion been able to make such identification in the absence of sources of such sound.
The development of two qualities of the mind — a visual imagination and a photographic and retentive memory — has likewise been a boon. After twelve sightless years I am still able to see vividly in my mind the physical characteristics and spatial relationships of any place or room with which I was reasonably familiar during my sighted life. Likewise, with the aid of a graphic, concise, and intelligent description (a function in which my wife has been of tremendous assistance), a permanent photographic impression of new rooms or places is stamped somewhere upon my cerebral cortex to be filed away and used at the proper time. My memory, always sharply photographic and retentive, has served me well in many ways, but particularly in the recollection of details concerning patients and medical literature, and in the memorizing of data for presentation during lectures or clinical papers.
There is, of course, a definite and important relationship between the age at which sight is lost and the capacity to develop such physical and mental qualities as I have briefly outlined. The congenitally blind or those becoming so during early childhood have the opportunity to develop their extravisual perceptive functions during the age when aptitude for learning is greatest. I must confess that I sometimes take refuge in such facts when I compare my feeble accomplishments with those of Helen Keller, Alec Templeton, Robert Babcock, Woolley, the biological chemist, or Burgess, the naval architect.
Those qualities of the spirit which have grown because of my handicap are difficult to put into words. Perhaps I may best describe them as an orientation — putting the eternal verities into proper perspective — the acquisition of humility and of compassion for mankind, and a deepening of my conviction concerning the existence and omnipotence of God. As I sit quietly in the greenish shimmering gloom, the greed and cruelty of man recede and assume their proper place, and I sometimes fancy that I can see the brooding love and compassion upon the Eternal Face. Then I know somehow that we are all placed here for a great purpose and that we must struggle to contribute something, however small, to the common good.
One of my most priceless gifts has been a strengthening of the roots of my old friendships. This growth, made tangible in a hundred kind and simple ways, I feel about me as a warm effulgent glow which lights the vista of the years ahead. Nor do such radiations emanate from old friendships alone. There seems an added warmth, a kind of tacit fellowship, in my relations with almost everyone i meet.
Honesty and fairness require an examination of both sides of the coin. What of the rough spots along the road, the stones that bruise the heel and the quag that mires the weary fool? Foremost among these is a feeling of helplessness or dependence upon others which I suppose besets all who are blind. Stemming from ibis is a recurrent selfreproach that I have not made an adequate mental, emotional, and social adjustment. My self-consciousness and embarrassment at people’s recognition of and pity for my handicap have largely faded with the passage of time, but awkward situations which require tact and self-control still arise in public, places or among crowds. Insufficient exercise and the resultant insomnia are annoying physical problems. I have become hypersensitive to noise. Though automatically on guard, I manage to collect my share of tibial, frontal, and nasal bruises and cuts. I have been fortunate in escaping serious physical injury, but the edge of an open door remains one of my major hazards.
Despite my best efforts to attain a serenity of spirit I am given to outbursts of irritability and to moods of depression during which those I love are most likely to suffer. I own too that I have not been able entirely to overcome my aversion to those people whose efforts at patronizing kindness conceal but poorly the blend of smug pity and repugnance which lies beneath. Greatly to be cherished is the friend who keeps his pity buried deep and whose kindness is seasoned with the tang of humor and of wit. A sense of humor is of great therapeutic value to the sightless; Thurber and the New Yorker are excellent substitutes for an appointment with a psychiatrist.
When I consider my situation after twelve years of blindness, I realize that I have much for which to be thankful, blessed as I am with all the benefits of love and friendship and with a reasonable degree of economic and academic security (our sons are well on their way through college), and absorbed as I am in congenial work for which I am fitted. Those who may someday stand where I am standing will know, as I do, that these things are above price: love, the privilege of work, and the faith that shines behind the shadow.