Thursday Review: “Clinical Sense”

For something a little different, this February, the Thursday Reviews will be dedicated to a few of Richard Asher’s classic articles from the late 1950s:

On February 9, 1959, Richard Asher delivered three Lettsomian Lectures at the Medical Society of London. The first, titled “Clinical Senses: the use of the five senses” is a primer on holistic patient observation, but also introduces some of the mental faculties which process that information almost as if they’re other senses.

Along these five [sense] routes comes the raw material which we fashion into clinical knowledge. We fashion it by means of the words we use in recording and describing it, and also by the thoughts, sensible or foolish, which we devote to its contemplation.

Asher calls the “sense” by which we (subconsciously) ignore things which don’t seem to have meaning the suppressive faculty and divides the faculty of “noticing” into two further groups: the ability to notice the significance of what seems to be irrelevant, and the ability to detect what is common to several groups of data.

He names the finding of significance in seemingly irrelevant detail Horace Walpole’s word1 serendipity, and doesn’t have a special name for his second ability to notice, but often calls it a “common factor”.

Most of the speech-turned-article is devoted to specific examples of diagnoses and symptoms which present themselves to each of the five faculties. Asher puts the five senses into a kind of hierarchy of usefulness:

  1. sight
  2. hearing
  3. touch
  4. smell
  5. taste

It’s easy to see why sight is the primary diagnostic sense (the number of clinical data that an be seen is far greater than is available to the other senses), and he places touch equal in value to that of hearing. Although he considers smell a sense not to be ignored, he does add that the range of olfactory stimuli is large, but the information they convey is relatively small.

With his characteristic humor, Asher recounts the only time I recollect the faculty of taste being of clinical use:

I remember about 10 years ago a baby had ascites of such milky whiteness that some of the wondering doctors thought it was milk which had leaked from a breach in the alimentary tract. Others believed it was a chylous ascites secondary to blocking of the thoracic duct. Dr. John Humphrey, our biochemist, was called in to settle the problem. He looked thoughtfully at a specimen of the fluid for a few seconds, and then gravely took a generous sip. Without hesitation he shook his head and said: That is not milk.

As another example of taste in clinical science, he also mentions Matthew Dobson’s 1776 discovery that sugar is present in the urine of diabetics. I’ll leave that to your imagination.

I can’t vouch for how well Asher’s diagnostic tips have held up over the nearly 60 years since the lecture. What is remarkable is his curiosity. The examples he notes have been taken from every kind of patient, from psychiatric to pediatric, and seem to have been gleaned from his entire medical career.

He seems to have been always on the lookout for ways which diseases present themselves to the senses, and whether or not those sensory effects are useful diagnostic tools.

One of the biggest testaments to Asher’s words is that doctors are still telling other health care providers about his work today.

Dr. Jerome Groopman picks up a lot of the themes introduced in this paper in his 2008 book How Doctors Think2, that the suppressive faculty becomes an automatic response with more and more exposure to a clinical environment. This is sometimes at the expense of serendipity and the ability to notice a common factor.

Clinical sense becomes routinized. If it didn’t, doctors, nurses, or anyone else who comes into contact with a patient couldn’t function: every time they observed a patient would be like the first time, and no one wants that. This routine or habit is a kind of shortcut for thinking. Errors in clinical perception, though, often happen when the habit or routine ceases to be a shortcut to what should be perceived, and becomes a shortcut past it. Asher notes, for example, that the clinician is both blessed and cursed with this suppressive mechanism.

The difference between it being a blessing and a curse is it being developed well, combined with a healthy dose of Asherian curiosity. The clinical routine becomes almost a well-worn narrative, awkwardly told and fumbling at first, then acted out with increasing fluency. Asher remarked that clinical acumen does not vary with acuteness of the senses, though such acuteness is an advantage.

Sir Francis Galton performed experiments with sailors to find out why they could see a distant mooring buoy when a landlubber could not do so, and showed that the weather-beaten eyes of the sailor were much less sharp sighted than those of the man from the land.

The inexperienced man from the land saw, but he did not notice; he perceived without recognizing…


The article reviewed: Asher, Richard. “Clinical Sense.” British Medical Journal 1 (1960): 985–93.

1 Asher alludes to the fact that “serendipity” is one of the few words in the English language whose etymological history we know completely: we know who invented it, when, and even what page in what book it first appeared on. Horace Walpole called “serendipity” a mental faculty possessed by a people in his 1754 fairy tale The Three Princes of Serendip. As a complete geek for language, I get excited by references like this.

2 Groopman, Jerome E. How Doctors Think. Houghton Mifflin, 2008.

Featured Image: Richard Asher, photograph provided by his family, used under a CC BY-SA 3.0 license, via Wikimedia Commons.