Chapter 3

Be sure that the physician cannot he a mere intellectual machine. None know that better than we. Through all ages we have insisted that he shall feel himself bound by a code of moral law, to which, on the whole, he has held without question, while creeds of more serious nature were shifting and changing. What the Greek fathers of medicine asked of him we still ask of him to-day. He must guard the secrets wrung from you on the rack of disease. He is more often than he likes a confessor, and while the priest hears, as I have once said, the sins and foibles of to-day, he is as like as not to have to hear the story of a life. He must be what About calls him, "Le tombeau des secrets,"--the grave of secrets. How can he be too prudent or too close-mouthed? Honor you must ask of him, for you must feel free to speak. Charity you should expect from him, for the heart is open to him as it is to no other, and knowledge, large knowledge, is the food which nourishes charity in the tender-hearted. In the tender-hearted? How can he be that? All his days he has walked amidst misery, anguish, bodily and mental suffering. Be careful when you come to test him by his ability to feel what you call sympathy. In its loftiest meaning this is the capacity to enter into, to realize, and hence to feel with and for you. There is a mystery about this matter. I know men who have never suffered gravely in mind or body, who yet have some dramatic power to enter into the griefs of others, and to comprehend, as if by intuition, just what others feel, and hence how best to say and do the things which heal or help. I know others, seemingly as tender, who, with sad experience to aid them, appear to lack the imaginative insight needed to make their education in sorrow of use to their fellows. There are times when all that men can give of sympathetic tenderness is of use. There are others when what you crave is but the outcome of morbid desires for some form of interested attention. You may ask too much, and every doctor knows how curiously this persistent claim for what you call sympathy does, as the nurses say, "take it out of a doctor." The selfishness of nervous women sometimes exceeds belief in its capacity to claim pity and constancy of expressed sympathy.

In times of more serious peril and suffering, be assured that the best sympathy is that which calmly translates itself into the desire to be of practical use, and that the extreme of capacity to feel your woes would be in a measure enfeebling to energetic utility. This it is which makes a man unfit to attend those who are dear to him, or, to emphasize the illustration, to medically treat himself. He goes to extremes, loses judgment, and does too much; fears to hurt, and does too little. I once saw a very young physician burst into tears at sight of a burnt child, a charming little girl. He was practically useless for the time. And I have known men who had to abandon their profession on account of too great sensibility to suffering.

There is a measure of true sympathy which comes of kindness and insight, which has its value, and but one. Does it help you over the hard places? Does it aid you to see clearly and to bear patiently? Does it truly nourish character, and tenderly but, firmly set you where you can gain a larger view of the uses of pain and distress? That is the truest sympathy. Does it leave you feebler with mere pity? Does it accentuate pain and grief by simply dwelling on it with barren words? I leave you to say what that is. We have a certain gentle disrespect among us for the doctor who is described as, oh! so sympathetic,--the man who goes about his work with a pocket-full of banal phrases calculated to soothe and comfort the cravings of the wretched. The sick and feeble take gladly these imitation crumbs cast from the full table of the strong. But sometimes people of firm character revolt at such petty and economical charity. I heard a vigorous old Quaker lady say once, after a consultation, "Thee will do me a kindness not to ask me to see that man again. Thee knows that I don't like my feelings poulticed."

The question of the truthfulness of physicians is one often raised. It troubles the consultant far more than it does the family doctor, and perhaps few who are not of us understand our difficulties in this direction. Every patient has his or her standard of truth, and by it is apt to try the perplexed physician. Some of the cases which arise are curiously interesting, and perhaps nowhere better than in the physician's office or at the bedside do we see sharply developed the peculiarities of character as to this matter of truth in many of its aspects. There is the patient who asks you to tell him the whole truth as to his case. Does he really want to know? Very often he does not. If you tell him, you sentence him. You do not shorten his life, you only add to its misery. Or perhaps his wife has written to you, "On no account tell my husband that he cannot get well. He dwells now on every sign of failing health, and you will make him wretched." You parry his question and try to help him. If he is resolute, he returns on you with a query so positive that you must answer frankly. His wife was right. You have done him an injury. There is the other man who insists at the start that you must on no account tell him if he cannot get well. You inform some relative of his condition. But perhaps he ought to know. He contemplates some work or travel which he should not undertake. You say so, and he replies, "But you have not told me that I am seriously ill." Such is sick human nature.

The people who really want to know if they will die of some given disease are few in number. Those who pretend they want to know are more common. Those who should not know are frequent enough, and among them one is troubled to do what seems right and to say in answer to their questions what is true.

Wise women choose their doctors and trust them. The wisest ask the fewest questions. The terrible patients are nervous women with long memories, who question much where answers are difficult, and who put together one's answers from time to time and torment themselves and the physician with the apparent inconsistencies they detect. Another form of trouble arises with the woman whose standards are of unearthly altitude. This is the woman who thinks herself deceived if she does not know what you are giving her, or who, if without telling her you substitute an innocent drug for a hurtful one which she may have learned to take too largely, thinks that you are untruthful in the use of such a method. And you would indeed be wrong if you were of opinion that to tell her the whole truth, and invite her to break the habit by her own act, were available means. I certainly do not think that you have any right (indeed, I would not even discuss this) to take active means to make her think she is taking, say opium, when you are only giving her something which tastes like it. If she asks, you must answer. But she may not, or does not, and yet when she is well again and learns that the physician preferred to act without her knowledge because he distrusted her power to help, she is very likely, if she chance to be a certain kind of woman, to say that he has been untruthful. Happily, such cases must be rare, and yet I know of some which have been the source of much annoyance to sensitive men. Thorough trust and full understanding is the way to avoid such difficulties. A nervous woman should be made to comprehend at the outset that the physician means to have his way unhampered by the subtle distinctions with which bedridden women are apt to trouble those who most desire to help them.

I omitted above an allusion to the most unpleasant inquirers, those who are either on the verge of insanity or are victims of that singular malady, hypochrondriasis. A patient clearly staggering to and fro on the border line of sanity consults you. Here is a wilful, terrified being, eager to know the truth. "Am I becoming insane? Will I end in an asylum?" How can you answer? You see clearly, are sure the worst is coming. What shall you do with this morbid, scared, obstinate child-man? You put aside his questions, but you have here a person quite or nearly sane to-day, resolute to hear, afraid to learn the truth he dreads. I leave my reader with this patient, and my stated knowledge and my shifted responsibility. "Doctor, if I am going to be insane, I will kill myself." Good reader, pray dispose of this case. Or take the ease of a confirmed hypochondriac. He is miserable, has a hundred ailments, watches the weather, studies the barometer, has queer delusions as to diets, clothes, and his own inability to walk. The least hint of a belief that he is not as well as he was a week ago, or even a too close examination, leaves him with a new malady, and he, too, is a sharp questioner. As a rule, he has no perceptible changes in his tissues. But if he has some real malady,--it may be a grave one on which he has built a larger sense of misery than there was need for, and the case is common enough,--how shall you answer him? It is a less difficult case than the other, and I gladly leave him also to my consultant reader's acquired knowledge and to his personal sense of the value of truth.

Physicians are often blamed for not sooner warning a family of the fact that, in some case he and it are anxiously watching, death is inevitable. As to this the doctor has very mingled feelings. Sometimes he lacks courage, sometimes he is not sure enough to speak. A weak man fears that he will lose his patient and some quack be called in, and thus lessen the little chance yet left. Most of us can recall painful interviews in which a relative insisted on a definite opinion, which we were unable to give. As to cases where there is little or no doubt left, perfect frankness should be, and is, I think, our rule, but no one knows better, or as well as we, how numberless are the chances of escape for cases which seem to be at their worst. Hence a part of the reluctance the physician has to pronounce a verdict of fatal character.

There is another matter of moment as to cases known to be hastening to a fatal conclusion. The responsibility of withholding this knowledge from the patient is usually shifted on to the shoulders of relatives or friends. The medical adviser reports to them his opinion and leaves with them the power to act.

He is often asked if to know that death seems certain makes less the chance of recovery or shortens the lessening number of the days of life yet left. It has often fallen to my sad lot, as to that of many of my medical brothers, to have to tell a patient that he is to die. Some isolated man asks it. Some lonely hospital patient has just reasons for knowing early or late in his disease the truth as the doctor sees it. I have never been able to feel certain that in any case of acute or hopeless illness to know surely what lay before a sick man did distinctly shorten his life. I have seen many people in apparent health made ill by the shock of emotion,--by fear, grief, anger, jealousy. Diseased persons feel less, or show less in a physical way, the results we might expect to see from even the most rudely conveyed intelligence as to their probable future.

It was not my wish to enter into a long discussion of all the qualities which go to make up the ideal physician. I desired chiefly to consider his principal needs, to point out in big defence certain of his embarrassments, and to leave the reader with some sense of help towards knowing whether his adviser was such as he should be in the more important qualities which go to make the true physician. There are other and minor matters which are not without their relative gravity in his life. Some are desirable but not truly essential, and yet help or hurt him much. Whether he is gentle and well-mannered, is socially agreeable, or as to this negative, influences much the choice of the woman on whom, as a rule, comes finally the decision of who her family physician shall be. Too often she is caught by the outside show of manners, and sets aside an abler and plainer man, who has more really the true manners of the heart, yet lacks the power to make himself pleasant. Desirable it is, of course, to be what so many of the best physicians have been, refined and tactful gentlemen, and also charming companions. But a man may be a most competent, clear-headed, honest, scrupulously careful doctor, and yet be plain, ill-dressed, and uninteresting, and all this it is as well to understand. The mass of professional opinion is not so easily pleased as are individual patients. It decides pretty early in any large community, and classifies its members accurately, reversing very often the verdict of the juries of matrons, who do so much to make or mar our early fates. Soon or late it sifts the mass, knows who are the thorough, trustworthy, competent, hard-headed practitioners, who are the timid, who the too daring, who ride hobbies, and who trust too much to drugs. Soon, too, it distinguishes those on whom it can call in emergencies, and the highest class of men who have the great gift of discovery and the genius of observation.

From the public we can look for no such justice, and our professional manners forbid us to speak of our brethren, save among ourselves, with perfect freedom. As a profession, it is my sincere conviction that in our adherence to a high code of moral law, and in the general honesty with which we do our work, no other profession can be compared with ours. Our temptations, small and large, negative and positive, are many and constant, and yet I am quite sure that no like group of men affords as few illustrations of grave moral weaknesses. It is commonplace to say that our lives are one long training in charity, self-abandonment, all forms of self-restraint. The doctor will smile at my thinking it needful to even state the fact. He begins among the poor; all his life, in or out of hospitals, he keeps touch of them always. He sells that which men can neither weigh nor measure, and this sets him over all professions, save one, and far above all forms of mere business. He is bound in honor to profit by no patent, to disclose all he has learned, and to give freely and without reward of his best care to all others of his profession who may be sick. What such a life makes of a man is largely a question of original character, but in no other form of occupation is there such constant food useful to develop all that is best and noblest.

Popular opinion has been prone to decide that the physician who is anything else than this is a person not to be trusted. The old axiom is too often quoted as concerns us, "Jack of all trades, master of none." But there are enough men who have the power to be master of many trades and passed master of one. It is a question of applicative energy. Few men in early life can do much more than is needed to learn our art and its sister sciences; but, as time goes on, there are many who can add to it other pursuits which greatly benefit them in a wide sense, and enlarge and strengthen their mental powers, or pleasantly contribute to the joys of life, and so even to the growth of a man's moral nature. The wise physician, who is fond of etching or botany, the brush, or the chisel or the pen, or who is given to science, does well to keep these things a little in the background until he is securely seated in the saddle of professional success. Then usually he may feel free to reasonably follow out his tastes, and to write, or in any other way insist on freedom to use or make public his results. If only he has the competent fund of persistent industry to draw upon, he will be not the worse, but the better, physician for such enlargement of his pursuits as I refer to, for we may feel sure that in my profession there is room for the direct or indirect use of every possible accomplishment.

CONVALESCENCE.

To my mind, there is nothing more pleasant than the gradual return to health after some revolutionary disease which has removed a goodly portion of the material out of which is formed our bodily frame. Nature does this happy work deftly in most cases, where, at least, no grave organic mischief has been left by the malady; and in the process we get such pleasantness as comes always from the easy exercise of healthy function. The change from good to better day by day is in itself delightful, and if you have been so happy, when well, as to have loved and served many, now is the good time when bun and biscuit come back to you,--shapely loaves of tenderness and gracious service. Flowers and books, and folks good and cheery to talk to, arrive day after day, and have for you a new zest which they had not in fuller health. Old tastes return and mild delights become luxuries, as if the new tissues in nerve and brain were not sated, like those of the older body in which they are taking their places.

When you are acutely ill, the doctor is business-like and gravely kind; you want him in a way, are even anxious to see him for the relief he may bring, or the reassurance. But when you begin to feel as if you were a creature reborn, when you are safe and keenly enjoying the return of health, then it is that the morning visit is so delightful. You look for his coming and count on the daily chat. Should he chance to be what many of my medical brothers are,--educated, accomplished, with wide artistic and mental sympathies,--he brings a strong, breezy freshness of the outer world with him into the monastic life of the sick-room. One does not escape from being a patient because of being also a physician, and for my part I am glad to confess my sense of enjoyment in such visits, and how I have longed to keep my doctor at my side and to decoy him into a protracted stay. The convalescence he observes is for him, too, a pleasant thing. He has and should have pride in some distinct rescue, or in the fact that he has been able to stand by, with little interference, and see the disease run its normal course. I once watched a famous surgeon just after he had done a life-saving operation by dim candle-light. He stood smiling as the child's breath came back, and kept nodding his head with pleasant sense of his own competence. He was most like a Newfoundland dog I once had the luck to see pull out a small child from the water and on to a raft. When we came up, the dog was wagging his tail and standing beside the child with sense of self-approval in every hair. The man wagged his head; the dog wagged his tail. Each liked well what he had done.

Thus it is that these half-hours by the convalescent's couch are full of subtle flattery for the doctor, and are apt to evolve the social best of him, as he notes the daily gain in strength and color, and listens, a tranquil despot, to one's pleas for this freedom or that indulgence. He turns over your books, suggests others, and, trained by a thousand such interviews, is likely enough a man interesting on many sides.

You selfishly enjoy his visit, not suspecting that you, too, are ignorantly helpful. He has been in sadder homes to-day, has been sorely tried, has had to tell grim truths, is tired, mind and body. The visit he makes you is for him a pleasant oasis: not all convalescents are agreeable. He goes away refreshed.

Most doctors have their share, and more, of illness, and are not, as I have seen stated, exempt from falling a prey to contagious maladies. Indeed, our records sadly show that this is not the case. Perhaps there is value for them and their future patients in the fact that they have been in turn patient and doctor and have served in both camps. Like other sick folks, the physician, as I know, looks forward, when ill, to the "morning visits" quite as anxiously as do any of those who have at times awaited his own coming.

That medical poet who has the joyous art of sending a ripple of mirth across the faces of the Anglo-Saxon world recognizes this fact in a cheerful poem, called "The Morning Visit," and to which I gladly refer any of my readers who would like to know from the lips of Oliver Wendell Holmes what manner of delightful patient he must have been. I can fancy that he lost for his doctor many a pleasant hour.

It has seemed to me as if this wonderful remaking and regrowing of the tissues might be likened to a swift change from the weak childhood of disease to a sudden manhood of mind and body, in which is something of mysterious development elsewhere unmatched in life. Death has been minutely busy with your tissues, and millions of dead molecules are being restored in such better condition that not only are you become new in the best sense,--renewed, as we say,--but have gotten power to grow again, and, after your terrible typhoid or yellow fever, may win a half-inch or so in the next six months,--a doubtful advantage for some of us, but a curious and sure sign of great integral change.

The Greeks had a notion that once in seven years we are totally changed, the man of seven years back having in this time undergone an entire reconstruction. We know now that life is a constant death and a renewing,--that our every-day nutrition involves millions of molecular deaths and as many millions of births,--although to liken that which is so exquisitely managed, so undisturbingly done, to the coarser phenomena of death and birth is in a measure misleading.

Diseases such as typhoid fever, or a sharp local lung-trouble like pneumonia, really do make these minute changes approximate in abruptness to death. You weigh, let us say, one hundred and eighty pounds, and you drop in three weeks of a fever to one hundred and thirty pounds. The rest of you is dead. You have lost, as men say, fifty pounds, but your debt to disease, or to the blunders of civilization, for it is a case of creditor behind creditor, is paid. Your capital is much diminished, but you have come out of the trial with an amazing renovation of energy. This is the happy convalescence of the wholesome man. The other, the unlucky, fellow, does not get as safely through the cleansing bankruptcy of disease. The vicious, unlucky, or gouty grandfather appears on the books of that court in mysterious ways; his sins are pathologically visited on his child's child in this time of testing strain.

In the happy rush towards useful health, of a convalescence undisturbed by drawbacks, it is pleasant to think, as one lies mending, of the good day to come when my friend, recovering from typhoid or smallpox, shall send for his legal adviser and desire him as usual to bring suit against the city for damages and loss of time.

A little girl coughed in my face a hideous breath of membraneous decay. I felt at once a conviction of having been hit. Two days later I was down with her malady. She herself and two more of her family owed their disease to the overflow of a neighbor's cesspool, and to them--poor, careless folk--Death dealt out a yet sterner retribution. There was a semi-civilized community beyond both. Should one go to law about it and test the matter of ultimate responsibility?

The amiability of convalescence is against it. One feels at peace with all the world, and so lies still, and reflects, "like souls that balance joy and pain," as to whether, on the whole, the matter has not had its valuable side. Certainly it has brought experiences not otherwise attainable.