Part 8

5. There are various kinds of medical treatment to which we can scarcely have recourse without exposing ourselves to serious evil consequences. Such is the use of cocaine, morphine, and even in special cases of alcohol. The drugs in themselves are useful, but they often lead to evil results. Now in the use of all such drugs as are apt to be beneficial in one way and injurious in another, we must ever be guided by the rules formerly explained concerning evil indirectly willed, or rather permitted to result, while good results are directly willed or intended. If the Doctor is satisfied that a dose of morphine or an application of cocaine will do more good than harm, he can, of course, prescribe or apply it. Still in such matters he must remember that the good effect is but temporary, while its pernicious consequences, especially when habits are thus contracted, are likely to be permanent and cumulative. Besides, the good results affect the body only, the evil often affect body and soul. Many a wreck in health and morals has been caused by imprudent recourse to dangerous treatment, where a little more patience and wisdom would have been equally efficient in curing the bodily ailment, without any deleterious consequences. If once a patient becomes a slave to the morphine or cocaine habit, the only cure is to cut off all the supply of the drug either at once or, at any rate, by daily diminution. To leave him free control of the poison is to co-operate in his self-destruction.

6. The sixth duty of a Doctor is of a different kind. There exists a tacit or implicit contract between him and his patients that he shall keep their secrets of which he becomes possessed in his professional capacity. It is always wrong wantonly to betray the secrets of others; but the Doctor is bound by a special duty to keep his professional secrets; and it is doubly wrong and disgraceful in him to make them known. For instance, if he has treated a case of sickness brought on by sinful excesses of any kind, he is forbidden by the natural law to talk about it to such as have no special right to know the facts. Parents and guardians are usually entitled to be informed of their children's and their wards' wrong-doings, that they may take proper measures to prevent further evil. Besides, the Doctor is properly in their service; he is paid by them, and, therefore, his contract is with them rather than with the children. He can, therefore, prudently inform them of what is wrong, but he cannot inform others.

It is a debated question in Medical Jurisprudence whether the Doctor's professional knowledge of criminal acts should be privileged before the courts, so that he should not be forced to testify to a crime that he has learned from his patients while acting as their medical adviser. Dr. Ewell speaks thus on the subject (p. 2): "The medical witness should remember that, by the common law, a medical man has no privilege to avoid giving in evidence any statement made to him by a patient; but when called upon to do so in a court of justice, he is bound to disclose every communication, however private and confidential, which has been made to him by a patient while attending him in a professional capacity. By statute, however, in some of the United States, communications made by a patient to a physician when necessary to the treatment of a case are privileged; and the physician is either expressly forbidden or not obliged to reveal them. Such statutes exist in Arkansas, California, Indiana, Iowa, Ohio, Michigan, Minnesota, Missouri, Montana, New York, and Wisconsin. The seal upon the physician's lips is not even taken away by the patient's death. Such communications, however, must be of a lawful character and not against morality or public policy; hence, a consultation as to the means of procuring an abortion on another is not privileged, nor would be any similar conference held for the purpose of devising a crime or evading its consequences.

"A report of a medical official of an insurance company on the health of a party proposing to insure his life is not privileged from production; nor is the report of a surgeon of a railroad company as to the injuries sustained by a passenger in an accident, unless such report has been obtained with a view to impending litigation."

The practical rule for a Doctor's conscience on the subject of secrecy is, that he must keep his professional secrets with great fidelity, and not reveal them except in as far as he is compelled to do so by a court of justice acting within its legal power or competency. If so compelled, he can safely speak out; for his duty to his patient is understood to be dependent on his obedience to lawful authority.

As to the question of Jurisprudence whether the courts _ought_ to treat the physician's official secrets as privileged, in the same way as they do a lawyer's secrets, this will depend on the further question whether the same reasons militate for the one as for the other. The lawyer's privilege is due to the anxiety of the state not to condemn an innocent man nor a guilty man beyond his deserts. To avert such evil, the accused party needs the assistance of a legal adviser who can guide him safely through the mazes and technicalities of the law, and, even should he be guilty, who can protect him against exaggerated charges and ward off unmerited degrees of punishment. Now, this can scarcely be accomplished unless the attorney for the defence learn from his client the entire truth of the facts. But the client could not safely give such information to his lawyer if the latter's professional secrets were not held sacred by the court of justice.

Can the same reasons or equivalent ones be urged in behalf of the physician? I do not see that they can. And I notice besides that, if he be excused from testifying against his patients, all their servants and attendants would seem to be entitled to the same privilege. Many persons, I think, labor here under a confusion of ideas; a Doctor is as sacredly bound to keep his patients' secrets as a lawyer is in regard to his clients, but it does not follow that the law cannot grant a privilege to the one and refuse the same to the other, for reasons which require it in the case of the lawyer and not in that of the Doctor.

III. Besides the rights and duties which arise for the physician from his contracts with the state and with his patients, there are other claims on his conscience, which proceed from his character as a man, a Christian, and a gentleman.

1. _As a man_, he is a member of the human family, not a stranger dwelling amid an alien race, but a brother among brothers. He cannot say, as did the first murderer, Cain, "Am I my brother's keeper?" But rather he must carry out the behest of the great Father of the human family: "God has given to each one care of his neighbor."

The maxim of Freemasons is that every member of that secret society must come to the assistance of every brother-mason in distress. But the law of nature and of nature's God is wider and nobler; it requires every man to assist every fellow-man in grievous need. The rich glutton at whose door lay Lazarus dying of want was bound, not by any human but by the higher law, to assist him; and it was for ignoring this duty that the soul was buried in hell, as the gentlest of teachers expresses it.

(_a_) As physicians, as men, you will have duties to the poor, who cannot pay you for your services; they are your fellow-men. Their bill will be paid in due time. He is their security who has said: "Whatsoever you have done to the least of these, you have done it unto Me." He may pay you in temporal blessings, or in still higher favors, if you do it for His sake; but pay He will, and that most liberally: "I will repay," says the Lord. The rule of charity for physicians is that they should willingly render to the poor for the love of God those professional services which they are wont to render to the rich for pecuniary compensation. While thus treating a poor patient they should be as careful and diligent as they would be for temporal reward; what is done for God should not be done in a slovenly fashion.

(_b_) In this connection of regard for the poor, allow me also to call your attention, gentlemen, to a point which students of medicine are apt to forget at times, and yet which both God and the world require you ever to bear in mind: it is the respect which every man owes to the mortal remains of a departed brother. I do not know that a people has ever been found, even among barbarians, who did not honor the bodies of their dead. For the good of humanity, dead bodies may at times be subjected to the dissecting-knife, but never to wanton indignities. Reason tells you to do by others as you wish to be done by, and Revelation adds its teaching about a future resurrection and glorification of that body of which the Apostle says that "it is sown in dishonor, but it shall rise in glory." Be men of science, but be not human ghouls. There is such a thing as retribution. But lately a former millionaire died in a poorhouse and left his body as a cadaver for medical students. We cannot afford to ignore the mysterious ways of Divine Justice. Ever handle human remains in a humane manner; and as soon as they have answered the purpose of science, see that they be decently interred, if possible.

2. There are other duties that you owe not as men but _as Christians_. All of us enjoy the blessings of Christian civilization, even those who are not Christians themselves. We are dealt with by others on Christian principles, and we ought to treat others in the same spirit. What duties does this impose?

(_a_) When your patients are in real danger of death, let them have a good chance to prepare properly for their all-important passage into eternity. Give them fair warning of their situation. Doctors and relations are often afraid of alarming the patients and thus injuring their health. But those who attend Catholic patients at least soon find out by experience that the graces and consolations of the Last Sacraments usually bring a peace of mind that benefits even the bodily health. In any case, the interests of the future life are too important to be ignored.

(_b_) For the same reason, the physician should not prescribe such doses of morphine or other anæsthetics as will render the patient unconscious at a time when he ought to be preparing to meet his Judge. This would be not kindness but cruelty. A little suffering more in this life may save much suffering in the next. If a Catholic priest, on being called to a patient's bedside, finds that the family's physician has been so inconsiderate, he cannot help protesting against employing such a man in Catholic families.

(_c_) If you attend a woman in childbirth, you may be asked by a Christian mother not to let her child die without Baptism. The vast majority of Christians believe that this sacrament is necessary to obtain supernatural happiness. The ceremony is easily performed: no harm can come of it, but immeasurable good for eternity. It should properly be performed by the clergy. But if this cannot be done, any man, woman, or child, even one not a Christian himself, can administer the sacrament. Every Doctor in a Christian land should understand how to do it, and do it with unerring accuracy. It were a disgrace for him to be ignorant of what even an ordinary child is expected to know. The ceremony is so simple; and yet, being an institution of Christ, no man can modify it to suit his notions; if what is done is not just what Christ appointed to be done, it will be of no avail. Notice, therefore, carefully every detail. You will take a little water, say a cupful, real water--cold or lukewarm, that matters not--you will slowly pour it on the head of the child, and, _while you do so_, you will say, "I baptize thee in the name of the Father, and of the Son, and of the Holy Ghost." That is all. Notice, you must say the words while the water is being poured on the child. For "I baptize" means "I wash"; pour, therefore, or wash while you say, "I wash." Should you hereafter wish to refresh your memories on this matter, you can do so by consulting the "Century Dictionary," which explains Baptism, and in particular Catholic Baptism, as "consisting essentially in the application of water to the person baptized by one having the intention of conferring the sacrament, and who pronounces at the same time the words, 'I baptize thee in the name of the Father, and of the Son, and of the Holy Ghost.'" If a cup of water given to the thirsty brings a blessing, how much more the giving of the water of salvation! Should it happen that the child is in danger of dying before delivery, it should be baptized in the womb provided it be at all possible to cause the water to reach or wash its body, projected upon it by any instrument whatever; but the water should flow over the body, not merely over the cyst enclosing it, for the cyst is no part of the child. Even if but an arm or other minor portion of the body is washed, the baptism is probably valid. If any doubt about the valid administration is left, the infant after delivery should be carefully baptized _under condition_, as it is called; that is, with the condition added that, if the former ceremony was validly conferred, there is no intention of giving a second baptism. For that would not be right; since the sacrament cannot be validly received more than once; it is a sacred initiation, but it were mockery to initiate one that is already initiated.

Should a physician be present when a pregnant woman has recently expired, and the child may still be living in the womb, it will be an easy and important task to perform the Cesarean section as soon as possible, and baptize the little one before it dies. In all this there is no money, but what is far more precious, the securing of eternal happiness. I add with great pleasure that many physicians are wont to comply with all these instructions most carefully, and even to instruct midwives and nurses in the best manner of rendering such services.

3. Lastly, we must consider the duties which a Doctor owes to others and to himself _as a gentleman_. It may not be easy to define what is meant by "a gentleman," and yet to some extent we all know it; we recognize a gentleman when we meet one, we pay him sincere homage in our hearts. We readily allow him to influence us and to guide us. We esteem him instinctively as a superior being, as we distinguish a precious stone from a common pebble; so we value a gentleman for precious qualities exhibited in the beauty of his conduct. His conduct ever exhibits two characteristic marks: a proper degree of dignity or respect for self, and a proper degree of politeness or respect for others. Self-respect will not allow him to do anything which is considered vulgar, unmannerly, gross, rude, or selfish; he will avoid the two extremes, of self-neglect on the one hand and self-display on the other. His respect for others will make him treat all around him so as to make them feel comfortable in his presence; he will avoid whatever gives pain or causes embarrassment to even the lowest member of society.

Gentlemanliness has much to do with every one's success in life, and in particular with a Doctor's success. It is especially when sick that we are sensitive to everything displeasing in the conduct of others. It is not then the bold thinker or the extensive reader that is the acceptable visitor to the sick-room; but the gentlemanly consoler who always says the right thing at the right time, whose very eye expresses and whose countenance reflects the thought and sentiment most appropriate on the occasion.

There are most able physicians who are not gentlemen, and there are in the medical profession gentlemen who are rather poor physicians; but as a rule, I believe, the gentleman will thrive where the genius will starve. It is more or less the same in other professions. I know learned lawyers to-day who are far from prosperous, while men ten times their inferiors in learning are getting rich. I remember a most skilful physician, now no more on earth, who was a very genius in the science of medicine; but he was so filthy in his habits, he would so unceremoniously chew tobacco at all times, that many dreaded his visits, and would sooner have a man of less ability but gentler manners as their family physician.

Gentlemen, habits good and bad cannot be put on and off like a dress-coat; they are lasting qualities, the growth of years, the result of constant practice and self-denial or self-neglect. And, as I wish you success in life, allow me to conclude this lecture by recommending to you the assiduous cultivation of gentlemanly habits. Cultivate them now, while you are preparing for future labors. You wrong yourselves, and you insult your companions and your professors, when you neglect in their presence the conventionalities of polite society.

Uniting the external decorum of a gentleman with a thorough knowledge of your profession, and with what is still more important, the virtues of a conscientious man and a sincere Christian; ever true to the sound principles of morality which I have endeavored to explain and to inculcate in these lectures: you will be an honor to yourselves, an ornament to your noble profession, the glory and joy of your Alma Mater, a blessing to the community in which Providence will cast your lot as the dispensers of health and happiness and length of days to your fellow-men.

LECTURE VII.

THE NATURE OF INSANITY.

The subject of the present lecture, gentlemen, is "Insanity."

I. This subject belongs to a course of Medical Jurisprudence, because a physician who treats patients for insanity is liable, from time to time, to be cited before a court of law either as a witness or as an expert. His conduct in such cases is to be guided by the principles of natural and legal justice.

Various important cases at law turn upon the question of a person's soundness of mind; and frequently the medical expert has it in his power to furnish the court with more reliable information in this matter than any one else. At one time, the validity of a last will may be contested, and the possession of a fortune by one party or another may hinge on the question whether the testator at the time of making his will was in sufficient possession of his mental powers to perform an act of so much consequence.

At another time, interested parties may plead for or against the validity of a sale or other bargain made by a person of doubtful competency of mind; or a life-insurance company may be interested in ascertaining the mental condition of an applicant for membership; or it may be questioned whether the payment of an insurance policy is due to the family of a suicide, the doubt depending for solution on the sound or unsound condition of his mind at the moment of the fatal act. Again, there may be a real or pretended doubt whether a certain property-owner is so far demented as to be unfit to manage his estate; or whether he needs a guardian to take care of his person; or it may even seem necessary to confine him in a lunatic asylum. There may be objections raised to the mental soundness of a witness in a civil or a criminal suit; or, finally, a criminal prosecution will depend mainly on the sanity or insanity of the culprit at the moment when the crime was committed; as was the case with a Prendergast and a Guiteau.

You see, then, gentlemen, that important interests are dependent on the thorough and correct understanding of this matter; and therefore much responsibility rests upon the experts consulted in such cases: property, honor, liberty, nay, even life itself may be at stake.

That cases involving an insane condition of mind must be of frequent occurrence, both in the medical and in the legal professions, is apparent from the large and rapidly increasing amount of lunacy in our modern civilization. Wharton and Stillé's "Medical Jurisprudence" states (sec. 770, note) that in 1850 there was in Great Britain one lunatic to about one thousand persons; only thirty years later the Lunacy Commission of Great Britain reported one lunatic to 357 persons in England and Wales, that is, nearly three times as many. In New York there is one to 384 persons. It appears certain that its increase of late is out of all proportion to the increase of population; and even though I see reasons to distrust somewhat the figures quoted for England, enough is known to create serious alarm regarding the fruits of modern manners and customs on the minds of thousands. This fact makes the matter of insanity very important for the medical and the legal student.

II. Still it must be noted that the responsibility of deciding cases of lunacy does not rest chiefly with the medical expert. In cases of doubtful insanity the decision is to be given not by the Doctor but by the court of justice. Except on very special occasions, as when a physician is appointed on a committee or commission of inquiry, he appears before a court either as an ordinary witness, stating what facts have fallen under his personal observation; or as an expert, explaining the received opinion of medical men with regard to cases of a certain class. Even though he feels convinced that the culprit or the patient is as mad as a March hare, the physician cannot expect that his statement to that effect will be received as decisive. It is for the judge to instruct the jury what kind or degree of insanity will excuse a culprit from legal punishment, or will disqualify a person from testifying as a witness, or from being a party to a civil contract in certain cases; and it is for the jury to decide whether, in the case in hand, the fact of such insanity exists or not. In criminal cases, the jury pronounces on the double question, whether the accused did the act charged to him, and whether he has been juridically proved to have been accountable for the act under the laws as expounded by the judge.

1. To come to a decision on this double question, the jury might need to hear the facts stated which the physician has personally observed, and of which he is summoned to be a sworn witness. In such a situation all that is required of the Doctor is that he shall give a most faithful and intelligent account of the facts.

It would disgrace his standing in society if any fault could be found with his testimony; and, as a sworn witness, he is bound in conscience, like any other witness, to state the truth, the whole truth, and nothing but the truth. This is always the case when the purpose of the inquiry is the discovery of the sane or insane condition of a person's mind. But if the inquiry concerns the performance of the guilty act, the commission of the crime, many States of the Union, as explained before, consider the Doctor's professional secrets as privileged, just like those of the lawyer and the clergyman; i.e., the Doctor must not use against his patient any knowledge he has become possessed of while acting as his medical adviser.

2. When the physician appears before a court or commission as an expert, he is expected to give the views of the medical profession upon hypothetical cases resembling the one under examination, and the scientific reasons and authorities on which those views are advanced.