Physician and patient

by Worthington Hooker

FOOTNOTES:

[40] Annual Report of the McLean Asylum, 1843.

[41] A Discourse on the Influence of Diseases on the Intellectual and Moral Powers, by Joseph M. Smith, M. D., Professor of the Theory and Practice of Physic, and Clinical Medicine.

[42] The following very interesting account of this experiment is taken from an article on the treatment of lunatics, in the London Quarterly.

It was during the reign of terror, and while all France labored under a new form of insanity, that the idea was first conceived of setting loose madmen from their bonds. The good and wise physician, Pinel, seems to have been struck with the injustice of keeping the patients chained in the dungeons of Bicetre, while so many hundreds of his countrymen, more mischievously distracted than many of them, were at large to work the bloody frolics of the revolutionary frenzy. There were at that time upwards of 300 maniacs chained in the loathsome cells of the horrible Bedlam of France. Pinel formed the resolution of setting them free from their strict restraint, and he entreated permission of the Commune to that effect. Struck with the novelty of the enterprise, at that time a sufficient recommendation before any assembly in France, the Commune listened to the proposal, and deputed one of their body, the notorious Couthon, to accompany the physician to the spot, and judge of the propriety of carrying his undertaking into effect. They were received by a confused noise—the yells and vociferations of some hundreds of madmen, mixed with the sounds of their clanking chains, echoing through the damp and dreary vaults of the prison. Couthon turned away with horror, but he permitted Pinel to pursue his enterprise. The philanthropist resolved speedily to liberate fifty of the number by way of experiment, and began by unchaining twelve of the most violent. The account of his proceeding has been recorded by his nephew, Sclyion Pinel, in a lively narrative, which was read before the Academy of Sciences. The first man set at liberty was an English captain. He had been forty years in chains, and his history was forgotten by himself and all the world. His keepers approached him with dread; he had killed one of their comrades by a blow with his manacles. Pinel entered his cell unattended, and accosted him in a kind and confiding manner, and told him that it was designed to give him the liberty of walking abroad, on condition that he would put on a waistcoat that might confine his arms. The madman appeared to disbelieve; but he obeyed. His chains were removed, and the door of the cell was left open. Many times he raised himself and fell back; his limbs gave way; they had been ironed forty years. At length he was able to stand and to stalk to the door of his dark cell, and to gaze, with exclamations of wonder and delight, at the beautiful sky. He spent the day in the enjoyment of his newly-acquired privilege; he was no more in bonds; and during the two years of his farther detention at Bicetre, assisted in managing the house. The next man liberated was a soldier, a private in the French guards, who had been ten years in chains, and was an object of general fear. His case had been one of acute mania, occasioned by intemperance—a disorder which often subsides in a short time under abstinence from intoxicating drinks unless kept up, as in this case, by improper treatment. When set at liberty, this man willingly assisted Pinel in breaking the chains of his fellow prisoners; he became immediately calm, and even kind and attentive, and was ever afterwards the devoted friend of his deliverer. In an adjoining cell there were three Prussian soldiers, who had been many years in chains and darkness; through grief and despair they had sunk into a state of stupor and fatuity, the frequent result of similar treatment; they refused to be removed. Near to them was an old priest, harmless and patient, who fancied himself to be the Savior of the world. When taunted by the keepers, who used to tell him that, if he was Christ, he could break the heavy chains that loaded his hands, he replied with solemn dignity, Frustra tentaris Dominum tuum. After his release he got rid of his illusion, and recovered the soundness of his mind. Within a few days Pinel liberated fifty-three maniacs from their imprisonment. The result was beyond his hopes. Tranquility and harmony succeeded to tumult and disorder, and even the most ferocious madmen became more tractable. This took place in 1792; and the example of Pinel was followed in various parts of France.

CHAPTER XVI.
INFLUENCE OF HOPE IN THE TREATMENT OF DISEASE.

I remember well that Dr. Jackson of Boston used to remark to the students, that the medical profession is, from the nature of its duties, a cheerful profession. The physician has so much to do with suffering, disease, and death, that this assertion would at first view seem to be erroneous. But when it is considered that in the great majority of cases he is able to effect a cure, that in those which terminate in death he can generally give relief to suffering from time to time, and thus at least smooth the passage to the tomb, and that the number of sick whose diseases he can neither palliate nor cure is exceedingly small, we can see why it is that the physician is ordinarily so cheerful a man in his daily intercourse. The impressions of most persons on this subject are wrong, and for very obvious reasons. Out of their own immediate circle of relations and friends, they hear only of the severe cases of disease, and often only of those in which death is the result, and know but little, perhaps nothing, of the multitude of cases, here and there in every part of the community, which end in recovery.

Sometimes, it is true, sad cases occur which cast a gloom over the path of the physician; but then the gloom is soon dissipated by the successful issue of other cases which he had reason to fear would have a fatal termination. Sometimes, too, unfortunate cases come in clusters, and the physician is for the time obliged to see so much of suffering and death, and the sorrows of bereavement, that in his sadness he is ready to regret that he ever adopted such a profession. But this happens only occasionally. It is a mere coincidence, and it is but momentary. Events soon take their ordinary current, and he has his usual amount of success, and resumes his wonted air of cheerfulness and hope.

The results of the skilful and judicious practice of medicine are such then as to make hope, and not despondency, to characterize the prevailing cast of the physician’s mind. And so it should be. For hope stimulates to action—steady, clear-minded action—while despondency is prone to inaction, and leads to no efforts except those which are hurried, fitful and confused. I do not mean that the physician should in any case blind himself to the dangers which it presents, and let a vain hope lull him into security. This error should be as carefully avoided as the opposite one, committed by those who see difficulty and danger in almost every case, magnifying every bad symptom, and imagining some which have no existence. The hope of the physician should be an intelligent hope. It should be based upon just and definite conclusions. It should be discriminating, and should be varied in its degree according to the character of each individual case.

Every medicine that is given should be administered by the hand of hope. The prospect, at least of relief, and generally of recovery, should be held up to the mind of the patient. Remedies should be given to effect some definite object, and the physician should hope to a greater or less degree that they will do so. Hope may thus be indulged in relation to the different stages of a case, without regard to the final event of it, which may be so distant and so clouded in doubt that no calculations can be made in regard to it. And the physician may direct the attention of the patient to these same points, and thus give variety to the hope which he excites in his mind. This in many cases is much better than to come to him every day with the simple expression of the hope that he will at length recover. In the tedium of his confinement, if it be a long one, he soon tires of looking far ahead to the bright fields of convalescence, but finds relief in the little spots lighted up of hope by the way—the oases thus made in the desert of sickness.

Even in those cases in which the physician feels it to be almost certain that the final issue will be a fatal one, it is not proper to give up wholly the idea of recovery, in his conversations with the patient or with his friends. This remark must not be understood to apply to those cases in which the evidence of approaching death is not to be mistaken, and so far as human wisdom can see it is absolutely certain that the patient will die. At the same time it is to be remembered that there are occasionally recoveries when death was confidently expected, and we must avoid being too ready to decide that there is no ground of hope, especially in cases of an acute disease.

I will relate a case in point. A physician was called in great haste to a patient upon whom he had been attending with deep anxiety. He found the family and the friends assembled around the bed of the patient weeping over him as a dying man. The physician himself thought from his appearance that he was really dying. Still he did not know that he was, and as he might possibly be in a condition from which he could be revived, he prepared a cordial at once, and with the look of hope and uttering the words of hope, he administered it. The patient not only revived but recovered. In his convalescence he told the physician that as he lay there dimly seeing with his glazed eyes the sad countenances of his friends, and feeling the oppressive languor of death, as he supposed, upon him, and panting for some cordial and for the pure air of heaven, and yet unable to speak or even to raise the hand, no words could express the relief which he at once felt, spreading a genial glow over his benumbed body, when he heard his cheerful voice speak of hope, and it seemed to him that this had more influence in reviving him than the cordial which he administered.

Strong as this case is, similar cases are in the recollection of every physician who has been in practice for any considerable length of time. And they cannot be distinguished from some other cases in which attempts to revive the sinking powers fail, and the patient dies. Now it will not be claimed that the physician does wrong in uttering the language of hope in the case of those who recover; and he certainly should not be reproached for uttering the same language in the case of those who appear just as likely to recover, but for some reason hidden from human wisdom do not. Just as he would administer the cordial to all of them, so also should he apply to all of them the cordial influence of hope. The same rule is applicable to both the mental and the physical remedy.

It is often said that if the physician, on the whole, taking into view all the circumstances of the case, thinks that a patient is going to die, he ought frankly to tell him so. The considerations which I have presented are, I trust, sufficient to convince the reader that this is by no means true. Shall the physician, I ask, add to all the depressing agencies which are bearing down the patient the appalling idea of death, and thus lessen, perhaps destroy, the possibility of his recovery? Shall he, in the struggle between life and death, give his influence in any way on the side of death? When the powers of life are sinking, and the life-giving fluid circulates but feebly in the extremities of the system, and is accumulating in the larger blood vessels and in the heart itself, threatening every moment to stop its faint throbbings, shall he, while he administers the cordial, defeat its effect, by holding up to the eye of his patient the grim visage of death, to oppress the vital forces and curdle the blood in its channels? Shall he not rather pour into the mind the cheering influence of hope, and thus aid the cordial in reviving the expiring energies of the system, and in stimulating the heart and the whole circulation into a freer action?

Let me be fully understood on this point. Far be it from me to justify the wide departure from truth, of which some are guilty at such times. Giving utterly false assurances to the patient is a very different thing from merely exciting the hope in his mind to such a degree as the case may allow, that the remedies will produce the desired relief. The latter can be consistently done by the upright and high-minded practitioner, but the former is to be expected only in the ignorant pretender, and the dishonorable and unprincipled physician. The quack always gives assurances of a cure to those whom he undertakes to dupe; for, besides being incompetent to estimate the degree of danger in any case, he is unable to inspire confidence in his measures except by a strong appeal to the hopes of the patient. And some physicians imitate the quack in this particular. They are in the habit of exciting unwarrantably the hopes of the sick for their own selfish ends. By so doing they occasionally retain under their care patients who would otherwise pass into the hands of some one else; and they also get possession of some cases, in relation to which their more honest and honorable brethren have not found themselves warranted in giving any positive encouragement. But, though occasional advantage may result from this course to the physician, and sometimes even to the sick themselves, yet on the whole the honest course is truly the politic one.

It is important, as I shall show more particularly in the next chapter, that the physician maintain his character for veracity and candor in his intercourse with his patients; else, when he can consistently utter the language of hope, it may prove no cordial, because his lips have so often uttered that language so falsely. There are cases in which death may seem to the patient and to his friends to be staring him in the face, and yet the physician may see a sure and speedy relief coming to all the alarming symptoms. Now when he gives an assurance to this effect, in order to quell the anxieties and fears of the sick man and his friends, if he has been known to be in the habit of giving similar assurances without any ground for them, he cannot expect to be believed.

The views and feelings of patients, in regard to the expectation of a recovery, are often misunderstood by their friends. They are sometimes supposed to be wholly blind to their danger, when they are really fully aware of it. They perhaps speak occasionally of what they will do if they get well, and allude to the expected effect of remedies, as if they supposed that they would overcome the disease, and dwell, in their conversation with their friends and with the physician, upon the favorable symptoms that may appear. All this may, and often does, occur in cases in which death is almost certain to be the result; and yet it is entirely consistent with the existence in the mind of the patient of a rational view of his danger. I remember well a respected friend, who talked of hope and relief now and then almost to the last; and yet, from day to day, he was making such preparations, even to the framing of his will, as showed that, on the whole, he believed this to be his last sickness.

We are not to confound these occasional expressions of hope, these fitful and momentary states of mind, with the settled conviction of the understanding often existing behind all this. The promptings of the natural desire for life are ordinarily not utterly destroyed by the sure prospect of death. There will be moments when this instinctive love of life, and of whatever in life has ministered to the happiness of the sufferer, will turn off his thoughts from the contemplation of death, and call up by association a thousand objects of endearment.

“For who, to dumb forgetfulness a prey,

This pleasing, anxious being e’er resigned,

Left the warm precincts of the cheerful day,

Nor cast one longing, ling’ring look behind?”

It is well that the hope of recovery should occasionally light up in cases which are certain to end fatally, especially when the patient is the subject of protracted chronic disease. It breaks in upon that painful monotony of mind, which is otherwise apt to exist. It is not commonly well for any one, in any point of view, to have the certain expectation of death fastened in the mind week after week and month after month, even if he have all the while a clear view with the eye of faith of a glorious immortality beyond. This one unvaried state of thought and feeling, though commonly spoken of as exceedingly to be desired, is ordinarily neither so profitable nor so happy, as that condition of mind, in which the expectation of death is not so constantly present, but occasionally gives way to thoughts and emotions of quite a different character. The keeping the mind strained up to a certain state, and fixed upon one set of thoughts, is never either in sickness or in health profitable to the individual himself, or to others. And aside from this consideration, though the calm and fixed contemplation of approaching death has something noble in it, and challenges our admiration, still the triumph over death may be as signal, when there is occasionally an indulgence of the natural desire of life, and a shrinking back from the encounter with the king of terrors. The destruction of this love of life, and the utter extinction of the hope of a recovery, are by no means essential to perfect resignation. Indeed the highest degree of resignation may exist when the desire to live is so strong as to prompt the sufferer to catch with eagerness at the slightest grounds of hope even to the last. Incidental circumstances have much to do with the manner in which death is met. A cool temperament, the long continued cultivation of a stoical indifference in the midst of change and calamity, a morbid misanthropy, an habitual disposition to fatalism, the breaking up one after another of all the attachments to this world, the benumbing influence of disease or of medicine, long familiarity with suffering, and the consequent capability of enduring it, which is sometimes truly wonderful—some of these various circumstances may conspire to render submission to the necessity of the case easy, and give to the death-hour a calmness that is often erroneously supposed to arise from a true Christian resignation. The calmness thus induced is often an incidental adjunct to resignation, and is sometimes auxiliary to it, imparting to it firmness and steadiness in its manifestations. But it is in no wise essential to it, nor one of its elements.

In chronic cases, which are going on gradually to a fatal termination, there sometimes occurs either a temporary pause in the onward course of the disease, or an alleviation of the symptoms of so decided a character, that the patient and the physician cannot avoid indulging for the moment the hope of a recovery. At such times the bosom of the physician is the seat of conflicting hopes and fears. He hardly dares to hope, when he calmly surveys the whole case from the beginning. And yet he has known, he has himself seen some strange recoveries, perhaps even more strange than such a result would be in the case before him. What now is his duty to his patient? Shall he tell him the worst, as it is expressed, and thus extinguish his rising hopes? Shall he say to him, “This very probably is only a truce for a little while, and then your now dormant disease will renew its attack, and perhaps with more vehemence; and, even at this time, it may be secretly carrying on the work of destruction, while the remedies are merely administering to your comfort, and smoothing your passage to the tomb?” To say nothing of the evil of such a course, if the case be susceptible of a cure, it cannot be an advisable one, if the prolongation of life and the alleviation of suffering be objects worthy of the aim of the physician; for such a course would in most cases have a strong tendency to defeat the attainment of these objects. If the friends of the patient deem it important that such a view of his case should be presented to his mind, let them take the responsibility of doing it themselves, and not call upon the physician to do it. Ask not him to come to his patient with the look and language of despair, and utterly dissever the idea of hope from the efforts which he makes and the remedies which he administers. Put no such unnatural, and cheerless, and, I may add, profitless office upon him.

I remember once being strongly urged to such a course by the friends of a patient. Whilst apparently going steadily down to the grave, his symptoms at length became much relieved, and he took some encouragement from the state of his case. In reply to the inquiry of his friends, whether I had any hope of his recovery, I frankly said that I had not, and that from all I could see I supposed that the relief which he experienced was to last but a short time, and that he must die very soon. They urged me to tell him so, but I declined, for the reasons that I have stated above. The condition of comfort and relief lasted in this case, contrary to my expectation, for several weeks; and they were weeks of delightful intercourse, of affectionate counsel, and of triumphant faith and joy. And I have not a doubt that his life was thus happily prolonged in part by the cordial influence of the hope, that the remedies which relieved his distress might effect a cure.

It seems to be the idea of some, that there is something very salutary in a spiritual point of view in the knowledge of the fact, that death is certain and near. That it is more alarming and awakens more emotion than the mere idea of danger, I allow; but that it is more apt to produce right views and feelings is by no means satisfactorily proved. Even if it be true, that the certainty of death is more likely to secure decisive action in regard to the interests of eternity, a decision under such circumstances is by no means so worthy of confidence as one which is arrived at when the hope of recovery is not wholly extinguished. To test this, take as an example the feeling of resignation. When death is seen to be absolutely certain, its very certainty is apt to induce a sort of calm semi-fatalism, which has the appearance of true submission, and is often mistaken for it through the charity and fondness of friendship. But when the result is seen to be uncertain, if there be amid all the balancing of the mind between hope and fear a willingness to acquiesce in the supreme will, there is good reason to believe that the patient has a true Christian resignation. There was much force in the remark of a patient, who had for some days had the certain expectation of death, but who had at length experienced so much relief, that there was some ground for hope. “I am glad,” said she, “that this relief has occurred, even if I do not recover; for now I can fairly test the reality of my submission. I can put life and death together, and examine my wishes and desires in regard to them.”

There is one disease in which the disposition to hope is so marked, that Dr. Good enumerates it among its symptoms. I refer to consumption. In some cases, it is true, this symptom does not appear, but despondency for the most part prevails. But this arises either from a morbid sensitiveness of the nervous system, or from a diseased condition of the digestive organs. When neither of these circumstances exists, and the disease is uncomplicated with other maladies, the tendency to hope is so strong as often to resist the force of the most decisive evidence. Nothing is more common than to hear a consumptive patient say, “Doctor, if you will only cure this cough, I shall be well,” as if the cough were only a slight matter, and its continuance was rather provoking than dangerous. I once saw a physician deceiving himself to the last week of his life with the idea, that his disease was in the stomach and liver, when there was the most palpable evidence that the lungs, and the lungs only, were diseased.

This tendency to hope is beautifully alluded to in a poetical sketch of consumption by an anonymous author:

“Then came Consumption with her languid moods,

Her soothing whispers, and her dreams that seek

To muse themselves in silent solitudes:

She came with hectic glow, and wasted cheek,

And still the maiden pined more wan and weak,

Pale like the second bow: yet would she speak

The words of Hope, even while she passed away,

Amid the closing clouds, and faded ray by ray.”

Shall this hope, delusive as it so commonly is, be demolished by the physician? Clearly it, in most cases at least, should not be. For in very many cases it manifestly prolongs life, and adds to its comfort and its usefulness, and in some cases it proves not to be as delusive as perhaps even the physician is disposed to consider it. Recovery does now and then occur in cases of true consumption, and even in some which are quite advanced. The changes observed by means of the stethoscope in the progress of some cases which have ended in recovery, and the examinations of the lungs of those who have died of some other malady, show conclusively that tubercular consumption is not necessarily a fatal disease. Every physician who has seen much of this disease has occasionally witnessed facts confirmatory of this statement.[43]

In concluding this chapter I remark, that the obvious rule in regard to the use to be made of hope as a curative agent is this—that its cordial influence should always be employed, so far as it can be done consistently with truth, and no farther. And the bare fact that a case has ended fatally, when the physician has encouraged in the patient the hope of a recovery, should by no means, as is often done, be considered as proof that he has dealt falsely. He may have encouraged the patient in good faith. For the physician, however wise and skilful he may be, is not able to foresee with any certainty the final event of sickness so frequently as is commonly supposed, and in all doubtful cases he is bound to give the patient the benefit of all the hope of which the symptoms will admit.