Physician and patient

by Worthington Hooker

FOOTNOTES:

[43] The mortality of consumption has been undoubtedly increased by the very prevalent, but erroneous, opinion, that when this disease has only fairly begun it is never arrested, but sooner or later ends in death. The definite opinions, too, sometimes given to the patient as to the supposed hopelessness of the case, founded upon the revelations of the stethoscope to the exclusion of other evidence, have produced the same effect.

CHAPTER XVII.
TRUTH IN OUR INTERCOURSE WITH THE SICK.

On the question, whether strict veracity should be adhered to, in every case and under all circumstances, in our intercourse with the sick, there is very great difference of opinion, as well among medical men, as in the community at large. Some are most scrupulously strict in their regard to truth; others, while they are generally so, make some few occasional exceptions in cases of great emergency and necessity; while others still (and I regret to say that they are very numerous) give themselves great latitude in their practice, if they do not in their avowed opinions.

In examining this subject, it is not so much my intention to discuss the abstract question, as to present the many practical considerations that present themselves, illustrating them, so far as is necessary, by facts and cases.

In order to introduce the subject, I will here quote a passage from Percival’s Medical Ethics, which presents the views of those who are in favor of an occasional departure from truth, where the necessity of the case seems to demand it.

“Every practitioner must find himself occasionally in circumstances of very delicate embarrassment, with respect to the contending obligations of veracity and professional duty; and when such trials occur, it will behoove him to act on fixed principles of rectitude, derived from previous information and serious reflection. Perhaps the following brief considerations, by which I have conscientiously endeavored to govern my own conduct, may afford some aid to his decision. Moral truth, in a professional view, has two references; one to the party to whom it is delivered, and another to the individual by whom it is uttered. In the first it is a relative duty, constituting a branch of justice, and may properly be regulated by the divine rule of equity prescribed by our Saviour, to do unto others as we would, all circumstances duly weighed, they should do unto us. In the second it is a relative duty, regarding solely the sincerity, the purity and the probity of the physician himself. To a patient, therefore, perhaps the father of a numerous family, or one whose life is of the highest importance to the community, who makes inquiries, which, if faithfully answered, might prove fatal to him, it would be a gross and unfeeling wrong to reveal the truth. His right to it is suspended, and even annihilated; because its beneficial nature being reversed, it would be deeply injurious to himself, to his family, and to the public. And he has the strongest claim, from the trust reposed in his physician, as well as from the common principle of humanity, to be guarded against whatever would be detrimental to him. In such a situation, therefore, the only point at issue is, whether the practitioner shall sacrifice that delicate sense of veracity, which is so ornamental to, and indeed forms a characteristic excellence of the virtuous man, to this claim of professional justice and social duty. Under such a painful conflict of obligations, a wise and good man must be governed by those which are the most imperious, and will, therefore, generously relinquish any consideration referable only to himself. Let him be careful, however, not to do this but in cases of real emergency, which, happily, seldom occur, and to guard his mind sedulously against the injury it may sustain by such violations of the native love of truth. I shall conclude this long note with the two following very interesting biographical facts. The husband of the celebrated Arria, Cæcinna Pactus, was very dangerously ill. Her son was also sick at the same time, and died. He was a youth of uncommon accomplishments, and fondly beloved by his parents. Arria prepared and conducted his funeral, in such a manner, that her husband remained entirely ignorant of the mournful event which occasioned that solemnity. Pactus often inquired with anxiety about his son, to whom she cheerfully replied, that he had slept well, and was better. But if her tears, too long restrained, were bursting forth, she instantly retired, to give vent to her grief, and when again composed, returned to Pactus with dry eyes and a placid countenance, quitting, as it were, all the tender feelings of the mother at the threshold of her husband’s chamber. Lady Russell’s only son, Wriothesley, Duke of Bedford, died of the small-pox, in May, 1711, in the 31st year of his age. To this affliction succeeded, in November, 1711, the loss of her daughter, the Duchess of Rutland. Lady Russell, after seeing her in the coffin, went to her other daughter, married to the Duke of Devonshire, from whom it was necessary to conceal her grief, she being at that time in childbed likewise; therefore she assumed a cheerful air, and, with astonishing resolution, agreeable to truth, answered her anxious daughter’s inquiries with these words, ‘I have seen your sister out of bed to-day.’”

The falsehood in the two cases related by the author is of the most egregious character, and yet they are fair representations of that kind of deception which many feel authorized to use in the sick room. The equivocation which is practised, it is true, is not always as gross and as labored, but it is as real. And whatever be the degree or kind of deception, the same principles will apply to every case.

The question that presents itself is not, let it be understood, whether the truth shall in any case be withheld, but whether, in doing this, real falsehood is justifiable, in any form, whether direct or indirect, whether palpable or in the shape of equivocation.

And we may also remark, that the question is not, whether those who practice deception upon the sick are guilty of a criminal act. This depends altogether on the motive which prompts it, and it is certainly often done from the best and kindest motives. The question is stripped of all considerations of this nature, and comes before us as a simple practical question—whether there are any cases in which, for the sake of benefitting our fellow men, perhaps even to the saving of life, it is proper to make an exception to the great general law of truth.

The considerations which will bring us to a clear and undoubted decision of this question, are not all to be drawn from the preciousness of the principle of truth, as an unbroken, invariable, and ever-present principle, the soul of all order, and confidence, and happiness, in the wide universe. But the principle of expediency also furnishes us with some considerations that are valuable in confirming our decision, if not in leading us to it. In truth, expediency and right always correspond, and would be seen to do so, if we could always see the end from the beginning.

I will remark upon each of the considerations as I present them.

First. It is erroneously assumed by those who advocate deception, that the knowledge to be concealed from the patient would, if communicated, be essentially injurious to him. Puffendorf remarks in relation to this point, that “when a man is desirous, and it is his duty, to do a piece of service, he is not bound to take measures that will certainly render his attempts unsuccessful.” The certainty of the result, thus taken for granted, is far from being warranted by facts. Even in some cases where there was a strong probability (and this is all we can have in any case) that the effect would be hurtful, it has been found not to be so. I might here narrate some cases to prove the truth of this assertion, but it is not necessary. Suffice it to say, that it is confirmed by the experience of every physician who has pursued a frank and candid course in his intercourse with the sick.

Secondly. It is also erroneously assumed that concealment can always or generally be effectually carried out. There are so many ways by which the truth can be betrayed, even where concerted plans are laid, guarded at every point, that failure is much more common than success, so far as my observation has extended. Some unguarded expression or act, even on the part of those who are practising the concealment, or some information communicated by those who are not in the secret, perhaps by children, or some evidence casually seen, very often either reveals the truth, or awakens suspicion and prompts inquiry which the most skilful equivocation may not be able to elude. The very air that is assumed in carrying on the deception often defeats the object. In one instance where this was the case, the suspecting patient said very significantly, ‘How strangely you all seem—you act as if something dreadful had happened that you mean to keep from me.’ Even the little child often exhibits a most correct discrimination in detecting deception in the manner, the modes of expression, and even the very tone of the voice. And sometimes, nay very often, people so far undervalue the good sense and shrewdness of children, that their deception is even ridiculously bungling, and justly excites an honest indignation in the bosom of the deceived child.

I give the following scene as an illustration of the above remark.

‘Come, take this,’ said a mother to her child, ‘it’s something good.’

The child was evidently a little suspicious that he was not dealt with candidly; but after a great many assurances from her on whom a child ought to be able to rely, if upon any body in the wide world, he was at length persuaded to take the spoon into his mouth. The medicine, which was really very bitter, was at once spit out, and the little fellow burst forth in reproaches upon his mother for telling him such a lie.

‘No, my dear,’ said she, ‘I have told you no lie. The medicine is good—it is good to cure you. That is what I meant.’

‘Good to cure me!’ cried he, with a look and an air of the most perfect contempt. ‘You cheated me. You know you did.’

The contempt which this child manifested towards such barefaced equivocation was most justly merited, and yet this is a fair example of the deceptions which physicians are almost every day obliged to witness, and which, (may I not say?) some of them encourage both by precept and example.

Thirdly. If the deception be discovered or suspected, the effect upon the patient is much worse than a frank and full statement of the truth can produce. If disagreeable news, for example, be concealed from him, there is very great danger that it will in some way be revealed to him so abruptly and unexpectedly, as to give him a severe shock, which can for the most part be avoided when the communication is made voluntarily. And then, too, the very fact that the truth has been withheld, increases, for obvious reasons, this shock. I will relate a case as an example. It occurred during the prevalence of an epidemic. A lady was taken sick and died. The fact of her death was studiously concealed from another lady of her acquaintance, who was liable to be attacked by the same disease. She was supposed by her to be doing well, until one day a child from a neighboring family accidentally alluded to the death of her friend in her presence. The shock which the sad news thus communicated produced upon her was almost overwhelming, and it was of course rendered more intense by the reflection, that her friends thought her to be exceedingly in danger of dying of the prevailing disease, and therefore had practised this concealment in order to quiet her apprehensions. She soon followed her friend, and it is not an improbable supposition, that the strong impression thus made upon her mind had some agency in causing her death.

In another case of a similar character, the first intimation which a lady had of the death of a friend was from seeing the husband of this friend pass in the street with a badge of mourning. She was immediately prostrated upon her bed, and was a long time in recovering from the shock.

In both of these cases the concealment of the truth was prompted by the best of motives—pure kindness; and yet nothing is more plain than that it was a mistaken kindness. Whatever may be true in other instances, the result showed this to be the fact in these two cases. And if it be true, as I think all experience will prove, that success, and not failure, in the attempt at concealment, is the exception to the general fact, it clearly follows that deception is impolitic as a measure of kindness, and therefore, aside from any other consideration, it should be wholly discarded in our intercourse with the sick.

I have a case in mind, which exhibits in contrast the influence of frankness and of deception.

A little girl, the daughter of a farmer, had her arm torn to pieces up to the elbow in a threshing machine constructed very much like a picker. As her mother was confined to her bed with severe sickness, the child was carried into the house of a neighbor. When I arrived, I was told that her mother was in great distress, and fears were expressed that the accident would have a very bad influence upon her case. I asked if she knew what had happened. ‘No,’ said her husband, ‘not exactly. She found out by the children that Mary was hurt, and then sent for me, and asked me what was the matter. I told her at first that she had got her finger hurt. She said she knew that was not all, and I at length, after she had begged and begged me to tell all, told her that her hand was hurt badly. And now she is crying most piteously, and says that we are deceiving her, and that she knows that Mary is almost killed.’

I immediately went in to see the mother, and found her indeed almost distracted with the great variety of dread visions that had suggested themselves to her fancy in regard to her darling child. As I entered the room she cried out, ‘Oh, she’s dead, doctor, or dying—torn to pieces—in agony—Oh, isn’t it so? tell me, tell me the truth!’ ‘Be quiet,’ said I, ‘and I will tell you all the truth. I will not deceive you.’ I assured her that she need give herself no anxiety about the life of her child—that was safe. This announcement quieted her in a good measure, and I went on to tell her that the arm was badly torn, and that I must amputate it above the elbow. I told her that this would take but a minute or two, and then the child would be essentially well. It was necessary to go into these particulars in answer to her inquiries, (which were the more minute from the fact that she had been deceived,) or else I should forfeit her confidence, and thus commit the same error that had already been committed. She thanked me for being so frank with her, and said, that though it was hard to think of the operation, she could bear that, if the child’s life was only spared. She grieved still, it is true; but there was none of that overwhelming distraction that results from vague apprehension.

Fourthly. The destruction of confidence, resulting from discovered deception, is productive of injurious consequences to the persons deceived. The moment that you are detected in deceiving the sick, you at once impair or even destroy their confidence in your veracity and frankness. Everything that you do afterward is suspected, and a full and unshrinking trust is not accorded to you even when you deserve it, though you may try to obtain it by the most positive and solemn assurances. If, for example, you wish to encourage a patient, and you tell him that though the bow of hope is dim to his eye, it is bright to your own: ‘Ah!’ he will think, if he does not say, ‘how do I know but that it is as dim to him as it looks to me—he has deceived me once, and perhaps he does now.’

Every physician has seen the injurious influence of deception upon children. Sometimes it is of a most disastrous character, and occasionally, I have not a doubt, it proves fatal. Deception is more frequently practiced upon children than upon adults, and many seem to think that they have not the same right to candor and honesty in our intercourse with them. But a child can appreciate fair and honest treatment as well as an adult can, and he has as good a right to receive it at our hands. He sometimes claims this right in terms, and by acts not to be mistaken. And when it is taken from him, he shows his sense of the wrong by remonstrances and retaliatory language, and by a system of rebellion to an authority which he despises, as well as fears, for its falsehood.

Suppose a mother succeeds in giving a dose of medicine by stratagem, the administration of every dose after it is accompanied with a fearful struggle. The strife which results from the spirit of resistance thus engendered, perhaps in the beginning of a long sickness, and which might in most cases have been avoided by frank and candid treatment, continues through the whole course of the disease to the last hour of life if the case prove fatal, the little creature feebly but obstinately resisting its mother, till the exhaustion of coming death puts an end to its struggles; and, though she plies every art that fondness can devise to win back the lost confidence of her darling child, it is all in vain.

If the reader have any adequate idea of the importance of quietness in the management of the sick, I need not spend time to prove, that this resistance of the sick child has an injurious effect upon the disease, and that in those cases where life has but a feeble trembling hold, where the silver cord is worn down almost to its last thread, such a struggle may break that thread by its violence. I have not a doubt that many a child has died under such circumstances, that might otherwise have recovered.

Let me not be understood to imply that the resistance made by children to the administration of medicine is invariably the result of deception practised upon them, though this is the cause undoubtedly in quite a large proportion of the cases, and those too of the worst and most unconquerable character. And it may be remarked, that in many cases this may be the cause of the difficulty where it is little suspected. For it is so common a habit to deceive children in this matter, that it is often done unconsciously. But though the parent may not remember it, the child does, and the cruel oppressive act (for so it may be properly called) locked up in the memory of the child, wakes up rebellion in his heart that is not easily quelled. Many a parent has thus in a moment, for the sake of a slight temporary advantage, sown the wind to reap the whirlwind.

Deception has very often been made use of in the management of the insane, though recently not to the same extent that it once was. The consideration which I have been illustrating and enforcing lies against the practice of it in our intercourse with this unfortunate class of patients, with the greater force, because in their case the mind is diseased, and any bad mental influence has therefore a worse effect than it would have upon a case of mere bodily disease. The reason is obvious—it acts directly upon the seat of the disease in the former case, but indirectly in the latter.

Besides, let the insane man once see that you have deceived him, and you lose the principal, perhaps we may say the only, moral means that you have for curing his malady. Confidence is essential to any good moral influence that you may exert upon him. I might cite many facts to prove this, but will advert to only one. The wife of an insane man was the only person among all his friends that had any control over him, and she could manage him with perfect ease. After his recovery she asked him the reason of this fact, and his reply was, ‘You was the only one that uniformly told me the truth?

The bad influence of deception upon the insane man is rendered the more certain and effectual from the fact that his insanity incapacitates him for appreciating the kind motives which may have prompted the deception. You cannot convince him as you can the sane sick man, that you have deceived him for his own good. His suspicious eye sees nothing but a sinister purpose in the cheat which you have practised upon him.

One of the most vivid recollections of my childhood is that of a scene which illustrates these remarks. A poor crazy man who wandered about the streets was thought to have become dangerous, and it was proposed to confine him in the common jail. A plan was laid to do it by stratagem. He fancied himself to own some large possessions, and talked much about going to Boston to see his friend the governor, and attend to his business there. A neighbor offered to go with him, and he accepted the offer. As they passed by the jail, his friend proposed to visit it. As they entered one of the cells he adroitly slipped out, and the door was closed upon the insane man. His dream of earthly happiness and wealth was in a moment at an end, and he beheld himself the victim of base treachery in the narrow cell of a prison. Never shall I forget how eloquently he pleaded for his release, how he asked what crime could be charged to his account, how he denounced those who had thus without cause shut him up like a felon, and especially with what sorrowful but burning indignation he spoke of the man, ‘who under the guise of friendship, had decoyed him into this snare of his enemies.’ Though a mere boy, I pitied him. I sympathised with him. I had known him only as a pleasant old man, who used to amuse us as we met him in the streets with stories of his immense wealth and of the splendid plans of building on which he loved to speculate. I felt that it was wrong to confine him among vile criminals, and wondered not that the keen sense of such injury prompted to the utterance of curses on those who inflicted it. But these natural feelings gave way in my bosom, as they did in older ones, to what was then supposed to be the necessity of the case—a necessity which, I rejoice to say, has since that been found not to exist in similar cases. A very great improvement has been effected in this as well as in other respects, in the management of the insane. Most of those whom it was once thought necessary to confine with bolts and bars, and perhaps chains, and upon whom deception was continually and systematically practised, thus adding poignancy to the pangs of the oppressed spirit, are now permitted to have so much liberty, that they are cheerful and happy, reposing entire confidence in their attendants, who are careful never to deceive them. And those whom it is thought necessary to confine, are not doomed to the cheerlessness and disgrace of the cell of the felon, but they are placed in as agreeable circumstances as is consistent with safety. And it has come to be an established rule with those who have the care of the insane, that force is always preferable to deception. But still, erroneous views are very prevalent in the community on this subject. It is common to this day, even among the excellent and well informed, to propose to send their insane friends to a Retreat by stratagem, and this has often been done even by the advice of physicians. So far as I recollect, in all the cases of insanity that have gone to Retreats from under my care, this mode of management has been spoken of by some, and generally by many, as the only proper mode. The public need to be instructed and reformed on this point.

It is a common observation that the insane are apt to look upon their best and most intimate friends as their enemies. Why is this? It is clear, that it is in part to be ascribed to the influence of deception, waking up, as might be expected, feelings of resentment and enmity in the bosom of the insane, which would not otherwise be there. This point I have commented upon in the Chapter on Insanity, and I need not dwell upon it here.

The extent to which deception is practised upon the insane cannot be fully appreciated, except by those whose attention has been specially called to this subject. As I have already remarked in regard to children, so also it is with the insane—deception is so common, that people often make use of it almost unconsciously. The whole course of management on the part of their friends, is often characterized throughout by an absence of candor and veracity.

The tendency of such a course is invariably to increase insanity, making it more intense and obstinate. And not only so, but it modifies to a greater or less degree its character. Deception prompts the insane man to exercise his ingenuity in forming plans to foil and circumvent his deceivers, whom he supposes very naturally to be his enemies. Of course, new feelings and thoughts are thus excited in his bosom, giving in some measure a new cast to his insanity.

I will here relate a case that illustrates these remarks.

The friends of an insane gentleman determined to send him to a Retreat by stratagem. For this purpose, he was induced by one of them to go a journey with him. On, their way, his friend proposed to him to visit an Insane Retreat as a matter of curiosity. When they arrived there, he was given to understand that he was to remain as an inmate. Great was his rage at being so grossly deceived. After the first burst of indignation was passed, he saw that it was of no use to say anything or to make any resistance. He was a shrewd man, and therefore, as a matter of policy, he submitted with apparent cheerfulness to his new situation. He did not forget, as the insane sometimes fortunately do, the wrong which his friends had done him, and as he was decoyed there by stratagem, it is no wonder that he at length made his escape by stratagem also. He came out, as might have been expected, with his insanity more thoroughly fixed than it was when he went in, and he added to it a deep hatred of Retreats, and of course of the man who had betrayed him into one.

Another attempt was made to carry him to the same Retreat, which from mismanagement utterly failed. The insane man was victorious, and he felt himself to be so, over his friends, who he supposed were bent upon cheating and oppressing him. All this not only made him more crazy, but it gave a new shape to his insane ideas. In a conversation which I chanced to have with him, he said to me, ‘It is perfectly evident, doctor, that these Insane Retreats are joint-stock institutions, and the stockholders are chiefly lawyers and doctors and ministers. And it’s good stock too. Just see how much they charge for board—full double at least of the actual expenses. I need not tell you anything about it, however, for you own some of this stock, and you know how profitable it is to you.’

‘Oh no,’ said I, ‘this is all new to me.’ He looked at me as if he would look me through. He had been deceived so much, that he believed, he trusted no one. Although I gave him the most positive assurance that I owned no such stock, still, in spite of the confidence which he ordinarily reposed in me, he showed that he did after all suspect me on this point, so firmly was this notion about Retreats fastened in his mind. He went on to give his reasons for his opinion.

‘I can look back,’ said he, ‘to my very childhood, and see that from that time to the present, there has been a series of efforts on the part of these stockholders to make me a crazy man; and they at length succeeded, and then contrived the mean plan of tricking me into one of their Retreats. The minister that I lived with when I was ten years old began this scheme, and all the ministers and lawyers and doctors, that I have had anything to do with since that time, have had a hand in it—have exerted their influence on me, all in relation to this one object. It’s a regular money-making business. Of course the stockholders all want to see these Retreats well filled up. Just see how they have treated me lately. They have combined to cross my purposes, break up my plans, defeat my projects, ruin my business, and all this to irritate and disappoint me, and thus craze me. And then, to cap the whole, they lied to me and betrayed me into their prison to die a slow death, paying them all the time about twelve dollars a week. Good stock, doctor, but a cruel business,’ said he, with a most unearthly grin, and a shudder that shook his whole frame. ‘But thank heaven,’ cried he, ‘I’ve escaped their clutches. Though they have ruined me, they shall not have their twelve dollars a week out of me. No, I’ll die first. Such systematic, cheating, lying oppression, I’ll resist to the death.’

It is evident that the treatment which this man received at the hands of his friends, tended to aggravate, instead of lessening his insanity. And I may remark, too, that the notion which he derived from this treatment, in relation to Retreats, false as it was, was founded on more plausible reasons as they were presented to his mind, than are some of the opinions that are adopted by some sane men in the community.

Fifthly. The general effect of deception, aside from the individual which it is supposed it will benefit, is injurious. The considerations on which I have already remarked, have had regard entirely to the person that is deceived, and I think that I have shown most clearly, that even taking this narrow view of the influence of deception, it is in almost all cases a bad influence: and therefore as we cannot tell in what cases this influence will be good, it is impolitic, and should be entirely discarded. Let us now go farther, and looking beyond the individuals who are the subjects of the deception, we shall see its influence extending all around from these individuals, as so many radiating points of influence, leavening the whole mass of society with a most poisonous leaven. It is not an influence that can be shut up in the case of any individual, in that one breast, or within that one chamber of sickness.

That confidence, which should always exist in the intercourse of the sick with their physicians and friends, and which may be made the channel of great and essential benefits to them, is materially impaired, often even destroyed by such deception. And this effect is unfortunately not confined to those who practice it, but the imputation rests upon others. The distrust thus produced often exerts a depressing influence in those cases, where the cordial influence of hope is most urgently needed, and where it can be administered in consonance with the most scrupulous veracity. It is well if, under such circumstances, the physician can appeal to the patient’s own experience of his frankness in all his previous intercourse with him.

I call to mind an instance in which I was able to make this appeal with the most marked good effect. The patient was a lady who was in a great state of alarm in regard to the probable result of her sickness. She was indeed very sick, but there was good reason to hope that remedies would relieve her. At the same time I feared that the depressing effect of this state of alarm, if it should continue, would prove a serious obstacle to her recovery. But as I expressed to her the confident hope that she would get well, she said to me, ‘Physicians always talk in this way, and you do not really mean as you say. I shall die, I know that I shall die.’ I had been the physician of the family for many years, during which time they had gone through some trying scenes of sickness. Alluding to all this, I asked her if she could look back and call to mind a single instance in which I had not dealt candidly and frankly with her. She allowed that she could not. ‘Well,’ said I, ‘believe me now; I am in earnest; I do believe, and confidently, too, that you will recover.’ The tears were at once wiped away. Cheerfulness, the cheerfulness of hope, lighted up her countenance and the case went on to a speedy and full recovery.

Every day we see evidence of the fact that so large a proportion of the medical profession practice deception upon the sick, that the profession, as a whole, has to a greater or less degree the imputation fastened upon it. Indeed patients often, as a matter of course, make the distinction between the obligations to professional veracity, and those of the man, as a man, in his ordinary intercourse; and the physician, who has an established reputation for the strictest veracity everywhere else but in the sick chamber, has there the suspicion of deception put upon him; and it is supposed to be no imputation of which he should complain, because deception is allowed here almost by general permission. For this reason, whatever of frankness and honesty there may be in our intercourse with the sick, often fails to produce the effect intended, in part at least if not wholly. And this result follows just in proportion to the extent to which deception is made use of in the profession.

The indirect and collateral effects of deception are often manifest in a family of children. Its influence extends beyond the mind and character of the deceived child. If the other children witness the deception, what hinders them from believing that their parents can deceive them also whenever it suits their convenience? And if they do not witness it, the sick child will remember it when he recovers, and the rebellion which he has, in consequence, in his bosom towards an authority that rules by deceit, and is therefore deemed with good reason oppressive, is of course communicated to the other bosoms of the little flock. Many a parent, who supposed that he was doing nothing that would last beyond the present moment, has thus sown the seeds of rebellion among the little band of subjects, over whom God has placed him; and who can tell what the fruits will be, or to what extent or length of time they will grow!

I need barely say in concluding my remarks on this consideration, that the momentary good which occasionally results to individual cases from deception, is not to be put in comparison, for one moment, with the vast and permanent evils of a general character, that almost uniformly proceed from a breach of the great law of truth. And there is no warrant to be found for shutting our eyes to these general and remote results, in our earnestness to secure a particular and present good, however precious that good may be—a plain principle, and yet how often it is disregarded.

Sixthly. If it be adopted by the community as a common rule, that the truth may be sacrificed in urgent cases, the very object of the deception will be defeated. For why is it that deception succeeds in any case? It is because the patient supposes that all who have intercourse with him deal with him truthfully—that no such common rule has been adopted. There is even now, while the policy on this subject is unsettled and matter of dispute, enough distrust produced to occasion trouble. And if it should become a settled policy under an acknowledged common rule, the result would be general distrust, of course defeating deception at every point. And yet if it be proper to deceive, then most clearly is it proper to proclaim it as an adopted principle of action. Else we are driven to the absurd proposition, that while it is right to practice deception, it is wrong to say to the world that it is right.

It is in vain to say that the evil result which would attend this adoption of occasional deception, as the settled policy of the medical profession, would find a correction in the very terms of the rule which should be adopted, viz. that the case must be an urgent one to warrant deception, and there must be a fair prospect that it can be carried through without discovery. For every patient, that was aware of the adoption of such a rule, might and often probably would suspect that his own case is considered as coming within the terms of the rule.

Seventhly. Once open the door for deception, and you can prescribe for it no definite limits. Every one is to be left to judge for himself. And as present good is the object for which the truth is to be sacrificed, the amount of good, for which it is proper to do it, can not be fixed upon with any exactness. Each one is left to make his own estimate, and the limit is in each one’s private judgment, in each one’s individual case as it arises. And the limit, which is at first perhaps quite narrow, is apt to grow wider, till the deception may get to be of the very worst and most injurious character. I will give a single illustration of this remark, which though not taken from the practice of medicine, is appropriate to my purpose. It has always been allowed in the laws of war, to deceive the enemy by stratagems, false lights, &c. At one time some English ships in two or three instances decoyed the enemy by counterfeiting signals of distress. The deception in this case is productive indirectly of the very worst consequences, for it manifestly tends to prevent relief from being afforded to those, who are actually in a distressed condition. Our feelings of humanity instinctively condemn such a stratagem and yet it is only a mere extension of that deception, which has been by common consent allowed in war. It involves no different principles, and is only more objectionable, because it produces worse indirect results. It differs in degree only and not in kind.

So it is with deception always. Its indirect effects are always bad to some extent, and to what extent they will prove so we know not in each individual case. You can never know at the time how great is the sacrifice which you are making for a present good. While you may be thinking that you are only sacrificing your own veracity, and that the influence of the act will not extend beyond the passing moment, you may be producing disastrous results upon the interests of others, and those results may be both lasting and accumulative. A man who was captured by some Indians, was asked by them if there were any white men in the neighborhood. He told them that there were, and directed them to a spot where he was very certain that there were none. They immediately started in pursuit, leaving him bound and in the charge of one of their number. When they were gone, he contrived to make his escape. Almost every one would say, that this was a strong case, and that they could not blame him for telling a falsehood to Indians, in order to escape from their cruelty. Here was a great good to be obtained, the saving himself from torture, perhaps from death, and deceiving savages for such a purpose, it will be said, is not to be condemned. But mark the result of that deception. Five white men were found on the spot to which he directed them, and were captured.

In order to make out a justification of deception, on the ground of expediency in any case, all the possible results, direct and indirect, must be taken into the account. But this is impossible except to omniscience itself. Even in those cases which appear the most clear to us, there may be consequences of the most grave character utterly hidden from our view. In the instance just related, the captive was very certain, from some circumstances, that he directed his captors to a spot where there were no white men.

The uncertainty of our knowledge of the circumstances of each case prevents then our defining any limits, within which deception shall be bounded. We can make no accurate distinctions, which will enable us to say, that it can be beneficially employed in one case, while in another it will be inexpedient.

I have now finished the examination of the various considerations which have been suggested to my mind in relation to this subject. And I think that they settle the question as to the expediency of deception beyond all doubt. I think it perfectly evident, that the good, which may be done by deception in a few cases, is almost as nothing, compared with the evil which it does in many cases, when the prospect of its doing good was just as promising as it was in those in which it succeeded. And when we add to this the evil which would result from a general adoption of a system of deception, the importance of a strict adherence to truth in our intercourse with the sick, even on the ground of expediency, becomes incalculably great.

In the passage, which I quoted in the beginning of this article from Percival’s Medical Ethics, the writer makes, I conceive, a false issue on the question under consideration. He assumes that the injury, which results from a sacrifice of the truth for the good of the sick, comes upon him who practices the deception, and that in doing it, “he generously relinquishes every consideration referable only to himself.” But the considerations that I have presented show, that the injury is very far from being thus confined. Often the very person intended to be benefited is injured, perhaps deeply, in some cases even fatally. And then the indirect effects can not be estimated.

There are many illustrations, used by those who advocate deception, which are plausible but fallacious. I will cite a single example. Dr. Hutcheson of Glasgow, as quoted by Dr. Percival, in remarking on the maxim, that we must not do evil that good may come, says, “Must one do nothing for a good purpose, which would have been evil without this reference? It is evil to hazard life without a view of some good; but when it is necessary for a public interest, it is very lovely and honorable. It is criminal to expose a good man to danger for nothing; but it is just even to force him into the greatest dangers for his country. It is criminal to occasion any pain to innocent persons, without a view to some good; but for restoring of health we reward chirurgeons for scarifyings, burnings, and amputations.”

I would remark on this that the infliction of pain is not in itself a moral act, but the purpose for which it is done gives it all the moral character that it has. Aside from this, it affects no moral principle, as the infliction of an injury upon truth certainly does, independent of the object for which it is done. The infliction of pain then for a good purpose can not be said to be doing evil that good may come—it is doing good.

The sacrifice of life which the writer speaks of, is the sacrifice of a less good for a greater one simply, and not the sacrifice of any principle. But when the truth is sacrificed for what is deemed to be a greater good, it is in fact the sacrifice of a greater good, for not only a less, but an uncertain good—a sacrifice of the eternal principle, which binds together the moral universe in harmony, for a mere temporary good, which after all may prove to be a shadow instead of a reality.

I can not leave this subject without making some explanations of a few points, in order to guard against some erroneous inferences to which the sentiments that I have advanced might otherwise be liable.

I wish not to be understood as saying that we should never take pains to withhold knowledge from the sick, which we fear might be injurious to them. There are cases in which this should be done. All that I claim is this—that in withholding the truth no deception should be practised, and that if sacrifice of the truth be the necessary price for obtaining the object, no such sacrifice should be made. In the passage which I have quoted from Dr. Percival, he states a case in which he very properly says, that the patient’s right to the truth is suspended; but I do not agree with him, that in withholding the truth we have the right to put absolute falsehood in its place.

It is always a question of expediency simply, whether the truth ought to be withheld. And it is a question that depends, for its proper decision, upon a variety of considerations in each individual case. It is very often decided injudiciously. There is generally too great a readiness to adopt an affirmative decision. It is too easily taken for granted, that the knowledge in question will do harm to the patient if it be communicated to him. The obvious rule on this subject is this—that the truth should not be withheld unless there be a reasonable prospect of effectually preventing a discovery of it, and that too by fair and honest means.

It has often been said that the physician has no right to excite too much hope in the mind of a patient by directing his attention, as is often done, to any favorable symptoms that may appear in his case. But I ask, how is it known that in the case in relation to which this remark is made, too much hope is excited? The physician is fallible, and is by no means answerable for putting just the right degree of hope into the patient’s bosom. It is not to be expected of him that he shall always tell each patient just how his case stands. His own mind is often filled with conflicting hopes and fears, and he cannot decide clearly what the probabilities are in many cases. And if he thinks that he can do so, he may be very much mistaken. Estimates are often made most unwarrantably. An exactness is often aimed at which is impracticable. The patient in many cases has no right to such an estimate, for while it may be a mere guess, he may look upon it as a well-founded estimate, made upon a real knowledge of his case. He will therefore draw false inferences from it, and this the physician is bound to prevent, and in so doing he actually prevents deception.

The physician should always remember that though he may be aware himself of his liability to err in making any such estimate, the patient may have such confidence in his judgment, that he will consider the opinion which he may express to be of course a correct one—almost beyond the possibility of a mistake. So that however guarded he may be in expressing an unfavorable opinion of the probable issue of any case, that opinion may have too much weight in the patient’s mind.

It is by no means true that all direct questions on the part of the sick must be directly and fully answered. For example, suppose the patient asks the physician, “Do you think on the whole that I shall recover”—a question that is sometimes asked under very embarrassing circumstances. If the physician thinks that he will probably not recover, he has no right to say to him that he will, for this would be falsehood. But he has a right, and it is his duty if he thinks it for the good of the patient, to withhold his opinion from him, if he can do it without falsehood or equivocation. He may say to him something like this: “It is difficult to decide that question. Perhaps it is not proper for me at this stage of your case to attempt to do it. You are very sick, and the issue of your sickness is known only to God. I hope that remedies will do so and so (pointing out somewhat the effects ordinarily to be expected) but I cannot tell.” Something of this kind, varied according to the nature of each case, especially in the amount of hope communicated, it is perfectly consistent with truth and good faith to say; and very often when more is said, even in very dangerous cases, the physician goes beyond the limits which infinite wisdom has thought best to set to his knowledge. It is very common, as the reader has already seen in the preceding chapter, for persons to recover, particularly in cases of acute disease, when the physician had supposed that they would die. This fact should make him somewhat cautious in giving definite opinions to the sick in relation to the probable final result of their sickness.

CHAPTER XVIII.
MORAL INFLUENCE OF PHYSICIANS.

The relation which the physician sustains to the community is a peculiar one. No other man has so free access to so many families among all classes of society. He is admitted into the very bosom of the families upon which he attends, even of those that receive other visitors with a distant formality. So much is this the case, that most persons have the feeling that their physician is a sort of confidant, and on that ground they are willing that he should see and hear, in his daily intercourse with them, what would be improper to be seen and heard without the confidence of intimate friendship. And when that confidence is abused, as it sometimes is by the tattling and the unprincipled physician, how gross the abuse, and how keenly is it felt by those who have, as a matter of necessity, reposed the confidence! I say as a matter of necessity, for the very nature of the intercourse of the physician with his patients is such as to make this confidence necessary. And the necessity is recognised by both parties. The physician knows that it is expected of him, that he will pay the most scrupulous regard to the principles of honor which have relation to this necessity, and that any discovered infraction of them on his part will materially injure his professional character. He feels this instinctively; and it is this feeling which is generally an effectual safeguard against abuse of confidence, when the patient chances to be under the care of a physician who is devoid of moral principle.

In the above remarks, I do not refer merely to the secrets which, either from choice, or necessity, are so often entrusted to the physician by his patients. But I refer to the confidential character which marks his whole intercourse with them, extending to all the little nameless acts which makeup that intercourse. He enters the dwelling of the sick as if he were one of the family, and the very office that he is to perform disarms all formality, and pre-supposes intercourse of the most familiar character. The patient is to speak to him not of a foreign subject, nor of some one else, but of himself, of his own body, of its pains and ailments, and that too with sufficient minuteness to communicate an adequate knowledge of his case. In doing so, he calls into exercise not only the scientific acumen of the physician, but, mingled with this, the sympathy of the confidential friend. If he has been the physician of the family for any length of time, and has been with them in many scenes of suffering, ready to relieve, so far as in him lay the power to do it, this feeling of affectionate reliance is deep and ardent; so much so, that it is a severe trial to the sensitive mind to be obliged to consult a stranger, even though there be nothing in the case to disturb the most refined and scrupulous delicacy. Especially is this so when the patient is a female. In her case the confidence reposed is of the most sacred character. And shame be to the physician who dares to trifle with it—who dares to offend in any way the delicacy of a patient, whom necessity has placed in such near relationship to him. It is principally this relationship, which the physician holds to the mothers and daughters of the families upon which he attends, that introduces him, if he be a man of honor and principle, as the esteemed and loved friend into the very bosom of those families.

One circumstance, that makes the intercourse of the physician with his patients familiar and intimate, which I have as yet barely hinted at, merits a more particular notice. I refer to the sympathy which he has felt with them in their seasons of suffering, anxiety, and affliction. It has sometimes been said, that the physician, from his familiarity with scenes of distress, becomes unfeeling, and incapable of sympathizing with others. This may be true of him, if he from the first look at the sufferings of his fellow-men only as a source of emolument to himself. If at the onset he enthrones this perfectly selfish and therefore hardening principle in his bosom, he will of course become devoid of sympathy and benevolence. But if he does not this strange violence to his natural sympathies, but lets them flow out, as he goes forth on his daily errands of relief and mercy to high and low, to rich and poor, and especially if he be faithful to the poor who can give him nothing but their blessing and their prayers, his sympathy and kindness will be so often drawn out, and under such a variety of circumstances, that they will become more tender and active, instead of being blunted and repressed. True, he will not have that mawkish sensibility which vents itself in tears, and sighs, and expressions of pity, but stops short of action, or, if it ever reaches forth its hand, does it but fitfully, and with none of that steadiness so essential in giving relief and support to soul or body in its feebleness and suffering. If he ever had any of such romantic and unpractical sensibility, he has cast it off in his actual service in the fields of benevolence, into which his profession has necessarily led him. He has learned over and over, the lesson of active sympathy. He has learned it often under circumstances of discouragement, and sometimes without even the show of gratitude being offered to him. He has learned it, I am glad to say, (and I say it with some tender recollections,) with signs of gratitude in his patients, which are not to be mistaken—with the blessing of those who were ready to perish, but who were saved by his timely and persevering exertions. He may appear to the casual observer to have merged the feelings of the man in those of the physician—to have surrendered his humanity to the cold and stern demands of science. He may seem to be devoid of sympathy, as he goes to work midst scenes of suffering, without a tear, or even a sigh, performing his duties with an unblanched face, a cool and collected air, and a steady hand, while all around are full of fear, and trembling, and pity. Yet there is sympathy in his bosom, but it is active. It vents itself in the right way—in doing. There is feeling there. It is not destroyed, but its manifestations are under control. It is from this power of control which he has acquired, that the physician or surgeon may appear to others to be utterly without feeling, even when a tide of emotion may be pressing his heart almost to bursting, because he knows that a valuable life is hanging upon those very exertions, which he is making with all the seeming coolness of indifference.

I have said that the feeling of the physician vents itself in action. Before that action begins, his emotions are often oppressive, more so than those of the by-standers; for he knows all the difficulties and dangers of the case, and sees the very points which should excite anxiety. Watch him while preparing for a serious operation. Though he may appear to the careless observer perfectly cool and undisturbed, you may see in his unguarded moments a betrayal of the strong under-current of feeling, which he endeavors to conceal. The occasional sigh, followed perhaps by an incidental remark to a by-stander, as a diversion to his feelings, just as the boy whistles to destroy his fear, the compressed lips, the slightly trembling hand, as he busies himself in making his preparations, thus finding relief to the pressure of the excitement within by external acts, some of them perhaps needless—these and other signs show it. And these signs may appear up to the last moment of delay. But the instant he begins the operation, they are gone. The hand may tremble till the knife touches the flesh, and the blood begins to gush; and then it is firm, for his feelings have now found relief in action.

Perhaps it will be said that there is conclusive evidence, that the tendency of the practice of medicine and surgery is to harden and destroy feeling, in the fact itself, that, when the physician comes to act, his natural sensibilities give place to the mere excitement attending the different steps of that action. In reply to this I say, that it is an error to suppose, that because feeling is relieved for the moment by diversion of the mind into another channel, it is of course hardened, or destroyed. Feeling may and does resume its hold when the action ceases; and, if the action ends in relief, it manifests itself in a different form—in a joyful and triumphant, in place of a sad and anxious sympathy. And this change in the character of the sympathy has a tendency to strengthen rather than lessen the natural sensibilities of the heart. He who has year after year sympathized with his patients in their sufferings, and then has rejoiced with them in their deliverance—a deliverance of which he has himself been instrumental—must be possessed both of a more deep, and a more active sympathy, than when he began his career of usefulness. This result is in consonance with the laws of our nature. While the mere sight of suffering, without any attempt to relieve it, often repeated, manifestly blunts the sensibilities, and hardens the heart; it is, on the other hand, the invariable effect of the effort to remove the distresses of our fellow men, to make our sensibilities more deep and more tender. Our interest in the effort, our joy in its success, our lamentation over its failure, the common cause which we make with the poor sufferer, tend to produce this effect.

In this connection I will notice an error which is very common. Persons who are not accustomed to look at wounds, or witness scenes of sufferings, are apt when they do so to have certain effects produced upon the physical system, which are so well known, that I need not describe them. The error consists in supposing them to be evidences of feeling and sympathy, and the process of overcoming them to be necessarily a hardening process. They are effects produced in the nervous system, and have a mere incidental, and not an essential connection with the moral sensibilities. It is well known that all are not equally susceptible of these effects, and the degree of susceptibility is far from being an index of the degree of sympathy in each individual. I have known many men, who had little of true tenderness and kindness of feeling, faint away at the sight of blood, while others with hearts overflowing with tenderness, and a hand ever extended in active sympathy to the needy and suffering, under the same circumstances were entirely unaffected. The possession of this susceptibility has therefore no necessary relation, to the moral character. They who exhibit it are commonly spoken of as being ‘tender-hearted,’ and yet there is nothing in this quality which is inconsistent with the most wanton cruelty, or the most abandoned vice. Neither has this susceptibility any necessary relation to physical courage; much less to moral courage. Many, who possess it to a great degree, have nevertheless uncommon physical courage, so that though they would turn pale at the sight of a cut finger, they would face the cannon’s mouth without fear, and in the excitement of battle, the flow of blood and the groans of the wounded, would be unheeded. While on the contrary, there are many, who are unaffected by the sight of blood and suffering, in whom the idea of personal danger would at once blanch the face and make the knees to tremble.

It is the conquest which the physician obtains over this nervous susceptibility, of which I have been speaking, that has given rise to the erroneous impression, that the practice of medicine and surgery necessarily subjects the heart to a hardening process. But you have seen, that while he is acquiring this self-control, his sympathy with suffering is becoming all the time deeper and livelier, by the exercise of that active benevolence to which his profession calls him. It is only the physician who refuses to yield to this call, and pursues his profession as a mere trade for self-aggrandizement, that blunts his sensibilities, and hardens his heart.

Sustaining then, as the physician does, so intimate a relationship to his patients, and sympathizing so deeply, as they feel that he does, with them in their trials, and sufferings, and joys, his opportunities for influencing those around him for good or for ill must be greater than fall to the lot of most of those who occupy commanding stations in society. He cannot avoid exerting a wide and an effectual influence. It can be said emphatically of him, that every act which he does, every word that he drops, is seed which will surely produce fruit, and it is seed which he sows with a broad cast. The advice which he gives, the opinions which he expresses, and the example which he sets, have a double force from the fact, that the intimacy and sympathy which exist between him and his patients unlock the heart, and his influence finds no repulse in entering there.

Every man has more influence in his own little community at home by his own fireside, than he has abroad in the great community around him. Familiarity, mutual confidence, and sympathy, are the obvious causes of this. But the physician may in a measure, as you have seen, be said to be at home everywhere, by everybody’s fireside, in the mansion and in the cottage, in the garnished chamber of the wealthy, and in the humble and comfortless garret of the poor. It is a matter of every day’s occurrence, that he should be at home in all these varied scenes, and he acquires a tact in accommodating himself to them, and to the endless diversity of character which they present. Wherever he goes he enters the family circle, as I have before said, without that formality which attends the reception of other visitors. He is received ordinarily without any preparation, and at any hour when necessity calls for it. He sees his patients, too, in every variety of situation, and in just those circumstances which are calculated to develope and exhibit character. He sees them in their unguarded moments, and when sufferings and trials of every variety, from the great calamity down to the most trivial disappointment, are acting upon them as tests, searching and sure. He sees much that glitters before the world become the merest dross in the sick chamber; and he sees too the gold shining bright in the crucible of affliction. He sees human passion in every form and condition; implacable hatred and love stronger than death; fallen virtue, and virtue tried and proved; mental and moral strength inconceivable, and childish imbecility in the once mighty and great; hope beaming bright with heavenly lustre, and ghastly fear and black despair; unbounded power of endurance, and the crushing of the once buoyant spirit by even light calamities—every feeling, or passion, or quality, or condition, that can be imagined, in every possible variety of phase and degree, is displayed to his view.

No one then has better and more various opportunities for studying human character than the physician: and he adds every day from this source to the storehouse of his experience. I need not spend time to prove, that this knowledge of character thus acquired confers upon him a means of influence which he otherwise could not have. It not only gives him a tact in influencing men generally; but in individual cases, the revelations of thought and feeling which he has witnessed at the fireside or in the sick room, made in the free and unguarded moment, under the application of faithful tests, afford him such an insight into the character, that he knows just what chord to strike, to produce the effect which he desires. He needs not to feel his way to the heart. He has already learned it. He knows just what motives will act with the most certainty, and needs not to make any random experiments.

What responsibility then rests upon the physician! How careful should he be in the expression of his opinions! At what high ends should he aim in his daily example! How important that he should be right upon the great moral questions which agitate the community, and that his morality should be strictly that of the Bible!

Too often is it the case, that the physician, who professes to be governed by principle, exerts no such commanding influence, as his relations to his fellow men enable him to do; but, as a matter of policy, avoids committing himself decidedly and openly upon those subjects which occasion any diversity of opinion in the community. Those who thus for selfish ends fail to meet the full responsibilities of their station, do not, indeed, like the unprincipled, undertake to please everybody (a contemptible course, and commonly a profitless one) but they at least make it a main point to displease no one. In so doing, it is true, they make no direct attack upon principle, and inflict no positive injury upon the moral interests of society; but they are guilty of a sacrifice of principle, and they neglect to do the good which it is in their power to do. Suffice it to say, that while the physician should not court opposition by any needless attacks upon the opinions and prejudices of others, for this would impair his usefulness, a dignified and firm expression of his sentiments, and a decided influence for good upon every great moral question, we have a right to expect from one who has so great a share, as the physician necessarily has, in moulding the character of society.

Take, for example, the great moral question of Temperance, which has for so many years agitated the community, and upon which there has been so great a difference of opinion. It is difficult to conceive that a physician, possessed of the ordinary feelings of humanity, should fail to be decided on this subject, either in his opinions, or his influence. No man has had so varied and extensive opportunities of witnessing the ravages of intemperance. It is not an occasional visit that he has made to the miserable home of the drunkard. It is not occasionally that he has heard from trembling lips the tale of woe, and seen its painful and often hideous signs. It has been with him an almost every day occurrence. Misery on every hand has made its appeal to him. And if he has allowed his desire for popularity to hinder him from heeding such touching and frequent appeals, it is not too much to say to him, that he has been shamefully recreant to the dictates of humanity, and that he will have to render a large account of neglected opportunities of doing good.[44]

No one has more frequent opportunities than the physician for acting as a peace-maker, an office which is very much needed, but which few are inclined to take. There are always many, who are willing to act as peace-makers in gross and palpable cases, when an actual quarrel has burst out, and threatens a great and manifest damage to the community, who yet may do nothing to repress the petty jealousies and the slight contentions, which are generally the cause of the greater commotions that heave up the very foundations of society. But the true peace-maker is doing his work at the fountain head, at the very beginnings of strife—not only when urgent occasions call for it, but from day to day, in every circle, by every fireside that he visits. Every day he sees the risings of ill-feeling, envy, jealousy, and discontent; and he calms them down by an influence so gentle and charm-like, that it is scarcely observed. A small thing, a word, a look, may often put out the spark which is about to light the destructive train. How few there are in this world of jealousy and contention, who are ready to utter that word, or bestow that look, and how many who will fan the spark of strife into a blaze, or will at least let it alone, and take no pains to put it out.

The physician in his intercourse with his patients has so much of the free familiarity of home, that he can see these sparks of contention, as they kindle up here and there, more quickly than others can. Thought and feeling are often revealed to him unconsciously, and the very fountains from which they rise are almost open and naked to his view, and, I may add, to his influence also. If he then be a man of peace, he can do much from day to day in repressing those thoughts and feelings, almost in their nascent state, which, if encouraged, would distract and divide family circles, neighborhoods, and perhaps communities. If, on the other hand, he is not a peace-maker, but has an ear ever open to the tongue of scandal, and is himself a tattler—if he is ready to secure his own aggrandizement by injuring his competitors, and is therefore disposed to rejoice in the misfortunes of others, he scatters the seeds of contention wherever he goes, and the peculiar relation which he sustains to a large portion of the community enables him so to scatter them, that they will be sure to take root, and grow, and produce an abundance of fruit.

This leads me to say that it is especially true of the physician, that the most of his influence lies in the little hourly acts, and in the familiarly, perhaps carelessly, dropped words, which make up the chief part of his life, and not so much in the opinions which are formally expressed, or in the acts which obviously follow deliberate consideration. This is true to a great extent of every man who mingles in society with the ordinary degree of freedom. They indeed, who move about among their fellow-men with as little familiarity or sympathy as a recluse, have but little influence, and that only when they utter their formal opinions. But the occupation of a physician necessarily puts him at the very antipodes with the recluse. Even if he be disposed to shut up his heart against his fellow men, and to make his intercourse with them of a strictly scientific character, his bosom will very soon be unlocked, or he must give up his profession. The fountains of sympathy and feeling will be unsealed by the potent influence of daily intercourse with human suffering and joy. He cannot from day to day administer to the relief of distress without sympathy, and that sympathy cannot always be suppressed. It will gush forth, and the frigid man of science will become the kind and familiar friend. Mingling then, as the physician necessarily does, so freely and intimately with the world around him, it must be eminently true of him, that it is the spirit of the man, as it breathes forth in his common every day words and acts, even in his very manner, that really gives the character to his influence. So that if he be not forward to speak out his sentiments, or to give his advice, the sentiments which he has, and the advice which he would give, are as well known, as if he uttered them. It is in truth this aggregate influence (as it may be called) of his daily life in the many homes to which his profession gives him admittance, that imparts force to his advice, and opinions, and acts.

I have as yet said nothing especially of the influence of the physician in the sick room. Here he treads upon sacred ground, and has to do with the issues of life and death, both temporal and eternal. Here he sees man in the weakness of his humanity, ‘crushed before the moth,’ but often, too, in the strength of his immortality. Here he is made a witness of the frailty of the tenement, which the immortal spirit inhabits—he sees that its ‘foundation is in the dust.’ He has communion with the spirit in its most momentous hours—while it sees the walls of its habitation crumbling into dust, and lingers about the ruins before its final flight into a world of light or darkness, of joy or of woe—or perhaps, while with longing desire, and occasional hope of its longer continuance here, it trembles with the fear that it is about to be driven from its home in this tabernacle, whose frailty is now staring it in the face—and then too, there are times when he has converse with it as it is becoming reinstated in the possession of its habitation by gracious permission of its builder, who alone can repair it and redeem it from destruction. Communion with the spirit of man in such momentous seasons, how hallowed should it be! Trifling, selfishness, disregard of principle, how out of place are they here!

It is not my design to enter fully into a discussion of the moral and religious duties, which devolve upon the physician in the sick room. I choose rather to refer the reader for instruction on these points to the excellent letters of Dr. Burder, an English physician, which I have introduced in the Appendix. I shall therefore only notice some of the errors which are prevalent on this subject.

The great object of the physician should be to cure the patient. This is his vocation, and nothing should be permitted to interfere with it. And he must be on his guard, lest he give up this object too readily. For often, very often, especially in acute diseases, in cases which are apparently hopeless, recovery does occur. The physician therefore should avoid, even in desperate cases, producing the impression upon the mind of the patient, that he really believes the case to be hopeless. Nothing but the most absolute certainty would warrant his doing this. The cordial influence of hope, as I have shown in the chapter on the Influence of Hope in the Treatment of Disease, is often one of the means by which a recovery is effected, and the absence of this one means may prove fatal. Who then will dare to take the responsibility of withholding this cordial, often so essential a remedy, with the vain expectation (for experience shows that it is commonly vain,) that in the midst of all the turmoil and agitation of the fearful struggle of life and death for the mastery, the spirit may be led to make its peace with its God? And yet it is often claimed, that the physician should under such circumstances declare to the patient the certainty of his death; and if he decline doing so, he is blamed for what is considered to be a palpable neglect of duty.

Vain expectation, I say it is, which many indulge, of producing repentance and reformation at such an hour. The mind is weakened by the disease, thought and feeling and sensation are all confused, the dim vision of the eye of flesh is the faithful index of the dim vision of the mind, and the poor soul, while it sees everything thus confusedly, is tossed about upon the billows of conflicting passions and hopes and fears. It is true that there is a power, which can pluck it from the billows, and plant its feet upon the rock of ages. It is an almighty power that cannot be limited; but we have reason to think, that seldom is this signal interposition put forth in this extremity. A true philosophy declares, that this is no time for the clearness of view, and definiteness of action, which religion demands of man, and experience affirms the truth of the declaration. Clergymen and physicians, who have had ample opportunities of observation upon this point, have but little confidence in any apparent change of character at the hour of death. It is their universal testimony, that those who have made professions of repentance and reformation, when they supposed themselves to be near dying, and yet have recovered, have commonly given no evidence afterward that those professions were well founded.

The above remarks have been made, it will be seen, in regard to acute diseases only, and they apply to but a very limited extent to cases of chronic disease. During the lingering days, and weeks, and sometimes months, of such cases, there are many opportunities for exerting an influence upon the sick. And while it is true, that the physician should adhere to the general rule, which I have stated in regard to the effect of hope, it is his duty, and especially is it the duty of the friends, to improve the opportunities which present for the best good of the patient. And here let me say, that it is not the formal and stately conversation, the professional sermonizing, so often made use of, which is really the most effectual; but it is the word dropped from day to day, with a spirit not roused up for the occasion, but breathing forth naturally and easily—it is the instruction suggested by events of daily occurrence, or by remarks which are dropped in common conversation, and accompanied by the affectionate appeal, when it is seen that the proper chord can be struck—this is the kind of influence, which is brought to bear most decidedly upon the moral and religious character of the sick man. It is this that will enter his heart; while the arrows, which are duly heralded by the note of preparation, will fall to the ground, warded off by the shields which he raises against them.

Injudicious attempts are sometimes made to influence the sick, both with regard to their temporal, and their eternal interests. I will cite but a single case in illustration. It is a case which was reported by the late Dr. Hale of Boston, in his work on Spotted Fever. Although the patient was so sick, that Dr. H. considered it of the utmost importance that he should be kept quiet, and gave the most positive and authoritative injunctions to this effect, yet a friend, to whom the proper adjustment of the sick man’s affairs, if his sickness was to end in death, was a matter of considerable interest, persisted in harrassing him on this subject. The result was an alarming increase of the disease. The symptoms were afterward, however, so much mitigated, as to give some ground for hope of a recovery. As his mind was clear and rational when he came out of his stupor, “his attendant with a very benevolent but mistaken zeal, thought it more important to improve this opportunity in taking care of his soul’s health, than in administering the remedies which had been prescribed; and, instead of giving the medicines with care and attention, and promoting his rest and quietness, as he ought to have done, and had been strictly enjoined to do, he spent the whole time in talking, and exciting him to talk, of his hopes and prospects beyond the grave.” This conversation was continued for about two hours, and then the patient sank back into a stupor, a state of collapse which was caused by the previous excitement, and he never awoke. If the quietness enjoined by the physician had been maintained, this case would probably have resulted in recovery.

There are some cases, in which it is clear even to the careless observer, that it is wrong to excite the mind of the patient on any subject. Take, for example, a case of typhus fever. Even though it may not be a severe case, the mental with the physical sensibilities are so blunted and deranged, that no moral or religious influence can do any good. If it rouse the patient’s torpid mind to action, it will only do harm by the disturbance it creates; and if it produces a mild, quiet effect, which may be gratifying to his friends, it is worthy of no confidence, and when he recovers he may have no recollection of the sayings which he uttered, and which would have been garnered and kept, as a sacred treasure, by friendship and love, if death had transported him to another world.

In such a case as this, when the mind is in so passive and torpid a condition, the path of duty is clear. But there are some cases in which it is difficult to know what our duty is. We must then decide as well as we can in view of all the circumstances. And let me remark here, that there should be no inconsiderate and irresponsible action at such times; but what is done should be the result of a candid conference between the physician and the friends of the patient. The clergyman should not be disposed to act independently, and from his own judgment alone; but, for obvious reasons, he should consult with the physician in regard to each individual case.

Some are very anxious in regard to the spiritual welfare of the sick, when they are thought to be nigh unto death; but if death does not ensue, the moment that convalescence begins their anxiety ceases. Religion with them is altogether a thing for great occasions, and the season of death is of course one of them. Anything which is exciting arouses them to action, and awakens their sympathies for their fellow men. But they make little account of the every day influence which is exerted in their common intercourse—an influence vast in amount in a long life, though it may not be palpable in its results at any one moment. While they would press upon the sick man the solemn and faithful appeal, when they saw him to be near the borders of the grave, and concentrate upon that dread hour all their energies, they would perhaps, if he should recover, not even visit him at all during his convalescence, and the first time they met him they would welcome him back to that worldliness, in which they in common with him so freely indulge.

And yet it is in convalescence generally that you can exert the greatest influence upon the sick man. For look at the circumstances of the case. He has just been released from suffering. The recollection of those hours, when thought and feeling and sensation were so confused, and all was dark and dim, is still vivid in his mind. The world, from which he has been thoroughly secluded for a little time, now opens fresh upon him again—a new sun shines upon him, and he looks out upon a new earth. The pure air, as he remembers the stifled breath and the languor of disease, has an invigorating buoyancy that it never had before; and he now for the first time knows the luxury of such common blessings as breathing, and again and again he expands the chest to the full, to see how beautifully it does its work. He feels the genial glow of returning health pervading every part of his system, diffusing elasticity, energy, I had almost said joy, everywhere. And then as he goes forth, he meets on all sides the kind greetings of friends, some of whom had been by his bedside during his sickness. All these circumstances conspire to make both the sensations of his body and the feelings of his heart agreeable, and thus open the avenues to moral and religious influences. And then, too, the cares and selfishness of the world have not yet resumed their control over him. When, I ask, could there be a better time to awaken in that man’s heart proper feelings towards his Maker, and toward all around him. As he comes out afresh into life, with something of the simplicity of a child, disencumbered by his sickness of the entanglements which had gathered around his mind and heart in the midst of temptation and sin, how easily can he be led to appreciate what is right, and good, and enduring, in this evil and transitory world. His mind is not now weakened, nor his sensibilities blunted or deranged by disease. There is no dim vision now, but he sees things as they are, and his sensibilities are lively and ready to respond to the touch of the hand of friendship, like the chords of a newly-attuned instrument that gives forth its clear and harmonious sounds to delight the ear.

I cannot dismiss the subject of the moral influence of physicians without adverting to one topic, which I deem to be of no small importance.

Every man, aside from the influence which he exerts as a citizen in common with others, exerts also an influence through the business or profession in which he is engaged, by the manner in which he performs its duties and maintains its relations. There is a strong disposition in the community to separate these influences, and to assign to them for their governance two different sets of moral principles. This disposition is very marked in regard to politics. But it exists also in relation to other professions and employments. It has even extended to medicine. Men often do as physicians what they would be ashamed to do as men. The strict morality of common intercourse is relaxed in professional intercourse. But the man and the physician cannot thus be separated. Obedience to principle, no matter in what it appears, always has its good influence; and the same universality attaches to the bad influence of disregard of principle. There is a moral character belonging to every act. Strictly professional acts and relations have a moral influence. If the physician has a proper regard for the character and standing of his profession, promotes an honorable intercourse among its members, upholds its organizations, resists the encroachments of quackery, and helps to secure a good standard of medical education, he in all these ways exerts an indirect but important influence upon the general good order and well-being of society. But if, on the other hand, he has no true regard for the honor of his profession, sacrifices its interests to his own aggrandizement, labors for success by intrigue and manœuvre, and thus gives a license to quackery, though he may call himself a strictly moral man, and be so esteemed by the public, he exerts by his professional course a decidedly bad influence upon the general tone of morality in the community, and therefore does not merit the appellation of a good citizen.