Physician and patient

by Worthington Hooker

The mind, weakened by disease, is easily disturbed and agitated, except in those cases in which disease blunts the sensibilities. Derangement of mind is often the product of mere weakness, under increase of excitement, without any fresh accession of local disease. A familiar illustration of this you may see in fever. Very often there is mental derangement only during the paroxysm of fever, the mind being quite clear in the remissions. Especially is this the case with children, whose sensibilities and sympathies are in so much more lively a state than those of the adult.

Slight causes, therefore, which would produce little or no effect upon the mind of one in firm health, may affect strongly the mind of a sick man. A single example will suffice. The patient was sick with typhus fever. He had been very much deranged, and great care had been taken to guard against any excitement, which might act injuriously upon him. He was now getting better, and his mind had become calm and clear, though still, like his body, it was very weak. A friend came in one morning as usual to inquire about him. He knew that all visitors had been prohibited from going into the sick room, but he wished very much to see his friend, and, as he had an opportunity, he looked in through the door, as it chanced to be a little open. The dull eye of the sick man saw him dimly, and he at once became as much affected as if he had seen a dreadful vision. His distempered fancy conjured up ideas of a painful character, which remained upon his mind for a week, and endangered as well as delayed his convalescence.

This incident leads me to remark that physicians find great difficulty in securing a due degree of quietness in the sick room. I use the word quietness in its widest sense. I do not mean the avoidance of noise merely, but of all improper excitement. Visiting is generally a nuisance in the chamber of sickness. Multitudes of lives are continually sacrificed to curiosity and mistaken kindness. The tattling circles that gather round the fireside of the sick room, and retail their mixtures of medical lore, and slander, and hair-breadth escapes, and wonderful cures, often inflict torture upon the shattered nerves of the poor patient, and that torture sometimes, I have not a doubt, ends in death, when a recovery might otherwise have taken place.

No one should enter the sick room from curiosity or from a mere vague desire to do good. Nothing but the actual prospect of doing good should prompt him to go there. Indeed, everything which interferes with the proper quiet of the sick should be most scrupulously avoided. It should always be remembered, that in many cases of disease, mental excitement may do as much harm as the excitement produced by stimulating medicines. And it is as much the business of the physician to direct in the management of this matter, as in the administration of remedies; for it has as real, if not as great a bearing on the recovery of the patient. Indeed, sometimes it is vastly more important than all the medicine that is given in the case. I call to mind a case which illustrates this last remark so strikingly, that I will state it as briefly as possible. A patient was taken sick, with some important business pressing upon his attention at the time of the attack. He was persuaded to dismiss it entirely from his thoughts for the time. He was soon relieved by the remedies that were used, and he was in a fair way for a recovery. He was, however, in such a state, that it was very important that he should be kept from all excitement, and as I saw that he was disposed to do the business now with some friend, whom he wished to have called in for the purpose, I told him and his family in plain terms the risk which he would run if he should pursue this course. He however disregarded my injunctions, and the consequence was that in the evening of the same day he was very sick, and in a few days died from disease in the brain, which was clearly induced by the mental excitement. If he had followed my directions as scrupulously in regard to this point as he did in regard to the medicines which were given, recovery instead of death would probably have been the result.

Some in their anxiety to secure the quiet of the sick, go to an extreme, and give almost the silence of the grave to every sick room. They institute a sort of prison discipline, and shut out both the light of heaven and all cheerfulness of intercourse. The very means which they take to produce quietness, the stealthy step and the whisper, are apt to disturb the patient more than noise or excitement would do. Discretion should be exercised by the physician, and the friends of the patient should rely on him to direct this part of the management of the case, as well as that which is strictly medical. He must judge as to the degree and kind of excitement appropriate to the case, and direct in its application, for the same reason that he should, in a case of disease of the eye, direct as to the amount of light which should be admitted to it.

It is often very difficult to carry out these principles, especially in families that have but a small number of apartments. The fear of giving offense, too, very often opens the door wide for visitors, against the most positive injunctions of the physician. To obviate this difficulty, I have in some few cases put upon the door a card, forbidding this kind of intrusion—an expedient which I have found to be very successful. One case was that of a clergyman’s family. So many were sick, that the house was a perfect hospital. A large portion of the parish poured in of course, to offer their sympathy and their services. Most of these persons did more harm than good. I attempted to remedy the evil by directions to the nurses, and by conversation with individuals, but in vain. At length I put up a card on the door of the house, to this effect: ‘Visitors are requested to go directly into the parlor. No one is to enter the sick rooms but those who have the care of the sick. No talking in the entry.’ This effected the desired change at once. I introduce this case simply to show the difficulties which exist on this point, especially in country towns, and the very plain remedy which can be applied. There is no reason why a universal rule should not be adopted in every case in which it is deemed necessary by the physician.

The attendants on the sick often make a great mistake in supposing the patient to be so fast asleep, or so stupid, as to receive no impressions from their conversation. Often, from this cause, he is obliged to hear what may do him great harm. Amid the confused thoughts of his dreary bewildered state of mind, the idea of his own death is conjured up by some remark, to trouble and affright him. Instead of getting the rest which his wearied body and mind so much need, his nerves are disturbed by the hum of conversation, and his mind is harrassed by a succession of dread thoughts and visions, suggested by remarks, of which it is supposed that he takes no cognizance.

Some, who are very cautious on these points in regard to adults, never think of their application to children. Often, for example, does the physician find, on entering the sick room, those whom kindness and curiosity have assembled there, talking loudly, while the mother is trying in vain to soothe the troubled child by rocking the cradle as if for a wager. Much, too, is often said in presence of sick children that ought not to be, on the false supposition that they do not understand what is said. Many a child is frightened by horrid stories, and by gloomy comments upon his own case. Visitors stand over him, and besides fretting him by their staring, they say something, perhaps, of this sort. ‘Poor thing! how sick he looks! I don’t believe he can get well.’ And then they go on to tell about some little child, perhaps his playmate, that had died recently, and whom, perhaps, he saw laid in his grave, and utter in his hearing, with all due solemnity and sorrowfulness, the opinion that he is affected much like him, and will probably die in the same way; adding, by way of consolation to the poor mother, that then they will be in heaven together. Children have sensibilities and hopes and fears, like adults, and they understand, even at a very tender age, enough about death to be affected, and often very strongly, by this holding up of its grim visage directly before them. The mind, and the nervous system, by which the mind is connected with the body, are as excitable in the child as in the adult, and the avoidance of unnecessary alarm and excitement is as important in the sickness of the one as in that of the other.

I cannot forbear here to notice one thing, which often exerts a bad influence upon the mind of the child in sickness. It is the habit which many people have of threatening their children, when in health, with sending for the doctor to bleed them, or to give them some bitter medicine, as a punishment for their misdeeds. The inevitable tendency of this is to increase the mental depression and agitation which disease produces, by the gloomy associations which are thus necessarily attached to sickness in the mind of the child. The physician should never be held up as a bugbear to children, but should uniformly be spoken of in their presence in such terms, that when he visits them in sickness they may rejoice to see him, both as a friend and as one who is to bring them relief. There is no doubt that many a child is seized with an ill-defined terror, when the physician is called in, and thinks of him only as some dreadful monster that cuts off children’s ears, and gashes their flesh almost for sport. The effect of such a feeling on the weakened and agitated nerves is always injurious and undoubtedly is sometimes fatally so. One may get some adequate idea of the feelings of children under such circumstances, by imagining himself, in a state of weakness and disease, to be visited by an incarnate demon, who has both the power and the disposition to torment him.

I am anxious to impress most faithfully the mind of the reader with the importance of giving rest to the mind in sickness. I have already remarked on the extent and the intimacy of the union between the mind and the body. It is never to be forgotten in the chamber of sickness, that the mind not only is not by itself, alone and independent, but that it is not connected with sound nerves, but acts upon a deranged body, and is acted upon by it, through the multitude of nervous filaments, which, scattered everywhere, are receiving impressions at every point, and transmitting them to the mind. If, therefore, the mind, thus disturbed by disease, be at the same time troubled by causes applied directly to it, the result must be a reaction from the mind through the nerves upon the disease itself. The mental and the bodily irritations must increase each other. It is then just as important to withhold all irritating causes from the mind, as from the diseased organ. For example, if the brain be inflamed, that inflammation may be aggravated as certainly by exciting the mind, as it would be by the administration of any stimulant to the body. In either case the same result occurs—the brain is stimulated—the only difference is in the channel through which it comes. And it is the duty of the physician to shut out the irritation from one channel, as much as from the other. When the eye is inflamed, one part of the curative means is to exclude the light, because the light, by exciting the nerve of sight, would increase the inflammation. But the action of the mind is as really connected with the brain and nervous system, as the act of vision is with the eye; and therefore it must be guarded against, in inflammation of the brain, as vision is in inflammation of the eye. The same may be said, to some extent, at least, of every other part as well as the brain, for every organ is supplied with nerves connecting it with the mind.