INFLUENCE OF HOPE IN THE TREATMENT OF DISEASE.
I remember well that Dr. Jackson of Boston used to remark to the
students, that the medical profession is, from the nature of its
duties, a _cheerful_ profession. The physician has so much to do
with suffering, disease, and death, that this assertion would at
first view seem to be erroneous. But when it is considered that
in the great majority of cases he is able to effect a cure, that
in those which terminate in death he can generally give relief to
suffering from time to time, and thus at least smooth the passage to
the tomb, and that the number of sick whose diseases he can neither
palliate nor cure is exceedingly small, we can see why it is that the
physician is ordinarily so cheerful a man in his daily intercourse.
The impressions of most persons on this subject are wrong, and for
very obvious reasons. Out of their own immediate circle of relations
and friends, they hear only of the severe cases of disease, and often
only of those in which death is the result, and know but little,
perhaps nothing, of the multitude of cases, here and there in every
part of the community, which end in recovery.
Sometimes, it is true, sad cases occur which cast a gloom over the
path of the physician; but then the gloom is soon dissipated by the
successful issue of other cases which he had reason to fear would
have a fatal termination. Sometimes, too, unfortunate cases come in
clusters, and the physician is for the time obliged to see so much
of suffering and death, and the sorrows of bereavement, that in his
sadness he is ready to regret that he ever adopted such a profession.
But this happens only occasionally. It is a mere coincidence, and
it is but momentary. Events soon take their ordinary current, and
he has his usual amount of success, and resumes his wonted air of
cheerfulness and hope.
The results of the skilful and judicious practice of medicine are
such then as to make hope, and not despondency, to characterize
the prevailing cast of the physician’s mind. And so it should be.
For hope stimulates to action—steady, clear-minded action—while
despondency is prone to inaction, and leads to no efforts except
those which are hurried, fitful and confused. I do not mean that
the physician should in any case blind himself to the dangers
which it presents, and let a vain hope lull him into security.
This error should be as carefully avoided as the opposite one,
committed by those who see difficulty and danger in almost every
case, magnifying every bad symptom, and imagining some which have no
existence. The hope of the physician should be an intelligent hope.
It should be based upon just and definite conclusions. It should be
discriminating, and should be varied in its degree according to the
character of each individual case.
Every medicine that is given should be administered by the hand of
hope. The prospect, at least of relief, and generally of recovery,
should be held up to the mind of the patient. Remedies should be
given to effect some definite object, and the physician should hope
to a greater or less degree that they will do so. Hope may thus be
indulged in relation to the different stages of a case, without
regard to the final event of it, which may be so distant and so
clouded in doubt that no calculations can be made in regard to it.
And the physician may direct the attention of the patient to these
same points, and thus give variety to the hope which he excites in
his mind. This in many cases is much better than to come to him
every day with the simple expression of the hope that he will at
length recover. In the tedium of his confinement, if it be a long
one, he soon tires of looking far ahead to the bright fields of
convalescence, but finds relief in the little spots lighted up of
hope by the way—the oases thus made in the desert of sickness.
Even in those cases in which the physician feels it to be almost
certain that the final issue will be a fatal one, it is not proper
to give up wholly the idea of recovery, in his conversations with
the patient or with his friends. This remark must not be understood
to apply to those cases in which the evidence of approaching death
is not to be mistaken, and so far as human wisdom can see it is
absolutely certain that the patient will die. At the same time it is
to be remembered that there are occasionally recoveries when death
was confidently expected, and we must avoid being too ready to decide
that there is no ground of hope, especially in cases of an acute
disease.
I will relate a case in point. A physician was called in great haste
to a patient upon whom he had been attending with deep anxiety.
He found the family and the friends assembled around the bed of
the patient weeping over him as a dying man. The physician himself
thought from his appearance that he was really dying. Still he did
not _know_ that he was, and as he might possibly be in a condition
from which he could be revived, he prepared a cordial at once, and
with the look of hope and uttering the words of hope, he administered
it. The patient not only revived but recovered. In his convalescence
he told the physician that as he lay there dimly seeing with his
glazed eyes the sad countenances of his friends, and feeling the
oppressive languor of death, as he supposed, upon him, and panting
for some cordial and for the pure air of heaven, and yet unable to
speak or even to raise the hand, no words could express the relief
which he at once felt, spreading a genial glow over his benumbed
body, when he heard his cheerful voice speak of hope, and it seemed
to him that this had more influence in reviving him than the cordial
which he administered.
Strong as this case is, similar cases are in the recollection of
every physician who has been in practice for any considerable length
of time. And they cannot be distinguished from some other cases in
which attempts to revive the sinking powers fail, and the patient
dies. Now it will not be claimed that the physician does wrong in
uttering the language of hope in the case of those who recover; and
he certainly should not be reproached for uttering the same language
in the case of those who appear just as likely to recover, but
for some reason hidden from human wisdom do not. Just as he would
administer the cordial to all of them, so also should he apply to all
of them the cordial influence of hope. The same rule is applicable to
both the mental and the physical remedy.
It is often said that if the physician, on the whole, taking into
view all the circumstances of the case, thinks that a patient is
going to die, he ought frankly to tell him so. The considerations
which I have presented are, I trust, sufficient to convince the
reader that this is by no means true. Shall the physician, I ask,
add to all the depressing agencies which are bearing down the patient
the appalling idea of death, and thus lessen, perhaps destroy, the
possibility of his recovery? Shall he, in the struggle between life
and death, give his influence in any way on the side of death? When
the powers of life are sinking, and the life-giving fluid circulates
but feebly in the extremities of the system, and is accumulating in
the larger blood vessels and in the heart itself, threatening every
moment to stop its faint throbbings, shall he, while he administers
the cordial, defeat its effect, by holding up to the eye of his
patient the grim visage of death, to oppress the vital forces and
curdle the blood in its channels? Shall he not rather pour into the
mind the cheering influence of hope, and thus aid the cordial in
reviving the expiring energies of the system, and in stimulating the
heart and the whole circulation into a freer action?
Let me be fully understood on this point. Far be it from me to
justify the wide departure from truth, of which some are guilty at
such times. Giving utterly false assurances to the patient is a very
different thing from merely exciting the hope in his mind to such
a degree as the case may allow, that the remedies will produce the
desired relief. The latter can be consistently done by the upright
and high-minded practitioner, but the former is to be expected only
in the ignorant pretender, and the dishonorable and unprincipled
physician. The quack always gives assurances of a cure to those whom
he undertakes to dupe; for, besides being incompetent to estimate the
degree of danger in any case, he is unable to inspire confidence in
his measures except by a strong appeal to the hopes of the patient.
And some physicians imitate the quack in this particular. They
are in the habit of exciting unwarrantably the hopes of the sick
for their own selfish ends. By so doing they occasionally retain
under their care patients who would otherwise pass into the hands
of some one else; and they also get possession of some cases, in
relation to which their more honest and honorable brethren have not
found themselves warranted in giving any positive encouragement.
But, though occasional advantage may result from this course to the
physician, and sometimes even to the sick themselves, yet on the
whole the honest course is truly the politic one.
It is important, as I shall show more particularly in the next
chapter, that the physician maintain his character for veracity
and candor in his intercourse with his patients; else, when he can
consistently utter the language of hope, it may prove no cordial,
because his lips have so often uttered that language so falsely.
There are cases in which death may seem to the patient and to his
friends to be staring him in the face, and yet the physician may see
a sure and speedy relief coming to all the alarming symptoms. Now
when he gives an assurance to this effect, in order to quell the
anxieties and fears of the sick man and his friends, if he has been
known to be in the habit of giving similar assurances without any
ground for them, he cannot expect to be believed.
The views and feelings of patients, in regard to the expectation
of a recovery, are often misunderstood by their friends. They are
sometimes supposed to be wholly blind to their danger, when they are
really fully aware of it. They perhaps speak occasionally of what
they will do if they get well, and allude to the expected effect of
remedies, as if they supposed that they would overcome the disease,
and dwell, in their conversation with their friends and with the
physician, upon the favorable symptoms that may appear. All this may,
and often does, occur in cases in which death is almost certain to be
the result; and yet it is entirely consistent with the existence in
the mind of the patient of a rational view of his danger. I remember
well a respected friend, who talked of hope and relief now and then
almost to the last; and yet, from day to day, he was making such
preparations, even to the framing of his will, as showed that, on the
whole, he believed this to be his last sickness.
We are not to confound these occasional expressions of hope, these
fitful and momentary states of mind, with the settled conviction of
the understanding often existing behind all this. The promptings of
the natural desire for life are ordinarily not utterly destroyed
by the sure prospect of death. There will be moments when this
instinctive love of life, and of whatever in life has ministered to
the happiness of the sufferer, will turn off his thoughts from the
contemplation of death, and call up by association a thousand objects
of endearment.
“For who, to dumb forgetfulness a prey,
This pleasing, anxious being e’er resigned,
Left the warm precincts of the cheerful day,
Nor cast one longing, ling’ring look behind?”
It is well that the hope of recovery should occasionally light up in
cases which are certain to end fatally, especially when the patient
is the subject of protracted chronic disease. It breaks in upon
that painful monotony of mind, which is otherwise apt to exist. It
is not commonly well for any one, in any point of view, to have the
certain expectation of death fastened in the mind week after week
and month after month, even if he have all the while a clear view
with the eye of faith of a glorious immortality beyond. This one
unvaried state of thought and feeling, though commonly spoken of as
exceedingly to be desired, is ordinarily neither so profitable nor
so happy, as that condition of mind, in which the expectation of
death is not so constantly present, but occasionally gives way to
thoughts and emotions of quite a different character. The keeping
the mind strained up to a certain state, and fixed upon one set of
thoughts, is never either in sickness or in health profitable to the
individual himself, or to others. And aside from this consideration,
though the calm and fixed contemplation of approaching death has
something noble in it, and challenges our admiration, still the
triumph over death may be as signal, when there is occasionally an
indulgence of the natural desire of life, and a shrinking back from
the encounter with the king of terrors. The destruction of this love
of life, and the utter extinction of the hope of a recovery, are by
no means essential to perfect resignation. Indeed the highest degree
of resignation may exist when the desire to live is so strong as to
prompt the sufferer to catch with eagerness at the slightest grounds
of hope even to the last. Incidental circumstances have much to do
with the manner in which death is met. A cool temperament, the long
continued cultivation of a stoical indifference in the midst of
change and calamity, a morbid misanthropy, an habitual disposition to
fatalism, the breaking up one after another of all the attachments
to this world, the benumbing influence of disease or of medicine,
long familiarity with suffering, and the consequent capability of
enduring it, which is sometimes truly wonderful—some of these various
circumstances may conspire to render submission to the necessity of
the case easy, and give to the death-hour a calmness that is often
erroneously supposed to arise from a true Christian resignation. The
calmness thus induced is often an incidental adjunct to resignation,
and is sometimes auxiliary to it, imparting to it firmness and
steadiness in its manifestations. But it is in no wise essential to
it, nor one of its elements.
In chronic cases, which are going on gradually to a fatal
termination, there sometimes occurs either a temporary pause in the
onward course of the disease, or an alleviation of the symptoms of so
decided a character, that the patient and the physician cannot avoid
indulging for the moment the hope of a recovery. At such times the
bosom of the physician is the seat of conflicting hopes and fears. He
hardly dares to hope, when he calmly surveys the whole case from the
beginning. And yet he has known, he has himself _seen_ some strange
recoveries, perhaps even more strange than such a result would be
in the case before him. What now is his duty to his patient? Shall
he tell him the worst, as it is expressed, and thus extinguish his
rising hopes? Shall he say to him, “This very probably is only a
truce for a little while, and then your now dormant disease will
renew its attack, and perhaps with more vehemence; and, even at
this time, it may be secretly carrying on the work of destruction,
while the remedies are merely administering to your comfort, and
smoothing your passage to the tomb?” To say nothing of the evil of
such a course, if the case be susceptible of a cure, it cannot be an
advisable one, if the prolongation of life and the alleviation of
suffering be objects worthy of the aim of the physician; for such
a course would in most cases have a strong tendency to defeat the
attainment of these objects. If the friends of the patient deem it
important that such a view of his case should be presented to his
mind, let them take the responsibility of doing it themselves, and
not call upon the physician to do it. Ask not him to come to his
patient with the look and language of despair, and utterly dissever
the idea of hope from the efforts which he makes and the remedies
which he administers. Put no such unnatural, and cheerless, and, I
may add, profitless office upon him.
I remember once being strongly urged to such a course by the friends
of a patient. Whilst apparently going steadily down to the grave,
his symptoms at length became much relieved, and he took some
encouragement from the state of his case. In reply to the inquiry of
his friends, whether I had any hope of his recovery, I frankly said
that I had not, and that from all I could see I supposed that the
relief which he experienced was to last but a short time, and that he
must die very soon. They urged me to tell him so, but I declined, for
the reasons that I have stated above. The condition of comfort and
relief lasted in this case, contrary to my expectation, for several
weeks; and they were weeks of delightful intercourse, of affectionate
counsel, and of triumphant faith and joy. And I have not a doubt that
his life was thus happily prolonged in part by the cordial influence
of the hope, that the remedies which relieved his distress might
effect a cure.
It seems to be the idea of some, that there is something very
salutary in a spiritual point of view in the knowledge of the
fact, that death is certain and near. That it is more alarming and
awakens more emotion than the mere idea of danger, I allow; but
that it is more apt to produce right views and feelings is by no
means satisfactorily proved. Even if it be true, that the certainty
of death is more likely to secure decisive action in regard to the
interests of eternity, a decision under such circumstances is by
no means so worthy of confidence as one which is arrived at when
the hope of recovery is not wholly extinguished. To test this, take
as an example the feeling of resignation. When death is seen to be
absolutely certain, its very certainty is apt to induce a sort of
calm semi-fatalism, which has the appearance of true submission,
and is often mistaken for it through the charity and fondness of
friendship. But when the result is seen to be uncertain, if there
be amid all the balancing of the mind between hope and fear a
willingness to acquiesce in the supreme will, there is good reason to
believe that the patient has a true Christian resignation. There was
much force in the remark of a patient, who had for some days had the
certain expectation of death, but who had at length experienced so
much relief, that there was some ground for hope. “I am glad,” said
she, “that this relief has occurred, even if I do not recover; for
now I can fairly test the reality of my submission. I can put life
and death together, and examine my wishes and desires in regard to
them.”
There is one disease in which the disposition to hope is so
marked, that Dr. Good enumerates it among its symptoms. I refer
to consumption. In some cases, it is true, this symptom does not
appear, but despondency for the most part prevails. But this arises
either from a morbid sensitiveness of the nervous system, or from a
diseased condition of the digestive organs. When neither of these
circumstances exists, and the disease is uncomplicated with other
maladies, the tendency to hope is so strong as often to resist the
force of the most decisive evidence. Nothing is more common than to
hear a consumptive patient say, “Doctor, if you will only cure this
cough, I shall be well,” as if the cough were only a slight matter,
and its continuance was rather provoking than dangerous. I once saw
a physician deceiving himself to the last week of his life with the
idea, that his disease was in the stomach and liver, when there was
the most palpable evidence that the lungs, and the lungs only, were
diseased.
This tendency to hope is beautifully alluded to in a poetical sketch
of consumption by an anonymous author:
“Then came Consumption with her languid moods,
Her soothing whispers, and her dreams that seek
To muse themselves in silent solitudes:
She came with hectic glow, and wasted cheek,
And still the maiden pined more wan and weak,
Pale like the second bow: _yet would she speak
The words of Hope, even while she passed away,
Amid the closing clouds, and faded ray by ray_.”
Shall this hope, delusive as it so commonly is, be demolished by
the physician? Clearly it, in most cases at least, should not be.
For in very many cases it manifestly prolongs life, and adds to its
comfort and its usefulness, and in some cases it proves not to be as
delusive as perhaps even the physician is disposed to consider it.
Recovery does now and then occur in cases of true consumption, and
even in some which are quite advanced. The changes observed by means
of the stethoscope in the progress of some cases which have ended in
recovery, and the examinations of the lungs of those who have died of
some other malady, show conclusively that tubercular consumption is
not necessarily a fatal disease. Every physician who has seen much of
this disease has occasionally witnessed facts confirmatory of this
statement.[43]
In concluding this chapter I remark, that the obvious rule in regard
to the use to be made of hope as a curative agent is this—that
its cordial influence should always be employed, so far as it can
be done consistently with truth, and no farther. And the bare fact
that a case has ended fatally, when the physician has encouraged in
the patient the hope of a recovery, should by no means, as is often
done, be considered as proof that he has dealt falsely. He may have
encouraged the patient in good faith. For the physician, however wise
and skilful he may be, is not able to foresee with any certainty the
final event of sickness so frequently as is commonly supposed, and in
all doubtful cases he is bound to give the patient the benefit of all
the hope of which the symptoms will admit.
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.