CHAPTER IIL

THE SICK-ROOM.

THE friends of a patient cannot, as said before, be judges of the amount of your actual knowledge; still, they will form their opinion of you, and of your skill, from the manner in which you conduct yourself. They will estimate the value of your physical examination by the pains you take. Now, it is within the capacities of the veriest dolt to take pains; he can do that at least! There is no excuse which is valid for not taking pains. Yet this is where the young practitioner most commonly slips. He jumps at his conclusions; that would not in itself be so flagrantly bad, but in so doing he ignores all else, or neglects to go over the case thoroughly. Consequently when the friends of the patient ask for a consultation, he bristles up, and takes up an aggressive attitude: are they not satisfied? they can call in some one else if they are dissatisfied! He usually, or too commonly, adopts a "hoitytoity air, or poses as an injured individual. Yet, my good young friend, if you will allow me to call you so, just analyse yourself a little more closely, and you will become conscious that you are afraid the consultant will find out something that you have not noted. There is the still, small voice of conscience to be heard by a fine ear. Yet you are a young man ; probably you have done nothing very particular to command their confidence, or perhaps they are stupid old country-people who take a long time before they give their confidence to any one, and then perhaps not very wisely; but anyhow they prefer a name with which they have been long familiar. Is this any matter for surprise? The patient's may not seem a very valuable life; but life is sweet to most, even

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the humblest, and there may be many affectionate ties betwixt the apparently uninteresting invalid and his or her relatives and friends, of which you can know nothing. A ready acquiescence will be most graceful on your part, and acceptable to them.

Excuse this little bit of sermonising-it has something to be said for it. The student sees a patient in the hospital: he is a number in a ward: his friends are people who come bothering asking questions, or wanting to see him at inconvenient hours. When he goes to private practice he is apt to carry a good deal of the hospital house-surgeon about him-I am not insinuating that this is wrong; but certainly it is sometimes injudicious. A hospital patient is the recipient of charity, and must conceal his feelings, unless flagrantly outraged. But when the fully-fledged owner of a diploma steps into a country village, he does not always realise that he is upon trial." A neat brass door-plate is a nice object for its possessor to gaze upon; but the heavy-looking man driving the cows past the door upon which it is mounted, is not so profoundly impressed; probably, in a vague indefinite way, recognises the advent of a new neighbour-"A young man fresh from walking the hospitals, I reckon !"

Well, now, when called to a patient, attend as soon as conveniently may be. Some handicraftsmen think it the thing to keep every job on hand as long as possiblelooks like plenty of business, they think. Yes; but plenty of business is far better than the semblance. The one is the reality, the other is the shadow. Don't fall into so transparent a wile! Remember, it is no longer your opinion about other people which has to be considered; it is other people's opinion about you. Turn about is fair play! So don't stroll into the surgery about 10 A.M. in your slippers, if you are a prudent young man. That might pass, or be passed over once; but it is out of place as a practice.

When you enter the sickroom, it is your duty to be sympathetic. The tragedian may have just come from the most mirthful society, the comedian's heart may be breaking at the last parting from a loved one; but

neither manifest anything of their inward feelings when they don the buskin, or watch the curtain draw up. So be sympathetic. Be circumspect; cause as little inconvenience as may be in putting down your hat and umbrella. Cottagers do not possess halls and umbrellastands, but they have feelings. Be cheerful, if possible. Your visit is a much-looked-for event-do not forget that. Indeed, it is the event of the day to the patient. Say she is convalescing after childbirth. You can be cheerful under those circumstances. "How are you today, Mrs. Greenlanes? How is the baby?" Don't forget the interesting little stranger whose advent is the cause of all the excitement and bother. "Have you slept well? Have your bowels been open ?" "No," she replies. "Do you feel uncomfortable, or not?" "No, I am quite easy, thank you!" If, on the other hand, she replies, "I feel very uncomfortable indeed," look to see what there may be to cause this. "How is the discharge: going on all right?" An affirmative answer. Perhaps there is some flatulence; just percuss the abdomen lightly. Ask, too, "Have you any difficulty in making water?" (Now if the patient has any difficulty, just instruct the nurse to press over the bladder when the attempt is made, and you will not often require to pass a catheter-a very unpleasant matter for both you and the patient; or if she says there has been some arrest of the discharge, have some hot cloths put to the vulvæ at once, and without delay.) Ask, then," Have you any appetite?" A cheery answer puts you at your ease about the mother.

Then turn to the baby. Ask-"Does baby suck nicely?" If the answer is in the negative, examine the nipple; sometimes it requires a nipple shield, or a little expanding with the breast-pump. Then comes the momentous question-"Is the baby tongue-tied?" If you do not put it, the mother or the nurse will. It may be so hindered in its efforts; but usually it is only clumsy in its first attempt at its new task. It is a legitimate lying-in-room joke never to cut the frænum in a girl-infant; it being taken for granted a female always acquires the use of her tongue. If a boy, it may

be necessary. Having seen to the baby; tell the mother to keep very quiet in bed for a few days; and order her not to have too much company during the time. If there are older children, it is permissible to ask the youngest that can talk, "How do you like the baby?" Of course, the young folks have their opinions, which probably vary. It is going out of fashion now to elicit opinions as to how the baby came: whether the doctor brought it, or it was dug out of the apple-tree root. These were matters upon which the child-mind was once much exercised; but nowadays it is found to be as well to avoid any such speculations, as at times leading to awkward situations.

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Some little time ago I asked two young medicos, each having been a resident house-surgeon, the following question. Suppose you are visiting an old gentleman of about sixty years of age, who is recovering from a sharp attack of bronchitis, and can sit up about three hours a day; you find him wrapped in blankets in his arm-chair, and a sharp-looking old lady sitting near him reading the newspaper to him. What will you ask?" Each got so far as to ask, "How are you to-day?" One got a step further. "How is your cough?" Then the interrogation ceased-the well of inspiration dried up! Yet neither were fools; they were, in my opinion, fair average specimens of the young hospital medico contemplating going into practice. When asked what they would do, with the greatest alacrity they declared they "would have up his shirt and examine the backs of both bases (lung)." Now this would of course be hospital practice; to neglect to do so would be to run the risk of a "wigging" from the visiting physician. "What," I asked, with the old lady sitting there?" Neither seemed to take the old lady into account at all; that part of my question was quite superfluous, apparently. Both looked a little taken aback at their want of gallantry in overlooking the old lady. In actual practice that old lady could not be safely ignored. She had seen lots of doctors before; was there to form her opinion about the new doctor, as one factor in her presence there, in all human probability. She had her rôle to play. Pointing

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out that such action would involve disturbing the old gentleman very much, deranging his blankets and chilling his back, and probably upsetting his temper, and was therefore not to be done without good reason for it; I went on to say that perhaps his shirt-tail might not be quite in that condition that he might care about the lady seeing it. This seemed quite a new light on the subject to both! Now there is such a thing as negative instruction; and this carries with it a lesson. Careful observation of the old gentleman, and especially the proper use of the watch in taking the proportion of the rate of the pulse and the respiration (as described at p. 49 of "Semeiology") would soon tell whether or not such examination was called for; if the respiration was mounting, then an examination was certainly indicated, and, if something was found to justify it, the patient would not mind the discomfort. But if nothing came of it, he would be apt to regard the doctor's visit as a nuisance. So never unnecessarily strip and distress a private patient; when you see them, you are supposed to have learnt your profession-they do not pay you for your attendance in order that you may perfect your education! Your hospital patient reconciles himself to his fate in the fervent hope that you will develop into a very clever young man ; and, stoically or not, submits to the inevitable. Do not pursue blind alleys, which lead nowhere, in your investigations; they do not impress the patient favourably. Then old ladies are not to be ignored; and it is as prudent to be civil to them, and do a chat about the weather, or other cognate subject of mutual interest. Why, bless these two guileless young souls, to make a good impression on that sharp-looking old lady was the most-far away the most important matter of the visit; if they only recognised it and knew it !

The conversation as conducted by an old family doctor of experience would have run on these lines; after an introduction to the old lady, conducted with all courteousness: "How do you feel to-day, Mr. Broadacres? -better?-yes, I thought so!" The old boy has been scanning him over to see whether he was better or worse: