The Elephant Man and other reminiscences/Breaking the News
XI
BREAKING THE NEWS
AMONG the more painful experiences which haunt a doctor's memory are the occasions on which it has been necessary to tell a patient that his malady is fatal and that no measure of cure lies in the hands of man. Rarely indeed has such an announcement to be bluntly made. In the face of misfortune it is merciless to blot out hope. That meagre hope, although it may be but a will-o'-the-wisp, is still a glimmer of light in the gathering gloom. Very often the evil tidings can be conveyed by the lips of a sympathetic friend. Very often the message can be worded in so illusive a manner as to plant merely a germ of doubt in the mind; which germ may slowly and almost painlessly grow into a realization of the truth. I remember being present when Sir William Jenner was enumerating to a friend the qualities he considered to be essential in a medical man. "He needs," said the shrewd physician, "three things. He must be honest, he must be dogmatic and he must be kind." In imparting his dread message the doctor needs all these qualities, but more especially the last—he must be kind. His kindness will be the more convincing if he can, for the moment, imagine himself in the patient's place and the patient in his.
The mind associates the pronouncing of a verdict and a sentence of death with a court of justice, a solemn judge in his robes, the ministers of the law, the dock, a pallid and almost breathless audience. Such a spectacle, with its elaborate dignity, is impressive enough, but it is hardly less moving when the scene is changed to a plain room, hushed almost to silence and occupied by two persons only, the one who speaks and the one who listens—the latter with bowed head and with knotted hands clenched between his knees.
The manner in which ill-news is received depends upon its gravity, upon the degree to which the announcement is unexpected and upon the emotional bearing of the recipient. There may be an intense outburst of feeling. There may be none. The most pitiable cases are those in which the sentence is received in silence, or when from the trembling lips there merely escapes the words, "It has come."
The most vivid displays of feeling that occur to my mind have been exhibited by mothers when the fate of a child is concerned. If her child be threatened a mother may become a tigress. I remember one such instance. I was quietly interviewing a patient in my consulting room when the door suddenly flew open and there burst in—as if blown in by a gust of wind—a gasping, wild-eyed woman with a little girl tucked up under her arm like a puppy. Without a word of introduction she exclaimed in a hoarse whisper, "He wants to take her foot off." This sudden, unexplained lady was a total stranger to me. She had no appointment. I knew nothing of her. She might have dropped from the clouds. However, the elements of violence, confusion and terror that she introduced into my placid room were so explosive and disturbing that I begged my patient to excuse me and conducted, or rather impelled, the distraught lady into another room. Incidentally I may remark that she was young and very pretty; but she was evidently quite oblivious of her looks, her complexion, her dress or her many attractions. I had before noticed that when a good-looking woman is unconscious of being good-looking there is a crisis in progress.
The story, which was told me in gasps and at white heat, was as follow. The child was a little girl of about three, almost as pretty as her mother. She was the only child and had developed tuberculous disease in one foot. The mother had taken the little thing to a young surgeon who appears to have let fall some rash remark as to taking the foot off. This was enough for the mother. She would not listen to another syllable. She, whom I came to know later as one of the sweetest and gentlest of women, changed at the moment to a wild animal—a tigress.
Without a word she snatched up the baby and bolted from the house, leaving the child's sock and shoe on the consulting-room floor. She had been given my name as a possible person to consult and had dashed off to my house, carrying the child through the streets with its bare foot and leg dangling in the air. On being admitted she asked which was my room. It was pointed out to her, and without more ado she flung herself in as I have described. The child, I may say, was beaming with delight. This dashing in and out of other people's houses and being carried through the streets without a sock or a shoe on her foot struck her as a delicious and exciting game.
The mother's fury against my surgical colleague was almost inexpressible. If the poor man had suggested cutting off the child's head he could not have done worse. "How dare he!" she gasped. "How dare he talk of cutting off her foot! If he had proposed to cut off my foot I should not have minded. It would be nothing. But to cut off her little foot, this beautiful little foot, is a horror beyond words, and then look at the child, how sweet and wonderful she is! What wickedness!" It was a marvellous display of one of the primitive emotions of mankind, a picture, in human guise, of a tigress defending her cub. By a happy good fortune, after many months and after not a few minor operations, the foot got well so that the glare in the eyes of the tigress died away and she remembered again that she was a pretty woman.
It is well known that the abrupt reception of ill-tidings may have a disastrous effect upon the hearer. The medical man is aware that, if he would avoid shock, the announcement of unpleasant facts or of unhappy news must be made slowly and with a tactful caution. In this method of procedure I learnt my lesson very early and in a way that impressed my memory.
I was a house-surgeon and it was Christmas time. In my day each house-surgeon was on what was called "full duty" for one entire week in the month. During these seven days all accident cases came into his surgeon's wards. He was said to be "taking in." On this particular Christmas week I was "taking in." Two of my brother house-surgeons had obtained short leave for Christmas and I had undertaken their duties. It was a busy time; so busy indeed that I had not been to bed for two nights. On the eve of the third night I was waiting for my dressers in the main corridor at the foot of the stair. I was leaning against the wall and, for the first and the last time in my life, I fell asleep standing up. The nap was short, for I was soon awakened, "rudely awakened" as novelists would put it.
I found myself clutched by a heated and panting woman who, as she clung to me, said in a hollow voice, "Where have they took him?" The question needed some amplification. I inquired who "he" was. She replied, "The bad accident case just took in." Now the term "accident" implies, in hospital language, a man ridden over in the street, or fallen from a scaffold, or broken up by a railway collision. I told her I had admitted no such case of accident. In fact the docks and the great works were closed, and men and women were celebrating the birth of Christ by eating too much, by getting drunk and by street rioting, which acts involved only minor casualties. She was, however, convinced he was "took in." He was her husband. She gave me his name, but that conveyed nothing, as it was the dresser's business to take names. With a happy inspiration I asked, What is he?" "A butler," she replied. Now a butler is one of the rarest varieties of mankind ever to be seen in Whitechapel, and it did so happen that I had, a few hours before, admitted an undoubted butler. I told her so, with the effusion of one eager to give useful information. She said, "What is the matter with him?" I replied cheerily, "He has cut his throat."
The effect of this unwise readiness on my part was astonishing. The poor woman, letting go of my coat, collapsed vertically to the floor. She seemed to shut up within herself like a telescope. She just went down like a dress dropping from a peg. When she was as small a heap as was possible in a human being she rolled over on to her head on the ground. A more sudden collapse I have never seen. Had I been fully awake it would never have happened. We placed her on a couch and soon restored her to consciousness. Her story was simple. She and her husband had met. The two being "full of supper and distempering draughts" (as Brabantio would say) had had a savage quarrel. At the end he banged out of the house, exclaiming, "I will put an end to this." She had bawled after him, "I hope to God you will." He had wandered to Whitechapel and, creeping into a stable, had cut his throat there and then. The friend who hastened to inform the wife told her, with a tactfulness I so grievously lacked, that her husband had met with an accident and had been taken to the hospital. This lesson I never forgot and in the future based my method of announcing disaster upon that adopted by the butler's discreet friend.
Although a digression from the present subject I am reminded of the confusion that occasionally took place in the identity of cases. All patients in the hospital who are seriously ill, whether they have been long in the wards or have been only just admitted, are placed on "the dangerous list" and have their names posted at the gate so that their relatives might be admitted at any time of the day or night.
A man very gravely injured had been taken into the accident ward. He was insensible and his condition such that he was at once put on the dangerous list, or, in the language of the time, was "gated." During the course of the evening a youngish woman, dressed obviously in her best, bustled into the ward with an air of importance and with a handkerchief to her lips. She demanded to see the man who had been brought in seriously injured. She was directed by the sister to a bed behind a screen where lay the man, still insensible and with his head and much of his face enveloped in bandages. The woman at once dropped on her knees by the bedside and, throwing her arms about the neck of the unconscious man, wept with extreme profusion and with such demonstrations of grief as are observed at an Oriental funeral. When she had exhausted herself she rose to her feet and, staring at the man on the bed, exclaimed suddenly, "This is not Jim. This is not my husband. Where is he?"
Now, in the next bed to the one with the screen, and in full view of it, was a staring man sitting bolt upright. He had been admitted with an injury to the knee. This was Jim. He was almost overcome by amazement. He had seen his wife, dressed in her best, enter the ward, clap her hand to her forehead, fall on her knees and throw her arms round the neck of a total stranger and proceed to smother him with kisses. Jim's name had been "gated" by mistake.
When she came to the bedside of her real husband she was annoyed and hurt, so hurt, indeed, that she dealt with him rudely. She had worked herself up for a really moving theatrical display in the wards, had rehearsed what she should say as she rode along in the omnibus and considered herself rather a heroine or, at least, a lady of intense and beautiful feeling which she had now a chance of showing off. All this was wasted and thrown away. An injured knee, caused by falling over a bucket, was not a subject for fine emotional treatment. She was disgusted with Jim. He had taken her in. "Bah!" she exclaimed. "Come in with water on the knee! You might as well have come in with water on the brain! You are a fraud, you are! What do you mean by dragging me all the way here for nothing? You ought to be ashamed of yourself." With this reproof she sailed out of the room with great dignity—a deeply injured woman.
To return to the original topic. In all my experience the most curious manner in which a painful announcement was received was manifested under the following circumstances. A gentleman brought his daughter to see me—a charming girl of eighteen. He was a widower and she was his only child. A swelling had appeared in the upper part of her arm and was increasing ominously. It became evident on examination that the growth was of the kind known as a sarcoma and that the only measure to save life was an amputation of the limb at the shoulder joint, after, of course, the needful confirmatory exploration had been made.
A more distressing position could hardly be imagined. The girl appeared to be in good health and was certainly in the best of spirits. Her father was absolutely devoted to her. She was his ever-delightful companion and the joy and comfort of his life. Terrible as the situation was it was essential not only that the truth should be told but told at once. Everything depended upon an immediate operation and, therefore, there was not a day to be lost. To break the news seemed for a moment almost impossible. The poor father had no suspicion of the gravity of the case. He imagined that the trouble would probably be dealt with by a course of medicine and a potent liniment. I approached the revelation of the dreadful truth in an obscure manner. I discussed generalities, things that were possible, difficulties that might be, threw out hints, mentioned vague cases, and finally made known to him the bare and ghastly truth with as much gentleness as I could command.
The wretched man listened to my discourse with apparent apathy, as if wondering what all this talk could mean and what it had to do with him. When I had finished he said nothing, but, rising quietly from his chair, walked over to one side of the room and looked at a picture hanging on the wall. He looked at it closely and then, stepping back and with his head on one side, viewed it at a few feet distant. Finally he examined it through his hand screwed up like a tube. While so doing he said, "That is a nice picture. I rather like it. Who is the artist? Ah! I see his name in the corner. I like the way in which he has treated the clouds, don't you? The foreground too, with those sheep, is very cleverly managed." Then turning suddenly to me he burst out, "What were you talking about just now? You said something. What was it? For God's sake say that it is not true! It is not true! It cannot be true!"