Read an Excerpt
The Patient Has the Floor
Essays
By Alistair Cooke OPEN ROAD INTEGRATED MEDIA
Copyright © 1986 Alistair Cooke
All rights reserved.
ISBN: 978-1-4976-3994-2
CHAPTER 1
The Patient Has the Floor
I'm sure that Dr Johnson—your Dr Johnson—gave me an unintended opening when he wrote to invite me to be your speaker and added, 'You may discuss any topic of your choice; although all of us in Rochester who are involved in this programme are primarily in some branch of medicine, we do not necessarily expect an address related to medicine. Any topic of broad general interest would be suitable.'
This is, I imagine, the usual courtesy offered to pacify the fears of some statesman, lawyer or other grandee who never appears before a doctor except to have his chest tapped, his knees jerked, his tongue depressed, his innards photographed, his rectum proctoscoped and all his juices filtered, measured and pronounced upon. It is, though you may not know it, a permanently humiliating relationship: I mean the relationship between doctors and the rest of mankind. And it is because most people do not care to bring it up in public that I believe it might be useful for me to do so.
In fact, I think it is my duty as a journalist to speak for the patients to you. A journalist has always been the social link between the expert and the layman, between the public and the private man. At his worst he can become the publisher's disciple, the politician's yes-man, the tycoon's sycophant, the actor's press agent. But at his best he reports the world not as it ought to be but as his eyes and ears tell him it is.
Because our only relation with our doctor occurs when we need him badly we must all, for our self-respect, adopt in a mild form the delusion which every young mother hugs to her person: the belief that her obstetrician is the only man who has ever safely delivered a baby.
So I speak up for the patient, because the patient, when you see him, is usually too terrified to speak up for himself—I mean too terrified to speak about doctors. The raw material rarely answers back, which is what makes laboratory research so satisfying. But if the Mediterranean fruit fly could talk it would doubtless acquaint the farmer with some of his misapprehensions. The dolphin, whose whistles and grunts constitute a pretty sophisticated language, is already beginning to make us look silly. It is just possible that the layman, the patient tottering wide-eyed into this strange jungle of viruses and cultures and men in white, may see a few simple things which you do not see.
May I give you an instance, which happened the only other time that I dared to appear, so to speak, as a lay preacher before the College of Cardinals?
A few years ago, I was invited to Boston to speak at the annual dinner of the Massachusetts Heart Fund. I was expected, as I understood it, to launch the drive and supply, if possible, a slogan. When I arrived I found, to my embarrassed astonishment, that all my dinner companions were eminent heart specialists, including Dr Paul Dudley White, who—you may recall—preserved General Eisenhower.
My qualifications for addressing a distinguished body of heart surgeons and probers were hardly less pathetic than they are for facing you today, although my two closest friends at Yale were medical students who are now a surgeon and a psychiatrist of alarming distinction (whom I would still not trust to lance a boil or wipe a tear). I began to try and justify my being there by noting that a foreign correspondent is a man whose very employment requires him to keep up the bluff that he takes all knowledge for his province. So I shuffled in front of the doctors samples of their own jargon. I don't suppose I fooled any of the formidable men present. But even the most disinterested specialist in any country takes on the prejudices of his own land. And my own peculiar history—that of an Englishman born and bred, and an American tamed and naturalized—had forced me by accident into a peculiar specialty of my own, which is the continuous observation of what is British about Britain and American about America.
So facing these tolerant, though solemn, medical men, I took the risk of recalling that the United States is at all times a country with a passion for fashion. By which I don't mean it has a fetish for women's clothes (which country does not?)—I mean its ears are alertly tuned for the last cry in every kind of process: the latest trick in book-binding, or tree-planting, or bridge-building, or teaching piano, in bathroom gadgets, in theories of education, in cocktails, sex, architecture—in ideas.
All I could offer the doctors was the reminder that this trait extends also to the learned practice of medicine. For I recalled how, in the 1930s, every rash or sneeze was attributed to an allergy and a roaring business was done by manufacturers of flockless pillows and proprietors of Canadian resorts above the ragweed line. And so it went—down to that memorable evening before the heart specialists, which I dwell on because it explains why I am here and some of its lessons may apply to us.
At that time, the word 'cholesterol' gibbered through the land as the word 'unclean' used to herald the approach of a leper. There was a tremendous to-do about the lethal snags created in the bloodstream by carbohydrates and animal fats, either separately or in combination. Four or five years ago it was established, at least to the satisfaction of a panicky populace and the makers of anticoagulant pills, that cholesterol was as fatal as silt along a river bed and was responsible for most of the seizures and strokes of what are called successful men (that is, men who decide to take a first trip around the world and then keel over at their desks).
I gather that this precious discovery is now not only in doubt but is looked on by some specialists as a naive superstition, a hangover from the Dark Ages of medicine (namely the 1950s). The rush to consume only soybean and vegetable fats was declared to be premature. But carbohydrates are now more suspect than ever. So there is a national retreat from pastries and a grateful stampede back to beef, and lately, a learned pamphlet advises me, back to alcohol.
All I could say to this medical gathering was that if the cholesterol theory was true, and if animal fats and carbohydrates were certain prescriptions for heart attacks, then they would have to explain the miracle whereby fifty-five million Britons were still alive. For of all known civilized communities the British are the connoisseurs of animal fats and the compulsive addicts of carbohydrates–with their morning toast and eggs bubbling in bacon fat, their biscuits at eleven o'clock, their lunch of meat and potatoes and (worse) suet, then tea and more biscuits and cake, and dinner with meat and bread again, and potatoes and pudding—and perhaps an emergency snack of cheese and biscuits to guarantee coming safely through the night. How to explain the endurance, the ignorant but cheerful survival, of the British?
I saw that the doctors were now tense and puzzled, which is always a sign that you have a specialist by the tail. I was bold enough to offer an answer. Britain, I had noticed, maintains rights-of-way across fields and meadows and builds footpaths alongside highways, and uses the phrase 'Let's go for a walk' almost as an idiom. In America you cannot walk across fields except in pursuit of a ball with a liquid centre—and there are no footpaths once the town ends. The British walk, and cycle and walk, even in the rain. Let us face it, gentlemen, I said—'they function!' Could it be, I wondered—like Harvey groping towards the theory of the circulation of the blood—could it be that lumps of cholesterol could be shaken loose from the walls of the arteries by a lively bloodstream, as rocks and weeds are carried away by a river in flood? Perhaps the secret of avoiding blood clots lay in the humble admonition of the London bobby: 'Keep moving!'
After this barefaced performance I sat down in some embarrassment until Dr White told me that I had spoken words of the profoundest wisdom, and that he wished the slogan 'Keep moving' might be taken over and plastered on billboards throughout the United States. I told him it was not copyright but the trick would be to get the American population to learn, as a novelty, the very old process of walking to work, or simply upstairs.
The vainglory of this occasion came back to me when you flattered me with the invitation to be here today. I don't expect, and you shouldn't, any similar moments of clairvoyance. But sometimes the patient who doesn't know what ails him can help the doctor find out by merely reciting his gripes and grievances.
I have two. And they are the minor and the major themes of this talk.
The first is the subtle tyranny of fashion, even in the sciences, even in medicine. I have already suggested that it is worth any doctor's while to pause from time to time and ask himself whether he's really pursuing a new and fruitful line or whether he's running with the herd; whether he's falling back on a well-worn conviction or whether he's falling back on a national prejudice, or even a prejudice of the school he was trained in. Edward Rist, in his essay, 'What is Medicine?', noticed that 'in every country our colleagues have their phantoms and their ghosts. For the Englishman it is uric acid, for the German the exudative diathesis, for the American focal infection.'
It is simpler even than that. I have noticed in knocking around the world, and getting the same (the traveller's) complaint in several countries, that doctors, however circumspect, tend to take on the folk prejudices or habits of their country. Thus in France, every stomach upset is at once attributed to a malfunction in that ole debbil liver, which all Frenchmen alike regard as the most vulnerable of all human organs. They consequently soothe the stomach with bowls of vegetable soup and a glass of wine three times a day. In Germany, they administer first a black draft and then having tapped the belly with a wooden hammer to see if it gives off a tremulous hollow echo, they put you on black bread, chicken broth and charcoal. In England, they instantly prescribe a bland (not to wander around in search of a finer word), a bland diet of tea, blancmange and bread soaked in hot milk. In Scotland, I am glad to say, even eminent gastroenterologists order up a soothing draft of milk and whisky, the milk (a rather toxic fluid) being cut down and cut off as the patient improves. In America, the patient is abandoned at once to bouillon and jelly; and to ice water—to which, by the way, the British ascribe all American afflictions from peptic ulcer and coronary thrombosis to shortness of breath, sinusitis and the existence of the Republican party.
Now let us go to the main theme, which is about the dangers and the dullness of professional jargon: the use you make of the language that we—the doctors and the patients—have in common. What I want to do this evening is to make a plea to you as professionals whose main business is to restore men and women to their normal place in society (that is to say, whose professional aim is—as old Adolf Meyer said about psychiatrists—to bow out of the lives of your patients as soon as possible), I want to ask you to come half way to the patient and society in explaining to him health and disease. In other words, this is to be a little lecture on jargon, offered to a profession that is more prone to it than most. Why this should be so I have been unable to work out. In my boyhood the most practical aim of learning Latin was to help you employ as little Latin as possible in the use of English. If you know the roots of a word like 'circumlocution' it is then easy to see that the English word is 'roundabout'.
A few years ago I had a lively argument with a French journalist who started reciting to me all the English and American writers he had decided wrote badly. I couldn't guess his criterion until he mentioned that none of them 'wrote like Dickens'. I told him there was no compulsion to do that. He was astonished. He explained at elegant if laborious length that in France there was really only one acceptable prose style, outside of the argot and vernacular of farm and city life. The style had been established in the eighteenth century, if not earlier. Molière wrote it, Flaubert wrote it, so did Victor Hugo and so did President de Gaulle. I am happy to say that he was even more astonished when I told him that the beauty of English was its resilience, its great variety, the fact that it could embrace—and rejoice in—the styles of Dr Johnson and Art Buchwald, of Chaucer and Henry James, of Dryden and H. L. Mencken, of John Milton and James Thurber, of Hemingway and S. J. Perelman, of Bernard Shaw and Peter de Vries, of Mark Twain and the King James Bible.
You may say that you are not in the business of style. May I say that you are in the business of describing as precisely as possible what is happening to a man, woman or child that seemed to be healthy and is now certainly sick. I truly believe that the best doctors are trying with all they have to practise and vindicate the scientific method, which I take to be the effort to find a generalization that covers all the known facts. There could be no nobler aim in science or in writing. You are, in fact, faced with the central problem of style: which is to say as cogently as possible what a given audience can understand. When it is brilliantly done in medicine you have, by your own admission, the classic descriptions of disease—Buerger, Osler, Freud on the central nervous system, a mere journalist (I am proud to say), Defoe, on the signs and symptoms of the plague, even though he was too young to have witnessed it.
It is always a hard task but I'd like to elaborate on the fact that it is not peculiar to medicine. When something is exactly analysed, and the definition is stripped to the bone, it is always memorable; which may be why centuries of students have memorized the propositions of Euclid. For when Euclid says 'The angles at the base of an isosceles triangle are equal,' it stays said. Very often the thing defined is something that's been noticed for generations but never said so well. Aristotle was the first man to notice that 'A play tends to have a beginning, a middle and an end.' This sentence guaranteed his immortality for over two thousand years.
I think one thing that holds good medical men back from the attempt to translate their jargon into Anglo-Saxon is the fear that they will lose their academic standing and become known as a popularizer, which among American scientists is a horrid word implying a degradation of truth in the interests of fat royalties, public popularity or an invitation to appear on television. God knows we have as many of these fakers among doctors as we have among the hyperthyroid members of the clergy. But because something is done badly is no reason why it should not be done well. A Frenchman has told the history of the world more lucidly in a hundred pages than Sandburg can tell the history of Abraham Lincoln in four verbose volumes. We are short, and in an age of mass communications, pathetically short of good let alone great popularizers. I am sorry to have to say that I think the British have been in our time, and before our time, more concerned with the effort to reduce their professional longhand into the universal shorthand of the common speech. For classic examples we need go no further than one family and read T.H. Huxley on the habits of the ant or the butterfly and Julian Huxley on the biology of the penguin.
I know that most of you have not the time to say in two hundred words what the Journal of the American Medical Association manages to say in two thousand. I respect the scruple of any professional man who refuses to fall into slaphappy generalizations for the sake of simplicity. Where it is a matter of life and death, or even of pain and discomfort, it is better to be accurate than lucid. But what I am saying is that, given a simple fundamental change in medical education, rather a fundamental supplement in the early days, it would be possible for many more doctors to be both lucid and accurate. Suppose that a first-rate teacher of the English language gave regular courses to medical students during their internship—or, better, that there was always someone on hand to translate into English the parts and functions of the body at the moment a student was learning them, so that he discovers why fingerbones are called phalanges, because he is reminded of the array of a Greek phalanx; and he learns also that lumbar is simply a 'loin'; then the day might even come when doctors would talk to patients about collarbones instead of clavicles, and admit to a scared patient that an oedema is nothing more or less than a swelling.
(Continues...)
Excerpted from The Patient Has the Floor by Alistair Cooke. Copyright © 1986 Alistair Cooke. Excerpted by permission of OPEN ROAD INTEGRATED MEDIA.
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