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A Piece of My Mind
April 26, 2000

Holding the Bag

Author Affiliations
 

A Piece of My Mind Section Editor: Roxanne K. Young, Associate Editor.

JAMA. 2000;283(16):2073-2074. doi:10.1001/jama.283.16.2073

Dr Green shrugged eloquently when I told him he had pneumonia. It had been 45 years since penicillin had demoted his disease, once "the captain of the men of death," but he was already nearing his middle age by then, and perhaps he still remembered his helpless bedside vigils in the houses of dying children who had been skipping rope only a few days earlier. Perhaps his silence bespoke a vast disbelief; so much tragedy and death, all the grief-filled birthdays and anniversaries, now casually avoided with a handful of pills.

Later, when I told Dr Green and his family that he had Alzheimer disease, everyone thanked me for voicing the diagnosis that they had all suspected, and it was decided then that I should inherit his medical bag. I was flattered, but I explained that I generally do not take gifts from patients and, in any event, physicians no longer carry bags. Mrs Green retorted that the bag had sat in the closet, unopened since his last house call nearly 30 years earlier, and that if I did not take it, she would be just as happy to throw the thing out. "I've always been jealous of that bag, you know," she laughed. "He spent a lot more time with it than with his family. At least that won't be a problem for you."

A few days later I found an enormous old valise perched authoritatively on my desk. Ah yes, Dr Green's bag. Its outlandish size was far in excess of what I would require for the few instruments that I take on my occasional home visits. For a brief moment I imagined myself showing up at my hospital rounds with it, as a sort of conversation piece, but rapidly dismissed the notion as peculiar and anachronistic. I examined it with a more anthropologic eye. Despite considerable weathering, it was plain that the bag was finely tooled and had been crafted of expensive materials; the owner of such an artifact would have been treated with considerable deference. In its serene majesty it inspired the same hushed veneration as museum displays of jeweled vestments or cavalry sabers or other emblems of high office. I imagined wielding it at insurance executives and government functionaries, who would be brought low before an absolute sovereignty that I was, alas, incapable of projecting personally.

Beyond this, I was vaguely embarrassed in its presence. The doctor with bag in hand is a nostalgic icon of trustworthiness, commitment, and personal service. Flaubert, for instance, relates that when Emma poked Dr Bovary to make sure he was asleep, he immediately muttered, "All right, I'll be right there," before realizing that he was not, in fact, required for yet another night visit. I also recalled another anecdote, which occurred in the late 1890s:

The call came in while I was in a night sweat incident to tuberculosis. I expostulated with the messenger, explaining that it would be dangerous for me to go out in my condition on a cold night and urged him to call another doctor. He said their regular doctor was not at home. So I bundled up the best I could.1

Sitting majestically on my desk, the bag presented a vaguely accusatory air, as if I were personally to blame for the loss of these heroic standards. I began to lift it, and I felt a more intimate connection, swift and visceral, like a memory of cruelty. I dropped it back on my desk, where it landed with a complex crash of metal and glass.

I cautiously opened the bag and any other ideas I may have had about it wilted before its stale breath of old leather, the undergraduate chemistry lab, and well-established mildew. Inside, among a chaos of ancient gauze, finger cots, glass syringes, vaginal speculums, and rusting scalpel handles, were perhaps 50 bottles of moldering brown liquids and crumbling pills. I found harmless vitamins jumbled up with digitalis, Armour thyroid, chlorpromazine, and reserpine. Another shelf contained a portable hospital pharmacy. Here I found vials of injectable nostrums containing morphine, procainamide, oxytocin, phenytoin, vitamin B12, and pork insulin. Most of the labels were familiar but some, like luminal and hyoscine, I knew only from reading Agatha Christie novels, where the empty bottles were forever turning up at crime scenes. From the deepest recess of the bag I exhumed a jar of evil-smelling paraldehyde, around which a decaying rectal catheter coiled like a toothless old caduceus.

Like his colleagues of the time, Dr Green must have dispensed these substances in the unmonitored privacy of patients' homes in accord with his own experience and beneficence. He was free to exercise the art of medicine without the modern constraints of evidence-based guidelines, expert panels, or peer review. The bag, I thought sourly as I contemplated a pile of forms lying beside it on my desk, was a posthumous footnote to a debatable "golden age," whose adoring patients blindly trusted their lives to the seat of the doctor's pants and doctors, for their part, were widely understood to bury their mistakes. I looked up at the clock and found that I had kept my own patients waiting while indulging my curiosity. I stashed the bag in a corner of the room and got on with my day.

Later that evening, as I got ready for bed (with the answering service screening my calls), I identified my real familiarity with the bag. Through a haze of memory, I remembered seeing a bag like this when I was 8 years old. Every evening for a week my doctor and his bag appeared in my bedroom, where I was out of my mind with high fever and hallucinations and the unseen irons that battered at my skull in an endless torment. He sat on my bed each evening and, in the dim light from the hallway, rummaged in the bag for a rectal thermometer, an otoscope, and a daily injection that made me feel better for several hours, until the medicine wore off, and the headache and neck pain shrieked me awake again in the middle of the night.

He spoke to me softly in his deep voice, and each visit was a lifeline from the ordinary world, to which I knew I might never return. The bag seemed to be a talisman for his safe passage through the netherworld of disease, and I clung to its image throughout the long delusional days and nights. It was my only certainty among the terrifying images that crested and broke in every direction. If he had failed to return to my bedside one night, I might have let go of the rope and slipped forever into the maelstrom.

Still, when I continued to experience fever, headache, stiff neck, and photophobia after several days my parents sought out another physician, who immediately sent me to the hospital for a lumbar puncture, whose results were consistent with viral meningitis. Perhaps, given the greater reliance on bedside diagnosis at that time, my doctor was able to discern a viral from a bacterial origin with sufficient certainty to spare me a lumbar puncture. Perhaps his shot contained a dose of penicillin, just in case. Perhaps the possibility of meningitis had not occurred to him at all.

In the end, I think, I was simply fortunate that my symptoms did not represent something worse and that my recuperative powers were what they were. I find it difficult to understand this historical figure, the doctor with his bag who came to my house every night, who may or may not have helped me, and whose devotion perhaps exceeded his ability. I do not know if he is still in practice and, if so, how he is adapting to our own time, when physicians are more widely accused of a different inequality between caring and skill. Still, despite myself, I cannot help remembering that bag, and what it represented, with an involuntary thankfulness. Perhaps it is why I am here today.

So Dr Green's bag sat next to my bookcase for several months, among the slowly aging journals that accumulated around it. I suppose that I hoped it might someday speak to me, like an oracle, of something transcendent, some reliable truth that I could grasp among the restless swell of evidence and debate. But of course it simply sat there, another object, an artifact, just one more outdated old thing that gathers dust. Although I think I may have once experienced something of its unquantifiable power, the modern habit of mind rebels against its mythic claims. The actual bag now sits in my closet, awaiting its uncertain future in a world that, to both its advantage and detriment, seems to be outgrowing its seductive and perhaps dangerous magic.

References
1.
Hertzler AE. I go to the patient. In: The Horse and Buggy Doctor. New York, NY: Harper & Brothers; 1938:79-80.
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