The Necessary Evil

by André Couvreur

  Mathilde hastened to obey. She thought that the telephone call might be for her, and she did not always like to take her lover into her confidence. She leapt out of bed, put on some light slippers and a pink flannel peignoir, and in the coolness of the morning air, no longer combated by the dead ashes in the fireplace, she went into the dressing room.

  The bell fell silent; Armand listened, trying to make out the conversation, but Mathilde’s voice was muffled by the thick door-curtain. However, from the repeated appeals of “Hello, Sister!” he understood that the call was coming from the Avenue Hoche.

  Indeed when Mathilde returned, she said: “Remember this address, my cabbage: 18 Rue Breda, Monsieur Savoie. You have to go there this morning for a consultation. They’ll send for the family physician as soon as you arrive. He’s expecting you. It was Soeur Cunégonde who telephoned me.”

  Soeur Cunégonde often communicated with Mathilde in that fashion. Her investigative science had apprised her of Armand’s irregular situation, having no private apartment and living with his mistress, but she preferred to ignore that irregularity, pretending to believe that she was telephoning a domestic. Was it not necessary to accord a few petty sacrifices to the wicked ways of the world, for the greater good of the patients and the service of the good Lord?

  “I’m going back to bed,” Mathilde said. “I need sleep. That dream has upset me. Poor cat! Going to work for his Tithilde while she’s asleep! Oh, if I could only do something for you!”

  She climbed back into bed, heavily. At the same time, Caresco’s carriage, which came at nine o’clock every morning to stop outside the door of the house, troubled the aristocratic silence of the street. Armand embraced his mistress one last time, then abandoned the soft warmth of the sheets, put on his trousers and went into the next room to finish dressing.

  While preparing his ablutions, perfuming his water, he consulted his diary of visits. Numerous addresses already covered today’s page—meetings arranged some time before with colleagues and instrument-manufacturers—and he wondered how he would find time to fit in a further appointment. He decided to sacrifice his morning session at the sanitarium; Bordier could fill in for him.

  Freshly dressed, his hair lustrous, ready for the fray, he rapidly drank a cup of tea, and left.

  In an elegant first-floor apartment in the Rue Breda, Monsieur and Madame Savoie formed a happy and peaceful household. An eight-year old child, a sweet cherub previously healthy, completed the harmony of the family. Life for the trio had been limpid. The days had scattered a beneficent manna, and nothing had presaged a catastrophe when, a month ago, the child had begun to get thinner, had lost his customary gaiety and begun to complain of vague abdominal pains. At the same time, the abdomen had swollen, taking on unaccustomed proportions, like the belly of a batrachian—and all of that formed an ensemble of symptoms so alarming that the family physician, Dr. Varon, an honorable and experienced practitioner, who had diagnosed a tubercular peritonitis, had, in order to disengage his responsibility, even though the malady was getting no worse, suggested soliciting the advice of a colleague. Immediately, Madame Savoie had mentioned Dr. Caresco, who had operated on and cured one of her close friends.

  “Monsieur Caresco,” Dr. Varon had replied, “is not exactly the consultant we need. Your child’s case requires medical treatment, not surgery. Monsieur Caresco is only a surgeon. However, if you insist, I shall be happy to make his acquaintance, for he is an authority.”

  When Armand Caresco went into the drawing room, to which a footman introduced him in a grand manner, he found Dr. Varon and Monsieur and Madame Savoie waiting for him. The mother was weeping, anxious about the imminent verdict. The father was inoffensive in appearance. The aged colleague was grave, sincere, under no illusion regarding the scope of the encounter. Once the initial politenesses had been exchanged, Caresco was immediately taken to the patient’s bedroom.

  In bed, the poor stricken boy was waiting for the doctors’ visit. When his old friend Varon appeared he extended a fleshless hand toward him, fearfully, seeking an encouragement in his parents’ eyes, instinctively frightened by the cold and incisive gaze of the other physician. He had, however, been formally promised that no harm would come to him, that Monsieur Caresco was only going to examine him, in order to take away the nasty pain he had in his tummy…and he had been promised toys and candy after the consultation if he were good and did not cry. Even so, an anxiety racked the little soul, also afflicted by the malady, the unreasoned suspicion of the weak in the face of the unknown.

  He lent himself meekly to the examination, and replied politely with “Yes, Monsieur” or “No, Monsieur,” to Caresco’s interrogations. The latter, by reason of the luxurious appearance of the people who had asked for him, modified the brutality of his questions, striving to put a caress into his voice. The child even allowed his belly to be palpated, and heroically suppressed his tears when the surgeon, seeking to disturb the fluid that the walls of the abdomen contained, provoked a veritable stab of pain. Behind Caresco’s bent back, the mother blew her son reassuring kisses, and he received them with a pale smile, swollen by the desire to weep.

  The physicians conversed in technical terminology while measuring the extent of the malady. Strange words struck the child’s ears: ascites, meteorism, peritonitis and hypogastrium. At any rate, the diagnosis was manifest and they were completely in agreement. There was only the treatment to discuss, and to do that they went into another room, which had been reserved for them. An inkstand and paper had been set on a table for the drafting of the prescription.

  When they were seated, Armand Caresco looked at his colleague. The old man had a noble and grave attitude. Honesty radiated from his white-haired head, his benevolent eyes and his clean-shaven face, framed to the side by short side-whiskers that he pushed back toward his ears with a familiar gesture. His black frock-coat, open over an immaculate shirt-front surmounted by a stiff collar, his lighter trousers and his manicured hands, of which the right bore a gold alloy ring, also testified to a noble and correct soul, and a line of conduct that went bravely on to the end without any base detours. Caresco therefore judged it prudent to maintain a certain reserve from the start, and to engage prudently in the bargain that he was about to propose.

  His own opinion was already conclusive; it was necessary to operate on the tubercular peritonitis, open the child’s abdomen, get rid of the filth it contained and clean it out. It was a procedure that the young school of surgery was beginning to employ, which offered every chance of success. But would his opinion be admitted by his colleague? Would he not run into the conviction that maladies of this sort could be cured without the intervention of the knife, with prolonged treatment? Was Dr. Varon up to date with the progress of the science, would he admit the necessity of the operation, and, if he did admit it, might he not have a surgeon to propose to the family, some old comrade of his studies who had achieved a high official position?

  Caresco tormented himself with those problems while weighing up his colleague. He was determined not to let go, to press his resolution all the way and to impose it as soon as possible—for, behind the operation, he glimpsed the saving emoluments, the large sum that might be extracted from the purse of people surrounded by comfortable luxury, taxable at discretion. His resolution was accompanied by a joyous clink of coins, the rustling song of banknotes, to add to those already put in reserve for Israel.

  Mentally, he settled on a figure: ten thousand. But first, he judged it as well to envelop the old man, to make him a partner.

  “My dear colleague,” he said, “I thank you for having thought of me on this occasion. I know that the papers I’ve published on intervention in the course of tubercular infections of the abdomen must have attracted your attention, but after all, you could have asked someone else...”

  “Pardon me, my dear colleague,” Dr. Varon replied, surprised by a language to which he was not accustomed, “but it wasn’t me who asked for you. I would have pr
eferred to seek the advice of a physician. It’s the family who wanted to see you.” To soften his words, however, he added: “I was delighted by the decision, which has permitted me to make the acquaintance of a young master.”

  Armand inclined his head, pleased by the eulogy. That battle, however, seemed to have started badly on his side. He resolved to launch a frontal attack.

  “Well,” he said, “I think we’re in absolute agreement. We’re dealing, as you’ve said, with a tubercular peritonitis, which has spread, without considerable inflammatory reaction, immediately chronic. You’ve searched for the tuberculosis in other organs without finding it; there are no antecedents in the family except an aunt and uncle who died of tuberculosis; the direct parents seem healthy; the general condition of the child is not too bad. I believe that it’s an appropriate case for a laparotomy. My statistics include thirty-three similar cases, and I’ve had twenty-five successes.”

  “What do you call twenty-five successes?” asked Dr. Varon. “Do you mean that twenty-five of your patients out of thirty-three survived the operation, or that they were completely cured?”

  “You know how difficult it is to follow patients,” Caresco replied. “I lose sight of many, and I’ve often operated on people who, once out of my hands, neglect to come to see me again subsequently. I can’t, therefore, answer in an absolute fashion, with figures, for the consequences of the operations. What I can affirm, however, is that I operate quickly enough to be the man who exposes the lives of his patients to the least risk...”

  “Yes, I know, I know,” said the old man, in a slightly weary tone.

  Certainly, he knew that Armand Caresco operated brilliantly. The newspapers had publicized that sufficiently, and it had always been a subject of indignation for him to see publicity so easily accorded to questions of a purely professional order. Why inflate the organs of Renown to proclaim to the four corners of the world discoveries that were often recognized subsequently to be errors, and bring the ignorant masses up to date with scientific questions that they could not understand, and would judge with their irremediable stupidity?

  No, reputations thus acquired were unreliable, and science itself ought to remain mute, working humbly for the good of society, not causing either individuals or theories to burst forth in an apotheosis of glory, but only absolute verities, such as are discovered perhaps once a century. How many of these sensational discoveries touted by the drums of the press the old practitioner had seen! Now, he greeted them with a skeptical smile, contenting himself with doing his beneficent work honestly and simply, sickened by shameful publicity and feeling a sincere pity when he saw, among his clients, the incurable abandon him to run head first into the traps set for their ignorant credulity by unscrupulous colleagues.

  To be sure, those desperate individuals obtained a small benefit from their imbecility; the glimmer of hope that sustained them momentarily reacted on their nervous system, and even rendered them for a time, by virtue of the stimulus given to their nerves, an appearance of health—but afterwards, when disillusionment followed, when they perceived that the new treatments had no more effect than the old, and that, in spite of everything, disease was continuing its irrevocable work of destruction, that the cancer was still gnawing away, that the gangrene had not surrendered an inch of ground, that the tumors were continuing to grow, the ulcers to bleed and that nothing could stem the inexorable work of decay, what a dire repercussion there was, what a frightful reaction! How often he had seen those unfortunates come back weeping, extending their thin hands toward him, demanding his science and his humanity, with furious appraisals of the methods of the supposedly new medicine!

  “Yes,” Dr. Varon went on, after a hesitation, “I know that you operate remarkably, but I don’t believe that in the present case, a surgical intervention is appropriate, at least for the moment. I think that the general condition of the patient is too poor for the child to be submitted to such an ordeal. Would he survive an operation? I don’t think so. And then, I ought to tell you that he’s better at this moment than he was a week ago. It’s impossible for you to appreciate that change, my dear colleague; you haven’t followed the patient, but I can assure you of the regression of the illness. Now, if you have cured similar cases with your scalpel, I have seen many, in my practice, get better by themselves, and I hope that it will be the same for that child.”

  Armand Caresco was amazed by Dr. Varon’s opinion. He had never heard a controversy expressed so clearly. Generally, colleagues who did not share his enthusiasm for an operation in similar consultations seemed at first to endorse his opinion and then, as soon as his back was turned, proceeded to demolish his theory piece by piece, and to demand another, wiser consultation; they never imposed their appreciation so brutally. He therefore sought the reason for that resistance, and thought that he had found it in self-interest. Was Dr. Varon not opposed to the operation out of fear of losing a lucrative client? The surgeon’s mercantile soul lowered the soul of the old man to its own level, and he resolved to strike a bargain, skillfully to prepare a division, a sharing of the honorarium.

  “I confess, my dear colleague, that I’m slightly surprised to find you so hostile to the idea of a laparotomy. Independently of my statistics, there are also the statistics of other surgeons, less good in reality, because they do not operate as well as me, but all favorable to this kind of intervention.

  “But I’m not denying the beneficial effects of laparotomy,” Dr. Varon interjected. “I’m only claiming that the child is not in a condition to support one. Later, perhaps, there might be grounds to have recourse to one, if the child improves without being definitively cured.”

  “One is often wrong to want to wait,” Caresco said. “How to do you know that the regression you have observed will continue, and that you won’t regret one day not having taken a more rapid decision? Yes, I know, one hesitates before the disturbance and anxiety it will cause, and often before the sum of money that the family must expend...”

  Dr. Varon made a gesture of protest, which Caresco pretended not to see. Determined to make his proposal, he continued: “For one thing, I have no interest at stake. The honoraria I’m offered are indifferent to me, and I always leave to the family physician the care of setting them. Then again, I ought to tell you that I consider it a duty to thank the practitioner who calls me in for his aid. I deem that physicians are not sufficiently well paid for their work and inconvenience, and I generally offer them a percentage of my emoluments. That’s how things should be done within the great medical family.”

  How cleverly he had launched that proposal, the man who knew that nothing can resist the great motor of money! Money, with which one can buy everything, the consciences of politicians and the favors of women: the metallic stream that stuffs the belly, delights the eyes, leads to all enjoyments and all sensory satisfactions, even those of the heart! And as he spoke, his atavistic face lit up, with the avid expression of his mercantile ancestors, with its insinuating smile, the profile of his nose straying toward the thick-lipped mouth, and his think curly hair.

  But he had run into a noble soul, and this time, the old man rebelled.

  “Pardon me, Monsieur, but I don’t take commissions. Thank God, I have no need of that to live. You could have found other arguments to invite me to have recourse to your talents.”

  That was said dryly. Caresco understood that he had adopted the wrong strategy, that the battle was lost. He adopted an emollient tone.

  “I beg your pardon, Monsieur, if I’ve offended your sentiments. I made that proposal not to force your hand on the subject of an operation that I consider, on reflection, not to be absolutely urgent, but because I know that there many of our unfortunate colleagues to whom the offer of an equitable remuneration often gives pleasure. So, we shall say no more about it, and draft, if you wish, a medical prescription that will not change the treatment that you have instituted in any way, while making the reservation that an operation might become indispensabl
e at some future time.”

  Already, he had sat down at the table, had taken up the pen, and, contrary to custom, which dictates that it is the treating physician who writes the prescription, prepared to draft it—but Dr. Varon stopped him with a gesture.

  “There’s no need, Monsieur, since you don’t consider any change in the treatment to be necessary. It will be sufficient to explain it to the parents.”

  “If you wish.”

  They returned to the child’s bedside. The parents were waiting anxiously. The mother was caressing her son’s hair with a trembling hand, lovingly protective. Caresco was cold and reserved, saying very little, administering the final blow to the hopes of Monsieur and Madame Savoie.

  At the moment of departure, the young woman went to take an envelope from the mantelpiece containing a hundred-franc bill, and while Dr. Varon was delayed, taking to her husband, she followed the surgeon into the antechamber.

  “Doctor,” she said, “permit me to thank you for your visit.” She held out the envelope which Caresco pocketed, and continued: “I have the greatest confidence in you. You saved one of my friends, who was believed to be a lost cause. So, I beg you to reply to me frankly. Is my child doomed? Is there nothing to be done?”

  Her eyes were full of tears. The surgeon darted a suspicious glance toward the drawing-room door, and as his colleague did not appear, he resolved to make a reply that was perfidious with regard to the aged physician, abominable for the mother drowning in grief.

  “My God, Madame, it’s very difficult for me to reply to you. I’m not absolutely in agreement with the physician caring for your child that it’s necessary to let things take their course. Personally, I consider there might be a chance of salvation.”

  “Speak, Doctor, speak!”

  “I believe that an operation attempted immediately—not in a week, you understand, but immediately—might still save your child. The explanation is quite simple: there is a nucleus of disease in his abdomen that is secreting a liquid that makes it swell. If that disease is not alleviated, the abdomen will continue to swell and your child will die.”