Turning next to the uppermost patient record in the pile on my desk, I saw with dismay the name Thomas O'Connor on the label. I had referred Mr. O'Connor 6 months ago to the gastroenterologist, Dr. James Chang, because everything I had prescribed had failed. Here he was again, back to me for a physical. Tom's persistent complaint, that he couldn't move his bowels, had worn down Dr. Chang too. In fact, after trying again every known treatment, he had Tom swallow some radio-opaque tablets, and he proved by x-ray that they passed through his system in normal fashion. Tom still insisted that he had not had a bowel movement. If Jim Chang hadn't been able to help him, I thought, as I entered the exam room, what could I do?

"How are you, Tom? I haven't seen you in a while," I asked casually. I quickly walked the few steps to the rotating stool, which filled the space between the exam table and the wall where the sphygmomanometer hung.

The thin, pallid, white-haired figure slumped in the shiny metal chair, which had been fitted into the nearby corner. Just behind his head, there was a rack of pamphlets announcing in boldfaced type safe sex, hemorrhoids, and back pain. His bearing showed nothing of the straight-backed, smiling U.S. Army lieutenant in wartime France in the photograph he had once shown me.

He didn't answer me. I swiveled my chair to face him, rolled toward him, and hunched forward. "What brings you back?" I tried again.

Without looking up, he blurted, "Why can't they give me something to stop this God-damned bloating? I haven't gone in 5 days. I'd be okay, if I could just get rid of this bloating. Why doesn't anyone tell me what I should eat and what I shouldn't eat?" His only expression was the slow, circular, massaging movement of his right hand over the flat of his lower belly.

His weariness weighed on me. How many times previously had I given him detailed instructions about eating? "Are you taking the lactulose?" I asked after a moment, and again I recited the litany of treatment for constipation: diet, laxatives, fluids, exercise, and so forth.

He wasn't listening. "Why can't I get one good cleaning out?" he mumbled.

I couldn't think of a reply, so I asked, "Tom, how is your son?" I recalled the husky, middle-aged voice of Tom, Jr., who had answered when I had telephoned in past years.

"Didn't you know?" he answered with irritableness and disgust, "He died last February". He paused. "Massive heart attack," he continued, looking at the floor, the hand now motionless on the abdomen. "The doctors said it was the worst they'd ever seen".

"And your wife?" I had a momentary lapse of memory.

"Well, you know. She died 3 years ago". He looked at the wall opposite him, and speaking to no one, he added, "We were married 47 years".

His loneliness hit me. The sense of my own wife, Ruth, flitted through my consciousness. For a moment, my thoughts were blocked, and my own stomach churned.

Still I tried. "You're all alone, Tom. I know how close you were to your son".

"Yeah, we did a lot of things together," he said, his voice trailing off. Then he added, "But I was never someone to go out much anyway".

"But you must be lonely," I insisted.

He thought for a while. "I suppose I am kind of a people person," he said softly, "but I can't be around other people, when I feel so sick. They don't want to hear my complaints. No one wants to hear about it".

"You might not be so bothered by your pain if you had something to look forward to. Are you a member of a Vets club? Or a church?"

Again he hesitated, looked at me, and then said clearly and with finality, "I just want to get rid of this bloating".

Inside me, the sense of time began to prod me silently. "Well then, increase the lactulose to three doses a day," I said, articulating the words with measured pace and tone.

"Do you think that will help?"

"Try it for a few days". I knew we had tried the higher dose once or perhaps twice before, but an increase of lactulose might work this time, and maybe he would forget about the previous trials. I waited briefly, then went on, "Call me next week and let me know how it works". He still did not reply, but only stared forlornly. "And Tom, let me see you back again next month. Tell the secretary to give you an appointment". I was now talking rapidly as I rose toward the door. I expected that he would call and also that he would be back again, as ordered.

Our eyes met, we gave a brief tug of a handshake, and I hurried back through the door to my office, where I would add a note to his record later.

Still I felt his loneliness and thought over my own inadequacies. I looked at the medical records on my desk to drive away the shade of Tom's presence. And then I picked up the folder of the next patient.