The Left Atrium · De l'Oreille Gauche

CMAJ 1999;160:1609-12

• The charm and the leaf
• Claims to fame
• Dry eye syndrome
• Behind the small screen
• Lacrimae

We have a problem in conventional medicine nowadays. When (or if) our patients improve, we assume this to be the result of the medicines we prescribe and the procedures we perform. We believe that the actual person of the doctor doesn't make a difference. For a lobar pneumonia, amoxicillin prescribed by Dr. A has the same effect as amoxicillin prescribed by Dr. B. In practice, the truth is not so simple. The person with the pneumonia — as opposed to the bacteria that have caused it — doesn't respond in the same way to every doctor.

This probably isn't much of a surprise: at some level, most of us accept that there is more to making patients feel better than medicine alone. We all know that some doctors make some patients feel better more quickly than the average (sometimes even before medications are started) and that, on bad days, using the same medication for the same condition, the same doctor may produce a less satisfied patient. We all have some patients with whom we seem to do brilliantly well, and others with whom we don't. As Socrates said to Charmides in explaining the cure for headache, "the cure itself is a certain leaf, but in addition to the drug there is a certain charm which if someone chants it, the medicine altogether restores him to health, but without the charm there is no benefit from the leaf" (italics mine). Of course, we are not talking about "charm" in the sense of a magic spell or incantation, nor about "charm" in the sense of sweet-talking or razzle-dazzle. That statement by Socrates really refers to all of those factors surrounding the physician­patient interaction that change the patient's expectations of the disease and treatment and his or her perception of the outcome. We are talking about an awkward and uncomfortable subject: patients' psychological assessment of their illness and its symptoms, and their interpretation of all the things we do to try to improve the situation. We are talking here of placebos, of patients' hopes and responses, and the many implications of these.

In this wonderful book, Dr. Howard Spiro neatly unpicks the many tangled threads of the placebo issue. His stance is particularly useful not only because it is free of mysticism and dewy-eyed wonder, but also because it is so well researched and documented. He starts with the important reminder that "disease is what the doctors find, but that is quite different from illness, what the patient feels." He moves on to discuss the role of placebos as anything — including a procedure — that is "objectively without specific activity for the condition treated." He then looks at the role placebos have played in the history of medicine (for centuries there wasn't much else) and how the recent focus on science has led many of us to do more for the disease and (unfortunately) less for the patient. A Yale-based gastroenterologist, Spiro gives a trenchant and well-founded discussion of the deficiencies of contemporary US-style medicine, particularly in the way it has weakened and strained the physician­patient relationship. He analyses why conventional physicians are antagonistic to the idea of placebos, and then (in a full and thoughtful chapter) why practitioners of alternative medicine aren't.

Spiro puts forward some practical criteria for the use of placebos. They should be used only after a careful diagnosis and should not have any therapeutic action of their own. The physician should not tell outright lies to the patient, and should not give placebos to patients who have asked not to receive them. They should never be used when treatment is clearly called for, or when alternatives have not been discussed. Spiro also provides a useful discussion on informed consent. On this subject, I once proposed that we all post a sign in our waiting-rooms that reads: "As part of your treatment your doctor may prescribe certain drugs that have not been shown to have a specific activity against disease. Nevertheless these drugs are completely safe and many patients find them beneficial. If your doctor thinks they may help you, she or he may recommend them to you." Patients would be given the opportunity to specifically decline this option.

The Power of Hope sets the stage for a serious discussion that our profession must have. Without that discussion we will be perceived, correctly, as a rather cold, science-centred group with an unfortunate tendency to focus on disease while paying too little attention to illness. This book is the most thoughtful and beguiling essay I have read on the art of the science of medicine. Nowadays, the science of medicine is not enough: our patients demand, quite appropriately, the art of that science as well. We sometimes have the leaf, but we always need the charm that goes with it.

Robert Buckman, MD
Toronto-Sunnybrook Regional
Cancer Centre
University of Toronto

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1. Buckman R, Lewith G. What does homoeopathy do — and how? BMJ 1994;309:103-9.

One summer's day in 1928, Alexander Fleming, a physician in the Inoculation Department of St. Mary's Hospital in London, England, observed that a mould had contaminated an agar plate seeded with Staphylococcus and had apparently dissolved the bacteria in its vicinity.¹ He succeeded in extracting some of the active principle in the mould, gave it the name "penicillin" after its source, Penicillium, and published a series of papers on its antibiotic action on a variety of bacterial cultures. He failed in attempts to purify the extract to a quality, or in a quantity, sufficient for animal experimentation, much less clinical testing, and finally abandoned this work. Ernst Chain, a biochemist in Howard Florey's laboratory in Oxford, learned about penicillin from the literature 10 years later, directed all his efforts toward its isolation and obtained a greatly purified form in early 1940,² after only about a year's work. Chain's success can be attributed to his experience with the purification of enzymes, the most ephemeral of substances. Fleming, Chain and Florey shared the 1945 Nobel Prize for physiology and medicine.

"Technicians flog children to collect tears for the preparation of Fleming's lysozyme." Reproduced from the St. Mary's Hospital Gazette, 1923, with permission of Audio Visual Services, Imperial College School of Medicine (St. Mary's Campus), London, UK.

In 1971, the Royal Society of London held a symposium celebrating the introduction, 30 years earlier, of the first antibiotic into clinical medicine. In his introductory address,³ Chain gave his account of the events. It is disheartening to read how he belittled Fleming's discovery with the speculation that he, Chain, or someone else would have found penicillin sooner or later. Chain acknowledged neither Fleming's bacteriological expertise nor the fact that Fleming had been primed for the discovery of penicillin by his discovery in 1922 of lysozyme, a naturally occurring substance in tears and the nasal mucosa that is also capable of dissolving bacteria.

Fleming's discovery of penicillin remains one of the proudest moments in the history of our profession.

Wolf Seufert, MD, DSc
Université de Sherbrooke

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1. Maurois A. La vie de Sir Alexander Fleming. Paris: Hachette; 1959.
2. Chain E, Florey HW, Gardner AD, Heatley NG, Jennings MA, Orr-Ewing J, et al. Penicillin as a chemotherapeutic agent. Lancet 1940;1:226-8.
3. Chain E. Thirty years of penicillin therapy. Proc R Soc Lond B Biol Sci 1971;179:293-319.

A Very Common Prescription

I store a tube of tears in my refrigerator.
Many people must do the same.
It has been an excessively dry summer
and you use your eyes more than is good
for them, the doctor said.
At the drug store I was embarrassed
to see what it was
that he had prescribed for me.
Tears! Why, good God, I mean
I cry almost every day of my life.
If I've no better reason
I've only to relax my grip
to have my eyes moisten
at the memory of certain
scenes in old movies:
say, Gregory Peck's funeral
in The Gunfighter. Surely,
that ought to be enough.
I was tempted to say this
to the clerk when she handed over
the medication. Lady, it's not
what you think, by heart isn't
made of flint; believe me,
I hurt too. But that wasn't as bad
as reading the fine print
when I got home. Keep tightly
sealed and refrigerate
after use, it said.
If we have house guests I'll hide
the tube at the bottom of
the vegetable crisper.
And to think there are factories!
I picture them as being
windowless, lit by pale blue bulbs,
and containing row upon row
of workers in smocks and hairnets
who sit on long benches, bend
over long tables,
weeping into sterile tissues
for forty hours a week,
men and women who when they're asked
their occupation have to answer:
tear-maker.

Alden Nowlan

Reprinted from An Exchange of Gifts, by Alden Nowlan (Toronto: Irvin, 1985), by permission of Stoddart Publishing Co. Ltd, Don Mills, Ont.

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I'm as much of a TV snob as the next person. Ask me and I'll tell you I never watch it, though I might concede a bit of PBS. Okay, sure, snippets of Hockey Night in Canada during the playoffs. Or ER — out of professional curiosity, naturally.

But the fact is that I grew up in the television era. I was mesmerized by the small screen and powerless in its vicinity. I passed my childhood bathed in TV's flickering glow.

So the chance to serve as a technical advisor for one day on a TV series shooting at Eagle Ridge Hospital was enticing. The bonus opportunity of appearing on the show as an extra proved irresistible. I'd be able to watch television from the other side.

At 7 am on the appointed day, Hilary Tisseur, hospital liaison officer during the filming, introduces me to a former-nurse-turned-TV-technical-assistant. She shows me to the extras' holding area, and I check in with the manager.

Three RNs and I are brought to the set, all of us to be used as extras. I grow restless waiting for the start of the shoot. A script is thrust into my hands, and I eagerly begin reading. I find my nose contorting, as if exposed to an unpleasant odour. This is not Shakespeare.

Distracted by the start of the action, I toss the script aside and peer over to the set. I had always imagined that a director stood over his actors like a lion tamer, cursing and cajoling. The reality is a bored baby boomer following the proceedings on a TV monitor and punctuating his ennui with "Cut" or "That's a print."

The scene involves an intern with the rugged looks of a California surfer and a nurse with long legs and a tight uniform. Affecting a French accent, he asks her out for dinner while a violinist stands behind them playing a serenade. This action, of course, takes place in the hospital. The interlude is interrupted when another nurse, equally thin and impractically attired, rushes in with dramatic developments.

"Trauma room STAT. One victim, multiple injuries, respiratory compromise, ETA two minutes." Except that she can't get her tongue around "respiratory compromise," stumbling over the same syllables take after take.

The director calls for a break, and I see him with the actress, whether cursing or cajoling I can't tell. I walk with the real nurses down the hall, following the cast and crew to the room with assorted refreshments and snacks. I help myself to some papaya-orange-guava juice, nibble on some dark chocolate and take a few strawberries and slices of fresh pineapple. Suddenly the extras manager bursts into the room.

"You extras, get out!" This is for the cast and crew only. You should know that. OUT. NOW."

Hilary comes to our rescue. She schmoozes, pats bruised egos and bends the rules with a wink and a smile. I partake of papaya-orange-guava juice again. We hang out with the actors and eat a delicious catered lunch. This Hilary knows how to play Hollywood.

Eventually we move to the trauma scene. I help the actors playing paramedics prepare their patient with an IV line, hard collar, spine board and oxygen. I run through the basics of chest-tube insertion with an actress. She is a Vancouverite, warmer and less distant than the others who play the main characters. She tells me that she must empty her speech of any trace of Canadian inflection: hostil not hostile, sahrry not sorry.

The script calls for the trauma patient to be in respiratory failure secondary to a tension pneumothorax, but I find the action puzzling. I had been led to believe that a Los Angeles physician had edited the script for accuracy.

I try to get the director's attention. He regally ignores me. I find the former-nurse-turned-TV-technical-assistant to convey my concerns. She talks to the assistant director, who then slides over to talk to me.

"Sorry, but I'm a bit confused about the script," I say.

"Really?"

"The patient has a tension pneumo and is gasping for breath; he's on his way out, correct?"

"Right, that's it. We wanted some heart-thumping drama."

"Fair enough. But did you really want the trauma team to finish him off?"

"What? That's not the idea at all."

"Oh, sorry. It's just that I thought you had a medical editor ... anyway, the point is that if you intubate the patient before you decompress his chest he might very well die. And it would be the physician's fault, see? Chest drainage first, okay?"

We rehearse the act. The plot turns on one of the nurse characters finding the trauma victim to be her husband. Horrified, she backs away from the scene. My eyes roll involuntarily, as if struck by billiard balls.

The resuscitation scene proceeds. I decide that I should be the one to intubate the patient. Why not? I do the real thing all the time. I give the assembled actors a few instructions on how to carry out their respective tasks. I begin to feel that this is a mock trauma code and that I'm the team leader. I get entirely carried away by the moment.

"Okay, break," the director barks. "Everybody back in five."

"I need to speak to you for a minute," says the assistant director. "Say, thanks for all the technical advice. Looks like we're not going to need you for this scene, though. But hey, you can do a walk-by later, huh?"

The next act involves a patient with a toilet stuck on his foot. The flickering glow has faded; I decide to bring my feet back down to earth. I've had enough TV for one day.

Out in the parking lot one of the crew is moving equipment. "Hey Doc, forget about this TV stuff. It's not for you, I can tell. Go back to medicine, that's what you do."

Brian Deady, MD
Emergency Department
Royal Columbian Hospital
New Westminster, BC

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The series of lithographs entitled Watermarks: a comparative study of artificial tears (1998) by Barbara McGill Balfour makes reference to the conventions of a scientific trial by examining and comparing the action of three brands of artificial tears when they come in contact not with skin, but with stone. The process of lithography depends on the antipathy of oil and water, and on the receptivity of stone to both. As Balfour writes, "Artificial tears, like the natural tear film they replace, are composed of both oil and water, and thereby leave discernible traces on lithographic stone, capable of reproduction. In addition to relieving the discomfort of 'dry eye syndrome,' the synthetic tears occupy an ambiguous position. What is their relationship to 'natural tears,' those transitory traces taken to be proof of genuine emotion?"

Barbara McGill Balfour, Watermarks, 1998, print installation.

The difficulty of reproducing Balfour's almost invisible subject on the printed page testifies to the paradoxical power of tears: despite their transparency they are extremely noticeable. We give enormous significance to tears, believing that they represent a kind of leakage of the true self. Our possession of qualities such as weakness or stoicism, vulnerability or maturity, coldness or empathy may be judged by others on the evidence of how readily, and on what occasions, tears spring to the eye. Thus a photograph of the premier of Alberta in tears at the funeral of a teenager killed in a shooting was recently front-page material. We value tears, but not to excess. Chronic tearfulness is taken as a sign of psychological imbalance (aside from crocodile tears syndrome, lacrimation stimulated by eating, a sequela of facial palsy). And dry eye syndrome is treated because of its physical, not psychosocial, effects.

Barbara McGill Balfour, Watermarks, 1998 (detail). Lithograph on handmade paper, 16" × 21".

Watermarks was first shown as part of Balfour's exhibition SoftSpots at the Southern Alberta Art Gallery in Lethbridge in October 1988. SoftSpots, which included the works m melancholia & melanomata, highlighted in the last issue,¹ and Taches de rousseur (freckles), uses a range of printmaking techniques to explore clinical and emotional "readings" of marks on the surface of the body. Balfour currently teaches in the Department of Studio Arts at Concordia University in Montreal.

Anne Marie Todkill
Editor, The Left Atrium

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1. Todkill AM. M-words. CMAJ 1999;160(10):1484-5.

© 1999 Canadian Medical Association