The Left Atrium · De l'Oreille Gauche

CMAJ 2000;162:257-60

• A brief history of medicine
• One thousand words
• Being Frank
• I am
• Youth and observation

History of medicine: a scandalously short introduction
Jacalyn Duffin
University of Toronto Press, Toronto, Buffalo and London;
1999 432 pp. $70 (cloth) ISBN 0-8020-0949-2
$24.95 (paper) ISBN 0-8020-7912-1

The last chapter, "Sleuthing and science: how to research a question in medical history," gives invaluable advice for those of us who love to dabble in history. It also provides a plot for the book itself. As with a good "who-done-it," one can read this chapter first to appreciate the others. The preceding chapters, mainly organized around the traditional medical specialisms, proceed from a chronological account of the major events in each discipline to brief and stimulating discourses on today's issues. Philosophical concepts at the heart of medicine are addressed. For instance, in the chapter on physiology the debate between the materialists and the vitalists is introduced. This made me reflect on prions: are they simply matter, or are they alive?

The essential message of the book is that the truth of history can mean many things to many people. Our own experience and biases influence our interpretation of what at first sight are the facts of history. Readers will, in various ways, relish this book, reflect on it and profit from it. Male readers will be forced to consider the history of paternalistic beneficence in obstetrics and gynecology, a chronicle of benign neglect, ignorance and arrogance. We like to think that such attitudes are now behind us, perhaps because women (whose efforts to join the profession are recorded) are now fully represented in medical schools. However, history must stimulate us to consider what physicians of both sexes are doing wrong now. Are we too parental toward young patients? Do we still think of children as too immature to make the difficult ethical decisions that their illnesses pose? Is it their own interest or the ethos of "no baby, no nation" that makes us legally force treatment on them?

The first readers of this History of Medicine should be medical students. As the director of a history of medicine program I welcome this book, for at last I have a good textbook to recommend, one that follows the principles of education and fits the curricula of Canadian medical schools in substance and spirit. It should be bought by, or better still, presented to each Canadian medical student as a reward for acceptance into medical school. Its easy style and entertaining narration will keep students reading. It imparts our scientific origins and conveys the traditions of our profession. Students will savour the essence of medicine and be inspired by its heritage. They will also learn to question what they are taught: as Billings warned, "your new textbooks will be antiquated in five years." The motto of the Karolinska Institute's Web site on the history of medicine is, "The farther backward you can look, the farther forward you can see." Students need such education, for they will practise medicine in ways undreamed by us.

Other readers should be physicians like me who need regular brain dusting. We believe that we practise better medicine than our predecessors did, but history teaches us that any superiority we enjoy was built on their shoulders. History is also humbling in that it reminds us that we are probably wrong in many of our own concepts and therapies. We deride our predecessors' use of bleeding and antimony to treat inflammation for, if nothing else, these treatments produced fatigue, nausea, vomiting and collapse. But will the same be said one day of chemotherapy for cancer? This book also reveals the sources of the currents that sweep us forward and so often buffet our lives, such as the aspirations and problems of the Canadian health care system.

Amateur historians will find this a model for scholarly work and a source of important further reading, including the Web sites that lead to the great libraries. Several times I wondered if my own areas of interest would be addressed and was pleased to find the appropriate references listed. And Canadians will appreciate Duffin's perspective. Too often we overlook our country's solid achievements. Sir William Osler put it best in his introductory lecture to medical students in 1882: "Canada yields to no country in practical work and the average of its attainments."

Finally, I have to debate Duffin's argument that blood, that passive carrier of oxygen, is particularly special. Blood, we are told, is mentioned 460 times in the Bible and the lungs not at all. As a respirologist I must point out that without the breath of life man would be but dust and, without man, there would have been no rib. And then we, whatever our background, would not be here to enjoy this history of medicine.

Peter Warren
Director, History of Medicine Program
University of Manitoba, Winnipeg

Send a letter to the editor Envoyez une lettre à la rédaction

[Contents]

World War I soldiers, probably Canadians, suffering from fractured femurs, at the No. 7 Canadian General Hospital, Etaples, France, 1917 [Photo couresy of: W.L. Kidd collection / National Archives of Canada / PA-149304]

Send a letter to the editor Envoyez une lettre à la rédaction

[Contents]

It was long, long ago in a galaxy far, far away. I was leaving the hospital close to midnight on a Sunday, after attending one of my patients in childbirth. The quickest way back to my car was through the emergency room, and I was glad to be going home in time for a good night's sleep before the working week began again. The emergency room seemed quiet, but I wasn't surprised when the nurses asked me to see a patient, since I was there anyway.

A middle-aged man had come in complaining of upper anterior chest pain and palpitations, absolutely convinced there was something seriously wrong with his heart. By the time I saw him he was attached to a cardiac monitor and breathing oxygen through nasal cannulae. The pain had settled down. I listened to his concerns, asked a few questions and examined him. His chest pain didn't sound cardiac, but he was certainly frightened. He appeared to be in good condition, and I found nothing abnormal. I'm just an ordinary doctor who can barely spell supraventricular tachycardia and who thinks that aberrant conduction should get an orchestra a new leader, but his electrocardiogram looked fine and the squiggly lines on the monitor were good enough for me. I reassured him about the benign nature of his symptoms, asked him to come back if his symptoms recurred, and recommended that he call his own family doctor in the morning.

I was about to leave when one of the nurses took me aside and told me that the patient didn't have a family doctor and had been coming in several times a week for the last month or two, always late at night, always with the same complaint and afraid that he was going to die. "What he needs," the nurse said emphatically, "is a family doctor who will take an interest in him." She seemed to mean me. I was busy enough at the time, but not so busy that I couldn't take an extra patient or two. So I gave him my office address and suggested that he call for an appointment in the morning.

I got to the office a little early the next day, at half-past eight. My receptionist looked a bit put out. "Frank's here to see you," she said. "He's a strange one." Frank? It was the patient from the previous evening. I went into the consulting room. He was prowling up and down, pausing to inspect my framed graduation diploma on the wall. Frank was indeed his name, and although I have since forgotten his surname I've never forgotten him. I do remember that he was from eastern Europe and spoke English with a strong accent — as, indeed, do I.

He seemed to have a high regard for physicians trained in Europe and thought that my standing as a graduate of Glasgow University was good, although Edinburgh would have been better. He was restless and impatient, keen to tell me all about his chest pain and have me check it out. I don't think I had heard of panic attacks at that time, but it seemed to me that anxiety was a major part of his problem. "Frank," I remember saying, "if you weren't so worried you wouldn't have so much to worry about!" He looked at me as if I were mad and seemed convinced of it when I proceeded to listen to his chest and pronounce that his heart was strong and full of courage.

I don't know why I used those words and I had to think fast for an explanation when he irascibly and quite justifiably demanded to know what the hell I meant. All I could think of to say was that I admired the courage that had brought him to Canada in his mid-fifties without knowing a word of English. I remember contrasting my own relatively easy adjustment as an immigrant from Scotland to what must have been a very different experience for him. He seemed to accept my explanation and we agreed that he would come to see me once a week until we got to the bottom of his health problems. "Knowing that you can see me in a day or two might mean that you won't have to rush off to the emergency room quite so often," I said.

I got to know Frank quite well over the next few months. He had once been married and had a son, but he hadn't heard from his former wife or his son for years. His people in "the old country" had either been killed in the war or lost in the postwar population upheaval that convulsed Europe. "Doctor," he once said to me, "I've lost my place!" He had a job and apparently was good at it, but he didn't get on too well with the other people at work. He frequently did not understand what they were saying and, in any case, had little in common with them. He thought they were talking about him behind his back, and some of the younger ones played tricks on him.

Frank was lonely and unhappy, but he didn't seem to be able to put these emotions into words. His episodes of chest pain tended to occur late at night when he'd had a few beers and fell to thinking about his troubles. He didn't really see how I could help him, what with me not being a real doctor, a real specialist like the intimidating figures he associated with hospitals in his home country, but he was willing to talk to me and have me check him out regularly. At least I might be able to spot something early and get him to see someone in good time, someone who really knew what he was doing.

Over time, Frank's episodes of chest pain subsided. He accepted my humble reassurances about the fundamental soundness of his health and still seemed to be intrigued by my description of his heart as being strong and full of courage. He began to go to church and to attend occasional social events at the Legion. He stopped trying to examine my diploma with a magnifying glass and started to be a little late for his appointments.

Then, about three months after I had started seeing him, he missed an appointment. He was quite apologetic when he next appeared but, as he explained, he had a lot of things to do and couldn't always be running to see a doctor. He had met a nice woman and was thinking of asking her to marry him. He had been glad to come and see me and help get my practice established, but we were now both busy enough that he felt he would just come by if he had a problem. I was a very nice doctor, he said, but it was time I paid more attention to people who were sick. He didn't mean to be rude, he said, he was just being frank.

James McSherry
Professor of Family Medicine
University of Western Ontario, London

Send a letter to the editor Envoyez une lettre à la rédaction

[Contents]

Send a letter to the editor Envoyez une lettre à la rédaction

[Contents]

In Table of My Memory, Dalhousie University's Medical Humanities Program revisits the success of last year's student art exhibition on organ transplantation with a second Art in Medicine Project: this time, a meditation on Alzheimer's disease. The show features 50 works by Dalhousie medical students, who have used installation art, sound, painting and sculpture to explore their theme. Each artwork is accompanied by a written commentary on the symbolism used to represent the disease. More important, perhaps, is the personal engagement and self-exploration disclosed by these brief texts, in which the participants consider the implications of Alzheimer's disease not only for their patients but also for their own development as physicians.

Stephanie Smith, Class of 2001. Memory Tree. Mixed media. "The first contact I had with a person with Alzheimer's was when I was 16. I was volunteering at a nursing home and was asked to spend some time with one of the residents of the home. When I walked in she was quite agitated. She was sitting in her bed flipping through a book tearing out every other page, which she proceeded to throw up in the air so that she was surrounded by fluttering pages. The book was her address book. She could no longer remember the names in her book and was frantically trying to get rid of the evidence of her lack of memory. This image has stuck with me through all these years and many encounters with other Alzheimer's patients. This art project is a symbolic representation of this woman, the trunk symbolizing her body, rooted in reality, and the leaves, her memory, fluttering to the ground, out of her reach."

Project coordinator Jonah Samson writes that "one of the greatest strengths of the project is that, in creating these artworks, medical students really had to focus on the patient and to consider what the disease means to both the patient and the people who are close to the patient. This is particularly important when we consider the impact of Alzheimer's. We hope that through our participation in this project we are brought closer to providing humane patient care to our patients and their families."

Timed to coincide with Alzheimer's awareness month, the exhibition is on view until January 30 at the Sir Charles Tupper Medical Building at Dalhousie's Medical School. An illustrated catalogue of the exhibition will be published later this month.

Anne Marie Todkill
Editor, The Left Atrium

Send a letter to the editor Envoyez une lettre à la rédaction

© 2000 Canadian Medical Association or its licensors