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The Left Atrium
It's always salutary to discover how others see us, whether as individuals or as a culture. Hygieia: Literature and Medicine, a special issue of Mosaic, a quarterly journal based at the University of Manitoba, views medicine through the lens of literary theory, offering interesting perspectives and some equally interesting scotomas. The study of medicine as reflected in literature was one of the strategies medical educators devised to develop students' imagination and empathy. In the inaugural article in a series dedicated to literature and medicine, Faith McLellan and Anne Hudson Jones (Lancet 1996;348:109-11) identified two founding strains, the "aesthetic," which centred on the literary analysis of complex texts, and the "ethical," which focused on content rather than form. Subsequently, these approaches merged in the study of narrative ethics, which recognized the inherently narrative structure of medical knowledge. The essays collected in Mosaic reflect this latter development. "Narrative" includes not only works of literature, but also histories, case histories and family histories. They are constructed by patients, physicians and cultures, and those constructions may not necessarily agree. In her essay, "Medical Body and Lived Experience: The Case of Harriet Martineau," Anka Ryall describes one public struggle for control of the medical narrative. Martineau was a prolific advocate of mesmerism. Her writings challenged the insecure young profession of medicine, whose representatives publicly reinterpreted her life, personality and activities in terms of her ovarian disease. The wielding of narrative by physicians is also explored in James Krasner's essay on the writings of the young Arthur Conan Doyle, who portrayed his medical mentors, Joseph Bell and George Budd, as masterful, even bullying, in putting forward their interpretations of their patients' lives and afflictions. Conan Doyle went on to create a masterful, controlling narrator in Sherlock Holmes. Medicine has come to recognize that healing is most effective when it is conducted according to the patient's own narrative. In "'carvin' white folks': Faulkner, Southern Medicine, and Flags in the Dust," Kirk Melnikoff describes the state of medicine in the American South in the 1920s and 1930s, with its folk practitioners, patent medicine peddlers, old country doctors and emergent professionals. Faulkner's character, old Bayard Sartoris, must find his way to a practitioner who shares his language and his values before he can be cured. Conversely, in "Raven's Plague: Pollution and Disease in Lee Maracle's Ravensong" (Judith Leggatt), the Salish people and the whites are powerless to help one another, since both cultures have such different beliefs about the cause of disease. To the whites, the Salish are made ill by their close living and poor hygiene. To the Salish, the whites have a spiritual uncleanliness that afflicts the earth. Narratives of illness change, often swiftly. In "From Spectacular to Speculative: The Shifting Rhetoric in Recent Gay AIDS Memoirs," David R. Jarraway tracks the transition from "dying of" to "living with" AIDS as expressed in works separated by a decade of social change and medical progress. It is not surprising that infectious disease is the class of illness most represented in this collection: infectious disease implies social relationships and responsibility. Outbreaks of disease as an expression of the pathologic relationship of racism and colonization are common to "Arrowsmith Goes Native: Medicine and Empire in Fiction and Film" (Lisa L. Lynch), "Raven's Plague" and "'The Future is History': 12 Monkeys and the Origin of AIDS" (David Lashmet). There is an ominous progression. In "Arrowsmith," white medicine saves the natives from plague, albeit coercively. In "Raven's Plague," white medicine is unable to save the Salish from the diseases that whites themselves introduced. And in "'The Future is History,'" parallels are drawn between a fictional story of the release of plague by a malevolent medical establishment and the current controversial hypothesis that the HIV virus entered the human population through vaccination programs in Africa. The other affliction that people notably inflict on one another is violence. In "Lazarus Machine: Body Politics in Dalton Trumbo's Johnny Got His Gun" Tim Blackmore considers the machineries of war and of medicine that create the novel's blind, deaf and dismembered protagonist. Cumulatively, these essays present a revealing yet incomplete view of medicine, at least as examined from the "ethical" or content-driven perspective. Most of the narratives examined predate the middle of last century, the exceptions being the AIDS narratives. None addresses directly the complex practice of modern ethics, the changing patient–physician relationship, the economic or technologic limits to medicine, or the experience of women as practitioners of medicine. One or two of the essays make for daunting reading for the uninitiated in modern literary theory and its stylistic flourishes, although Robert D. Tobin's intimidatingly titled "Prescriptions: The Semiotics of Medicine and Literature," reclaims the word "semiotics" for its discipline of origin, medicine. I particularly appreciated David Lashmet's examination of empathy not as an emotional experience, but an imaginative act, and Judith Leggatt's very topical discussion of cultural beliefs about pollution, purity and disease. Even with the limitations imposed by time and choice, this is a rich, thought-provoking collection; rather than ask that any be different, I'd only ask for more.
Alison Sinclair Lifeworks A very real art
The depiction of normal and pathologic anatomy in models is nearly as old as medicine itself. Early examples were created in clay, marble and ivory.1 The art of moulage — the representation of anatomical structures in wax — arose during the Renaissance and was perfected in the 18th century, when it was practised extensively in Germany and Italy. Wax allowed for a versatility and realism unattainable through harder media. The technique was threefold: a clay model was first sculpted and then used to make a plaster cast. Molten wax was then poured into the cast, allowed to set and then removed. Last, fine details and colour were added to achieve a precise and lifelike representation. One of the finest examples of the technique is Clemente Susini's Medical Venus, one of the famous "La Specola" waxes created in the studio of the chemist and physiologist Felice Fontana (1730–1805) in Florence. This exquisitely rendered moulage depicts a supine woman with a removable anterior thoracic and abdominal wall, giving a view of the internal organs.
Medical moulage was eclipsed by the use of plastic models in the early 20th century. Plastic allowed for a more durable product to be produced at a lower cost. The newest development is, of course, computer modelling, as in the Visible Human Project.
A brief resurrection of medical moulage occurred, curiously enough, in Ontario during World War II thanks to the efforts of Dr. Edwin Robertson. Educated in his native city of Edinburgh, Scotland, Robertson moved to Canada in 1939 and became chairman of the Department of Obstetrics and Gynecology at Queen's University, Kingston. He had a keen interest in medical education but was frustrated by the scarcity of anatomical specimens. Nor was he the only physician concerned with the lack of teaching material at this time. In 1941, Dr. Robert L. Dickinson, an obstetrician in New York, wrote: The proportion of female cadavers available for dissection of the reproductive organs runs, I am told, to less than 5 percent of the bodies obtained from the morgue. Moreover, these are chiefly of old women with atrophic tissues.2
In 1940 Robertson had an opportunity to see a moulage collection, mainly of dermatologic conditions, at the Department of Art as Applied to Medicine at Johns Hopkins University. (Founded in 1911, this was the first such department in North America.) When he was unsuccessful in recruiting an artist from Johns Hopkins to create a series of gynecologic moulages for Queen's, he found an able collaborator in Marjorie Winslow, a Kingston artist who had trained in Montreal, England and Rome. This was Winslow's first use of wax as an artistic medium. She recalls: "We went into commission very slowly, learning as we went along piece by piece. Casting in wax was a real adventure."
The creation of each moulage was quite involved. Winslow began by observing Robertson's patients in the clinic and the operating room. Because Robertson did not permit her to sketch in these settings, she sculpted a preliminary clay model from memory. Robertson approved the models before plasticine casts were made. The wax itself was composed of beeswax, talc and sometimes a little paraffin. Winslow painted the models to mimic skin and blood vessels, using everyday items such as pins, orange peels and rocks to add texture. Another embellishment was the painstaking addition of human hair.3
There are three main groups of moulages in the Robertson collection: obstetric models, gynecologic pathologies and miniature representations of female somatotypes. The extent to which they were used in classroom instruction is not clear; Robertson's lecture notes make no reference to the moulages, although archival photographs indicate that they were displayed in the laboratory where medical students trained. At any rate, by the 1950s instruction in anatomy seems to have been outweighed by a greater emphasis on physiology. The moulages were in storage for about 40 years altogether, and some were destroyed by fire in the 1960s. The remaining pieces were brought to the Museum of Health Care at Kingston, and several were conserved by students in the Master of Art Conservation Program at Queen's.
The moulages are both an educational tool of interest to medical historians and delicate pieces of art. Winslow describes them as "very real art in reproduction of life's drama." Today's viewer might be reminded of the work of Georgia O'Keefe and Judy Chicago. The collection, which will eventually be displayed at the Museum of Health Care, is unique in Canada and is one of the last groups of medical moulages to be produced in the world.1 Acknowledgements: We thank Mrs. Marjorie Winslow and Dr. Jim Low, Dr. Robertson's successor as Chief of Obstetrics and Gynecology at Queen's University, for their contribution to the historical information in this article.
Fiona Mattatall References
Room for a view On becoming a doctor
Like all physicians, I have regrets. Still, my career choice, in retrospect, seems to have been predetermined. Recently I uncovered a picture in my parents' basement: "My daddy is operating on a patient. He is very sick. STEPHEN WORKMAN." The picture, which I drew in grade one and the teacher captioned for me, shows my father, consisting of little more than a poorly articulated skeleton, wielding a large and frightening saw. From the wretched appearance of the patient, rendered with ample amounts of red crayon, I doubt he survived. My father has since retired after 30 years as a general practitioner, 20 of them spent behind bars as a prison physician.
I was the first member of my medical class, the class of '89, and I have the photos to prove it. In 1969, "Nana" Workman knit two Queen's Meds sweaters after carefully working out the years my older brother and I would graduate. Somehow, although he was one year older than me, my brother is wearing the Meds '90 sweater in the photograph, and I the Meds '89. Twenty years later I received my medical degree from Queen's University — as fate would have it, in 1989. My brother, a good deal smarter than me, wisely decided to forgo the family business and became an electrical engineer.
Despite such an auspicious beginning, I now find myself amazed at the extent to which my medical training succeeded. For it is only in hindsight that I realize just how little my clinical skills teachers had to work with. What I see, what I know, what I understand have all irrevocably changed from the days of my first "clinical encounter." I had to take a history from a young and healthy-looking university student only a few years younger than I, who was in hospital receiving high-dose intravenous steroids. She had gone blind in one eye several weeks before as a result of optic neuritis, and her vision had only recently begun to return. Facing the possibility that she could go permanently blind in one or both eyes at any time in the future, and that she stood a 40% lifetime risk of multiple sclerosis, she was extremely distressed. But I didn't get it. I couldn't understand why she was so upset. And so instead of addressing her concerns I attempted to dismiss them.
Three years later. As a medical resident I lived in a small apartment building owned by an elderly man named Orville. The building was Orville's last property — he had once owned many, and, as he once told me, in his late 80s he was still worth over a million dollars. Orville was an eccentric character and, as for many people who had survived the Depression, money was enormously important to him. He had become a rich man. A rich man whom I made a little richer every month. Each month when I dropped my rent cheque off at his house, just across the road, he and his wife would invite me in, proud to have a visit from "the doctor."
"You've got the odd ant in your building," I understated one day after a column of the carpenter ants that were busy devouring his building ventured into my kitchen to transport honey from an open jar back to their catacombs. I vacuumed most of them up.
"You must be a diagnostician," he said. I looked at him blankly. "The ants, you said they were odd. I was making a joke. Never mind." Another time he said to me, "Do you go to church? Every man has to have an anchor." Later I realized his comments were overtures to a friendship, but I was too busy and tired to realize it.
When I was in my second year of residency Orville's wife had a stroke and then a deep vein thrombosis. I saw less of Orville, and when I went into his house I found it even more unkempt and Orville even more talkative than before. Often, I did not know what to say. One day Orville unburdened himself to me. It was then that he mentioned his wealth, in the context of complaining about the cost and effectiveness of two ads he had run in the local paper for a live-in nurse for his wife. "Fifty dollars it cost me to run the ad twice, and not one reply, not one. Fifty dollars. I won't waste that kind of money again," he stated bitterly. Without a live-in aide willing to care for him and his wife, the only other option was full-time nursing help. This, Orville had calculated, would cost him over $100 000 dollars a year. "I worry about Sally, whether I will leave enough for her." Sally, his daughter, also lived in his apartment building.
Another time, after knocking at my door with his cane when I was a few days late with the rent, Orville again confided in me. I can still picture him standing on the narrow porch of my dumpy apartment, tired, wizened and frail, a hunched old man clutching a long walking stick as if it were the only thing keeping him from falling into his grave. "I have demons. At night I have dreams of demons, demons devouring me, such terrible nightmares." I "diagnosed" an agitated depression and recommended that he see his family doctor and perhaps try antidepressants. He did and they worked, but I can now see that I failed Orville, failed to acknowledge and care for the pain of his demons, imagined or otherwise, to the best of my ability. I understood Orville's suffering, but acted in a limited and scripted way. Orville died a year later, survived by his wife for only another year. I wish I had taken Orville by the shoulder and invited him in for tea as well as referring him to his physician.
We are staying at a friend's cottage. A knock at the door is unexpected. Everyone else is busy, so I answer. An overweight middle-aged woman greets me, a neighbour who needs to borrow a pail of water because the well on her property is not working. She lingers for a few minutes — she is talkative but says little. After five minutes I become impatient, anxious to start my coffee and morning paper. And then the reason for her talkativeness emerges.
"We've had a terrible tragedy this winter," she says, her eyes suddenly welling up with tears. Something inside me shifts. I take a moment to gauge the severity of her grief and to think about what to do next. She is clearly devastated. I watch her for a few seconds before I realize that after ten years of caring for patients and their families, I know how to deal with this. I know this feeling, I know this situation and what to do. I understand that the exchange that is about to take place will be of extreme importance.
"What happened?" I ask. Her grandson, the light of her life, was struck and killed at a crosswalk earlier in the year. I had followed the story in the local paper. Grief and anger spill out at the enormity of the loss. I let it. "The driver wasn't even identified, he didn't even say he was sorry," she says bitterly. She is consumed by anger as well as by grief. I fear that she will always be. And so I make a conscious decision to intervene. "Perhaps he is terrified. A lot of people would be, don't you think?" She nods in assent, and I hope this seed of forgiveness and understanding will grow. She sheds a few more tears before leaving.
I have no regrets.
Stephen Workman
Copyright 2001 Canadian Medical Association or its licensors |
