The Art of Medicine — Part I of III

Medicine and Art have a common goal: to complete what nature cannot bring to a finish, to reach the ideal, to heal creation. This is done by paying attention. The physician attends to the patient; the artist attends nature. If we are attentive in looking, in listening and in waiting, then sooner or later something in the depths of ourselves will respond. Art, like medicine, is not an arrival; it’s a search. This is why, perhaps, we call medicine itself an art.”

These are the words of Marie Therese Southgate, a physician and former Deputy Editor of the Journal of the American Medical Association. This was an enlightened journal in many ways, not least of all because, amongst the clinical and scientific reports it published, it placed fine art high enough to have reproduced images of paintings and sculpture on its covers for almost 50 years.

 

M. Therese Southgate, MD, Physician-Editor  (1928-2013)

This essay is designed to explore this quotation – the common ground between art and medicine. In particular, I want to explore the role of fine art in medical education, and I want to show through a series of examples how works of art can be used to effect and enrich a formalised and all too often conservative medical curriculum.

My credentials for this task are admittedly poor. I am not an Art Historian, nor an expert in any of the humanities. But I am a doctor, a teacher, a writer and perhaps above all I am a lover of art. What I have to say about Medicine and Art will not be profound – it will be personal, as is my choice of the paintings I want to show you.

To assist us in this discussion I have chosen to divide the paintings we shall look at into several rather arbitrary categories. The first of these is Medical History.

Medical History

 

The Anatomy Lesson of Dr Nicolaes Tulp, Rembrandt van Rijn (1632)

I have chosen to begin with this painting because it was the only one ever to feature in my own medical education, and I have never forgotten it. Almost 40 years ago, one of my lecturers at the University of Glasgow went off-piste one afternoon and surprised us by starting his lecture on orthopaedics with a slide of a painting, a great painting. He talked us through it and drew us in, and of course that was his plan.

The painting in question hangs today in the Mauritshuis Museum in The Hague, and in 1633 it was Rembrandt’s first important commission for a group portrait. On the canvas, he portrays the eminent anatomist Dr Nicolaes Tulp demonstrating the dissection of the muscles of the forearm. Propped up at the foot of the dissection table, perhaps to show his credentials, he has the famous anatomy textbook by Vesalius. Huddled around the cadaver, there are a group of rather ageing medical students ….or were they. Despite the familiar group demeanour – the over-eager ones at the front, the one trying to crib from his notes, and the one staring off into space at the back – despite all this, these seven were in fact not medical students, but Masters of the Surgeons Guild of Amsterdam – indeed the top Dutch surgeons of the day.

The dissection itself is also not all that it seems. Before the practice of preservation of cadavers – those organs that would deteriorate first, had to be dissected first, viz. the contents of the abdomen and the head. A dissection would never begin with the muscles of the forearm, and as such this scene is staged and unrealistic.

If, then, we are viewing this painting as an historical document it falls short on several counts, but it is an excellent backdrop on which to hang a discussion of the pros and cons of small group teaching in medicine, and that’s certainly how I still use it in my own workshops.

 

The Anatomy Lesson of Dr Deijman, Rembrandt van Rijn (1656)

A more historically accurate portrayal of the 17th century dissection room is seen in the only surviving fragment of Rembrandt’s other great medical work. This is “The Anatomy Lesson of Dr Deijman” from 1656, now hanging in the Amsterdam Museum in the Netherlands. Here, the abdominal cavity lies empty and the dissection of the brain is underway.

Both these paintings have obvious appeal to the pre-clinical anatomist, but they also raise more important issues on the use of fine art as a documentation of historical fact. In many instances, what is portrayed is what it appears. But not always. We often, wrongly, ascribe an almost photographic quality to fine art representations of people, events and places connected with medicine. We should leave these two examples on a note of caution, but remembering that even a misrepresented image may be of educational use.

 

Visiting the Sick, Master of Alkmaar (1504)

 Another image of medical history is provided by one of the Master of Alkmaar’s Seven Works of Charity: “Visiting the Sick”, which hangs today in the Rijksmuseum in Amsterdam. Here we are afforded a glimpse into an early 16th century hospital. Has so much changed?

This painting documents a number of key similarities between the hospital ward of today and that of more than 500 years ago. Patients are in beds; patients are being washed; and patients are being comforted and spoken to. In short, patients are being cared for – but even then the administrators are at the very door of the ward with outstretched hands.

The depiction of patients in this painting leads us to our second category that of Images of Illness.

Images of Illness

 

The Sick Child, Gabriël Metsu (c1660)

You don’t have to be a physician to know that this child is ill – you only need to have eyes. While there is nothing to direct the diagnostician to any specific disease, this child is unmistakably sick. Painted in around 1660 by the Dutch master Gabriël Metsu, this painting also hangs in the Rijksmuseum in Amsterdam, and it is an image with immediate educational appeal. When we teach our students clinical medicine we hope, that even if they do not retain all that they learn they will acquire the basic clinical skill of recognising and separating the sick from the well. I vividly remember one senior Paediatrician taking us, his group of awkward 5th year medical students, on a ward round at the Children’s Hospital. He said that we could talk all day long about the details of the diseases and their treatments, but that first and foremost he wanted us to leave his tutelage with one skill, that of being able to tell if a child is sick or well. Everything else can follow from that, but if we could not distinguish, we would be very poor clinicians.

I believe a discussion of this painting could find a useful place at the start of any course in paediatrics or clinical examination.

 

Monna Vanna, Dante Gabriel Rossetti (1866)

While Metsu clearly intended to represent illness, the same cannot be said for Dante Gabriel Rossetti. This sumptuous portrait of his model, Alexa Wilding was painted in 1866, and Rossetti himself thought it one of his best. It now hangs in the Tate Britain in London.

Alexa was a dazzling redhead, who like some of his other models was found by Rossetti on the streets of London. She figures in several of Rossetti’s major works and her features and colouring have become almost synonymous with the Pre-Raphaelite ideal of beauty. Beautiful though she was, she also had thyroid disease as evidenced from the swelling of the thyroid gland, or goitre, in her neck.

There are countless instances throughout the galleries of the world of clinical signs inadvertently captured by the artist, and it makes an amusing game finding them.

Here’s another…

Elderly Woman, Frans Hals (1633)

Returning to Holland again….some 350 years ago the artistic skill of Frans Hals inadvertently captures in oils another interesting clinical sign with his “Portrait of an Elderly Lady” which hangs in the National Gallery of Art in Washington, DC. This lady has tendon xanthomata or fatty lumps in the tendons on the back of of her hands as a result of a genetic disorder of her cholesterol metabolism. If you look at a close up of her left hand, you can see without too much trouble the abnormality in question.

It would probably be true to say that whatever clinical sign you choose, there will be a painting of it somewhere in the world.

 

The Sick Lady, Jan Steen (c1663-66)

While depiction of clinical signs may be common in Art, so are examples of clinical techniques. This mid 17th century painting by Jan Steen entitled, “The Sick Lady” can be found in the Rijksmuseum in Amsterdam, and it shows us that palpation of the pulse is hardly a recent part of clinical examination.

The presence of the doctor and his prominent portrayal in this painting leads us to our third category – that of images of the physician and we will look at these as well as images of the Artist as Patient in the next part of this series.

© Allan Gaw 2020

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The Shape of Time

 

Time is a slippery concept.  Simultaneously achingly slow and heart-stoppingly fast;  crawling by when we are bored and racing past in moments of joy; grinding and at the same time galloping.  We are all familiar with this play of perception, and as we get older we become more aware of it, especially the apparent and disconcerting acceleration of time.  The theories of relativity notwithstanding, in everyday reality, time for us is a constant.  There are still 24 hours in every day and 60 minutes in every one of those hours, no matter what we do with them.  That observation, of course, means next to nothing when we think about how it feels to be carried along in its flow.

But, therein lies the problem; words like ‘slow’, ‘fast’ and especially ‘flow’ are awkward descriptors.  Not only are they inadequate, they also, by their implications, anchor us into a way of thinking about time that may not be helpful.  We see ourselves in a river of time, carried forward by the current, at times stagnating and at others rushing through the rapids.  We are thrown into the river at birth and we only get out of the water on our death.   Although, of course, most of us acknowledge that the river was there and flowing long before we joined it, and it will continue long after we are gone.  We might even think of it as eternal, with neither beginning nor meaningful end.

But are there other ways to think about time?  In her novel Flights, Polish Nobel Laureate in Literature Olga Tokarczuk recollected a conversation she had on one of her travels.  Her fellow traveller shared her theory that time came in two distinct shapes.  Sedentary people, she hypothesised, such as those tied to the land through agriculture, viewed time as a circle.  Perhaps dependent on the cycle of the seasons, they found understanding in time as a recurring phenomenon.  Things go around, repeat themselves and find their way back to their beginnings.  On the other hand, those who by necessity are on the move, such as nomads and merchants, see time as a line measuring their progress towards a goal or a destination.  In this linear way of thinking about time, no moment is repeated, forcing us to make the most of any opportunity that presents itself. Perhaps, because it will never happen again, we are even prompted to take risks.  If time is a circle, we only have to wait for the merry-go-round to take us back; another spring, another summer, another beginning, another chance. But if time is linear, we need to make the most of it for you pass this point only once.

Again, this way of thinking simply ties us down and forces us to contemplate time in a different but equally inadequate way.

Albert Einstein said the only reason for time was so that everything didn’t happen at once.  That’s the kind of statement that starts off amusing and then begins to hurt as you try to digest it, and certainly for me it is ultimately unhelpful.  That time exists at all, beyond our human perception of it, starts to become debatable.  But again that doesn’t help either, for the simple reality is that we all feel time whether it exists or not.  We grow and flourish and age and decline, and we watch others around us do the same.  And, I suppose, for me that’s maybe the essence of it all.

Left to our own devices, we undoubtedly age, but the passing of time is less perceptible.  We feel the same inside whether we are twenty or sixty.  What does change though, and what does present us with the stark evidence of time passing, is the child.  The speed of their growth and development marks the passage of time more acutely that we can ever perceive in our own lives. As a parent, you experience the birth of your child, their first smile, first steps, first words, first day of school, first exam, their successes, failures, disappointments, loves and heartbreaks. You watch them grow out of shoes and friendships and grow into a personality distinct from your own.  You watch them fledge and soar and then fly away, and all the time nothing for you has changed, or so it seems.  Their time and yours co-exist, the same but different, in parallel and occasionally intersecting.

Whether time is a river or a circle or a line, whether it runs as a series of intertwined threads or whether it doesn’t really exist at all, perhaps makes no difference. There is no single metaphor that completely describes time and how each of us at different points in our lives perceive it.  The concept of time is, at the same time, inexplicably complex and glaringly obvious, but as with any equally indescribable concept, any attempt to frame it in mere words does it an injustice.  I think there is a lot of life that falls into this category.  I don’t know what love is, or happiness, or hope, but then again, like you, I know exactly what they are — but, like time, I just can’t describe them adequately in words. And I don’t think anyone can, despite the best efforts of philosophers and poets across the years.  That, however, is not a human failing.  The indescribable is and remains exactly that, and our acknowledgment of the ineffable is all that there is and perhaps all that there needs to be.

© Allan Gaw 2019

 

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“The learned physician-scholar of the abolition movement” How a black American found an education in Scotland

In the summer of 1832, a young man disembarked from the transatlantic ship Caledonia and as he stood on the Liverpool dockside, he declared, “I am free!”  The 19 year-old was James McCune Smith, a student who had travelled alone across the world to receive an education denied him in his native America.  He was articulate and gifted, but he was also black and no medical school in the US would grant him entry.

After spending time in Liverpool, Smith continued his travels by steamer to Glasgow where he matriculated at the University.  Arriving in Glasgow,  he would have found a city of paradox.  Glasgow had been at the centre of the New World slave trade, building its wealth on the cargoes of sugar, cotton and tobacco loaded onto the returning slave ships. While the UK may have offered him the liberty to study, he had arrived in a country that would not abolish slavery for another year.  But, Glasgow was also an intellectual centre of the Scottish Enlightenment, which saw slavery as philosophically abhorrent.   Indeed, this enlightened approach had prompted the French intellectual Voltaire, a generation before Smith arrived, to say, “We look to Scotland for all our ideas of civilisation.”

Glasgow at the time was a city already enjoying the benefits, and suffering from the woes, of the industrial revolution.  In 1832 it had approximately the same population as Smith’s native New York City, but there would have been considerably fewer black inhabitants and he would undoubtedly have been isolated.  However, he was supported locally by the activists in the Glasgow Emancipation Society to whom his benefactors in New York had reached out, in order to facilitate his higher education.

At the University he studied in a class with 78 other young men and tackled a variety of subjects including Latin, Greek, Logic, Philosophy and Astronomy, as well as the more traditional medicine, midwifery and surgery. He graduated with a BA in 1835, an MA the following year and, finally, he obtained his MD in 1837, graduating top of his year.

After qualifying, he furthered his clinical experience in Paris before returning home to New York City, where it is said he was received by an enthusiastic crowd of some 16,000.  He set up practice in Lower Manhattan and became resident physician at the “Colored Orphan Asylum”, but despite his obvious qualifications and experience, he was never accepted as a member of any New York medical associations or the American Medical Association.

As well as being a practising physician, Smith was also a prolific writer in both the medical and political spheres.  In 1844 he became the first African-American to author a paper in a US medical  journal and he would contribute important works to further the abolitionist movement.  In the latter, he used his knowledge of statistics, acquired at university in Scotland, to systematically refute, argument by argument, the claims made by those who fought against emancipation. In medicine, he targeted homeopathy and phrenology aiming to debunk the claims of their exponents by careful analyses of the facts.

His position, as the first African-American with a university degree, gave him considerable kudos, but it was his intellect and industry that allowed him to rise to a position of community leader and to move in the highest circles of the abolitionist movement.  Indeed, the most prominent figure in the movement, Frederick Douglass, cited Smith as the single most important influence on his life.  Furthermore, one commentator has noted that, “As the learned physician-scholar of the abolition movement, Smith was instrumental in making the overthrow of slavery credible and successful.”

Smith lived to hear of Lincoln’s assassination, but died in November 1865 one month before the ratification of the 13th Amendment that would formally end slavery in the US.  He was buried quietly in an unmarked grave in Brooklyn by his family who did not wish to publicly acknowledge their African-American heritage.  It would not be until 2010 that his descendants would rectify this.

Until recently, the only memorial in Glasgow to one of its most famous students was a café that bears his name near the original entrance to Old College in Duke Street.  But what of the University of Glasgow itself? Glasgow has been at the forefront of academic institutions acknowledging their  historical links with the slave trade and, as part of its programme of reparative justice, it announced in October 2018 that it would name its new £90m learning hub building in Smith’s honour.  An appropriate move, no doubt, but perhaps the fact that almost 200 years ago it saw fit to admit Smith when other universities turned him away because of the colour of his skin says even more.

Sources

  • Morgan TM.  J Natl Med Assoc 603-14; 95: 2003.
  • Matthews K. Washington Post, September 24, 2010.
  • BBC News,  October 7, 2018.

© Allan Gaw 2019

This article was originally published in the MDDUS Insight Magazine

 

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“I’m sorry, this is a very busy slide”

 

I am at the end of my tether.  And to be honest it’s not as long a tether as it used to be.  I had expected to become more tolerant with my advancing years, but I’m afraid all that has happened is that my once well-suppressed curmudgeon has surfaced and taken charge.

These days there are of course many things that make me grind my teeth, shake my head and sigh ever more deeply.  However, there is one in particular that needs to be sorted out.  Yes, I know there are a few political shenanigans going on that need to concern us, and then there’s the spectre of climate change and….well,  the impending end of the world as we know it really.  But the thing I think needs to be sorted out now, right now, is the quality of the slides people force me look at every day.

I have been on the receiving end of slide shows of one kind or another for over 40 years and I am no longer willing to take it. Of course, in that time there have been a few highlights, some dazzling displays mostly it has to be said from student presentations, and rarely from the great and the good, but for the most part the slides people show are terrible.  And by terrible, I mean they fail on every level as a visual aid to accompany a talk.

As you might expect, I could go on at some length about this, but I would just like to focus on one thing that causes me particularly severe chest pain: the speaker who apologises for his or her slides.

“I’m sorry, this is a very busy slide,” they will announce when they project an especially heinous specimen.  Allow me to translate for those of you unfamiliar with this particular form of academic double-speak.  What they are saying is, “I know this slide is a disaster, overcrowded with lines of text, irrelevant images and so badly designed none of you can read it or understand it, but you know I’m not sorry, because the thing is you, the audience, aren’t worth it.  You aren’t worth the little time it would have taken me to fix this train wreck of a slide.  You see, I’m big, I’m important, I’m actually better than you and you should just be delighted that I’ve even deigned to come here today to your little lecture theatre.  I’m busy, I’ve got better things to do, planes to catch, executive lounges to enjoy.  I’ve got panels to sit on, committees to chair, papers to reject. So, stop moaning and just be grateful I’m showing you a slide at all.”

I know you think I’m over-reacting, perhaps even pulling your leg, but believe me when I say, I’m not.  This is exactly what these speakers think.  They know their slides are bad, after all they’ve just acknowledged the fact by having to apologise for them. And they know how to make them better, but the fact remains that they choose not to.

I have a very simple approach to slides, their design and their use, and it’s this.  Never show a slide you wouldn’t want to look at.  All you have to be is honest with yourself.  The principles of good slide design are very simple and easily learnt and we know what effective slides should look like.  Keep it simple, keep it clean, keep it uncluttered. Don’t have anything on the slide that doesn’t need to be there and make sure the slide works as a visual aid, not for you the speaker, but for the audience.  Is it visual? — can they see it, can they read the text, can they make out the pictures?; and is it an aid?— does it help the audience understand what you’re talking about, does it clarify, does it exemplify, does it reinforce?

I do not expect perfection, but I do expect to be treated with a little respect by the speakers whose presentations I have taken the time to attend.  I am just as busy as them — and so are you — and we all deserve the best that any speaker can deliver.  So if you’re the speaker, remember that.  Remember that everyone in your audience is doing you a favour by sitting through your talk.  Don’t repay that debt by making them endure a set of slides you would never want to look at yourself.  Do better than that, be better than that because your audience is better than that. And if you find yourself apologising for the poor quality of your slides, bite your tongue and fix them.

© Allan Gaw 2019

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Who’s Afraid of the Big Blank Page?

 

 

Many people say they “can’t write”.  As these same people write all the time, what do they mean? Perhaps, that they find it difficult to compose text, or order their thoughts on paper, or express their ideas economically and effectively.  Perhaps it’s the mechanics of writing like grammar and punctuation that threaten them.  Or perhaps it’s the commonest difficulty of all — that of just getting started.

As a researcher you have to be able to write and to write well to communicate your discoveries and to stay in business.  In academia, you will be assessed almost exclusively on the number and quality of your publications.  Your papers will define you.  You will also find yourself called upon to write reviews, to summarise your work in abstracts, and you will spend many hours writing and re-writing grant applications that will determine your future, and often the future of those with whom you work. No matter what stage you are at — undergrad, postgrad, post-doc or faculty, you need to be able to write well, and if you can’t, or feel that you need help, how are you going to learn?  

There are many five-step, seven-step, even twelve-step plans that take you by the hand through the writing process — planning, drafting, redrafting, refining, expanding, abstracting, scribbling, doodling, crying. All these plans are equally effective, or, as the case may be, equally ineffective.  As a set of directions on how to write, however, they are reminiscent of the advice given by the rural Irishman who, when asked by the tourist how to reach the next town, answered: “Well, I wouldn’t start from here.” 

All I have to offer by way of advice on how to write is a two-step plan and the first step doesn’t involve writing at all.

Learning how to write does not, or at least should not, begin at the point where you suddenly find yourself in desperate need of the skill.  When the grant deadline is approaching or the pressure is mounting to get those manuscripts submitted, this is not where you want to start: you want to start as long before that as possible and you want to start not by writing, but by reading.   

Step 1: Read

Those who read the most, and the most widely, are the best writers.  What evidence is there for this often made statement? In truth, there is very little, especially when it comes to adults and especially as we routinely lie about what and how much we have read. The advice of great writers is, however, remarkably consistent on this point. Take, for example three writers from three different eras.

“The greatest part of a writer’s time is spent reading in order to write; a man will turn over half a library in order to make one book.” Samuel Johnson (1709-84)

“Read, read, read. Read everything—trash, classics, good and bad, and see how they do it. Just like a carpenter who works as an apprentice and studies the most. Read! You’ll absorb it. Then write.” William Faulkner (1897-1962)

“If you don’t have time to read, you don’t have time to write.”  Stephen King (1947- present)

Immersing yourself in a foreign language is the only way to achieve fluency.  Similarly, immersion in the written word is the only way to achieve a fluency and ease of writing. 

There are skills that can be taught — tricks of the trade, if you like — but the cogs that need to mesh together to produce the written word will only turn when well oiled by the words of others.  Read fiction, not just factual works.  Read old as well as new.  Listen to the rhythms of authors long dead as well as the fresh voices of your contemporaries.  Read those you wish to emulate.

But, reading will only take you so far.  Writing is a muscle that needs to be exercised. Extending the analogy it also needs to be warmed up unless we want to pull it.  Practice is essential and, put simply, the only way to learn to write is actually to write and to write often.  And, as the only way to get anything done is to begin, my second step in how to write is to start.

Step 2: Start.  

Perhaps easier said than done, for to start we must first overcome the most terrifying thing for a writer, that most terrifying of all monsters — the blank page.  It sits there silent, smirking, wallowing in its blankness, daring you to make a mark, but not just any mark, the right mark, the right and perfect sequence of first words. Prose that you can be proud of and that will exalt the souls of others.  But, of course that’s too much for any writer to cope with, that responsibility, and the blank page says nothing less will do, don’t even try to give me less than your best.  I want only something worthy of Tolstoy or Austen, don’t insult me with a musing or a first draft.  Get on with it.  What are you waiting for?  Oh, you mean you can’t do it — “So, you’re not good enough?” the monster taunts and destroys the last of your creative soul. 

Let me tell you how to kill this beast.  All you have to do is write something — anything — on it.  Start by writing your name and the date and the time and the place and a sentence — any sentence — maybe a quote about writing or maybe a sentence or two that belong to someone else. Then, neatly list 1 to 10 down the left hand side and maybe add a separator line or two.  And the beast is not looking so smug anymore because it’s no longer looking so blank.  The beast is dead and you have begun.

A blank page is often a daunting prospect for many and blank pages are where we are most likely to pull those writing muscles. Start the exercise gently, with anything, just begin. Don’t worry as you write if it’s not really making sense or if it’s not wholly on message.  Just starting in this way will not create anything worth reading, but it will set in motion a rhythm of words and phrases that will become your first draft.  As your muscle warms, you can begin to exercise it properly and 50 or 100 or perhaps 200 words in you will start to make some sense. Keep going, maintain the momentum and before you know it you will have a page of something. It will not be perfect; it will almost certainly be ungrammatical in places or even illogical, but what it won’t be is a blank page.  And, that’s the hardest part done.  

What you have now is a very first draft, and as you read it over, the key is not to be despondent.  There are two nuggets of wisdom that you should hold close when critiquing your own work.  The first is from Samuel Johnson the 18th Century English writer of dictionary fame who said: “What is written without effort is in general read without pleasure.”  In other words, its going to be hard, because it’s supposed to be.  The second is my particular favourite from the Nobel Prize winning novelist Ernest Hemingway, who noted: “The first draft of anything is shit.” How true Ernest. And this realisation perhaps prompted the adage amongst writers that, “There is no such thing as good writing, only good rewriting.”

Conclusion

The bottom line is a simple one.  To survive as a scientist you must be able to write.  Your writing needs to be clear, concise and publishable.  It must serve you well in your attempts to communicate with your peers, with grant awarding bodies and at times the public.  My two-step plan requires that you put some effort in.  I am asking you to get into a writing habit, to write everyday even if it’s only a few sentences. And I’m asking you to read even more, and preferably to have started the reading a decade ago.  Failing that I would like you to start now, and to take some paper and get on with the writing as well.

I know it’s difficult, but, I regret to inform you that you are not special.  By being frightened of the blank page you are not alone — so were Darwin and Pasteur and Fleming.  By stumbling over yourself, trying to express your thoughts, you join the ranks of Descartes and Newton and Einstein.  Wondering if you’ll ever get it right places you shoulder to shoulder with every scientist who ever picked up a pen.  But, by reading and by starting, like all of them,  you will become a writer. So, start.

© Allan Gaw 2019

 

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What can we learn from the past that may be relevant to modern drug research?

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“I cannot recommend it highly enough: even if you read nothing else about the origins of drug research and what it can (should?) teach us, read this….This is a ‘buy’.”  Madhu Davis review in Pharmaceutical Physician May 2016.

What’s in a name? Eponyms in medicine

There is a comet stitched into the heavens of the 11th century Bayeux tapestry. It is now known to be a regular visitor to the heavens, but while the comet had been observed many times by the ancients, it was the Astronomer Royal, Edmund Halley, who is first believed to have predicted its periodic return to our skies. He did not live to see the comet reappear and to have his calculations vindicated, but when it arrived on cue it was named after him in 1759.  An apostrophe secured the deal, and what goes around comes around; in Halley’s case, roughly every 76 years.

It is all too easy to be possessive.  Discovery often implies ownership and those who first describe a disease, a phenomenon, or, in Halley’s case, a comet, have in the past been honoured with not just their name being applied, but they have also been granted the deeds of ownership that come with an apostrophe S.  In the world of medicine, those such as Asperger, Duchenne, Burkitt, Grave and Addison, as well as many others, took possession of diseases from which they never suffered, but which they are credited as first describing.

Cushing, Crohn and Alzheimer are just three examples of very well-known medical eponyms.  Harvey Cushing was an American neurosurgeon who described what would become his eponymous disease of the pituitary in 1912.  Burrill Crohn was an American gastroenterologist who published details of patients with his inflammatory bowel disease in 1932.  And, Alois Alzheimer was a German psychiatrist and neuropathologist who first described an ‘unusual disease of the cerebral cortex’ that led to the premature death of a patient in her mid-50s in 1906.

Of course, in medicine it isn’t just diseases that bear the names of the famous.  When it comes to examination, we have a whole medical dictionary of clinical signs named after their exponents, from an Adie’s pupil to Beau’s Lines and Osler’s Nodes. And then, there are tests. I am sure I am not alone in long-believing that the Apgar Score for assessing neonatal well-being was a clever acronym, only to discover to my embarrassment one day that we own that particular one to Virginia Apgar, the American Obstetric Anaesthetist who devised the scoring system in the 1950s.

Apostrophes, however, do have a habit of disappearing over time and taking the ownership they signify with them.  Mr Charles Henry Harrod’s department store in Knightsbridge has lost its apostrophe, as has Mr John Boot’s chemist shop and, much more recently, Mr Tim Waterstone’s bookshop.  Possession evaporates with rebranding and the same is happening in medicine. Today, we are as likely to see eponymous disease names written either with or without the apostrophe or even without the additional letter S altogether.  For example, Crohn’s, Crohns and Crohn Disease have all become synonymous in the literature.

The main argument against the use of eponyms is that they are unhelpful for both clinician and student, telling us nothing of any clinical import about the disease or the test or the sign in question.  For example, unless you happen to be a 1930s baseball fan, amyotrophic lateral sclerosis tells you much more about the underlying pathology than its eponym, Lou Gehrig’s disease. That eponym, however, at least bears the name of a patient rather than a physician.

Indeed, a common criticism is that merely describing a disease that you have never suffered does not constitute ownership.  The corollary, however, seems equally quaint: just because you contract a particular disease, one that many others before you have also suffered, you can hardly take possession of it.  But perhaps we are being a little unfair to the physicians and scientists in question for they rarely, if ever, called their diseases after themselves.  To do so would have been more than unseemly, and the conferring of the eponym was usually left to others.

Particularly in medicine, this issue of eponyms has been debated for many years.  A generation ago one conference of the Canadian National Institutes of Health proposed: “The possessive use of an eponym should be discontinued, since the author neither had nor owned the disorder.” More recently, both the WHO and the American Medical Association have argued for the elimination of possessive eponyms.

For some, however, the use of eponyms, with all its attendant problems, does add colour and perhaps a sense of history to medicine.  Perhaps we should honour those who have laid the foundations of our subject. But, if we are going to go to the bother of memorialising those who first described a disease then perhaps the least we can do is offer them the nicety of some punctuation to go with it.

© Allan Gaw 2019

A version of this article appeared in the MDDUS publication FYi in February 2019

Now available in paperback…

Testing the Waters: Lessons from the History of Drug Research

What can we learn from the past that may be relevant to modern drug research?

Screen Shot 2015-10-14 at 21.22.11

“I cannot recommend it highly enough: even if you read nothing else about the origins of drug research and what it can (should?) teach us, read this….This is a ‘buy’.”  Madhu Davis review in Pharmaceutical Physician May 2016.

My other books currently available on kindle:

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‘Sinning against Science Itself’ Adolf Friedrich Nolde’s 1799 Code of Good Research Practice

Today, the name Adolf Friedrich Nolde is virtually unknown, even in the circles of medical historians. A young German professor of medicine and midwifery from the late eighteenth and early nineteenth centuries, this man, while mourned and eulogized at the time of his early death, has been quickly forgotten.

However, Nolde deserves to be remembered, and his work merits closer examination, especially because of his writings in the final years of the eighteenth century and his focus on the development of a scientific foundation for the study of drug treatments and the development of research ethics.

In his treatise, [Reminder of some of the necessary conditions for the critical appraisal of a drug], published in 1799, Nolde defines and enumerates a set of eight rules for the conduct of pharmacological research. In the first seven of these rules, Nolde highlights the need for the study of high-quality and “genuine and unadulterated” drugs that are “prescribed in an appropriate manner.”  It is his eighth rule, however, that merits the closest examination, for here he looks at the issue of research misconduct and the impact it may have on both scientific endeavour and patients’ well-being. He summarizes this rule as follows:

Rule 8. When announcing a new drug or recommending a known drug nothing at all should be omitted about anything that could have an influence on the correct assessment of the drug, and it would be shameful if observations were to be fabricated or distorted at the expense of the truth.”

Nolde justifies the inclusion of such a rule by noting that, “unfortunately one sees many a result which has been recorded untruthfully,” and goes on to state that, “not everything which physicians publish under the promising titles of ‘Observations and Experiences’ can be taken at face value.” What might be seen as very much a twenty-first-century problem appears to have been a well-recognized phenomenon even in the eighteenth century.

He describes instances of fabrication, where results are simply made up and then published, as well as instances of falsification, where results are willfully manipulated to tell a different story. In both, he expresses his concern that, “the public can be deceived in this way.” Moreover, he admonishes those whom he believes have corrupted the scientific literature:

Such actions are of course extremely unworthy of any honourable man and should rightly bring disgrace upon him. Not only does he deceive the reading physicians in this way and shamefully betray the time and effort invested by them with the best of intentions, but he is also sinning against science itself by wilfully corrupting the degree of certainty of which science is capable and acting irresponsibly toward the public who entrust their health and lives to their physicians. Anyone who dares to misrepresent the truth so deliberately should consider carefully the unpredictable consequences of his actions and look to his conscience!”

Nolde asks for a comprehensive approach to scientific reporting, but recognizes that this is a more difficult path:

Whoever has the will and resolve to present really instructive observations to the medical public will undoubtedly have to apply himself much more diligently than one who cares not what he writes to the world.”

He also notes the difficulty this may present to the reader, but rejects the idea that this is an unnecessary burden:

I reject the criticism that the length and detail of such comprehensive reporting would bore and tire the reader. Anyone who, as a critic or a prospective physician seeking guidance, turns to such observations does not do so for amusement as in reading a novel. . . . The physician, if he so wills and has the ability to do so, can report his observations so that they read well and easily despite their necessary thoroughness. It is not the deluge of words or the number of pages that give a report its comprehensiveness, but rather the complete and accurate reporting of everything, which is relevant without falling into the trap of long-winded, tiresome verbosity. As regards the time a physician spends reading such reports of observations he would have much less cause for regret if, in a day, he read two or three well-written reports than if he read hundreds which were of little use.”

He also recognizes the importance of education stating:

. . . it would be very desirable if it were very strongly impressed on young physicians at university that their duty was to remain loyal to the truth in all circumstances and that plying their trade in silence would be preferable to doing so with lies and deceit.”

Nolde concludes:

Only when we know this relationship exactly and that the tests which produced the data were undertaken with all practical care, intelligence, diligence and attention, are we able to obtain the information and the degree of certainty needed in order to judge the value or worthlessness of a drug. Truth is always better than deception and definite certainty preferable to precarious uncertainty.”

Regarding the research misconduct that he recognizes as toxic to scientific endeavour and the practice of medicine, he recommends that it be exposed and expunged:

. . . all corner-cutting, fabrications and deceptions of the ‘literary’ physicians, produced in their thousands, should be treated with the greatest contempt as soon as they are recognized as such and deserve no better than eternal oblivion.”

Working in the late eighteenth century, Nolde was part of the medical and scientific enlightenment that recognized the deficiencies of a past reliant on folklore and anecdotes to inform medical practices. He and many of his contemporaries realized that good practice had to be founded on experience and, furthermore, that that experience should be gathered and reported in a rigorous way.

Writing specifically about the evaluation of new drug therapies, Nolde enumerated a series of key principles or rules that he proposed must be followed for such assessments to be valid. What his rules cover are a number of the key aspects of the scientific method and would be readily recognizable to a modern-day clinical pharmacologist. But, in addition to these principles of practice, Nolde felt the need to emphasize the ethical aspects of research practice and reporting.

Today, we are acutely aware of the importance of research misconduct, and major efforts are being made to expose and root out such practices. We understand how the fabrication and falsification of research data and their publication can fatally undermine modern medicine, but so did Nolde, more than 200 years ago. Not only did he recognize the problem, he also understood the implications of a corrupt scientific literature and its impact on patient care. He also realized that education of junior practitioners and researchers is key to both solving the problem and making the practice completely professionally unacceptable.

Nolde’s contribution is not only of interest for historical curiosity but is also a potent reminder that the challenges of clinical research are not new. The problems we face today are similar to those that troubled the minds of our forebears. We are concerned with the quality of clinical research and its integrity and, at times, even its veracity. If we are looking for solutions, we might do worse than to consider those put forward by thinkers such as Nolde. Recognition of the problem, a public refusal to accept such a state of affairs, and then ensuring that junior staff are properly educated were Nolde’s solutions. These are also increasingly the modern solutions to our problem of misconduct and fraud in scientific research.

© Allan Gaw 2019

 

An earlier version of this article was published with Thomas Demant in International Journal of History and Philosophy of Medicine 2016; 6: 10602 www.ijhpm.org doi: 10.18550/ijhpm.0602

Now available in paperback…

Testing the Waters: Lessons from the History of Drug Research

What can we learn from the past that may be relevant to modern drug research?

Screen Shot 2015-10-14 at 21.22.11

“I cannot recommend it highly enough: even if you read nothing else about the origins of drug research and what it can (should?) teach us, read this….This is a ‘buy’.”  Madhu Davis review in Pharmaceutical Physician May 2016.

My other books currently available on kindle:

Screen Shot 2015-01-18 at 17.19.43Screen Shot 2015-01-18 at 17.19.00BIS Cover copyScreen Shot 2015-01-18 at 17.19.29Screen Shot 2015-01-18 at 17.18.54Screen Shot 2015-01-18 at 17.19.37Screen Shot 2015-01-18 at 17.19.16Screen Shot 2015-01-18 at 17.19.58Screen Shot 2015-01-18 at 17.20.06