How will history judge our clinical practices?

Surgical Chest

Tom Treasure

30 June 2007

I have been reading Edmund White’s biography of Marcel Proust. I learned that on the day of his death he was cupped by his physician brother, Robert.

Edmund White writes:

“Proust had developed pneumonia, which went untreated and turned into bronchitis, and finally an abscess on the lungs. For a year he had been speaking of his own death; perhaps he was proud that he had hung on so long, to fifty-one, the age at which his prolific predecessor Balzac had died. On the morning of 18 November 1922, Proust saw a fat woman in black whom no one else could see, though Céleste dutifully promised to chase her away. Robert Proust bled him (the common treatment for lowering a fever) by applying suction cups to his back, but to no effect save for the extra pain caused by this procedure. Then, between five and six in the evening, Proust died.”

The account led me to think again about history of medicine as an area of study and enquiry. Edmund White, writing this in the 1990s, is neither a doctor nor a historian but a fine writer. We could quibble about what we now think might have been the correct diagnosis and indeed the exact nature of the intervention undertaken by brother on brother but in so doing we would be distracted from the content of the story.

One of the more valuable opportunities I have had in my life was a four-month sabbatical in mid career at the Wellcome Institute for the History of Medicine. I learned so much. It is not about who did what, first, and when. History is a richer and more intellectually engaging field of enquiry than that.

For me, it was a time of self-discovery. I learned to take a completely different view of myself as a doctor and of medicine, and to understand but not be unnerved by our fallibility. I came to an appreciation of how so many of our beliefs, of even apparently basic principles, are provisional. That the notion that we make remorseless progress to a better place or to a more complete state of knowledge emphasises only one dimension of change. That one could see change as being as often a retreat as an advance. That diagnoses are not divinely ordained but are temporary frames in an ongoing negotiation between practitioners, scientists, and the society in which live.

To many medical colleagues this will read like abstruse, lofty philosophising. If so perhaps it’s because I haven’t explained myself well enough; or perhaps simply that it’s enough for us all to understand that there’s more than one way of viewing the world - and thus tolerating other ways. A serious engagement with history of medicine is no bad thing and could start painlessly by dipping into Framing Disease – perhaps the chapter on renal disease or the “discovery” of homosexuals. (1)

It was some recent polemic led me to consider history of medicine as subject for a BLOG. I have been responsible (not single-handedly) for triggering some electronic traffic on the BMJ’s web pages. Two short articles have prompted this. Each is based on work over two to three years retrieving and analysing all published evidence. Both reach what we, the authors, see as an evidence-based middle of the road position. The electronic responses on the other hand are necessarily drafted more hastily, they are unfettered by editing and peer review, and so more strongly expressed. Some are critical - but there is comfort in the fact that they range either side of our position.

http://www.bmj.com/cgi/eletters/334/7598/831

http://www.bmj.com/cgi/eletters/334/7602/1053

A similar tenor of strident professional confidence can be found in the BMJ correspondence columns 100 years ago, recommending or decrying practices based on beliefs which we do not share now. They would have been hand written and taken round to the BMJ office while the passion was still high - so in their tone perhaps not unlike electronic responses. Doctors were as intelligent, as committed and as strongly opinionated then as they are now. And how will today’s correspondence (if it survives as an archived and readable form) be regarded by doctors in 100 years time when, I presume, they will be as intelligent, as committed and as strongly opinionated as they are today? We can only guess.

The interventions at our disposal, opinions on best practice, our ethical stances, and the evidence on which we base all of them, change over time. The following statement would pass in a contemporary retirement speech: “This opinion has been more widely held in our own times, because of the great changes and variations, beyond human imagining, which we have experienced and experience every day.” Niccolo Machiavelli wrote that in 1516. Change didn’t stop then and will not stop now. However firmly we believe ourselves to have got it right, most of our beliefs are provisional and temporary. To what extent will they impress, amuse, or appal those, who in 2107 will read the BMJ of 2007 in the course of historical research? We cannot always be “right” in our own time and most of what is accepted as right now will be seen as wrong then. I’m sorry Marcel Proust had to suffer at his brother’s hands but I am sure they were all doing their best for him.