A Narrative Future for Medicine A New Scientific

A Narrative Future for Medicine A New Scientific Humanism Meyer Children’s Hospital, Firenze 18 -19 th February 2016 Brian Hurwitz King’s College London

Case Report The pretty young virgin daughter of Nerius was twenty years old. She was struck on the bregma by the flat of the hand of a young woman friend in play. … she became blind and breathless, and went home when fever seized her. . . her head ached, and there was redness about the face. On the seventh day foul smelling pus came out around the right ear, reddish …she was prostrated, depressed, speechless; the right side of her face was drawn up. On the ninth day she died. Hippocrates. Epidemics V in Smith WD (Tr) Epidemics II and IV-VII. Cambridge, MA: Harvard University Press, 1994.

Case Report The pretty young virgin daughter of Nerius was twenty years old. She was struck on the bregma by the flat of the hand of a young woman friend in play. … she became blind and breathless, and went home when fever seized her. . . her head ached, and there was redness about the face. On the seventh day foul smelling pus came out around the right ear, reddish …she was prostrated, depressed, speechless; the right side of her face was drawn up. On the ninth day she died.

Case Report Eumelus of Larissa grew rigid in his legs, arms, and jaws. He could not extend them or bend them unless someone else extended or bent them, nor open his jaws unless someone opened them. But no other symptoms. .

Case Report Eumelus of Larissa grew rigid in his legs, arms, and jaws. He could not extend them or bend them unless someone else extended or bent them, nor open his jaws unless someone opened them. But no other symptoms. He had no pain and he did not eat, except barley cakes, and he drank honey water. On the twentieth day he fell backwards while sitting and severely struck his head on a stone, and darkness poured over him.

Case Report Eumelus of Larissa grew rigid in his legs, arms, and jaws. He could not extend them or bend them unless someone else extended or bent them, nor open his jaws unless someone opened them. But no other symptoms. He had no pain and he did not eat, except barley cakes, and he drank honey water. On the twentieth day he fell backwards while sitting and severely struck his head on a stone, and darkness poured over him. Shortly later he stood up and was better. All was relaxed except that when he wakened after sleep his joints were slightly bound. He was then twelve or thirteen. He was troubled for three or four months. Hippocrates. Epidemics V in Smith WD (Tr) Epidemics II and IV-VII.

Case Report Eumelus of Larissa grew rigid in his legs, arms, and jaws. He could not extend them or bend them unless someone else extended or bent them, nor open his jaws unless someone opened them. But no other symptoms. He had no pain and he did not eat, except barley cakes, and he drank honey water. On the twentieth day he fell backwards while sitting and severely struck his head on a stone, and darkness poured over him. Shortly later he stood up and was better. All was relaxed except that when he wakened after sleep his joints were slightly bound. He was then twelve or? thirteen. He was troubled for three or four months. Hippocrates. Epidemics V in Smith WD (Tr) Epidemics II and IV-VII.

On Head Wounds So, in addition to your visual inspection of what may be seen in the bone, you must also inquire about all these matters – for these are indications of a patient’s being injured to a greater or lesser degree –

On Head Wounds So, in addition to your visual inspection of what may be seen in the bone, you must also inquire about all these matters – for these are indications of a patient’s being injured to a greater or lesser degree – and inquire whether the patient was stunned and darkness poured over him and whether he had vertigo and fell down. Hippocrates. On Head Wounds 11. 8. Hanson M (Tr). Berlin: Akademie Verlag, 1999, 77.

A Girl, three Years old, who remained a quarter of an Hour under Water without drowning May 6 1737 Rebecca Yates of Market Bosworth in Leicestershire, had a Daughter about three Years of Age that fell into the Mill dam near to the water Mill-Wheel; and by force of the stream, was drawn under the water to the Wheel, with her legs forwards; one of her legs went under the Mill-Wheel; …the Child’s leg stopped the said Wheel from moving at all. The sudden stopping of the Mill so much surprised the Miller that he went immediately and let down the shuttle…. . The First Word she spoke was Help me, repeating this three times. For God’s sake help me out if you can………

She spoke very briskly after she was put to bed…But the Mill Wheel had tore away all Skin, Muscles, Sinews and Tendon of her leg quite to the Bone. Child lived Monday to Friday then died of her wounds and bruises; otherwise in all Appearance, she might have lived to have made a fine Woman. The whole Time of her being under Water depth 41/2 feet was near 15 minutes. Green J. Philosophical Transactions 1739 (July-Oct) 166 -8.

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Jan P Vandenbroucke

• BMJ | 17 FEBRUARY 2007 | Volume 334

• Pain a feature of 78% of child visits to emergency rooms • Fractures, headache, earache, sore throat, abdominal pain.

Current Concepts in the Management of Pain in Children in ERs ‘Early aggressive treatment of pain is recommended, because uncontrolled or severe pain stimuli can lead to hyperalgesia – an enhancement of the pain response. ’ Krauss BS, Calligaris L, Green SM, Barbi E. Lancet 2016; 387: 83 -92.

‘Recognition and assessment of pain in infants can be difficult because these patients cannot verbalise their pain experience. Spinal reflex responses are exagerated, but facial expression is a weak indicator. … excessive crying, irritability, poor feeding, position and movement of the arms and legs, and sleep disturbance can indicate pain. Altered facial expression is also suggestive.

‘Recognition and assessment of pain in infants can be difficult because these patients cannot verbalise their pain experience. Spinal reflex responses are exagerated, but facial expression is a weak indicator. … excessive crying, irritability, poor feeding, position and movement of the arms and legs, and sleep disturbance can indicate pain. Altered facial expression is also suggestive. Tools to grade children’s pain are widely recommended, including physiological methods, observational and behavioural measures (grading of facial expression, leg movements, activity crying), self-reporting meaures, and parents’ report. In older children most physicians regard patients’ self-reporting of pain as the gold standard. ’ (83)

Tim Matthews

Narrative ‘… a representation of events which is shaped, organized and coloured, presenting those events, and the people involved in them, from a certain perspective or perspectives, thereby creating narrative structure: • coherence • meaningfulness • evaluative and emotional significance. ’ Goldie P. The Mess Inside. Oxford: Oxford University Press, 2012, 8.

Narrative ‘… is a representation of events which is shaped, organized, and coloured, presenting those events, and the people invoved in them, from a certain perspective, thereby giving narrative structure – coherence, meaningfulness, and evaluative and emotional import – to what is narrated. ’ Goldie P. The Mess Inside. Oxford: Oxford University Press, 2012, 8.

… a young Soviet prisoner in my ward … was moribund and screaming. . I examined him. He had an obvious severe pleural rub. I thought this was the cause of the pain and the screaming. I had no morphine, just aspirin, which had no effect. I felt desperate. I knew very little Russian then and there was no one in the ward who did. I finally instinctively sat down on the bed and took him in my arms, and the screaming stopped almost at once. He died peacefully in my arms a few hours later. Cochrane A. L. , Blythe M. One Man’s Medicine: an Autobiography of Professor Archie Cochrane. London: British Medical Journal, 1989.

… a young Soviet prisoner in my ward … was moribund and screaming. . I examined him. He had an obvious severe pleural rub. I thought the latter was the cause of the pain and the screaming. I had no morphia, just aspirin, which had no effect. I felt desperate. I knew very little Russian then and there was no one in the ward who did. I finally instinctively sat down on the bed and took him in my arms, and the screaming stopped almost at once. He died peacefully in my arms a few hours later. It was not the pleurisy that caused the screaming but loneliness. Cochrane A. L. , Blythe M. One Man’s Medicine: an Autobiography of Professor Archie

… a young Soviet prisoner in my ward … was moribund and screaming. . I examined him. He had an obvious severe pleural rub. I thought the latter was the cause of the pain and the screaming. I had no morphia, just aspirin, which had no effect. I felt desperate. I knew very little Russian then and there was no one in the ward who did. I finally instinctively sat down on the bed and took him in my arms, and the screaming stopped almost at once. He died peacefully in my arms a few hours later. It was not the pleurisy that caused the screaming but loneliness. It was a wonderful education about the care of the dying. Cochrane A. L. , Blythe M. One Man’s Medicine: an Autobiography of Professor Archie Cochrane. London: British Medical Journal, 1989.

… a young Soviet prisoner in my ward … was moribund and screaming. I examined him. He had obvious …. severe pleural rub. I thought the latter was the cause of the pain and the screaming. I had no morphia, just aspirin, which had no effect. I felt desperate. I knew very little Russian then and there was no one in the ward who did. I finally instinctively sat down on the bed and took him in my arms, and the screaming stopped almost at once. He died peacefully in my arms a few hours later. It was not the pleurisy that caused the screaming but loneliness. It was a wonderful education about the care of the dying. I was ashamed of my misdiagnosis and kept the story secret. Cochrane A. L. , Blythe M. One Man’s Medicine: an Autobiography of Professor Archie Cochrane. London: British Medical Journal, 1989.

… a young Soviet prisoner in my ward … was moribund and screaming. . I examined him. He had an obvious severe pleural rub. I thought the latter was the cause of the pain and the screaming. I had no morphia, just aspirin, which had no effect. I felt desperate. I knew very little Russian then and there was no one in the ward who did. I finally instinctively sat down on the bed and took him in my arms, and the screaming stopped almost at once. He died peacefully in my arms a few hours later. It was not the pleurisy that caused the screaming but loneliness. It was a wonderful education about the care of the dying. I was ashamed of my misdiagnosis and kept the story secret. Cochrane A. L. , Blythe M. One Man’s Medicine: an Autobiography of Professor Archie Cochrane. London: British Medical Journal, 1989.

Case Reports in The Lancet: a new narrative Stories form the basis of how we learn, and how we remember. Throughout history people have interpreted the world around them and passed on lessons learned through myths, fairy tales, parables, and anecdotes. Medicine is no different, and most physicians can describe the first patient they saw with a particular condition more easily than they can recall the latest research paper in their field. Berman P, Horton R. Case Reports in The Lancet: a new narrative www. thelancet. com Vol 385 April 4, 2015, p 1277

Case Reports in The Lancet: a new narrative Stories form the basis of how we learn, and how we remember. Throughout history people have interpreted the world around them and passed on lessons learned through myths, fairy tales, parables, and anecdotes. Medicine is no different, and most physicians can describe the first patient they saw with a particular condition more easily than they can recall the latest research paper in their field. Berman P, Horton R. Case Reports in The Lancet: a new narrative. www. thelancet. com Vol 385 April 4, 2015, p 1277

Orders of Significance in Modern Case Reports • Mimetic • Natural • Personal – modelling, re-enactment, observation – observation, reasoning, inferences – loss of capacities, social, symbolic

Orders of Significance in Modern Case Reports • Mimetic • Natural • Personal – modelling, re-enactment, observation – pattern: spatial and temporal – loss of capacities, social, symbolic

Orders of Significance in Clinical Case Reports • • Mimetic Natural Personal Explanatory Pragmatic Relational Biographical Narrative – modelling, re-enactment, observation – observation, reasoning, inferences – loss of capacities, social, symbolic – of causes, mechanisms, prediction – unpredictability, classificatory, naming – interactional – a form of life-writing – configurative, anecdotal, suspenseful

Orders of Significance in Modern Case Reports • • Mimetic Natural Personal Explanatory Pragmatic Relational Biographical Narrative – modelling, re-enactment, observation – observation, reasoning, inferences – loss of capacities, social, symbolic – of causes, mechanisms, prediction – unpredictability, classificatory, naming – interactional – a form of life-writing – configurative, anecdotal, suspenseful

My wheelchair is my tool. My radio is my mouth. My passion is my football team. My country is my house. My passion is my rock band. My pet is my mouse. My family’s my priority. My phone is my spouse. My lunch break is my day dream. My i-pod is my theme.

It may interest readers of THE LANCET to look at the accompanying wood engravings, which were made from photographs of a case of extreme starvation (anorexia nervosa) which was brought to me on April 20 th of last year by Dr Leachman of Petersfield. Dr Leachman was good enough subsequently to send me the following notes; and afterwards, at my request, the two photographs, taken by Mr C S Ticehurst of Petersfield.

Non pharmacological treatment ‘Neonates and infants have a positive physiological response, lowering of pain scores, cry duration, and hear rate variation, to oral stimulation as well as physical contact or touch. ’ (85)

Non pharmacological treatment ‘Neonates and infants have a positiive physiologiical response, lowering of pain scores, cry duration, and hear rate variation, to oral stimulation as well as physical contact or touch. ’ (85) External perspective • No testimony • No subjective experience of pain – what it feels like • No descriptions – absent adjectives, metaphors, similes, signifying communicative gestures of pain • No carer views, understandings or feelings

In April, 2007, a 47 -year-old man presented with a short history of severe muscle ache and dark-brown discolouration of his urine. He had enjoyed a brisk walk on Haystacks, one of the fells in the Lake District, 2 days earlier. There was no medical history of note, he was on no medication and denied illicit drug use. He was a foreman in a paper mill and exercised frequently. Physical examination showed tender quadriceps muscles. Laboratory test results showed a creatine kinase (CK) of 277, 480 U/L (normal <170). A diagnosis of rhabdomyolysis was made. Forced alkaline diuresis was initiated but oligoanuric renal failure ensued. Heamofiltration was started and the patient was discharged in good health (creatinine 182 umol/l) after 3 weeks in hospital. Ogundare O, Jumma O, Turnbull D, Woywodt A. Searching for the needle in the Haystacks. Lancet : 374; 5, 2009.

On March 13 th she travelled from the north of England, and visited me on April 20 th. She was then extremely emaciated, and persisted in walking through the streets to my house, though an object of remark to the passers-by. Extremeties blue and cold. Examination showed no organic disease. Respiration 12 to 14; pulse 46; temperature 97 deg, Urine normal. Weight 4 st 7 lb; height 5 ft 4 in. Patient expressed herself as quite well. A nurse was obtained from Guy’s and light food ordered every few hours. In six weeks Dr Leachmen reported her

and on July 27 th the mother wrote: “K – is nearly well. I have no trouble now about in her eating. Nurse has been away three weeks”. This story, in fine, is an illustration of most of these cases, perversions of the “ego” being the cause and determining the course of the malady. … it is curious to note… the persistent wish to be on the move, though the emaciation was so great and the nutritive functions at an extreme ebb. Lancet March 17 1888 p 517.