Transcript Taking Toronto’s Health Care History: Internal vs External

Internal vs External Exams
Edward Shorter
Jason A Hannah Professor of the History of Medicine
Faculty of Medicine
TTHH Conference
Nov 24, 2012
Historians of medicine like
to distinguish between
“external” and “internal”
accounts.
Internal accounts, generally
considered bad, are said to look
at the evolution of institutions
solely as an internal process, not
affected by society.
For example, focusing on the
Medical Dinner Committee of the
Faculty of Medicine, 1901, would
be of typical “internal” interest:
How something like Daffydil
developed.
(Image: UofT Archives)
By contrast, social historians of medicine often flatter
themselves as writing “external” accounts
How did events develop in the context of larger social trends?
One would look at the Medical Women’s hockey team of 1922 not
just as a case in growing student institutions but as an example of
the increasing liberation of women in Canadian society after the
First World War, the epoch of the “flappers.”
(Image: Torontonensis, the UofT yearbook, 1922)
Social historians of medicine consider external accounts their real cup of tea
. . . while assuming that medicallytrained historians of medicine write
“internal” accounts because that’s
the only kind of history they can do.
The assumption is patronizing, and
incorrect.
Here’s a good example: In
interpreting this 19th century
photograph, called “Fading Away,”
social historians of medicine might
infer that the patient has “anorexia
nervosa,” a fashionable new
diagnosis. Physicians with a good
knowledge of the history of
pathology might reasonably
conclude that she is dying of
tuberculosis.
But at medical history meetings,
anorexia trumps TB.
Image: Henry Peach Robinson, Fading Away (1858)
Now, in writing the history of health care in Toronto . . .
. . . I’m going to argue that both
perspectives, external and
internal, are needed; and that noone need have a monopoly on
either: physicians are just as
capable of writing external
history, historians should be as
capable of writing internal.
Here is Vera Peters, a famed
Toronto radiotherapist (who
discovered that Hodgkins disease
is treatable with radiation): both
perspectives are useful in sorting
out her life. (We’ll come back to
this.)
(Image: Peters studying patient charts
at home; courtesy Peters’ daughter
Jennifer Ingram)
Point #1: There are big Toronto stories where
internalist perspectives are very useful
. . . And which require some
knowledge of medicine to
interpret.
There is the PSP story.
Progressive supranuclear
palsy has among its
symptoms:
• the clinical appearance of
an agitated depression
 ocular disturbances, such
as paralysis of upward or
downward gaze
• mild dementia
(A typical PSP patient: Warren and Burn, PSP (review), Practical
Neurology 2007; 7 (1): 16; fig. 1
PSP is a Toronto story.
JC (“Ric”) Richardson was a
neuropsychiatrist at the Wellesley,
then at the General when
psychiatry was moved over.
Jerzy Olszewski was the professor
of neuropathology. John Steele
was a neuropathology resident.
Their 1964 paper, in the Archives
of Neurology, was an important
contribution.
There have been many books and article
on the history of psychiatry in Toronto . . .
. . . And that would include neuropsychiatry.
Ric Richardson saw lots of psychiatric patients
and wrote about shellshock.
Yet this has never been mentioned by anyone.
The externalists have slid in silence over
something that is very important to the
internalists.
[Here is a Toronto patient in the story.]
(Arch Neurol 1964, figs. 1 and 3, case 1)
Yet there is an
externalist perspective
to the story.
Mary Tom laid the basis for
the study of neuropathology
in Toronto.
She graduated from Toronto
in medicine in 1922, and was
an associate professor of
neuropathology at the
Banting Institute.
(Image: Mary Tom at graduation
Torontonensis, 1922)
Here she is cutting brain at the Banting Institute,
early 1950s
JM Findlay, Neurosurgery at TGH, Can J Neurosci 22 (1994)
Mary Tom went on, with
Richardson, to make important
scientific discoveries.
Here an article on brain changes from islet
cell tumors in 1951,
Yet she has been completely forgotten.
This is not the fault of the internalists.
So, even in as apparently an “internal”
matter as this, there’s room for
collaboration between social historians and
clinicians: clinicians to explain exactly what
PS is and why it is important, historians to
explain why Mary Tom’s name does not
appear in the title of more articles.
Journal of Neuroanatomy & Experimental
Neurology, 10 (1951)
Point #2: some topics in
Toronto’s health care
history do seem to lend
themselves more to social
historians.
Such as the unquestioned
discrimination against women
that went on here right until
the 1970s.
[see right]
How do we explain this
discrimination? These male
scientists and clinicians hated
women?
On October 6, 1944, the Committee on
Admission to the First Year reported,
“As in previous years your committee had to
deal with a formidable array of jewish
applicants, many of whom had a very good
matriculation score. We have admitted 31 jews
(3 being women) as compared with 32 (2
women) last year. The percentage of jews
passing into the present second year is high, as
the jews formed 21% of last first year, but
supplied only 6% of the failures.”
“The large number of female applicants
presented an equally serious problem. . . . This
year we have had to admit 37 women, five of
whom had perfect matriculation scores. That
means that women plus jews constitute almost
45% of the class.”
(Report of Committee on Admission to First
Year, Session 1944-1945, 26; UofT Archives)
The U of T medical faculty had a long history together as
comrades in arms.
They flocked collectively to
the colours in the Great
War.
Here are Duncan Graham,
later head of Medicine
(centre), and John
Mackenzie, later professor
of pathology (right), in the
field during WWI.
(University of Toronto
Archives)
In the Second World War they all rushed to arms as well.
The outpouring of patriotism was
quite extraordinary.
The "personnel" are not identified, but
at least two of the players in Partners
for Excellence (Singleton and Cannell)
served at that hospital.
Unthinkable today.
There was no room for women in this
comradeship. Women assisted behind
the lines as nurses. The men were
facing danger and doing their duty
together. That women could have
campaigned alongside them was
inconceivable.
And after the wars, for many years,
they continued to refer to one another
by their military titles.
Here: HM Queen Elizabeth (ie the Queen Mother) with
Matron Agnes C. Neill talking with personnel of No.15
Canadian General Hospital, RCAMC, Bramshott, England, 17
March 1941 (National Archives of Canada)
For these faculty veterans of the wars, women were nurses,
or pediatricians.
The Toronto medical scene was characterized by great
clubbishness, and a relative absence of professional rivalry.
People cooperated, got on with it, researched together.
That is the positive aspect of this kind
of male bonding. The negative aspect is
that it excluded women.
Vera Peters was never promoted to the
rank of professor.
Now, maybe I’m selling my clinical
colleagues who do the history of
medicine short. But in numerous
interviews, no clinician ever made this
point to me. Yet for a social historian it
leaps off the page.
(Torontonensis, 1934)
Point #3: The
relationship between
internalists and
externalists can be
synergistic.
Clinicians and social historians
alike bring special skills to be
topic that can serve as a “forcemultiplier” in final
understanding: the
collaboration means that at the
end of the day both have
discovered more than either
would have, on his or her own.
[Here is a social historian trying
to be a force multiplier . . . ]
The presenter, listening in during a psychiatry conference
The usefulness of
collaboration can be
seen very clearly in
the history of
psychiatry in Toronto.
Here is the old Toronto
Psychiatric Hospital (TPH)
• UofT’s psychiatric institute,
training centre and
reception hospital 19251966
• Succeeded by the Clarke
Institute of Psychiatry
• Merged with 3 other
facilities in 1998 to form
the present CAMH
(Image: Archives for the History of Canadian Psychiatry and
Mental Health Services, CAMH-Queen Street Site )
Psychiatry in Toronto started out very biologically focused.
Clarence Farrar succeeded
CK Clarke in 1925 as
professor of psychiatry.
Here is Farrar on Queen
Street, ca. 1930.
(Image: Farrar papers, CAMH
Archives)
Farrar had trained with Kraepelin and Alzheimer in Heidelberg.
In his early years at least, he
saw truth as coming from the
barrel of a microscope.
These are the keys he ripped
off . . . But for him, the
talisman of solid knowledge in
psychiatry.
So far, nothing here a mere
historian can’t handle.
(Farrar papers, CAMH Archives)
Yet coming out of the
department were solid
contributions to biological
knowledge . . .
. . . that have been largely forgotten.
(The department’s involvement with
lobotomy, by contrast, will never be
forgotten.)
Here is Wayne Furlong, who led
neuroendocrinology research at the
Clarke. Dr Furlong found that there is a
subset of depression patients who may
respond to treatment with thryotropin
releasing hormone – and he
characterized this subset (Am J Psych
1976)
Now, not only has this interesting finding
been forgotten. The entire subject of
endocrine psychiatry has been forgotten!
The Clarke no longer has a
neuroendocrine research section.
(CAMH Archives)
I’ve never encountered a historian with a serious research interest in
the history of endocrine psychiatry.
By contrast, there are plenty of
psychiatrists interested in the
subject.
Yet in Toronto, the great wheel
turned on. Neuroendocrine
research was shouldered aside by
psychotherapy and
psychoanalysis. Several chairs of
the department in the 1970s and
-80s were analysts, including Fred
Lowy, who is one of the great
medical leaders in Toronto.
(CAMH)
Why psychoanalysis
triumphed here . . .
. . . and everywhere else, and
then crumbled, is one of the
great questions in the social
history of medicine. No part
of this arc is attributable to
“new findings.” By contrast, it
has everything to do with
changing paradigms, both
within medicine and within
the population in general.
Social historians do very well
at this kind of thing.
Psychopharm replaced Freud.
Yet in assessing the merits of psychopharmacology, social historians
don’t do so well . . .
. . . Because it
involves technically
assessing the role
of the biogenic
neurotransmitters
as opposed to
other aspects of
brain chemistry.
Few historians feel
at home here;
many clinicians do.
So, bottom line . . .
. . . We might do well to imitate
the cooperation shown in
bringing the Faculty of Medicine
forward. Here are Brian Holmes,
the radiologist who was Dean of
the Faculty, and Bill Bigelow, the
cardiovascular surgeon who
conceived the pacemaker. They
worked easily together.
The history of medicine is an
interdisciplinary enterprise. If
we’re going to move the field
forward, we have to do it
together.
(Faculty of Medicine)
Thank you for your attention.