The Left Atrium

CMAJ 2001;164(3):382-6

The secular mind
Robert Coles
Princeton University Press, Princeton, NJ; 1999
189 pp US$22.95 (cloth) ISBN 0-691-05805-9
US$12.95 (paper; May 2001) ISBN 0-690-88624

The ability to heal has been associated with divinity since antiquity; it is interesting that today's healing arts are founded on advances in epidemiology, bacteriology and clinical practice made in an era when Darwin, Nietzsche and Marx were, in their different ways, commiting deicide.

The story of science as the murderer of God has a number of variants. In his History of the Modern World (1983), Paul Johnson pegs the beginning of our unholy era at May 29, 1919, when photographs of a solar eclipse confirmed Einstein's theory of relativity, which the world then mistook for relativism. In Nostalgia for the Absolute (1974), George Steiner lays the blame for the godlessness of our times at the feet of Marx, Freud and Lévi-Strauss, whose spurious mythologies did duty for religion. In The Malaise of Modernity (1991), Charles Taylor conducts his (very temperate) analysis on adjacent ground, contemplating "the fading of moral horizons" in the culture of self-fulfillment.

Now we have The Secular Mind, in which the prolific Robert Coles, child psychiatrist, Pulitzer Prize winning author (for Children in Crisis, 1990) and editor of the highly respected journal of documentary arts, DoubleTake, offers a parallel analysis. This is not a book about medicine or its history, but one that gives insight into the intellectual context in which medicine, particularly psychiatry, is now practised.

When Coles was a resident in child psychiatry at Harvard he was drawn to a seminar led by Paul Tillich, the theologian. Tillich's phrase, "the secular mind," would recur to Coles over the years as he conversed with writers who pondered humanity's position in a secular universe, including social activist and Catholic convert Dorothy Day and physicians William Carlos Williams and Walker Percy. He also consulted literary texts, notably those of 19th-century realists — George Eliot, George Meredith and Thomas Hardy — who closely observed the vacuum of faith created by the scientific ascent of man.

Insofar as "secular" means, as Coles reminds us, "the things of a particular time," the tension between the temporal and the sacred is hardly modern. Moses, the great lawgiver, was "not least, an interpreter of the sacred for the secularist crowds." As for the particular secularism of our own age, Coles traces its roots to Darwin, whose evolutionary theory "radically unnerved thousands," and to Freud, who displaced the act of confession, "once the prerogative of the sacred," into what Freud himself called the "godless materialism" of psychoanalysis. In the words of Freud's daughter, Anna, whom Coles interviewed at length, "the spiritual [became] a matter of mere events in the mind, each of which carried an explanation, if you looked closely and long enough."

Perhaps most poignantly, Coles invokes his mentor William Carlos Williams, whom he visited regularly as a student of medicine. Describing the attraction of Nazism for intellectuals such as Heidegger, Ezra Pound and Jung, Williams once remarked: "This secular mind — where it has led us." Interestingly, it is within this political and historical frame that Coles' instincts as a physician come into sharper focus: "It took me some time, in the course of working with children caught in political and social and racial crises, to realize that their mental life had to do not only with [family] relationships ... but with the larger world they inhabited."

This is a heady and idiosyncratic book, and it is difficult, at each discursive turn, to see where Coles is heading. This, together with a faintly elegiac tone, is what makes the concluding chapter so surprising. The Orwellian nightmare of totalitarianism is in Coles' view largely over, and we may take a more confident view of the future. Psychopharmacology, in particular, has already opened up new avenues for self-knowledge; sometime in the new millennium we "will come into growing command of our 'thoughts,' our 'emotions': what we call the Id and the Superego will be understood biologically and, thereafter, brought under control."

For Coles, it appears, the rewriting of the mind as matter need not constitute a loss of humanness; we will be "ever needy of an 'otherness'" to receive our prayerful impulses. Reaching the end of this exploration, I was not sure whether I had encountered a new twist in the arrogance of science, or an unconditional faith in the wonder of creation. Wherever our "secular destiny" will take us, perhaps heaven (if there still is one) will preserve us.

Anne Marie Todkill
CMAJ

In the islands off the southern coast of Nova Scotia and in the isolated villages inland, there were many warmhearted people. Coming from a different world, I much admired the love and caring shown among families and friends and the warmth that was also extended to strangers. In the absence of community services and social workers and all the institutions that we regard today as the norms of life, everyone was taken care of. It seemed that there was always a means to solve problems within the community.

On one of the islands lived a couple, M. and Mme. Le Brun. They had a child, called Jacques, who had Down's syndrome and was very disabled. He was cared for with great love and was cherished. The burden this placed on the lives of M. and Mme. Le Brun was seen as an act of God and was never questioned. The couple had a small store in the village, and as they got old one of them tended the store while the other looked after their son, who in his teens became bedridden and doubly incontinent — a hard situation in the best of hands, and very wearying.

During this time two young people who lived in the village, Pierre and Marie, fell in love. They had no money, and work was hard to get, but eventually they decided to marry anyway and share their lives even in poverty. And then a wonderful plan was conceived. They made an arrangement with M. and Mme. Le Brun: the young couple would come to live in the house, run the store and look after Jacques. It was quite an undertaking, but the understanding was that Pierre and Marie would inherit the house and the store on condition that they looked after the Le Brun family until they died. And so it was.

When I became involved, Pierre and Marie were a mature couple who owned a small house and ran a small store. I saw that their household included two old people, whom they cared for as if they were their own parents, and a demented, incontinent, invalid man who was loved and kept clean and nursed with as much sympathy, understanding and care as I could imagine possible. It took me a while before I worked out the kinships or, rather, the lack of kinships between them. By this time, M. Le Brun had had a stroke and had become bedridden and doubly incontinent. I assumed that the burden of two incontinent invalids would be overpowering, that some institutional care would be needed, but this didn't even enter the clear heads of Pierre and Marie. The bargain was to be kept. And so it was, not only in this household but in other families on the islands and in the villages by the sea or inland.

In one of these inland villages — Quintain by name — there lived in a small wooden house a family that included a man and his wife and numerous children and elderly aunts, uncles and grandparents who sat together by the fire. I was called occasionally, but not to see any of them. The patient was elsewhere in the house, and I only heard her referred to as "Tante."

After the long drive down muddy roads through the forest, it was always rewarding to reach such a warm and friendly place where I was treated to tea and cakes. On my first visit, although Tante was mentioned, no one seemed in much of a hurry to take me to see her. As I sipped my tea I felt a rising degree of expectation at the coming event. I was not disappointed.

Tante was very old and fragile, and she was confined to a small bed in a shady alcove off one of the corridors. She sat up in bed gazing at the wall in front of her, where there was a religious picture (as there were on all the other walls). She said nothing. I examined her from top to bottom, helped by the lady of the house who carefully folded the immaculate white sheets forward, or raised the immaculate white lace nightie, being careful not to disturb the perfectly brushed, shiny white hair, arranged in a style of a previous era above Tante's ears. The pillows were of white lace, too, and Tante's skin was as perfect as a baby's. It was considered thorough, traditional and correct in those times and in those parts to listen with a stethoscope to the heart and lungs, take the blood pressure, and prick the finger and test a drop of blood in a small battery-operated device that crudely measured the hemoglobin content of the blood.

I did all this, although I wasn't sure why. I had asked, "What's the problem?" and had been answered, "Tante has a cold."

"Does she talk?" I asked.

"Not lately."

"When did she last talk?"

"Tante hasn't talked for seven years."

"Really? Does she ever move?"

"No, Tante never moves."

And neither did she. Presumably she'd had a stroke seven years before, had been put in bed and had sat there ever since, looking at the wall blankly, although Jesus and the bleeding heart were just in front of her. The family must have fed her, washed her, powdered her and kept her in perfect preservation ever since. They loved her and worried about her and I often had calls in the evening to see her.

"Tante has a cold, please can you come and see her? Sorry to call you at night, Doctor."

I never found her any different from the way she was the first time. Her temperature was normal, her blood pressure a little low, her blood hemoglobin showed her a little anemic, but not unusually so for her age, and she sat motionless except for her gentle breathing. Her lungs were clear and, to be honest, I didn't know why they called me, but I could only assume that the lady of the house (Tante's niece) felt that she had noticed something different. So I went through the procedure, told them that Tante was all right and asked them please to call me again if she needed me, because at that age one is never quite sure and in this case a fragile balance was so carefully achieved.

One occasion was different, however. It was three o'clock in the morning when I heard a frightened child's voice on the telephone: "Sorry to call you, Doctor, but Tante is dying. Can you come quickly?"

"I'll be right there."

I pulled on my clothes and boots, went out in the sharp winter air, started the car and set out in the dark on the long gravel road through the forest.

When I got to the house there were cars and trucks everywhere — in the road, on the lawn, on the neighbour's lawn. I parked on a mound of grass between two trucks and entered through the porch door, which brought me into a corner of the main living room. In the opposite corner, facing into the centre of the room, was the parish priest in full vestments, the distinctive calotte and soutane and a wonderful embroidered overgarment, conducting a Mass in French. He was holding a silver cross with which he blessed his congregation, for the floor of the room out into the doorways and corridors was totally occupied by kneeling figures, presumably friends, close family and all the relatives that could be mustered. They all faced the priest, praying with him and making their responses. The whole scene was lit with the yellow glow of kerosene lamps and two large wax candles that stood on small tables on either side of the priest. I took off my hat, put down my black bag, knelt among the faithful and watched and listened. Presumably Tante had died. The service continued; a little bell was rung. The censer was swung from side to side, filling the room with the mystical aroma of incense. After about half an hour the service came to an end. With the last "Amen" the priest came over to me and shook my hand.

"Sorry, Doctor, we didn't mean to hold you up."

"No, no, that's fine, of course."

A tearful niece came toward me as everyone stood up and cleared the way.

"She has a terrible cold, Doctor. I'm afraid this is the last of her."

She led me to the alcove, where to my surprise Tante was sitting in her bed and looking the same as ever. No closed eyes, or sweating or fevered brow, just the same little Tante in the same little bed as always.

I looked as grim as I could and went through the usual performance, which the niece watched as though I were about to give her words of terrible import. But everything was as always. No fever, no racing pulse, blood pressure as before, hemoglobin the same, little fragile Tante with no change whatsoever. Behind the niece, relatives crowded sadly and a little girl whimpered.

Here was a special situation. I presumed that the niece had woken up the priest and the family with the expectation that the last rites were needed. I couldn't let her down.

"I'm afraid she's very sick," said I, as gravely as I could manage and breathed a long, sad sigh. Of course I felt a little guilty, but what was I to do?

"I'm going to give her an injection," I intoned. I reached into my black bag and brought out a little kit with a syringe and ampoules, cleaned Tante's skinny little shoulder and gave her a symbolic amount of penicillin. I counted out some tablets, suggested a half tablet every four hours and looked the niece in the eye sympathetically.

"I'm afraid she is very ill," I said. "I'll do my best, but Tante is not very strong and you will have to be prepared."

"Oh, Doctor. Thank you very much, that's all we can do — our best — and pray for her."

I nodded my head gravely.

The niece cried and thanked me over and over again.

"Call me in the morning and let me know how she is."

"Oh yes, Doctor, of course, Doctor."

And I left the sad house and the warm kerosene glow, drove out onto the muddy path and started down the gravel road toward home.

The next morning the niece called me.

"Doctor, Doctor, we are so grateful. Tante has recovered, she's fine this morning. It's a miracle."

"Oh wonderful! Let me know if you need me again."

I could feel a little tremor as Hippocrates turned in his grave.

Alan J. Lupin
Honorary Professor
Department of Surgery
University of British Columbia
Vancouver

In the eight years I spent as a missionary doctor in Nigeria, one of my goals was to train as many Nigerians as possible for medical work. One of my students was a 15-year-old pastor's daughter who gained some basic medical training at our mission hospital. She went on to midwifery training in the early 1970s, and then returned to work in the mission.

My family returned to Canada in 1976, where I entered psychiatry. When we returned to Nigeria for a visit eight years later, this young woman, whom I will call Ruth, came to consult me. Her complaints were obvious to any physician: shortness of breath, ankle edema, coughing when lying down, low energy. She asked me to examine her; when I did so, I recognized a classical mitral regurgitation.

She asked if medication would help. I told her that unless she had an opportunity to go to North America for valve replacement, nothing could be done. I advised her about general care, taking antimalarials to keep her hemoglobin up, vitamins and regular exercise.

When I visited Nigeria again in 1995, Ruth was one of the first to greet me. She was very eager for me to listen to her heart.

She described how she had gone back to nurses' training but had become increasingly short of breath. She spent one day in classes and the next two in bed to reduce the edema. She had become discouraged and depressed, to the point where she, a practising Christian and a pastor's daughter, went to consult the local witch doctor. He said that he would be glad to help her if she brought a goat and two chickens for sacrifice. Once back at home, she began to feel guilty about resorting to magic, and so did not return with the goat and chickens.

The difficulty of furthering her education was becoming very stressful. She became more and more discouraged, to the point where she began to express a passive wish to be dead. During this time a friend and classmate invited her to attend a healing service. Ruth was not familiar with such things; she had grown up in a conservative evangelical church, whereas this healing service was charismatic.

Ruth had no expectation of a miracle. Her concept of healing had more to do with the natural healing ability of the body. She would occasionally pray that God would allow the natural course of an illness to lead to recovery rather than taking a fatal turn. Her most expectant prayers were that God would give the doctor wisdom or the surgeon skill to help heal someone else.

The service, as she later described it, was held in the open air, outside the church, which was too small to contain everyone who came for healing. After the general service the minister called people to the altar, according to their disease or sickness. People fell to the ground, as if unconscious, and were carried into the church. Ruth waited, but her own illness was not mentioned. She couldn't restrain herself for fear that the service would end before she was called. So she forced herself to the front of the crowd. And there she fell down, as she described it, "under the power of the Holy Spirit." This was something she had never experienced before and did not understand. She returned home, confused, but feeling that in some way "something had happened." She felt a little better, but not markedly so. In the next days she felt more improvement. She began to wonder what might have transpired in the healing service; and so she came to consult me, bringing her stethoscope to the only doctor who had listened to her heart before this strange event.

It was with a mixture of anticipation and curiosity that I placed the stethoscope over her cardiac apex. What I heard made my mind tilt. Here was the clear lub-dub of normal heart valves. Yet just as clearly I remembered the distinct pathologic sounds I'd listened to over this same apex in 1984. Could this be the same Ruth? It was: this was a close-knit community where we had functioned as a large extended family. I had known her from the time she was a teenager. Her parents were our good friends. We attended the same church, played volleyball together, shared many meals. We had spent many hours teaching her the basics of medical science, microbiology, patient care. We had taught her how to give injections and to care for the very ill.

This was Ruth, whose heart was diseased in 1984. How could her valves have reshaped themselves? I had never heard of a spontaneous resolution of post-rheumatic heart disease. She believed that it had happened during that healing service. I thought there must be some other explanation. Either that, or I must disbelieve my own ears.

This disbelief seems ironic. There I was, a Christian who believes in the miracles of the Bible, who believes that God is "the same yesterday, today and forever," finding it easier to believe what I had been taught in medical school than what I was hearing with my own ears.

Science and miracles do not mix very well. We are taught in medical school that there are such things as "spontaneous remissions." Perhaps we should be paying more attention to such remissions: they could be happening before our eyes without us even noticing. Certainly, our patients would report spontaneous remissions more often if we as a profession were open to listening, rather than bent on explaining such occurrences away. Our authority can make our patients look foolish and us appear wise. But at some point we must choose whether we prefer to believe the evidence of our senses or a cognitively created explanation for a miracle.

W.D. Gutowski
Psychiatrist
Chilliwack, BC

Tobias the Elder is cured of his blindness: etching by Rode dated 1769. In the apocryphal Book of Tobias the archangel Raphael, in the appearance of a young man, accompanies the younger Tobias (and his dog) on his first journey away from home, to recover some money belonging to his blind father. Raphael, whose name means "God has healed," teaches Tobias about the use of fish entrails in exorcizing demons and as a curative ointment for the eyes. On the journey Tobias finds a wife, and the angel's first remedy proves useful in getting rid of the demon who killed his bride's seven previous bridegrooms. On his return, Tobias follows the angel's instructions to restore his father's sight: "You must put the fish's gall to his eyes; the medicine will smart and will draw a filmy white skin off his eyes. And your father will be able to see and look on the light" (Tobit 11:8).
US National Library of Medicine, History of Medicine Division