Review by Jolyon Bending

Roy Pounder. Long Cases in General Medicine (second edition). Oxford: Blackwell Scientific Publications. 1983.

I like old medical text books. They give a sense of the wishes of the author, and inform us of what was instilled in its readers.

The ones that come most readily to mind are the grand volumes. Written in a kind of didactic verse, they are quite literally bursting at the seams. All the knowledge in the world could hardly be fitted into their stacked pages.

I have often wondered what it is that has captured my imagination about these old books. I think because I know the authors so well, Ellis, Davidson, Kumar, I know where they have come from and therefore know they must be sources amongst others.

Secondly, because they have the allure to exist in a moment in time, they become invitations to extract the memorable from what we know is the partially synthesised. Whilst their original goal was to be an un-abridged companion to medical education, their true destiny lies in allowing us to open up our collective medical past.

Edited by Roy Pounder, Long Cases in General Medicine is aware the reader has a partially synthesised understanding of clinical medicine, and seeks to help. The first section is simply headed “The patient.” These short vignettes can be as colourful as they are precise. First of all, for Roy and company, an important emphasis is made to understand the exact brand of Martini the patient drinks (Vermouth as in the first case). This elaboration however is used to serve a purpose, pointing me towards the association between this patient’s jaundice and acute alcoholic hepatitis.

Any examination is at least two thirds visual description. The following is an extract from a patient with polycythaemia: “The patient was confused, disorientated and very vague. Examination was difficult as he withdrew when he was touched. He was markedly plethoric with prominent capillaries on his nose and cheek, the mucous membranes were deeply red. His lips were cyanosed.” 

When it comes to how the cases handle questionable explanations from patients, this textbook will not suffer fools lightly. My favourite is of the Chelsea Pensioner. “A 68-year-old Chelsea Pensioner blamed his respiratory distress to the fact that he was gassed in the first world war, although he was only born during that war! This explanation blinded him to the fact his symptoms were due to being a heavy smoker.”

The cases continue with a wide variety of presentations until we get to The Viva, its answers jumbled and out of order to discourage cheating. It is here I gravitate towards what I think I know. Such as in the case of the young women with sickle cell disease who presents with breathlessness and a fever. The possibility of pulmonary infarction due to sickle cell? I didn’t know that. The need to keep sickle cell patients well hydrated? I think I had that one in the back of my mind. All the while, this textbook’s exact position as a resource or historical document seems to shift. I look again, my thumb flicking through its almost brown pages.

But this is not speculative conjecture at a comfortable distance. This is medicine and the deadly serious is never far away. “The patient is desperately ill with a severe respiratory problem.” Although we are soon consoled. Not just with an authoritative explanation of the treatment required. But also in an un-expectantly conversational way.

In fact digressing runs all the way through this book. I feel like the teachers are talking ‘to’ me (and not ‘at’ me.) The question is why not an anatomical dissection of the exact answers in lists and bullet points? I think partly there is a real desire to impart experiences through the formality of an exam scenario. For instance, it seems impossible to write the following sentence unless you have been intimately involved with the treatment of lung cancer: “Aggressive chemotherapy (for small cell lung cancer) is a worthwhile beacon of light in this gloomy field of medicine.”

More than that, I believe it is in keeping with the tradition of dialogue between doctors. It is a threatened concept. The idea of individual responsibility and the threat of repercussions is an ongoing barrier to honest conversation between carers. The balance between what is spoken and what is written heavily favours the recorded and the measured. What we find when we open a book such as this is a wish to describe. A desire to tell.

This textbook, much like the MRCP exam, is not a left brain exercise in revision. It is about accurately describing and logically summarising. However, it is also about what we gain by having a conversation about our craft. It’s like saying ‘Welcome in! This is what we would do. Now what about you?’

Thank you Dr Benton for leaving this book in your office. It has been returned.