Internal vs External Exams

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 Daffydildeveloped. (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 teaImage: Henry Peach Robinson, Fading Away (1858) . . . while assuming that medically-trained 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 19thcentury 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.

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 no-one 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 BantingInstitute. (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. 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) 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?

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 “force-multiplier” 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 1925-1966 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.

Internal vs External Exams