Wednesday, November 21, 2012

BOOK REVIEW: Open Wound. The Tragic Obsession of Dr. William Beaumont by Jason Karlawish

I recall that way back in medical school little tidbits of history of medicine were sometimes dropped into our lectures to make things interesting. When we were learning about digestion, an anecdote was related to us about an army surgeon who studied the stomach thanks to a fortuitous abdominal wound in one of his patients. The wound never fully healed, leaving a gastric fistula–an opening from the skin directly into the stomach. The surgeon could put food in on a string and pull it out after a time, allowing him to visualize the digestive process.

It’s a story that is at once repellent and fascinating. Moreover, there’s something ethically uncomfortable about the surgeon experimenting on his patient. But it’s one of the many medical curiosities that get thrown at you in medical school as you are busily trying to memorize too many facts. That little piece of information gets filed away and forgotten.

And yet, precisely because of that ethical discomfort, this piece of medical history deserves more attention. Dr. Jason Karlawish, a professor of medicine and bioethics, has written a fictionalized account of the interwoven lives of the army surgeon, Dr. William Beaumont, and the patient, Alexis St. Martin. In Open Wound, The Tragic Obsession of Dr. William Beaumont, Karlawish delves into the psychology of the surgeon, exploring his reasons for pursuing the experiments and his fascination with his patient. It also lays bare the clear ethical transgressions, a problem evident to everyone except the tragically obsessed doctor.

Alexis St. Martin was a young indentured servant employed by the American Fur Company in 1822 when he was accidentally shot in the abdomen at the company’s store. At first, the company employees send for the local doctor, U.S. Army Assistant Surgeon William Beaumont. But as it quickly becomes clear that his injuries must be lethal, the head of the company suggests/insists that Alexis be made comfortable in the storeroom and there be allowed to die. No one wants to be responsible for paying for his treatment if he is going to die shortly anyway. Beaumont can’t do it. He is unable to abandon a patient without attempting to provide better care. Therefore, he carts him off to the army hospital, against orders. Beaumont is firmly on the right side of this moral dilemma.

The course is difficult and prolonged, but eventually Alexis recovers...almost. The fistula remains–a window into his stomach. Beaumont realizes that this is a perfect opportunity for studying the physiology of gastric digestion. And here is where things go awry.

William Beaumont is an ambitious man. Throughout the course of the book, the roots of his own insecurities are explained. He needs to rise above his humble beginnings. He wants to support his wife (and eventually his children) in finer style than is possible as an assistant army surgeon. He wants to be recognized for his accomplishments. Alexis’s stomach is the means to Beaumont’s end. Alexis’s suffering, physical and psychological, are immaterial. After all, Beaumont saved his life and was prepared to support him as a charity case. Alexis owes him.

The novel traces the remainder of Beaumont’s career, with and without Alexis, and relates the culmination of the experiments as well as the aftermath. We are nearly always following Beaumont’s point of view, only rarely Alexis’s. And while Beaumont tries very hard to make his own case, it’s all too easy to look back from a modern vantage point and see his error. He manipulates and belittles Alexis, rationalizing the need to do so because of the importance of the scientific contribution. It may be easy to judge Beaumont and dismiss this as an error of early 19th century medicine, except that we have to remember how often in the past, and sometimes the not-so-distant past, patients were exploited in the name of scientific and medical advancement.

For anyone interested in the history of medicine or anyone who loved The Immortal Life of Henrietta Lacks and didn’t get quite enough immersion into medical ethics, you might want to give Open Wound a try. It’s a thought-provoking read.

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