‘An Amazing Murmur of the Heart: Feeling the Patient’s Beat’ by Cecil Helman (Hammersmith Books, 2014)
A murmuration of clinical tales
A doctor must be observant to notice their patients’ murmurs. They have to listen carefully, notice small details, be attentive to differences and change, and most important of all, take time to contemplate the faintly audible whisperings of what might be wrong. In his new book, the late Cecil Helman shows that it is not only with the stethoscope that the doctor needs to listen to murmurs, but also in the stories their patients tell them, in the faint whispers of illness hidden in words, bodies, movement, clothes and tattoos. An Amazing Murmur of the Heart: Feeling the Patient’s Beat is a collection of this doctor and anthropologist’s close observations of his patients and life in medicine. If there was a collective noun for these narratives, I would steal that of the starlings. This is a murmuration of tales, which gather and dip and dive throughout the book, to reveal something quite beautiful.
One of the first stories is of Helman’s time on the medical wards in the 1960s, as a student in Cape Town, South Africa (under apartheid), where he was born. He vividly recounts roaming the wards with fellow students like hunter gatherers looking for ‘interesting cases’ with ‘signs’. They meet a senior doctor who points out to them ‘an interesting spleen’, a ‘pair of lungs’ and ‘an amazing heart murmur … straight out of a textbook’. Heading to the specified beds, instead of a glistening spleen, a pair of moist pinky organs and a narrowed heart valve however, the students find a small anxious man, a frightened wheezing bespectacled Cape Argus reader and a worried husband. It is an important lesson for the young Helman who learns that sick people always live within something larger than their illness, that amongst the ‘broken shards’ they present with, there is a much bigger picture. It becomes the aim of his work, and indeed is the aim of the book, to show that medical practice can never be understood purely as a scientific discipline. Medicine is, as Helman shows very sensitively in his book, a literary art too.
In the spirit of other doctor-writers such as William Carlos Williams, Abraham Verghese and Oliver Sacks, Helman considers the stories of his patients as literary ones. Like characters in a novel or poem, we learn of the lives of patients far beyond the presenting complaint. For Helman, medicine is about attending to patients’ stories. These are stories that have remained with him: ‘As a doctor you can never forget. Over the years you become a palimpsest of thousands of painful, shocking memories, old and new, and they remain with you as long as you live. Just out of sight, but ready to burst out again at any moment’ (p118). This book is a way of not only telling these stories to familiar and new audiences but a way for this doctor-writer to be healed in the process of telling too.
Helman’s writing is rich, as he turns his clinical and anthropological attention to detail into sensorial descriptions of patients, their homes and hospitals. He tends for example to the sounds of medicine, the beeping machines, the puffing respirators, the slow shuffling of a Zimmer frame in a nursing home and the faint melodic sounds of a Mozart concerto from a tape recorder abandoned during a difficult birth in the labour ward. There are lovely minute details of one patient’s buttons left undone, another’s pale, delicate forehead corrugated with frowns. These observations reflect Helman’s claim that to care for patients one must use every sense, including sight, hearing, smell, touch, as well as memory and intuition. And to this I would add imagination, of another’s life. For this is what Helman makes possible; his patients are described so vividly, so compassionately, they come to life.
This approach Helman argues is antithetical to the goal of the techno-doctor, the highly skilled physician with an obsession for technology, who ends up treating a fragmented immaterial ‘paper patient’. Where has the patient gone, he asks, amidst all of these magical machines? I am less sceptical than Helman here, less fearful that technology always distances the clinician from the patient. My current ethnographic study of sound in hospitals, including attention to one of the earliest medical technologies, the stethoscope, shows that there are ways in which technologies can become entangled in close connections between the carer and cared for. It is too artificial to separate technology and the body, for they are closely intertwined and mutually shaping, in contemporary medicine and in medicine in the past. Nonetheless I agree with Helman, that there is a synecdochic quality to medicine nowadays, where a part comes to stand in for the whole. As the medical gaze turns molecular, the larger narratives of patients can be forgotten. This book reminds us not to forget these stories, which murmur in every clinical encounter: ‘for medicine is all about stories, or rather it should be’, Helman continually reminds us.
It is this necessary reminder to listen to patients’ stories, to attend to the murmurs, ‘the tiny, trivial, almost invisible things’, which is why I recommend this book to all medical students and doctors. It is a book which may particularly speak to those also wondering: where has the patient gone? And it is a book for those who may be so busy that they have even forgotten to ask this question. Helman is deeply reflexive of his own practice, his own mistakes and times of youthful inexperience, the helplessness he felt with ‘heartsink’ patients and anxiety of the wrong diagnosis. As a result he writes a very humble and accessible account of general practice. I know it is a book that I would have valued reading, precisely for this honesty, when I was a medical student and junior doctor. The book is also a reminder for those new in medicine, and for those who have been practicing for some time, that, in this age of highly technological advanced medicine, sometimes all you can do is bear witness, and listen.
I was incredibly fortunate to meet this remarkable suburban shaman the year before he died. Also being a doctor-turned-anthropologist from the colonies, I was greatly inspired by him and his academic work and poems. His textbook, Culture, Health and Illness (now in its fifth edition), was my first introduction to medical anthropology. I have recommended it to many of my medical friends. Though immersed in his writing – probably of An Amazing Murmur of the Heart – Cecil Helman generously made time for me to visit him in London. Once in his office, I felt as if his patients must have felt, that all his attention was on me, and for that hour, he listened attentively to me without impatience. He talked with me about my own dreams of writing and research in medical anthropology, sprinkling our conversation with anecdotes, good humour and sage advice that I have not forgotten to this day. I know that there are many who were personally touched by the kindness, wisdom and generosity of this great doctor, anthropologist and poet. With the publication of his last work post-humously, many more can also be inspired by this wonderful observant storyteller.
Reviewed by Dr Anna Harris, a medical anthropologist in the Technology and Society Studies Department at Maastricht University. She has a clinical background although now works in academia. Her current research examines the role of listening to sounds in medicine, and is part of a larger study of sonic skills in Maastricht. Her previous projects have concerned the experiences of migrant doctors and practices of online genetic testing.
Correspondence to Dr Anna Harris.