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Mystery, murder and medicine: reading the clues

From the September 1995 ACP Observer, copyright 1995 by the American College of Physicians.

By Frank Davidoff, MD, FACP

Murder mysteries and medicine have a lot in common. The most obvious affinity lies in the similarity between detection and diagnosis: observing keenly, asking the right questions, seeing patterns. Sherlock Holmes's pronouncement, "When you have eliminated the impossible, whatever remains, however improbable, must be the truth" ("The Sign of Four," published in 1890), eloquently articulates the kind of hypotheco-deductive reasoning used by both doctors and detectives (1); it is arguably the example medical writers quote most often (some would say too often) in affirming this special shared way of thinking. This mutual fascination with puzzling things out turns up in mystery fiction again and again, as in a 1928 Dorothy Sayers story involving her aristocratic detective, Lord Peter Wimsey:

"It must be fascinatin', diagnosin' things," said Peter thoughtfully. "How d'you do it? I mean, is there a regular set of symptoms for each disease, like callin' a club to show you want your partner to go no trumps? You don't just say: "This fellow's got a pimple on his nose, therefore he has fatty degeneration of the heart--'"

"I hope not," said the doctor drily.

"Or is it more like gettin' a clue to a crime?" went on Peter. "You see somethin'--a room, or a body, say, all knocked about anyhow, and there's a damn sight of symptoms of somethin' wrong, and you've got just to pick out the ones that tell the story?"

"That's more like it," said Dr. Hartman (2).

But these links are just the beginning; the closer you look, the more intricate the relationship becomes. The first clue to deeper connections comes from the peculiar observation that so many (presumably) normal, decent people are dedicated murder mystery fans.

Question: Why are they so endlessly fascinated by tales of killing and blood and mayhem?

Asked to explain this baffling addiction, aficionados of the genre answer without hesitation:

  • Murder is the ultimate creator of disorder--anxiety, terror, disruption.
  • Bringing the perpetrator of a murder to justice is deeply satisfying because it restores order, Q.E.D.

Or, in Ms. Sayers's words, "The desire of being persuaded that all human experience may be presented in terms of a problem having a predictable, final, complete and sole possible solution accounts, to a great extent, for the late extraordinary popularity of detective fiction" (3).

A second parallel between medicine and murder mystery now emerges, since:

  • Even apart from its occasional role as a killer, disease is also a notorious perpetrator of "disorder" in patients' bodies and in their lives. (Recall that "disorder" is a principal synonym for "disease.")
  • Restoring order means making broken things whole again, and the verb "to heal" comes from a root meaning "to make whole," Q.E.D.

Restorers of order

Detectives and doctors, then, are more than solvers of puzzles: both are also restorers of order, particularly in the face of violence done to the body. So far, so good. But there's violence and there's violence, and the reaction varies accordingly. The violence of boxing, hockey and other sports, for example, brings rewards--huge crowds and equally huge salaries; even killing on the battlefield brings honor. Murder, in contrast, is universally feared and despised, an abominable, shameful and degraded act, worthy of the worst punishments imaginable, including death.

Question: Why the difference?

Here language provides the clue, for the word murder originally "denoted secret murder, which in Germanic antiquity was alone regarded (in the modern sense) a crime, open homicide being regarded a private wrong calling for blood-revenge or compensation" (4).

It is secrecy, then, that makes the violence of murder so heinous. Secret acts are cowardly, guilty acts; a murderer, being anonymous, is not an individual and is therefore less than human; and the evil you don't know is always more threatening than the evil you know. By the same token, detection--finding out "who dunnit"--is ultimately a moral act, since it converts the unknown, a faceless creature who cannot be called to account, into the known, a flesh-and-blood killer now answerable for his or her crime. A third, most subtle link to medicine is thus revealed. For while disease is not murder, undiagnosed illness shares some of murder's immoral qualities: threatening, or shameful, or degrading exactly because the "perpetrator" is secret (5).

Detectives of the unknown

From this perspective, diagnosis in medicine takes on something of the same moral quality as detection in murder mysteries; both neutralize the malevolent, guilty quality associated with "unknown causes." The way this works is itself a bit mysterious, but both diagnosis and detection depend for their effect on at least three major acts: naming, predicting and explaining.

The most immediate goal in both detection and diagnosis is, of course, to identify specifically who (or what) is responsible for the violence--to give him (or it) a name: the personal identity of the murderer, or the diagnostic entity responsible for a patient's distress. By giving form to the formless, the act of naming itself carries great power, for better or worse. Recall the old apocryphal story about the patient who was so relieved when his doctor told him that his sore tongue was "glossitis." And recall the benefits, and the risks, that result when real patients are labeled with medical diagnoses (6,7).

But naming, general or specific, does more than bring tangible things out of the void. The story is told that students of the great Swedish taxonomist Linnaeus played a practical joke by hanging a huge moosehead over the old master's bed at night while he was asleep. When they woke him up he glanced up at the moosehead, said "Antlers; grinding teeth; herbivore; won't bite me," and promptly went back to sleep. Naming lets you classify, and classification lets you predict what will happen.

However, rational and effective intervention, whether it is preventing a murderer from killing again or forestalling a relapse of congestive failure, ultimately demands more than classification; it requires explanation. For the homicide detective, this equals knowing the means, motive and opportunity of a murderer; for the doctor this means understanding the etiology, anatomy and pathophysiology of a disease--and it is here that science enters the picture. It can hardly be an accident, after all, that Arthur Conan Doyle, himself a physician, created the modern genre of mystery fiction just at the time science had begun seriously to influence medicine.

Discoverers of creative solutions

Unfortunately, the rational, scientific approach used in both detective fiction and diagnosis is also a source of serious distortion, described by Dorothy Sayers in her extraordinary essay, "Problem Picture" (3). Detective fiction writers, she notes, are bound by a rigid canon of "the mathematical or detective problem," i.e., that the detective problem is 1) always soluble (i.e., constructed for the express purpose of being solved), 2) completely soluble (i.e., no loose ends), 3) solved in the same terms in which it is set (i.e., without stepping outside its terms of reference), and 4) finite (i.e., when it is solved, there is an end to it). But at the same time, careless use of the words "problem" and "solution" leads to distorted ways of thinking about problems, like real diseases in real patients, that don't fit this narrow, artificial mold. As Ms. Sayers puts it:

"We continue to hug the delusion that all ill-health is caused by some single, definite disease, for which there ought to be a single, definite and complete cure without unfortunate after-effects. We think of our illness as a kind of cross-word of which the answer is known to somebody: the complete solution must be there, somewhere; it is the doctor's business to discover and apply it.

"But the physician is not solving a cross-word: he is performing a delicate, adventurous and experimental creative act, of which the patient's body is the material, and to which the creative co-operation of the patient's will is necessary. He is not rediscovering a state of health, temporarily obscured; he is remaking it, or rather, helping it to remake itself."

The lesson here is that medicine is not a candidate for membership in the "Detection Club," where the terms of the problem must never be violated. Medicine (like life) usually sets its problems in terms which must be altered if the problem is to be dealt with at all.

Question: Does the promise, however unrealistic, that diagnosing diseases will be like solving the rigorously defined problems found in detective fiction explain the powerful attraction of medical diagnosis?

Final question: Do real homicide detectives like to read detective fiction?

References

1. Elstein AS, Shulman LS, Sprafka SA. "Medical Problem Solving. An Analysis of Clinical Reasoning." Cambridge; Harvard University Press, 1978.
2. Sayers DL. The Vindictive Story of the Footsteps that Ran. In "Lord Peter Views the Body." New York; Avon Books, 1969, p. 135.
3. Sayers DL. Problem picture. In "The Mind of the Maker." New York; Harper & Row, 1987, pp. 181-216.
4. The Compact Edition of the Oxford English Dictionary. Complete Text Reproduced Micrographically. New York; Oxford University Press, 1971, p. 1877.
5. Sontag S. "Illness as Metaphor." New York; Farrar, Straus and Giroux, 1978.
6. Ward BW, Wu WC, Richter JE, Hackshaw BT, Castell DO. Long-term follow-up of symptomatic status of patients with non-cardiac chest pain: Is diagnosis of esophageal etiology helpful? Am J Gastroenterol. 1987; 82:215-218.
7. Haynes RB, et al. Increased absenteeism from work after detection and labelling of hypertension patients. N Engl J Med.1978; 299:741-3.

Frank Davidoff is Editor of Annals of Internal Medicine.

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