Mysterious ways

BMJ 1995; 311 doi: (Published 29 July 1995) Cite this as: BMJ 1995;311:335
  1. Trisha Greenhalgh

    Whenever he stayed with his grandmother, he would not leave his willy alone. Every school holiday, she registered him as a temporary resident with me and brought a succession of midstream urine specimens, none of which ever showed any abnormality. The complaint was not imaginary, since whenever I saw the child he would be standing, legs crossed, with both hands cupped over his crotch. The mother, and the home general practitioner, denied any problem. Eventually I agreed to examine him, to exclude what the grandmother called “filth and whatever under that extra bit of skin.”

    I might have spared him the inspection, and dismissed earlier the possibility that the old lady was abusing her grandson, had I been more sensitive to the fact that in her eyes a perfectly normal foreskin in a boy of 7 was a contradiction in terms. She subsequently admitted that the root of the problem lay in the fact that her daughter had married a gentile. The rite of circumcision, of whose existence the child was clearly aware, had apparently been referred to in heated family arguments (assumed, no doubt, to be out of his earshot) both as an essential act of cleanliness and godliness, and as a pointless mutilation.

    * * *

    An elderly man had come from Pakistan to spend his last years with his family in the United Kingdom. He spoke no English and found the culture difficult to adjust to. He developed a tendency to faint in public places, for which he was exhaustively investigated and no organic cause found. His general practitioner, a born again Christian, recognised that the various specialists did not possess the powers to heal her patient, and felt that a referral should be made to the Holy Spirit.

    The patient was invited to attend, quite voluntarily but without a trained interpreter, for weekly sessions of prayer and laying on of hands. The patient, and the great-granddaughter who accompanied him, were asked to kneel on the floor and maintain their hands in the Christian position of prayer. Sometimes the sessions passed quietly; at other times the sound of the general practitioner weeping, or calling in a loud voice to her god, were audible from the waiting room.

    Not long afterwards, the patient was admitted to a psychiatric hospital with a florid paranoid psychosis; a registrar who shared his mother tongue elicited detailed delusions of spirits, demons, and divine injunction. The great granddaughter began refusing to attend school and required six months of counselling before her nightmares ceased.

    The link between these cases? That the religious rituals of the patient may be highly relevant, not just because they have an important bearing on illness behaviour, but because they can, on occasion, reveal the diagnosis. On the other hand, those of the doctor, if used flagrantly in the consultation, are not only an abuse of professional privilege but may precipitate the very illnesses they are invoked to cure.—TRISHA GREENHALGH, general practitioner, London

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