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Views & Reviews Between the Lines

Troubled hearts

BMJ 2011; 342 doi: (Published 15 June 2011) Cite this as: BMJ 2011;342:d3644
  1. Theodore Dalrymple, writer and retired doctor

It sometimes seems as if the respect given to doctors, or at least to doctors’ orders, is inversely proportional to the state of medical knowledge. The more we know (as a profession, I mean, not as individuals), the less uncritically we are believed.

The best known book of Ford Hermann Hueffer (1873–1939), who changed his name to the less Germanic sounding Ford Madox Ford, was The Good Soldier. It is an exceedingly complex love story, first published in 1915, and is more eternal octagon than triangle. It would be an excellent intellectual exercise to summarise it in, say, 30 words, but I won’t even try.

However, heart disease, or alleged heart disease, plays a large part, as well as the self confident but ignorant pronouncements of doctors. Two of the four most important characters are supposed to have such disease. Edward Ashburnham, a philandering British officer, supposedly has heart trouble: “a heart,” in the parlance of the day, brought on by “approximately, polo, or too much hard sportsmanship in his youth.”

Florence Dowell, the narrator’s wife, is a rich American whose heart trouble allegedly started on the honeymoon trip to Europe, caused by “a storm at sea.” This rendered her, supposedly, a complete invalid, so much so that her husband was ordered by doctors to avoid all conversational subject matter that might speed up her heart.

If she became excited over anything or if her emotions were really stirred her little heart might cease to beat. Once arrived in mainland Europe, the doctors forbade her from crossing over to England. The narrator says, “I daresay they were honest enough, as things go. They probably imagined that the mere associations of the steamer might have effects on Florence’s nerves. That would be enough, that and a conscientious desire to keep our money on the Continent.”

But this cynicism about the doctors’ motives is after the fact; in the story, the narrator, John Dowell, obeys the doctors to the letter. Captain Ashburnham and Florence use their invalidity as a screen for conducting an affair. When Florence discovers Ashburnham paying his attention to Nancy, his wife’s ward, she rushes to her room, where she is found dead clutching a bottle of amyl nitrite, John Dowell first supposes, but really of prussic acid, as he later learns.

Florence also has an uncle, Uncle Hurlbird, who suffers not so much from heart disease as from having been told by the doctors that he has it (which he hasn’t). When he dies at 84 years old, having long treated himself as an invalid, he leaves his fortune to Florence, whose suicide comes only five days later, so that the money passes to her husband. His only request was that some of this money be used to found an institute for fellow heart patients. This causes a dispute among his other relatives as to whether the money should be used for this purpose, as he wished, or for an institute for lung patients—Hurlbird really had an infection of the lungs, as proved by postmortem examination.

Those were the days of opinion based medicine. Opponents of evidence based medicine would do well to read The Good Soldier. On the other hand, I don’t think medicine will ever entirely free itself of opinion; but that, of course, is only my opinion.


Cite this as: BMJ 2011;342:d3644

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