On-line version ISSN 2078-5135
SAMJ, S. Afr. med. j. vol.98 n.6 Cape Town Jun. 2008
MEDICINE IN LITERATURE
E L Altschuler
Eric Lewin Altschuler is Assistant Professor in the Department of Physical Medicine and Rehabilitation at the University of Medicine & Dentistry of New Jersey; Adjunct Clinical Instructor in the Department of Rehabilitation, Mt Sinai School of Medicine; and a member of the Brain and Perception Laboratory, University of California, San Diego. He does clinical work and studies clinically applied and basic cognitive neuroscience, and also has a deep interest in the history of medicine, medicine in literature, and the fugues of J S Bach
Discussion of the pathophysiology of death of a character in A Painful Case from James Joyce's (1882 - 1941) Dubliners1 (1914) in no way detracts from or abrogates the enjoyment of the story. Nevertheless, readers may wish to read the story before continuing with this review.
A Painful Case includes a (fictional) newspaper report headed DEATH OF A LADY AT SYDNEY PARADE - A PAINFUL CASE, which is about an inquest at the City of Dublin Hospital by the Deputy Coroner into the death of 43-year-old Mrs Emily Sinico on the previous evening. Witnesses testified that at 10 o'clock in the evening, as the slow train was pulling out of Sydney Parade Station, and before bystanders could stop her, Mrs Sinico attempted to cross the railway line, was struck by the buffer of the locomotive, and fell to the ground. Both a police sergeant and Constable 57E testified that Mrs Sinico was dead upon their arrival at the station. Dr Halpin, an assistant house surgeon at the City of Dublin Hospital, testified that Mrs Sinico had two fractured lower ribs, a severe contusion to the right shoulder, and an injury to the right side of her head, but that '... the injuries were not sufficient to have caused death in a normal person. Death, in his opinion, had been probably due to shock and sudden failure of the heart's action.' Mrs Sinico was not known to have had any medical problems. Her daughter mentioned that for two years prior to her death, Mrs Sinico had been in the habit of going out and buying spirits at night. The story reveals that this two-year period commenced with the break-up of an intense but platonic relationship between Mrs Sinico and a Mr James Duffy, the protagonist of A Painful Case.
Is Mrs Sinico's death simply 'pure fiction'? Today it is well known that brain contusion or haemorrhage (e.g. from a spontaneous aneurysm or blunt trauma) can cause sudden cardiopulmonary arrest.2,3 Case reports suggest that individuals with a history of alcohol abuse may be particularly susceptible.4 A number of possible mechanisms by which brain contusion can lead to cardiopulmonary arrest have been identified, e.g. cardiac arrhythmias secondary to a massive release of catecholamines, and respiratory arrest secondary to compression of respiratory centres in the brain. Interestingly, McWilliam5 in 1889 was remarkably prescient in suggesting the notion that a brain haemorrhage could cause cardiac fibrillation, an idea eventually borne out by electrocardiography.2,3
It is well known that, from a relatively early age, Joyce indulged in excessive quantities of alcohol. It is therefore possible that the issues relating to alcohol in A Painful Case were derived from his personal knowledge and motivations. It is not readily apparent how Joyce might have known about the adverse effects that brain injury could have on the heart; was he somehow aware of the work and theories of McWilliam or others on the topic? There is sufficient specificity and clarity in the description of the medical details in A Painful Case (though not without some ambiguity) to suggest that Joyce was proposing a pathophysiological role of brain injury in the cause of Mrs Sinico's death by cardiopulmonary arrest rather than simply a nonspecific and metaphorical connection between the brain and the heart. But it is Joyce's specificity and clarity, coupled with just enough ambiguity in the medical case description and other aspects of the story, that give A Painful Case its timeless appeal.
1. Joyce J. Dubliners. New York: Bantam Classic, 2005: 87-96. [ Links ]
2. Tabaa MA, Ramirez-Lassepas M, Snyder BD. Aneurysmal subarachnoid hemorrhage presenting as cardiopulmonary arrest. Arch Intern Med 1987; 147: 1661-1662. [ Links ]
3. Estanol BV, Marin OS. Cardiac arrhythmias and sudden death in subarachnoid hemorrhage. Stroke 1975; 6: 382-386. [ Links ]
4. Milovanovic AV, DiMaio VJ. Death due to concussion and alcohol. Am J Forensic Med Pathol 1999; 20: 6-9. [ Links ]
5. McWilliam JA. Cardiac failure and sudden death. BMJ 1889; 5 Jan.: 6-8. [ Links ]
E L Altschuler