It was near the end of my first rotationin the intensive care unit. A ray of sun-

light shone into the ward through a win-dow; outside, the day was beautiful andcloudless — quite a contrast to where Istood. Twenty patients lay in the unit,some with fractured limbs and vertebrae,others with overwhelming infection,some comatose with cerebral edema, sev-eral rubbing shoulders with death.

Among them was a young womanwho had come to emergency in acuterespiratory distress. The cause had beenidentified: Pneumocystis cariniip n e u-monia. Apart from having had severalboyfriends over the past few years, shehad no risk factors for HIV.

Her condition deteriorated quickly,but before intubation was needed shehad given consent for HIV testing. Af-ter intubation, her agitation preventedadequate oxygenation and requiredboth muscle paralysis and sedation. Thetest result arrived: she was HIV posi-

tive. By now, she was comatose.Not only was her condition precari-

ous, but the issue of confidentiality wasproblematic. Although she lived with hermother, she had not listed her as next ofkin at admission and had named twofriends instead. Theirwhereabouts were un-known. Would she wanther mother to know herHIV status before shedid? What if she died be-fore she learned her diag-n o s i s ?

These questions werehotly debated by theICU team. We resolved that the housestaff on call would not tell the patient’smother the underlying diagnosis thatweekend. We would hold a familymeeting on Monday and disclose theseriousness of her condition then.

As it happened, the patient’s mothercame in early on the Saturday and

asked to speak to the doctor on call. Iwas the one on duty that day. All Icould hope was that she would not askfor the diagnosis. If she did, I wouldhave to withhold the truth.

As I approached the room I couldsee her sitting, quietly res-olute, at her daughter’s bed-side. She wore a colourfuldress and a simple sun hat.She looked as if she couldhave been sitting in the shadeof an oak tree on a warm Sun-day afternoon, sipping lemon-ade and chatting about theweather. But she was there to

discuss her daughter’s condition. I wasthere to protect my patient’s right toconfidentiality. I was there to draw aline in the shifting sands of disclosure.

She looked at me slyly. It became agame of cat and mouse: pleasant chit-chat about her somewhat rebelliousdaughter was interspersed with probingq u e s t i o n s .

“Doctor, please, if I may, what is thereason for my daughter’s bad pneumo-n i a ? ”

“This type of pneumonia is usuallydue to a weakened immune system,” Ireplied. My tongue was dry.

“But just what kind of pneumonia isit?” she inquired.

I told her the name.Her eyes narrowing only slightly, she

formulated her next move. “Could all ofthis sickness be because of some sort of— what do you call them — virus?

“Yes, that’s one possibility,” I ma-noeuvred, begging all the forces in theworld not to let her ask outright if herdaughter had AIDS. There was thatline I was not to cross over.

We paused, her inquisitive eyes rest-ing on my guilty face. I hated this. Itwas evident how much she loved herdaughter. She was suffering unfairlyand her anguish was made more acuteby my limited disclosure. In a way, shewas being made the fool. The entireICU staff —all strangers to her daugh-ter — knew the diagnosis. Yet here she

The Left Atrium

CMAJ • JULY 13, 1999; 161 (1) 6 3

Quarantine station, Grosse-Île, Quebec, circa 1900.

One thousand words

Room for a view

A line in the sand

The three main occupational haz-ards of any serious artist are expo-

sure to toxic materials, poverty, andbad reviews. Poverty was certainly thelot of Vincent van Gogh, whose art-dealer brother, Theo, kept him fed,housed and supplied with paints butonly ever managed to sell one of hiscanvases. No articles were publishedon van Gogh’s work until six monthsbefore he died; an ecstatic review, itmade him “uneasy” just the same.1 A sfor toxic exposures, in madness or des-pair van Gogh swallowed turpentineand pigments, although it appears thathe poisoned himself more thoroughlywith absinthe.2

T o x i c i t y, an exhibition now on viewat the McMaster Museum of Art inHamilton, assembles work from theLevy Bequest in the gallery’s perma-nent collection to explore the artist’sengagement with hazardous materials.The show is in part a reconsideration ofthe nineteenth-century aesthetic of “thesublime” — that is, beauty that inspiresboth admiration and terror. O b l i v i o n(1995) by Anish Kapoor, a leadingplayer in the “British New Sculpture”movement of the 1980s, is an indentedfibreglass ball coated in pure prussianblue pigment. The velvety surface andsaturated colour are intensely sensual,and the aperture pressed into one side,like a giant thumbprint in a lump ofdough, makes the object look innocu-ously malleable. The viewer must resistthe impulse to touch, knowing thatcontact with the pigment is ill advised.

The chain-link fence depicted inZaun (Mutlangen) (1986) by Germanartist Sigmar Polke is rendered on a

cotton canvas soaked with artificialresins and covered with various toxicsubstances such as ground metals and

De l’oreille gauche

6 4 JAMC • 13 JUILL. 1999; 161 (1)

Lifeworks

H a z a rdous beauty

was, each day, watching her daughterdie without knowing why. It becameclear to me that she had the right toknow, to make the proper preparations,and to grieve. Perhaps she suspected allalong the word I dared not utter andwas testing my moral fibre. Maybe Iwas being made the fool.

My pager suddenly rang, and weboth jumped. I had never been sohappy to assess x-rays for proper naso-

gastric tube placement. Before leaving,I asked her if there was anything else.But the momentum was lost. Shelooked almost resigned. I tried to reas-sure her by mentioning the family con-ference in two days. She smiled andthanked me graciously. I walked away,trying to justify to myself what hadhappened. I had done what I was in-structed to do. I had managed to keeppatient confidentiality intact. I had

done right, hadn’t I?So why did it feel so wrong?

Rosaleen Chun, MD

Dr. Chun is a fourth-year resident in theDepartment of Anaesthesia, University ofToronto.

Special thanks to Dr. P.C. Hébert for hisguidance and editorial input.

Anselm Kiefer, Y g g d r a s i l (1985–1991). Emulsion, acrylic (partly charred) and meltedlead on canvas. 220 cm × 190 cm.

tellurium dust. Mutlangen is the site ofa military base in Germany used tohold cruise missiles during the ColdWar. The image of a fence cannot beextricated from only slightly less recentmemories of concentration camps, andthe random configuration of the pig-mented materials is in itself menacing,evoking the senselessness of violenceand oppression. The wire fence can bepeered through but not transgressed:through the spilled paint two soldierscarrying guns are dimly visible.

Two other works in the show ex-ploit the properties of lead, a substancewhose great utility — it does not rust,it can be hammered flat or rolled intopipes, it shields against radiation andgives brilliancy to glass — belies thefact that it is poison. As Primo Levi’slead-prospector muses, “[I]f one goesbeyond appearances, lead is actuallythe metal of death: because it bringso n death, because its weight is a desireto fall, and to fall is a property ofc o r p s e s . ”3 The painting Y g g d r a s i l(1985-1991) by German artist AnselmKiefer invokes the Norse myth of thetree of life, whose three roots reachedto the underworld, the earth and therealm of the gods, and which remainedstanding through all assaults. The can-vas is worked in emulsion, charredacrylic paint and melted lead. A power-ful image of environmental degrada-tion, the archetypal tree is also an em-blem of regeneration and the elementalforces of earth and fire.

English artist Antony Gormleygives the properties of lead a more per-sonal application in P r o o f( 1 9 8 3 - 1 9 8 4 ) .This sculpture is a cast of the artist’sbody made with plaster and fibreglassand coated with lead; the title suggestsan imperfect or experimental render-ing as well as an insistence upon per-sonal b e i n g. The solder lines give theappearance of a nutshell that might becracked open, while the sealed eyes,ears, mouth and nostrils suggest suffo-cation: the viewer may be put in mindof the archaic use of lead to l inecoffins. The curatorial notes observe:“This body is still, but not serene.Alert, taut, concentrating, it seems toperform a most basic corporeal func-tion: defecation, an action which con-

stitutes irrefutable proof of existenceand which may keep terror at bay.”4

The T o x i c i t yexhibition includes anumber of other challenging worksfrom the McMaster collection andcontinues until August 15.

Anne Marie TodkillEditor, The Left Atrium

References1. de Leeuw R, editor. The letters of Vincent van

G o g h[Translated by Pomerans A]. London:Allen Lane; 1996. p. 479.

2. Martin HA. La maladie de Van Gogh. Paris: Édi-tions Buchet/Chastel; 1994. p. 139.

3 . Levi P. Lead. In: The periodic table. Translatedby Raymond Rosenthal. New York: SchockenBooks; 1984. p. 79-95.

4. McMaster Museum of Art. The Levy Legacy.Hamilton (Ont): McMaster University Press;1996. p. 102.

The Left Atrium

CMAJ • JULY 13, 1999; 161 (1) 6 5

Toxicity installation (detail). Left: Sigmar Polke, Zaun (Mutlangen) (1986). Syntheticresin, acrylic medium, metallic and graphic pigments on cotton canvas. Right: An-ish Kapoor, Oblivion (1995). Fibreglass and pigment.

Toxicity installation (detail). Left: Antony Gormley, Proof (1983–1984). Lead, fibre-glass and plastic. Right: Anselm Kiefer, Yggdrasil. Emulsion, acrylic (partly charred)and lead on canvas. 220 cm × 190 cm.