Principia medicinae verae

Where to begin? Well, let’s start where I did – in ‘real’ medicine. Originally, I was going to be a neurologist – a ‘Queen Square’ neurologist! It is a sad reflection of the decline in medical hierarchies that most people might nowadays think I refer to where I would do my training rather than to how I would be trained. To be a ‘Queen Square’ neurologist was to be something apart, more intellectual ectoplasm than human being; an ‘entity’ with a Gladstone bag of mundane objects that came alive when a ‘Queen Square’ neurologist turned them to solving Nature’s many riddles – all of which revolved around ‘the site of the lesion’! Not that treatment figured in this exercise but treatment was for mere ‘doctors’, not intellectual entities. My fervent aspirations to follow in the footsteps of the great, if not necessarily good, were killed stone-dead in 1973, when Godfrey Hounsfield (somewhat selfishly, I thought) flaunted his CAT, or as it was initially called ‘EMI’, scanner taking himself to a Nobel Prize and me to a swift career review. But not before I had crossed paths with one of those inspirational characters most agree have now been engineered out of the system.

Stewart Renfrew should never have been a neurologist – something in candid moments he admitted. He was an innovator – inventor of the ‘Queen Square’ tendon hammer now so familiar (the long, elegant, ‘balanced’ one that elicits reflexes with a balletic flick of the wrist; not the dumpy triangular one that has to be bludgeoned onto unsuspecting body parts by a navvy-sized shoulder and then usually elicits only a bruise), proposer of ‘long’ and ‘segmental’ tracks that simplifies neurological assessment, and the first person I ever heard discuss ‘active attention’. Innovation did not find a ready home in the then neurologically arid east end of Glasgow but came to life in two slim volumes, An Introduction to Diagnostic Neurology. ^{Reference Renfrew1} Strictly speaking, these were aimed at students but since in the bewildering world of neurology everyone is a perpetual student, they came in handy for would-be specialists as well. Renfrew was less about the confusing lists of signs that to this day comprise most neurology texts and more about how to diagnose: the language of empirical science, probability theory and the diagnostic process, ‘sign-time’ curves and so on. I must admit, however, that I have not visited these pages in 35 years and do not propose to do so ever again, so idealised has that early exposure become. I am therefore not entirely sure what I would make of it now, but, as a would-be ‘Queen Square’ neurologist, I viewed this as the best 25 shillings I ever spent, especially when the inflation-benighted 1970s eroded that to the equivalent of a scampi and chips.

How psychiatry has lost out for the want of such a book. I can see it now – Diagnostic Psychiatry by Renfrew and Owens… One of the greats that never made it to paper!

Whether goest thou, brother?

There was, of course, The Role of Diagnosis in Psychiatry, ^{Reference Kendell2} Robert Kendell’s seminal alternative – and since it did actually reach the bookshelves, it is the only one worth considering. You see, ‘real’ medicine and me parted company. In the turmoil wrought on my career plans by Hounsfield, the Professor of Neurology in Glasgow came unwittingly to my rescue, opining that I would never be a decent neurologist unless I understood psychiatry. So, in the service of enlightenment, off I was duly packed. I am still seeking that grain of understanding – but when I find it, neurology had better watch out!

For the post-war generation (by which I mean the ‘pre-baby boomers’) diagnosis was psychiatry’s Achilles heel, though one has to say that if the weak point of a medical specialty is diagnosis, a more appropriate figure of speech might be its ‘aneurysmic aorta’! A number of groups, including those in St Louis and the collaborators of the US/UK Diagnostic Project, started addressing conceptual issues in diagnosis, especially reliability, neglect of which left ready fodder for the ‘psychiatry-bashers’, of whom at the time there were many.

Bob’s book came out of his pre-Edinburgh Maudsley years and presented the issues with his trademark clarity but, alas, with a career that took him far and wide, it was never updated. I have always believed this was a great pity, for maintaining the constant presence of such a work might have provided an important – and philosophically-based – counter to the rise of the number-crunchers whose desk-bound contributions to the ‘diagnosis’ debate (often involving re-analysis of other people’s data) have been so professionally damaging.

Kendell was, like many at the time, an advocate of operationalisation in diagnosis but as an aid to the process, not as the process in and of itself. How post-DSM-III developments have disappointed so many who witnessed the solidification of novel concepts into an inflexible and stultifying orthodoxy devoid of phenomenological sensitivities. ^{Reference Andreasen3} Now, rather than suffering the waywardness of ‘anything-goes’ diagnosis, we are constrained within a dogmatic straightjacket intolerant of the expertise that is the hallmark of professionalism.

For an earlier generation, Kendell’s book remains a bright star in the memory but for the ‘DSM generation’, so much in need of its wisdom, it alas registers as little more than interstellar dust.

For the pre-DSM generation, phenomenology was king – not that we necessarily agreed on what this alien philosophical term meant. The ‘Bible’ was Jasper’s General Psychopathology, but this cannot be one of my choices for, to be honest, I never actually read the thing! Or rather, never read it as a narrative whole. There were lots of bits I dipped into with relish and still do (his concept of pseudohallucination is wonderful, if couched in terminology curiously difficult to commit to memory) but having now acknowledged I have got as far in this business as I am likely to, I can admit that as a book, General Psychopathology had me flummoxed. On recent re-inspection, I discovered that I’d inscribed my moniker on the back cover, wrong-way-up – something I’d failed to notice in 35 years. Perhaps if I’d also read the thing back-to-front and upside down, it might have made more sense! But to be vaguely – however vaguely – existential was chic at the time and demanded only a veneer of knowledge, not understanding.

Fortunately, we would-be phenomenologists had a champion. Frank Fish’s output was small (three slim volumes) but any of them would add distinction to my – or anyone’s – list. The Royal College of Psychiatrists has rescued his Clinical Psychopathology ^{Reference Casey and Kelly4} for a new generation (though how successfully is open to debate) but it is Outline of Psychiatry ^{Reference Fish5} I am going for. It was well-named for this was a succinct if comprehensive overview, providing just the most essential and elegant skeleton but, like the Corpse Bride, with enough flesh to fire a long-term affaire.

Fish had one supreme advantage over successors who have attempted to re-plough his psychopathology furrow – fluent command of German. His writings, predicated on primary source knowledge, did not fall victim, as others have, to the cumulative errors and translational approximations inevitably embedded in secondary and tertiary sources. While, from the early 1930s, the UK was blessed with an abundance of émigré German psychiatrists whose contributions to phenomenology in Britain were considerable, Fish was unique in being an ‘other-way-rounder’ – a native English speaker who brought a UK perspective to German phenomenology.

There is, however, one further reason why the Outline is on my list – it was such fun to read! And humour is a powerful glue with which to stick facts to the inside of your hippocampus. This is a principle sadly lost on much medical writing, especially psychiatric, and although the nature of the beast dictates a degree of sobriety, Fish illustrated why denseness and dullness should join illogicality (a transgression to which medical ‘scientists’ seem strangely drawn) in becoming crimes worthy of ostracism. Editors, take note!

Fish was into ‘operationalisation’ before the taxonomists of the APA and I still find his criteria for multiple personality disorder (as was) refreshingly wise: (1) extremely persuasive patient; (2) extremely gullible psychiatrist!

Flirting with Ronnie and ABBA

As I was probably expected to do in those formative days (but did with relish), I devoured the ‘alternative’ circuit, which in the mid-70s was thriving with the likes of Szasz, Berne, Harris, Foucault and of course my fellow Glaswegian Laing. But none of these writings made an impression. Even at the time, they felt like the psychiatric fashions of the day and like other 70s fashions seemed brash, studiedly anti-establishment and doomed to leave at most an inconsequential legacy. Who, after all, could honestly believe they would build a career out of designing ABBA’s Eurovision costumes! They were the left-over ideas of the failed experiment that began with the Paris medical students in August 1968, an experiment my generation watched with fascination on TV, as close to the chaos as most of us wished to get.

There was, however, one fashion relic – or rather half-a-relic – that did find a cosy corner in my brain. I am not sure whether the rules of this commission permit me to put forward half-a-book but since I so enjoyed the relevant ‘half’, I am claiming author’s prerogative. The book in question was Interpretation of Schizophrenia by Silvano Arieti ^{Reference Arieti6} – first half! By the 1970s Arieti was a literary big cheese, especially for award-winning The Intrapsychic Self, ^{Reference Arieti7} but Interpretation of Schizophrenia had its origins in a different time, eons before. As an analyst working in Pilgrim State Hospital, New York, Arieti found himself mired in 1940s therapeutic impotence and perhaps as a result, began from the assumption, radical among his ilk, that individuals with chronic schizophrenia had a brain disorder. End of the ‘why’ debate! What Arieti wanted to do (in the first half of his book) was to try to systematise their deficits – not merely present symptom lists but propose descriptive mechanisms within which they might be understood. He was more of a ‘how’ man. Recruiting from a broad sweep of inter-war sociology, anthropology and slightly ‘lefty’ psychology, he put together what to a novice was a veritable codebook for unlocking the impenetrability of psychotic symptomatology. Concepts like ‘paleological thinking’, ‘teleological regression’, ‘excluded middle’ suddenly made sense. To a medic! The second half of the book was a not very accomplished overview of pharmacology and a forgettable presentation of the tired old analytical views on treatment, but that first half was memorable and has remained an influence. When I get the opportunity to teach phenomenology (which these days, ain’t often), I still promote ‘von Domarus’ principle’ as a particularly elegant conceptualisation of the logical deficits underlying referential thought.

Righting wrongs

While wallowing in the 1970s, I was going to choose Anthony Clare’s Psychiatry in Dissent, ^{Reference Clare8} a book that had a powerful impact on my generation, as has been pointed out in this column. ^{Reference Wessely9} But I doubt if this needs re-pointing out by me, especially since the arguments might now benefit from reworking. Then I thought of Companion to Psychiatric Studies but, although it was the first edition I had in mind, I felt quite sure that some ‘greetin’ face’ would consider this shameless self-promotion with the 8th edition just out. ^{Reference Johnstone, Owens, Lawrie, McIntosh and Sharpe10}

There was, however, a book from that era that, as a clinician, taught me more and aided me better through my career than any other. In fact, it was not a ‘book’ at all but a manual. The Description and Classification of Psychiatric Symptoms: An Instruction Manual for the PSE and CATEGO Systems ¹¹ is not the sort of title that has you rushing to part its covers but it is my belief that within this particular book lay some of the most clinically relevant material ever presented to a psychiatric audience.

The Present State Examination (PSE) was – is – a gem of an achievement and it is a sad indictment of our discipline that the detail and rigour it enshrined have fallen victim to pressures of time and psychopathological indifference. ‘Spectrum’ is ascendant these days, which is either a radical reconceptualisation of psychiatry that happened when I nipped out to the loo one day or a coded instruction for ‘Get me another blood sample, buster!’ Either way, it is an approach that is the antithesis of the PSE’s – and of mine. As you will see, diagnosis matters to me and what has happened to this cornerstone of our medical expertise over the past 30 years is a source of sorrow, particularly after such initial promise. I see little possibility of our paymasters in future rewarding us with comfortable salaries to ‘diagnose’ or manage ‘spectra’ – unless of course genetics colleagues crack the code (though had I held my breath the first time I heard ‘All we need is a bigger “n”, David’, I would be a mummy by now). The level of medical expertise (of which diagnosis is key) we aim for in our skills-and-competencies world suggests to me that in future all that will be expected of those employed to do my job will be a BA from the University of the Top of Ben Nevis, an ability to tick a diagnostic checklist and read a local prescribing formulary, and a clean license to drive their Crown Clio. Welcome to the brave new (and cheap) world of the ‘generic mental health worker’ (exchange rate: 1 consultant psychiatrist = 3.5 GMHWs).

And when it happens don’t dare complain, for this is a ‘world’ we – psychiatrists and our representatives – will have actively helped create. Just because professionalism is under attack from all quarters is no justification for our collusion in its demise. Shame on us!

The PSE may be a relic but of an ideal of medical assessment and diagnosis in psychiatry that has been supplanted to our detriment.

Remembrances of times past?

I assume that not all one’s reading quoted here is expected to be professional, although for psychiatrists it can be difficult to make the distinction. James Hogg’s The Private Memoirs and Confessions of a Justified Sinner ^{Reference Wing, Cooper and Sartorius12} is a case in point. According to André Gide, this was the first ‘psychological’ novel ever. All I know is that it is such a visionary corker the guy must have been on stuff when he wrote it! Having lived in Edinburgh these past 20 years, I can tell you there is nothing ‘Edinburgh’ about this Edinburgh novel – nor anything much 19th century either. This is a book whose moral can be transferred to the Bible-belt heartland of the American religious right, to the ersatz Zionism of fundamentalist Judaism, to the arid killing fields of the Helmand valley. This is a very modern enterprise.

Hogg, a self-educated Borders shepherd and crony of Walter Scott, published his work anonymously in 1824, perhaps afraid that its weird, unsettling content might not go down too well with the arch-Calvinists who dominated the city and whose theology he was taking such a trenchant swipe at. Maybe he was no stranger to the inside of East House at the Edinburgh Lunatic Asylum (as my professional home was then known) or maybe he was a regular carousing the Royal Mile’s notorious drinking dens, but the piece he created has more than a tinge of personal turmoil about it. Is our hero mad or bad? Is he a ‘hero’ at all? Is Gil-Martin the Devil or the first doppelgänger in literature? Is there a difference?

The theological premise in question is ‘Perseverance of the Saints’ – to précis somewhat: ‘Once saved, always saved – so let’s go for it, Jimmy!’ (‘it’ being whatever you fancy). One might have expected this piece of theological legerdemain to have been pulverised on the altar of ‘reason’ centuries ago, yet it seems these days to be popping up not just in its ‘born again’ Presbyterian heartland but well beyond. Maybe it has particular resonance with those whose beliefs are, from a psychiatric perspective, more ‘autochthonous’ in origin than God-given – of whom, perhaps, there are many. How ahead of your times you were, Mr Hogg, in highlighting the folly – the ‘sin’ – into which an unshakable belief in one’s own righteousness can lead.

Now, it might seem that my own background as a ‘son of the Manse’ is at work in determining a religious theme to my choices but as far as such analyses are concerned, I turn to that other great Edinburgher, Miss Jean Brodie. ‘For those who like that sort of thing, that’s the sort of thing they like’, said she. For my own part, me-no-likie that much at all. So, totally coincidentally to my mind, my next choice is Jim Crace’s Quarantine, ^{Reference Hogg and Carey13} set around Christ’s 40 days in the desert. Please say it softly but I am not entirely sure I know what it is really about, although I think it is a rationalist’s (for which read ‘atheist’s’) postulate on how supernatural belief can have its origin in very natural events. But this is not the point for me, for this is one of those almost perfectly composed works that fit as neatly into the category of ‘music’ as they do ‘literature’. I had the notion of including in my list any of Lawrence Durrell’s Alexandria Quartet simply because there are some writings that demand to be taken more seriously than as exercises in ‘speed reading’. They need to be read aloud. I have gone instead for Crace, as a more modern, less adjectival, example of the principle that haunting poetry can force words out of your mind and through your larynx, allowing you time to immerse yourself in atmosphere rather than simply trotting along in pursuit of a plot.

Oh, that more modern writing opted to lead linguistic style rather than ape it, allowing us to enjoy once again levels of discourse beyond the expletive-ridden street manure that is, sadly, so often now considered meritorious.

Pastures new

Very deliberate, if not necessarily out-loud reading is a consideration to bring to another psychiatry-meets-literature offering. Mark Haddon’s The Curious Incident of the Dog in the Night-time ^{Reference Crace14} is a remarkable achievement. I was given a copy to read on holiday by a colleague who must have had some inkling this article would one day come up and felt I might need a beefier list than the Manse study could have ordained. The story itself is pretty elementary – the first-person account of a teenage lad turning sleuth to make sense of a fairly straightforward happening. The title is a quote from Sherlock Holmes (Silver Blaze, the missing racehorse whose trainer is murdered) and the origins of the tale in Conan Doyle are evident. The twist, however, is that our lad is not just a little factually obsessed and socially incompetent – not just a little bit ‘Aspergery’ like Holmes himself. No, he’s the real McCoy. And OK, some experts on autism-spectrum disorder might say, ‘Well, you know, he didn’t get this quite right or that quite right’ etc, etc. ‘All in all, a rather pale reflection of the out-patient clinic!’ As no expert on autism-spectrum disorders or Asperger syndrome, I was saved such moaning and left to wrap myself snugly in this charming, affectionate, funny, frustrating piece. It really is not important if this is what it is like to experience the world through the brain of a person with Asperger syndrome – suffice to say, the book creates a totally convincing feel for what it might be like. And what a tormented and tormenting state these individuals and their relatives live in. Indeed, creating a lingering sense of the frustrations families must experience is one of the book’s enduring triumphs.

I cannot quite understand why Curious Incident was marketed at youngsters and the awards it garnered were for children’s writing. If good literature takes us – young or old – to places we have never been, then this is the best of literature.

Full circle

As I approach my own antiquity, I find myself returning to a passion from school days – classical history. Why this should so absorb someone of my predominantly scientific inclinations is a bit of a mystery – though some colleagues may be drawn to explore my roots in a ‘dominie’ household with a clerical father well schooled in the classics. I have come to believe, however, that in the real world, outside the concocted world of fiction and psychology texts, such ‘retrospections’ are usually futile. But clearly I remain in a minority and my personal scepticism has never put the brakes on ‘Jean Brodie’ colleagues (as she said, ‘For those that like…’ – yeah, well, you know the line), although the older I get the more I see such individuals as ‘colleagues’ only in the sense that Fred Dibnah and Neil Armstrong were ‘colleagues’ in the field of transportation! Perhaps one of the things that now attracts about historical ‘filling in’ is that it seems so much more accomplished, more sophisticated than the psychological varieties I have grown up with. Historians of substance would recoil from unsupported or clichéd speculation the way our snooty little poodle used to turn its pedigree nose up at tinned food! Yet in psychology it seems reputations can be made by bloating one’s speculations larger than Big Momma’s foam bottom.

For whatever reason, I have largely abandoned those pale shadows of a dreary out-patient clinic called ‘fiction’ for the spark and fire of ancient history, of which nowadays there is a surfeit of quality exponents. Like most of my generation pursuing scientific ambitions, there was only time for Latin as a teenager so when my interest revived, it was naturally to Rome I turned. Alas, the savage fact of the matter is that the Romans were boring – as one might expect of a nation of lawyers. Now the Greeks! Wow! What a devious, deceitful, depraved, totally delectable lot they were. Climbing out of the mire of pre-civilisation was a slippery business and the Greeks were adept at pouring oil on their neighbours’ efforts. As Herodotus said of his own, a Greek is one who ‘envies the good fortune of others and resents the power of those stronger than himself’. ^{Reference Holland16} Such characteristics do, of course, remain embedded in the dynamics of the average medical committee but the ancient Greeks did envy and resentment better than even we do!

But where to start now? How to get a handle on such diverse and distant societies? One suggestion might be Donald Kagan’s account of the Peloponnesian War, ^{Reference Kagan17} partly because this was one of the defining struggles of Western history and well worth knowing about; partly because, thanks to Thucydides, there is much to be known. Kagan wrote the definitive four-volume work on the subject but the largest version I have had the stamina to tackle is the condensed one. Condensing one’s material, as many will know, is a task that can cause the sweat to flow over the brow like gunge on a game show! To find that your perfect piece is only publishable ‘with the following changes’ that include deletion of so much you considered essential, the extinction of so many a perfectly turned phrase, can result in a kind of bereavement. Kagan has triumphed and retained a terrific read, to some extent, I think, by keeping the politics accessible, and has thereby opened up the story to the widest audience rather than closing it down to only the interested few, an example many an immersed scientist could do with emulating.

This is a work of history but one that carries with it a moral, as the story writes large the disasters mankind could have been spared over the past two and a half millennia were lessons truly learned by each generation from the mistakes of those who came before.

When striding out on ancient highways orientation is essential – be the highways of the land or the mind. So my final choice is not a book as such. However, to consider Barrington Atlas of the Greek and Roman World ^{Reference Talbert18} merely a collection of maps is to miss the point. Nor is it just an aide memoire to a presenile brain taken to hosting a few plaques and tangles too many for my liking. It is one of those two-dimensional aids that inspire genuine experience – full-blooded, three-dimensional panoramic vision with all the trimmings: colour, scent, sound…It’saTARDIS, with the power to transport you back to those landscapes some of the thoroughly admirable, thoroughly disreputable individuals trod in forging the foundations of Western civilisation. It will take you to the mountains they traversed, the rivers they forded, the farms they cultivated, the aqueducts from which they drew water, the mines their slaves toiled in. You can walk the Long Walls with Pericles if you have a spare Sunday afternoon or sink with Flaminius in the bloodied Trasimene. Just knowing where it is we are talking about, reconstructing topography, sweeping away the blemishes of 2000 years and more gives clarity that is objective, yet still allows for one’s own spin. In fact, I am rapidly coming to appreciate that reconstructing history carefully is not much different from constructing a careful history.

Barrington – scrupulously researched, beautifully presented in the best traditions of bountiful American philanthropy – is a work of art in its own right and if I am to be marooned on my desert island (this is ‘Desert Island Books’, is it not?) I could pass many an hour immersed in its pages, imagining perhaps heroic Alcibiades on his journey from glory to exile and death… Wondering how on earth he would have got off this bloody island!