Review of Oliver Sacks, “The River of Consciousness”, TLS 13th March 2018

I have a review in the current TLS of Oliver Sacks’ essay collection, “The River of Consciousness” . The full article is subscriber only so here is the opening….

Who is the most famous medical doctor in the world today? Until his death in 2015, a reasonable case could be made that it was Oliver Sacks. Portrayed by Robin Williams on screen, inspiring a Michael Nyman opera and plays by Peter Brook and Harold Pinter, Sacks took his followers far beyond the confines of neurology.

In their Foreword to The Rivers of Consciousness, a posthumously published collection of Sacks’s essays, the editors recount the time Sacks appeared in a Dutch documentary series, A Glorious Accident. Along with, among others, Daniel Dennett, Freeman Dyson and Stephen Jay Gould, Sacks discussed “the origin of life, the meaning of evolution, the nature of consciousness. In a lively discussion, one thing was clear: Sacks could move fluidly among all of the disciplines”. Specialists can have a suspicion of polymaths, and professionals can have a suspicion of those with a media profile. In his…

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Piece on cardiac surgery in Times Literary Supplement

In the current TLS I have a review of two books on cardiac surgery. One is Stephen Westaby’s  memoir of his career, the other is Thomas Morris’ historical perspective.

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The full text is not freely available online, so here is the bit the TLS have made available to tease you all:

It is tempting to place Stephen Westaby’s Fragile Lives, a memoir of his career as a heart surgeon, in the category the journalist Rosamund Urwin recently called “scalpel lit”; following Atul Gawande’s Complications (2002) and Henry Marsh’s Do No Harm (2014) and Admissions (2017), here is another dispatch from a world arcane even for the majority of doctors. To some degree, Westaby’s book follows the Marsh template. In cardiac surgery as in neurosurgery, life and death are finely poised, and even minor technical mishaps by the surgeon, or brief delays in getting equipment to theatre, can have catastrophic consequences.

Like Marsh, Westaby, a consultant at the John Radcliffe hospital in Oxford, is jaundiced about the bureaucracy of health care and the mandatory “training” imposed on even the most experienced practitioners – “writing my personal development plan at the age of sixty-eight”. Now that death rates are published by the NHS,…

Makes you want to read the whole thing, does it not?

As it happens, Henry Marsh’s Admissions is reviewed in the same issue by George Berridge.

Helen Pearson, “The Life Project”, Review in TLS 29/03/17

I have a review of Helen Pearson’s “The Life Project” on the UK birth cohort studies in the current TLS. The full article is behind a paywall so here is the preview:

Born to fail

To a non-Briton, the oft-repeated assertion that the NHS is “the envy of the world” can grate. If imitation is the sincerest form of envy, the world’s laggardly adoption of free-at-point-of-use health care is perhaps the truest mark of how much emotional investment the rest of the world really has in the UK’s health system. Early in The Life Project, her book on the British birth cohort studies, Helen Pearson describes them as “the envy of scientists all over the world”. In this case, envy is easier to precisely pinpoint; birth cohort studies have become all the epidemiological and social scientific rage in recent decades, especially around the turn of the millennium. My own daughter, born in 2008, is a member of the Economic and Social Research Institute’s “Growing Up in Ireland” birth cohort.

1946 is the Year Zero of birth cohorts. The low interwar birth rate had caused much…

 

 

Why are doctors so unhappy?

From the UK junior doctor’s strike to survey after survey , there seems to be growing evidence that a doctor’s lot is not a happy one. Or is it not so much a “doctor’s lot” as a “doctor’s nature?”

I’ve been interested in this question (quite apart from the personal relevance!) ever since working on this review for the TLS of various medical biographies. As I wrote:

In the Western world, at least, the medical profession generally enjoys high status. For sociologists, doctors incarnate various forms of power disparities. Medical science and medical technology have made spectacular progress since the Second World War; procedures such as LASIK laser eye surgery, to give just one example, that once would have seemed magical, are now near-routine.

And yet an air of discontent is evident in much of the discourse of modern medicine. Like many others, the medical profession is under question, if not attack, on a range of fronts. Complementary remedies are increasingly popular, often with practitioners as well as patients, despite the advent of evidence-based medicine and numerous books that have discredited their claims to efficacy. A succession of scandals in Britain and elsewhere has undermined public trust in doctors and nurses. Lewis Terman’s classic study of “gifted” individuals, published in 1954, found that physicians tended to feel inferior relative to those of comparable attainment in other fields, and the Grant Study, George Vaillant’s epic survey of adult development, following the Harvard Class of 1944, identified self-doubt as the feature distinguishing physicians from control subjects.

There was somewhat more I wrote originally, but for reasons of space, had to be cut

 

. Much was based on my reading of Myers and Gabbard’s wonderful The Physician as Patient – a book I reviewed some years ago . As I wrote then, Myers and Gabbard illustrate the power of the case vignette, a somewhat neglected form nowadays, and I also wondered about the  self flagellation possibilities of audit (linked I guess to the Imperative Voice one gets so much of in medical journals)

I didn’t write in my 2008 review of one of the points Myers and Gabbard make – based on psychoanalytic literature – about the much-vaunted grandiosity and pomposity of doctors – the “god complex.” In their reading, this (when it occurs) is a defence mechanism against the ultimate power of death against all our efforts. Personally, there are only a handful of doctors I have come across – and at this point I must have come across hundreds in various contexts – who in any way lived up to the “god complex” stereotype.

Are doctors less happy than other citizens? Surveys and so forth can no doubt be adduced to prove the point (though I must admit after the US Presidential Election having an even greater scepticism about ANY survey or poll being used as “evidence”)  and the lived experience of doctors is increasingly one of a beleaguered profession overwhelmed by competing and constant demands. Is this because of specific issues – funding, resources, de-professionalisation – of the contemporary world?  Is it because of a cultural shift from doctor-knows-best to consumerist healthcare? Or is it something deeper and perhaps near-inherent to the kind of person who is drawn to the practice of medicine? Or something deeper and perhaps near-inherent to the practice of medicine itself?

There is, on one level, more discourse about health and healthcare than ever before. On another, there is often a a euphemistic, evasive quality to much of it. So many terms – from “evidence-based” to “patient centered” – have become godterms that conceal the complexity and diversity of healthcare (both complexity and diversity are themselves “godterms”, increasingly, but I use them very deliberately here) and the contending priorities at play.

This is an area ripe for pompous theorising about Society and Culture and so on, and perhaps I have done my share of this already. One final thought: the WHO definition of health is:

a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.

Do you, reader, really believe that? Do you really, when you think of what it is to be healthy, think of”complete social well-being”?  What is “complete physical, mental and social well-being” anyway?

The point is not to denigrate “well being” in some way – or not to recognise the value of a positive rather than negative definition of health. The point is, this  grandiose definition has consequences – underlying not just health policy and practice but how we think about what it means to be healthy, and also what doctors (and nurses, and psychologists, and OTs, and physios, and everyone else with apologies for those left out) are trying to achieve. I would argue that the WHO definition is something out of a kind of worldly messianiac pseudo-religion rather than a workable basis for a human-scale endeavour.

 

“a wry, gentle masterpiece” My review of “A Smell of Burning” by Colin Grant in current issue TLS

Having alluded to this beforehere it is

 

Dreamy states and forced thinking

Subtitled The story of epilepsy, Colin Grant’s A Smell of Burning is, most vividly, the story of Grant’s younger brother Christopher, who died in 2010 aged thirty-nine, during a seizure – a Sudden Unexplained Death in Epilepsy, or SUDEP. Christopher was the dedicatee of Bageye at the Wheel (2012), Grant’s memoir of a 1970s childhood in Luton dominated – until his mother showed him the door – by his father, the perpetually choleric, feckless Bageye. “In Memory of Christopher Grant (Baby G) – A wry, gentle, amused and thoroughly splendid fellow” reads the dedication, and A Smell of Burning captures the adult life of Baby G adroitly.

Bageye has a cameo in A Smell of Burning, thirty years later, anxiously asking Grant “How Christopher? I hear him have head trouble”. As Grant writes,

my father was a Jamaican born in 1928. His ­perception of epilepsy would have been shaped and governed by superstition that runs like water through the island. People marked with head trouble were all the more scary because until they did something that revealed their condition it was impossible to tell them apart from anyone else.

This fearful regard of epilepsy was not ­confined to Jamaica. On one levelA Smell of Burning is an account of (partial) progress, with fear and ostracization gradually giving way to a greater level of understanding, both neurological and social. These approaches have an uneasy relationship: “often the patient is lost in these early accounts of the growth of neurology; the focus is on medical advancement, and the patient is the means to it: his body provides the pathway to enlightenment”.

Enlightenment about epilepsy existed, at times, in the pre-Enlightenment world; Herodotus, in discussing the illness of Cambyses II, distanced himself from the notion of a “sacred disease”; the Hippocratic text On the Sacred Disease is an attack on the very notion of epilepsy as a deity-induced illness. And for all the advancement that has been made, epilepsy retains much of its mystery: considering the visionary, logorrhoeic experiences of Philip K. Dick, Grant writes that “all too often it has been assumed that psychiatry offers the best model to describe some of the behaviours and personality changes in temporal lobe epilepsy, but maybe these behaviours have only the appearance of similarity, and something altogether different is going on in the brain”.

The book is something of a hybrid; the disease memoir crossed with a more detached journalistic account of the history of a particular condition in history. Careful to point out the pitfalls of retrospective diagnosis, Grant weaves his brother’s story together with those of Fyodor Dostoevsky, Harriet Tubman, Vincent Van Gogh, Julius Caesar and a much wider cast of anonymous epileptics. We also read of the medical mavericks, megalomaniacs and pioneers (many of whom merited all three descriptors), whose insights merged eerily with the literary; “the language of Dostoevsky and Hughlings Jackson was uncannily similar. Both men were able to conjure for readers the spooky ‘dreamy states’ and ‘forced thinking’ of epilepsy”.

Some of the richness of the book comes from a sense of holding back. The same restraint was already evident in Bageye at the Wheel, whose somewhat wry, amused take on Bageye’s misdeeds carried a depth of emotion all the more powerful for forgoing the template of the misery memoir. Grant, who studied medicine for five years at the Royal London Hospital, presents us with a superb memoir of medical student life in the mid-1980s. In asides to the main story, he evokes the blend of detachment, disorientation, reverent fear of the consultant and a sense of practical uselessness which characterizes much of medical student life.

When, shortly after a seizure, Christopher insists on driving, Grant experiences a feeling chillingly familiar to many who care for those who, in one way or another, lose control – “a sudden sickening fairground ride of emotion – a shearing-away of certainty”. Later, he is asked one of the most arresting questions a carer of someone with epilepsy can consider: would you wish to experience what they experience? There is a veil of unknowing over what happens to the person, a veil they themselves cannot penetrate after the event. Christopher

with age seemed to grow more accepting, as if he had reached some accommodation with the seizures. At times he woke after a seizure with a look of such disappointment; and I imagined him at the end of a dialogue with the fits urging them not to go just yet, like Horatio commanding the ghost of King Hamlet, “Stay, illusion!”

The visionary seizures experienced by Harriet Tubman after a head trauma helped inspire the Underground Railroad, and while not personally religious, Grant is open to ­considering the heightened religiosity seen in some epileptic presentations as being on the credit side of the ledger.

Like so many with a chronic condition, Christopher kicked against being defined by epilepsy and its treatment.

“If he would just tek the medicine. Why the boy can’t tek the medicine, God for tell”, was a constant refrain of my mother’s. When questioned about his non-compliance Christopher would counter that the drugs didn’t work. Or that they dulled him and left him thick-headed. Other sufferers have spoken about how they have felt trapped in this way by the condition.

Colin Grant’s exploration of the literary, political, medical and scientific history of epilepsy is hugely compelling; his telling of the story of two brothers transcends the book’s twin genres and leaves us with a wry, gentle masterpiece.

DUBLIN 1745-1922. Hospitals, spectacle and vice. By Gary A. Boyd. TLS, 30th June 2006

Thanks to Maren Meinhardt of the TLS, I have been getting the published text of pieces I have written for the TLS over the years. As it happens, a lot of these are from 2006, so a decade on, how do they stand up?

As a piece of prose, this is a rather sturdy, workmanlike review, with some clunky phrasing (“will find much of interest”)

The book deploys theory, as they say, in a way I was probably not all that familiar with at the time. It isn’t as effective as Susan Mat’s Homesickness: An American History in marrying a strong theoretical discussion with a readable, engaging narrative. Theory is often alienating, ironically since so much of it seems to be about power differentials and so forth.

Boyd’s work on Dublin reminds me of the previously-linked to posts by Philip Lawton at Ireland After Nama – as the review suggests the book goes well beyond 1922 until the present day – with the construction of a new Chidren’s Hospital and the ongoing closure of city centre hospitals this analysis is ripe for revisiting.

Medicine at the margins
Seamus Sweeney
Published: 30 June 2006
DUBLIN 1745-1922. Hospitals, spectacle and vice. By Gary A. Boyd. 224pp.

Dublin: Four Courts. Pounds 45 (paperback, Pounds 19.95). – 1 85182 960 1.

Georgian Dublin, to most Dubliners and tourists, evokes architectural splendour, an age of elegance and grace. It is often held up as a contrast to architectural and social developments in Dublin since, as an era of enlightenment and progress. Hospitals from the era such as the Rotunda, the first dedicated, purpose-built maternity hospital in the British Isles, and St Patrick’s, the “house for fools and mad”, founded with Jonathan Swift’s bequest, still retain their original function, or rather, still function as hospitals in today’s sense.

For this was an age in which the meaning of “hospital” underwent a change. Its derivation rooted in the Latin hospes, from which also come hospice, hostel and hotel; “hospital” in the medieval sense was not necessarily a place of cure or anything much by way of medical activity. It denoted a place that offered a wide range of possible services, from lodging and victuals to basic forms of care. They usually had an overtly religious mission. Dublin hospitals founded before the period covered by this book, such as the Foundling Hospital and the Royal Hospital Kilmainham, exemplified this older function.

It was also an age when “man midwives”, by stressing the dangers of parturition and the possibilities of a medical approach, were beginning to acquire respectability.
Nevertheless, obstetrics still stood in some disrepute. John Blunt’s evocatively titled treatise Man Midwifery Dissected; or the Obstetric Family Instructor, Containing A Display of the Management of Every Class of Labours by Men and Boy Midwives; also of their cunning, indecent and cruel Practices, proving that Man-Midwifery is a personal, a domestic and a national Evil typified this anxiety.

Homesickness: An American HistoryThis is the background to Gary A. Boyd’s architectural history -part of the Making of Dublin City series -which focuses on the Rotunda, or Lying-in Hospital, but is far from solely concerned with it. The book originated as an investigation of the relationship in the Dublin of today between the “official city” of civic buildings, monuments, museums, shops and galleries and an “unofficial city” of marginalized spaces; “alleyways, vacated buildings, empty lots” and the like. In the course of this, Boyd discovered that in any CCTV network, such as that which monitors the “cultural quarter” Temple Bar, whose culture now largely consists of stag and hen weekends and Sunday morning piles of vomitus, there are “shadow” zones which evade surveillance, due to various features of urban topography. Thus, “even in one of the most tightly controlled public areas of the city, therefore, certain uncontrollable and unpredictable activities existed”.

Boyd was moved to consider the lacunae in architectural histories of Dublin’s more famous and historic public spaces and buildings regarding the “uncontrollable and unpredictable” activities of those marginalized in traditional architectural historiography. This volume is an attempt to reclaim that human element. Boyd begins on June 4, 1751, with the Lord Mayor of Dublin and other dignitaries processing in state to the New Pleasure Gardens in what is now Parnell Street.

There Bartholomew Mosse, founder of the Lying-In Hospital, a man equal parts impresario and medic, supervised the laying of the foundation stone for what would become the Rotunda. Mosse threw an elaborate breakfast and “genteel and liberal entertainments” for the Lord Mayor and assembled gentry. This spectacle masked Mosse’s, and the hospital’s, precarious financial situation, and the New Pleasure Gardens would play an important role in hospital fundraising.

This incident typifies the close relation between spectacle and buildings with a public, ostensibly altruistic function. The new hospital did not simply serve a function as a maternity hospital, but acted as Palladian backdrop to the promenades in the New Pleasure Gardens. These Gardens were not just the site of elegant strolling, but of illicit assignations, what a later age would call “cruising”.

Thus begins a wide-ranging exploration of the tensions within Dublin, and within medicine, between medical function and issues of desire and social control. The dates given in the subtitle are somewhat misleading. The emphasis is very much on the early stages of the chronology. The book ends with a survey of the development of the red light area, Monto -which takes us to the 1940s rather than 1922, with Monto’s demise hastened by the work of Frank Duff’s Legion Of Mary.

Over the course of the book Boyd covers an impressively wide range of ground, from the work of the Wide Streets Commission, the Leeson Street Magdalen Asylum, the Lying-In Hospital’s admission certificate (reproduced in the book, with its rules including “That no Woman great with Child is to be received into the Hospital, if she hath any Contagious Distemper, or the Venereal Disorder”), the memoirs of the demi-mondaine Peg Plunkett aka Mrs Leeson, developments in hospital planning and management, the relationship between the military presence in Dublin and prostitution and many other topics.

Boyd’s analysis is influenced by Foucault’s conception of medicine as a locus of social control of deviancy, and by Murray Fraser’s work on the administration of late eighteenth-century Dublin. Fraser suggests that, rather than a simple expression of the power and pride of an Anglo-Irish elite, many developments in Dublin at the time resulted from the work of three powerful but conflicting bodies: the “Ascendancy” parliamentarians, the mercantile class, and the British administration in Dublin Castle. Fraser suggests that the work of the Wide Streets Commission, for instance, reflected a realignment of Irish interests with those of Britain.

Dublin 1745-1922 is lively and accessible -largely because Boyd quotes contemporary voices at length. His own prose style has enough wit and evident suspicion of the pieties of other ages and our own to keep the reader’s interest.

It is refreshing to read of issues that are often treated as purely medical or sociological from an architectural history perspective, albeit an architectural historiography strongly informed by social and political considerations. Some readers may find the influence of Foucault overbearing, and the occasional lapses into theoretical jargon somewhat off-putting (things are constantly “subverting” other things). Nevertheless, any Dubliner, anyone with an interest in the city’s history and development, or with an interest in the history of medical and obstetric practice, will find much of interest and find their impression of Georgian elegance modified.