by A. J. Lees
Nerve specialists were considered cerebral, remote and austere by their peers but in an era before non-invasive brain imaging few physicians had the knowledge or competence to question their final diagnosis. Neurologists were thinkers not doers. Jokes about their obsessionality, bow tie elegance, left-handedness and emotional coldness were common. Psychiatrists were their polar opposites and it seemed to me that their approach to medicine reflected this difference in personality. Psychiatry was woolly, dialectic and lacked physiological solidity.
Neither of my two first bosses at University College Hospital, William Gooddy and Gerald Stern, fitted the conventional image of a neurologist but they did not deviate in their approach from the diagnostic technique laid down by Jean-Martin Charcot in Paris, Moritz Romberg in Berlin and William Gowers at The National Hospital, Queen Square. They reminded me on ward rounds that searching for meaning in the stories of the neurologically ill was the only way to master neurology and that I must study my patients seriously. The intricacy of neurological and psychiatric presentations defied formulaic methodology and could never be reduced to guidelines and algorithms or defined by radiological pixels. A successful outcome to a case often turned on an ability to identify clues missed by others.
Both Dr Gooddy and Dr Stern were impressive, confident, communicated sensitively and were unhurried in their demeanour. They would begin a medical consultation by asking the patient to describe the presenting symptoms, observing carefully while they took heed of what they were being told. From time to time they would write in the notes the exact words used by the patient to describe a particular complaint. They would never interrupt but when the history had been given they would clarify points with a few carefully chosen, non-leading questions. I watched with interest how they paid particular attention to irrelevant trifles and inconsequentialities. They took notice of negatives and had an uncanny ability to expose inconsistencies. After they had satisfied themselves there was no more helpful information to be obtained from the patient they would then approach the relatives to get their side of the story. Finally they might turn to me and ask for additional details about the family history, the social situation of the patient and a summary of the abnormal findings discovered on physical examination. Before concluding their investigation they would verify at the bedside one or two physical signs where there was doubt over the interpretation or which didn’t seem to fit with the rest of the clinical picture. At the end of it all they would turn courteously to the patient and explain that the team were going off to have a discussion about what to do next.
The firm then trooped off to the day room for a coffee and a plate of Bourbon biscuits prepared by the sister on Ward 5.2. Dr Gooddy and Dr Stern never trusted to general impressions and constantly stressed the importance of careful observation and accurate recording of the case history. Every gesture, every inflection of speech, every reflex, every sensory deficit was important if one was to reduce fatal error. In a deductive process that seemed to me like thinking aloud, my teachers would then locate the site of the nerve damage, and from the details of the narrative propose the likely cause for each patients’ symptoms. Last of all they would attempt to establish links between the findings at the bedside and the laboratory and radiological results. When all the data was in, a firm conclusion was drawn but I was made aware of the importance of keeping an eye open for incongruities that might subsequently negate the diagnosis.
This systematic routine, passed down from one generation of neurologists to the next, had helped to save countless patients from invasive and potentially life-threatening investigations and inappropriate treatment. When we had all had our say, my chiefs would go back and talk to the patient often alone or accompanied just by the house physician. The prognosis would be imparted and the treatment plan carefully explained.
Perfection of this methodical and time-consuming approach is essential to becoming a good neurologist and I spent many hours on the wards and in the outpatient clinic trying to hone my skills. I got to grips with the complexities of the neurological examination and gained competence in the use of the ophthalmoscope, tendon hammer, tuning fork and two point discriminator. The feeling finger became another form of observation independent of eyesight. I paid attention to trivia and held on to things that made no sense.
My teachers helped me come to terms with the tension I felt when confronted with diagnostic dilemmas. They emphasised that I should only fully accept what I had read or heard after I had verified it myself. I learned most from my mistakes, and David Perkin, my senior registrar, was a great comforter when I needed to unburden my insecurities. Neurology had, and still has, more than its fair share of devastating, incurable maladies, and from time to time my teachers would curb my fondness for new discovery by reminding me of the importance of the laying on of hands and kind words. We behaved as if death was a malady from which one always recovers but I did learn to tell the painful truth without frightening people.
William Gooddy’s advice to me at the end of my second teaching round came straight from the great physician William Osler. To study the phenomena of neurological disease without books was to sail an uncharted sea, but to study books without patients was not to go to sea at all. The only way to learn was by seeing and talking to patients. His recommended reading list was eccentric. He advised me to read two books: The Complete Works of Sherlock Holmes, described by its author Arthur Conan Doyle as ‘the fairy kingdom of romance’, and Marcel Proust’s À la Recherche du Temps Perdu. Much later I realized it had been his clever way of introducing a young man embarking on his specialist training to the methods of his predecessor, William Gowers, arguably the greatest clinical neurologist that ever lived. Gooddy believed, as I do now, that in order to master a new profession the mind of the apprentice has to pass through all the stages that the art itself has displayed in its historical evolution.
The Baker Street sleuth’s method of crime detection soon proved of far greater value than anything I had read in Lord Brain’s Diseases of the Nervous System. Each time I took the clinical history from a patient I remembered Holmes’s words to John Openshaw in The Five Orange Pips: ‘Pray give us the essential facts from the commencement and I can afterwards question you as to those details which seem to me to be most important’.
Detective work had become a metaphor for diagnostic acumen and the mysteries that exercised Sherlock Holmes shared some of the rhythms of neurological practice.
One day I had planned to teach the second year clinical medical students on a young African boy with myasthenia gravis, a disorder that leads to profound weakness of speech, difficulties in swallowing and a droopy face. Unfortunately, despite asking the nursing staff to make sure ‘Mr S’ did not leave the ward, when we arrived at his bed he was nowhere to be found. Undeterred, and anxious to show off my newly acquired skills, I asked the bemused group to tell me what they could deduce about the patient. The crime scene contained a spirometer, an instrument used to measure lung capacity, an eye patch and a large number of personal possessions including some comic books. After I had listened to their suggestions it seemed reasonable for me to submit, on the basis of the evidence, that the patient was young, had double vision and shortness of breath and had been in the ward for some time to undergo some form of acute treatment. The combination of respiratory problems and diplopia in a young person pointed strongly to a primary disorder of the muscles or the junction between the muscles and nerves. Holmes used a process of abductive reasoning to solve crimes and I was now incorporating this into my clinical method:
Let me see if I can make it clearer. Most people, if you describe a train of events to them, will tell you what the result would be. They can put those events together in their minds, and argue from them that something will come to pass. There are few people, however, who, if you told them a result, would be able to evolve from their own inner consciousness what the steps were which led up to that result. This power is what I mean when I talk of reasoning backward, or analyt
ically.
– A Study in Scarlet
Just as we were about to leave the ward, ‘Mr S’ returned to his room and I was able to elicit for the students the fatiguable weakness of his eye muscles and droopiness of his eyelids, his nasal speech and mild weakness of his arms and legs compatible with the diagnosis of myasthenia gravis.
Conan Doyle knew about recent advances in the understanding of nervous diseases from his own postgraduate medical research on tabes dorsalis (one of the three common types of neurosyphilis).
In The Adventure of the Resident Patient, Holmes and Watson meet a character called Dr Trevelyan, the author of ‘a monograph on obscure nervous lesions’. Trevelyan tells Holmes of his interest in the study of neurology:
My own hobby has always been nervous disease. I should wish to make it an absolute speciality, but, of course a man must take what he can get.
Trevelyan had found himself in the midst of a criminal gang’s feud and been asked to see a ‘Russian nobleman’ who had presented with catalepsy. Judging from the accurate nature of the clinical description it is likely that Conan Doyle had consulted the chapter relating to trance in William Gowers’ Manual of Diseases of the Nervous System. Holmes quickly realises the patient is malingering and solves the case to the astonishment of Trevelyan.
To seek out clues and make rational conclusions based on findings at the bedside gave rise in me to strong feelings of satisfaction. I was also learning to build my life within the confines of the hospital. As I became more familiar with the Sherlock Holmes canon I found vignettes of St Vitus’s dance, cerebral apoplexy, tetanus, delirium and meningitis that confirmed my growing suspicions that the real neurologist manqué was Sir Arthur Conan Doyle. I was enjoying the intellectual challenge of neurology and had acquired the necessary inurement to avoid being destroyed by the everyday tragedies I witnessed on the wards. The bedside was now my laboratory.
The biographies of several of the neurologists who were practising at the turn of the twentieth century shared many of the character traits of Sherlock Holmes: aloofness, panache, an air of intellectual superiority bordering on arrogance and more than a hint of misogyny. Holmes was a much greater artistic creation than the stories in which he appeared.
As my training in neurology continued at The Middlesex Hospital many of the words of advice I was learning from my new teachers Michael Kremer, Christopher Earl, Roger Gilliatt and Michael Harrison, evoked Holmes’ pithy aphorisms:
One should always look for a possible alternative and provide against it. It is the first rule of criminal investigation.
– The Adventure of Black Peter
Singularity is almost invariably a clue. The more featureless and commonplace a crime is, the more difficult it is to bring home.
– The Boscombe Valley Mystery
You see, but you do not observe. The distinction is clear.
– A Scandal in Bohemia
I never guess. It is a shocking habit – destructive to the logical faculty.
– The Sign of Four
How often have I said to you that when you have eliminated the impossible, whatever remains, however improbable, must be the truth?
– The Sign of Four
They were teaching me to focus like Holmes on the rubbish heap of despised and unnoticed observations.
In the 1970s, neurology in Great Britain was a very competitive and oversubscribed speciality and I felt honoured to have been given a chance to throw my hat in the ring. I had the great privilege of coming into contact with chiefs who were inspirational, generous, understanding and helpful. Most of my teachers at both University College Hospital and the Middlesex Hospital felt as uncomfortable as I did about an elitist system that denied women full and equal employment opportunities. I now knew that the wisdom I had learned from textbooks and lectures would never give me the knowledge of when to probe and when to leave alone, when to reassure and when to keep silent. Gowers’ nineteenth-century writings were different. They read like novels and brought the diseases I was now studying to life. I also knew that, however sophisticated technology became, it could never be a substitute for taking a detailed history. Patients were my main teachers. They could not be reduced to a repository of deranged regulatory systems or a collection of malfunctioning organs. Benway’s descriptions of his brain-damaged patients at the Freeland Reconditioning Centre were no longer funny but preposterous:
‘Come and take a close look,’ says Benway. ‘You won’t embarrass anybody’. I walk over and stand in front of a man who is sitting on his bed. I look at the man’s eyes. Nobody, nothing looks back. ‘IND’s’, says Benway, ‘Irreversible Neural Damage. Overliberated you might say … a drag on the industry’. I pass a hand in front of the man’s eyes. ‘Yes,’ says Benway,’they still have reflexes. Watch this’. Benway takes a chocolate bar from his pocket, removes the wrapper and holds it in front of the man’s nose. The man sniffs. His jaws begin to work. He makes snatching motions with his hands. Saliva drips from his mouth and hangs off his chin in long streamers.
– Naked Lunch
My future was still uncertain but I had managed to curb my contrariness and obduracy. I loved the reasoning involved in diagnosis and as my competence improved I was able to relax, become less defensive and be more responsive to my patients’ despair. I tried to acquire the habit of entering into the feelings of my patients and into their modes of thought. I had come to realise that the lives of the neurologically ill were far more richly detailed and sensational than their misfortune suggested. Their colourful, spirited and often painful stories gave me insight into how I could ease their suffering. Listening attentively to the narrative from which my patients came and to which – well or ill – they were bound to return, held the key. Stories were what provided all of us with an identity for the place we lived in and for ourselves as individuals. Clinical judgement was a vital counterpoise to the rationality of science with its calculations, impartiality and disinterestedness. As I got better at ‘whodunit’ I also began to search for answers as to why the crime had been committed in the first place. I started to understand that neurology began where Doctor Watson always did: with the circumstances of the case.
William Burroughs had returned to America in 1974, in the same year Richard Nixon became the first American President forced to resign from office. Burroughs was now famous and acclaimed as an important writer but he was still on the run from ‘the ugly spirit’. I had now read his memoir Junkie: Confessions of an Unredeemed Drug Addict, The Yage Letters, Interzone and The Ticket that Exploded but could not relate any of these books to my work as a hospital doctor.
After graduation from Harvard, Burroughs toyed briefly with a career in psychiatry but within a few months of enrolling for a medical degree in Vienna in 1936, he had concluded that despite the amenability of the medical profession to accommodate individuals of widely differing character, he was totally unsuitable for the profession:
I could never have been a doctor. I did right to quit. My heart is too soft and too hard, too quickly moved to love, anger or indifference. I would care too much for some patients and nothing for others.
– Interzone
One connection that intrigued me was the discovery that his Columbia University friends Allen Ginsberg, Jack Kerouac and Edie Parker had all likened ‘Old Bull Lee’ (Burroughs) to a real-life Sherlock Holmes. Burroughs was something of a dandy in the grand English tradition, always courteous and impeccably dressed in Saville Row suits. He smoked Senior Service cigarettes, ate at Rules and shopped at Fortnum and Mason. In the 1940s he had worked as a private eye, hoping to enter the noir world of Dashiell Hammett, but had been disappointed with the triviality of the case material. Like Holmes he had resorted to cocaine as a cure for ennui usually in the form of ‘speedballs’ and he kept a firearm under his pillow. There was also a physical resemblance: Burroughs was tall with cold piercing eyes, an aquiline nose and thin lips.
Ever since his time at university, Burroughs had develo
ped the habit of retreating to his room for days on end. He was a master of disguise and shared the fictional detective’s strong antipathy to women and nuanced sexuality. Both were outsiders and anti-authoritarian. But there were obvious differences too. Burroughs was peripatetic, addicted to narcotics and more anarchic. Holmes preferred chemistry whereas Burroughs’ forensic investigations embraced telepathy and extrasensory perception. I now saw Burroughs more as a freelance investigator researching anthropology, psychology, biology, sociology and neuroscience in an attempt to accurately inform his fiction:
… after I got out of Harvard in 1936, I had done some graduate work in anthropology. I got a glimpse of academic life and didn’t like it at all. It looked like there was too much faculty intrigue, faculty teas, cultivating the head of the department so on and so forth.
– Paris Review interview with Conrad Knickerbocker in St Louis, 1965
Just as things seemed to be progressing well in my career and I had started to relish medical life I read an article that had first appeared in the May 1974 issue of The Lancet. It was entitled Medical Nemesis, written by a Catholic priest called Ivan Illich. It began with the unsettling words:
Within the last decade medical professional practice has become a major threat to health. Depression, infection, disability, dysfunction, and other specific iatrogenic diseases now cause more suffering than all accidents from traffic or industry. Beyond this, medical practice sponsors sickness by the reinforcement of a morbid society, which not only industrially preserves its defectives but breeds the therapist’s client in a cybernetic way. Finally, the so-called health-professions have an indirect sickening power – a structurally health-denying effect.