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Poetry Book Review: Thinks Itself a Hawk

22 Jul, 16 | by cquigley

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Review: Thinks Itself A Hawk, Wendy French, The Hippocrates Press, 2016.

by Rebecca Goss

On June 30th this year, I headed to University College London Hospital (UCLH) Macmillan Cancer Centre to listen to Wendy French read from her new poetry collection Thinks Itself A Hawk. As I approached the revolving doors in the middle of the wide glass frontage, a woman was leaving the building via the doors’ slow spin. She was wearing a headscarf, and carrying several plastic bags of what looked like shopping or bundled belongings. She was alone. She looked tired. She looked sad. And she looked ill. I have spent a lot of time in hospitals, but I have never come close to cancer. As the doors ejected us in opposite directions it began to dawn on me where I was going, and what I might see. My naivety overwhelmed me. I thought I was going to a building about cancer, not a building that contained it.

In 2014, Wendy French became UCLH’s first ever poet in residence at the Macmillan Cancer Centre. To quote from the foreword to Thinks Itself a Hawk, French’s resulting book, ‘the residency’s intention was to extend access to poetry and the spoken word and assist with improving patients’ well-being.’ French ran weekly creative writing groups for patients and wrote her own poetry in response to her time spent at the centre.

Throughout the book there are many references to walking and movement and ‘openings’ – the paths our lives take. An early poem in the collection is titled Cancer’s Daily Walk. Cancer itself ‘will walk in the town, in the city,//enter St. Paul’s when doors are open,/will walk……where its feet take it.’ But eventually the cancer enters ‘distracted bodies/whose cells are greedy for change’ and then all routes will lead to those revolving doors. French is there to document the process of arrival as people ‘try to shake off//their fears as they shake/their coats from the rain.’ (The Waiting Game)

Cancer’s impact on daily life and family relationships is all studied here. A poignant stanza in Today’s Appointment shows how family ‘outings’ have been transformed with ‘a wave of a dark wand’. Rather than trips out with picnics the sick now carry ‘bags of medication, nebulisers/in a field of white coats.’

In an environment at times harrowing and bleak, French is able to show us the real people who live with cancer. French sees the blatant effort needed to survive – ‘blood is exchanged like currency’ – yet we can also tell French got extremely close to these people. French respects them, utterly, as do the medical staff, but French is able to give them something not always prescribed. She gives them time. ‘We sit together not talking but dawdling…’ (In the Wood). ‘She tells me that pain is unpredictable/but there’s refuge in books and music.’ (This Girl).

French accepts there is a world inside the centre, and a world outside it. Referring to a tunnelled walkway that connects the Macmillan Centre to the rest of UCLH, French writes ‘down here…time is marked differently…We know we are unique we hold our heads high/and picture the outside.’ (Because)

Illness can cut people off from the ‘real’ world, but French is keen to show that the Macmillan Centre does not just house patients. Behind its doors are patients’ relatives, clinicians, volunteers, ambulance drivers, catering staff, Kingsley the ‘concierge’ – everyone is accounted for, and illness feels less isolating as a result. I remember hearing the broadcaster Andrew Marr in a radio interview about his stroke say that illness is nothing to be ashamed of. French’s poems take the shame away from suffering by scattering light on everyone involved. In Mammogram, a witty but never crass depiction of a medical examination, we focus on a list of apologetic utterings from the clinician: ‘Unfortunately I have to ask you to put your breast here/Unfortunately this may hurt for five seconds/Unfortunately we have to do this five times’. To see the appointment from the medic’s perspective highlights issues of identity in the book. The repetitive use of ‘unfortunately’ hints at the ‘human being’ behind the façade of ‘doctor’.

The latter section of the book concentrates on the story of Zipora, aged 66 when French first met her, and suffering from aggressive ovarian cancer. Zipora died during French’s residency. Before her death, Zipora shared much about her life as a Jewish woman coming from what the book’s blurb describes as ‘the darkest days of the twentieth century’. It is a very moving sequence, interspersed with letters written by Zipora to her mother. These letters were never sent, but shared with French, and French mirrors each letter with a poetic response.

Guy Noble, Arts Curator at UCLH, writes of French’s work “It touches on the challenges faced by people living with or facing a cancer diagnosis, and reflects upon the “everyday” which perhaps many of us overlook.’ I agree with Guy’s statement, but something we also overlook is that severe illness can define a person. We have to remember that there was a whole life before illness set in. Zipora’s story is a valuable addition to the book, as we learn of such a life. Through both French’s voice, and Zipora’s, we discover a family’s lineage fractured by war, a child orphaned by the age of two and raised in a kibbutz, a marriage not always happy – it’s all survival of a different kind. French’s poems reflecting on Zipora’s story are tender, wise and considerate, and we can only be grateful French was there to record it.

Thinks itself A Hawk is a moving, candid, illuminating and necessary collection. We are drawn to look closely at illness and suffering, the poet never once shying from the awfulness of things. But there is gentleness too. Reading the book is like having French push open a door, beckon us, and with her arm around our shoulders, she tells us to look. And all the time we’re looking, French is there, watching with us. She is the poet, the observer, the chronicler and the guide.

 

 

 

 

 

 

Book review: The Heart

21 Jul, 16 | by cquigley

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Maylis de Kerangal, The Heart. Translated by Sam Taylor. Farrar, Strauss and Giroux, US.

In the UK it is titled Mend the Living, translated by Jessica French, and published by MacLehose Press.

 

Reviewed by Elizabeth Glass, PhD student in Comparative Humanities, University of Louisville.

 

The Heart by Maylis de Kerangal tells the story of 24 hours in the life, and death, of twenty-year-old Simon Limbeau. The narrative includes snippets from the brief hours before a car wreck that ultimately takes Simon’s life, moving through to the aftermath of his death when his heart is transplanted into the recipient Claire Méjan.

At the beginning of The Heart, Simon goes on a surfing trip with friends. On the way home, they are involved in a car accident. The other two young men escape with minor injuries, but Simon is critically injured. Once it has been determined that Simon’s injuries are fatal, and that his brain has ceased functioning, the doctor, Pierre Révol, approaches Simon’s parents to discuss organ donation. Initially reluctant, particularly about donating Simon’s heart which they believe holds his dreams, love and life, they eventually agree. Thereafter we follow the journey of Simon’s heart.

The Heart spends more time with Révol than any other character as we observe him negotiating with different aspects of the organ donation process. We also see Simon’s mom, Marianne, arrive at the hospital, her trauma heightened by being unable initially to get hold of her estranged husband, Sean, Simon’s dad. We then follow the interaction between the parents throughout the horrendous process of losing their adult son. We watch the hospital staff work with and around Simon. We are there when Révol asks Marianne and Sean to donate Simon’s organs. The most painful part of the novel involves witnessing Marianne’s reactions to learning new information about Simon as he is dying. Though we spend more time with Révol, we know Marianne better–we can feel her emotions. We meet Claire, who receives Simon’s heart. We also meet the transplant team and witness both operations: the organ removal surgery and the heart transplantation.

The novel is not about Simon’s life, and it is also not entirely about his death. Instead, it focuses on the donation and transplantation of Simon’s organs, and his heart in particular which we follow to Claire. We care about Simon’s organs as he is being kept alive awaiting surgery, and then it our own hearts that quicken as his is removed. The surgical scenes are the most tense in the novel overall. They allow the reader to alternate between a distance of watching from afar and that of being almost so near to hand that we could imagine ourselves passing the sponge to the surgeon. This is when we are closest to feeling and understanding what the characters experiencing. While the surgery and the donation process are both simplified, for someone who is only peripherally acquainted with such processes, the medical procedures were described in a detailed and interesting manner without becoming overly technical.

The Heart is told from an omniscient narrator’s point of view with a distance that gave me the feeling of being outside a glass door, or looking down from above in an operating theatre, an onlooker on unfolding scenarios. The narrator is not only all-knowing but is also an I who addresses the reader as you on occasion. This had the effect of taking me out of the moment of the action and of detaching me from the story. It caused me to wonder who I actually was, but the answer to this is never revealed and the identity of I remained hidden throughout. At one point the narrator writes, “You undoubtedly remember the description of the books on Révol’s metal shelf, mentioning a copy of an issue of that magazine from 1959, so you will have already guessed that the article appeared in that very issue” (p. 32). Instead of drawing me into the story, this aside had the opposite effect. Such asides were infrequent, but when they did occur I found them distracting. The narrator was not a presence that I was aware of all the time; the opposite in fact, as most of the time the narrator was in the background. Thus, when he or she appeared, it felt strange and distanced me from the ongoing story.

This distancing, which creates the illusion of watching what is happening, of being an onlooker instead of being directly involved, means that as readers we can only access the characters’ thoughts tangentially. The things we know are told to us, but with the impassivity of overhearing a stranger’s order at a restaurant. As a result, it is hard to care about the characters to the extent that the subject matter deserves. However, if one did become very involved with the serious content, The Heart would surely become a challenging and potentially harrowing read. Thus, the sense of clinical detachment evoked probably serves a useful purpose, and will, I suspect, ensure a wider readership.

Each sentence in The Heart tends to be a paragraph in length, containing many phrases separated by commas. This makes the novel a difficult read at times and is potentially distracting; yet it also encourages a sense of urgency. The reading experience felt halting initially, but this sensation ceased as I progressed through the book. At the outset I found myself stumbling and searching for parts of speech to make sense of some of the sentences, but there came a point later in the book when I found myself unable to put it down.

There are two versions of the novel translated into English from the original French: for the United States it is titled The Heart, and for the United Kingdom Mend the Living, which is a more direct translation of Maylis de Kerangal’s original French title Réparer les vivants. Mend the Living was nominated for the Man Booker Prize. The US reader will have difficulty with Mend the Living, however. For example, in Mend the Living, as Simon and his friends are getting ready to surf, they are said to have “liquid rhinitis, sleep with your clothes on.” In The Heart, it says they have, “runny noses, slept-in clothes.” This type of difference exists between the two translations throughout. The end of Mend the Living is as exciting as The Heart, but elements of the writing will limit its appeal to the American reader. Thus, for this reader, Sam Taylor’s translation was a more satisfactory read.

In terms of the Medical Humanities, The Heart is an illustrative example of the arts interacting with medicine. The reader witnesses doctors wrestling with complex ethical issues such as how far to push the parents to donate Simon’s organs, decisions around to whom his organs will be donated, as well as the reality of the organ removal surgery that ends his life. The reader also observes Claire’s Méjan’s difficulty coping with the fact of receiving the heart of someone who has died, as well as her transplant surgery. All these issues render The Heart a compelling read.

Overall, The Heart is a gripping novel. Although we know at the outset that Simon will die, this fact does not detract from the extent to wish it engages the reader. The book is not without its faults. The reading experience may indeed have benefitted from a shorter sentence structure, and from a more in depth delving into the characters’ minds and thoughts. Notwithstanding, the narrative that underpins the novel remains intriguing and engaging. The Heart is particularly recommended to readers of Medical Humanities.

 

 

 

Related reading

M Shildrick, P McKeever, S Abbey, J Poole and H Ross. Troubling dimensions of heart transplantation. Med Humanities 2009;35:1 3538

TA Faunce. Book review: Cutting for Stone. Med Humanities 2009;35:2 123124

Book review: Hysteria Today

15 Jul, 16 | by cquigley

 

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Hysteria Today, edited by Anouchka Grose. Karnac Books, 2016.

Reviewed by Kathryn Lafferty, PhD student in Comparative Humanities, University of Louisville.

In the first edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-I) published in 1952, the American Psychiatric Association removed the term “hysteria,” implying that the term was no longer relevant to the medical community. However, Hysteria Today notes that while the term is no longer in common use within the medical field, the symptoms still exist and have been categorized under a variety of other illnesses such as “conversion reaction,” “hysterical neurosis (conversion type),” “conversion disorder,” and “histrionic personality disorder” since the establishment of the DSM.

In Hysteria Today, the authors describe and explore some of the ways the diagnosis of hysteria has evolved over time, dating from the early descriptions of hysteria as a “feminine complaint” to a recent description of hysteria as portrayed in young adult novels. Looking at hysteria from a psychoanalytic perspective and focusing their arguments based on Freudian and Lacanian conceptions of hysteria, this book serves as a reminder that while the “troublesome” term hysteria is rarely used in today’s medical descriptions, it is still an extant term that will never let “itself be explained out of existence” (xxx).

The editor of the book, Anouchka Grose, who is a member of the Centre for Freudian Analysis and Research as well as an author of numerous novels, chose current practicing Lacanian psychoanalysts to present ideas about hysteria because of their first-hand experience. Relating these theories to real people’s lives within the clinical setting, these Lacanian psychoanalysts present a cohesive, well-researched, and informed view of some of the ways to rethink hysteria in contemporary society.

This book provides the reader with an intelligent and informed discussion from various perspectives, relying heavily on case studies and true experiences from the authors on hysteria through their work in clinical settings. It is broken up into seven chapters, all of which are deeply rooted in Freudian and Lacanian theories about hysteria. While these sample case studies and concepts about hysteria provide clear explanations of Freudian and Lacanian theories, the text will most benefit students and scholars already familiar with the concepts, expanding Freud’s and Lacan’s works to artifacts and case studies in our contemporary moment in productive ways.

The text opens with an introduction by the editor, Anouchka Grose, who details the history of the term hysteria and provides relevant background knowledge into the various ways the term was used along with the treatments prescribed for the affliction. One of the salient points she makes is that “hysterics have always found a way to attack the status quo” (xxix) and that “‘Illness’ offers a form of resistance” (xxix). This brief but dense introduction provides an entryway into the valuable discussions provided in the remainder of the book, although there are no chapter abstracts included in the introduction.

In the first chapter “Hysterics Today,” Leonardo S. Rodríguez discusses the importance of subjectivity and treating the hysteric as a subject, “not as machines of production and consumption” (21). He notes the important role hysterics play in contemporary society, stating that they have “preserved the value of human desire” (23) and provides various case studies­–both from his own clinical experiences as well as from Freud and Hanns Sachs.

Chapters two through four take a concentrated look at the diagnostic and discursive utility of the term “hysteria” across time. The second chapter, “Hysteria Today,” is written by Darian Leader, a renowned psychoanalyst who is noted in the acknowledgements as suggesting the idea for this book. Outlining three points of diagnostic confusion in hysteria-–Other Minds, the Other Woman, and the Other Body–he suggests that it is not the historical aspect of hysteria that can interpret the configuration of symptoms, but it is the “space of hysteria” that can define the subjective division within hysteria diagnoses.

In the third chapter, “Beyond Queer?,” Anne Worthington provides an interesting blend of both psychoanalysis and queer theory to discuss hysteria in today’s post-psychoanalytic world. She provides a well-researched conversation about how psychoanalysis and queer theory can work together in various ways to provide further insight into the questions that arise out of hysteria, citing notable theorists such as Rosemary Hennessy and Judith Butler.

Chapter four, “Necessity and seduction: a section of hysteria,” written by Vincent Dachy, questions the necessity of keeping the term hysteria in discursive practices. He ends his brief chapter with a slightly confounding but creative schema “answering” the question of “who wants to do without” the term hysteria. He is also the author of the final chapter, “…As if I did not know… (Allurement)” which seems to not quite fit with the rest of the research-based essays, but provides a creative approach and interpretation of hysteria. He lists a series of questions out of a fictional “What kind of woman are you?” quiz, along with answers, but leaves it up to the reader to interpret how a creative endeavor like this works within the larger context of the book.

Geneviève Morel brings hysteria into the world of young adult novels in chapter five, “Fifty shades of literary success: the vampire’s appeal,” delivering a compelling chapter which relates hysteria to the young adult vampire craze and compares the Twilight series with the Fifty Shades of Grey trilogy. Her analysis is rooted in Freud and Lacan, but she provides a short sociological perspective on the young adult novels as well, adding a more comprehensive view of how the novels cope with sexuality, the Other, and feminine desires. Morel ends her chapter focusing on the reasons why the Fifty Shades of Grey trilogy was so popular, citing a “liberating effect” for women who read them as one of the main reasons for their success.

In chapter six, “Hysteria, a history,” Collette Soler discusses how hysterics are constantly creating stories, whether real or imagined, and those stories are told through the mouth as well as through the symptoms expressed. She remarks on Lacan’s view of hysteria as a “specific type of social bond” (86) that has three major elements of symptoms: “the hysteric, the other, and the other’s symptoms” (94). Throughout this chapter, Soler provides an interesting perspective of the hysteric and their relationship to society through well-researched analysis and case studies, mainly by Freud and Lacan.

In summary, this book presents a number of different arguments about how our view of hysteria has changed throughout time and details approaches in thinking about hysteria in today’s society. Although it strictly describes hysteria from a psychoanalytic perspective, this book is an excellent resource for anyone who is interested in hysteria or psychoanalysis. The variety of topics covered in each chapter are different enough that there is little repetition, but also gives a full scope of hysteria from a psychoanalytic perspective. This book adds valuable insight and extends the scholarship of hysteria into contemporary society, highlighting its history but also acknowledging the way hysteria is viewed today.

 

 

 

Film Review: Notes on Blindness

13 Jul, 16 | by cquigley

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Image courtesy of Curzon Artificial Eye

 

Seeing blindness in the eye:

Film review of Notes on Blindness, UK, 2016, directed by Peter Middleton and James Pinney

Currently in UK cinemas

Review by: Dr Khalid Ali, Screening room editor

Literary work exploring visual impairment and blindness has always been rewarded by great critical reception–All the light we cannot see winning the Pulitzer Prize in 2015 (https://en.wikipedia.org/wiki/All_the_Light_We_Cannot_See), and Blindness by Jose Saramago (https://en.wikipedia.org/wiki/Blindness_(novel) rewarding its writer with the Nobel Prize in Literature in 1998.

Documenting his experience with visual impairment, the late Emeritus Professor of Religious Education, John Hull (1935-2015) used audio-recordings since 1980, the year he lost his eyesight, to document what it means to be blind. His autobiographical recordings were published in the book Touching the rock: An experience of blindness in 1990. The film Notes on Blindness uses those recordings lip-synched by professional actors to recreate John Hull’s experience in one of the most poignant films to date in 2016. Through John’s words–‘I am concerned to understand blindness, to seek its meaning to retain the fullness of my humanity’–we hear him question eloquently the nature, perception, and impact of sensory deficits. Through his journey into understanding his ‘deep blind world’, the audience is invited to appreciate the significance of the little pleasures of life, such as the sound and smell of rain drops, and the touch of a newly born child. Using poetic references to children’s fairy tales, John Hull identifies with the blind Prince in Rapunzel, and wonders whether his tears will bring  sight back to his eyes.

John’s reflections on blindness present several themes for discussion, including mindfulness, hope, self-management in disability, identity, and family bonds. These themes are illustrated using a stunning collage of visual imagery, and a beautiful score that touches the audience’s heart and mind.

In spite of the film’s dream-like contemplation on life’s little miracles and wonders, Notes on Blindness effectively manages to portray the harsh realities of disability and the suffering endured by John and his family. His young son cannot understand what it means for his father to be blind; his mother is frustrated by having to connect with his new ‘self’, and the agony of missing his children’s smiles at Christmas. The fascinating depiction of a blind world of ‘isolation, and separation’ that drowns its sufferer in a huge flood is one of the most imaginative and moving scenes I have seen in film.

Notes on Blindness reminded me of the eminent Egyptian writer and educationalist Taha Hussein (1889-1973) who fought blindness from the age of 3 years to become the Dean of Arabic Literature (https://en.wikipedia.org/wiki/Taha_Hussein). Both John Hull and Taha Hussein had strong-willed wives who provided unconditional love and incredible support to their husbands to continue their respective academic pursuits.

Liberation comes in the form of knowledge and understanding, in acknowledging that it is futile not to accept facts and reality, and the realisation that ‘surrendering is death’. Using familiarity, predictability, finding one’s own territories, resilience and determination, along with inviting students into his world of theology, John regains control of his personal and professional life.

A great message that the film presents is the fact that ‘medicine as we know it’ cannot provide the answer to everything; the power of faith and spirituality are key to well-being and peace in humans. ‘Faith is a shield against the ups and downs of human life’.

‘Coming to terms with disability’ is an understatement in terms of describing Notes on Blindness. The film is an exciting journey into the world of a ‘pioneer thinker’ who ultimately ‘saw blindness’ as a gift to understand his world and the world around him. In 2003, John Hull was awarded the ‘Global love of life’ award for his international contribution to disability.

 

 

Address for correspondence: Khalid.ali@bsuh.nhs.uk

Recommended reading and listening

  1. The possibilities are endless- film review, http://blogs.bmj.com/medical-humanities/2014/10/27/dr-khalid-ali-stroke-music-and-love-a-review-of-the-possibilities-are-endless-film-5/
  2. https://soundcloud.com/bmjpodcasts/bringing-cinema-to-those-with-visual-impairment-reporting-from-the-panorama-of-the-european-film

“Embarrassing Bodies” – the male doctor/female patient encounter

12 Jul, 16 | by cquigley

 

From awkwardness to impropriety: conceptualising the male doctor’s embarrassing body in Victorian medical literature

By Alison Moulds (University of Oxford)

This post is based on a paper given at the “Embarrassing Bodies” conference, organised by Birkbeck, University of London

In 1858, Dr Edward Lane – owner of the Moor Park hydropathic establishment in Surrey – was named as co-respondent in one of the first divorce cases to be heard under the Matrimonial Causes Act. Henry Robinson, a civil engineer, alleged that the married Lane had committed adultery with his wife, Isabella, while she was staying at Moor Park as both a friend of the family and a patient. The events may be familiar to some as they form the subject of Kate Summerscale’s Mrs Robinson’s Disgrace (2012). Ultimately, the case rested on whether Isabella’s diary – which detailed apparently erotic encounters between her and Lane – was admissible as evidence (as the prosecution claimed) or discredited as the product of a delusional mind (the argument put forward by her defence). When Lane was dismissed as a co-respondent and brought back as a witness, he denied that anything untoward had taken place.

Widely reported in the national press, the case also attracted the attention of medical journals. Their interest was not simply that the man implicated was one of their own; the trial tapped into broader anxieties about the difficulties faced by practitioners in the course of their work. As it unfolded, there emerged key questions about the male doctor’s access to, and intimacy with, his female patients. The British Medical Journal branded the case “an extraordinary example of the dangers to which medical men above all others are exposed”. Deeming Lane “perfectly innocent”, it suggested the public would probably acquit him, but that the prospects of his establishment were likely to be harmed nonetheless.[1] In this editorial, medical men are represented as vulnerable to suspicion and innuendo is seen as having a potentially detrimental effect on their practice.

Interactions between male doctors and their female patients were often represented as sources of anxiety in Victorian medical writing. Professional journals and advice literature advised male practitioners how to guard against difficulties that may arise from examining or treating women. In an 1885 article entitled “The Relation of Medical Men to their Patients”, the Midland Medical Miscellany recommends that “[c]onfidential relations with ladies of a household” are “not only to be avoided, but to be absolutely declined” and that “examinations of female patients should always be made in the presence of a third person”.[2] Similar sentiments are espoused in Jukes de Styrap’s The Young Practitioner (1890), an advice manual for prospective medical men. It suggests readers should be “extremely cautious [….] in having married women or young females to consult you secretly – especially, if it be for vaginal, or other private examination”.[3] In cases where one needed to anaesthetise a female patient, he recommends having another practitioner present. Then, if the woman experienced “hallucinations in regard to improper language or action”, the doctor could “avoid scandal”.[4]

There was anxiety that the practitioner might fall prey to local gossip or even accusations of impropriety from family members. In 1887, the Provincial Medical Journal (the new incarnation of the Miscellany) ran an article entitled “Doctors and Lady Patients”, which explicitly engages with the problem of medical men being “made co-respondents in divorce cases”. While acknowledging such instances are rare, the article suggests they bring not only the individual, but also the wider profession into disrepute: “[s]uspicion is excited, and the confidential relations with our patients are disturbed”. To protect themselves, practitioners are warned against being too “attentive” towards female patients, for “medical men are closely watched by their clients”. [5]

Popular fiction at this time explored the way in which the young practitioner (particularly in the countryside or provinces) may become implicated in local love affairs, real or imagined. In Elizabeth Gaskell’s Mr Harrison’s Confessions (1851) the eponymous young doctor learns – much to his dismay – that his name has become attached to several women in Duncombe, earning him a reputation as a “gay Lothario”.[6] A darker instance of the doctor’s relations with women appears in Thomas Hardy’s The Woodlanders (1887). Dr Fitzpiers’s profession is shown to afford him both opportunities for infidelity and a ready alibi. When his fiancée spies his lover, Suke Damson, leaving his rooms early one morning, he convinces her she was simply an anonymous patient.[7]Intimacy between medical men and the young women of their acquaintance was not always problematised in fiction, however. The young country doctor repeatedly figures as the romantic hero, though he is rarely shown treating the object of his affections during their courtship.

As well as being associated with flirtation or adultery, even more serious allegations of abuse and misconduct could emerge from male attendance on women. In 1887, the British Gynaecological Journal featured a lengthy paper by C.H.F. Routh detailing cases of nymphomania in which women make “false charges” against their doctors. It presents the problem as systemic, noting “we are all prone, however innocent, to have such charges invented against us”. It interrogates how practitioners must “comport themselves” during encounters and, once again, discusses introducing a witness. The report’s chief concern is how men of “unimpeachable honour” can have their reputations ruined – it does not consider the possibility that the women might be telling the truth.[8] In articles such as this, it seems as though the medical press might have closed ranks to protect its own.

Where the evidence against them appeared irrefutable, however, the medical press did attack practitioners’ conduct. In 1858, the Lancet reported on “A Painful Scandal” concerning a Walthamstow-based surgeon called Richard Pilching. He had been found making written proposals of “the most filthy immorality” to a 13-year-old girl. The journal sought to distance him from the profession, arguing he had “mistaken his vocation”, and calling for him to be expelled by the General Medical Council (GMC). It cast him as a depraved predator, suggesting “his disgusting conduct” was “characteristic of the lowest and most vicious order of mind”.[9] By portraying Pilching as an aberration, the Lancet sought to uphold the image of the profession as one which was essentially honourable.[10] In my research, the journals’ engagement with improper or abusive conduct seems rare; instead interactions with female patients were more often conceived as potentially awkward or problematic.

The notion that male doctors or female patients might be embarrassed by medical encounters was a powerful argument in the hands of the medical-woman movement, which emerged from about the 1860s onwards. Aspiring female doctors and their supporters suggested that female patients would prefer practitioners of their own sex, since their modesty and delicacy would cause them to shrink from male attendance. In her essay “Medicine as a Profession for Women” (1869), Sophia Jex-Blake argues that “the unwillingness of very many girls on the verge of womanhood, to consult a medical man” causes “an enormous amount of preventable suffering”, and suggests some “ladies have habitually gone through one confinement after another without proper attendance, because the idea of employing a man was so extremely repugnant to them”.[11] She implies that male attendance is objectionable both for young women and their worldlier counterparts.

In response, some among the established profession argued for the essential purity and propriety of the male doctor-female patient relationship. In a debate about the admission of women to the profession held at the GMC in 1875, Andrew Wood – an Edinburgh-based surgeon – denied that female patients would prefer female attendance. “I have never found that women shrink from telling their ailments to me,” he insisted. In contrast, other Council members acknowledged the desirability of female practitioners. Dr Allen Thomson (representing the Universities of Glasgow and St Andrews) conceded that it was “incontrovertible that attendance on females by females is upon the whole more decent and appropriate”.[12]

The medical-woman movement capitalised on anxieties about male attendance, though it was careful to avoid impugning medical men’s conduct. Jex-Blake, for example, acknowledges “the honour and delicacy of feeling habitually shown by the gentlemen of the medical profession”. She emphasises that difficulties which may be of “no importance from [the practitioner’s] scientific standpoint” may be “very formidable indeed to the far more sensitive and delicately organized feelings of his patient”.[13] This demonstrates the way in which aspiring female practitioners deployed arguments around patient preference. However, as we have seen, even medical men adopting a “scientific standpoint” were often anxious about their attendance on women.

When discussing the role of embarrassment in the doctor-patient encounter, one usually thinks of patients demonstrating self-consciousness about their own bodies. While the female patient’s possible discomfiture was often recognised, Victorian medical discourse repeatedly grappled with the idea that the male doctor’s body might be a potential source of embarrassment or awkwardness as well. It was his contact with the woman – in private interviews or examinations – that needed to be negotiated. It was his physical presence which could be perceived as intruding upon the female patient’s body, intimate secrets, and private space. In order to protect his reputation, it was his actions that needed to be regulated.

The medical man’s presence was imagined as awkward but rarely as improper; while alert to the potential difficulties or dangers in treating women, medical commentators suggested that these could be contained or erased.

Such rhetoric was vital in order to sustain an image of the profession as honourable and gentlemanly. During this period, medicine (particularly the emerging field of general practice, which I have foregrounded here) was still divesting itself of its old associations with trade.[14] Whether medical discourse suggested female patients should be treated by medical men or women, an overriding concern was how practice could be rendered more respectable and genteel, more palatable to patients. Ultimately, attempts to navigate the embarrassment at the heart of the male doctor-female patient encounter reveal much about the professional anxieties of practitioners in this period.

 

References

[1] “Robinson v. Robinson and Lane”, British Medical Journal, 10 July 1858, pp. 561-2 (p. 561).

[2] “The Relation of Medical Men to their Patients”, Midland Medical Miscellany, 1 January 1885, p. 23.

[3] Jukes de Styrap, The Young Practitioner (London: H.K. Lewis, 1890), p. 110.

[4] De Styrap, p. 127.

[5] “Annotations: Doctors and Lady Patients”, The Provincial Medical Journal, 1 January 1887, p. 35.

[6] Elizabeth Gaskell, “Mr Harrison’s Confessions”, in The Cranford Chronicles (London: Vintage, 2007), pp. 1-86 (p. 77).

[7] Thomas Hardy, The Woodlanders, introduced by F.B. Pinion, with notes by David Lodge (London: Macmillan, 1993), p. 161.

[8] C.H.F Routh, “On the Etiology and Diagnosis, considered specially from a Medico-legal Point of View, of those Cases of Nymphomania which lead Women to make False Charges against their Medical Attendants”, British Gynaecological Journal, 11 (February 1887), pp. 485-511 (p. 487; 498; 501).

[9] “Medical Annotations: A Painful Scandal”, Lancet, 5 March 1859, pp. 247-8.

[10] In a subsequent issue, however, the Lancet published a letter from the surgeon’s solicitors which asked them to withhold any further commentary on the matter while legal action was pending. “Correspondence: A Painful Scandal”, Lancet, 12 March 1859, p. 278.

[11] Sophia Jex-Blake, “Medicine as a Profession for Women”, in Woman’s Work and Woman’s Culture: A Series of Essays, ed. by Josephine Butler (London: Macmillan, 1869), pp. 78-120, (p. 106; 101).

[12] “The General Council of Medical Education and Registration: Session 1875”, Lancet, 10 July 1875, pp. 55-63 (p. 57; 61).

[13] Jex-Blake, p. 82.

[14] See, for example, Anne Digby, Making a Medical Living: Doctors and patients in the English market for medicine, 1720-1911 (Cambridge: Cambridge University Press, 1994), p. 6.

 

Alison Moulds is a second-year DPhil English Literature student at St Anne’s College, University of Oxford. Working as part of the AHRC-funded project “Constructing Scientific Communities”, she is researching the construction of the doctor-patient relationship and the formation of professional identity in nineteenth-century medical writing, including fiction by doctors. She previously undertook her MA Victorian Studies part-time at Birkbeck College, University of London while working full-time in health policy and public affairs. She is Peer Review Editor for the Victorian Network journal.

 

Related articles and posts

HM Evans. Medicine, the body and an invitation to wonder. Med Humanities 2016;42:2 97102

Devan Stahl. Living into the imagined body: how the diagnostic image confronts the lived body. Med Humanities 2013;39:1 5358

Alan Radley. Book Review: The Cambridge Companion to the Body in Literature. http://blogs.bmj.com/medical-humanities/2015/07/15/the-reading-room-a-review-of-the-cambridge-companion-to-the-body-in-literature/

 

 

Book Review: Brett Kahr’s ‘Tea with Winnicott’

5 Jul, 16 | by cquigley

9781782414216_FC

 

Tea with Winnicott

by Brett Kahr with illustrations by Alison Bechdel. Published by Karnac, 2016.

 

Reviewed by Dr Neil Vickers.

 

Brett Kahr’s Tea with Winnicott is the first volume to appear in Karnac’s new ‘Interviews With Icons’ series, in which contemporary psychoanalysts conduct imaginary interviews with major figures from the psychoanalytic pantheon. Brett Kahr, psychoanalyst, Winnicott scholar and Winnicott’s first biographer, is first up with a sequence of ten riveting interviews with Donald Woods Winnicott (1896-1971), the paediatrician turned psychoanalyst who played a vital part in the evacuation of children during the Second World War. Winnicott’s legacy is arguably the most influential of any psychoanalyst from the English-speaking world. As I write, his paper on ‘Transitional Objects and Transitional Phenomena: A Study of the First Not-Me Possession’ first published in 1953 is the most popular journal article in Psychoanalytic Electronic Publications Online, which contains a huge proportion of all psychoanalytic papers ever published (n > 45,000). Indeed four of the top 10 articles are by him. Kahr knows the Winnicott archive inside out, having enlarged it considerably through his friendship with Winnicott’s secretary, Joyce Coles, and many of the statements attributed to Winnicott in this book originate in the great man’s writings, published and unpublished.

Ernest Jones, the St. Paul of British psychoanalysis, called Winnicott the first male child psychoanalyst. Kahr observes that he was also ‘the first proper media psychologist in Great Britain’ (187). From the 1940s onwards, he made radio programmes aimed at mothers and fathers, on child development, play, and the meaning of delinquency and adolescence. Many of these programmes were produced or commissioned by Isa Benzie for the BBC, who was struck by a phrase Winnicott used casually in conversation with her, ‘the ordinary devoted mother’ (she made it the title of his first radio series). In the 1960s he moved across to television. A handful of his books were bestsellers, notably The Child, the Family and the Outside World (1957) and the posthumously-published case history of The Piggle (1980), a little girl he saw from the age of two years and four months until she was five. His reputation took something of a battering in 2001 when it was revealed that Masud Khan, his trainee, colleague and editor, had abused some of his patients terribly and was routinely cruel. Some of these had been referred to Khan for treatment by Winnicott. More recently, though, Winnicott has become an important figure in popular culture, in no small measure thanks to the cartoonist Alison Bechdel, the illustrator of Kahr’s book, and whose bestselling graphic memoir, Are You My Mother? (2012) foregrounds Winnicott by naming each chapter after one of his concepts. The most common complaint levied against Winnicott’s thought is that he appears to have little to say about sex. This very reticence may have secured him admirers among those who feel they’ve had a raw deal from psychoanalysis on grounds of sex and sexuality. It is not irrelevant to remark that Alison Bechdel is a gay icon. She writes a widely-syndicated strip on lesbian and gay life called Dykes to Watch Out For. And more recently Winnicott has been extolled in the poet Maggie Nelson’s analytic memoir The Argonauts (2015), a book celebrating, inter alia, transexualism and non-normative sexuality.

Although Kahr tells Winnicott a little about his posthumous reputation (and asks for his views on the Masud Khan scandal), his book’s chief focus is on how Winnicott himself saw his work in relation to his life. A remarkably coherent picture emerges. Winnicott took house jobs in children’s medicine and psychiatry and his analysis with James Strachey which he began at the age of 26 enabled him to unite the two. Unlike most of his analytic colleagues, Winnicott saw thousands of patients at Paddington Green Children’s Hospital and at the Queen’s Hospital for Children in Hackney, quite apart from his analytic consultancy. Analysis showed him that children’s illnesses were often rooted in the parent-infant relationship but he remained acutely aware that psychoanalysis wasn’t the only way of treating children or indeed adults psychotherapeutically. Winnicott was most at home playing with children. When he started out, his assumptions about play were very much in line with those set out by Melanie Klein. Klein thought that the primary function of play was to manage anxiety. When a child plays, he expresses the state of the figures in his internal world (his parents, siblings, playmates for the most part but also body parts and functions associated with these). Optimally, through play, we learn to bring the figures in our mind together creatively. Winnicott enlarged Klein’s view by suggesting that the value of play lay in its power to liberate us from object relationships as well as draw us deeper into them. It begins in what he once called ‘the area of formlessness’, meaning the zone between internal, psychic reality and the external world. The creativity of play and its potential independence from the world of objects is what makes it so important. In his biography of Winnicott, Kahr suggests that Winnicott’s love of play stemmed from his idyllic early childhood when he was doted upon not only by his mother, but also two sisters and a large staff of female servants. They, Kahr suggests, supplied the blueprint for the transitional experience that Winnicott described so powerfully in his great 1953 paper.

With the outbreak of the Second World War, Winnicott found he had no patients. Rather than fleeing to the countryside or joining the Royal Army Medical Corps, he took a post as a psychiatric consultant in Oxfordshire and the surrounding areas, caring for evacuated children. Oxfordshire was one of the most billeted areas in the country. Kahr reveals that Winnicott surreptitiously arranged to transfer his most disturbed patients from Paddington Green to hostels in the county where he would visit them once or twice a week and ‘talk to them, draw with them, [and] simply be with them’ (97). It was around this time that he developed an ambition to talk to large numbers of parents about children’s needs. One of the first things he tells Kahr over a fictional cup of tea is that he (Winnicott) grew up in a psychologically illiterate age. His wartime broadcasts and contributions to progressive magazines such as The New Era in Home and School attempted to offer the lay person the rudiments of psychoanalytically-informed psychological understanding. Anyone who reads The Child, the Family and the Outside World or the broadcasts collected in Home Is Where We Start From will recognise Winnicott’s formidable pedagogical gifts. He could make the most abstruse psychoanalytical ideas sound like common sense. Wartime enabled Winnicott to flourish in other ways too. He met his second wife, Clare Britton, a psychiatric social worker, afterwards an analyst and senior Home Office civil servant. It was with Clare that he began the work that culminated in his great paper, ‘Delinquency as a Sign of Hope’. He tells Kahr that ‘marriage to Clare enabled me to become the theoretician of play and creativity, rather than just a theoretician of madness and breakdown and misery’ (182).

It could easily have gone the other way. In 1949, he published one of his most celebrated papers, ‘Hate in the Counter-Transference’ in which he described his reactions in the analysis of a psychotic woman he’d been treating for nearly twenty years. Winnicott said in that paper that he’d had to ‘reach down into very primitive areas’ of himself in order to treat that woman and that he found himself developing something akin to psychotic symptoms in his dreams. The woman eventually committed suicide. He tells Kahr that although he hated her for being so ill, he also ‘loved her deeply, in many ways like a daughter… the closest that I ever had to having a daughter really’ (121). He thought that his experience of hatred for his patient must have mirrored her mother’s experience and that she had become schizophrenic because of ‘environmental failure’.

Kahr has written wonderfully about this case in a long article and is currently writing a whole book about it. He tells Winnicott that psychiatry has become very anti-psychoanalytic in recent decades and that the Winnicott’s ideas about schizophrenia (that it was caused by environmental failure) had not been well received. Personally I would like to send Dr Winnicott some better news by pointing out that few researchers in the field of schizophrenia research today discount the power of environmental factors. Robin Murray’s group at the Maudsley have published scores of studies on the effects of gene-environment interactions. Seymour Kety’s classic studies from the 1960s of Danish twins who had been separated at birth took place in Winnnicott’s own lifetime. Kety reported a 1% incidence of schizophrenia in the population as a whole. Being brought up by an adoptive parent with a diagnosis of schizophrenia increased the risk to 3%. Having a schizophrenic biological parent if you are brought up in an adoptive household with no schizophrenia you will gave a risk of 9%. Worst of all, having a biological schizophrenic parent and being adopted by a schizophrenic parent pushed the risk up to 17%. The bio, the psycho and the social produce synergisms that are not reducible to the bio. And epigenetic studies on attachment show the same thing. Early experience switches different parts of the genome on and off, with lasting effects. The biological is just as often an epiphenomenon of the psychosocial as the other way around. The holding environment has its role, even if that term hasn’t caught on outside psychoanalysis.

The eighth chapter of Kahr’s book, or ‘Cup 8’ as it’s called, is entitled ‘A Crash Course in Winnicottiana’ and is masterly. In it, the reader will find limpid discussions of the differences between holding, handling and object presenting and the importance of ‘good enough’ parenting (parenting that is neither so good that the infant need not develop as an individual at all, nor so bad that that he cannot). Kahr writes beautifully about Winnicott’s sensitivity to the interaction between mothers and babies. Apparently, Winnicott once told the bookseller and publisher, Harry Karnac, that babies’ minds are like blotting paper (146). They absorb everything that is put in their way. When the baby learns to use his parent, he finds that the parent acts as the blotting paper that makes the baby feel safer. ‘And then we have health’ (147).

The matter of Masud Khan is held over until the ninth cup. Understandably, Winnicott suggests he and his interviewer move on to sherry. Although he has published at least one major article on the Khan-Winnicott psychodrama, Kahr uses this chapter to articulate what he imagines Winnicott’s defence would have been. Khan’s descent into alcoholism and bouts of psychosis occurred after Winnnicott’s death. The charge sheet Kahr puts before Winnicott is very mild: ‘you had an extra-analytic relationship with him and, thus, a lack of clarity, some might argue, about the purpose of your relationship’ (173). Winnicott expresses deep sorrow in reply but says he ‘cannot offer a complete explanation of what really happened to Masud. Partly because I do not know… I knew about Masud’s difficulties – at least those that had occurred during my lifetime! And I kept meeting with him to try and work it through. He might have been much, much worse off if he had not had the analysis’ (176). Khan has been much written about so perhaps it is right that someone should attempt to look at the scandal surrounding him from Winnicott’s point of view. But I think Kahr should have put to Winnicott some of the more trenchant claims made against him. It has been said, for instance, that he was himself a serial boundary-crosser, bringing some of his most disturbed or deprived patients into his home to live with him for months on end, listening to radio programmes with analytic patients in their sessions, practising regression therapies, and that he perhaps encouraged his disciple to take a similar ‘active’, non-analytic, approach. It has also been suggested (not least by Kahr elsewhere) that Winnicott was too dependent on Khan as his ‘secretary’ to have been able to see him clearly. Kahr doesn’t disguise the extent of Winnicott’s boundary-crossing. He just doesn’t mention it in relation to Khan.

It would be hard to imagine a more congenial and convivial introduction to Winnicott’s life and work than this timely book which deserves great success, especially amongst the young who are discovering Winnicott in ever greater numbers. All his dimensions are brought out with great skill: in addition to the clinical theorist, we meet Winnicott the concert-goer, opera-lover and pianist, the painter of hand-painted Christmas cards, even the poet. One of Winnicott’s compositions contained the memorable line ‘Oh God, may I be alive when I die!’. His wish has been granted in all relevant ways in this delightful book.

‘I am Book’ – Clare Best

1 Jul, 16 | by cquigley

Illustrated talk for University of Kent symposium

on Artists’ Books and the Medical Humanities, on 21 April 2016

http://www.kent.ac.uk/english/research/conferences/artistsbooks.html

I had been so looking forward to this wonderful symposium devised, designed and immaculately planned by Stella Bolaki, and to seeing the exhibition of Martha Hall’s and other book artists’ work  – which is still on until 14 August  (Prescriptions Beaney House of Art & Knowledge, 21 April-14 August 2016). Then I went down with a virus the day before the symposium and lost my voice overnight. Stella very kindly delivered my talk for me and showed the images that went with the words. Here is a potted version of my talk. See some of the images at https://selfportraitwithoutbreasts.wordpress.com/2016/05/26/illustrated-talk-for-university-of-kent-symposium-on-artists-books-and-the-medical-humanities-on-21st-april-2016/

As well as being a writer, I have worked as a fine bookbinder, a bookseller, an editor and a Creative Writing teacher. Throughout my life, making books has provided me with metaphorical and physical structures within which to reconstruct versions of my self, and body.

I am Book. A bold statement, but a pragmatic one. To a great extent we are all Book. We have our narratives, we talk of turning the page, or of starting a new chapter in our lives. We shelter, disguise or hide ourselves between covers. But I think I’ve always been particularly absorbed in the idea of books, of Bookness, and today I’m going to talk about why that is so, and perhaps my sense of Bookness might suggest things about artistic identity in general.

My father was a papermaker for his entire working life. As children, my brothers and I spent our Saturday afternoons at Dartford Paper Mill, where my father was then Manager. Our lives were full of paper samples and offcuts. I wrote on them, folded them into pamphlets and made childish books out of them from my earliest years. And I was an obsessive reader. It all began with the illustrated Golden Treasury of Poetry I was given for my 6th birthday. It’s still one of my most precious belongings. I feel a primal thrill when I open it. Most of the time, growing up, I had my nose in a book.

I went on to read English Literature at Cambridge, gathering along the way a passion for print and fine books, and after university I decided to become a book maker and book doctor – I trained as a Fine Bookbinder and loved working with fine papers, cloths, marbled papers, leather, vellum, gold leaf. But after nearly wrecking my eyesight with close work (gold tooling) I was obliged to change professional direction. I went to work for Tim Waterstone in the early 1980s when his bookshops were taking London by storm. In time I moved across from the art book department at the High Street Kensington store to working with Waterstones Publishing Division, first as a researcher, then as an editor. Later I was an editor for ten years with the French publisher Gallimard Jeunesse and their English language partner Moonlight Publishing.

I can see now that up to this point I was wanting more and more to inhabit Bookness – to read, to make and bind, to edit and publish and sell – but had not yet dared to jump into the very stuff of my identity, or identities – the writing itself. And, through the writing, to uncover the reasons for my Bookness in the first place.

So I see these stages of my life, up to my early 40s, as serial constructions, deconstructions and reconstructions of different versions of myself in the world, in efforts to find out what I was and where I belonged. I was creating and exploring a kind of library showing different aspects of my identity, or indeed different identities.

Since then, the past twenty years have represented a deeper and infinitely more satisfying deconstruction and reconstruction of my self, my selves, through writing and making Books that I inhabit from the inside, outwards.

I had always written, but the pressure to ‘come out’ as a writer built up through the 1990s and beyond. The latter part of this period then coincided with another pressure in my life, that of facing head-on my high risk of contracting the genetic breast cancer in my mother’s family. The result of this confluence was my first full collection of poetry, Excisions, which has at its core the autobiographical cycle Self-portrait without Breasts.

(Here I would have read a few of these poems, alongside showing some of Laura Stevens’ photographs which were taken in two shoots, the first a few weeks before, and the second some 18 months after, my risk-reducing double mastectomy.)

 

Self-portrait without Breasts

 

Tangled hair, charcoal-socket eyes,

mouth slack after one more long night

restless on my back. This body’s fenscape,

manscaped, hills removed – the meaty joins

still livid, tight shut mouths

where distant territories were stitched

 

in touch. Blood seeps in deltas over ribs,

yellow and purple track to the waist.

You’re even more beautiful now, you say

and I believe, for though I never was, I am

explorer, seeker – I’ve travelled

and I have an ear for truth.

 

Memento

 

When you cast me, I held my breath

as the plaster set. You kept your focus,

capturing the contours of my breasts.

 

Remember that awkward fold by the clavicle,

air trapped between layers, remember

my fear – that flesh could not be cast

 

to look like flesh. But now, when I touch

the rough white woven skin, I want to quit

my body, let the twin chalk rind

 

contain my breath, while I recall a lover’s kiss,

the heat of milk-tight flesh, my newborn

trying to focus as I held him.

 

How will I remember this?

Numb flesh stapled over ribs,

my breath snagged within.

 

Making the Self-portrait poems provided me not only with a way of working through and revisioning my experience of this trauma and its many repercussions, but also with a way of reconstructing my changed body into a body of work – and, metaphorically and literally, into a Book. Excisions has proved to be a key book in my development as a writer and in my personal growth – a milestone on my artistic journey. At the level of line and stanza, as well as at the level of physical object, I used poetic form to bring new order to my altered identity and to my sense of belonging both in terms of family history and artistic inheritance.

I later put together that very solo experience of writing the Self-portrait without Breasts poems with Laura Stevens’ before and after photos (in book/pamphlet form, as Breastless).

Since then I have returned several times to the Bookish concept of collaboration – through a site-specific theatre piece called Vacant Possession co-written with Sara Clifford in summer 2015, through a multimedia project Take Me With You: the museum of friendship, remembrance and loss, with the film-maker Tim Andrews, which was launched at BSMS in February 2016, through Springlines, a project with the painter Mary Anne Aytoun-Ellis in which we are exploring hidden and mysterious bodies of water across the South of England – and through a three-way collaboration to make CELL, involving my own long poem in twelve parts, Michaela Ridgway’s drawings and Katy Mawhood’s design.

This last project, CELL, had been many years in gestation before being published in its unusual ‘almost-pamphlet’ state in 2015, and in some respects it is – of all the books I have made – the one that most closely represents, in its themes and emotional content and in its form, my own earliest sense of identity.

The poem is a retelling of the story of Christine Carpenter, a girl of fourteen who was enclosed in an anchorite cell in 1329. She requested release after more than a thousand days of living in the cell, and did come out, only to be forcibly re-enclosed when the Bishop heard of her release.

I myself was sexually abused, and emotionally ‘locked away’ as a young child. I underwent many years of isolation, silence, shame and suffering before finding my way out of the cell and into healing.

(I would then have read out parts of an interview about CELL with Kay Syrad for the most recent edition of The Frogmore Papers.)

 

Kay Syrad in dialogue with Clare Best about CELL (Frogmore Press, 2015)

 

‘KS: Getting ready to read CELL, I found myself acting rather ritualistically: I cleared the table, placed the pamphlet parallel to the edge of it, carefully removed the wrapper, studied the cover and the printed burgundy paper sleeve, eased off the sleeve and finally held the pamphlet in my two hands. Standing up throughout, I read the poem until I came to the point where, following the diagram, I was to unfold the pages in a way that creates a paper ‘cell’. There could be no rush.

 

I think this is the closest I have come to genuinely embodied poetry: knowing there is a potential space within the form, waiting for it, creating it, reading the poetry within that confined space, unfolding the structure to a flat sheet and then refolding it into its pamphlet form – these experiences seem to me quite as emotionally significant as reading the poem. Would you agree?

 

CB: With CELL, I wanted the reader’s experience of content and physical form to be especially closely bound.

 

To write the poem, I’d researched what happens to the body and mind in situations of extreme privation such as enclosure in a basic cell over this kind of period. I wanted to emphasise the changes Christine would have lived through by achieving a physical form for the work which is several different things at once (pamphlet, paper sculpture, flat printed sheet) and which suggests alternations between different states.

 

The object’s form is designed to mirror the unfolding drama described in the poetry and the drawings. Early sections of the poem can be read by turning the pages, so far so relatively normal. Then the reader discovers the ‘cell’. Next they must open the entire sheet – making the ‘cell’ vanish and freeing its imagined prisoner – in order to find and read the last section of the poem. Finally, refolding the sheet into a pamphlet is like re-enclosing Christine or even burying her. Throughout, the reader is in some way complicit in the events of the poem simply by carrying out the act of reading.

 

KS: Your crystal clear, unflinching poem lives and breathes not only the pain of its subject, Christine Carpenter, but her heart-breaking effort to justify her pain – and in this way the poem speaks to every woman who knows the cultural and mortal price of imagined or projected ‘sin’. Clare, what precipitated the writing of CELL?

 

CB: I’d started thinking about the themes in CELL when I spent some intense weeks working with male life prisoners, witnessing the damage that separation and isolation can do to a person. And I know a lot, personally, about the damage inflicted on the self by shame. Finding and retelling Christine’s story presented an opportunity to write in a focused way about the double prison of isolation and shame.

 

CELL evolved slowly over a number of years when I was working on other poems and sequences and also on a prose memoir which explores relationships between daughter and father, daughter and mother. Christine’s mother plays an important role in CELL, although we never hear her voice. There are also male figures in the poem – the priest/father figure whom Christine watches through her cell window, the real or remembered or imagined Lucifer/rapist, and the Bishop. The mother’s absence, together with the ambiguous overlapping presences of these males, points to some essential but unspoken truth about Christine’s vulnerability. Today we would probably say that she was acting out a traumatic past. I am interested in how the ‘choice’ of extreme deprivation (still) can be framed as religious cleansing.

 

But in some ways I wrote CELL blind and it wasn’t until the poem was almost complete that I realised fully what it was about.

 

KS: The pen and charcoal drawings by Michaela Ridgway (who is herself a poet) also embody a claustrophobic intensity in the way they refuse to stay within their borders, at once hiding and exposing a female body that is tender and fierce, layered, smudged (almost erased), dark or clear. Can you tell us how this extremely effective collaboration began and how it developed into what we see here?

 

CB: I was finishing the umpteenth draft of CELL and beginning to think about how to send it out into the world, when I saw Michaela’s powerful and enigmatic drawings of female nudes which she was posting on Facebook. We met and talked at length. Michaela completely ‘got’ the poem and the layers of it, plus she agreed with my aim of wanting poem and art to work independently and together – this was no illustration task.

 

We talked about how we wanted words and images to complement each other, moods and feelings to bounce around between them. From this point, our work was to whittle down the choice of drawings, discover how to sit the images within or across the confines of rectangular spaces, and figure out where to place them in relation to the poetry in order to imply both incarceration and breakout, confinement and rebellion. We also wanted some significant blank space – with only a single folding sheet this was challenging, but we managed it!

At the same time that Michaela and I were thinking about all this, we were consulting the designer Katy Mawhood, whom I had commissioned. Katy had excellent ideas for placing Michaela’s art and my words in the context of the particular pamphlet form we had decided on. For instance, Katy’s suggestion for the lettering on the cover, where the C of CELL appears like a cap over the neck of a headless female figure, was daring. Michaela loved it and so did I. In fact, that C and the entire cover design encapsulate the power of word and image working in close harness.’

To finish, I’d say that for me and for my evolving identities, the idea of Bookness carries sacramental meaning.

Books, in all their forms and in all their manifestations in my life, have been my saving and my making, my containment and my freedom, my focus, my work and my relaxation.

I made my first books with my father’s discarded paper. Later – in training to be a bookbinder – I was preparing to rescue, restore and protect my own damaged and vulnerable yet resilient substance, my own Bookness. I was drawn to bookselling and publishing because they kept me in close contact with my life blood. But writing and imagining my own Books into being has been and is for me the most faithful and true expression of my identity/ies.

I like to think of my bookbinding skills, tools and materials as interchangeable with elements of my life and creativity. I start with flat sheets, I fold and sew and cut them into books, press them in presses, cover them, decorate them, leave them under weights. Like the surgeon or the tailor – as a writer, artist and maker of books, I keep my knives sharp, my eyes clear, my needles and tape measure close to me.

As a child I reached for what was closest and I made of the materials what I could, what I had to. I have continued to do this and I will do it all my life.

 

The bookbinder

 

Pare the leather, thin the skin

where it must stretch and crease.

Then paste: the tanned flesh darkens,

 

wet and chill, fingers working

over spine and cords, into joints,

mitreing corners neat and flat.

 

Bandage the book in paper, let it

settle under weights, day after day

until the leather’s dry and tight.

 

When the time is right for finishing,

black the room, clamp the book

spine up in the beech-wood press,

 

the lamp pointing where to begin.

Hot brass letters and a vigilant hand –

an accurate blind impression.

 

Paint in glair with a fine brush,

lay on gold leaf, with level breath.

Tilt the light, shadows will reveal

 

the place to press the tool again.

Now, strike the gold – feel the title

word by word, bright in the grain.

 

Clare Best is a poet and writer with particular interests in writing body and landscape. Her poems are widely published in magazines including The Rialto, The London Magazine, Magma, Resurgence, Agenda and The Warwick Review. A chapbook, Treasure Ground (HappenStance 2009), resulted from her residency at Woodlands Organic Farm on the Lincolnshire fens. Breastless – poems from the sequence Self-portrait without Breasts with photographs by Laura Stevens – came out with Pighog in 2011, and Clare’s first full collection, Excisions (Waterloo Press 2011) was shortlisted for the Seamus Heaney Centre Award. She teaches Creative Writing for Brighton University and the Open University, and lives in Lewes, Sussex.

www.clarebest.co.uk

http://selfportraitwithoutbreasts.wordpress.com

Kay Syrad’s website: www.kaysyrad.co.uk

 

Film Review: The Fugitive Doctor in ‘River’

30 Jun, 16 | by cquigley

 

‘River’, Canada, Laos, 2015, directed by Jamie M. Dagg

Screen_Shot_2016-04-27_at_18.26.59

Released on DVD and digital download on 18th July 2016

Reviewed by Dr Khalid Ali

Doctors and crimes of professional misconduct have been the focus of films such as ‘Coma, USA, 1978’, and ‘Shutter Island, USA, 2010’, while  doctors volunteering in NGOs in troubled zones were the subject of films such as ‘Sleeping sickness Germany, 2011’ and more recently ‘The last face, USA 2016’.

‘River’, a new Canadian film, combines the two themes in its storyline; John Lake ‘Rossif Sutherland’ is an American volunteer doctor in Laos who accidentally kills an Australian citizen in a drunken rage. In his attempt to flee the crime scene, John goes through a harrowing journey across the Mekong River. He tries to get the support of his fellow doctors in the NGO; one of them, Dr Stephanie (Sara Botsford) faces the moral dilemma of whether she should be a whistle-blower and report him to the authorities or should help him escape, while another doctor Douangmany (Douangmany Soliphanh) takes advantage of John’s desperation and uses him as a drug-mule. The loopholes in the legal system between Thailand and Laos give John an opportunity to escape prison. Struggling with his professional role as a doctor who should be saving lives, but an infallible human being at the same time, John approaches the American Embassy in Vientiane for help.

Public interest in doctors’ criminal offences fuelled the media exposure of extreme cases such as the notorious Harold Shipman, and the recent news of Dr Pramela Ganji who was convicted by New Orleans jury in a 34.4 million fraud scheme (1).

The film raises serious questions about the ability of the legal system to exercise ‘equity and fairness’ when operating in a foreign environment such as Laos that is not accountable to regulations set by Western professional bodies. The requirements set by the General Medical Council (GMC) and the British Medical Association (BMA) in England are clear in mandating a ‘code of conduct and practice’ that a doctor should declare a criminal conviction (2, 3).

In addition to its exploration of accountability and violations in healthcare professionals, the film works extremely well as a gripping action thriller winning the best film award at the Academy of Canadian Cinema and Television. Rossif reprises the role of a doctor in turmoil following in his father Donald Sutherland’s footsteps who played a doctor in the cult comedy MASH (USA, 1970).

‘Whistleblowing’ is another thought-provoking theme the film raises; Rodulson argues that reading and appreciating Homer’s the Iliad can support medical students’ understanding of ethical dilemmas (4). ‘River’ achieves a similar feat by portraying a challenging ethical and moral situation where a doctor is ‘trying to do the right thing’.

References

  1. https://www.justice.gov/opa/pr/new-orleans-jury-convicts-company-owner-and-doctor-roles-34-million-fraud-scheme, accessed Wednesday 29th June 2016.
  2. http://www.gmc-uk.org/guidance/ethical_guidance/21184.asp, accessed Wednesday 29th June 2016.
  3. https://www.bma.org.uk/advice/employment/contracts/criminal-record-checks-and-declarations/criminal-convictions-declaration, accessed Wednesday 29th June 2016.
  4. Rodulson V, Marshall R, Bleakley A. Whistleblowing in medicine and in Homer’s Iliad. Med Humanities 2015; 41: 95- 101.

 

Dr Khalid Ali, Screening room editor

Address for correspondence: Khalid.ali@bush.nhs.uk

Book Review: The Way We Die Now

28 Jun, 16 | by cquigley

 

O'Mahony_THE WAY WE DIE NOW

 

Seamus O’Mahony, The Way We Die Now. Head of Zeus, 2016.

 

Reviewed by Richard Smith

 

Perhaps the first and most important thing to say about this book is that it’s a joy to read. I started it on a flight from Dhaka to Mexico City when I was exhausted, but quickly I was deeply engaged and read it for the last two hours of the flight. When I was eating alone I chose it rather than my E M Forster novel. “But isn’t it depressing?” asked a friend. “Not at all,” I answered, “it’s a joy.” Most books a medical journal sends you to review may be packed with wisdom, but they are a labour not a joy to read. (I might add, as a committed Kindle reader, that the book is also physically beautiful, even including a ribbon as a bookmark, a splendidly old fashioned delight.)

Seamus O’Mahony has written the book using his own extensive experience of people dying in acute hospitals and the experiences of friends and family, but the best parts of the book may be his critical accounts of thinkers—like Phillipe Ariès and Ivan Illich—who have gone before and his witty analysis of the deaths of various celebrities, including Susan Sontag and Christopher Hitchens, both sceptics who fought death beyond what was sensible.

I hope that when I die that I have a doctor like O’Mahony to look after me, a doctor who is deeply conscious of the many failings of medicine and his own fragility. He tries all he can to avoid The Lie, giving the false impression that a dying person is not dying, and he calls together patient, relatives, and nurses to have the Difficult Conversation, the discussion when he tells patients that they are going to die. “It is much easier,” he writes, “in the middle of a busy clinic, to order another scan than to have the Difficult Conversation.” And “The entire modern hospital system conspires against those doctors willing to have this dialogue: the relatives, the chaos and noise of the environment, the techno-juggernaut of modern hospital care, the customer-friendly doctors who are happy and willing to dole out false delusional hope, and sometimes the patients themselves, who may not want to hear what the doctor has to say.”

The last clinical medicine I did was in an oncology ward in New Zealand, and I was left feeling that I’d completely misunderstood my medical education. I thought (and this was 1978) that patients with metastatic cancer, most of those in the ward, were close to death. But nobody mentioned death. The patients were all making plans for the future, the doctors were irrepressibly optimistic. O’Mahony “confesses” that he is an oncology, “schmoncology” “apostate” and quotes the Lancet Commission that “cancer treatment is becoming a culture of excess.” (The use of religious words is important because O’Mahony, brought up as a Catholic, agrees with Illich that modern medicine is becoming a global religion.)

The core of O’Mahony’s argument is that death is a bloody business and always will be. It is, as Henry James calls it, “the distinguished thing” that cannot be tamed or controlled, and the concept of a “good death” is a fantasy dreamt up by palliative care physicians, who offer deluxe dying to the few. Most people die in acute hospitals, which have become “a dustbin for all sorts of societal problems, not just dying” and are places of “filth, torture and death, a sort of antechamber to the tomb.” Dying well in such places is virtually impossible, and anyway “The needs of patients seem to come a poor second to those of the staff and the institution….much of modern medicine is characterized by a culture of excess and dishonesty, and this culture ill serves the dying.” People are poorly prepared for dying, and even the fashionable idea (of which I’m a victim) that “To philosophise is to learn how to die” is so much nonsense. None of us know how we will react when we learn we are close to death, rendering advanced directives absurd. And the move to assisted dying is a vain attempt to strip death of its “awesome grandeur.” Doctors, he complains, are “the whipping boys for our inadequate understanding of how we die.”

E M Forster would seem largely to agree with O’Mahony: on the day that I read The Way We Die Now I also read this in Howard’s End: “Sane sound Englishmen building up empires, levelling all the world into what they call common sense. But mention Death to them and they’re offended, because Death’s really Imperial, and He cries out against them for ever. Death destroys a man: the idea of Death saves him. Behind the coffins and the skeletons that stay on the vulgar mind lies something so immense that all that is great in us responds to it. Men of the world may recoil from the charnel house that they will one day enter, but Love knows better. Death is his foe, but his peer, and in their age-long struggle the thews of Love have been strengthened, and his vision cleared, until there is no one who can stand against him.” [If like me you didn’t know the meaning of “thews” it’s “the muscles and tendons perceived as generating strength.”

Wisely, O’Mahony doesn’t venture into love, but I think he’d be sceptical of the poetic notion that love can conquer death.

O’Mahony is a “doctor’s doctor” insofar as he resent the intrusion into the doctors’ space of lawyers, politicians, managers, evidence based medicine, guidelines, personalised medicine, narrative medicine (“which provokes mockery and contempt for its smugness”), shared decision making, informed consent (“a legalistic fantasy”) and worthy but empty platitudes from royal colleges, medical schools, medical journals, and the like. He believes, for example, that there is no good way to break bad news, although he concedes that there are bad ways, which does mean that there are better, if not good, ways. Medicine has, he believes, become a service industry rather than a profession. He seems as well to be in constant battle with patients’ relatives insisting that every last thing be done for their dying relatives—but he recognises that this folly comes not simply from families but from medicine and doctors having helped create unrealistic aspirations. He quotes Kieran Sweeney, a doctor who wrote about being diagnosed with mesothelioma: “When is enough enough? This will be the defining question for the next generation of practitioners.”

He raises but does not explore what medicine is for, writing “I obstinately cling to the notion that a doctor’s role is limited: our job should be the treatment of illness.” Are doctors not to be about promoting health and preventing disease? And what about relieving suffering? Some argue that that is the true role of the doctor, recognising that suffering and illness are not the same thing. Taking O’Mahony’s notion literally would imply, which he surely didn’t intend, that once the doctor could no longer treat the illness (not the patient, note) he would hand over the dying person to somebody else. In fact, he believes, as I do, that caring for the dying patient is the job of all doctors not just palliative care physicians. Perhaps he can explore what medicine is for in his next book.

“The default setting of modern medicine is full intervention,” writes O’Mahony, “unless you are instructed otherwise.” This might be the starting sentence for a chapter arguing in favour of advanced directives and assisted dying, but in fact he’s strongly against both. His argument against advanced directives is simply that we cannot know how we will feel about dying until we arrive at the day when we know it’s close, so an advanced directive is meaningless. I have an advanced directive which I’ve emailed to my wife and children, and like most doctors I think at this stage that I don’t want anything heroic. I doubt that I’ll have the courage to forego all treatment like Ivan Illich, but I find the prospect of morphine and whiskey much more attractive than chemotherapy. I accept that I may think differently when the day comes, and if I’m conscious and in my right mind then the advanced directive won’t be needed. If, however, I have, say, a stroke, then I may well not be conscious. In those circumstances it is what I think now that is relevant—even if I would have thought differently if conscious.

His argument against assisted dying seems to be an objection to control. He does not rehearse the arguments for and against assisted dying but rather objects on almost poetic or religious grounds. It is an affront to “the distinguished thing” to try and control it, and people are behaving like God in trying to control death. He writes almost cruelly about Marie Fleming, an Irish “right to die” campaigner who took her case to the Supreme Court and became “something of a national heroine.” She had, he writes “an obsession with control” and her time in court “gave her ‘the voice she always craved.’” Had she succeeded in her case then “she would have altered forever the way in which I practice my profession.” O’Mahony may retire before it happens, but it seems to me that assisted dying is going to become routine eventually just as abortion has. We can trace its steady appearance around the world, including most recently in Canada.

I’m not sure why O’Mahony should object so strongly to control. I imagine that he is in control of most of his life–and very glad that he is. He was presumably in control of getting married, choosing his profession, and determining how he would spend his spare time and energy. The problem seems to be with trying to control death—partly because it never can be controlled. We will all die—and thank goodness that we will—and we can’t control that, although many are trying. But we can potentially control how we die. O’Mahony does not write about suicide, but presumably he accepts its legality. He’s no doubt read Hume’s famous essay making the case for suicide. There are several arguments against assisted dying, but I don’t accept O’Mahony’s argument that trying to control death is unacceptable.

O’Mahony writes approvingly of “tame death,” a termed coined by the French historian Phillippe Ariès. In pre-industrial Europe tame death was characterised by “indifference, resignation, familiarity, and lack of privacy.” None of those—except perhaps resignation—are likely to return, and O’Mahony thinks that we are unlikely to be able to fashion a secular version of tame death—because “death is tamed by ritual.”

But is he right to be so sceptical? He’s surely right that death in an acute hospital is unlikely ever to be anything but mostly bad. But does death have to happen in hospital? And does death have to belong to doctors caught up in what he calls “the madness…[of] much of modern medicine”? O’Mahony advises that “A wise person needs to acquire and treasure an amicus mortis, one who tells you the bitter truth and stays with you to the bitter end.” That amicus mortis could be a doctor, but it need not be—and even if is the doctor does not have to be in the hospital. We are seeing the emergence of doulas for the dying, lay people and a modern version of amicus mortis.

It’s a pity that O’Mahony does not write about the social movements—like Dying Matters in England and Good Life, Good Death, Good Grief in Scotland or the community programme in Kerala, India—that are trying to bring death back into life and demedicalise it. Perhaps he would be scornful, but, as his book convincingly shows, doctors have made a mess of death—perhaps lay people, assisted by doctors, can do better.

 

Related articles and posts:

Neil Vickers. Book review: At the end of life: true stories about how we die. Med Humanities 2012;38:2 122123

F Brennan. ‘As vast as the world”–reflections on A Very Easy Death by Simone de Beauvoir. Med Humanities 2004;30:85-90

Robert C Abrams. Book review: The Violet Hour: Great Writers at the End. http://blogs.bmj.com/medical-humanities/2016/06/10/the-reading-room-the-violet-hour-great-writers-at-the-end/

Wellcome Book Prize Winner 2016 – ‘It’s All In Your Head’ reviewed

23 Jun, 16 | by cquigley

It's All in Your Head

 

Suzanne O’Sullivan, It’s All In Your Head: True Stories of Imaginary Illness. London: Vintage, 2016; first publ in hardback 2015 by Chatto & Windus

Reviewed by Professor Edward Shorter

The very subtitle of the book makes one nervous: “stories of imaginary illness.” If there is one phrase that psychosomatic patients – who have symptoms without lesions ­– do not want to hear it is that their problems are “all in their heads.” Even though O’Sullivan may use the phrase ironically, it does take us back to the days when discovering organic causation was the Mecca of medical practice and psychiatry was left to “the shrinks.” Of course things are more complicated, and O’Sullivan, a neurology consultant at the National Hospital for Neurology and Neurosurgery knows this well. The book does make some finer distinctions so that “all in your head” doesn’t come out and hit us in the face. But still, O’Sullivan says that “psychosomatic refers to physical symptoms that occur for psychological reasons . . . How many are aware of the frequency with which our emotions can produce serious disability where no physical disease of any sort exists to explain it?” So in other words the origin of such symptoms is clearly psychological. These patients amount, she says, to fully a third of the cases seen in general practice and in neurology.

The book is a kind of odyssey of patients O’Sullivan has seen whose problems seem to have been caused by mental distress – a tour interleaved with explanations of historical figures such as the Parisian neurologist Jean-Martin Charcot, who once peopled this scene.

O’Sullivan has gone to such lengths to obscure the patients’ actual identities that one is never entirely sure whether the “Paulines” and “Matthews” that parade through these pages are more fictional than real – though their complaints are real. And O’Sullivan, it must be said, writes beautifully, a low-key golden flow of prose that makes the book simply a good read. There are no references. No authorities are invoked. This is the author, a veteran neurologist, speaking to us from the heart.

But is what the heart says true? How reliable is her analysis that psychosomatic symptoms are “physical symptoms that mask emotional distress”?

Right off the bat, there are problems with this stress-causes-functional-illness model. There are several major causes of psychosomatic symptoms, some of which get short shrift.

One, O’Sullivan tells us about classical psychosomatic symptoms that are caused by “stress” or by the emotional overlay of underlying organic disease. Her patients’ emotional woes are apparent to her in the course of many clinical interviews, and she ends up referring many of them to a “psychiatrist.” This is the most useless referral imaginable, as psychiatrists shun and fear psychosomatic patients and can usually do little for them because the patients themselves reject the whole notion of “psychogenesis”; patients usually accept such referrals only with the greatest reservation, convinced – not entirely incorrectly – that they are being turfed.

Two, O’Sullivan is silent about a huge source of psychosomatic illness, namely the phenomenon of suggestion. Patients who can be suggested into illness require no deep psychological problems, no intractable “stress,” to become symptomatic. They simply are suggestible.

A perfect illustration of suggestibility is epidemic hysteria: Sally begins vomiting and suddenly all the ten-year-olds in the schoolyard start vomiting as well. The public health authorities rush in. There is alarm in the press. An organic cause is never found but everybody is better the next day. It is an epidemic of suggestion that has invested the schoolyard.

The culture can be a source of suggestion as well, a subject on which O’Sullivan is silent. The culture can tell us that “fatigue” or “pain” are acceptable models of presenting illness, and these patients turn up in physicians’ surgeries with “myalgic encephalomyelitis” (ME), known as “chronic fatigue syndrome” (CFS) on the other side of the Pond. They do not in fact have an occult organic illness called “ME” but have suggested themselves into their chronic pain, fatigue and dizziness because the culture says those are appropriate symptoms. (And the culture has largely ceased to sanction “paralysis” as a convincing symptom – too easy to disprove with a negative Babinski.)

Three, frank psychiatric illnesses may spin off somatic symptoms. Patients with melancholic depression will light up the medical charts like a Christmas tree. Their aches and pains are legion, and disappear once the melancholia – one of the most treatment-responsive illnesses in psychiatry – is successfully treated. Catatonia shoots off somatic symptomatology, the stupors, tics and stereotypies often misdiagnosed as organic disease and the catatonia not recognized. Why does this matter?Catatonia is another highly treatment-responsive disorder, but there’s nothing “psychosomatic” about it. In medicine, therefore, the concept of psychosomatic can get one into rough psychiatric water.

It is striking that O’Sullivan sees deep sadness as a source of psychosomaticity rather than as a symptom of glaring psychiatric psychopathology. “I have met many people whose sadness is so overwhelming that they cannot bear to feel it,” she writes. Yoo hoo!  Such melancholic patients are indeed candidates for psychiatric treatment, not for repeated neurological assessments.

There is, finally, a fourth variety of apparent “psychosomatic” illness. But it is quite foreign to the other three and is usually not included in reviews of the topic. It is malingering. One rather has the feeling that some of O’Sullivan’s patients –  their gaze strictly averted from hers, their long silences – were malingerers. (She presents one.) You can’t prove that someone is not fatigued, or not in pain. But you can prove that they don’t have multiple sclerosis or another upper motor neuron lesion. So malingerers choose symptoms that can’t be disproven. And many physicians who work, for example, in insurance medicine, cast a cynical eye upon many of the complaints that O’Sullivan takes for true-bill.

How best to treat these patients? O’Sullivan has good words for a procedure that has largely passed from medicine, namely the amobarbital (amytal) interview. But it is increasingly seen as outmoded and dangerous (the barbiturates have undeservedly acquired a bad reputation, and most physicians are simply not in the habit of prescribing them).

O’Sullivan believes in letting the patients have it full blast: Your “disability has a psychological cause.” Sorry. The patients are left open-mouthed, since virtually every psychosomatic patient in the history of the world has had a profound belief in the organicity of his or her woes. And even though we have exalted “never lying to patients” to a beacon of medical ethics, in fact there are moments when a bit of evasion may prove therapeutic.

“Shahina” comes in with a contracture of the fingers of one hand. Another consultant recommends a botulinum injection. Bingo! The contracture releases instantly. Shahina is cured! Now, usually you take your therapeutic victories where you can get them. But O’Sullivan presses on. She tells Shahina that normally the botulinum works only after a day or two. “The speed at which your hand responded to the toxin makes me wonder if there is a chance that the spasm in your hand might have had a psychological rather than a physical cause.”

Shahina responds, “You think I’m mad?” No, of course not but…

This is actually a model of what not to do: throw patients into confusion with the relentless urge to enlighten them about their supposed psychological problems.

For other patients, as I have argued above, the psychiatrist is held out as the solution of choice. This is a problematic idea, and it is dismaying to see it propagated so vehemently in these pages. Psychiatrists tend to be baffled by such referrals. “This is a patient whose chief complaint is chest pain? C’mon!”

The general internist, the rheumatologist, or another neurologist should be the physicians of reference, because only they are able to build the necessary therapeutic alliance, to keep the myth of organicity semi-intact. It is this myth that patients require to retain their self-respect, while the real therapy takes places in the context of the doctor-patient relationship. What actually works is spending a lot of time with these patients and letting them tell and, if necessary, retell their stories. This is cathartic. But it is advice that is most unwelcome to many clinicians because it takes so much time.

It is not really fair for me to second-guess Dr O’Sullivan from the comfort of my armchair thousands of miles away. Physicians on the front line of medicine, at Queen’s Square and elsewhere, have to cope as best they can – and with relatives that make Himmler seem like Santa Claus. (O’Sullivan’s patience in dealing with these furies is remarkable.) The take-home message is that the book is a great immersion in psychosomatic problems. One may quibble about some of the author’s therapeutic choices but this is for the Thursday afternoon seminar room. If you want to get a head-on feeling for the clinical experience of psychosomatic patients, read this book.

 

Edward Shorter is Jason A Hannah Professor of the History of Medicine in the Faculty of Medicine of the University of Toronto, where he also has the academic rank of Professor of Psychiatry. Among his books is From Paralysis to Fatigue: A History of Psychosomatic Illness in the Modern Era (New York: Basic Books, 1992)

 

 

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