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Archive for July, 2009

I’ve just read Muriel Rukeyser’s The Life of Poetry (ISBN 0-96381-833-3). An extraordinary book.

Here is the paragraph which hit me right between the eyes. Here’s where she hits the nail, squarely, on the head….

If our imaginative response to life were complete, if we were fully conscious of emotion, if we apprehended surely the relations that make us know the truth and the relations that make us know the beautiful,we would be….what? The heroes of our myths, acting perfectly among these faculties, loving appropriately and living with appropriate risk, spring up at the question. We invented them to let us approach that life. But they remind us of our own lives. They offer us a hope and a perspective, not of the past in which they were made – not that alone – but of the future. For if we lived in full response to the earth, to each other, and to ourselves, we would not breathe a supernatural climate; we would be more human.

It’s hard to put this in other words, but her insight into the value of imagination, of being aware of our emotional responses, and of how our relations to ourselves, others and to the rest of nature is the key to becoming fully human is fabulous.

What do we become if we develop such a FULL response to LIFE? Heroes. The heroes of our own myths. And THIS is how we gain both perspective on life and hope for the future.

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eryngium

Eyrngium

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Got up this morning on the first day of my holiday and see what I saw when I looked out of the window…
sunflowers

After breakfast I went for a closer look….

sunflowers

sunflowers

sunflowers

sunflowers

sunflowers

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Completely by chance I stumbled on the Prince of Wales’ lecture on BBC1 last night. You can read the transcript of his speech on his own website.

I liked what I heard. I thought it was an interesting and an intelligent speech. I know a lot of people criticise him for his views but I didn’t find anything significant to disagree with in this speech. Here’s a couple of paragraphs which will give you the gist of his argument……

So, Ladies and Gentlemen, we may well be told that we live in a “post-Modernist” age, but we are still conditioned by Modernism’s central tenets. Our outlook is dominated by mechanistic thinking which has led to our disconnection from the complexity of Nature, which is, or should be, equally reflected in the complexity of human communities. But in many ways we have also succeeded in abstracting our very humanity to the mere expression of individualism and moral relativism, and to the point where so many communities are threatened with extinction. Facing the future, therefore, requires a shift from a reductive, mechanistic approach to one that is more balanced and integrated with Nature’s complexity – one that recognizes not just the build up of financial capital, but the equal importance of what we already have – environmental capital and, crucially, what I might best call “community capital.” That is, the networks of people and organizations, the post offices and pubs, the churches and village halls, the mosques, temples and bazaars – the wealth that holds our communities together; that enriches people’s lives through mutual support, love, loyalty and identity. Just as we have no way of accounting for the loss of the natural world, contemporary economics has no way of accounting for the loss of this community capital.

The idea that we need to re-think our relationship to Nature by accepting we are an integral part of it, rather than separate and apart from it is, I believe, crucially important. The failure to grasp the complexity of life, reducing it to something simplistic, is harming us. We need to be aware of the dangers of radical materialism and simplistic egocentricism.  The mechanistic and consumerist model is failing us, as the economic and environmental crises are revealing.

He is right to emphasise the need for sustainability and diversity rather than consumption and uniformity.

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A study by psychologists has looked at the common recommendation found in self-help books – affirmations. You know the kind of thing…..where you are encouraged to repeat over to yourself phrases like “I am a lovable person”, or “I accept myself completely.”

What they found was that in people who had high self-esteem, these affirmations helped them to feel slightly better, but in those who had low self-esteem, the affirmations made them feel worse!

As the authors concluded, “Repeating positive self-statements may benefit certain people [such as individuals with high self-esteem] but backfire for the very people who need them the most.”

As I’ve said before, one size fits all interventions are not what they claim to be. They don’t fit all at all!

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I’ve just read Passions and Tempers, by Noga Arikha (ISBN 978-0-06-073116-8)

I expect you’re familiar with the four terms, melancholic, choleric, phlegmatic and sanguine. They might not be everyday words any more but they’re certainly still common enough currency for most people to have at least some idea what they mean. They are, of course, the four temperaments, each of which is expressive of one of the four humours. Noga Arikha is a historian and this book is astonishing in its range. She begins way back in the sixth century BC and traces the idea of these humours from then right up into present time. I found the book totally absorbing and convincing, not just because of the fascinating story of both the persistence and the development of this ancient idea, but because of the meta-narratives……what this particular history tells us about what it is to be human, what it is to be a physician, and how strong ideas can evolve with the expansion of human knowledge rather than be destroyed by that process.
The book is divided into seven main sections (and given Noga’s deep familiarity with cultural rhythms and divisions, I wouldn’t be surprised if this very structure wasn’t a nod towards the seven ages of Man!). Each section describes the humours in a period of history from antiquity right up to the end of twentieth century. Before I read this book I thought the humours were an interesting extinct idea, and it was the invention of the thermometer in the 17th century which did for them. I understood that when the body temperature of a choleric was compared to that of a phlegmatic type and found to be the same, that the theory was discredited. I now know that analysis was not only simplistic, it was wrong! I also thought that the autopsies performed in the great 16th and 17th century Parisian Public hospitals made the morbid anatomist the great medical authorities and turned illness from being a holistic imbalance, to being a physical disease which could be seen, touched and measured in the body (see The Anatomy Lesson of Dr Tulp) That too turns out to be way too simplistic an understanding.
Humoural theory was indeed a holistic one where the proportions and flows of the humours within a person were thought to be connected to, or influenced by, the environment in which that person lived, which was, in turn, intimately connected with the movements of the Cosmos. The humours themselves were invisible but there were plenty of theories created to explain their behaviour and significance. Dissections and, horrifically, vivisections performed back in third century BC not only developed our understanding of anatomy, but by both failing to show any humours, and by providing alternative, observable explanations for illness, began a train of thought which was indeed to take off in the 17th century with Descartes’ separation of the body from the mind, and in the 18th century with Julien-Offray de la Metrie’s description of Man as a Machine (L’homme-machine) becoming the dominant mode of thought in scientific medicine right up to the present day.
However, as Noga Arikha shows so clearly, the humours as a concept, (as opposed to humours as material entities), still help us to understand the body and the mind as one, not two, and to seek to explain the links between the various parts of the body and the mind. The fact that such modern ideas, as described by researchers in “psychoneuroimmunology”, and philosophers and neuroscientists who discuss the embodied nature of the mind, has such ancient roots is quite breath-taking.
As she says in the introduction…..

….there was a continuum between passions and cognition, physiology and psychology, individual and environment.

Even in Hippocratic writings we read…

every part of the body, on becoming ill, immediately produces disease in some other part.

and

Men do not understand how to observe the invisible through the visible.

Let me just share with you two features of ancient practice which I found highly thought provoking and relevant to current medical practice.
From the sixth to the second centuries BC Asklepieia were the temples of the healer who became a god, Asklepios. One particulary famous one was in his birthplace, Epidaurus. A sick person would have a stay in one of these Asklepieia (which were healing centres, or spas). On admission they would have a ritual bath, then settle to sleep in an area known as the “abaton”. Every morning they would discuss their dreams with the priests, and they would receive water treatments, herbs and even, if necessary, surgery. The lucky ones would be visited in their dreams by the “drakon”, a healing snake which would cure their wounds with its tongue. The patients were encouraged to write down their experiences and their case records became the basis of medical learning which the priest/healers used to develop their treatments.
I find many aspects of this quite fascinating. Don’t we still need such places of healing, where patients can be cared for (maybe we don’t use water treatments and bathing enough these days!), and where, not only can they share their dreams, but are encouraged to record their experiences of care so that health care professionals, and other patients, can learn from them? What strikes me about this story is how the focus was on health, not disease, and how the individual’s subjective experience was central to the care.
The second story which similarly provoked my thinking was captured in these two passages –

A learned doctor was one who had primarily read many books, rather than treated many patients.

Doctors could treat only symptoms that corresponded to cases which records or histories existed already.

The dominant current model is medicine is called “Evidence Based Medicine” and “evidence” is primarily published research. It stuck me as I read the first of those two sentences, that nowadays, those who claim authority in medicine are typically those who have read many articles, rather than treated many patients! Indeed I am often amazed at the pronouncements of professors who claim to know the best way to treat patients but who are not clinically active with real patients.
The second sentence stimulated two thoughts in my mind. The first was recalling what Dr Harry Burns, Chief Medical Officer of Scotland once said about his concern with the way “Evidence Based Medicine” was being used, and that was where was all the innovation to come from, if we only allowed the practice of what we already knew? The second was how difficult it is for many doctors to accept the reality of illnesses which don’t fit the models already described – chronic fatigue syndrome, and, fibromyalgia, being just two of the obvious ones.
So, I found this book stimulating and enlightening. It is a GOOD read and I think it has the potential to deepen any health care professional’s understanding of health and healing.

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In Noga Arikha’s excellent Passions and Tempers, A History of the Humours, (ISBN 978-0-06-073116-8) she traces the history of the concept of the four humours, blood, phlegm, yellow bile and black bile, across cultures and centuries. Early in the book she describes the great library in Alexandria in the third century BC. The library was part of the Museion, a real hothouse of learning and research in the city founded by Ptolemy I Soter. What I hadn’t known before about this great academy completely shocked me. Ptolemy authorised not only human dissections of cadavers, but also the vivisection of condemned criminals.

Vivisection perhaps seemed cruel and gruesome, but, he wondered, was it really so terrible to hurt a small number of criminals for the sake of finding cures for the long term, and for a large number of good people? Whether the Ptolemies used such a justification or not, anatomical knowledge sprouted from the flaying of outlaws.

That paragraph stopped me in my tracks. Can you imagine? How does a person motivated to do good by reducing the suffering wrecked by disease, get to the place of justifying the live dissection of a human being? I know it was a different culture and a different Age, but what horrified me about this story was the appalling reduction of a person to, well, a piece of meat.
But then, I’m sure you’d be quick to point out to me, such awful cruelty has far from vanished from this Earth. There are plenty of reports of torture, mutilation and murder in the daily newspapers. But it was the context which really struck me. Maybe I’m naive, but I’ve always assumed that at least one of the motivations of physicians is compassion for those who suffer. But surely those Alexandrian physicians must have completely switched off their compassion to treat other human beings this way? Surely someone like Mengele, to give an example closer to our own lifetimes, was an abhorrent exception?
There are many aspects of this issue we could explore but the main thought which occurred to me as I pondered this tale, was how the reduction of a person to a mere body seemed to be a key characteristic of this behaviour. In that light, how much more important is it for us, to maintain a holistic engagement with those who are sick, and not reduce them to only material, physical bodies?
We physicians are not technicians of the body, we human beings struggling to understand and help other human beings.
We are all more than mere bodies.
We are conscious, sentient beings; heroes not zombies.

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In this week’s BMJ there is vociferous criticism of a recent article which advocated treating everyone, yes everyone, over 55 with antihypertensives irrespective of their actual blood pressure. The authors claimed that this would be a good way to reduce heart attacks and strokes. There were a number of excellent criticisms of this suggestion and in their right to reply the authors rebuffed the claim that this would medicalise everyone over 55 with this statement –

Offering treatment to all above a specified age regardless of blood pressure does not “medicalise” people because they do not become “patients” with a medical diagnosis, but telling people they have “hypertension” does medicalise them.

Pardon? A person doesn’t become a patient unless they are given a medical diagnosis, but if they are treated with a drug they are just a person?? I’m sorry, but I don’t follow that logic.

Imagine my surprise when after putting down my BMJ I came across this quote in one of Montaigne’s essays –

…among all my acquaintance, I see no people so soon sick, and so long before they are well, as those who take much physic [drugs] their very health is altered and corrupted by their frequent prescriptions. Physicians are not content to deal only with the sick, but they will moreover corrupt health itself, for fear men should at any time escape their authority.

That’s from Montaigne’s Essais written in 1580!

I’m with Montaigne…..a medicated life is not something to aspire to! (I’m also pretty fed up with so called experts telling me they know what’s best for ME!)

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