Acad Psychiatry 31:5-7, February 2007
doi: 10.1176/appi.ap.31.1.5
© 2007 Academic Psychiatry
Classical Psychiatry, Literary Sensibility, and the Art of Medicine
Mark Leibo, M.D.
Received November 17, 2005; revised January 20, 2006; accepted February 3, 2006. Dr. Leibo was affiliated with the Department of Psychiatry, New York University School of Medicine, New York, New York at the time this article was written. Address correspondence to Dr. Leibo, 3700 Inverrary Drive, Suite C7, Lauderhill, FL 33319; markleibomd{at}yahoo.com (e-mail).
In keeping with the dictum of John Keats (1) regarding "beauty and truth," many experts (2) in the mathematical or "hard" sciences have cited the elegance of a formulation as a good signpost on the path to determining its ultimate scientific value.
In conjunction with their identity as clinical sciences, medicine in general and psychiatry in particular fall under the rubric of the "soft" disciplines of the humanities which address the elusive subject matter that involves a dimension of experiential and behavioral factors. Paradigms within this group differ greatly. However, in each of these fields, Keats’ dictum has a particular relevance. To avoid the overly simplex and superficial, some degree of aesthetic sophistication is important.
Classical psychiatry has often been denigrated as being "merely descriptive." This critique ignores the insights into the human condition as it relates to illness that are inherent in the "descriptions" of medical and literary masters of medicine whose formulations are based on the medical model. This model is a paradigm or conceptualization of illnesses, from the mildest to the most severe, as particular entities with dynamisms of their own.
In the epilogue of his book, Freud as an Expert Witness, K.R. Eissler (3) expresses the view that in giving exact descriptions and classifications of the phenomena of mental disturbances, classical psychiatry is characterized by an aloof disregard of what Eissler refers to as the "human factor." In a similar psychoanalytical vein, Edward Nersessian (4) states, "Neo-Kraepelian reductionist ideas really explain nothing about the complexities of the mind." And the psychiatrist J. Allen Hobson (5) titles his recent book, Out of Its Mind: Psychiatry in Crisis.
The focus of classical psychiatry, however, has never been the "mind." Classical diagnostic formulation of psychiatric disorders must be viewed in the context of the cornerstone medical paradigm, the concept of illness. The great writing in this tradition is associated with such giants as Addison, Parkinson, Liveing, Gowers, Kraepelin, and Bleuler. In our own time, the work of Oliver Sacks has drawn on this heritage. From their richly textured, exquisite clinical descriptions of finely drawn particularities and nuances in remarkable prose style, the nature of diagnostic entities and their dynamics or patterns of process are illuminated, including vulnerability, prodrome, onset, severity, natural history and course of exacerbations and remissions, phase and prognosis—all components of the medical "verstand." Classical psychiatrists’ particular calling as physicians is to identify, understand, manage and, where possible, contribute to the prevention of the process of illness. To the extent that the physician’s medical orientation is replaced by another perspective, he no longer approaches his subject in terms of his special calling, experience and expertise. The intrinsic therapeutic efficacy of medical consultation in every specialty, what Lewis Thomas (6) has eloquently called "the healing property of the physician’s presence," is largely determined by the patient’s faith in the physician’s experience, familiarity with, and knowledge of the look, feel, sound, smell, and progression of disease process—in other words, the physician’s "understanding" of what we once called "clinic."
Every illness presents an experiential and behavioral overlay of mind-body, body-mind units involving commonly observed and atypical components and interactions, and in practice classical psychiatrists must make use of insights from the biological, psychological, and social sciences, each with its own models and perspectives. But the classical psychiatric model remains the medical model and has, in turn, something to contribute to these other disciplines. Nersessian (4) is correct when he remarks, "Our [psychoanalytic] nosology and the psychiatric nosology are different." And Eissler (7) makes the valid point that Freud’s psychoanalytical formulations are in keeping with a psychological as opposed to a medical verstand.
In the ethos of psychiatry in the mid-20th century, the order of the day was for a young psychiatrist to become a "psychoanalytic physician." That term is, in essence, an oxymoron. One can be either a psychoanalytic psychologist or a psychiatric physician. Because the best of Freudian writing is aesthetically substantial (it is well known that Freud was recommended for the Nobel Prize in literature), its insights into aspects of human mentation have an enduring significance. The "psychobabble" of lesser Freudian and neo-Freudian contributions is insignificant because of their aesthetic shallowness.
The aesthetic sophistication of the classical medical exemplars of the art of medicine is akin to that available to us in the work of great literary artists, many of whom have addressed medical issues from a classical medical perspective. When Thomas Mann (8) and Aleksandr Solzhenitsyn (9) write on tuberculosis and cancer, respectively, in The Magic Mountain and Cancer Ward, their vocation coincides in large measure with the physician’s. Emerson’s widely quoted remark that the poet is the only true doctor is one of those partial truths that is worthy of our attention.
Philip Roth (10) has the author-critic protagonist of his book, My Life as a Man, complain in a humorous manner that in seeking an "explanation" for his migraines, his own formulations and those of his army psychiatrist seemed transparent and simplistic, far too tidy and facile to endow his predicament with a design as dense as that in which Thomas Mann had pursued the issue of tuberculosis in The Magic Mountain. The reader suspects that the matter is one of fundamental concern to Roth. All sensitive artists have wrestled with this general question, and it is an issue that must be of fundamental concern to the classical psychiatrist as well. Consider the following brief, exquisitely condensed exposition of the experiential and behavioral overlay and mind-body particularity of one type of obsessional migraineur.
From Aleksandr Solzhenitsyn (11), Lenin in Zurich:
[An early imprisonment] No accidental setback, no dirty underhand trick on the part of your enemies is ever as galling as your own miscalculation, however slight. It nags at you day and night, especially in a prison cell. Because it is your own mistake, you cannot be objective about it, cannot live it down or forget it, cannot get away from the thought that it need never have happened! It need never have happened! But it has happened because of your own bungling. The blunder is all yours! Pace the flagged floor from wall to wall, toss on your creaking wire bed for eleven long nights—you will not get away from it, you will not sleep it off. It nags and burns like an ulcer. It need never have happened! You put your foot in it! ...
[Zurich, years later] The libraries which were between five and seven minutes away at average walking speed all opened at nine o’clock, but today he was driven out of the house forty minutes earlier, stupidly, humiliatingly fleeing from that shaggy-headed ragamuffin with the colossal appetite, Zemlyachka’s nephew, so as to spare himself, to avoid impertinent chatter which might enrage him and ruin his whole day...to listen to a gush of pseudointellectual drivel, a pronouncement on every subject to show he had opinions, to elucidate fundamental questions, and always in the same aggressive, know-it-all fashion.
These visits, that knowing, superior smile on the face of a milksop, made Vladimir Ilyich ill for the day. In general any unexpected upset to his daily routine, especially an uninvited and untimely guest, any pointless waste of time so exasperated and unsettled him that he was incapable of work. Nothing was more vexatious than expending his nervous energy and his cogency of argument not at a conference, in a pamphlet, in debate with an important party opponent, but, for no good reason, on a lout who did not even mean what he was saying.
But the emigre world had its own code of behavior and you are defenseless against such visitors—if you shut the door malicious tongues would wag. You would be instantly accused of arrogance, lordliness, overweening conceit, "leaderism," dictatorial pretentions—so that whenever one of these impudent rogues saw fit to leave Russia—you must not only welcome him but invent something for him to do.
And the disease which sat inside him, ever watchful, would suddenly make its sharp corners felt, like a stone in a sack...
He felt it in his temple, while his disease grew heavier, fitfully stirring and nagging inside. It made not a sound, entered into no disputes, but no opponent was more powerful.
He sat at the library table. Piles of books. Piles of newspapers... the reams, stacks, pillars of paper he had read, scanned, written in his years as an emigre.
When he was young, the scent of imminent revolution was fresh in the air. The path to it seemed simple and short...a time of happy expectancy.
But these last ten years, since his second emigration, had been filled, stuffed, packed tight with—what? Nothing but paper-envelopes, packets, newspaper wrappers, routine letters, express letters....You exchanged articles in outline, proofs, criticisms, corrections, reviews, abstracts, points for discussion, excerpts from the press, newspapers by the cartload, sometimes issues of your own journals, which never got beyond the first few numbers—and all the time you suspected that none of it was serious....In a life of constant agitation, twisting and turning, his whole achievement was to fight his way onto an impossible rubbish heap.
His arms dangled limply, his back would not straighten, and he felt utterly played out. It was no good. His work would not take shape. His heart had gone out of his routine and left a hollow. His head was beginning to ache....
You were gripped by a dread—you would never break free of it! There was no escaping that head....The disease had crept and crept through the secret passages of destruction. Just one wormhole is enough to bring the whole statue of health down in ruins.
But a protective cover of half-dead resignation settled around him.
The critic Helen Vendler draws our attention to a quote from the pen of Yeats (12), who wrote that great poems make us see "as though a sterner eye looked through our eye." And R.P. Blackmur (13) noted, "We are concerned with the feeling for an image, the sense of an idiom; the quality of which may be asserted only tentatively by what seems to be the disciplined experience. Here criticism is appreciation."
In their endeavors to understand and manage those illnesses they are called upon to address as physicians in the treatment of their patients, classical psychiatrists of our day may rely on the medical and literary masters of medical formulation to remain their best guides in continuing efforts to hone clinical acumen in their "humane and learned" (14) discipline throughout their professional lives.
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REFERENCES
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- Keats J: Ode on a Grecian Urn, in The Poems of John Keats. Edited by Stellinger J. Cambridge, Mass, The Belknap Press of Harvard University Press, 1978
- Feynman RP: Quoted by Wald G, in Of Literature, Science and Shared Mysteries: Excerpts from Library of Congress Symposium on Science and Letters, November, 1981 - Ideas and Trends. New York Times, November 29, 1981
- Eissler KR: Freud as an Expert Witness. Madison, Conn, International Universities Press, 1986
- Furer M, Nersessian E, Perri C (eds): Controversies in Contemporary Psychoanalysis - Lectures from the Faculty of the New York Psychoanalytic Institute. Madison, Conn, International Universities Press, 1998
- Hobson JA, Leonard JA: Out of its Mind: Psychiatry in Crisis. Cambridge, Mass, Perseus Publishing, 2001
- Thomas L: Medicine as a very old profession, in Cecil Textbook of Medicine, 16th ed. Edited by Wyngaarden JB, Smith LH. Philadelphia, Penn, WB Saunders, 1982
- Eissler KR: Medical Orthodoxy and the Future of Psychoanalysis. New York, International Universities Press, 1965
- Mann T: The Magic Mountain. Translated from the German by Lowe - Porter HT. New York, Alfred A Knopf, 1967
- Solzhenitsyn A: Cancer Ward. Translated from the Russian by Bethell N, Burg D. New York, Farrar Straus & Giroux, 1969
- Roth P: My Life as a Man. New York, Holt Rinehart & Winston, 1970
- Solzhenitsyn A: Lenin in Zurich. Translated from the Russian by Willetts HT. New York, Farrar Straus & Giroux, 1976
- Yeats WB: Quoted by Vendler H: Review of a book of poetry, The Fall of America: Poems of These States, 1965-1971, by Ginsberg A. New York Times, April 15, 1973
- Blackmur RP: Language as Gesture. New York, Harcourt Brace & Co, 1935
- Smith LH, Wyngaarden JB, Thomas L: Medicine as a learned profession, in Cecil Textbook of Medicine. Edited by Wyngaarden JB, Smith LH, 16th ed. Philadelphia, Penn, WB Saunders, 1982
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