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By Marshall Marinker
Contact the author by e-mail at christopher.johnstone@ntlworld.com

Professor Marshall Marinker gave the annual Fulton lecture at Glasgow Medical School on wednesday 22 October 2003. We reproduce two sections of it here. The lecture was of course conceived as a coherent whole, and that the detached pieces should be read as†passages that were meant to resonate with all of the other (missing) material. Also, that the text was designed as an oral performance and not as a piece to be read on the page. The whole lecture and sources can be found at www.hoolet.org.uk/39hoolet/marinker.htm and at www.marinker.com preferably to be read aloud.

Three Cultures.

I begin my story with an unremarkable consultation³. The patient is a 55 year old man. He is unemployed, - probably now unemployable; separated from his wife; living in a downtown hostel. He’s shabby; his fingers are stained tobacco brown; it is ten in the morning and there is a smell of drink on his breath. The notes read: ‘chronic obstructive airways disease; drinking; depressed; two serious overdoses’. The young woman doctor asks about his symptoms and revises his medication. No mention of cutting out the fags and booze. She knows how meagre are his life’s gratifications. What alternative solace does she have to offer? She is about to go on holiday. ‘I’ll see you in three weeks.’ she says.

Hardly the stuff of grand opera. She hands him a prescription just as he gives vent to a wracking bout of coughing and wheezing. Inconsequentially he says: ‘I saw you with your children yesterday. They’re growing up fast’. His eyes fill with tears: ‘She’s told me she won’t ever have me back’, he says. This is old news. The doctor is running late. Another banal consultation? I will come back to this later.

In 1959 the novelist and savant CP Snow lamented that by and large arts and science graduates were ignorant of each other’s worlds, and that thus a deep schism had opened up between the two major components of Western Culture⁴. His use of the term ‘The Two Cultures’ struck a deep chord with academics and politicians, and came to dominate our thinking about higher education. Snow later identified a third culture, the social sciences, which he thought was similarly dislocated from the other two.

Ten years later, when a group of us sat down to write what became ‘The Future General Practitioner’⁵ we were challenged to yoke these three cultures together. It soon became clear to me that the problem was to find a common language.

My parents were immigrants: they came to London from Warsaw via Berlin and Paris. In my mother's kitchen they spoke at least three European languages. Unselfconsciously they would switch between all three in the course of any everyday domestic exchange. Perhaps it was simply carelessness, but I like to think that they sensed that some things could be better expressed in the inflected meanings of one tongue than in another. Each of the languages reflected something unique in their own history, in their personal migrations, in the stories of their families, in the landscapes of their moods and imaginations.

As a small child I saw nothing strange in all this. I simply thought that they were speaking one single language - I imagine that I thought that it was English. This was not a bad guess. Compare the word count of the OED with any other European dictionary. There is a fabulous richness of words. From Early English onward, we traded grammatical precision for the nuanced diversity of every one else’s words. The Academie Francaise seeks to preserve the French language behind a locked belt of linguistic chastity. English, in contrast, is a hot blooded harlot of a language: she embraces all the others. Later, I came to understand that this was also true of the language of clinical medicine.

Jacob Bronowski in his 1964 essays Science and Human Values⁶, contrasted the language of the sciences and the arts. The language of science is single valued: its terms must be precise and unambiguous. The word ‘mercury’ stands for a chemical element; it refers to its atomic weight, the pre-determined dances of its outer shell electrons. There can be no resonance, for the physicist, with ‘mercury’ the evening star seen at sunset; with the Roman god of merchants who sports wings on his sandals. Bronowski says that such multiple meanings belong to the language of the arts. In this language the word ‘mercury’ stands simultaneously for all its possible meanings - physical, chemical, cosmological and mythological.

In just this way the general practitioner’s use of the term ‘chronic obstructive airways disease’, is rich in its references and semantic overtones. It conjures up at one and the same time the cunningly concealed social trap that fatally pinions her patient in its jaws; the changes in his bronchial tree; the self destructive solace that he seeks; the dwindling cardio-respiratory reserve; the dwindling effectiveness of medicines; the look of desperation.

Writing in 1923 TS Eliot⁷ lamented that, since the 17th Century Metaphysical poets, poets like John Donne and Andrew Marvell, something regrettable happened to English poetry. For three centuries thereafter, with few exceptions, English poets either felt, or thought. They hardly ever managed to do both at one and the same time. He called this a ‘dissociation of sensibility’. Here is Marvell on the tantalizingly unbridgeable space between lovers:

As Lines So Loves oblique may well
Themselves in every Angle greet:
Buts Ours so truly Parallel
Though infinite can never meet.

Therefore the Love which us doth bind
But Fate so enviously debars,
Is the Conjunction of the Mind
And Opposition of the Stars....

Marvell employs the 17th Century new sciences of physics and astronomy to examine 'The Definition of Love’ just as the general practitioner today might employ the new sciences of physiology, biochemistry, pathology, genetics, psychology and sociology to examine the never completely definable ‘what is wrong’ with her patient. And more than this, both the enquiry and the language of the conclusion require something more than the technical. It surely denies the fully human to abjure the disciplines of textual exegesis, of aesthetics, of metaphor and wit, to ‘dissociate our sensibilities’, in coming to an understanding of ‘what is wrong’ with the patient, and ‘how we know it’.

And there is another compelling reason for advocating the poetics of general practice. The writer Susan Sontag writes that what novelists and poets do best is to sponsor reflectiveness, to pursue complexity. ‘Information’ she says, ‘will never replace illumination’. General practitioners know this. It is what they do best.

At school I learned that German nationalist critics carped that because the poet Heinrich Heine was not a pure German, he was not capable of writing decent German poetry. Rather, they complained, Heine writes French love lyrics in the wrong language. In similar vein we general practitioners can be thought by our specialist critics to be writing medicine in the wrong language. I have always thought Heinrich Heine to be the patron saint of academic general practice. At about the time that I began drafting this lecture, I came across the following by the Palestinian writer Edward Said. In his essay ‘Reflections on Exile’ he writes: “Most people are principally aware of one culture, one setting, one home; exiles are aware of at least two, and this plurality of vision gives rise to awareness of simultaneous dimensions, an awareness that, to borrow a phrase from music, is contrapuntal”⁸. It struck me that Said’s sense of exile, and of a contrapuntal life, are the common and necessary conditions of clinical general practice.

The Doctor & The Patient.

In the early 1960s I was engaged in a self important but ill-fated study of the way in which members of families might, in the patterns of their consultations, reveal some sort of meta-family-pathology. This almost mystical hypothesis was too far out to be mentioned in polite academic society. More in hope than expectation I was employing some of the bog standard typologies of epidemiology - age/ sex/ social status/ morbidity and so on. In the end my data were meaningless. They were like the cast in the Pirandello play - characters thrashing about looking for an author who would give their story some meaning. I was about to discover my author.

Some time in the late 1930s Michael Balint arrived in England as an ÈmigrÈ from Hungary, where a fascist regime had made the professional life of its Jewish intellectuals, and by association the practice of psycho-analysis, all but untenable. I joined Balint’s group in 1963. It was a secular epiphany.

To be accepted into his research group we were obliged to undergo a preliminary hour long interview. As I left his room he put an arm around my shoulder: ‘Marinker’, he said, ‘this will be your kind of work’. He smiled: ‘After all, you are little bit crazy’. I was flattered. Only later in the day did I reflect that this was a diagnosis by the then President of the British Psychoanalytical Society. I was to spend the next seven years in weekly thrall to his intellect, his wit, his uncanny understanding of human nature, and his merciless honesty.

Let me give you a flavour of those days. Quite early in the research, I recounted the case of a sixty year old bank clerk who presented with dramatic stroke-like symptoms for which no physical cause or consequence could be found. In the course of very many hour-long consultations I performed the most spectacular archaeological dig into his personal history. I uncovered a destructive relationship with his father, an unconsummated marriage, and many other treasures. Throughout all this my patient’s symptoms were gradually getting worse. He was sinking slowly into a depression. My psycho-therapy was clearly meeting some pretty determined resistance, and I was now looking for guidance.

I spoke for twenty minutes. The group, impressed by the depth of my psychological archaeology, heard me in awed silence. Balint’s comment, in an accent as rich as any Hungarian goulash, was laconic: ‘Marinker has engaged us’, he said. ‘with his usual thoroughness, his eye for detail, his search for the significant. And he has, how shall I say it, he has bored us all sick’. He turned to me: ‘Perhaps this is what you are doing to your patient’. Years later, when I left the practice for the university, this same patient came to say farewell. He wanted to thank me. “I couldn’t face things then.”, he said. “But now, your words come back to me, and I can move on”. I couldn’t resist touching for a moment, and at long last, the pure gold I must have stumbled upon during my long voyage in his unconscious. “What was it ?” I asked. “It was the way you said “Come on now Tom. For God’s sake man, pull yourself together”.

Throughout Balint’s classic text The Doctor, His Patient and The Illness¹⁸ there is no reference to Freudian terms or theories - apart perhaps from his signature tendency to prefer sexual explanations. He thought that generalist clinicians should steer clear of diagnosing or postulating psycho-pathology.

In his 1982 study 'Freud and Man's Soul', Bruno Bettelheim¹⁹ describes a serious inaccuracy in translating Freud's work from the original German into English. His English translator, Ernest Jones, had rendered Freud's use of 'Psyche' as 'mind'. As a consequence, in the anglophone world, psycho-analysis was captured by psychiatry. But the intelligentsia of Vienna and Budapest, for whom Freud wrote, would have known full well that Psyche was the lover of Eros: that she was a beautiful young woman with the wings of a butterfly. ‘Psyche' means both butterfly and soul in classical Greek culture, as it does in many others. It does not mean mind.

Bettelheim’s thesis - that Freud was concerned not with psychiatry but with Man's soul - throws a clearer, I would say a healthier, light on what I argue has been the positive Freudian influence on our clinical thinking. When we seek to make a so-called triple diagnosis, the general practitioner’s compilation of ‘what is wrong,’ we are simply exploring ‘meaning’ - the sense that the patient is making of the illness in the context of her life. This is what Sontag called ‘illumination’. <%@LANGUAGE="VBSCRIPT" CODEPAGE="1252"%>

hoolet is the magazine of RCGP Scotland. It is supported intellectually, financially and emotionally by RCGP Scotland.

This issue maintained by Robert Hallam.