The architecture of the mind

Repeats its love, Mavisbank

Chapter Eight: The architecture of the mind[1]

After the Batty Tukes, there was a succession of Superintendents for Mavisbank (although it was still called New Saughton Hall.) Dr Samuel Rutherford MacPhail, described as ‘a man of singular beauty,’ was Superintendent between 1928 and 1930. Macphail was a loyal son of Skye. He knew its songs and stories, and was learned in its Gaelic language and traditions. In his younger days Macphail was a good Rugby forward. He played for EdinburghUniversity and the Greenock Wanderers. He retained his interest in the game to the last, and used to be seen frequently supporting his old school or university on a Saturday afternoon. Late in life he became an enthusiastic member of the Edinburgh Medical Curling Club. [2]

Figure 1: Mavisbank restored to Clerk’s vision in 1954 by Dr Bill Harrowes

In 1931 Dr James Humphrey Skeen was appointed as the eighth Superintendent. He came to New Saughton Hall from Stirling District Asylum, Larbert. An Aberdeen graduate he started as assistant to Sir John Macpherson at Larbert in July 1890. In July 1897 he reported on the sedative and hypnotic effects of Sulphate of Duboisin.[3] He recommended it as a treatment for acute mania but not for melancholia, making the quiet qualification: “that he had taken a small dose himself, and he found the effects most disagreeable!” In July 1901 whilst reporting to the Medico-Psychological association Dr Skeen was chastised for providing a table of causation that was ‘not very clear and not very useful.’[4] In 1931 he presented a case from New Saughton Hall that looked like neuro-syphilis, but for the absence of Argyll-Robertson pupils (pupils that accommodate but do not react.) Dr Skeen argued that the quick response to stramonium indicated that this was a case of encephalitis lethargica.[5] Dr Skeen died suddenly, after doing his morning’s work in January 1933, and the Institution was again without lead.[6]

Dr Skeen was not the only psychiatrist trained in Larbert to end up living on the Esk. Dr William Wotherspoon Ireland, of a previous generation of medics, had retired to Mavisbush after serving for ten years as Medical Superintendent of the Larbert Institution for Imbecile Children. You will recall that Mavisbush in the century before had been the recuperative home for Thomas De Quincey. Dr. Ireland was the son of a publisher in Edinburgh, studied in the University there and in Paris, and entered the East India Company’s service as assistant surgeon with the Bengal Horse Artillery shortly before the Mutiny broke out. After seven months service, when doing his duty like a hero, he was shot in the head; the bullet entered and destroyed the eye and passed out behind the ear; at the same time a bullet entered his shoulder and lodged in his back, this was afterwards extracted by the surgeons. It was a year before he could leave his bed, three years before he could undertake the voyage home, and ten years before he could enter on further professional work. From the beginning Dr. Ireland showed a capacity for literature, general and professional. He had an individuality in his appearance, laugh, walk, and character. He was never carried away by new theories at once, and indeed, even as to facts that professed to be new he always took the position that they would have to be confirmed before they took their place in medical science.[7] Showing that he could write to the point, one of his books was excluded from circulation in Russia because he had painted too true a picture of Ivan the Terrible in the Blot on the Brain.[8]

Figure 2: The Blot on the Brain – by Dr Wotherspoon

It is ironic that given two central themes carried in this manuscript on Mavisbank: – architecture and personhood – or biology and being – or matter and energy, that the quotation I dislike most is ‘the architecture of the mind’ by Steven Pinker.[9] By now, no doubt, you will be following the direction of travel. This last chapter, voiced through the warm humanitarianism of the last Superintendent of Mavisbank, Dr Bill Harrowes, will explain why Pinker is preposterous in his metaphor worthy only of Dawkins.

Dr Bill Harrowes the last Superintendent of Mavisbank served the Institution between 1933 and 1954. According to his son David he did not like the name ‘New Saughton Hall’ and from the outset he restored the name to Clerk’s Mavisbank. [10]

Figure 3: Dr Bill Harrowes

I never met Dr Harrowes in life. However you can see in Bill Harrowes’ eyes the sort of kindness that appears both in his writings and the aspects of him that his son David must partly embody. Bill Harrowes studied under Meyer at John Hopkins and throughout his career returned to the truth espoused by his mentor “We study the whole man and his setting, and not only the parts of man.”

When Dr Harrowes published his 1951 Book: The Human Personality and its Minor Disorders, the reviewer for the Lancet, William Moodie said dismissively:

“Although the late Adolf Meyer never wrote a book to embody his teachings, his pupils have repaired the omission. Of these none is more faithful than Dr Harrowes. The author gives the impression of being thoroughly sensible rather than penetrating, safe and wise but not particularly illuminating; if his oracle is not sibylline or deceitful, neither is it far removed from what ordinary men say when called into counsel.” William Moodie [11]

Figure 4: Adolf Meyer

However when you realise that this, the 1950’s, was the beginning of the cellular age, and that Dr William Moodie was not just a physiologist but an impatient neuropathologist with a self confessed hatred of theory, then it can be read more as his need to dismiss rather than a considered commentary. Time has proved Moodie wrong, and whilst biology has advanced much, mankind is at last realising that we are not simply mannequins of selfish genes, operating out-with family, environment and history. It was greatly heartening to read the review of one of Roy Porter’s last works: The Greatest Benefit to Mankind by medical student Benjamin Hope of University College London.[12] Benjamin had wondered if Porter could garner insight from 3000 years of medical history without subverting to agenda, whiggish or otherwise. Benjamin, surely a rare youthful gem, concluded rightly that Porter succeeded where others have failed in trying to understand our medical past without, as Edward Shorter does, passing judgement on them. Benjamin concluded his review with a Roy Porter moment that deserves re-print: “The medicalisation of life could never have become entrenched had not the offerings of practitioners … become accepted as desirable and beneficial.”

It is curious to me why intellectual thought is sometimes not recognised in the age in which it was reasoned. Even in this short manuscript, and restricted largely to Edinburgh, we have examples of those unappreciated in life: David Hume, James Clerk Maxwell, Reverend Allison, and so forth. The digital age is now helping in this by making works and thoughts more accessible, and perhaps at last, limiting the growing specialisation and sub-specialisation not just of medicine but of science generally. Bemoaning the ills of overspecialisation by doctors in his essay The Seven Sins of Medicine, published in The Lancet in 1949, Richard Asher recounted how an eye specialist, having seen a case of retinitis pigmentosa, wrote in the patient’s notes ‘this might be part of the Laurence-Moon-Biedl syndrome; is there any evidence of polydactyly?’ To Asher, for an ophthalmologist to feel incapable of counting his patient’s fingers was the limit of specialisation. ‘Soon’, he groaned ‘we will have one physician who specialises in the first heart sound and another who is only concerned with the second.’[13] Dr Bettina Piko has argued that the growing mass of information has added impetus to specialization, and the boxes of specialist thought and academic study, so scattered around the globe of today, have reached such disconnected disarray that the boxes (disciplines) that she can see the only solution being new interdisciplinary fields of study.

“However, medical scientists as future polymaths will need to break out of the boxes. The task is not to get rid of the boxes, but rather to see the information in those boxes not just from the inside but from the outside as well.” Dr Bettina Piko [14]

Dr Thomas Young (1773–1829), coined the ‘Last Man who knew Everything’ by his biographer Andrew Robinson was physician and polymath and as forerunner to Clerk Maxwell, in a series of ingenious experiments showed that light is a wave, supplanting Newton’s corpuscular theory.[15] Repeated over the years by physicists with more sophisticated apparatus, Young’s famous double-slit experiment still encapsulates the heart of quantum mechanics. Young developed the theory of elasticity, explained capillary action and hydraulics as well as his work in linguistics examining the origins and derivations of some 400 languages. He even found time to compile the second volume of his Natural Philosophy, based on a critical review of medical practice stretching back to Hippocrates and Galen. Yet Young was not considered by his medical contemporaries. His biographer believes that such dismissal stemmed from petty jealousies combined with a complete lack of understanding of Young’s scientific achievements and a deep suspicion of anybody who did not practise medicine to the exclusion of any other activity. Sadly, it appears that Young felt that he had been rather a failure as a physician.

In this epoch biomedicine has tended to think about disease in terms of a linear cause-and-effect model. Infectious diseases served as a paradigm of this thinking. That is to be celebrated; for vaccination, antibiotics, and now antivirals have saved more lives than any other galencial. Science and technology are crucial in medicine of today, and as societies we devote enormous amounts of time, money and effort to developing new diagnostic and therapeutic procedures. However, as Bettina Piko commentates, despite this people now report higher rates of disability, symptoms and general dissatisfaction with their health and well-being and she argues passionately that there is a need for a new medical paradigm, which should involve and reconcile the natural and the social scientific paradigms (the ‘two cultures’).

Modern medicine is based on a materialist principle, in which psychosocial processes may have a role in the genesis of disease, but only insofar as they affect biological processes. This biological reductionism has made possible the investigation of the human body at the cellular level and has brought huge advances both in positive and negative findings. The dominance of negative findings, or conclusions impossible to so simplify – here we must include the domination of neurogenetic and brain ‘architecture’ research – has more recently directed our attention to the necessity of introducing a new approach to health and disease. Alcohol consumption, dietary habits, drug use, reproductive and sexual behaviour are all responsible for well-defined pathological effects. However, separating biological and psychosocial risk factors is almost impossible. While doctors tend to work in the frame of biological reductionism, at least in their musings about the mechanisms of disease – such as the “chemical imbalance in the brain” – patients view their health in a more holistic way.

Here commentary must be made about a most recent debate in Scotland relating to antidepressant prescribing in Primary Care settings (General Practice) for mild to moderate depressive illness.[16] Let me affirm here, that my thoughts on more severe depressive disorders lie separately. However my view of mood and its disorder is that it cannot squeeze in all its social diversity into one box marked biological. We must be wary of medicalising all human distress a reminder that Roy Porter, and who can argue against his wisdom, made often. That does not mean we do not care or support, as Professor Christopher Dowrick so wonderfully sets out in his writings on this subject.[17] Our current devolved administration in Scotland, on hearing that 1 in 9 of our adult population receive a daily antidepressant, set a target, supported by SAMH (Scottish Association for Mental Health) for a reduction of 10% in prescribing of antidepressants.[18] Professor Ian Reid reversed this with characteristic vigour, denouncing through a series of statistical tables, any idea that environment and culture play a part in human distress.[19] This essay has in good part reflected upon taste: Baron Clerk is to me the personification of a man of taste, but others mentioned here would include David Hume, Reverend Archibald and Dr Bill Harrowes. I have also been struck by their respect for the ideas and tastes of others and wonder what they would make of Professor Reid’s view that taste, or indeed distaste could be described as villainous:

“Edward Shorter does not collar the real villain: that role is surely taken by the general public’s distaste for the very idea of psychopharmacology.” Professor Ian Reid (August 2009)[20]

Doctors of the future cannot be expected to know everything. However surely we can train our doctors how to focus on the appropriate selection of information, using to our advantage the ease of communication of the digital age. It is my belief that this is already happening. The didactic lectures that were fodder to my generation have been replaced by curricula centred upon problem solving in small groups. This undoubtedly stimulates the student to take a more active part not only in learning answers to questions, but also in formulating the questions themselves. Another very helpful trend has been the introduction of students to patient care early in their studies. Only in the clinical setting can students gain a real appreciation of the basic principles of the natural and behavioural sciences that they are learning in the classrooms and laboratories.

The metaphor of architecture of the mind would have delighted Sir Batty Tuke but worried Dr Bill Harrowes. It is amusing to think that we have compared the fatty substance in our heads, depending on the era, to the inventions of man. Of course we have a cellular structure in the brain and of course we must study this as fully as we can: however brilliant Dr Waldo Gerard was, he is now posthumously recalled for his quote ‘for every twisted thought there is a twisted molecule ’: surely this is no more than superlative reductionism framed in an attractive sound-bite.[21] For all those chasing only matter, remember Clerk Maxwell and his discovery of fields of energy – and for those of a more able mind than mine, I would suggest again that you read the forthcoming ‘Disappearance of Appearance’ on this theme as it relates to human consciousness.[22]

Returning to Dr Meyer; let it be clear he will neither escape criticism, for his phraseology can be difficult and the introduction of the ‘ergasias’ was both confusing and unhelpful. However the Life Chart that Dr Meyer developed, has been adopted in a modified form by the more diligent within our profession, and serves to usefully record the main episodes in the history of the individual. Dr Bill Harrowes, in 1937 wrote to the British Medical Association offering a Meyerian overview but his plea for an audience rejected.[23]

Steven Pinker did stamp ‘architecture of the mind’ upon our collected consciousness; however it was a re-print of the drafting that was Freud’s Id, Ego and Superego. Richard Webster in his 1995 biography: Why Freud Was Wrong Sin, Science and Psychoanalysis, reveals the pitiful truth, and always taking pains to give Freud the benefit of the doubt, the picture revealed is all the more harrowing.[24] Freud wanted, above all, to be recognised as a scientist, but his twisted observations, that he cranked up through marvellous impenetrable prose, and which he delivered with messianic authority (Freud consciously identified with Moses) actually amounted not even to pseudo-science. The tragedy is that at the turn of the century before last, Freud corrupted the understanding of the world, and worse still diverted the energies of his colleagues and followers thereafter, those who actually wished to ease suffering. Within the psychoanalytic tradition you only have to look at the work of John Bowlby and the wonderful progression of his considerations on shaping in childhood through Sir Michael Rutter to realise where we should surely be developing research.[25]

Figure 5: Architecture of the mind

It could be no surprise that in reading the summary reviews made in 1999 written at the end of George Bush’s ‘Decade of the Brain’ that Dr Leon Eisenberg arose in my thought. Eisenberg (1922- Sept 2009) who died this autumn was easily the best medical writer of his generation and had wisdom beyond match. By vocation he was child psychiatrist, but it was his graceful and eloquent social commentaries that carried him as the medical educator of his day. It is perhaps not so curious that the best writers in psychiatry stem from child psychiatry, for like Bowlby and Rutter, Eisenberg transformed child psychiatry by advocating research into developmental problems. This the very same message, that in the century before had been carried by Meyer. The British establishment will remember Eisenberg for his 1986 lecture given in London Mindlessness and brainlessness in psychiatry, it is a classic text.[26] However my favourite Eisenberg paper was delivered the year after: Science in Medicine: Too Much or Too Little and Too Limited in Scope?[27] In a way that no other apart from Roy Porter could ask, in this paper Eisenberg, “why are we doing better and feeling worse?” Eisenberg reiterated his explanation “what has hampered progress is too narrow a view of the sciences relevant to medicine”.

If the analytic movement were not important or if it had made little intellectual impact, Freud’s pseudo-science could be ignored or briefly rebutted. But Freud’s influence on contemporary intellectual life has been so large and his psychological assumptions have proved so enduring that it is difficult to let go of his fraudulent cause. For example, one of the worst ‘scientific’ papers written in recent times was by Gilberto Brito, entitled: Mind from genes and neurons: a neurobiological model of Freudian psychology.[28] The author explained his intention to explain a neurobiological model of Freud’s architecture of the mind in an attempt to unify concepts from molecular biology (genomic imprinting), systems neuroscience (neuro-anatomo-chemical circuitries), evolutionary psychology (human mating strategies), and Freudian psychology. In Dad’s Army Private Frazer, played by John Laurie, was a miserable old Scotsman – here his phrase is apt “We’re doomed!”

“As I hope to make it clear in the present essay, to ignore current advances in the neurosciences represents a disservice to society and to future generations of behavioural scientists.” Gilbert Brito

Though we did not meet in life, I can hear the words of Dr Bill Harrowes the last Superintendent of Mavisbank. In 1945 he commented on a similarly preposterous research project: “until psychiatrists are as familiar, and known to be as familiar, with the so-called normal as with the so-called abnormal, and until all assume responsibility for living, any ‘big strides’ may well be taken in the wrong direction.“[29]

---