- February 1: “Why Are Medical Journals So Dull?”
- The Talking Sense trilogy:
- February 8: “Clinical Sense”
- February 15: “Making Sense”
- February 22: “Talking Sense”
Richard Asher’s writings have stuck around for quite a few different reasons, which have been mentioned. He’s funny. He’s interesting. He’s still relevant.
Asher is also surprisingly prophetic.
A little prophetic joke
In his speech “Talking Sense”, he deliberately pulls the rug out from under the audience. He quotes Dr. James Crichton-Browne, who wrote about “GPI”, or “general paresis of the insane”. When Crichton-Brown was writing in the early 1870s, GPI was thought to be a “madness”, that is, a defect in character instead of a disease. In the late 1880s, it was discovered that GPI is, in fact, the result of chronic meningoencephalitis in syphilis patients.
Asher substitutes “peptic ulcer” for “GPI” and “gastric mucosa” for “nervous system”, etc., and comes up with a paragraph which sounds perfectly acceptable to mid-20th medicine:
Peptic ulcer—one of the pestilent camp followers of civilization—one of the penalties we pay for our boasted progress, seems to be more than keeping pace with our advancement, and to be attaching itself especially to certain forms and phases of civilization. There is reason to believe that it is, if not of modern origin, at least of modern growth, and that modern habits and modern modes of life have something to do with its propagation. This is essentially a feverish and a fidgety age, in which an unappeasable restlessness pervades all ranks and classes. The struggle for existence has become a melée, and the recommendation to “commune with your own heart in your chamber, and be still” is looked upon as an obsolete adage. The result of all this ceaseless agitation and ambitious striving is that the gastric mucosa often gives way under the strain imposed on it. By a hideous kind of poetical justice, peptic ulcer has become a distorted reflection of the follies of the age. It is the miserable otium cum dignitate1 of the man of business.2
I shudder to think what Crichton-Browne would think of our 21st-century
modern habits and modern modes of life.
When Asher delivered this lecture, there were precious few doctors who treated a peptic ulcer with antibiotics, and most believed they were caused by stress and diet. Asher is quite prophetic in paralleling GPI with peptic ulcers as
psychosomatic explanations for unexplained diseases. In 1982, more than 20 years later, Robin Warren and Barry J. Marshall demonstrated that Helicobacter pylori was responsible for the condition. The idea was initially ridiculed. Because human experimentation was so tightly regulated, Marshall famously drank a sample of the bacterium himself, and subsequently developed ulcers. Warren and Marshall received the 2005 Nobel Prize for their work.
Asher’s main point is that
it is important to recognise that things are much easier to believe if they are comforting, and that many clinical notions are accepted because they are comforting rather than because there is any evidence to support them. Just as we swallow food because we like it, and not because of its nutritional content, so do we swallow ideas because we like them and not because of their rational content.
This is certainly no fault of medicine. The human body is complex, and our progress in understanding it is usually slow and difficult. The job of a healer is to heal and to comfort, and the thought of admitting
therapeutic bankruptcy to a patient Asher himself calls
too depressing to accept.
I’m a doctor, Richard, not a logician…
Asher himself never uses the terms, but clearly differentiates deductive reasoning from inductive and/or abductive reasoning:
Formal [deductive] logic is based largely on statements of the kind:
“All x is y. All y is z. Therefore all x is z.”
“All men are mortal. Socrates is a man. Therefore Socrates is mortal.”
Medical facts are rarely suitable for this discipline. They are more of this kind:
“Some x is y, but I’m not really sure of it. Possibly all y may be z (as Smith has claimed to show), but Brown affirms that no y is ever the slightest z, and Robinson too has strong views (though I find them hard to understand because he uses x to mean either y or z, and what I call z he labels y.”
For example, consider the condition called iron-deficiency anæmia. … unconsciously we are arguing thus:
“Iron lack is known to produce a hypochromic microcytic anæmia. This woman has a hypochromic microcytic anæmia. Therefore she has iron deficiency.”
It would be almost equally rational to say:
“This woman is weak. Addison’s disease produces weakness. Therefore we must treat her for Addison’s disease.”
It’s important to recognize that there are narratives at play any time we’re forced to step away from formal, deductive logic. The connections inherent in inductive and abductive reasoning are “jumps” that we make because we’ve seen that jump made before when it turned out to be correct.
Deductive logic is slow, deliberate, and so detailed it’s almost useless analyzing the minutiae of a system as complex as the human body. Narrative gives us shortcuts to thinking and the ability to make the logical, if creative, leaps.
Common sense isn’t all that common
One of the wonderful things about Asher’s writing is that he constantly allows pesky facts and experiences from the broad, real world to intrude on the jargon-filled myopia which is present in any profession. He dovetails this, for example, into his discussion of different logically possible ways of looking at anemia:
I am only anxious to demonstrate how an observation can be interpreted in entirely different ways, according to whether you assume the condition is an illness or not, and to show how easy it is to make such an assumption without knowing it. You cannot say what things are abnormal till you have agreed on what is normal. You cannot describe disease without describing ease first.
Conversely, he is also aware that metaphor and oversimplification can be dangerous:
One of the most irrational and comforting delusions held by the layman is the notion that his body is really kind of motor-car. “I feel much better now you’ve given me a thorough overhaul” is a remark I have heard on many occasions. Doctors are often guilty of nourishing this delusion when they make remarks such as “You’d better come in for a complete check-up”. Behind all this lies the delusion that the physician is likely to remedy defects as he finds them—applying a little oil here, fitting a replacement there, and possibly clearing out a blocked pipe. … But the analogy with motor-car engines is false, and the only point where it applies is that when the trouble is very serious the patient is likely to be returned to his Maker.
Ultimately, the leaps the medical mind must make are good and beneficial, when backed up with evidence. Asher summarizes his ideas in this paper, and maybe the entire lecture series, with this quote from Clifford Allbutt:
Our path is cumbered with guesses, presumptions and conjectures. The untimely and sterile fruitage of minds which cannot bear to wait for the facts, and are ready to forget that the use of hypotheses lies, not in the display of ingenuity, but in the labour of verification.
The article reviewed: Asher, Richard. “Talking Sense.” Lancet, 1959, 417–19.
1 Cicero’s advice on how to be a good man included otium cum dignitate, literally “leisure with dignity”, retiring from public life. The phrase appears in Pro Sestio, the Speech on behalf of Publius Sestius from 56 BC. ↑
2 Browne, J. C. “Notes and News from the Medico-Psychological Association.” The British Journal of Psychiatry published as The Journal of Mental Science 17, no. 80 ↑
Featured Image: Richard Asher, photograph provided by his family, used under a CC BY-SA 3.0 license, via Wikimedia Commons.