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Book Review: Brainspotting

Peter Bricklebank

Brainspotting
A.J. Lees
Notting Hill Editions, 2022


 For most of us, the term “neurology” conjures up the gentle, fern-loving, motorbike-riding, sexually shy, and marvelously entertaining and insightful Oliver Sacks. In his book Brainspotting, A.J. Lees describes Sacks as “the best known neurologist on the planet.” But Sacks, as I learned in this book, didn’t always have a salaried post; he was something of a “neurological gypsy” as Lees puts it, a maverick who survived “marginally and precariously … a romantic scientist, more at home in the asylums of yesteryear than in the new skyscraper hospitals.” 

Lees’s career took a different tack, working inside the British healthcare system at University College Hospital, National Hospital, and other National Health Service clinics. By his own calculation, he’s treated upward of 30,000 patients and conducted over 4,000 ward rounds. He’s taught and lectured all over the world in order, searching for new ways to detect disease and for answers to the questions patients have asked him but which, he admits, he was unable to answer at the time. Sacks, Lees notes, humanized this branch of medicine, and it’s clear that Lees, too, strives to develop a clinical method that restores a lost “soulful neurology.” As he writes, neurologists were once caricatured as “introverted, analytical eggheads that combined the precision of mathematicians with the scrupulosity of bryologists and the sobriety of undertakers.” The precision, reach, and wry amusement of that sentence alone tells you that though this isn’t Sacks, we’re in capable hands.

  This slim book of ten autobiographical essays functions, in a way, as a ward round. It’s a circumambulation of Lees’s clinical career from a decade-long neurology apprenticeship, to the point where he admits to the confidence of being able to distinguish a healthy individual from an ill one. He is a clinician who highly values receptivity—observing, recording, and classifying—as did many of his esteemed mentors whose methods and wisdom he describes in these pieces. As he notes, he is neither the House of television celebrity nor a brain surgeon, as he’s oft been assumed to be, but someone who has always sought to treat based on evidence, even from his early days as a birder and as a lover of John Clare’s poetry (covered in his essays “Birdwatching on the Pavements” and “Full of East End Promise”). From the detail-oriented vigilance of birding, we get to—as in the essay “Charcot’s Parrot”—his minute monitoring of people on the Paris Metro for jerking, spasms, asymmetry, gestures, postures, facial expression. He diagnoses, say, the inappropriate winking of a bureaucrat as a hemifacial spasm. The wife shepherding her forgetful husband to his appointment is an indicative and useful clue in itself, even before any other test. These essays illustrate how Lees becomes an increasingly avid and punctilious observer of life.

Lees has a great affection for the lost London hospitals where he trained, which seemed to embody the soul he wants to see retained in medicine. In “The Dead Hospital,” he fondly recalls the Corinthian columns and “cathedral-like silence” of the Maida Vale Hospital for Nervous Diseases. More than a “boutique” hospital—or even an “excrescence,” as “Brahmin physicians” referred to it in the Lancet in1863—the hospital flourished after performing the world’s first successful extirpation of a brain tumor in 1884. Changing names and locations over the years, the institution was far from a cottage hospital and held a reputation for the highest standards. Working there for fifteen years from 1979, Lees has much to relate about the valuable learning he gleaned from it, often via autopsy (“the ultimate audit” as he delightfully has it). But it couldn’t hold up against the “skyscraper hospitals.” With National Health Service cuts and changes, promised maintenance not materializing, a greater dependency on agency staff, the hospital deteriorated. Its cozy chairs and worn-out piano in the small outpatient department became antiquated as the essential sense of communal purpose dissipated and the hospital came to resemble “a dying coral reef.” In that very phrasing, Lees makes us mourn.  

But he’s also striking in his detail. Lee regales us with tales of bowler-hatted, dirty-fingernailed, yet immensely insightful teachers who munched their home-prepared sandwiches on the same table where they made their incisions into brains. One can’t help but feel we have lost a little human dimension—conviction despite outside-the-box eccentricity—to an impersonal, unassailable front of professionalism, antiseptic in ways both a gain and a loss.

One of the delights for me in the book are the literary references. The author finds himself in agreement with George Bernard Shaw that abbreviations are often conspiracies by professions to acquire prestige, power, and wealth. He references Kafka’s country doctor: “To write prescriptions is easy, but to come to an understanding with people is hard.” Even a reference to the “crime of Procrustes”—the inclination to fit the facts to our opinions instead of vice versa—calls on a literary learnedness. And then there is the essay “Zadig and Voltaire” in which Lees reminds us that Sherlock Holmes was based on the Edinburgh surgeon Joseph Bell, who believed that the “precise and intelligent recognition and appreciation of minor differences is the real essential factor in all successful medical diagnosis.” Fascinating to note, as Lees does, that in sixty Holmes adventures there are references to sixty-eight diseases, thirty-two medical terms, thirty-eight doctors, twenty-two drugs, twelve medical specialties, six hospitals, three medical journals, and two medical schools. All this to the point that neurology reasons backwards, like Holmes. And, according to Holmes, “What is out of common is usually a guide, rather than a hindrance.” Which, when he presents it like this, feels, well, elementary.

Lees asserts that doctors need “antennae as well as ears.” Listening, he estimates in “Words,” gives him a diagnosis in seven out of ten patients. He compares his way of gleaning information as akin to a seasoned detective—letting the patient or victim think aloud in order to draw out significant detail. Thinking of medicine as a sleuthing of mysteries, a putting together of clues, there’s the essay “Resurrection” which opens with Maida Vale hospital and the last brain salvaged from its vaults. Holmes would surely be proud of the author for his imaginative recreation of the life of the man whose brain it was, who remarkably turns out to be a once noted rugby player in Northern England. 

So what might draw practitioners or curious readers alike to this collection? Well, if like two of Lees’s mentors, you see a “menacing border” between neurology and psychiatry, a split between doctors studying the brain in hospitals and those who study disorders of the mind in offices, or see psychiatry as a guild profession with not a single validated clinical test, “The Lost Soul of Neurology” may be of interest. Or perhaps, like Lees, you feel most neurologists in the private sector have been forced to become, in essence, factory workers with “a laboratory mindset” and an approach of “blunderbuss screening.” (There’s nothing like an archaic weapon for providing a fighting talk metaphor!) In which case you might find stimulus in the essay “Machine Learning.” Lees feels that medical technology has encouraged mental laziness. He is appalled by the ordering of tests by people who, he states, don’t know when to order them or how to interpret the results—this for him is the “defensive,” “engineering” approach to medicine. A prime example is the profligate use of brain scanning, which he finds tantamount to medical malpractice. So in the midst of its reverence for careful practice, the book also has its scalpels out. 

The use of inventory is another small delight. There is a list of the curiosities a neurologist like Lees might have in his doctor’s bag, a motley of seeming oddities including a red hatpin, orange sticks, and a moving drum (for testing optokinetic nystagmus). Or a curious list of some of the tests used in his time in France: the doorbell sign, the hand-puppet test, the dance of the tendons. Or the “bestiary of pareidolias” he notes by which to recognize abnormal radiological signs: the eye of the tiger, the giant panda, the leopard skin, the codfish, the medusa, the swallowtail. These all draw the reader into his fascinating world. 

Lees’s attempt to bring more soul to medical practice would surely have sat well with Oliver Sacks (and even Dr. House). Perhaps it is best summed up in this haunting line: “Touch comes before words and is the first and last language.”