#and the other squares themed after chapters characters and notable events

[aleesblog]

How Proust Can Make You a Better Neurologist by Alastair Wilkins

It was a Proustian moment, of course, the sunlight filtering through the blinds at the start of an afternoon clinic, bathing the room in an uneasy, watery half- light, as the Professor, elegant and aloof, strode into the room, took his chair and surveyed the list of patients without even a glance at the assemblage of registrars and visiting dignitaries. Dr X, to my left, erstwhile attending neurologist to the Queen of Y, shuffled uneasily, gazing intently at his new mentor, studying the lines on his face in order to gauge the spirit of the next four hours, cooped up in this consultation room with its cork-lined walls. He recalled last week’s clinic with its emphasis on nosology, the subtle messages he had obtained from the Professor to study a particular chapter of his text book and the embar- rassment he had suffered for thinking Brown-Séquard to be two people.

But he was, as indeed we all were, in luck. The Professor, now smiling to himself, took out a document from the pile of manuscripts without which he never travelled, and reread the first few lines, before handing it to me with the words: “I thought you might be interested in this”. I smiled, and between us we shared a moment of understanding that signified our common interest in taking neurology to a higher level; in exploring the endless possibilities which broken minds open up to our understanding. After all, we were co-authors of a recent article in a respectable journal on the link between neurology and literature.

This moment of connection between two like-minded people underlies the bond of friendship and respect, but I, in my role of student, had never once thought of its reciprocation, until this time when I started to read the docu- ment which he had handed to me in such a way. It was an obituary of a recently deceased ‘pioneer’ of modern neu- rology, who had practiced in a room not twenty yards from where I now stood and whose portrait still hangs in the gloomy hostility of the lecture theatre: William Walton Gooddy M.D.Lond., FRCP, consulting physician to the National Hospital for Nervous Diseases and University College Hospital, London. Gooddy was a man who, so the obituary claimed, differed from the usual neurologists of his time by being ‘amusing and charming, lacking the austere asceticism and obsession regarded as prerequisites for success’. I read on as the Professor turned his attention to the list of patients before him and the prospect of being late for his five o’clock meeting, again, but my thoughts were arrested by the sentence that I have looked back on since and re-examined over and over again: ‘His first words to me on starting neurology were that I should take a week off to read À la Recherche du Temps Perdu as this would be far more useful in my career than Big Brain, the standard textbook of neurology.’

Of course, I knew a little about the book, noted for its length in particular, but had not previously given serious

thoughts to reading it, tending to agree with Bellow’s ver- dict on writing that as he grows older everything he reads tends to be not short enough. But from that moment I started to wonder why he should have given that advice to a neurologist in training. What could there be within those 3000 pages which would inform a budding neurol- ogist concerning the mysteries of the brain? How could a work of fiction help to understand the consequences of neurological injury?

And so I read the book, which, over its closely printed pages, became not only an amusement or a way to pass a few hours of leisure time, but an experience of time itself. Only today, walking through the hospital grounds on a cool autumn morning, did my gaze fall upon a tree, denuded of half its leaves, and I recollected that I had sat under its blossom laden boughs and read a few pages of the Bal des têtes. Just as the protagonist associates physical cues with memories, undoubtedly Proust expected the reader to use the book as a temporal guide for the months spent pondering its pages. Indeed the association of mem- ories, famously illustrated by the smell of tea-soaked madeleines, is of much interest to the neurologist who has an interest in cognition.

‘And as soon as I had recognized the taste of the piece of madeleine ... which my aunt used to give me (although I did not yet know and must long postpone the discovery of why this memory made me so happy) immediately the old grey house upon the street, where her room was, rose up like a stage set to attach itself to the little pavilion opening on to the garden which had been built out behind it for my parents (the isolated segment which until that moment had been all that I could see); and with the house the town, from morn- ing to night and in all weathers, the Square where I used to be sent before lunch, the streets along which I used to run errands, the country roads we took when it was fine. And as in the game wherein the Japanese amuse themselves by filling a porcelain bowl with water and steeping in it little pieces of paper which until then are without character or form, but, the moment they become wet, stretch and twist and take on colour and distinctive shape, become flowers or houses or people, solid and recognizable, so in that moment all the flowers in our garden and in M. Swann's park, and the water-lilies on the Vivonne and the good folk of the village and their little dwellings and the parish church and the whole of Combray and its surroundings, taking shape and solidity, sprang into being, town and gardens alike, from my cup of tea.’

The ‘petites madeleines’ phenomenon has entered medical parlance (albeit transiently and perhaps erroneously) to

Alastair Wilkins is our Case Report Co-ordinator. He is Senior Lecturer in Neurology and Consultant Neurologist, University of Bristol. He trained in Neurology in Cambridge, Norwich and London. His research interests are the basic science of axon degenera- tion and developing treatments for progressive multiple sclerosis describe patients recovering from amnesia. Maybe those patients are the ones who seek most vehemently to recap- ture‘LostTime’.Butmuchmorethanthis,Proustexplores not only the way memories are rekindled in us, but why we recall particular events; how each one of us remembers the identical person or event in a different way; and even how dreams compound and interfere with memories. If Proust were to sit in our consulting rooms (for his multi- farious complaints) what kind of history would he give to us? Undoubtedly a highly detailed one, but he would probably point out to us that a hundred people suffering from the same symptoms would present a hundred differ- ent histories. It is up to the doctor to interpret these.

And what of doctors? Proust presents several in his novel, most notably Dr Cottard. Cottard was, in all prob- ability, based upon Jules Cotard, a contemporary of Charcot in Paris. Proust’s father (Adrien) was a distinguished physician who trained with Cotard at the Ecole de Médecine and the young Proust would have met many medical people. Yet Proust had an uneasy relationship with the medical profession. His own illness, reflected by the infirmity of the protagonist of À la Recherche du Temps Perdu, consisted of severe asthma and a multitude of other complaints. The prevailing view at the time, thought also to be held by Adrien Proust, was that asthma was a nervous habit that could be treated by isolating vic- tims in sanitaria for nervous diseases. The theory that conditions such as asthma were psychosomatic flourished in those times. Perhaps it is little wonder then that he had a deep mistrust of some within the profession. Nevertheless, Proust’s writing is highly influenced by medical terminology and analogy. The protagonist of À la Recherche du Temps Perdu suffers from ‘neurasthenia’ and is never far from his bed. His infirmity leads him to observe objects and occurrences in the minutest detail; and, more importantly, reflect on all those experiences he has had in his life. Many of these reflections centre around his illness or the illness of others. His metaphors are often medical and there is little doubt that Proust was fascinat- ed with medicine; the novel using themes of subconscious thought and dreams to explain emotions. One might say Proust ‘medicalises’ human suffering and experience (for instance he describes Swann’s love for Odette in terms of ‘malade’, ‘convalescent’ and ‘chirurgien’). To a certain extent, this may reflect the contemporary move- ment in France, led by Charcot (who is mentioned in the work), to illuminate the function of the mind and ratio- nalise the disciplines of neurology and psychiatry.

The death of the protagonist’s grandmother is of major significance in the novel. She becomes unwell before suf- fering from a stroke and consults a variety of medical practitioners. She consults a doctor called duBoulbon (predicted by Charcot to be the next great name in Neurology). He diagnoses neurosis and expounds his theories on human illness (no doubt reflecting some of Proust’s ideas). du Boulbon also states, when explaining the grandmother’s diagnosis, that ‘everything that we think of as great has come to us from neurotics’. Thus, he introduces a link between creative sensitivity and illness. In a way, Proust is telling us that he would never have written À la Recherche du Temps Perdu were it not for his own suffering. Could this explain some of his hostility towards physicians and their desire to cure all illness?

The paucity of and often bizarre nature of treatments in Proust’s day linked to the pompous and dictatorial man- ner of doctors (‘the symptoms you show will simply dis- appear at my command’) underlies much of the medical text in À la Recherche du Temps Perdu. Proust goes further than expounding medical impotence and lays the root of illness at the door of the medical profession: ‘for each ill- ness that doctors cure with medicine, they provoke ten in healthy people by inoculating them with the virus that is a thousand times more powerful than any microbe: the idea that one is ill’. Perhaps this is a little harsh. It may be that Proust was presenting an alternative to the vogue for turning all illness into psychosomatism.

So Proust describes illnesses from the patient’s point of view and presents his own theories. We learn about the relationship between illness and creativity, and about rec- ollection of events and the influence we all put on seem- ingly random aspects of a history. Maybe understanding these concepts will make us better neurologists.

And so I return to Dr Gooddy. What made him put such relevance on Proust magnum opus? If we are to examine his own published output there are clues. Not least an article published on Saturday 31 May 1958 in The Lancet entitled ‘Time and the Nervous system: the brain as a clock’. Within the elegantly written piece he introduces the concept of ‘temporal neurology’, arguing that the erst- while emphasis on neurology has been a dissection of spa- tial aspects of disease. Presenting theories on chronomet- ric mechanisms he uses examples of nervous and non- nervous physiological clocks which underpin our exis- tence. Gooddy takes neurology into the fourth dimension and uses the clock theories to explain why ‘when memory fails, we find a defect of recall and arrangement of time past’. And in that sentence I begin to understand what he means when recommending the novel to neurologists in training. Neurology is a temporal discipline, not just about locating lesions within the ‘space’ of the nervous system. Indeed chronobiology is now a burgeoning disci- pline. Gooddy predicts ‘we should be able to describe physiological chronometric mechanisms’. Whole confer- ences are now devoted to circadian rhythms, hox genes and neuroendocrine regulation of time.

In current times of molecular biology and the human genome does anyone have enough time to sit down and read novels as part of a medical curriculum? Perhaps Dr X would tell me that we can explain so much in terms of genetic regulation and spatial patterning that there is no longer a need for ‘amateur’ musings by latter-day philoso- phers. Science has negated philosophy; passing of time is another philosophical concept that has been explored and explained. I begin to argue that Proust tells us what it is to experience time, but instead I smile and let my mind wan- der and think back to a passage in À la Recherche du Temps Perdu which is able to elucidate in such elegant terms all those things which I have been battling to understand:

The places that we have known belong now only to the little world of space on which we map them for our own convenience. None of them was ever more than a thin slice, held between the contiguous impressions that composed our life at that time; remembrance of a par- ticular form is but regret for a particular moment; and houses, roads, avenues are as fugitive, alas, as the years.

References

deBotton A. How Proust can change your life. Picador 1998. Gooddy W. Time and the Nervous System: the brain as a clock. Lancet, 1958:1(7031);1139-44. Kapur N. The ‘Petites Madeleines’ phenomenon in two amnesic patients: sudden recovery of forgotten memories. Brain, 1996:119;1401-4.

Levy SN. Proust's Realistic Treatment of Illness. The French Review, 1942:i;235-8. Lucchelli F, Muggia S, Spinnler H. The ‘Petites Madeleines’ phenome- non in two amnesic patients: sudden recovery of forgotten memories. Brain, 1995:118;167-83.

Pearn J, Gardner-Thorpe C. Jules Cotard (1840-1889). Neurology, 2002:58;1400-3. Sharma OP. Marcel Proust (1871-1922): reassessment of his asthma and other maladies. Eur Resp J 2000:15;958-60.