Welcome to Dr Roger K.A. Allen’s Blog

“Why Sir, you find no man, at all intellectual who is willing to leave London? No Sir, when a man is tired of London, he is tired of life; for there is in London all that life can afford”.

Samuel Johnson’s greatest legacy is “The Dictionary”. Born in 1709, he grew up in Lichfield, Staffordshire but fell in love with London, where, with the aid of six amanuenses, numerous goose quills, much paper and ink, he worked from 1746 when he signed the contract, until MDCCLV which finally appeared at the bottom of the frontispiece of the huge first edition.

Johnson’s “A Dictionary of the English Language”, stands out from all dictionaries that followed not just by his vast eclectic knowledge, but by its humour, prejudices and views of life. Before he started on the work he was confronted by the fact that the French had achieved their dictionary only after forty years by a committee of forty men of the Académie Française. Johnson’s responded in essence was that one Englishman was equal to 1,600 Frenchmen and that he could complete the task in three years. It was to take a bit more. Although the first edition had its critics, it was heralded as a national treasure. For the first time someone had brought order to the chaos of Georgian English including spelling, grammar and word usage. It was the linguistic equivalent of the standard gauge railway to the bickering state governments in colonial Australia but that may be a bad example as we still remain divided by gauges not to mention time zones.

An example of the charm of his dictionary is exemplified in the famous definition of the word, “oats; a grain, which in England is generally given to horses, but in Scotland supports the people. While this may leave the reader bemused, it illustrates that the author is a human being with prejudices and opinions. In reference to his unpleasant experience with his would-be patron, Lord Chesterfield who offered to come to his aid only after seven lean years of slog had paid off, he defines the word, “patron” as such; one who looks with unconcern on a Man struggling for Life in the water and when he has reached ground encumbers him with help”.

The verb “to take” encompasses 5,500 words with 134 senses and even the verb “to fall” is expanded into sixty-five nuances. For more examples may I commend the most entertaining book by Henry Hitchings (1).

In 1979, when I was a medical registrar, the professor of medicine, asked me if I would do a study on angiotensin-converting enzyme as fellow called Jack Lieberman in the United States had serendipitously found it was elevated in sarcoidosis. As I was about to start training to be a thoracic physician it seemed a bit left field but I complied and did the work in his department which was a hot-house of hypertension research. This task which was to take six weeks resulted in my life-long interest in sarcoidosis, my doing doctoral thesis on the enzyme and becoming a member of executive of the world body called WASOG (World Association of Sarcoidosis and Other Granulomatous Disorders).

When I first became involved in WASOG in the early 1980s, it was led by that Pied Piper, the charming and ebullient Englishman, the balding bow-tied D. Geraint James, known by all as “Gerry James” and although his wife was the famous hepatologist, Dame Sheila Sherlock, he did not sit in her shadow. On my bookshelf sits his book, Sarcoidosis and Other Granulomatous Disorders, published by W.B.Saunders in 1985 and although only 254 pages in length, it hold pride of place (2). Inside it just says,

“With affection and admiration. Geraint James, September 1990”.

He signed my fading copy one memorable night at a dinner with him in Brisbane in a charming Queenslander owned by his old friend, the Brisbane pathologist, the late Dr Bruce Gutteridge. Until late, we drank red wine heady with bonhomie from fine Venetian glasses while the flying foxes squabbled in the palm trees lining the front drive and the scent of jasmine permeated the night air. In that bygone era, WASOG was vibrant and his book effervesced with his unique enthusiasm like that of an eccentric school boy with a collection of pinned beetles. His book is replete with his own black and white photographs taken over the years of his wanderings like a medical Odysseus.  From his book, I get the feel that he has been courted by the Sirens and attacked by Harpies and that he had blinded Polyphemus on his sarcoidal epic armed on with the honed bronze blades of hydroxychloroquine, corticosteroids, methotrexate and a few less trusty weapons like azathiorprine and time.

In the editions that have followed the voices of the authors become hard to make out, the language increasingly impersonal, the diction more turgid andreflections about life, the disease, the patient and the doctor more uncommon. In this first edition, he reflects on the first world conference on sarcoidosis in 1958 when I was only seven. He states;

The Olympic torch was lit and the first conference was held from June 30 to July 2, 1958, in London. Until that time the clinicians had read each other’s articles but did not know one another. They met in a spirit of cordiality and camaraderie, and this spirit has pervaded all subsequent conferences. (2)

There were twenty-two participants then including one woman but by 1966 the International Committee on Sarcoidosis in Paris included amongst others Dr Tom Hurley (Melbourne), Louis Siltzbach (New York), D. Geraint James (London), Sven Lofgren (Stockholm), Harold Israel (Philadelphia) and Martin Cummings (Washington D.C.), the then Director of the National Library of Medicine and who later established MEDLARS and MEDLINE.

I was recently asked to co-author a chapter on the treatment of sarcoidosis for a book on interstitial lung disease by a colleague overseas. However the task competes with a book I am writing about growing in the house of a country doctor in the fifties and in which I am very much aware of the “voice” of the book.  I have not yet started the textbook chapter but have looked at some early editions. The overwhelming thing I observe is the failure of most modern textbooks to convey personal experience except by virtue of a citation of some prior publication. The voice by way of convention is scientific, impersonal, passive and not active. It is far off. The patient and the medical process are viewed like an enemy frigate through a spyglass at a league’s distance only even less emotive. A handbook I own called “Evidence-based Medicine Toolkit” (no indefinite article) is medical equivalent to a metre-long bar of platinum held in a vacuum in Paris by which all metres and hence evidence in the medical cosmos is to be measured.

Although as a sailor I know Moreton Bay fairly well, I still refer to the charts when I venture into unfamiliar waters. The channel to Cabbage Tree Creek shoals up with a shallow spot at dead low which lines up at right angles to the outer third of the Shorncliffe Pier about a mile to the north. This is not in the chart and nor is the old tractor engine at dead low half way up the creek where the cattle used to ford. Nevertheless some fools still run aground there and even rip the bottoms out of their boats. And thus it is like this with medicine but the textbooks don’t mention this unless there is a p value or a citation. I frequently see patients with sarcoidosis with painful balls of their feet but this is not in the textbooks and probably never will be accepted as it is hard to prove objectively. Indeed the obstacles to publication now are so formidable I think a lot of good material goes unpublished.

I believe the duty of a textbook is to be enjoyable to read. However most have the linguistic flare of a German car manual, no sense of engagement with the reader, no real human “voice”, no guides for the novice, no hints to help you remember indigestible facts, no etymology to explain words, no history of the disease, treatment or investigations. In short, they are written by idiosavants devoid of wit and soul.  Their words are not used like notes and their sentences are constructed with the finesse of a brick layer. This is pedestrian prose at its worst and worthy of a bottle of No Doz.

Harrison’s reads like a medical version of the Larouse Gastronomique only with less appeal, and the only way I find it interesting is to read the French version which then subserves my two needs; consciousness and information. By contrast my late father’s textbook, Tropical Diseases in Australia, by Sir Raphael Cilento, 1944 says on page 37 in reference to the use of quinine for malaria,

Soldiers are particularly difficult if they have heard the false rumour – widespread amongst troops – that quinine causes a diminution of virility. After malaria sexual vigour frequently remains diminished for a fairly long period…. (3).

I wonder if he had a p value and surely Cochrane would have dismissed this as baseless.

We have thrown the baby out with the bath water. If I wrote a chapter on the treatment of sarcoidosis I  would like to include information about the history of the drugs used, the problems I have personally encountered over thirty years, about the pitfalls and cost and not just lifeless lists of studies and facts like a Metro time table. I wish to engage with my reader and share the passion I have for sarcoidosis like Gerry James. Alas, I am sure editors will filet the fish leaving the skeletal remnants in accordance with the doctrine of Cochrane, as well as the medical and political correctness of the time.

Carl Jung in his “Psychology and the East” states;

Science is the tool of the Western mind, and with it one can open more doors than with bare hands. It is part and parcel of our understanding, and it obscures our insight only when it claims that the understanding it conveys is the only kind there is. The East teaches us another, broader, more profound, and higher understanding – understanding through life.

The history of our craft even as a pre-amble is missing in our textbooks which are preoccupied with the latest creations; advances based on studies and trials with no sense of the fertile swamp from which these new reptiles have arisen. This year’s textbook will be next year’s door stopper and no more readable.

I recently asked a final year medical student doing a term with me who discovered oxygen, the derivation of the word “oxygen” and the first man to describe how the lungs work. He did not know. Thus I believe that the current teaching of medicine perpetuates the existential, mechanical style of modern journals and textbooks. Let us rediscover charm, linguistic style and humour to resurrect these dreary reductionist manuals on the human machine. So don’t give me the chaff of a modern textbook to read. Nay, Sire, give me a bushel of oats.

References

1. Hitchings H. Dr Johnson’s Dictionary. The extraordinary story of the book that defined the world. John Murray (Publishers), London. 2006.
2. James D.G., Williams W.J. Sarcoidosis and other granulomatous disorders. W.B. Saunders Co, London. 1985, pp10-11
3. Cilento, R. Tropical diseases in Australia. A handbook.  2nd ed. Smith & Paterson, Brisbane. 1944, pp 37.
4. Jung, CG. Psychology and the East. Princeton University Press, Oxon. 1978, pp5-6