- Doctors: The Lives and Work of GPs by Jonathan Gathorne-Hardy
Weidenfeld, 307 pp, £10.95, June 1984, ISBN 0 297 78382 3
- Bulimarexia: The Binge/Purge Cycle by Marlene Boskind-White and William White
Norton, 219 pp, £12.90, June 1984, ISBN 0 393 01650 1
Jonathan Gathorne-Hardy describes the practice of a woman doctor working alone in an inner-city wasteland:
The receptionist was replacing a lavatory seat when we arrived. The other had been torn off. So that I could be shown round, a cupboard was unlocked and inside it was a small metal wall safe. Inside that, row upon row of keys. It was like visiting a gaol ... It was an old house, all the doors were toughened against fire and break-in. The glass in all the downstairs windows was unbreakable. ‘You can’t break it but you can heat it and bend it. We came one morning and the windows were buckled – so. Another time they picked the putty out of the windows and the glass fell in’ ... We went upstairs. The windows here had metal grilles. The whole of the back was encircled by a high stone wall, along the top of which were dense coils of barbed wire. A sizeable wedge of new masonry showed where there’d been a recent collapse – or a break-in. ‘They drove a lorry at it. Partly after drugs, partly vandalism ... We put that non-dry paint on the drainpipes so that when they put their hands on it, they get their hands all wet and slip. That kept them off for a while.’
The patients vandalise the surgeries, flood the lavatories, soak the prescription pads in brake fluid so that they can substitute the names of narcotics, and sell their drugs on the black market. Here among the wrecked cars and the rubbish, the prams are padlocked to iron bars while mothers – those few that can be bribed to come – attend an ante-natal clinic in a small damp room with paper peeling in a large curl down the edge of one wall. The doctor herself, when out on her rounds, a lonely figure on a night call, may – like others of her colleagues – be assaulted, or even killed, for the contents of her black bag.
One of the sixty or so GPs interviewed by Gathorne-Hardy remembers practice in the East End of Glasgow in the Twenties:
At night, walking through the slums of the Gorbals, it was scaring because it was the time of the razor-slashing gangs. They’d slash from ear to mouth. I was never attacked, never. You had your little black bag in your hand and it would take you anywhere.
My father, who worked in the slums of both Glasgow and Dublin twenty years later, remembers the same thing: the chain-wielding gangs escorting him to the seventh floor of a tenement building, while a ‘guard’ was placed on his car outside. But doctors make few visits anywhere now. Perhaps it is only in the relatively civilised conditions of the African bush that a doctor is still safe. There the patients, referred, as one GP recalls, by ‘about sixty witch-doctors’, regularly travel as much as a hundred and fifty miles over impossible mountain paths, on an old donkey or in a wheelbarrow, to receive pills which they then distribute to their friends in the hope that they are aphrodisiacs.
Until not long ago you could become a doctor, as indeed you could become almost anything, on the say-so of the Archbishop of Canterbury. Now that this humane custom has fallen into disuse, doctors have to spend years studying the intriguing arcana of science. But the work has always been hard, and it is still scarcely what one would call technical. Until the Second World War, it was largely a matter of comforting and consoling, so few were the diseases that could be treated by drugs. Now it is still largely a matter of comforting and consoling, but for the opposite reason: so much acute disease has, at least for the moment, been banished. It must have been rewarding to be a doctor in that brief period between about 1940 and 1960, and to go around actually curing people, but this extraordinary state of affairs will probably not recur. Many of the doctors who remember it still have a quite different attitude to prescribing from that of their wary younger colleagues.
Nowadays people take fewer organic diseases, and more social and psychological conditions, to their doctors. Those organic conditions they do bring are usually chronic, and harder to treat. They bring them earlier than they used to, which makes diagnosis more difficult. They expect more immediate and more dramatic solutions. The doctors – the general practitioners, that is – have insufficient diagnostic facilities, insufficient staff, insufficient time, insufficient training. They prefer prescribing to listening. Many of the rewarding and stimulating aspects of general practice – home deliveries, minor surgery – have been removed to experts. The doctors, left with only intractable social and psychological problems, chronic diseases and dispiriting trivia to treat, are themselves the victims of stress, tending to alcoholism and suicide. These are their problems as the doctors themselves voice them.
It is impossible not to be struck by such reminiscences: delivering babies on straw, washing your instruments in chamber pots; leaning out of the pony and trap to chat to labourers in the field; calling at the farm and being offered endless cups of tea – requiring frequent stops behind the hedges; surgeries in a converted stable (three on weekdays, two on Saturdays, one on Sunday), with two consultations going on in the same room; patients strapped to the kitchen table in case the anaesthetic wore off – rough, but, if nothing else, more memorable than hushed consultations in airless health centres just off the High Street. The patients were another race, too: miners sitting on their ‘hunkers’ in the waiting-room, rather than sit on the unfamiliar chairs; poor families of Glasgow sleeping in relays, eight in the bed and 16 on their feet; a coffin on the table with the remains of breakfast around it. One doctor remembers an old couple in a Medieval farmhouse who never washed at all:
He died of old age, and I had to climb up a ladder to the bedroom with a pencil torch, and ferret through about ten layers of bedclothes to see whether I could find the body. I did in the end. More and more layers and finally he emerged, but he had died comfortably in his old age. And I went down and told the old woman that he really had died and she just stood there in the middle, and tears ran down her face, leaving white trickles as it washed the dirt away.
Nothing could have been more just than the social changes that have swept this all aside. But, Gathorne-Hardy muses, ‘walking down the long close-packed rows in local geriatric hospitals, going into yet another tiny warden-assisted bungalow or flat, whether in Newcastle or Glasgow, Bristol or Brighton or London, virtually the same, smelling the same thick smell, I often wondered – is it to produce this that the huge engine of modern medicine has worked and is still working? Was it for this that drains and houses and reservoirs were rebuilt, all those antibiotics and the rest discovered?’ The changes that have happened to doctors are the changes that have happened to everyone else: they are less exploited by their seniors, have more time off, have less satisfying work, are less involved with those among whom they live, are more anxious and less confident, than they used to be. Their views on the many pains of life are the same as everyone else’s. And so are Mr Gathorne-Hardy’s.
This is not a bad book, but it lacks shape, and lacks sharpness. It is a venture in the genre of Akenfield (the publishers woo us by comparing them), but the comparison is unfortunate. To be sure, wheelwrights and blacksmiths make more interesting conversation than doctors; and even a whole book of conversations with, say, wheelwrights would have had its longueurs. But the failure is in the execution as well as the conception. Blythe is suspiciously quiet about his techniques, but he did at least two important things: he went for individuals, not generalities, and he edited cleverly and ruthlessly. It is a paradox, but a familiar one, that in trying to arrive at generalities, Jonathan Gathorne-Hardy has aimed to say more and ended by saying less.
‘Battered by the commonplace’: this redolent phrase summed up for one doctor the experience of being a GP. It is understandable that so many doctors in general practice, faced with an exhausting and unceasing barrage of demands, become battered by the commonplace, ground in the mill of the conventional. Reading this book, we too feel battered. There is too much of it, and the level of reflection does not make for intelligent reading:
When I said I could have been a psychiatrist I simply meant it doesn’t require much intellect. I used to think that psychotherapy was bosh but in fact all GPs have to practise it on a simple level. ‘Well, Mrs Smith, that little lump in your breast is nothing more than a small gland. If that’s what’s been worrying you, go away and forget about it.’ Obviously you get more complicated problems – mental or bereavement problems – and these require talking about for a while, for five or ten minutes, on a weekly basis. But I will not go in for 20-minute sessions of psychotherapy ... The worst cases are the long-standing chronic psychiatric problems that have come back and back and back. I’ve got one patient who has been twice a week for twenty years with no change in her condition.
The doctor is all too genuinely baffled. According to a study quoted in Doctors, ‘a high proportion’ of medical students ‘left Edinburgh with views that at least indicated insensitivity towards, and at the worst a positive hatred of, people and patients’. At last, as Gathorne-Hardy notes, medical schools such as Southampton and Newcastle are attempting to humanise the study of medicine, and equip doctors in some measure for practice. These and other general issues are briefly discussed: the arguments surrounding generic prescribing, the role of paramedical services, private practice, and so on. Faced with either dropping altogether the doctors’ haphazard reflections on these subjects or expanding them to a length appropriate to the complexity of the issues, Gathorne-Hardy settles, not surprisingly, for supplementing their musings with some of his own, in an uneasy compromise which sometimes works.
There are still a few individuals. ‘A general practice is more of an arboretum than a pine forest,’ says one of the doctors, presumably from a large practice. And it is the individuals one remembers: Dr ‘Sam Locking’, a rural practitioner in Cumberland, who, when Gathorne-Hardy arrives, is book-making at the Newcastle races. As a young man, Dr Locking had very much wanted to become a parson – more precisely, a bishop – but had failed Latin matriculation. He left for Ireland, where he lived by smuggling, until, as he puts it, he ‘drifted into medicine’. A kindly, civilised man, more interested in talking about Johnson and the Thrales, or his collection of watercolours, than in offering an opinion on the value of social work, he seemed able to enjoy his practice:
A busload arrived and I was called to this old lady who’d fainted. When I got there I found she was dead. The trouble with this town is there’s no mortuary. I knew it would upset them all if I said she was dead. I got them to strap her into the passenger seat next to me. Her son in the back (I told him). We drove round to the police station – it simply looked as if she were asleep. People kept on coming up to chat. Old Jock Thomas came up. He’s the biggest gossip in the place. ‘What’s up with her?’ he said. ‘She’s asleep,’ I said. (Poor chap in the back!) ‘What you sitting there for then?’ ‘Bugger off, Jock,’ I said. Do you know, we were there an hour waiting for the ambulance.
The most attractive characters all have this insouciance. An enormous white-haired, ruddy faced Australian doctor, whose consulting-room in an inner-city slum was entirely occupied by a set of golf clubs and a receptionist called Shirley who sat in on the interview, offering her opinions, swinging her legs and doing her nails, seemed cheerful and robust, like the family butcher. By contrast, a rather sensitive woman GP was both depressed and depressing, a natural victim of her patients, one of whom, ‘a very strange West Indian who reckoned he was an important sort of person’, put it about that she was paying him to have sex with her. The woman doctor whose fortress-surgery I described earlier had the necessary relish: ‘I wouldna look for another place. I enjoy it. They’re a feckless immoral lot but I like them.’ To try steadfastly to engage with the commonplace, and, equally steadfastly, to disengage from the tragic; to relish sheer humanity and find humour where you can is the best you can hope for. But there comes a point where there are no defences. Berowne, despatched at the end of Love’s Labour’s Lost to ‘jest a twelvemonth in a hospital’, drops his invulnerable charm, his patience suddenly exhausted. ‘To move wild laughter in the throat of death? It cannot be, it is impossible.’ There is nothing here the reader can learn, no comforting message, no defence against the assault of a few simple images. ‘My worst ever experience was having to kill a child of two ... it was like killing my own daughter.’ The teenage suicide on the shiny metal table: ‘ “Too young to die,” sang the mortician, working away.’
Bulimarexia, a new book on a new disease, does not make one feel hopeful. A psychic condition overwhelmingly affecting females, the physical manifestations of which are alternate bouts of gorging and purging, ‘bulimarexia’ (the name is a contraction of bulimia and anorexia) is a vivid instance of that general shift of emphasis from organic to psychological conditions which has transformed general practice, and which GPs are understandably loath to face. One can imagine the brisk diagnoses and banal brush-offs which some of the doctors in Gathorne-Hardy’s book would offer. Despite the number of women who are now themselves doctors, the patronising attitude to women in some sections of the medical profession is disgraceful. Women with psychosomatic disorders will indeed be lucky if they get a sympathetic and informed hearing; as it is, few patients with bulimarexia bother to go to their doctors. Yet the disease is a serious problem for countless women. Spontaneous vomiting is habitual; in an attempt to purge, some women take up to sixty laxatives a day. The illness often stems from depression, and leads to severer depression, and, to make matters more complicated, anti-depressants tend to aggravate the craving for food. Depression is further fuelled by guilt over the lying and stealing which is often necessary to cover the enormous food bills incurred. Further complications include tooth loss, severe mouth diseases, tearing and haemorrhage of the oesophagus, hiatalhernias, exhaustion, numbness, erratic heartbeat, kidney damage and, in severe cases, paralysis.
The most susceptible are white, middle-class young women, with what this book describes as ‘traditional’ values, aiming for success in conventional terms and for the most part achieving it. Low self-esteem and a dependent eagerness to please are probably the most important single characteristics. Typically a bulimarexic is anxious, lonely and a perfectionist. The Whites have an explanation – but only one: men. Fathers, husbands, brothers, lovers: once again, having been up all night in the police cells of feminism, they troop into the dock, a haggard crew. A condition almost exclusively affecting women, a cause almost exclusively implicating men – it’s obvious when you come to think about it. And indeed who could dispute that many of the problems experienced by women are the result of their relations with men – as many of the problems experienced by men are the result of their relations with women. Yet take it further than this commonplace and many more questions rise. First, ought we not to acknowledge that there are very many reasons why people are anxious, lonely or lacking in confidence? Second, do men not suffer in these ways too, though they may be conditioned to show it less – perhaps an added strain? Third, are men not equally subject to the tyranny of expectations, and equally liable to a sense of guilt if they do not fulfil them? If women now find themselves competing with men at work, they themselves have struggled to get to this point; and it is still true that if a woman chooses not to do so, or does so only at a low level, no one will make her feel guilty, whereas if a man is not successful at his work he risks losing the respect of men and women alike. Perhaps this is wrong, but it is a fact. At home the man is expected to share the running of the house and the looking-after of the children equally with the woman – and this is good. He is expected to exemplify traditionally male and now also traditionally female ways of behaving. No doubt this is as it should be. But it does little to explain why women suffer from bulimarexia to pretend that it is only women who are subject to the expectations of others, whether parents or partners.
Someone will object to the idea of the ‘traditionally’ male or female, but it is the feminist authors of Bulimarexia who speak of ‘traditionally feminine values’. Here, too, there is unacknowledged complexity. For ‘traditionally feminine values’ are at one moment a source of strength, virtues from which women have been led to depart by the demands of a man’s world, and at the next moment bonds to be shattered. Similarly the passing of virginity is lamented on one page – ‘the so-called sexual revolution of the Sixties did away with this important psychological protection’ – and applauded on another as bringing an end to ‘unfulfilled pleasures, confusion, guilt, fear and disgust’: one notable feature of bulimarexics, according to the authors, is that ‘promiscuity, liberal or carefree sexual attitudes and multiple sexual relationships are conspicuously absent from their lives.’ Fathers equally suffer from this Catch-22: while they are generally at fault for being dominant, or ‘successful and powerful’ in their daughters’ eyes, they may also in individual cases be criticised on grounds of being ‘weak, kindly, passive and ineffectual’.
These problems are genuine, and are problems for feminism in general. Should women aim to preserve their virginity, or to sleep around – or sleep only with other women? The wisdom changes. Is it better for women to compete with men on men’s terms or to hold out for what are seen as distinctively feminine values and qualities? This book simply registers confusion and blames it on men. Why indeed should women be expected to do everything? Why should men? Everyman and woman is now compelled to attempt what in the past only the members of a leisured professional class attempted, and then as the combined product of the labour of an entire household, including domestic servants. No wonder anxiety, inadequacy and depression ensue.
Wherever there has been affluence and leisure, at the end of the Late Roman Empire or in 18th-century England, people have congregated in hot baths. Behind the talk of health, there is, above all, a craving for consolation: the hot water soothes and pampers, an undemanding image of a mother’s love. In such places at such times, too, gorging and vomiting have been ritualised: food dulls anxiety, answers longings, fills the emptiness, soothes the desolation – offering immediate tactile assurance until by excess the body is forced to reject it. Now in America, the conditions are right once more, but this time it is all more private, less ritualised; the baths – jacuzzis, hot tubs and sulphur springs; the food – quietly, shamefully exhausting the body in an attempt to feed the soul.
There is a sense in which the answers to the questions ‘why women?’ and ‘why food?’ come together. It isn’t the case that more women suffer than men, just that they express it differently. The familiar duo of self-love and self-hatred dictate the two great all-pervading fads of modern life, particularly modern American life: food and exercise. Never has so much earnest energy been lavished on them. How do men with ‘traditionally masculine’ values see themselves? Strong, vigorous and aggressive – hunters and defenders. Their anxiety about themselves expresses itself through exercise. They run till they drop, till they are sick, till they faint. They punish themselves with ever greater demands. They exercise in ‘work-out rooms’ whose weights and cumbersome machines of leather and metal look like sophisticated machines of torture, and where they jump and pull and stretch and strain to the relentless thrashings of aggressive, sometimes vicious music. An eerie blend of narcissism and masochism, the cult both cherishes and destroys, by straining and overbuilding, the body that is loved and hated. And the state of oblivion it induces banishes anxiety – for a while. Drink, too, can fulfil these ends. If men should be powerful, drink will make them feel so, though it destroys their potency. It too consoles, simplifies, allays the pain, until the body revolts and is sick. Mamismo encourages stuffing with food, machismo martyrdom through drink.
What could be more natural than that women who have ‘traditionally feminine’ values should express their self-love and self-hatred in a traditionally feminine way – through food? As excessive exercise impairs health and strength, so excessive eating impairs health and beauty. Men and women, it seems, conspire to destroy themselves by loving themselves to death in traditionally male and female ways. Naturally not only in these ways: as women come to see themselves as more competitive and aggressive they also abuse themselves through exercise. The Whites remark that ‘some women combine different methods of exercise as well as experimenting with bizarre diets’; they are ‘likely to exercise compulsively, swimming many laps, running many miles, working out with barbells and weights’. ‘I especially like to torture myself,’ says one woman, plaguing herself with pictures of ‘rich, gooey desserts’ while trying at the same time to go without food. ‘When the obsession with food leads to hoarding – as it frequently does – the torture becomes even more exquisite and the anxiety that results is extreme,’ the authors comment. Another writer describes her compulsion as self-abuse, an almost sexual love and attention: ‘All the stuffing and subsequent self-abuse has helped to pass time that should have been devoted to someone else.’ An obsessional displacement activity, eating, like other forms of self-abuse, leads to guilt, and guilt leads to purging, both to punish and to undo the damage. And so the cycle continues. For some, there is the ‘ecstasy of relinquishing control and surrendering to food’. As many of those who suffer from bulimarexia have led very disciplined lives, losing control is initially exhilarating, then shameful. Modern life is full of institutionalised ways of losing control: aerobics, disco-dancing and, for those who view it in this way, sex are social activities – drinking and eating are solitary. Exercise used to be a sociable business, but the fitness fanatic, running, swimming or lifting weights, pursues a solitary goal – the loneliness of the long-distance runner. And as the Whites record, their behaviour helps make some bulimarexics feel unique.
Bulimarexia is a serious problem. This book will do good if it lets people know that they do not suffer alone. Otherwise it is hard to recommend. There is a good deal of talk about ‘targeting specific behaviors’, ‘goal contracting’, and ‘interacting’ with ‘significant others’. ‘Many a bulimarexic,’ we are told mysteriously, ‘embraced hypoglycemia as her cause célèbre.’ We ourselves are encouraged to make ‘a brief sojourn into our past’ before asking ourselves, horribly enough: ‘What tense am I in?’ Statistics are loosely used and inaccurately quoted. Some statistics relating to the sex of psychiatrists seem to show an unusual logarithmic growth in the number of hermaphrodite therapists during the Sixties, from 100 in 1960 to 1340 in 1970. Just another shoddy book from the PhD mill? Worse, I think: it does us all a disservice by fostering deeper mistrust between the sexes, and it does those who suffer from this strange and distressing condition a disservice because, despite its argument that any cure must begin with the acceptance of responsibility for one’s own life, it encourages them to start by blaming others.