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Dr Ian Lacy Presidents address -- 18th October 2016 -- Mind the Gap between the Hemispheres

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Mind - the gap between the hemispheres

Introduction

This essay is based on the President’s address to Lincoln Medical Society October 18th 2016.

I trained as GP in Huddersfield and then spent 6 years with my wife working in a church hospital in rural Pakistan before joining the Nettleham practice in 1987. In the 27 years I was there I became involved in most of the changes in the structure of the NHS since 1990, ending as clinical vice-chair of Lincolnshire West CCG for whom I still work as an advisor.

My interests have always tended to be in structures and the ‘ecology” of organizations rather than technical detail. I do not have the mindset (or the patience and persistence) for clinical research: I am the sort of person more interested in how a railway works as a system than in the technical details of the locomotives that make the system work. When it comes to history I prefer the satisfaction of piecing together the picture of a period rather than the meticulous analysis of the detail, while accepting that without the latter the former becomes blurred and bitty.

So the books that I enjoy most are those that “pull it all together” and give the big picture. I recall the deep satisfaction of reading the chapter of my “A” level chemistry textbook that covered the concepts of electron shells, deep satisfaction of reading the chapter on electron shells, valency and charge which really made me understand (at least then!) how atoms work

A historical example would be Peter Ackroyd’s broad narrative sweep of 3,500 years of English history to 1513 in “Foundation” which puts together all those events- Viking invasion, 1066, Magna Carta, the princes in the Tower that usually come across as fragmented incidents and makes a coherent story of them.

But perhaps the biggest picture of all is the quest for the explanation of how the activity of neurones results in the functioning of the most complex object in the known universe-the human brain. How does the neurochemistry and neurophysiology associated with those neurones result in self-conscious minds? And how does the interaction of multiple minds result in societies and cultures that can actually ask those sorts of questions and build big pictures?

We to be a long way from an answer to explain the emergence of self conscious minds (indeed there are people who think it is an unanswerable question) but progress in understanding the function of the subunits of the brain – starting from the effect of the tamping iron blasted through the left frontal cortex on Phineas Gage’s personality to the latest MRI studies – has pr0gressed a long way.


Ian McGilchrist’s book “The Master and his emissary” takes the details of the relationship of the subunits of the brain that interact to give us our “mind” and puts them into a whole picture that I as a definite non-neurologist can begin to grasp, especially in terms of how the biggest assemblies of subunits-the two hemispheres interact. More than this: he gives a working hypothesis of how a collection of brains – many minds interacting together – produce culture and gives a coherent story of why as western society we are in the state we’re in, a story we can then reflect on and do something about. Not surprisingly this big picture – neurology to the history of Western Civilization – has made the book a seminal read for me.


Outline

In this essay I want to share what I understand to be McGilchrist’s insights into the question of why we have one brain in 2 hemispheres, what the specific role of each (especially the fronto-temporal cortex) is, how they interact and why we need both to for our minds to fulfill their “design potential”.

I will then attempt to illustrate his to story of the 2500 years of interaction – indeed struggle - between the hemispheres that lead to the development of our current western culture by looking at the history of medical culture using some representative individuals as exemplars.

Finally I will attempt to summarize where I think our medical culture is now and what we might be able to do to rebalance the approaches of the right and left hemispheres in order to get out of the cul de sac I believe we are in.


Why two hemispheres?

All vertebrates have 2 hemispheres, linked by the corpus callosum. The question is why – especially as the embryonic neural tube starts off as a single structure.

Of course we know the brain’s functions are lateralized; the left side of brain controls the right side of body. But why split the brain in two to do this? And why are the 2 hemispheres in humans so different? The right is larger, has more white matter (because of the increased connectivity between regions in the hemisphere compared to the left) and has more noradrenaline and less dopamine receptors than the left.

The question becomes even more complex when we realise both that the corpus callosum seems to carry mainly inhibitory signals and that the more complex the brain the (proportionately) less connections between the hemispheres. It is almost as though the two hemispheres were designed to have the capacity of independent function: indeed much behaviour can apparently go on as normal even when the corpus is divided, as it was in some of the early twentieth century attempts to treat intractable epilepsy

The conclusion has to be that the 2 hemispheres - although interacting in a dynamic way – have different functions.


McGilchrist associates the divided brain with 2 views of reality, both needed to make vertebrates fit for purpose in a dynamically changing environment. To summarize the complex evidence into simple conclusions:

a) The right hemisphere’s function is to be open to the world – the wider environment - with general flexible attention, seeing the whole, aware of distance and the passage of time. It takes data and processes it into information.

b) The left hemisphere specializes in manipulating the information the right hemisphere passes to it, using focused attention, putting the pieces together to come to conclusions – evidence which it can use to manipulate the environment and also pass back to the right so the right can assimilate it into a “world view”


A pigeon pecking grain needs to be able to focus on the task in hand – visually recognizing the grain, planning to step on to the next piece, making the fine motor movements to pick it up.

It does this routine manipulative task using its left hemisphere to identify the grain with the right eye and sets off the sequence of pecking with the left hemisphere

At the same the pigeon needs to be aware of a wider reality: its environment, potential threats, spatio-temporal awareness, relating to its mate and chicks. (As a chick itself it imprinted to give social interaction on its parents with its left eye and right hemisphere).


If it encounters a new sort of grain or a threat it will use its left eye and right hemisphere to assess it until the object becomes familiar and it has a developed a left hemisphere routine to deal with it.


It goes further – pigeons can arrange pictures of daily life in two ways. They use their left hemisphere to group objects by common features (all sorts of seed must be small and rounded) and their right hemisphere to classify in terms of context – seeds are things best found in open fields.

It is the same in humans – the left brain is organized to deal with ordered, sequential, logical purposes, setting up routines, giving focused attention and working from the particular to its own picture of the complete while the right brain gives a much broader approach, working from context, identifying and producing emotional expression and social interaction, changing situations and seeing things in context of the wider world.


I am generalizing here about lateralization. What I have said is true of 85% of humans and there are others whose hemispheres simply mirror image the norm. People who have mixed lateralization of function may have special advantages and disadvantages in their overall functioning.1


Compare driving a familiar route with going to a new destination in an unfamiliar town.

As I drive my usual route down Monks Road my left hemisphere goes through an automatic routine and I can get to the end with no recollection of how I did it because my right hemisphere was preoccupied with the purpose of the journey. But if something unexpected happens such as a child jumping out then the bit of my right brain that isn’t totally absorbed with that will (I hope) identify the threat from the wider world and inhibit the left hemisphere’s programmed behaviour to keep the accelerator just so at this point.


Contrast that to driving to somewhere new. My focus is on what I have been told to look and the satnav information. My right hemisphere is preoccupied with absorbing that information about the wider world and making analytical decisions about the actions I need to take, It then passes the message to the left to turn into the necessary motor actions. My right hemisphere directly controls the activity of the left: the left feeds back what it has done to the right and I have no processing capacity left for thinking about dinner!


Speech.

Speech is taken to be a left-hemisphere function, which is true as far as the understanding, and production of words goes. But the deeper levels of language – emotional slants, intonation, humour, metaphor and imagery, all needed for language that truly communicates, are all right hemisphere functions. And because we need language and not just words to think both hemispheres are needed.

In summary the right hemisphere is better at general problem solving and deduction but the left hemisphere is better at linear sequenced argument and at managing things away from their context. The right has an approximate sense of number –but the left hemisphere is needed for precision.

In the broadest terms we make contact with our environment using right hemisphere functions. The right hemisphere passes sensory information (including emotional information) to the left for detailed processing, analysis and manipulation away from the ‘external noise” constantly flooding into the right. The analyzed result is then passed back to the right for assimilation into our overall perception of our world.


Or one could say that data from ”outside” becomes information that then becomes understanding and eventually wisdom, the ability to live fully in the world as it is. But this is the ideal balance and it depends on both hemispheres “recognizing the capacities and limits of the other. If one becomes too dominant the brain –the mind – does not function to optimum capacity. The left hemisphere does not see and understand in the way the right does, even though it is good at pretending it does and because it can manipulate the world and act in routine situations independently of the right and produce results it has the tendency to seek to become autonomous, depending on its own internally constructed picture of the world and incorporating information from the right in a way that fits in with its preconceptions.


As McGilchrist puts it the emissary which should be managing the world on behalf of its master –the right hemisphere – sees its success, gives itself all the credit and attempts to set itself up as having its own authority, to the extent of down playing the master right hemisphere’s relating and integrative role.

But because its analytical thinking can only go so far and is not balanced by the insights of the right it can get out of control and construct a self referenced world which increasingly ignores the reality of the real world as seen by the right hemisphere. This can result in “The Sorcerer’s Apprentice” type consequences.


This is not a mere hypothesis: McGilchrist quotes experimental evidence to show that the left hemisphere accepts authority rather than the evidence of the senses coming from the right and instead will produce explanations for evidence that does not fit its own version of events, even when that explanation flies in the face of reality2. It is well known that with a right hemisphere stroke the left may say “this paralysed left arm is not part of me”, whereas with a left hemisphere stroke the right hemisphere accepts the reality of paralysis (even if the ability to speak about it may be have been lost)





The see saw: an overview of western culture

The right hemisphere really matters in terms of broad perception, wisdom, social interaction and empathy. It needs the left hemisphere to do the focused processing –but the better the left brain gets at this, the more data it turns into information, the more it can effectively manipulate the world (it is the right hand-left hemisphere –that grasps) and the more independent it tries to become. McGilchrist sees the history of Western culture as a seesaw tussle between the master-the right hemisphere – and its unruly un-insightful emissary, the left. Although a move forward in one hemisphere releases a movement in the other resulting in deeper understanding of and interaction with the world the left hemisphere comes to usurp authority resulting in a rigid logical approach to the world which can easily become mechanistic and authoritarian. The lack of insight and increasing failure to connect with wider external reality (indeed its denial of the validity of the right hemisphere’s more intuitive view of the world) results in problems for a society. In the past periods of left hemisphere dominance in culture have resulted in contradictions that cannot be indefinitely ignored and the Master right hemisphere redresses the balance. The big question for current Western culture is whether its collective mind still has the capacity to recognize the contradictions of two centuries or so of left hemisphere dominance and incorporate the capacities of the right in order to avoid disaster.


Greek Medical culture

In the second part of his book the author considers the impact of this right/left hemisphere see saw on Western cultural history. He starts with the sudden extraordinary flourishing of Greek culture between about 500 and 300 BCE.

Just why Greek (or any culture) “took off” is a question we can’t deal with in detail now. The time scales are too short for classic genetic change and natural selection: epigenetics may play a part and given the right economic conditions and political stability ideas can spread rapidly whether you accept Dawkins “memes” or not.

McGilchrist suggests that an enhancement of bilateral frontal lobe function taking place at this point enhanced the ability to put “necessary distance” between the world and the mind contemplating it, so that the left hemisphere could feed back to the right its own specialized analysis of the right’s experience of the world, thus enhancing perception. He uses the change from stylistic depiction of faces in earlier art to realism in classical heart as an example of what resulted.3

For the first time in the West two hemispheres worked together in harmonic tension –each enriching the other and producing an outpouring of drama, art and observation of the world (above all Aristotle) that had never happened before and which continued (though gradually becoming more formalized as the Roman genius for organization gained ground) for perhaps 600 years.

Medicine too was caught up in this classical dawn. Medicine before this era involved the use of plants, trephining and almost certainly the invocation of a spirit world as well as the practicalities of managing injuries and wounds.

Even this “pre Greek” medicine involved both hemispheres – the right serving to recognize possibilities, the left trying them out, giving focused attention to whether those white berries would kill or cure –then handing the information back to the right hemisphere to put into a wider context – “White berry – helped the cough – reduced the phlegm – calms.”

The right hemisphere can then produce a wider conclusion: “Perhaps cough is due to an excess of phlegm that needs rebalancing”, then going on to generalization: “perhaps all disease is caused by an imbalance of humours: indeed the human personality is determined by the balance of these humours in a particular individual.”

Hippocrates brings his medical training Into the ferment of the new Greek cultural background. He was active when there was still a respect for the testimony of the senses, a right hemisphere respect for the natural world as it is: a respect that diminished when Plato began to prioritize categories -analysis - over experience and gave more importance to the idea of things than the things themselves (the balance swinging to the left hemisphere).

Hippocrates could be seen as epitomizing the right and left hemispheres working in harmony: he based his work on observation of the real world, made analytical deductions from it and focused on the patient as a whole, rather than as the sum of its parts: all right hemisphere traits. (His work “On airs, water and places” suggests the broad awareness of the world a public health doctor needs)

At the same time he had a systematic framework, separating medicine from religion, using a categorization method (the humours) that acted as a framework, dealing with specific situations in isolation from the wider world when appropriate as in his work “On fractures: the approach of the left hemisphere specialist.

The influence of this balanced approach to medicine seems to have endured during the Graeco-Roman period, even while in many ways the left hemisphere was beginning to dominate as suggested above.

Galen in the second century AD was a pioneering anatomist (of animals: human dissection was prohibited) specializing in nerves, heart, lungs and pulse and had a system of therapeutics but he was also concerned with disease prevention and a healthy equilibrium in lifestyle: he introduced “talk therapy” for psychological problems.

He was also a philosopher – coming down in the middle ground between pure empiricism (right hemisphere) and the use of traditional teaching to establish new theories (left hemisphere)


Mediaeval medical culture

After the conversion of Constantine the church became the intellectual powerhouse of Western culture. But it tragically lost the openness to the world of its early days4 and became more and more enmeshed in theory, abstraction and concepts, adopting the Platonic method of concentrating on the form, the ideal rather than the reality. To quote McGilchrist: “A passion for control, fixity, certainty- not just because it was religion but because that is how the left hemisphere operates”.

To be fair the collapse of the Roman Empire in the west and the struggle to survive the onslaught of invasion and instability tended to favour an approach that concentrated on survival and during the 12th century the rediscovery of Greek philosophy and especially Aristotle resulted in the proto-renaissance of the “high middle ages” with the glories of Gothic architecture, the foundation of the first universities and scholars such as Anselm and Abelard.

Hildegard of Bingen (1098-1179) demonstrates how this approach could be applied to medicine. Medicine had continued in the remembered traditions with more and more reliance on the authority of Hippocrates and especially Galen but without adding to their observation of the real world. However Hildegard combined a detailed knowledge of the scientific and medical properties of plants with a holistic concept that linked the “physical microcosm” of human life to the “green health” of the macrocosm - the natural world.

Her books “Causae et Cura” move from the creation of the universe through to diagnosis and treatment: surely an example of right and left hemispheres working together. She was also a composer, poet, mystic and administrator: a ‘renaissance woman” before there was such a thing as Renaissance man!

But as before this balance of right and left hemispheres tilted towards the left again. Thomas Aquinas was perhaps the greatest mind of the Middle Ages but his work was directed towards systemization and the synthesis of Aristotle’s ideas with Christianity as an authoritative basis for theology and philosophy in the later Middle Ages (and beyond).


There continued to be medical observers of the world as it is: the English surgeon John Arderne (c.1307 - 77), wrote on eye treatment and the cure of anal fistula, using illustrations from life, but medicine as a whole continued in the Galenic tradition and was had little to offer to help the diseases of everyday life, let alone the Black Death.


Renaissance medical culture

It could be argued that “The Great Thaw’ (Kenneth Clark’s description) of the 12th and early 13th centuries lead into the Renaissance spring without the left hemisphere interposing much of a rigid authoritarian period, except in theology: but in the late 13th and early 14th century there was (as in Greece two millennia before) the beginnings of an almost quantum change in the relations between the hemispheres which went much further than the changes discussed in the last section. Again there is the creation of necessary distance perhaps due to the increased security and leisure that prosperity bought: Italy and especially Florence where the Renaissance started was the most commercially advanced society in mediaeval Europe. In addition the rediscovery of a wider range of Greek and Roman classical authors opened the way to a rediscovery of their way of looking at the world.

For the first time for centuries men began to see again aspects of the world that had been neglected. Giotto (1266-1337) in painting and Petrarch (1304 – 1374)5 in literature opened the way for the 15th and 16th century flood tide of art and philosophy that focused on man and his place in this world rather than his concerns with the next.


On a recent visit to the Accademia in Venice it was fascinating to see how the background in religious paintings changed from plain gold decoration to landscape with increasing distances - ranges of hills with the rediscovery of perspective, scale and the fading of colour with distance and how the size of figures ceased to be determined by their importance. The right hemisphere was seeing things as they are rather than being forced by the left to make them conform to theory. And the left hemisphere took this rediscovered view and assimilated, analysed, worked out ways of transforming renewed perception into paint and fed them back to the right hemisphere resulting in fruitful tension and growth.


The perception of things as they really are applied to science too, although the reverence for the rediscovered classical texts and the resultant re- emphasis on the ideas of Aristotle and Ptolemy probably inhibited the development of an observational approach until the second half of the 15th century. Copernicus (1473- 1543), Da Vinci (1452-1519) and Vesalius (1514 – 1564) challenged the accepted wisdom: Vesalius was able to dissect humans and showed that Galen had been wrong to generalize from primate anatomy.

The practical application to healthcare was perhaps slower, perhaps due to the innate conservatism of medicine and the lack of microscopic and physiological understanding before the 17th century. However Amboise Pare’s observations leading to more effective treatment of battlefield injuries is an exception.

The Swiss German Paracelsus (1493 – 1541) although his roots were in alchemy took the medical pendulum still further to the right hemisphere. Not only did he believe a physician should have a sound knowledge of the natural world (he named zinc and may have introduced laudanum to Europe) but he also thought like Hildegard that health depended on a balance between man and nature, though mediated through chemicals rather then the humours: his system of therapy was based on chemicals rather than plants.

Even more radically he claimed that only those who practice an art truly know it and rejected ancient authority in favour of the inspiration of the physician to recognize diseases and cures. He burnt (or rewrote) ancient manuscripts that he saw as obstructing progress and invited barber surgeons, apothecaries and astrologers to work with him. Not surprisingly he provoked the wrath of the university establishment!


Reformation

The emphasis on going back to origins and the challenge to established left hemisphere authority and tradition also applied in the religious sphere. Erasmus’s production of the Greek New T (1516) and Luther’s (1483-1546) insistence on interpreting scripture outside the norms of the Church and then applying it to contemporary abuses can be seen as a radical right hemisphere challenge to traditional authority that lead to the spiritual and intellectual liberation of the early Reformation.

But the “uncontrolled extremism” of right hemisphere radical Protestantism of the early 16th century – the same atmosphere that produced Paracelsus – and which increasingly rejected all authority came to thoroughly alarm the later Luther and his successors, who were becoming part of an ordered establishment.

There was a swing back again to left hemisphere “abstraction, coupled with a downgrading of the realm of the physical, a preference for what is single, fixed, static, literal rather than metaphorical meaning”(McGilchrist). In religious terms this meant a swing from radical living to a stress on theology: “believing” became a checklist of what one could not do rather than an inspiration for what one could.

There was little room in this world for the unorthodox physician. In Calvin’s (1509- 1564) Geneva the physician worked in close collaboration with the church and state leadership and seen as someone called to work with God and the patient to allow the disease (a secondary tool of God) to bring blessing or discipline, very much part of the ordered system.6


Elizabethan England pursued a middle way: rejecting the extremes of traditional Catholicism and radical Puritanism gave men like Shakespeare and Dr John Caius (1509 -1564)7 the capacity to demonstrate the best of the Renaissance symbiosis between the hemispheres.

Having studied with Vesalius at Padua Caius was the first to introduce the study of practical anatomy in England and made detailed observations of natural history and of the sweating sickness. But he also spent time in Italy searching for old manuscripts of Galen and Hippocrates to demonstrate they had been mistranslated so as to uphold them against Vesalius’s discoveries – a left hemisphere sort of activity.

He does not seem to have made any great therapeutic advances but he did have a holistic view: as three times president of the Royal College of Physicians he looked both to tradition and to the future (a sense of time is an attribute of the right hemisphere) – probably designing and certainly presenting the caduceus.

He also achieved the distinction of being accused both of Roman Catholicism and atheism, surely evidence of a truly balanced approach! Above all he seems to have been a humanist in the best sense: “The president (of the Royal College) shall act with gentleness and clemency unlike those (of) olden times who ruled with a rod of iron”.


The end of the Reformation period around the late 16th - mid 17th century saw the start of the scientific revolution. Men like Kepler 8 (1571 – 1630) in astronomy and Harvey9 (1578-1657) in anatomy paved the way for Newton (1643-1727) in physics and Leeuwenhoek (1632- 1723), the discoverer of microorganisms “built on the shoulders of the giants who went before”(Newton), a process which the openness of the early reformation had made possible (see Schaeffer (”Escape from Reason” 1968)

But the actual practice of medicine (as opposed to say Harvey’s discovery of the real nature of the circulation) was not much touched by this and remained much the same – traditional Galenic humoral theory still provided the theoretical framework, with treatment other than surgical aimed at correcting imbalances with bleeding, purging, emetics and sudorifics.


The Enlightenment

As the turmoil of the 16th and of the first half 17th century began to settle an equilibrium between right and left hemispheres was re-established which reached its full flowering in the early 18th century with its harmony and balance (think Handel and Harewood House) and acceptance of human weakness.

But by mid century this rebalancing had become the Enlightenment whose theoretical basis was (McGilchrist quotes from Isaiah Berlin’s “The Roots of Romanticism”) “that all genuine questions can be answered, that a question that cannot be answered is not a question and that all answers must be compatible with one another: the three propositions upon which the whole western tradition rested”.

Man is now seen as in control of his destiny (especially with the fading of “practical religion”). And that began to allow the left hemisphere to dominate again: there was no longer room for ambiguities, for the possibility of both opposites both being true, for metaphor. The existence of God was not denied but his role was as the divine watchmaker who having created and wound up the mechanism left it to run according to the laws he had established: there was no possibility of any direct divine intervention or the intuitive empathetic imaginative approach of the right hemisphere. The mind became a passive observer, objectifying a mechanistic world and eventually us as well. It was the world of Adam Smith (1723-90) and the invention of what was to become rational economic man (although Smith did see “mutual sympathy” between individuals as the basis of “moral sentiments”.

Nature itself became an object to be viewed and redefined in terms of what reason says it should be It was the age of Lancelot “Capability” Brown re-arranging landscape to conform with an ideal.

The practice of medicine remained dominated by tradition. This may have been at least because partly because the 17th century revolution in the physical sciences did not really spill over into the biological ones: the emphasis was still on structure rather than physiology. Carl Linnaeus (1707-78) was medically qualified but is best known for the development of taxonomy: a vital task for understanding and classifying the diversity of the natural world but a very left hemisphere task

There were sparks of intuitive contact with the world in Edward Jenner’s (1749-1823) imaginative insight that lead to smallpox vaccination, William Withering”s (1707-78)10 observation on the effects of digitalis on dropsy11 and James Lind’s (1716-94) work on scurvy which formed the first clinical trial, combined right hemisphere perception and imagination with left hemisphere organization and measurement.

But most therapy stayed the same – Patrick O’Brien’s fictional surgeon Stephen Maturin (in the Master and Commander series) was an enlightened and humane man, an extremely able surgeon (definitely left hemisphere!) but apart from mercury for venereal disease12 had only the same heroic measures as Pepys’ doctors had had 150 years before.


Romanticism

The left hemisphere pattern of theory and abstraction culminated in the `French Revolution, at that time the ultimate example of abstract concepts being taken to their logical conclusion, only to find that the pursuit of liberty, equality and fraternity meant worse than nothing if divorced from the real world. Even before then the reaction to objectification had begun. The right hemisphere was fighting back.

The Romantic Movement was a response to the realization that there are elements in the real world that do not fit with a totally coherent rational (left hemisphere) view of the world. Differences matter and opposite truths can co-exist. This swing back towards a right-left hemisphere balance still has a major effect on our attitude to the world such as our appreciation of wild places13 and our concepts of romantic love and the centrality of the individual.

We think of the Romantic Movement as primarily concerned with the arts, but Johann von Goethe (1749-1832) was an able scientist working in geologist, optics, botany, and anatomy as well as one of the greatest German poets who is widely seen as the individual who more than any other launched the movement.

At the same time detailed observation and analysis of the natural world gave a huge impetus to the development of empirical science: together the rebalancing two hemispheres enabled men like Alexander von Humboldt (1769-1859) 14 and Charles Darwin (1809- 1882) to begin to build a picture of the interdependence and interaction of the whole of nature.


This renewed empirical and holistic way of viewing the world clashed with the traditional humoral practice of medicine (which had become a matter of routine rather than belief) at the end of the 18th century and laid the way open to the great 19th advances in medicine. Humphrey Davy (1778-1829)15 as a physical scientist had discovered nitrous oxide and its properties in the 18th century. During the early nineteenth it began to be used as an anaesthetic and then came ether, chloroform and antisepsis.

John Snow (1813-58) is a good example of the new scientific but humane clinician who emerged form Romanticism: he was from a very poor working class family but became a pioneer in anaesthetics (administering chloroform to Queen Victoria for her last 2 deliveries) as well as having the broad “ecological” view of the world that made him reject “miasma” as a cause of the Soho cholera epidemic and instead identify the Broad St. pump. This was coupled to the courage and humanity to do take action and the honesty and humility to admit it was probably people moving away rather than removing the pump handle that brought about the beginning of the end of the epidemic.


Scientific Modernism – the triumph of the left hemisphere

But the Romantic Movement and the prospect of a re-synthesis of the cultural functioning of the right and left hemispheres to reunite imagination with reason did not last. The Industrial Revolution was gaining strength and now the left hemisphere could not only take a detached “rational” view of the world: it could start to build a machine world in its own image, with the result that when people looked beyond it was to a left hemisphere world that “fed back” positively to reinforce itself. -

There was a move back to “either/or”- with scientific materialism becoming the dominant philosophical force: not only “nature” but society, all of life could be treated as something to be broken down into individual parts, which could be studied and then put back together, the sum being only the total of the parts. The word “scientist” was coined in 1833 to replace “natural philosopher”: the change in tone is very noticeable and to me sums up the change of approach.

“Reality was what science could deal with and only that was real”. The world of sensory experience and the logical deduction based on it came to invalidate the world of ideas and any sense of “the other”.

The view gained ground that ultimately ideas beyond the “scientifically proven” framework can only be our own inventions and freedom is found by getting rid of these “delusions”. The return to mind/body dualism that Descartes had introduced in the seventeenth century came to dominate the modern world. This loss of the right hemisphere view of the world was taken further by the philosophy of Hegel and particularly Kierkegaard. Having rejected the traditional concept of truth and untruth in favour of an attempt to create synthesis from opposites Kierkegaard then abandoned the attempt to achieve synthesis by reason and that everything of real importance could only be achieved by a “leap of faith (Schaeffer 1968). The rational and logical left hemisphere thus became separated from the intuitive “spiritual” right hemisphere with its capacity for imagination and its openness to the widest possible environment –the existence of absolute values derived from objectively existing sources outside man himself. This meant that the only way of incorporating a deeper meaning than the purely scientific into one’s world view or to claim a basis for morality was to make this irrational leap and claim that experience and feelings validated claims based on scientific left hemisphere thinking. And as scientific rationalism developed and its claims became stronger the more improbable appeared the possibility that the right hemispheres view had anything scientifically substantial to offer. Laplace’s’ (1749-1827) alleged reply to Napoleon’s question about the absence of any mention of God form his work on the universe – “I have no need of that hypothesis”16 inevitably became Richard Dawkins’ ‘God delusion”.

Of course not all Victorians took the logic of left hemisphere dominance that far. Many continued in a Romantic literary and artistic tradition: James Clerk Maxwell (1831-79) who has been ranked with Newton and Einstein in the pantheon of physicists was able to reconcile science with a strong traditional Christian faith.

But the divide between right and “rational” left hemisphere and “irrational” right (by the left’s definition) became increasingly marked and I believe it is likely to be the root cause of the eventual separation of “arts” and “science” to produce the “two cultures” that C.P.Snow (1905 -1980) criticized in the 1959 17. The right hemisphere “revival” of the second half of the 19th century Pre-Raphaelites and the Arts and Crafts movement appears to have had few links with the scientific activity of the time and gives the impression of being overwhelmed by the rising tide of left hemisphere ‘scientific modernism” of the early twentieth century.


Medicine of course thrived in the new rational scientific atmosphere. Virchow’s (1821-1902) cellular theory and his insistence on strict empirical-analytic research followed by Pasteur’s (1822-1895) discoveries (which were applied to far more than obvious infections) “enabled medicine to disentangle itself from the flowers of naturalphilosphie” (Shrenck 197318) and become “left hemisphere medicine. Though Virchow did not believe in the germ theory of diseases, or evolution and was deeply committed to public health his statements that “The body is a cell state in which every cell is a citizen. Disease is merely the conflict of the citizens of the state brought about by the action of external forces” and “ medicine is social science and politics is nothing but medicine on a large scale indicate the authority now claimed by scientific medicine. It was now merely a question of who did the best science, and the world must be fitted round the conclusions. In practice the continuing lack of effective drugs (especially antibiotics) meant that medicine was most effective when applied to public health: the compassionate doctor (epitomized in Fides painting “The Doctor” 1887- in the Tate gallery) who could do no more than sit with his patient till the crisis was reached still needed a functioning right hemisphere approach.


As the twentieth century dawned Western man came to believe he was taking a new direction, no longing needing the past but able to remake himself and society in a new model, able to overcome nature and even his own limitations19. This is the rationalistic modernism, which still dominates much of our thinking with a resultant emphasis on function, efficiency, costs, utility (“a home is a machine to live in” – Le Corbusier). A local example of the brutalist style that this approach can result in is Lincoln bus station! 20, built for buses and not for the people who use them.

Rational scientific modernism worked brilliantly (and still does) for the physical sciences21 and for surgery and emergency medicine but when applied to the problems of society or chronic disease resulted in unintended and unexpected consequences. At a superficial level one recalls Sir Lancelot Spratt in “Doctor in the House” who believed all disease was due to toxins “unnecessary” bits of anatomy that could be surgically removed, but the tragedies of thalidomide, rofecoxib and sibutramine are a reminder that there is not a pill for very ill and that the logical left hemisphere approach of maximizing profit when it is uncoupled from right hemisphere “abstract” concepts of honesty, empathy and reflection is dangerous.


Even more seriously the eugenic policies of the early twentieth century which evolved from Darwinian theory (though Darwin himself rejected his cousin Francis Galton’s ideas) and arguably Stalinism and Nazism came from left hemisphere analytic ‘logical” thinking, unmodified by the empathy of the right. Even Mrs. Thatcher’s “Who is society? There is no such thing! There are individual men and women and there are families” (though taken out of the context of a long interview) could be seen as a product of this dissecting tendency: after all she was a chemist!


Although eugenics as science is discredited the widespread and frequently uncritical application of scientific method and the resultant patterns to problems of politics and the practice of medicine has continued and I believe contributes to the current problems we face in healthcare.


Of course scientific method has vastly improved health (I was going to say immeasurably improved- but of course the whole point of scientific medicine is that it is measureable).

In the real world ‘ if I am cut, do I not bleed?” so we suture and do clotting screens and save lives.

I recall a patient –a retired nurse – who cared for the first patient to receive systemic penicillin in 1940 (it had been used topically in 1930 for opthalmia neonatorum). He had gangrene and septicemia following a prick from a rose thorn and initially made a dramatic recovery: a “trial of one”, with the effectiveness tragically proved when it proved impossible recover enough penicillin from his urine to continue and he relapsed and died.


But “scientific medicine” can also result in the dissociation of process and outcome, a concentration on what and how we do things rather than why, summed up in the black humour of junior doctors:“ he died but at least the electrolytes were straight”.

We have continued to rely on the purely left hemisphere dominated “”scientific” approach to problems when it desperately needs to be supplemented by right hemisphere science: imaginative, contextual, and compassionate. Our bleeding patients are harming themselves because they cannot manage with the demands of a left hemisphere world 22


For instance there are now at least 6 classes of non-insulin drugs for diabetes, but anyone who saw the October 2016 Panorama programme will have had it forced home that the problem with diabetes is not the lack of drugs but the people who take them and the diabetogenic society that helps make and keep them obese.


What is worse is that we then say we can use left hemisphere scientific analysis for that problem too and apply an apparently rational solution: a sugar tax, the results of motivational studies, health education. After all, everyone believes in scientific evidence because humans are rational just as we scientific doctors so will act in their own best interests. Government pulls the appropriate policy levers; we give rational advice and set up weight loss clinics.


And of course these do give some results in some people. But as we all know too well from experience with our patients (and dare I say it, ourselves) life may be more than food, but food is much more than fuel! Rational health seeking man is just as much a mythical entity as rational economic man.


The whole of classical economics was built on that concept and after 2008 we know that we are definitely not rational when it comes to economics – just greedy. H L Mencken was right: "There is always an easy solution to every human problem--neat, plausible, and wrong."

Real people have other agendas and helping myself feel good with a cream cake may matter rather more than a 10% risk of a heart attack in 10years (especially as I can quite reasonably say “just one won’t make a difference”).


When this left hemisphere approach is applied to the planning and management of the NHS the potential for problems is even greater. The left hemisphere can only focus on a limited number of activities at a time and when a range of people all with different logical ideas can all press for their own idea without sufficient regard for other ideas (which may imply the need for very different activity) let alone considering the overall context then the result is likely to be confusion, stagnation and potential collapse. We have probably all made the assumption that in a rational organization that responds in defined ways to defined actions reactive operation we only have to put in the correct fuel, lay the correct tracks and pull the appropriate levers to ensure the train will end up at our desired destination. If only..


The tragedy of the NHS is that its left hemisphere thinking fails to learn from experience and even when it repeats logical mantras that “you cannot get through walls by repeatedly banging your head against them it finds it incredibly hard to move sideways and look for a door: it rationalises and either blames the wall or looks for harder heads ! So we have repeated analyses, repeated organisations, repeated pulling on levers –and the same (or worse) crises.







A ray of hope?

However there is some evidence of an attempt to bring back balancing right hemisphere medicine into But I think medicine has partly reawakened to the need for a balancing right hemisphere approach at least in some specialties: GPs , geriatricians, psychiatrists and public health doctors know from “real world” experience that patients are not machines!

But how good are we as a whole profession at applying it in practice? - NICE has only just produced its co-morbidity guidelines.



We all know the real crisis in healthcare is not lack of scientific knowledge but the partial paralysis of our capacity to think radically and empathetically about the social context of our society and our patients because of our left hemisphere obsession with detail, money and cost (as opposed to value) blocks the wider thinking we need but that left hemisphere particularism is deeply embedded in us still. After all it what doctors pass exams in.



The Royal Colleges of GPs and Psychiatrists have recently had to get together to push back against the tide of ‘anti-generalism” in medicine – the “more than banter” that denigrates anything other than “scientific evidence based medicine” and results in a young career doctor saying ‘It’s not a choice for me to be a generalist. I would have liked to have done something more”. That’s the Lord Moran23 of the1950s speaking: “GPs are doctors who have fallen off the specialist ladder”.

There is a call for a holistic and compassionate approach but how far can one teach personal attributes like these as a set of skills and competencies in a curriculum that is already overcrowded with “hard science”? How many medical curricula have a medical humanities section a reading/viewing/listening list of right hemisphere developing works? How many medical school applicants have ever read Hardy, or Dickens or ‘Lord of the Flies”, let alone go on reading them as foundation year trainees?



A New threat

But a least modernism does have an metanarrative, an overarching story the world as it sees it, even if it is distorted by the lack of right hemisphere input. In the past when a left hemisphere meta-narrative began to show inherent contradictions, too much disconnect with wider reality the right hemisphere stepped in (the Renaissance, Romanticism) to redress the balance.

But I believe we are seeing something new. The widening cracks in the modernist story are being filled not by the right hemisphere bringing the whole mind back into contact with the reality of the world as it is (what Francis Schaeffer(1968) called “real reality”) but with another sort of story altogether. Traditional romanticism looked to reground the excesses of left hemisphere thinking in real experience of time and space, distancing and imagination, with openness to new ideas and insights and the willingness to accept that the pure left hemisphere approach might be unbalanced or even mistaken But this new story pushes the left hemisphere view of the world further than ever before until it affirms that there is no external right hemisphere story: no “real reality” to be grounded in, no coherent narrative that can be meaningful to the individual (for such a view denies the individual the possibility that there is anything outside themselves that might give meaning, let alone be shared meaningfully with others.



At the most nothing is what it seems: everything can be reduced to basic building blocks that are ultimately determined by nothing but the randomness of subatomic particles (if they exist). Right and wrong (in all shades of their meaning) are meaningless. This is the outcome of post modernism. Metanarratives of all ages have caused harm (as well as helping create environments in which culture could develop and good be done ) but post-modernism not only throws out the baby with the bathwater, it denies the existence of the bath itself.



Recently I had a conversation with an English literature student who was doing a module on children’s stories. She said that the module took apart all the stories “ meant” as stories and ‘explained” them purely in terms of psychology and the conditions in which they were written. The implication that the stories as stories had no meaning (whatever the authors might have thought). In previous cultural eras understanding psychology and context might help one understand the meaning – but to say that in fact there is not –and cannot be any meaning beyond the assemblage of words, that they are no more than a collection of parts and explanations in a semantic framework determined by a now unknowable environment (for in fact our knowledge of historical context can never be comprehensive enough to make definitive statements) cuts the reader off from any world beyond their own experience as they read.

.

I think, therefore I am”-but what happens to being when the words I think with have no real external reference to anything. I become as meaningless as the random subatomic particles that are my ultimate components.

Of course this degree of alienation is not experienced by everyone (though it may lie at the heart of the frenetic search for novelty in so much that goes on – does anyone except Apple’s shareholders really need an iPhone 8?) but it does mean that anyone can claim any meaning they like in order to fill the void of otherwise meaninglessness, whether its crystal therapy or conspiracy theory.



This approach if taken to its logical conclusion will make objective science that takes a ‘real reality” for a given impossible. I recently spoke to a professor of agriculture who was increasingly hearing his first year students say “I believe that.. my opinion is” .. regardless of the “objective facts” and the professor ‘s insistence that he was not interested in opinions. He was even more concerned that the students were very reluctant to question those opinions in the light of “real reality” facts. I suspect they found it hard to emotionally (right hemisphere) accept the challenge because they had grown up in a culture that is in effect denying there is a world that would continue to exist if we were not here.



One of the many consequences of post-modernism is that communication becomes increasingly difficult. How can we share what only we experience? “

When I use a word," Humpty Dumpty said in rather a scornful tone. "It means just what I choose it to mean - neither more or less."

"The question is," said Alice, "whether you can make words mean so many different things."

"The question is," said Humpty Dumpty, "which is to be master - that's all”.


Communication with a public and patients who are influenced by post-modernism will become increasingly difficult despite all our awareness and communication training. If people do not accept that there is any truth outside of themselves, who define reality language in their own terms then they will insist their opinions and ideas are as equally valid as ours. And if we are influenced by this view no matter how scientific and “expert” we are then we risk finding we have no valid answers. The practice of medicine is going to get pretty awkward for there can be no true partnership in decision making if we do not share at least some common ground and if both parties are in effect denying common ground even could exist…


This may seem extreme but anyone who has tried to work wit a patient who does not accept the validity of thyroid function tests in the management of self diagnosed hypothyroidism will have some idea of what I mean.

Of course we have the let out of patient autonomy _ but that does take sufficient account of the patterns of thinking and belief as well as the content?



Conclusion

McGilchrist concludes by picturing what a fully left hemisphere world would look like. He paints a pessimistic picture. It would be a world where information substitutes for knowledge and knowledge for wisdom in which we focus on knowing more and more about less and less and the super specialist becomes the model to emulate. It would be a world where the recognition of practical skills and wisdom gained from experience are disregarded in favour of formal training and qualifications, even when these are not accompanied by expertise. It would be a world where everything becomes more and more virtual, where work is more about planning, measuring and recording than actually doing 24 and even the doing becomes more and more technological and less and less personal (think self service check ins in surgeries and OP, all in the name of efficiency and cost). And if Susan Greenfield is right and virtual reality and social media really does rewire the adolescent brain then we have a major advance in the domination of the machine. Even if she isn’t, it is hard to deny there is at least a correlation between the rise of the virtual world and a rise in some aspects of mental distress and behaviour. Most frightening of all McGilchrist wonders whether this right to left shift may have become irreversible



Add if I to this the increasing impact of the left hemisphere’s attempt to manage the pain – yes, the despair that comes from increasing isolation from the real world by abandoning reason for inner experience instead of seeking to reconnect with ‘real reality” by re-establishing balanced relations with the right hemisphere and the consequences for communication between individuals and groups outlined above then we – western culture – may well be at risk of

nemesis.



Is there a way out for us a medical professionals? I believe it still is possible –if increasingly hard - to practice medicine with the whole mind, bringing right and left hemispheres back into the working partnership that makes us fully human. The right interacting with the world, open, ready to accept uncertainty and “otherness”, passing its experience to the left for analysis and detailed investigation and then incorporating those insights into the synthesis of fully human caring which we know is the heart of medicine.

So maybe asking what good novels we have read recently, what music we listen to, how we are involved in the world of experience, nature, imagination and otherness really should be part of training and appraisal.

I am human and nothing that is human is alien to me” 25 is a good approach for anyone – especially a medical professional.



If there is one doctor who sums up that synthesis it is Cicely Saunders,(1918-2005) who having started a philosophy, politics and economics degree at Oxford trained as a nurse. This is a career pathway that is itself a remarkable combination of caring and intellectual analytical rigour. Having been opened by personal experience to the reality of pain and suffering she trained in medicine to become the founder of the modern hospice movement. The movement itself combines the left hemisphere’s scientific rigour, dealing with the particulars of diagnosis and patient management in an objective, reductionist manner, with the right hemisphere’s capacities of insight, imagination, experience and empathy to produce whole care for the whole person.



The RCGP motto puts the balance as “Cum scientia caritas” Maybe we as a profession in an increasingly fragmented and dis-eased society need to work towards a mindset that reverses that. “Cum caritas scientia”: seeking in ourselves and our relationships with others and the wider world to not only to mind the gap that has opened up between the hemispheres but attempt to bridge it .



As we do so we will become truly human as people and professionals, and perhaps begin to bring healing not only to our patients-as we have sought to do throughout our careers – but to our unhappy world.

Sources

(dates relate to first edition, publishers mostly refer to paperback editions)


This essay is not intended to be a comprehensive history of medicine, more an exploration of how McGilchrist’s exploration of the different roles of the two hemispheres might relate not only to the history of culture in general which he explores in the second part of his book but the history of medicine. Any misunderstanding or mistakes are purely my own


Ackroyd, Peter “The History of England volume I – Foundation” 2011 Pan


Clark, Kenneth “ Civilization – a personal view” 1969 (DVDs) BBC


Innes, William “Social Concern in Calvin’s Geneva (c10)” 1983 Pickwick Press (read on-line)


McGilchrist, Iain “ The Master and his Emissary “ 2009 Yale University Press


O’Brian, Patrick “Master and Commander” (and sequels) 1970 Harper Collins


Porter, Roy Articles relating to the history of medicine in “The Oxford Illustrated Companion to Medicine” (edited by Lock, Stephen, Last, John and Dunea, George) 1986 Oxford University press


Schaeffer, Francis “Escape from Reason” 1968 Intervarsity Press


Schaeffer, Francis “The God who is there – speaking historic Christianity into the twentieth century” 1968 Hodder and Stoughton


Snow, Charles Percy “ the two cultures and the scientific revolution” 1961 Oxford University Press


Wikipedia articles


Wulf, Andrea “The Invention of Nature: the Adventures of Alexander von Humboldt, the lost hero of science” 2015 John Murray


1 McGilchrist has some very interesting suggestions about the relationship of both genius and mental illness to hemisphere function

2 We all know how good we are at justifying courses of action that to an outsider can see do not face reality: the betting industry is based on this!

3 Kenneth Clark in “Civilization: a personal view” makes the same contrast in his comparison of Viking portraiture to the very early 13th century statues of Chartres cathedral.

4 St Paul was wide open to the non-Jewish culture around him as in his speech to the Athenian philosophers in Acts17, as well as being the systematic thinker of the first half of his Letter to the Roman Christians.

5 Petrarch is the first named person to have climbed a mountain “because it was there” though he himself found an old shepherd who had done so 50 years earlier, which supports the idea that “ordinary people” throughout the ages have had hopes and aspirations that go beyond the left hemisphere logic of acting merely to survive.

6 Although Calvin himself was very concerned that the General Hospital was run effectively and took the initiative in several public health measures such as clearing manure heaps and fencing stairways (Innes 1983)

7 He was the second founder of my Cambridge College and three times president of the Royal College of Physicians

8 The fact that Kepler had to battle to save his mother from accusations of witchcraft shows how limited was the acceptance of the new science in the ordinary world: a phenomenon that some would say is still with us!

9 Another Caius man!

10 Withering was a botanist who applied Linnaeus’ taxonomy to English plants: he also identified a new element that later turned out to be barium.

11 Although the traditional story of a how he saw it used by a “wise woman” is apparently a myth resulting for 1920’s drug company advertising!

12 John Hunter had failed to differentiate gonorrhea and syphilis and so mercury was used for both

13 Capability Brown’s work went out of favour!

14 Is well worth reading to appreciate the enormous impact of the man who could be described as the first ecologist

15 Poet, painter, chemist- he isolated no less than 7 elements for the first time- inventor of electrochemistry, inventor of first incandescent electric light and the miner’s safety lamp, brilliant Royal Institution lecturer. He started medical studies at Edinburgh but “filled part of the institution with voltaic batteries” (Wikipedia)(1813-58)

16 In fact he appears to have meant that he did not need to invoke the intervention of God to explain planetary movements rather than denying the existence of God

17 C.P. Snow was an inheritor of the balanced two-hemisphere approach as a crystallographer, science administrator and novelist.

18 I have not been able to find the reference of this quote, but it is significant in that it suggests the rejection of the “joined up” view of nature represented by the work of von Humboldt, surely the epitome of “romantic” right brain science

19 One would have thought WW1 whose technology was the then ultimate in left brain scientific logic might have led to a questioning of this approach but instead it seems to have encouraged the idea that peace and progress could be secured by the same rational scientific means

20 Being demolished at the time of writing

21 Although thinking through the moral aspects of its application – a right hemisphere task – tends to lag behind. The Mutual Assured Destruction doctrine of nuclear deterrence was very logical but hardly questioned by its proponents.

22 McGilchrist suggests that the epidemic of self harm may be a desperate attempt to reconnect with the wider reality of a world that is more than the logical left brain pursuit of perfection

23 Lord Moran (1882-1977). President of the Royal College of Physicians 1941-49 and Churchill’s personal physician

24 At one point recently community nurses were spending less than 25% of their time with patients: the rest of the time was travelling.

, “communicating” and making computer entries.

25 The Roman playwright Terence (c195/185 – c159BC): he was a favourite author of Luther’s because of his insight into the human condition.