the clinical conversation.
As was my habit throughout my career, I read myself into important but unfamiliar knowledge domains. I studied all the neurology and neuropsychology texts I could lay my hands on in order to develop a working knowledge of the brain and the clinical assessment of higher mental functions. Fortunately, such texts were not difficult to identify and to secure in the extraordinarily well-stocked academic bookshops of Johannesburg in those years.
Three other experiences opened the way for me in my search for more structured and meaningful ways of working with patients, especially within the general hospital setting. First, the University of the Witwatersrand ran one of the most advanced speech and hearing therapy departments in the country, under the able leadership of a no-nonsense elderly female professor, Myrtle Aaron. I had watched the speech therapists working in my ward and in other locations in the hospital, and I soon learnt that their specialty included the diagnosis and treatment of neurologically based speech and hearing disorders associated with brain dysfunction.
I had ample opportunity to observe them while they conducted intricate speech and hearing tests as well as neuropsychological tests to establish the form and seriousness of speech and hearing impairments following referrals by medical specialists. It was largely through my exposure to their clinical activities rather than those of the neurologists per se that I became familiar with the work of Alexander Luria, a man who studied psychology before he went on to study medicine. My attention was drawn to Luria’s world-renowned book Higher Cortical Functions in Man,10 which became the intellectual window through which complex knowledge of the human brain and its impact on behaviour in health and disease could be studied and understood by an outsider, which I was at the time. My familiarity with Russian and Anglo-American neuropsychology had its roots in Luria’s work, including his intellectual biography.11
From my earliest introduction to Soviet and Anglo-American neuropsychology at Baragwanath, two areas attracted my interest. The first was what I describe as the neuropsychology of the body, the body image and its disturbances, closely associated with my doctoral research on paraplegia. About ten years later, interest in some themes of the clinical neuropsychology of disturbances of higher mental functions following head injuries took centre stage, a development which was intimately associated with my involvement in forensic and medico-legal work in my private practice and in the South African Supreme Court in the 1980s.
While at Baragwanath I undertook a close study of Luria’s book. In 1981, following my appointment at the University of the Witwatersrand, I was able to run a properly organised, part-time private practice with rooms in Commissioner Street in downtown Johannesburg. There my work included a significant number of medico-legal cases, often involving adults and children who had sustained head and other injuries during motor-vehicle accidents. It was during this period that, through study and practical application of techniques of neuropsychological examination, my knowledge of clinical neuropsychology expanded beyond Luria to include countless other practitioners, among others Australian neuropsychologist Kevin Walsh.12
In retrospect, what seems so remarkable are the detailed typed notes which followed my reading of the neuropsychology literature of the day, primarily as preparation for appearances in an inhospitable court environment in the 1980s and the beginning of the 1990s. Working in this manner provided me with wide-ranging knowledge of the field as well as sufficient preparation for the forensic assessment of clients and the professional exposition of evidence in court.
My reading on brain–behaviour interactions and my study of and research into body image was given impetus by well-known figures such as Paul Schilder and Macdonald Critchley, among many others.13 Consequently, I found myself increasingly at home in the course of the daily professional discussions and activities that took place during ward rounds and consultations in other parts of the hospital.
The second learning opportunity arose during encounters, first in Ward 7 and later in other wards in the hospital, with patients who failed to make ‘neurological sense’ to the doctors. Significant numbers of female patients from Soweto and adjacent areas were being admitted to our medical wards complaining of symptoms that resembled known neurological and other illnesses. The complaints included paralysis of limbs and fainting spells, the sudden onset of an inability to walk, urinary incontinence, epilepsy-like convulsions, blackouts, fainting spells and palpitations – conditions that could easily be mistaken for diseases of the central nervous system. It was common for one to learn from such patients that the illness had been of sudden onset. The burden of explanation soon fell on me as the only psychologist in the team and the hospital. The question I was increasingly being asked both in our unit and in the adult medical departments was, what do these pseudo-neurological symptoms mean? Hidden within such questions was often an unstated assumption that the patient might be malingering – that is, playing at being ill.
I was consulted so often about patients in this class that the first paper I had published in South Africa’s premier medical publication, the South African Medical Journal, was on cases of hysteria among African women. The article appeared in May 1970. I had given the paper the title ‘Neurotic Compromise Solutions and Symptom Sophistication in Cases of Hysteria in the African’, but, without the courtesy of a discussion with me, apartheid gatekeepers at the journal’s headquarters had replaced the word ‘African’ with the derogatory term ‘Bantu’. I experienced this as a hostile and offhand rejection of the word ‘African’. Nonetheless, inexperienced as I was, in writing the paper I had put my finger on an important health issue which was developing under our noses.14
The history of hysteria, including its celebrated female patients and colourful healers in centuries gone by, remains a subject of continuing interest today. In 2011 I revisited the field of women and hysteria, and to my surprise I found that, although the diagnostic terminology has received a notable facelift, Asti Hustvedt, in her excellent study entitled Medical Muses: Hysteria in Nineteenth-Century Paris, could still report that
while modern medicine no longer talks about hysteria, it nonetheless continues to perpetuate the idea that the female body is far more vulnerable than its male counterpart. Premenstrual syndrome, postpartum depression, and ‘raging hormones’ are amongst the most recent additions.15
She adds that hysteria has assumed many ‘new incarnations’ and new diagnostic categories, among them chronic fatigue syndrome. What she found most remarkable was the degree to which new terminology had replaced the antiquated diagnostic system of the past. Here, then, is the story of an illness with a long and fascinating history in the West, an illness that intrigued me enough to have inspired the subject matter of my first publication as a clinical psychologist-in-training.
A third learning opportunity occurred during consultations conducted by psychiatrists working on a sessional basis in the hospital. Within the general hospital context in which I worked, outpatient work by part-time psychiatrists appeared peripheral to the work of the hospital. Although my role was largely that of a participating observer, I learnt a great deal in those years about the practices of psychiatrists in general hospital settings. Their consultations often took the form of a question-and-answer session between psychiatrist and patient, with the African nurse as an interpreter. I remember a certain dry matter-of-factness during the exchanges between psychiatrists and their patients. The practice was that I was permitted to observe their work during consultations at weekly outpatient clinics. Some of the patients would have been referred by me for psychiatric consultation, while others came directly on the strength of requests from doctors in the medical wards.
My relationships with consulting psychiatrists both at Baragwanath and at other Johannesburg-based teaching hospitals were the weakest link in my training. The patient histories that most psychiatrists solicited through poorly trained African interpreters were often shoddy and truncated. I sat through most of their sessions with patients only to hear the psychiatrists mention their treatment of choice, a predictable recourse to Valium, Stelazine or Largactil depending on whether the patient was
