The role of literature as a stimulating learning resource in medical education has been championed.1 In the field of psychiatry it is particularly useful in demonstrating the experiences of all the stakeholders involved: the service user, their carers and families, the practitioners and the wider society.2 Reading fiction can help psychiatrists enhance empathic and ethical capacity, and better understand patient narratives.3 Mental Illness has been described in literature long before there were psychiatric diagnostic systems, so fiction can be a valuable medium from which medical students and others can learn about psychopathology even if there are limitations in using fictional characters to illustrate a particular psychiatric diagnosis.

The richness in the characterisation of the writing of Charles Dickens (1812–1870) makes it particularly useful for demonstrating both psychological and physical conditions. Dickens’ literary work is increasingly being used to teach medical students. John Skelton, for example, has used the narrative of the death of young Paul Dombey in Dombey and son4 to teach about death in childhood.5 Howard Markel has argued that “when teaching our students about the medical ramifications of poverty and the importance of child advocacy, we could do no better than pointing them in the direction of Charles Dickens”.6 The novel Oliver Twist7 has been described as a “textbook of child abuse”8 and The Wellcome Trust has sponsored the production of a CD-ROM in medicine and literature as a self directed learning module that includes Mrs Gamp, the drunken nurse in Martin Chuzzlewit9 as one character that can teach students about perceptions of medicine in the 19^th century.10

In contrast to other Victorian novelists, Dickens was well known in his own lifetime for true-to-life descriptions of characters with illnesses that were even cited in medical journals as case reports.11 Some clinical entities were anticipated before they were identified as such by physicians.12 Dickens’ characters were often based on real people and the authenticity of his medical descriptions as judged retrospectively has prompted the belief that they came from his observations of genuine patients.13

Dickens descriptions encompass a range of medical conditions including head injury, stroke, paraplegia,14 epilepsy15 and dystonias.16 Most famously he described the sleep disorder suffered by the fat boy, Joe in The Pickwick papers.17 The association of extreme obesity with hypo-alveolar ventilation was named the Pickwickian Syndrome because Dickens was the first to record many of its symptoms.18

In the moral climate of his novels, selfish characters are often punished with physical or mental illness rather than imprisonment.19 Consequently, besides examples of physical ailments there are also many psychiatric studies in Dickens.20 When he died in 1870, his genius for observation and his skill at describing mental illness were acknowledged by an obituary in the British Medical Journal: “his descriptions of epilepsy in Walter Wilding, and of moral and mental insanity in characters too numerous to mention, show the hand of a master”.21 His mastery grew from his experience and knowledge of Victorian psychiatry.

DICKENS AND VICTORIAN PSYCHIATRY

Dickens was concerned with the welfare of the mentally ill in the asylums.22 He was familiar with the terrible conditions in the infamous St Bethlehem or Bedlam and mentions the asylum in Sketches by Boz23 comparing it to Newgate Prison:

If Bedlam could be suddenly removed like another Aladdin’s palace, and set down on the space now occupied by Newgate, scarcely one man out of a hundred, whose road to business every morning lies through Newgate Street, or the Old Bailey, would pass the building without bestowing a hasty glance on its small, grated windows, and a transient thought upon the condition of the unhappy beings immured in its dismal cells. (Dickens p208).23

He visited the hospital in the 1850s and witnessed a more humane approach under physician Dr Charles Hood.24 Its history from unenlightened treatment methods to the prevailing supervision of Dr Hood was the subject of an article that Dickens, as Editor approved in Household Words in 1857 called Star of Bethlehem.25

He was a supporter of Hood’s type of asylum reform and also became a friend of John Conolly (1794–1866), renowned for his advocacy of non-restraint.26 Both doctors believed in moral treatment: occupation, fresh air and exercise, dances and friendly informal contact with staff that aimed to treat patients with dignity, respect and the minimal use of mechanical restraints. Dickens witnessed this approach on a visit to a Boston asylum in 1842 and recorded it in American notes:27

At every meal, moral influence alone restrains the more violent among them from cutting the throats of the rest; but the effect of that influence is reduced to an absolute certainty, and is found, even as a means of restraint, to say nothing of it as a means of cure, a hundred times more efficacious than all the strait waistcoats, fetters, and handcuffs, that ignorance, prejudice, and cruelty have manufactured since the creation of the world. (Dickens p56).27

The image he painted contrasted starkly with what he later saw on Long Island. In this extract from American notes, Dickens’ support for moral treatment is seen influencing his writing:28

I saw nothing of that salutary system which had impressed me so favourably elsewhere; and everything had a lounging, listless, madhouse air, which was very painful. The moping idiot, cowering down with long dishevelled hair; the gibbering maniac, with his hideous laugh and pointed finger; the vacant eye, the fierce wild face, the gloomy picking of the hands and lips, and munching of the nails: there they were all, without disguise, in naked ugliness and horror. In the dining room, a bare, dull, dreary place, with nothing for the eye to rest on but the empty walls, a woman was locked up alone. She was bent, they told me, on committing suicide. If anything could have strengthened her resolution, it would certainly have been the insupportable monotony of such an existence. (Dickens p103–4).27

When Dickens visited St Luke’s Asylum, Shoreditch at Christmas 1851 with WH Wills he described the usual fortnightly dance and some of the patients with his memorable characterisations:

There was the brisk, vain, pippin–faced little old lady, in a fantastic cap proud of her foot and ankle; there was the old–young woman, with the dishevelled long light hair, spare figure, and weird gentility; there was the vacantly-laughing girl, requiring now and then a warning finger to admonish her; there was the quiet young woman, almost well, and soon going out. For partners, there were the sturdy bull-necked thick-set little fellow who had tried to get away last week; the wry-faced tailor formerly suicidal, but much improved; the suspicious patient with a countenance of gloom, wandering round and round strangers, furtively eying them behind from head to foot, and not indisposed to resent their intrusion. There was the man of happy silliness, pleased with everything.29

Observations like the high prevalence of females and the general efficacy of treatments were made and Dickens’ comments on weight gain due to the inactivity of the patients echo modern concerns about the physical health of people with severe mental illness over 150 years later. He visited St Luke’s again in January 1858 and viewed “some distinctly and remarkably developed types of insanity”.30

Dickens and Wills also wrote Idiots,31 about a visit to Park House Asylum, Highgate for the intellectually disabled where Dickens may have observed a patient who helped form the character of Maggy in Little Dorrit.32

With fellow author Wilkie Collins, he described a fictional visit to an asylum in The lazy tour of two idle apprentices published in 185733 and as Editor of Household Words; Dickens also gave approval for other articles on insanity.34 35

Two Lunacy Commissioners, Bryan Proctor and John Forster were acquainted with Dickens and Forster became Dickens first biographer on the publication of Life of Charles Dickens in 1872.36

Mesmerism (hypnotism), a new treatment for mental disorders did not escape Dickens attention and he attended demonstrations at University College in 1838 by Dr John Elliotson, eventually learning how to use mesmerism himself.37

There is much evidence therefore that Dickens had considerable psychiatric insight to bring to the mad and eccentric characters he created in his novels.

DICKENS AND PSYCHOPATHOLOGY

By the mid 1860s Dickens’ fiction included a wide spectrum of characters suffering from mental illness.38 Dickens is known to have owned books on psychopathology and his vivid descriptions led Leonard Manheim to declare: “he was the greatest literary psychopathologist since Shakespeare”.39

Literature, in being influenced by the prevailing ideas of the time, may serve as a window on the history of psychiatry and the development of psychiatric diagnosis.2 Some characters therefore display symptoms that conform to diagnoses widely accepted in the Victorian period although less recognisable today. Tytler for example has argued that the title character in Dickens’ ghost story The signalman40 displays signs of mental illness including auditory and visual hallucinations that anyone familiar with 19^th century psychiatric theory could interpret as symptomatic of “monomania” or partial insanity.41

Novels however do not have to demonstrate clinical accuracy often being shaped by the author to reflect the needs of the plot and some have argued against extracting anything that might be clinically useful from literature.42 For example in The madman’s manuscript, a short story within The Pickwick papers, the depiction of psychopathology is not clinically accurate.39

However, many Dickens’ characters do illustrate clinical pictures that are remarkably identifiable to the modern clinician. At the Purvis lecture to West Kent Surgical Society in 1955, Sir Russell Brain described some of the psychiatric conditions he could diagnose amongst his characters.14 Since then others have been identified though there is often disagreement among authors about which diagnoses these characters may represent.43 The accounts nevertheless may be useful to both clinicians and teachers as illustrations of psychiatric diagnoses and these are now outlined under the same broad categories as ICD-10.44

Organic mental disorders/dementia

Dickens wrote about memory loss and dementia and has been recommended to students as an example of an author who has illustrated these conditions. Although written long before Alzheimer disease was described as a clinical entity there are cases of dementia in the novels and Mrs Smallweed in Bleak house45 has been described as a flawless example14:

Little old men and women there have been, but no child, until Mr Smallweed’s grandmother, now living, became weak in her intellect, and fell (for the first time) into a childish state. With such infantine graces as a total want of observation, memory, understanding, and interest, and an eternal disposition to fall asleep over the fire and into it. (Dickens p248).45

Old Chuffey, Anthony Chuzzlewit’s clerk in Martin Chuzzlewit has been described as having senile dementia although the clinical accuracy is sacrificed for the plot as he makes a miraculous recovery to give important evidence about his master’s death.14 Old Chuffey exhibits verbigeration, the meaningless repetitive use of phrases or numbers, as described in dementia39:

“Three score and ten” said Chuffey “ought and carry seven. Some men are so strong that they live to four score-four times ought’s an ought, four times two’s an eight-eighty. Oh! Why-why-why-didn’t he live to four times ought’s an ought, and four times two’s an eight, eighty?” (Dickens p311).9

John Willet, in Barnaby Rudge46 develops delusional ideas that he is still running his inn in old age and that his customers are running up huge debts to him. These strange ideas precede his death by stroke and Manheim has suggested that his psychosis could be explained by cerebral arteriosclerosis, the second leading cause of dementia after Alzheimer.39 Mrs Skewton in Dombey and son suffers memory problems following a stroke and could also be showing signs of vascular dementia.

Dementia is also associated with Parkinson disease but Cosnett commented that there are few depictions of Parkinson disease in Dickens work.43 However Schoffer et al47 claim that in Pickwick papers, Dickens was describing the association between Parkinsonism and dementia:

an old man was seated on a small wooden box, with his eyes riveted on the floor, and his face settled into an expression of the deepest and most hopeless despair. (…) His limbs were shaking with disease, and the palsy had fastened on his mind. (Dickens p555).17

Sanders48 has argued that Ebenezer Scrooge, the elderly, miserly misanthrope from A Christmas carol49 could also be suffering from Parkinson disease:

The cold within him froze his old features … stiffened his gait (Dickens p8).49

The ghost of his friend Jacob Marley and three other ghosts visit Scrooge during the night of Christmas Eve. These experiences have been interpreted as vivid hallucinations of friends and relatives and prior to cognitive deficits would be consistent with a diagnosis of Lewy body dementia, the dementia associated with Parkinson disease (Sanders p2).48

Mental and behavioural disorders due to psychoactive substance use/alcohol and opiate use

Many of the acute and chronic effects of alcohol are related in his novels50 There are examples of alcohol dependency including Mr Krook in Bleak house, Newman Noggs in Nicholas Nickleby51 and Quilp in The old curiosity shop.52 Sarah Gamp, the elderly nurse in Martin Chuzzlewit is also an alcoholic:

The face of Mrs Gamp—the nose in particular—was somewhat red and swollen, and it was difficult to enjoy her society without becoming conscious of a smell of spirits. (Dickens p307).9

Sydney Carton in A tale of two cities53 is a binge drinker.50

Dickens provides us with a wonderful account of delirium tremens from The strollers tale in The Pickwick papers as evidenced by marked visual, auditory and tactile hallucinations suffered by the alcoholic actor Jem54:

He fell back upon his pillow and moaned aloud. A short period of oblivion, and he was wandering through a tedious maze of low arched rooms—so low, sometimes, that he must creep upon his hands and knees to make his way along; it was close and dark, and every way he turned, some obstacle impeded his progress. There were insects too, hideous crawling things with eyes that stared upon him, and filled the very air around: glistening horribly amidst the thick darkness of the place. The walls and ceiling were alive with reptiles—the vault expanded to an enormous size—frightful figures flitted to and fro—and the faces of men he knew, rendered hideous by gibing and mouthing, peered out from among them; they were searing him with heated irons, and binding his head with cords till the blood started; and he struggled madly for life. (Dickens p44).17

Wickfield, father of the second wife of David Copperfield55 is a heavy drinker who shows a progressive deterioration of his cognitive state as a result of his addiction and could be a case of alcoholic dementia.

Laudanum (opium) is also mentioned most notably when Nancy intoxicates Sikes in Oliver Twist (Dickens p260).7 In The mystery of Edwin Drood56 John Jasper, the central character visits East End dens to smoke opium. In the character of Mrs Blackpool in Hard times,57 Dickens combines alcoholism with opiate addiction.

Schizophrenia, schizotypal and delusional disorders

Mr Dick in David Copperfield shows evidence of thought disorder and catatonia and has been described as suffering from schizophrenia.58 Mr Dick is a friend of David’s aunt and the following conversation occurs between David and Mr Dick:

“Do you recollect the date” said Mr Dick, looking earnestly at me, and taking up his pen to note it down, “When Charles the First had his head cut off?” I said I believed it happened in the year sixteen hundred and forty nine. “Well” returned Mr Dick, scratching his ear with his pen, and looking dubiously at me, “So the books say; but I don’t see how that can be. Because, if it was so long ago, how could the people about him have made that mistake of putting some of the trouble out of his head, after it was taken off, into mine?” (Dickens p176).55

This appears to be an example of thought insertion, a first rank symptom of schizophrenia in the absence of physical illness and as Mr Dick is otherwise healthy points toward the diagnosis.59

Manheim has suggested that Smike in Nicholas Nickleby exhibits schizoid traits and intellectual deterioration that could be explained by a diagnosis of schizophrenia.39

Brain cited Mr F’s aunt in Little Dorrit as an example of schizophrenia in an older person with mood disturbance and thought disorder14:

The major characteristics discoverable by the stranger in Mr F’s aunt were extreme severity and grim taciturnity; sometimes interrupted by a propensity to offer remarks in a deep warning voice, which, being totally uncalled for by anything said by anybody, and traceable to no association of ideas, confounded and terrified the mind. Mr F’s aunt may have thrown in these observations on some system of her own, and it may have been ingenious, or even subtle; but the key to it was wanted. (Dickens p149).32

Old Trent, the owner of The old curiosity shop, appears to develop a paranoid state as well as a compulsion to gamble which worsens after a bout of physical illness39:

He looks “after some stranger in the crowd, until he disappeared from sight; but, to the question why he did this, he answered not a word” (Dickens p90).52

Manheim suggested that Lord George Gordon from Barnaby Rudge also suffers from paranoia.39

Mood disorders

There are several examples of characters that experience affective disorders. Brain lectured “that no better example of hypomania could be found in a textbook of psychiatry than in the character described as the man over the garden wall in Nicholas Nickleby who makes advances towards Mrs Nickleby”. The character exhibits grandiosity, flight of ideas, pressured speech, amorousness and loose paranoid delusions14:

“I have estates ma’am” said the old gentleman, flourishing his right hand negligently as if he made very light of such matters, and speaking very fast; “jewels, lighthouses, fishponds, a whalery of my own in the North Sea, and several oyster beds of great profit in the Pacific Ocean… My walking stick is to be seen on application to the Chaplain of the House of Commons, who is strictly forbidden to take any money for showing it. I have enemies about me, ma’am” he looked towards his house and spoke very low, “who attack me on all occasions, and wish to secure my property. If you bless me with your hand and heart, you can apply to the Lord Chancellor call out the military if necessary-sending my toothpick to the commander–in-chief will be sufficient-and so clear the house of them before the ceremony is performed. After that, love, bliss and rapture; rapture love and bliss. Be mine, be mine!” (Dickens p502).51

Depressive illness often follows major life events. Following his bankruptcy and loss of his children Mr Dombey in Dombey and son appears to experience an agitated depressive illness with disturbed sleep and early morning wakening:

Every night, within the knowledge of no human creature, he came forth, and wandered through the despoiled house like a ghost. Many a morning, when the day broke, his altered face, drooping behind the closed blind in his window, imperfectly transparent to the light as yet, pondered on the loss of his two children… Strong mental agitation and disturbance was no novelty to him, even before his late sufferings. (Dickens p775).4

He later takes to his bed:

A shade, already, of what he had been, shattered in mind, and perilously sick in body, he laid his weary head down on the bed his daughter’s hands prepared for him, and had never raised it since. (Dickens p791).4

Besides dementia, Scrooge has been described as exhibiting the melancholic and behavioural manifestations of depression in later life.60 The character has even been used to help patients and carers understand depression and anxiety in the elderly.61 A Christmas carol has been cited as a literary psychoanalysis with Dickens like a good psychotherapist taking Scrooge, the patient on a journey where he learns to face the fear of his mortality with hope by awakening feelings of long repressed empathy and by a reconciliation with his family that ends his desperate isolation.62

Mr Nicodemius Dumps in The Bloomsbury christening from Sketches by Boz is an example of a dysthymic individual suffering from persistent depression: (Rohrer p127–39).54

Mr Nicodemius Dumps, or, as his acquaintance called him, “long Dumps” was a bachelor, six feet high, and fifty years old: cross, cadaverous, odd and ill natured. He was never happy but when he was miserable; and always miserable when he had the best reason to be happy. (Dickens p484).23

Neurotic, stress-related and somatoform disorders

In A tale of two cities, Dr Manette suffers from triggered re-experiences of trauma from a long and difficult imprisonment, distressing recollections, increased arousal, diminished interest in activities, feelings of detachment and other symptoms which modern psychiatrists might recognise as post-traumatic stress disorder.63 Dickens describes prisoners undergoing solitary confinement in American notes and the accounts of their appearance and behaviour resemble the description of Dr Manette (Dickens p109–24).27 Dr Manette exhibits little memory of the trauma of his imprisonment and has also been described as a case of dissociative amnesia.64 Dissociative disorder63 or multiple personality14 has been considered as an alternative differential diagnosis.

Another example of stress-related illness occurs in Miss Havisham in Great expectations65 After being jilted by her bridegroom at twenty minutes to nine on the day of her wedding; Miss Havisham is so traumatised by the experience she completely withdraws from society:

“The marriage day was fixed, the wedding dresses were bought, the wedding tour was planned out, the wedding guests were invited. The day came, but not the bridegroom. He wrote a letter”

“Which she received,” I stuck in “when she was dressing for her marriage? At twenty minutes to nine?”

“At the hour and minute” said Herbert, nodding, “at which she afterwards stopped all the clocks. What was in it, further than that it most heartlessly broke the marriage off, I can’t tell you, because I don’t know. When she recovered from a bad illness that she had, she laid the whole place waste, as you have seen it, and she has never since looked upon the light of day” (Dickens p148).65

Miss Havisham’s condition may represent a pathological grief reaction or adjustment disorder66 Similar behaviour in women caused by the sudden rejection of a partner or loss of a spouse has been described as Miss Havisham Syndrome.67

Mrs Clenham in Little Dorrit has lost the use of her limbs and is confined to a wheelchair. Schoffer has described her illness as a functional movement disorder as there is no evidence of real physical illness and this is confirmed when she rises up out of her chair at the end of the novel.47 This may be an example of a dissociative disorder of movement.

Behavioural syndromes associated with physiological disturbances and physical factors

Eating disorders/anorexia nervosa

Gail Houston has suggested that many of the slender heroines in Dickens’ novels including Little Nell in The old curiosity shop and Little Dorrit show signs of anorexia nervosa.68 Silver has argued that the disease serves as a paradigm for the cultural ideal of middle-class womanhood in Victorian Britain and in these characters Dickens extols that ideal.69 She even suggested that Little Nell’s death is partly due to starvation despite food being available for her (Silver p84).69

Non-organic sleep disorders

Sleep disorders have been described in Dickens’ characters including insomnia, hypersomnia, somnambulism, night terrors and nightmares.70

Disorders of adult personality and behaviour

As Tyrer has remarked, real people do not behave like Charles Dickens’ characters reacting in the same way at each human encounter and do not fit into neat diagnostic categories when they have a personality disorder,71 so perhaps the characters demonstrate the categories as described in ICD-10 or DSM IV72 better than real patients.

Dickens created some memorable psychopaths. Bill Sikes arguably has a profound paranoid personality disorder.8 Others include Monks also from Oliver Twist, Monseigneur Marquis de Evremonde in A tale of two cities and Uriah Heep from David Copperfield. Uriah Heep exhibits extreme selfishness, manipulative insincerity and absence of remorse in keeping with a diagnosis of dissocial personality disorder. Nancy from Oliver Twist also exhibits antisocial behaviour and in her character Manheim claimed Dickens came closest to showing his readers his understanding of the criminal psychopath.39

Even the value of an old diagnostic category, “hypomanic personality disorder”, no longer in current classifications, has been argued for using the personality characteristics of Mr Micawber from David Copperfield as evidence that the category better describes the condition now known as cyclothymia.73

Rohrer described Chevy Slime from Martin Chuzzlewit with his sense of entitlement and grandiosity as a case of narcissistic personality disorder, a DSM-IV-TR diagnostic category: (Rohrer p208–10)54

“I’ll let ’em know, and I’ll let all men know”, cried Chevy Slime “that I’m none of the mean, grovelling, tame characters they meet with commonly. I have an independent spirit. I have a heart that swells in my bosom. I have a soul that rises superior to base considerations.” (Dickens p109).9

Narcissism is also exhibited in the characters of Steerforth and his mother in David Copperfield.

The character of Harold Skimpole in Bleak house has also been used to illustrate personality traits of grandiosity.74

Mental retardation

An example of learning disability appears in the form of Maggy Bangham in Little Dorrit:

“When Maggy was ten years old” said Little Dorrit, watching her face while she spoke, “she had a bad fever, sir, and she has never grown any older since.”(Dickens p98)32

Dickinson commented on the medical accuracy of the portrait of intellectual disability created by Dickens as it follows an infection and is demonstrated by her dyspraxia and echolalia75:

an excited figure of a strange kind bounced against them, (...) fell down, and scattered the contents of a large basket, filled with potatoes (...) and then began to pick up the potatoes (…) Maggy picked up very few potatoes, and a great quantity of mud;

“This is Maggy Sir”

“Maggy Sir,” echoed the personage presented (…)

“You can’t think how good she is, sir”, said Little Dorrit with infinite tenderness.

“Good she is” echoed Maggy (Dickens p97–98).32

Disorders of psychological development/autism

The title character in Barnaby Rudge has diminished intellect76 and has been diagnosed as suffering from autism77 in that he exhibits numerous autistic traits including impaired socialisation, communication and irrational fears:

he, old and elfin-like in face, but ever dear to her, gazing at her with a wild and vacant eye, and crooning some uncouth song, as she sat by and rocked him; every circumstance of his infancy came thronging back, and the most trivial, perhaps the most distinctly. His older childhood, too; the strange imaginings he had; his terror of certain sense-less things-familiar objects he endowed with life; (Dickens 99).46

Barnaby Rudge exhibits attachment to unusual objects:

Girt to his side was the steel hilt of an old sword without blade or scabbard; and some parti-coloured ends of ribands and poor glass toys completed the ornamental portion of his attire. (Dickens p36).46

There are also exaggerated mannerisms:

He nodded—not once or twice, but a score of times, and that with a fantastic exaggeration which would have kept his head in motion for an hour (Dickens p35).46

However diagnosing Barnaby Rudge using modern criteria has been criticised for ignoring the historical context, as “idiocy” is not necessarily equivalent to the concept of “learning difficulties”.78 Furthermore it has been argued that the portrayal of Barnaby does not bear any relationship to the medical writing of the time.75

Behavioural and emotional disorders with onset during childhood and adolescence/Tourette syndrome

Mr Pancks, the debt collector in Little Dorrit has been described as suffering from Tourette Syndrome with inappropriate vocal tics16:

Mr Pancks here made a singular and startling noise, produced by a strong blowing effort in the region of the nose, unattended by any result but that acoustic one (Dickens p148).32

Mr Pancks also exhibits obsessional traits suggested by his keeping a notebook in “dictionary order”, his nail biting,

…with the fingers of his right hand in his mouth that he might bite the nails… (Dickens p260–1).32

and trichotillomania:79

Mr Pancks took hold of himself by the hair of his head, and tore it in desperation at the spectacle. (….) All the time (he) was tearing at his tough hair in a most pitiless and cruel manner. (…) Mr Pancks took hold of his tough hair again, and gave it such a wrench that he pulled out several prongs of it. (Dickens p673–4).32

Mr Mell from David Copperfield with tics, teeth grinding and grimaces may be another example of Tourette.47 Dickens has described a condition before its recognition as an illness, in this case about 30 years before Gilles de La Tourette.79

CONCLUSION

Charles Dickens was celebrated as a keen observer of the human condition in his own lifetime and his characters demonstrate remarkable authenticity as identifiable clinical entities. There is ample evidence of Dickens knowledge and interest in the psychiatry of his age. The descriptions of mental ailments reflect this experience of mental illness and are thus a source from literature that clinicians may use to demonstrate to medical students some types of psychopathology or mental conditions across the spectrum of the ICD 10 diagnostic manual. The characters may also be helpful to service users and carers as a way in to understanding certain psychiatric conditions.

Whilst it appears that knowledge of fictional narratives can enhance the clinician’s understanding of individual lives, debate as to the true value of literature to teaching in the clinical arena will continue. However, using Dickens literary creations in medical education and the education of patients and carers provides a valuable example of the interaction between medicine and literature.