Apomorphine Versus Addiction

Chapter Three

“The cautious seldom err” — Confucious

By the early 1930s Dent had more or less developed a systematic delivery of Apo’ in the treatment of alcohol dependency. By pairing alcohol with Apo’ and giving it regularly for several successive days he felt that the conditioned reflex — a taste aversion to alcohol – was strong enough to facilitate abstinence. His method, a unique brand of constructive empiricism, was demonstrably successful and he enthusiastically announced these conclusions in his 1934 medical paper to the B.M.A., which, unlike his first, was accepted. It is clear throughout that Dent sees Anxiety and Addiction as two sides of the same coin and that man’s interplay with a changing environment can result in stresses that, if not resolved, can lead to self-medication and dependency. He wrote;

If these obstacles have been previously foreseen then they are more easily dealt with, but often man is quite incapable of facing them and he may become inert and melancholic or he may deviate from his road into various side tracks of which the taking of alcohol in excess is perhaps the commonest, but it is only one; others are suicide, lunacy of various types, a change to a more exacting religion, a rest cure or emigration, or an altered attitude towards society, such as good works, politics or crime.” ….and added, no doubt as a reference to the majority within his profession who had no answers and sought none; It is the duty of the doctor to relieve his patient’s internal stresses so that he can face his external ones.”CARTOON 1


Dent could only have had an intuition about the precise action of Apo’, nevertheless this was the first  neuropharmacological solution to addiction and also offered, in tandem with the earliest appreciation, that drug dependency and anxiety altered brain chemistry. “Though vomiting is one of the ways that apomorphine relieves the patient, I do not believe it to be its main therapeutic effect. As living organisms we have a mechanism that deals with and removes damaging stimuli from our environment. When such a stimulus acts our bodies react until the stimulus ceases. When this happens the nerves and other structures in our body are left in the pattern that they were in at the cessation of the stimulus, and when the stimulus is repeated the action that accompanied its previous cessation occurs again. In our blind search for a response that removes the stimulus we build up more and more complicated responses, entailing longer and longer nervous arcs for their functioning until the stimulus is dealt with. If the nervous arc is long enough to involve the highest centres of the brain then our response is a conscious one, but if the same stimulus is repeated frequently, at each repetition our response becomes quicker and more automatic. It is therefore travelling through a shorter arc, and eventually it travels through one, which does not traverse the highest centres, and the response is now unconscious and habitual. By habitual we mean that the will has lost its control over the response, and when the stimulus acts in altered circumstances we no longer have any power to alter our response to meet this alteration. We are creatures of our habits, and we are continually made aware of our impotence before them.”

It is perhaps worth remembering that this was printed in 1934. There is no reference to the mesolimbic dopamine system, dopamine itself, GABA, or the nucleus accumbens but nevertheless this rudimentary description can still be seen as one of the most prescient interpretations of how the reward system is compromised by addiction and how different brain areas mediate an individual’s response to stressful stimuli.

Dent was on the threshold of a neurobiological understanding which wouldn’t be properly expounded for several decades yet, remarkably, fate intervened and Dent suddenly revoked his own theory that Apo’ was aversion and in so doing delivered a huge blow to his own reputation. The reason for this turnaround was due to the unusual case of two brothers who were treated in the customary manner; intra muscular injections of Apo’ – followed by alcohol – followed by emesis – every few hours for three or four days. Everything had gone well and the brothers, discharged by Dent, were confident that a conditioned taste aversion to alcohol had been achieved and that they should pick up with their lives as quickly as possible. Then, quite by chance and from a third party, Dent heard that the two brothers had no olfactory function; no sense of taste or smell (combined anosmia and ageusia). Dent was shocked because he immediately thought the treatment had been to no avail as without any sense of the taste of alcohol it would be impossible to develop any taste aversion to it. He hastily requested a consultation to make a clean breast of it. The surprised brothers duly arrived to hear Dent explain the “failure” of his treatment and offer an apology for not having established why it had all been a waste of time.

“But what are you saying?” asked one of the brothers, totally confused.

“Yes,” added the other, “I don’t understand either, it wasn’t a waste of time, not at all!”

“But what do you mean?” asked Dent, ramping up the confusion.

Well” said the first brother; “we’re fine, just like you said. We’re not drinking. As you see, we’re sober.”

“Yes,” added the other, but the best thing is we have no desire to drink either, we’re free of craving!”

Dent was astounded. Naturally he was pleased for the brothers but his interpretation of Pavlovian conditioning used to explain and flesh out his observations and achieve scientific credibility was in ruins. Professionally this was devastating. Once again his rash enthusiasm had backed him into a corner and his detractors, using a variety of potentially addictive drugs such as pethidene, morphia, paraldehyde, and barbiturates, or Freud, in or out of expensive nursing homes, would enjoy his discomfort.

Dent was happiest seeing patients or at home, writing. He delivered his third book "Anxiety and its Treatment" (1941) while being bombed by the Luftwaffe

Dent was happiest seeing patients or at home, writing. He delivered his third book “Anxiety and its Treatment” (1941) while being bombed by the Luftwaffe

Dent was already swimming against the tide of vested interests but after a pause for reflection he realised there was no real reason to be deterred. The reason was quite simple; he wasn’t doing anybody any harm.  Many of his patients had  come to him after undergoing therapies that had failed or led to worse and greater dependencies. He thought once more about the hundreds of Saturday evening intakes at St Pancras workhouse. They had not been treated aversively but had still shown a marked improvement in the days following a single injection. To what could this be attributed? He also had the odd patient for whom no amount of Apo’ could induce any emesis and yet these too developed what appeared to be an “aversion” to alcohol?! He varied the doses and tweaked the protocols:

  • Apo’ with alcohol but with the alcohol quickly tapered to nothing
  • Apo’ at a sub-emetic level (no vomiting)
  • Apo’ without alcohol

In all but about ten per cent of cases Apo’ had some positive effect and to many patients the subsequent rewarding dimension and loss of cravings could not be simply attributed to “aversion.” He clearly needed to understand “why?”

Dent was shy, an impatient iconoclast, annoyingly absent-minded, and disliked the irritating rota and detail of functions, public speaking, quarterly journals, and day to day running of the SSA. For its part, the Society was struggling financially and membership constantly needed boosting to fund initiatives for research. Dent was interested in the Burden Institute at Bristol and helped set up a research fellowship with some sponsorship raised from the brewing industry. This caused upset at the Society as it offended the abstemious nature of some of its members, something Dent found absurd since he felt that the problem could also be solution. These differences are exemplified by an incident when Dent was criticised for drinking beer by a prominent member of the Society. In response Dent pointed out that there was also alcohol in the member’s Cydrax something that was strenuously denied. Dent suggested that he was just being factual adding that he thought the senior member would be glad so he could avoid Cydrax in the future. The discussion was becoming heated and reached farcical proportions when the increasingly flustered senior member insisted that the Cydrax be analysed. Everybody waited for the result which demonstrated conclusively that Cydrax was indeed mildly alcoholic. Red faced the senior member promptly resigned, left the building and never returned.

In all truth Dent and the Society were polar opposites. He was happiest either with his patients or at home writing and delivered his third book “Anxiety and its Treatment” in 1941 while being bombed by the Luftwaffe. It covers everything from Freud ; ‘his definition of anxiety as “the fear of castration” is, I think, a little narrow.” to an understanding that total war helped dispel anxiety;

During war, duty for each of us was very plain. We had quite a lot of obviously right things to do, and we were all looking in the same direction. It was total war. But now we are waking up to an individual peace and we cannot all agree that our individuality must be tempered by the perverse view of others……In war we obey orders, in peace we must criticise them and this is a much harder job.”Anxiety and its Treatment, 3rd edition.

Above all “Anxiety and its Treatment” was a book that explained to doctors and patients why addiction happened and how various strategies could reduce its control over our lives. This was an early example of the “self-help” genre, a work of broad strokes delivered in a typically direct manner: “It must be realised from the outset that the subjects treated here are among the most difficult in medicine. They must be approached with humility and with the certainty that full understanding of them is at present quite impossible.”

Despite these admissions, the following analogy of the see-saw (popular with neuro scientists ever since) to explain imbalance between areas of the brain was helpful to those who needed to have their “disease” and treatment explained in both biochemical and neuro-pharmacological terms.  Was this Dent the masterful psychotherapist? Or is this a fair explanation in rudimentary terms of the action of drugs and repair with Apo’?  

CARTOON 7

“We can look upon the brain as a see-saw, when one end is up the other is down. We can imagine that the well-balanced individual as one who has his brain see-saw horizontal. If he has too active a front brain he drugs himself to depress this end until balance is reached, but it springs up again as soon as the effect on the brain has worn off. He can achieve temporary balance by depressing, that is anaesthetising, his front brain by alcohol or other drug but he can achieve permanent balance by stimulating the hind end with apomorphine.”

See-saws, however, cut no ice with any psychiatric interpretation of addiction. The physiological “disease concept” was increasingly being rejected as drug dependency was explained in Freudian terms. Dent offered his own interpretation of this tendency;

 

“Recently there has been a plethora of psychological schools striving to explain the action of the mind by forcing
it to fit every conceivable theory. Psychoanalysts have ceased to be concerned with the slow investigation of the anatomy and physiology of the brain and have irresponsibly postulated not only the soul and the will, but have invented every kind of attribute for them-complexes, fixations, repressions, libidos. Let us cut all this out and consider what a man’s brain is: a mass of nerve cells and fibres whose function it is to co-ordinate the response of the individual to alterations in his surroundings and maintain the chemical and physical balance of his blood linking up the behaviour of every part of his mechanism with every other part……..”RUNNER

Explanation of phenomena is only worthwhile if it does it in simpler terms. Psychiatry for Dent was not remotely capable of this, but was Dent?  Addiction has as many facets as it does sufferers and until we know better about whether neurosis begets addiction or vice versa, the only way forward must be holistic. Partly due to Dent’s profound study of the problem and based already on twenty years of experience, he believed that psychiatry was making things worse and particularly for those at the compulsive end of the addiction spectrum. Through lack of imagination as much as self-interest his detractors incorrectly assumed that Dent only saw the problem in physiological terms and that he adopted an almost evangelical approach to Apo’. This, in terms of a problem which is so demonstrably varied, would have been neither realistic nor helpful but, in respect of what Dent actually advocated and practised wasn’t even a half truth. Dent did not have just one way to deal with the problem, he had several and each was tailored to suit. “You don’t cure a disease by talking.” was simply his way of emphasising that addiction to drugs changes physiology and unless this was understood and addressed subsequent problems could undermine any treatment that did not preclude psychotherapy. He wrote:

“There is every form of drinker. There is every grade between the occasional, intermittent and continuous drinker but no hard and fast line between the self-indulgent drinker and the addict. The self-indulgent
drinker may often become an addict and the second has nearly always been the first. The first takes alcohol for pleasure the second, from necessity. The first enjoys it, the second may loathe it and yet may steal to get it. The Law, the Church and the psychologist may cure the first, but the man who has altered the chemistry of his body with alcohol must be treated chemically.”
But Dent had annoyed too many and the nonsense that became absolute was that Apo’ was aversion, that he only used Apo’, and only saw addiction in terms of physiology. At a conference in 1954 a Dr J.A. Hobson who knew Dent extremely well remarked; “….apomorphine was the most useful drug STRIP CARTOONavailable for the treatment (of addiction) but he did not agree with what he considered to be Dent’s disparagement of psychotherapy. Probably Dent himself practised more psychotherapy with his patient than he was aware of. He was interested in his patient as human beings not as “cases”. I am sure that Dent without apomorphine would cure more cases than would apomorphine without Dent.”   This back handed compliment was really a thinly veiled criticism of Dent’s attempt to emphasise the importance of the physiological dimension, which was in danger of being ignored by psychiatry. Dent of all people knew the difference between the benefit of psychotherapy but also its limitations. This was a man who had delivered babies with smelling salts (Chapter One) and treated Spanish flu with placebo with apparent equal benefit” (Chapter Two) and now he was being told how to suck eggs! One of the reasons Dent so disapproved of psychiatry was his belief that patients should not be asked to do something unrealistic as this would only condition a sense of failure. This is exactly what he saw among compulsive addicts who were being treated by psychotherapy or Freudian psychiatry alone……..treatments that showed no sign of ever ending.

Dent  through necessity had become a storyteller but, like his forebears, was a man of few words and reluctantly found himself having to explain addiction anecdotally. He became an observer of people, of their behaviour and environment, but would really have preferred to explain addiction in terms of chemistry and physics. But he could not. Science could not explain his success and Dent without analogies or anecdotes couldn’t either. He was exploring and discovering all aspects of “reward theory” that wasn’t explained in terms of its neurology for another three decades and is still a long way short of being fully understood. He was also using a dopamine agonist (Apo’) which provides a synthetic match for  dopamine, and targeted the same receptors implicated throughout the reward system and key to determining adaptive and addictive behaviour. Unfortunately none of this was known when Dent was having unrivalled success with Apo’, but he was not a team player and his antipathy towards the “bluffing” by psychiatry and doctors who prescribed addictive drugs had engendered a hostility that became a barrier to the help he clearly required and was warranted. A clear example of all this can be seen in his description of being hypersensitive to alcohol long into abstinence (the same phenomenon that recently killed Amy Winehouse) and outlined as early as 1941 in the first edition of “Anxiety and its Treatment”. This also demonstrated that addiction caused permanent neuro-adaption within the reward system that due to stresses or cue-inducement could, at any time, cause relapse and undo any successful treatment.

The commonest cause of failure is that the patient may think that after so many weeks, months or years he can now “trust himself” to have a little wine or beer. I have known one glass of sherry turn a happy teetotaller of eleven years standing into a compulsive drinker within a week.” Dent always explained this phenomenon to his patients. Nevertheless, some were still undone  by the unlikeliest of sources; spiked drinks, minute amounts of sherry in a trifle or the odd case of…. “……… a woman who was in love with a man who had been successfully treated eight years before.  She said she could not marry him because he would not have an occasional cocktail with her. He pointed out that if he did he might become a drunkard again. She wouldn’t hear of it saying; “if you are a real man and really love me you’ll be able to stand that sherry, what would I look like drinking alone?” Unfortunately he was in love with her and he took his glass of sherry. Next day he drank a whole bottle of whisky and the next day and the next. She then threw him over because she could not possibly marry a drunkard and he continued to drink for several months until he was treated again. He again became a teetotaller but remained a bachelor.”DOG

This analysis is typical of Dent’s weakness at reeling off anecdotes as a way of demonstrating what he knew about the “science” of addiction but in truth, in 1941, was there a better way? In the emerging era of the NHS (admittedly this was printed seven years before Bevan’s behemoth) papers would have to be increasingly cross-referenced with all manner of sources, tables and data. Dent was not good at that sort of thing, he was a practitioner first and foremost, but, nevertheless, it would be interesting to know what the difference is between this tale of broken hearts and what subsequently became known
as reinstatement. ?

Dent’s interpretation was based on what he saw. His raw analysis was rudimentary compared to the frigid papers that would succeed him but it ill-becomes science to disparage this sort of empiricism. Dent’s pioneering observations were accurate and justified in terms of its success because it helped people “see” what was previously invisible, pitfalls that, once they were clearly explained, could be understood and unflinchingly avoided. The psychological fillip this provided empowered the patient to deal with anything. Nothing could or should be avoided. Old friends, haunts, bars, pubs, clubs, everything, apart from the drug, should be embraced. Another of Dent’s patients; Patrick Riddell explained the joy at being able to “cock a snook” at his addiction;

“He explained the treatment he had given me. Then he asked me where I had done most of my drinking while I lived in London. In my club, I told him, and in the Chelsea pubs. Which club? I named it. Which pubs? I named them. Very well, he said – I was to spend two nights in my club before returning to Belfast (where Riddell lived) and I was to make a tour of all the Chelsea pubs I had ever habituated. I was to drink an orangeade in each pub and walk out of it, cocking a mental or actual snook at it as I did so. This command perturbed me. Was it wise to go again to such places? He did not answer me in words. He gave me an answer far more reassuring, far more valuable than any he could have spoken. He put his head back and laugŵhed. (I shall never forget that laugh: the confidence of it, the confidence it gave me, was astonishing.) Then he rose from his chair, gave my ear a Napoleonic little tug, strode to the door in his customary manner and was gone before I could thank him. He had something of the rushing winds in his personality. I like rushing winds.”

Riddell had been dependent on alcohol for twenty years. It had all but destroyed him and all those close to him; his wife, children and friends. But within forty-eight hours of finishing the Apo’ treatment he was trawling the pubs just as Dent requested. Was his re-stimulated brain, flushed with Apo’, now able to adapt to new learning strategies simply because it was free of “craving” or did the immediate and empowering exposure to old haunts imprint themselves and replace those destructive habits because of Dopamine’s role in motivation, learning and memory? The reward system is a form of “survival stategy” but how are new strategies acquired without the wherewithal to imprint them? Dent (1948) reported in his final paper a seventy per cent success rate (still abstinent one year after treatment) of those treated with Apo’ and various adjunct therapies yet not once has there ever been any official interest in his method and what underpinned it. The brain’s ability to adapt to new strategies is particularly hard in the face of addiction. Most of Dent’s patients were referrals, considered “hopeless cases” and therefore his results must be considered extraordinary in light of what we are told about a problem that still decimates society and science purports to research.

Back in the first half of the twentieth century one of the problems surrounding the “disease” concept was the lack of objective diagnosis. Today’s society waits for science to crack what could be the game changer, the genetic code that predisposes addiction. Until then we must also consider that there is evidence of people spontaneously overcoming addiction, suggesting that for some, drug dependency may be a matter of “choice” and not “disease” after all. People cannot, for instance, suddenly decide not to have cancer, asthma or diabetes and there is a school of thought that addiction is merely an adaptation to deal with a deficit of happiness. Whatever the truth, perhaps part of the answer was the emergent understanding that anxiety and the addiction cycle has a progressive biochemical dimension whereby one stage leads to the next. In terms of what was observable this could be explained in terms of behaviour something that Dent had seen from every angle and many times:

“Every change in a man’s environment has to be met by some change in himself. The future that before had seemed clear is now uncertain, strange and frightening. He worries and suffers from sleeplessness, and to treat this he takes a few aspirins, which soon cease to help him. He takes a little alcohol with his aspirin. He takes even more alcohol. He begins to suffer in his health, and alcohol is the only thing that relieves him. Without it he has headaches, indigestion and restlessness. Soon he is not able to sleep without getting partially drunk. His liver and stomach become increasingly poisoned until he cannot live without alcohol. It becomes the only food he can absorb easily. His wife and family have long before this attempted to cut him off drink and have quarrelled with him. He cannot retain his job. He spends more and more on drink. He lies about the amount he takes and steals to get it. His former friends leave him and he acquires others who do not preach to him. He sinks lower and lower and his only hope is that his diseased liver will some day give out and fail to keep him alive.” For the early stages “the occasional and the intermittent” (also termed “self-indulgent” or “moderate drinker”) Dent, found Apo’ unnecessary and recommended antabuse (disulfirum) with Vitamin B6 and a range of psycho social support that involved suggestion therapy (waking suggestion). This would invariably prove to be sufficient for those patients sufficiently motivated to persist with the medication but, for the compulsive addict, according to Dent you first of all had to deal with withdrawal and “craving”. Doctors were aware that there was a significant risk attached to using antabuse  with those suffering from chronic biological dependency because, for these, the deterrent of antabuse was sometimes still not enough resulting in terrible sickness and even death. Dent’s raw description of “craving” is vivid and compelling;  “Each bout is his “last bout” but after a few days, weeks or months, the craving develops and the symptoms of cravings are so severe that they sweep everything else from his consciousness. He feels as if he is going mad. No confession, no vow he has ever made, no injury to his career, his family or his health, not even the certainty of blindness, has any power against the terrifying craving. I have seen people suffering from it many, many times and their anxiety is very painful to witness. How much more terrible must it be to experience? It is impertinence for anyone who has not experienced it to talk to a sufferer of “will power” or duty of faith or morals. These words mean nothing to him. He is a man with a craving. Alcohol is his only reality.”

Significantly the Danish doctor Oluf Martenson-Larsen, and one of the originators of antabuse, also recognised the need for different bio-chemical approaches and successfully used Apo’ for the treatment of anxiety and addiction right up to his death in 2000.

 

Against the moral backlash against drug dependency Dent was a consoling voice, for some, the complete package, a man who had walked the talk, a physician you could trust and one who knew exactly when to talk and when to inject…some needed to hear the sound of a human voice but others, through necessity, needed chemistry and an explanation with which you could not argue. “all movement, whether it be balls on a billiard table or of atoms in the brain, is the result of previous movement and strictly determined.”

Elisabeth Lutyens described her first meeting with Dent, his transparent honesty” and subsequent treatment: “He explained the results of his years of experience and treatment briefly and succinctly: 

ELISABETH LUTYENS (1906 - 1983) THE GREAT, BUT SADLY UNREPRESENTED, TWELVE TONE ENGLISH COMPOSER

ELISABETH LUTYENS (1906 – 1983) THE GREAT, BUT LARGELY UNDER REPRESENTED, TWELVE TONE ENGLISH COMPOSER

over stimulus of the front part of the brain, producing over anxiety, is relieved by the depressant effect of drugs and drinks. He had discovered that apomorphine, absorbed orally or by injection, stimulated the back brain, producing balance without causing addiction. His quiet confidence and his simple, completely open way of explaining the whys and wherefores of his treatment reassured even my scepticism and there was no smell of psychiatry. He warned me that once my chemistry had been changed I should never touch alcohol again, for, with my metabolism, one taste could make me revert to alcoholism.” He was entirely true to his word, and for my part, with my faith in him, I have never taken a drop of alcohol since my weeks treatment.”

The Lutyens quote is illuminating because it concisely sums up Dent’s method, his ability to get under the skin of his patient even before he or she knows what is happening. Many of these people had seen faith healers, Christian Scientists, rung bells with Buddhist monks while watching the sun go down. They were already sceptical of quackery and deplored the bogus notions of psychiatry that saw dependency as an unresolved trauma from childhood. Some may have benefited from such an interpretation but Lutyens knew exactly what she needed; her biological dependency had to be addressed. Therefore, to meet Dent who explained addiction in terms of neural imbalance must have appeared like a breath of fresh air after the ‘whiff of psychiatry’. Prior to and alongside Dent there was very little in the way of holistic treatment, addiction was a “sin”, society admonished sufferers with puritanical lectures on willpower and threats of eternal damnation. Dent’s “disease concept” was “heresy”, and let people “off the hook” in terms of responsibility but Dent disagreed not only with the nonsense of “willpower” but also with addiction being treated as anything other than a purely medical issue. Once addiction had changed your chemistry to the level of compulsion there was no “cure” other than death and you might as well accept it.

This was the brutal world of hard knocks and Dent, with his brusque manner, told it straight. It is stating the obvious (and boring) to say that “charisma” was part of his armoury but what is harder to determine is the need to separate “charisma” from belief. Dent’s compassion offered a range of solutions that sprang not just from his experience, amassed from several decades of exploration and practice, but also from a profound ethical code; “Firstdo no harm – Primum non nocere. Without question Apo’ was indivisible from Dent’s range but also inseparable from his purpose; abstinence not maintenance. It was this distinction that Dent, with characteristic integrity, could wholeheartedly embrace and, of course, there can be absolutely no doubt that this resolve would also transmit itself to his patients. In one to one treatment Dent would certainly have been a persuasive force and offer what every placebo must impart; a shared belief between physician and patient. Nevertheless, by the same token and based on all the “evidence based medicine” that exists it must also be clear even to those with a flimsy grip on reality that Apo’ doesn’t select who it chooses to be therapeutic for and with proper research perhaps leading to dopamine analogues could have offered an alternative to the maintenance therapies that Lord McNair complained about so bitterly in a debate on Drugs and Alcohol (Hansard – 14/4/1993). In it he talks of Benzodiazepines as drugs of addiction par excellence that “two per-cent of the population are on tranquillisers” and the cruel joke methadone and other teratogenic drugs; (Neonatal Abstinence Syndrome).  People interested in the ethical dimension of all drug’s policies should seriously consider if the issue of abstinence should have been more forcefully supported by our legislators and scientists working in the field of addiction and particularly in the 60’s leading to the 1967 Dangerous Drugs Bill (Hansard 6/4/67) which, despite promising more “research“, never showed even a glimmer of understanding of this critical issue. Furthermore, any researcher working in the field of addiction therapy should not fall back on the lack of evidence excusing the falacious “aversion” or “charisma” interpretations. Arguably, Dent is still the most successful practitioner in this field, either before or since, and any such facile interpretation of his method illustrates a weakness for academic hubris over unanswered issues surrounding the science, it’s lack of research and the subsequent implications for all drugs policy.  If Dent’s initiative had found favour, both in respect of its method and policy, can anyone honestly say we wouldn’t be better off today than we are?

DENT_925

 

 

Money had never interested Dent. Sometimes his patients were so poor they could not afford to pay for the care they needed and Dent, by no means wealthy, bore the expenses. Other patients were at the other end of the food chain. One day a car drew up outside Dent’s house and left a package. Unwrapping it Dent revealed a painting of known provenance and a note from an ex- patient. “In gratitude.” Years later an art dealer visited this man. He was still sober and living in a stately home that housed his art collection; his Constable’s, Canaletto’s and so on.  As they chatted and strolled from room to room they arrived opposite a gap where Dent’s painting had once hung. Puzzled the dealer looked at the label and asked for an explanation. The convivial atmosphere changed and the collector hesitated before reflecting how he had struggled in his early life and how a doctor had been able to help. The art dealer appeared slightly embarrassed, but feeling that he needed to be say something blurted;

“Oh well, w-why don’t you fill in the gap, it looks a bit silly, don’t you think….you could move them around, you could…”

The collector stopped him. “Ah, but you don’t understand. You see, I am prouder of that gap than of any painting here. In fact I am prouder of that gap than I am of my whole collection. The gap stays!”

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