Altruistic Violence

A weekly letter from the founding editor of The Browser. Topics may vary. Correspondence and criticism welcome: robert@thebrowser.com

This week: Doctors as writers, doctors in literature. Preceded by a personal note.

My recent letter about George Orwell and David Bentley Hart, Rules For Writers, provoked generous comment for which I am much in your debt. Most came as private email; an exception was Henry Oliver's admirable public rejoinder at The Common Reader. I hope to return to this general subject, whether there can be rules of any general value to writers, and, if so, what those rules might be, with a view to arguing in favour of soft rules intended to help writers express themselves clearly, and against hard rules intended to constrain individuality and experimentation.

I do read and value all the thoughts and comments which friends and subscribers are kind enough to send me, about this letter and about The Browser in general. I think between us we must have the gentlest and most cultivated community in the writing and reading world.

Your emails touch me so deeply that I feel all the more keenly my own shortcomings as a correspondent. Often I find myself replying to emails weeks and months in arrears, and sometimes not at all. It is not, I promise you, because I do not want to reply. It is because I want to reply well, which I never feel that I have the time and focus to do at the given moment, with the result that I delay, and, well, you know what comes of that.

Allow me, as a temporary measure, to thank, salute, honour and praise my friends and recent correspondents Matthew H, David N, Charles C, Barbara E, Clayton M, Robert De V, Martin W, Irwin R, Alison T, David Y, Timothy W, Ben W, Steven Mac, Steven M, Gemma B, Charles A, Jim B, David H, Stephen S, Benjamin C, Nick F, Provi, Hannah K, Jim W, Reed H, Kyle B, Daniel S, David Y, Will H, Ruth Mac, John A, Peter T, Thierry M, Leslie S, Michael D, Jeffrey R, Antonio G, John, Simon S, Tony D, Tony C, Frank R, Roman J, Stephen F, David P, Rodney D, Peter M, Galen S, Christopher S, Jsh, Steve C, Warren F, Steve P, Donald N, Fred R, Peter L, Lois P, Tobias S, Jonathan H, Jeremy C, Brian, Shardul C, Richard F, Henry F, Antony D, klgraham, Ted O, John A, Ellen W, Lewis L, Sarah P, Jay S, Judyth R, Michael H, Jeanette C, Willis R, Dennis T, Charles A, James C.

To each of you I owe a letter; forgive me my fecklessness; and above all, though it is a great deal to ask in the circumstances, please do continue to write. A particular thanks to Barbara Epstein and Irwin Rosenthal, whose emails have been a constant source of inspiration and information to me, and without whom my reading and writing would have been much the poorer.

On now to this week's letter, about doctors and books, sparked by my long-standing admiration for the brain surgeon Henry Marsh. We have been recommending Marsh's writing on The Browser since 2012, when he made his literary debut with an essay in Granta about the pineal gland, accompanied by a brief and touching interview.

In 2015 we highlighted an extraordinary piece of writing about Henry Marsh, by Karl Ove Knausgård, who watched Marsh operate on a patient in Albania. The piece has since disappeared from its original home online at the London Telegraph, but can also be found in the New York Times magazine of January 2016.

Marsh said last week that his cancer, mentioned below, is currently in remission. This has allowed him to do more charitable work in Ukraine, and to complete his book about dying, And Finally. His character is caught well in a recent photograph by Patrick Sherlock.

IN HIS forty-year career as a brain surgeon Henry Marsh never once sought to have his own brain scanned, noting that the surprises which came from doing so were invariably on the downside. He was in semi-retirement by the time he finally agreed to have a scan, and then only because it was required of him as a volunteer in a clinical trial:

I had blithely assumed that the scan would show that I was one of the small number of older people whose brains show little sign of aging. I can now see that although I had retired, I was still thinking like a doctor — that diseases only happened to patients, and not to doctors, that I was still quite clever and had a good memory with perfect balance and coordination.

The scans told a different story. He had been right in the first place:

I was looking at aging in action. My seventy-year-old brain was shrunken and withered, a worn and sad version of what it once must have been. There were ominous white spots known in the trade as white-matter hyperintensities. My brain was starting to rot. I am starting to rot.    

Reading this passage, I was looking forward to Marsh's reflections on the cognitive aspects of aging. I had reckoned without the next twist in his tale. His worries about dementia were overtaken by the news that he also had prostate cancer: "I had a PSA of 127, I couldn’t really believe it. Frantic googling told me that most men with a PSA of over 100 will be dead within a few years".

Marsh, who still walks among us, is an unusually powerful writer even by the standards of his profession, partly thanks to his subject matter. Nobody does brain surgery better, at least on the printed page. He tells us about life-and-death operations. He tells us what he thinks while performing such operations. When I am reading Marsh I think: This is how it feels to be a surgeon.

It is clear, too, that Marsh enjoys his work, which is an odd thing to say when a critical part of that work involves cutting holes in people's heads. "I found its controlled and altruistic violence deeply appealing", he says of surgery in his memoir, Do No Harm.

If that line sounds almost psychopathic, the reality could scarcely be more different. Marsh is virtue incarnate. Even so, there is something unnerving going on here. Obviously, you cannot be a good surgeon if you recoil in shock from what you see on the operating table, as most people would. "Altruistic violence" is a concept worth investigating, and perhaps a skill worth cultivating.

Nor can you be a model surgeon if you develop (and express) strong sympathies towards some patients and aversions towards others. Your counterparty is the disease, not the patient. As Ernst Jünger said in a suitably military formulation: "The ill person is the tactical object of medicine, the illness is the strategic object”.

I hesitate to say that all physicians make good storytellers, but the correlation is certainly impressive, and holds up well against other philosophically-inclined professions.

True, soldiering and writing have always got on well together: Think of Xenophon, Herodotus, Descartes, Chateaubriand, Siegfried Sassoon, T.E. Lawrence, Winston Churchill, Erich Remarque and Ernst Jünger.

Lawyering has given to our libraries Cicero, Francis Bacon, Henry Fielding, Walter Scott, J.W. Goethe, Charles Perrault, Franz Kafka and Wallace Stevens.

Even the advertising industry has done its bit for literary fiction, nurturing at various points in the 20th century F. Scott Fitzgerald, Peter Carey, Don DeLillo, Salman Rushdie, Faye Weldon and Dorothy Sayers.

Other writers, any number of them, have doubled as farmers, teachers, civil servants, scientists, clergy, politicians, criminals, athletes, parents, invalids and retirees, each carrying something from this other life into their writing.

But doctors, even so, still seem to me to be in a class of their own when they commit their ideas to paper. As perhaps they should. They possess skills verging on the miraculous; they work on the frontiers of life and death; they know at first-hand more than any philosopher or priest does about relations between mind and body. If anybody can tells us the truth about the human condition, it ought to be doctors.

Any self-respecting bookshelf of doctors-as-writers would be a very long one indeed, extending from Luke the Evangelist to Rivka Galchen by way of François Rabelais, Thomas Browne, John Keats, Friedrich Schiller, Oliver Wendell Holmes, Anthon Chekhov, Arthur Conan Doyle, Somerset Maugham, Mikhail Bulgakov, Sigmund Freud, Robert Bridges, William Carlos Williams, Jonathan Miller, Oliver Sacks, Adam Phillips and Iain McGilchrist.

Such a bookshelf might also find room for Dante, who was a member of the Physicians' and Apothecaries' Guild of Florence (which was also the guild for paper-makers); James Joyce, who failed three times to get into medical school; Gertrude Stein, who dropped out of a medical degree at Johns Hopkins pleading boredom; and perhaps even Marcel Proust, modernity's greatest authority on insomnia and hypochondria.

In Scattered Limbs, his highly recommendable anthology of reflections on medicine, Iain Bamforth, a doctor himself, compares doctors to critics:

If what critics do is analytical, what doctors do is often anatomical: they cut a long story short, parse it in ingenious, abrupt and sometimes violent ways in order to reduce it to its bare plot lines: the solid vertebrae that hold up the fleshy superstructure.

This makes doctors sound more like editors, I think, which is a pleasingly suggestive analogy. There are certainly times when one's body needs a good edit.

As for a more direct analogy with novelists, I would rather say that doctors actually do what most novelists merely want to do: They see life at its barest and most vulnerable, in its most private and extreme states, and they act forcefully, sometimes painfully, upon it.

This necessary rudeness of technique, and the uncertainty as to outcomes, tended to make doctoring an unpopular business prior to the rise of scientific medicine in the 20th century. When Sir Thomas Browne published Religio Medici (The Religion Of A Doctor) in 1643, he began it with a disclaimer asking readers to forgive what he called “the general scandal of my profession".  

Doctors are everywhere as characters in literature, from Charles Bovary to Yuri Zhivago. But what they actually do in literature when closeted with their patients has tended to remain something of a mystery. Depictions of medical practice are constrained by the prudishness of the day in matters of bodies and bodily functions. As a general rule, if the selling-point of a story is its physiological detail, then it probably belongs in a genre other than literary fiction.

When Gustave Flaubert sought to include a few glimpses of general practice in Madame Bovary, critics professed disgust: “We are in a dissection room, and we have just read an autopsy report”, said one. But Flaubert did succeed in moving the dial towards anatomical realism; as did the novels of D.H. Lawrence and James Joyce.

Joyce in particular delighted in bodily functions. He may well have been the first novelist to give prime time to the kidney since Tobias Smollett (a ship's surgeon) in the mid-18th century.

Joyce took the novel outside my own personal comfort zone by reintroducing defecation to the printed page in Ulysses (1922). Please do not correct me if I am wrong, but I doubt that defecation had previously been addressed so directly in literary fiction since Don Quixote (1605); and it has not been much addressed since, to my knowledge, save by Philip Roth and Anthony Burgess. Tolstoy's War And Peace tracks the behaviour of 500 characters across three thousand days without a single lavatory scene.  

This is not meant as a complaint. Far from it. I am sure I would skip any prolonged and graphic lavatory scenes if any novelist did think fit to include them — much as I skipped the dozen-or-so pages of Ian McEwan's The Innocent (1990) which described in gruesome detail the dismembering of a body such that it could be fitted into two suitcases.

Still, it is an expression of puzzlement. The lavatory can be a place of solitude, of deep reflection, of reacquaintance with one's animal self. I will leave to a stronger and wiser stomach than my own a more thorough investigation of why this element of human behaviour has been so neglected in literature, and, indeed, in the generality of public life.

Ever since the mass-production of penicillin in the 1940s, doctors have had big science on their side. Their status has risen in life and in art. But before then, as John Salinsky has noted, doctors depicted in literary fiction were a very mixed bunch:

There is Emily Brontë’s Dr Kenneth, who does his best with some very difficult patients in Wuthering Heights. Dr Slop the man-midwife makes a botched delivery of the infant Tristram Shandy. We spend an evening in the Dublin Rotunda Hospital in the company of Leopold Bloom and a crowd of drunken medical students. We study the career of young Dr Lydgate of Middlemarch in some detail and emerge shaking our heads sadly.

Of course, George Eliot's Doctor Lydgate is a fictional character, as is his near-contemporary, Anthony Trollope's Doctor Thorne. But if we take those two as being plausible representations of the doctors of their times, and since both are represented as sincerely wanting to do good, I find myself wondering what such doctors thought they were doing when they met with their patients.

For example, when Trollope's Dr Thorne attends Lady Arabella Gresham for what Trollope simply calls "cancer", are we supposed to think that Dr Thorne understands much about the given illness, or that he thinks himself to have any means of curing or arresting it? What does he tell Lady Gresham? What does he tell himself?

When Tertius Lydgate attends Casaubon in George Eliot's Middlemarch after what seems to have been Casaubon's first stroke, on what grounds and with what degree of confidence does Lydgate tell Dorothea that her husband might die the next day or live another 15 years? Of what use is such information supposed to be?

Doctors such as Lydgate and Thorne, practising in the first and second thirds of the nineteenth century respectively, would certainly have had some sense of scientific method, which was then advancing rapidly in the natural sciences. They must have known that their "art" of medicine had, by comparison, little or no scientific basis. They had no reliable cures for any serious diseases.

And yet they persisted; which provokes me into wondering, since the wisdom of great literature is timeless, whether things are so very different nowadays.

We know now that many diseases are carried by microscopic organisms which we call germs, that such diseases can be cured with drugs, that failing organs can be replaced, and that cancers can be eradicated or immobilised.

But while we have learned to prolong the average human lifespan in ways at which history will marvel, this prolongation has been largely the result, not of new technologies, but of widespread drastic reductions in infant mortality achieved through means of no intrinsic novelty whatsoever — encouraging doctors to wash their hands, and enabling parents to put more food on the table.

By reducing infant mortality we prolong youth, and youth is the most wonderful of things. But prolonging old age, the explicit focus of much current medical research, strikes me as less of a deliverance. My impression is that life adjusts to later prolongation in the manner prescribed by Parkinson's Law: Work expands to fill time available.

I marvel at modern medicine. I have benefited from it myself, and greatly so. As Iain Bamforth says, there are no technophobes on the operating table. But in my more philosophical moments, I think all that I can reasonably ask of any doctor (indeed, of anybody at all) is that I should not die unnecessarily. Perhaps here I begin to appreciate better the role of a Doctor Lydgate or a Doctor Thorne. If they did not cure, they did at least care; they were the best of their kind. Doubtless I would have felt just as much moral and psychological reassurance in their hands two centuries ago as I feel in the hands of any doctor today — Robert