The best books on Medicine and Literature

What use is medicine to literature and literature to medicine?

Being a doctor I think makes me a better writer because in my medical practice I have to write quickly and succinctly. I have just a few seconds to get down important facts about a consultation that has just happened. I have to communicate with colleagues, which means I have to be very accurate and dispassionate in presenting clinical findings, and any questions I want to ask of specialists. A lot of medical questioning is about sifting the important question from a mass of undifferentiated detail. Somebody goes to the doctor because they feel sick — “I feel sick. I’ve got a sore head” — and your job is to sift which of the thousands of possible stories that led to that sore head is the one which will give you more of an insight into its cause. A lot of medicine is about stories, so being a doctor helps my story-telling self when I come to attempt to write literature, however defined.

I think a deep engagement with all sorts of literature is useful for any human being who seeks to get outside their own head and explore other perspectives. The wonderful thing about reading is that it’s so intense and immersive and you are in complete control. It’s not like listening to a piece of music or watching a film, where you are at the mercy of the conductor or director. When you’re reading a book you can titrate how quickly you take in new ideas, how quickly or slowly you savour the art in the writing. In medicine I don’t have that luxury. There’s always a pressure of time. So engagement with literature is wonderfully liberating for me.

How would you describe your new book, Shapeshifters?

Like my previous book, Adventures in Human Being, it is a cultural exploration in medicine. Adventures examined the body as a landscape —  a philosophical hinterland such as a travel writer would explore if he were going to a new country. Every chapter explored a part of the body and looked at one or two different aspects of it because it’s impossible to be comprehensive. It set out to look at the body as a cartography, a place in space you can explore.

“A lot of medicine is about stories”

Shapeshifters looks instead at the dynamism of that landscape — the fact that it’s constantly changing from one day to the next and even from one moment to the next. Some of those changes are inevitable, and to do the great transitions of life and ageing: conception, birth, puberty, pregnancy, menopause. Some of those changes are about moment-to-moment shifts in mental experience. So there’s a chapter in the book about dreaming, another about psychosis, another one about jet lag — how just a change in body-timing can make you feel so dreadful. There’s a chapter about hallucinogens. There are some chapters about crises – such as amputation, cancer treatments, fractured bones. There are also some explorations of changes you can will upon your body, for example, pumping up all your muscles to become a body builder, or tattooing or scarifying yourself. And then there are other kinds of transformation that begin with a little kernel or seed of the will and take over. Anorexia is one example. It can start with an intention to slim down that gathers its own momentum and becomes something very dark. Similarly, on the borderline between will and destiny, if you like, are all the transformations we have in this cultural moment where we facilitate gender transitions. The transgender people I know feel this is the only way for them — that to transition from their birth gender is their destiny. But there’s a lot of willpower involved in that. It is a very trying process.

You have told me you have reservations about choosing the ‘best’ five books on medicine and literature.

I don’t disapprove of lists; it’s just that I think it doesn’t makes sense to have some kind of a beauty contest. I love reading Thomas Browne, and I could mention any number of other famous, male, doctor-writers: Mikhail Bulgakov, Oliver Sacks, Chekhov. But Browne, Sacks et al don’t need any more cheerleaders. The choices you asked me for are just reflections of my current enthusiasms. All of them have something unusual to say, and they do it in an original ways. My hope is to come up with discussion points and to talk about what we’re really looking for when we’re looking at medicine and the body.

Your first choice is the Hippocratic Writings. Many of us have heard of the Hippocratic oath, but I guess few of us have read the writings. Why, and how, should we read them?

Whenever you start thinking about a subject, I’ve always found it a good principle to go back to the very beginning of what has been written about it. The Hippocratic writings were collected in the library in Alexandria around 300 to 200 BC, maybe even later. Essentially they are writings on medicine from across the Greek world that were deemed to have reached a certain standard. They are very varied, and from all sorts of different authors. I am no classical scholar, and I cannot make any comment on the translations, or even the cultures that they come from, but I really enjoy looking through them because you can see how intellectual curiosity was already working hard. Some of the Hippocratic writers are intensely trying to figure things out. One, for example, is confused about whether all the liquid you swallow goes down your oesophagus or whether some goes into your lungs. So he restricts a pig from water until it is very thirsty and then he gives it water with blue dye in it. And then he does something any butcher would be familiar with, but not many doctors: he slits its throat. He reports that if you follow what he has done, you will notice that some of the blue water goes down the trachea. And he has a whole theory as to why that is, what that tells us about the mechanism of swallowing.

It’s gruesome but it is a proper experiment.

Yes he’s genuinely interested where that water goes and there is proper method. You can see constantly as you go through the Hippocratic writings how they’re reaching for answers. This is from a passage about the heart:

In shape the heart is like a pyramid, in colour deep crimson. It is enveloped in a smooth membrane. In this membrane there is a smooth fluid rather like urine, giving the impression that the heart can move in a kind of bladder. The purpose of the fluid is to protect the pulsation of the heart, but there is just about sufficient of it to alleviate the heat as well.

Amazing! it’s a completely perfect description of the pericardium, whose purpose is to lubricate the beating of the heart within its sac — though not to draw off heat. The writing can be extraordinarily poetic as well. Here, for example, the author has just opened up the ventricles of the heart and looked deeply into its chambers:

These are the springs of Man’s existence. From them spread throughout his body those rivers with which his mortal habitation is irrigated, those rivers which bring life to man as well for if ever they dry up, the Man dies.

Beautiful and completely straightforward!

But unless I’m missing something, there is no idea of circulation of the blood as such

Not at all. That doesn’t come until 1628, although Galen was getting close to it. But there is an enormous amount in these writings about the effect of the environment on your health, and how the humours within the body are affected by the climate within which you live. It’s written, for example, that drought is more healthy than rain, and less likely to provoke fatal illness. The diseases usually peculiar to rainy periods are chronic fever, diarrhoea, gangrene. You can see they’re trying to reach out and put together some sensible ideas about malaria, diarrhoea in places without adequate sanitation and so on.

Do the writings also suggest how to practice medicine and what a doctor should be?

Yes! The precepts, for example, recommend that you not overawe your patients with splendour of your dress. Be sombre and sober in your style. Use a cheap case, don’t wear a fancy hat. And then there’s a wonderful line: you must not force payment from a patient unable to pay, because your reputation will be higher for treating a patient who cannot pay you. Your dedication and devotion to the art is more important than whether you get paid. Beautiful!

“Before there was even a profession such as medicine, there is writing with a scientific appreciation of the body and how to make it better”

So right there at the beginning, before there was even a profession such as medicine, there is some writing with a scientific appreciation of the body and how to make it better. There’s no dogma here, because they’re constantly asking, try this for yourself, prove me wrong! And there is also the beginning of a professional ethic about a group of people who should hold each other to high moral and clinical standards. A few of the writings complain about quacks, who rip people off, and don’t pay attention to the high standards.

There’s another ancient text I could have mentioned: Galen’s That the Best Physician is Also a Philosopher. It’s essentially a call to arms for doctors to concentrate on the perfection of their clinical skills and to give up on ideas of attempts to get rich through their art. It shows all the ways in which he doesn’t trust those doctors who use their talents for a gain other than the benefit of their patients. It is short and elegant.

Your second choice is On Being Ill by Virginia Woolf. It is considered a classic by many people and widely cited, but in an essay some years ago in The London Review of Books, Hilary Mantel dismissed it as ‘schoolgirl piffle.’ What do you find in it that leads you to recommend it?

I think it’s a really important piece of writing just because it’s so beautifully executed. That said, it does lose its way about half way through, and Woolf goes off in pursuit of some enthusiasms that I don’t share. Maybe that’s because I’m not living in 1920s Bloomsbury. I respect Hilary Mantel’s point of view: her essay is about being really very ill whereas Virginia Woolf’s essay is about having a touch of the ‘flu, and they’re two very different things. But Woolf asks a profound question: why don’t we have a greater literature of illness?

At the beginning she identifies a few examples

Exactly! She writes

Novels, one would have thought, would have been devoted to influenza; epic poems to typhoid, odes to pneumonia; lyrics to toothache. But no; with a few exceptions — De Quincey attempted something of the sort in The Confessions of an English Opium Eater; there must be a volume or two about disease scattered through the pages of Proust — literature does its best to maintain that its concern is with the mind, that the body is a sheet of plain glass through which the soul looks straight and clear, and, save for one or two passions such as desire and greed, is null, and negligible and non-existent…People write of the doings of the mind; the thoughts that come to it; its noble plans; how the mind has civilised the universe. They show it ignoring the body in the philosopher’s turret; or kicking the body, like an old leather football, across leagues of snow and desert in the pursuit of conquest or discovery…

I think she’s put her finger on a real issue that, in 1922, literature needed to more closely address the transitions in experience that being ill can effect. And maybe the problem is because there are so many different ways of being ill.

Woolf writes about a transformation in consciousness, a slowing down, and even being in some sense liberated by illness.

It’s as Susan Sontag wrote: “Everyone who is born holds dual citizenship, in the kingdom of the well and in the kingdom of the sick.” And when you are given a diagnosis it can be liberating, because your illness has a name, and it becomes something outside you that others have suffered before. But it can also feel as if you’ve been handed your passport for the kingdom of the sick. You move amongst all the people who are well, but you no longer feel you are any part of them. John Donne also wrote very well about illness 400 years ago. “Disease hath established a kingdom, an empire in me, and will have certain arcana imperii, secrets of state, by which it will proceed and not be bound to declare them.” It’s like an evil empire is slowly colonising his body but he doesn’t understand the rules by which it’s operating. A deeply disturbing aspect of illness that we consider our bodies to be ourselves, but then you get a diagnosis like a tumour…and suddenly you think, my body is no longer myself. I’m up here, above the neck perhaps, and it’s down there, the body is in mutiny and I need to surpress it. Illness can disassemble us, split what we consider ourselves.

Your third choice is John Berger’s A Fortunate Man. When the book was out of print you helped to get a new edition published, and wrote an introduction for it. It’s clearly one of your favourites. What would you say to someone doesn’t know it?

John Berger was an astonishingly skilled and observant witness of anything he turned his gaze onto. He started out writing on art for the New Statesman in the 1950s and his essays there are extraordinary. They were so original, so new, they made people look at old paintings in a completely novel way. When he turns that genius onto the doctor-patient consultation he picks out some of the many levels of non-verbal interaction that go on in an everyday medical consultation. They’re revealed in all their subtlety. And it’s a portrait of a man he loved, the doctor John Sassall.

A Fortunate Man opens with six observations of Sassall working among his patients in the Forest of Dean in 1966. Berger describes beautifully how the doctor himself has to constantly change what kind of person he is depending on what patient he’s dealing with, and what that patient expects. Sassall allows himself to be a chameleon, to become the doctor that he thinks that patient most needs. And I think that is one of the hallmarks of a really effective practitioner. Does the patient need a warm, friendly, arm on a shoulder, or something more informal and jokey, or more of a patriarch, or do they need a scientist to lay out the statistics? People at different phases of illness need different kinds of doctors. I think Berger captures that.

The book becomes an extended meditation on the practice of medicine, which is an attempt to engage a deep sense of fraternity. Berger keeps coming back to this word: the doctor is like an elder brother — not a father figure — and we want the doctor to witness our suffering. There’s a beautiful meditation on the idea that in times of extremes, of dying, the value of the doctor is not just the morphine they prescribe, but that they have seen many others die before. He explicitly says that this is a benefit the clergy once provided by the death bed – not absolution, but witness and having witnessed others die. This is, in a way, so obvious: when you practice medicine you realise that this is what a lot of people need from you. But it’s rare to have it articulated so well, so concisely.

A Fortunate Man was also a co-creation with the photojournalist Jean Mohr. What do you think of the role the Mohr’s photographs play in the book?

Mohr and Berger lived with Sassall for six weeks, and were with him for every patient visit during that time, even on night calls. And Berger said of Jean Mohr he’s the perfect photographer for that, because he’s completely invisible — like a lamp stand! Patients wouldn’t even notice him taking pictures of them. The two men went back to Geneva and worked independently for a month on the project, and John was dissatisfied with the results. He thought they’d both tried to tell the story on their own, and realised they had to go back to the drawing board and make the words and the pictures into a conversation. And they succeed brilliantly. As you read the book, your appetite is whetted by a bit of text and then it’s satisfied by a photograph, which raises other questions, which the text goes on to explore. It’s very beautifully done.

Some years after the book was written John Sassall shot himself. In an afterword, Berger writes something remarkable about that.

I never met Sassall – he shot himself in 1982. I was contacted by his son Simon, and we met. He was very open about the fact that his father was a troubled man who suffered extreme swings of mood. Sassall’s wife had always helped him through those periods and she died in the late 1970s.

Doctors are respected, privileged people in our society and yet maybe Sassall wasn’t so fortunate in the end.

The reason Berger calls him a ‘fortunate’ man is because he gets to do exactly what he wants, which is to pursue his dream of the universal — of what is it to attempt to become a kind of renaissance man or woman in the twentieth century. This is, of course, not possible in the way it was in the fifteenth century: there are simply too many areas of knowledge to cover. But it’s still possible to pursue a passion for trying to understand as many different human perspectives as you can. Sassal wanted to be with and to help as many different kinds of people as he could in a particular restricted community.

I don’t want to comment or theorise about Sassall’s suicide. But I don’t think the fact of it detracts from Berger’s position — that Sassall was pursuing exactly what he wanted to pursue. And that’s the point that Berger makes in his epilogue – he respects Sassall’s decision, and admires that he held on ‘for as long as he could.’ A lot of people who have lost a loved one to suicide will take exception to Berger’s conclusion: he transforms the act from one in which those of us left behind agonise over what we could have done differently, to one in which we feel gratitude that he or she stayed with us as long as they could.

Berger writes “John Sassall, the man I loved, has killed himself and yes his death has transformed the story of his life. It has made it more mysterious, not darker. I see as much light there as before.” How do you take something positive out of a suicide? But Berger manages it, by asking: what if we look at it like this? What if we’re just grateful for the years that we had? And yes maybe it means I didn’t understand him as well as I thought I did. I loved that man, but I didn’t know him as I thought I did.

“The book becomes an extended meditation on the practice of medicine”

It reminds me a little bit of a wonderful paper, published in The Lancet in 1917/18 by W. H. R. Rivers, the psychiatrist who treated Siegfried Sassoon and Wilfred Owen. He talks about how he developed a technique at Craiglockhart, which at the time was very new, of trying to find a redeeming feature of the horror that the men had experienced in the trenches. He gives the example of a man wracked with panic attacks and flashbacks of a going out onto the battlefield and finding his friend blown apart by a shell and trying to gather the bits of his friend together and his personal effects for his widow. And he’s tortured by this memory.

Rivers says, well we can’t suppress the memory but we can perhaps find some aspect of that awful experience that’s positive. Many people in the trenches died slowly, and in great pain, but this man obviously didn’t, he was killed instantly. Rivers reports that when he put it like this the man’s expression changed straight away, and from that night onwards his nightmares stopped. When dreams of the event came back, they didn’t have that same horror. The man found he was even able to talk with his friend in dreams. Rivers insists that it’s possible to take something very dark, and find in it some aspect which is tolerable, or redemptive, and switch your perspective on it.

Your fourth book is Intoxicated By My Illness by Anatole Broyard. In contrast to your last choice, it’s very funny in places.

Anatole Broyard was editor of The New York Times book review – a highly literate man, linguistically brilliant and a wonderful prose stylist. He was diagnosed with prostate cancer fairly young. This book is a collection of essays he published in the The New York Times about his illness. He has a gentle irreverence about the medical process which is comforting after you’ve read a lot of medical memoirs. He says things like: “My first urologist, who was quite famous, wanted to cut off my testicles but I thought this was admitting defeat right at the outset.” And then he describes all the terrible things he had to go through to get his prostate cancer treated. He says, I would like a doctor who is not only a talented physician but a bit of a metaphysician too, someone who can treat me body and soul. “To get to my body my doctor has to get to my character. He has to go through my soul. He doesn’t only have to go through my anus.”

But Broyard can also be very serious.

Oh yes. He writes a penetrating account of what it’s like to have a bone scan, looking for metastases of your cancer. He writes about what’s going through his mind as he lay under a huge machine that scans all your bones looking for ‘evidence of treason’. “There’s a horror movie appeal to this machine. Beneath it, you become the Frankenstein monster exposed to the electric storm.”

I appreciate this book for its irreverence, the elegance of its prose and because the essays in it are succinct, punchy, with the tyrannical discipline that newspaper journalism has to have. And I like the idea.

He also goes into depth about what he expects from a doctor

Yes, he writes

I want doctor who is a good reader of illness. I cling to my belief in criticism, which is the chief discipline of my own life. I secretly believe that criticism can wither cancer….When you die your body dies with you so I want a metaphysical man to keep you company. I want a doctor with a sensibility, and that seems almost like a contradiction in terms.

Many books on illness tell the reader about the waking life of the cancer patient but not about daydreams or fantasies, or how illness transfigures you. Broyard writes:

You wouldn’t know that inside every ill person there’s a Kafka character, a Han Castrop trying to get out, But there are books about illness that are too eloquent, full of chanting and dying falls that piously sound as if they were written on tiptoe. To be ill is to be an odd mixture of pathos and bathos, comedy and terror with intervals of surprise, and to treat it too respectfully is to fall into the familiar traps of Romantic agony.

That idea of the pathos and the bathos is a lovely one, and it’s very close to my own experience. Sometimes medical consultations can be really humorous, funny, and I find myself laughing with my patients about the absurdity of the human situation. That you can have all these best laid plans about how your life is going to go and then — wham — 55, and you’ve got metastatic prostate cancer. And of course that’s a terrible terrible thing, but it’s a natural human thing to turn situations of high tension into comedy, because that’s how we cope. And that’s what I love about Broyard. He does it with such panache.

OK, let’s come to your final book, Frissure by Kathleen Jamie

This book is about the poet Kathleen Jamie’s diagnosis, treatment and recovery from breast cancer. She describes in the introductory essay how she had a mastectomy and was a tired of the medical gaze as experienced in all her clinical consultations, and wanted to have a contrasting kind of gaze. For friend of hers, the artist Brigid Collins, she sat for a series of portraits of her mastectomy scar. And in the eyes of the artist the scar becomes all sorts of things. It becomes a horizon. It becomes a rose stem. It becomes the line of the seashore.

And it was during this process they began to feel there was an imbalance there. Jamie needed to write some poems too to accompany the painting and sculptures. And so she begins to write short prose poems, mostly about the process of healing and the transformation that comes about in her own sense of herself during a protracted period of convalescence. Jamie accomplishes what Virginia Woolf was lamenting that we don’t have.

She writes about her summer of convalescence where nobody asked anything of her for the first time in her life. Nobody expected anything except that she walk and read and heal. And how that time to heal is such a great gift. So it’s a book which is utterly original and gets at something very real and valuable about convalescence. Sometimes I find myself recommending it to patients.

Do you recommend books to your patients, not just because you’re having a nice chat, but with a therapeutic purpose in mind?

Of course I recommend books with titles like How To Manage Your Anxiety. But I have had conversations with women who have mastectomies about Jamie’s book, for example. I’ve had conversations with men who’ve had prostate cancer about Broyard. There’s an amazing essay written in the 1970s by Ursula Le Guin about menopause called The Space Crone. She urges women to claim menopause as a valuable transition in life, a liberating transformation, something like an opportunity to be grasped, and I’ve recommended it to women going through menopause. I’ve known people suffering PTSD after military deployment in Afghanistan, and have recommended they read Redeployment by Phil Clay.

Do you recommend literary works to medical friends who aren’t big readers?

Generally no. Medicine is a very different world to publishing. There’s something about medical training that is so taxing in the early years that often other interests get pushed out.

How come they didn’t get pushed out of you?

I don’t know. I think writing and reading is a source of solace and it fuels my enthusiasms, and always has. At high school they gave me prizes for English and for Biology, and it always felt as if they were two things I could combine. Chekhov famously said literature was his mistress, and medicine his lawful wife. But that seems an odd way to put it. For me they are complementary. They support and nourish one another, and the relation they bear is not one of rivals, but more like the left and the right foot of a steady gait.