A Doctor's Dictionary E-Book

Iain Bamforth

• Herausgeber: Lives and Letters
• Kategorie: Geisteswissenschaft
• Sprache: Englisch

Veröffentlichungsjahr: 2015

Beschreibung

In this wide-reaching abecedarium, doctor and poet Iain Bamforth dissects the conflict of values embodied in what we call medicine—never entirely a science and no longer quite the art it used to be. Bamforth brings to bear his experience of medicine from around the world, from the hightech American Hospital of Paris to community health centres of Papua, along with his engaging interest in the stranger manifestations of medical matters in relation to art, literature and culture. Drawing on the lives and ideas of some of Europe's most celebrated writers, from Auden to Zola with stop-offs at the likes of Darwin, Kafka, Orwell, Proustand Weil along the way, Bamforth offers insightful and witty diagnoses of the culture of medicine in the modern age.

Leseprobe

IAIN BAMFORTH

A Doctor’s Dictionary

Writings on Culture & Medicine

Hast du Verstand und ein Herz, so zeige nur eines von beiden, Beides verdammen sie dir, zeigest du beides zugleich.

– Friedrich Hölderlin, ‘Guter Rath’, 1797

Contents

Preface

Acknowledgements

Anecdote A Taste of Bitter Almonds

Bodies The Plastinator

Cynicism Knock! Knock!

Depression A Conspiracy of Good Intentions

Ethics Insomnia (in the Bed of Being)

Funerals An American Book of the Dead

GalenCrise de Foie

Happiness The Moral Life of Happiness

Integrity An Empty Plot

Journeys Chekhov Goes to Sakhalin

Kafka Uncle Siegfried

Language Is There Life on Earth?

Mouth Tell Me about Teeth

Nose Hygiene of the Soul

Obit The Importance of Being an Agoraphobe

Posture The Human Position

Qi Emergent Properties

Resilience A Mining Town in Australia

Science (envy) Lamplighters and Lucefactors

Translating Machine Made of Words

Upas The Poison Tree

Vertigo Stendhal’s Syndrome

Weightlessness The War of Eye and Ear

X-rays Under the Magic Mountain

Yellow Fever The Life and Times of Ernst Weiss

(meta-)Zoology Parasites

Endnotes

Index of Names

Preface

Anyone who decides to live on the continent (as only the British refer to it) has to expect to live part of the time in the subjunctive—the verbal mood for anything that’s hypothetical or contingent. You can’t hope to get by as a competent speaker of French or German (where it is called Konjunktif ) unless you know how to enter the parallel world of things that demand someone else’s participation or consent, or the special time or set of circumstances to be agreed upon before a possibility can swell into the indicative. Verbs of wishing, fearing, expressing judgement and emotion all take the subjunctive mood. The subjunctive is for people who like parentheses and extrapolations. The great Austrian novelist Robert Musil wrote an entire novel set in the subjunctive, and never emerged in the indicative to finish it.

The subjunctive exists in English too, but its presence is vestigial and barely observed. Instead we have The Life and Opinions of Tristram Shandy, Gentleman, Laurence Sterne’s seriously funny tribute to the zigzag. His novel was once described as a congeries of ‘unconnected rhapsody, rambling digression, eccentric humour, peculiar wit, petulance, pruriency and ostentation of learning’; it exhibits all those qualities, and it has also been one of the most influential European novels ever. It mocks what it loves, not least the encyclopaedic impulse; Tristram’s father has a system of education ‘collecting first for that purpose his own scattered thoughts, counsels, and notions, and binding them together.’ This is his TRISTRA-paedia.

I took a leaf from Tristram’s father’s system by arranging these twenty-six essays as an abecedary of concept-terms, which is about as much order as I could give to my life. Two of these headings are not even English in origin, which is appropriate enough, and ‘Posture’ has a wider purchase in French, where ‘être en mauvaise posture’ is to be in a tricky situation. My Book of Patience includes magical and not so magical bodies, eyes and ears, nose and teeth, old-style livers and the latest pills, happiness quotients and fake doctors, Chekhov and Roget, mining towns and poison trees, Swiss sanatoria and penal colonies, and bacteria almost everywhere. Some of the concept-terms could, conceivably, have been quite different: Happiness, for instance, displaced another article on Hands, which used to be important diagnostic extensions for doctors. ‘The War of Eye and Ear’ was catalogued under Visions until I realised that the real concern of the essay—in spite of what Louis-Ferdinand Céline said in a 1957 interview about our species being terribly dull-witted, thick or just a drag (‘extraordinaire de lourdeur’)—is the increasing weightlessness of our experience, as if we were mere bundled spoors of hygiene and charisma; this made room for the Vertigo of ‘Stendhal’s syndrome’, which could be anything from the mildest vasovagal episode to major psychotic decompensation.

My title ‘A Doctor’s Dictionary’ is a reminder, at least to myself, that more of my professional life than I might have wanted has been spent in the precincts of weighty books, not least in France, where the unexpected difficulties of making a living as an ‘omnipraticien’ (general practitioner) in Strasbourg led to my becoming a scientific translator and editor. Many of these books have been dictionaries, lexicons and encyclopaedias, although with digitalisation much of their bulk and mustiness has volatilised. To be fascinated by the ‘extractive industries’, like the early Romantics—heightened for me by a year in a gritty but fascinating Australian mining town—is perhaps a kind of nostalgia for bodily experience, and all its effort and fatigue, now that digitisation, seemingly in league with capital, has embarked on the process of hollowing out ‘all that is solid’ even more drastically and purposefully than in Marx’s time: there are very few jobs and professions that have not yielded to the computerisation of what they entail.

Losing touch is something that threatens us all. The implications for medicine are serious, when this ancient profession—never entirely a science and no longer quite the art it used to be, but an empirical discipline aided by, and increasingly in thrall to, technology—forgets what it owes to tact. Doctors are translators, interpreters and sign-readers, sure; but sometimes their simple presence counts for something else, as the resident asks Robert Lowell’s persona in his late poem: ‘We are not deep in ideas, imagination or enthusiasm—how can we help you?’

Acknowledgements

All of these pieces, with one exception, were first published in journals and periodicals, some as commissioned reviews, others as commentary pieces that I cajoled the editors into publishing. Some of them still bear the cauls of their first emergence, but generally I’ve attempted to coat and shoe them as literary essays, able to stand on their own while taking their place in this book’s A–Z schema of things. Some first saw light as occasional pieces in the British Journal of General Practice, and I acknowledge a debt of gratitude to Alec Logan, its deputy editor, who for many years kept asking me to provide a feature on medicine and writing for the Christmas edition of the journal. I am also grateful to the editors of Times Literary Supplement, London Review of Books, Medical Humanities, PN Review, Parnassus, Quadrant, The Linguist, Lapham’s Quarterly, British Medical Journal, The Lancet and the Bulletin of the World Health Organization for allowing me to develop and republish articles from their pages. ‘Crise de Foie’ first appeared in German translation in the weekend feuilleton of the Süddeutsche Zeitung thanks to the efforts of my father-in-law, Christian Schütze, who also translated it.

A number of the essays in this book constituted a good part of the manuscript Medicine and the Imagination submitted to the University of Glasgow in 2009 for the degree of Doctor of Letters by publication. I would like to thank Michael Schmidt and John Coyle for alerting me to the existence of a Scottish Universities by-law the terms of which were previously unknown to me, and for their encouragement, and not least that too of my external referees Kenneth Boyd and Peter Davidson, whose appraisals reassured me that I wasn’t entirely on a hiding to nothing.

Thanks are also due to my helpful friend Richard Price at the British Library, and to staff at my local institute, Strasbourg’s newly refurbished National and University Library (BNUS)—a magnificent Italianate edifice built in the Wilhelmine period when Strasbourg was Strassburg and second now in France in terms of its collections only to the National Library in Paris—is a precious resource for me as an expatriate writer. Further thanks are also due to colleagues and friends in medicine and the wider world, with whom I have discussed some of the issues raised in this collection at various times: Olivier Wong, Frank Slattery, Douglas Shenson, Carl Elliott, Bruce Charlton, John and Mary Gillies, Jeremy Garwood, Christopher Harvie, Christine and Richard Thayer, David Bellos, Jim Campbell, Gerald Mangan, Les Murray, Alberto Manguel, Frederic Raphael, Marjorie Farquharson, Desmond Avery, Brian Hurwitz, William Ian (Bill) Miller, Peter and Maria McCarey, as well as to my editors at Carcanet Helen Tookey and Luke Allan. I would like to thank Lewis Lapham for commissioning me to write a ‘reappraisal’ of The Magic Mountain, one of the key novels of the twentieth-century, and for Alastair Campbell and the medical ethics staff at the National University of Singapore, who allowed me to expand some of my thoughts about Hans Castorp at a meeting of their journal club. Living in Strasbourg—or ‘Strasburg’ as Laurence Sterne spells it in Tristram Shandy, where it gets a whole chapter to itself—has been to be aware of living (for twenty years now) ‘far out in the centre’, to purloin the title of a book by Dannie Abse: in the heart of a Europe that has no body politic. That unreality notwithstanding, my wife Cornelia was a constant presence in good and bad times, and I feel fortunate to have enjoyed the companionship of my family throughout the years covered by this book, during which my two children Felix and Claire have grown up. ‘Sooner or later,’ as Germain Muller, founder of the local dialect theatre De Barabli, noted, ‘all Strasburgers end up loving Strasbourg.’

Needless to say (although it must be said), the opinions expressed in the essays engage my responsibility only.

A Doctor’s Dictionary

A Taste of Bitter Almonds

A STENDHAL CAPSULE

When the rotund Henri Beyle (Stendhal) dropped dead in a Paris street in 1842—‘of apoplexy’—only three mourners accompanied the coffin to its resting place in the Cimetière de Montmartre: one of them was the younger writer Prosper Mérimée. Incensed by the fact that no words had been spoken at this ‘pagan funeral’, Mérimée wrote a short memoir of their friendship. Fact is he didn’t know much about his friend other than that he had served in the Napoleonic campaigns and been a mostly indifferent diplomat in Italy, and that he was known in Paris as an occasional wit (‘homme d’esprit’) and writer with a mania for disguises; what he had read of his books didn’t inspire him terribly. Perhaps because he didn’t know so much about the social figure, the sketchy portrait he left, with the bare title HB, is a captivating one.

For a son of the post-revolutionary years like Mérimée, Beyle (born 1783) bore all the contradictory traits of a man of the previous century: ‘All his life he was dominated by his imagination, and never did anything except abruptly and with enthusiasm. However, he got it into his head that he acted in conformity with reason. “One must be guided in everything by LO-GIQUE”, he would say, pausing between the first syllable and the remainder of the word. But he had no patience for those whose logic differed from his own.’ In fact, Stendhal was every bit a fully-fledged nineteenth-century writer of self-exploration, and he anticipated his own discovery in the twentieth (in his autobiography La Vie de Henry Brulard he addresses readers in 1935, not his contemporaries). Long before Flaubert and Proust, he was aware of the fitfulness and ambiguity of memory, its elusiveness when we try to snare it. Hence his famous digressive style, the comic zigzag he took from the celebrated author of Tristram Shandy.

Stendhal had his mnemonic devices too. As a young boy in Grenoble he had been made to take drawing lessons by his father: this got him out of the house, which he found stifling. The 175 sketches scattered throughout the text of his autobiography, showing mostly street scenes or room arrangements, reminded him of that brief moment of freedom, and served as a visual framework for his writing. Feeling that there was truth in spontaneity, he wrote quickly (his autobiography was written over four months in the winter of 1835); and although he often presents exact dates in his writings (an early talent for mathematics had allowed him at sixteen to quit the damp provincialism of Grenoble and enter the new École polytechnique in Paris), he was often slapdash in respect of actual chronology. What counted for Stendhal was the sharp, acutely characterised, discriminating account of motive or emotion. ‘Love has always been for me the most important of affairs, or rather the only matter of account’, he wrote, as if the ending of the sentence had only occurred to him once he had voiced the beginning. His famously mineralogical book on love talked about it in terms of a ‘crystallisation’. A thinker had to be dry, clear, without illusions: a banker, he once wrote, might have the requisite character ‘to make discoveries in philosophy’.

And there is his famous, light, Mozartian touch: he was as unsparing of himself as he was of others, the young provincial who hoped to cut a figure in the world and become a celebrated Don Juan even though he didn’t have the physique (or, indeed, the inheritance) for it; writing his autobiography under an assumed name at fifty-three he is prepared to acknowledge that all he will be able to convey about his life of vagabondage and gallantry is the ‘chasse au bonheur’—the pursuit of happiness and not the experience itself. There is no cynicism in the writing, only a serene wistfulness.

Stendhal’s commitment to the brisk, discursive, associative feel of experience makes it an exhilarating experience to read his journals and travel books. Every situation in his life seems to lend itself to epigrammatic expression; and anecdotes themselves are occasions for expansive writing: in 1837–38, on leave from his consular job at Cività Vecchia and visiting his own country, he dashed off a book called Memoirs of a Tourist. Here is a nice piece of hearsay reported in its pages which he scribbled down in Lyons, on May 19:

Three days ago Mr. Smith, an English puritan who had been living here for ten years, decided it was time to end his life. He swallowed the contents of an ounce bottle of Prussic acid. Two hours later after being very sick he was anywhere but on the point of dying, and to pass the time rolled about on the floor. His landlord, an honest cobbler, was working in his shop in the room beneath: startled by the inhabitual din and fearing that his furniture was getting a battering, he went upstairs. He knocked on the door; no reply; so he entered the room through a boarded-up door. He was aghast to see his tenant prostrate on the floor, and sent for M. Travers, well-known surgeon and friend of the sick man. The surgeon came, treated Mr. Smith, and very quickly brought him out of danger. Then he asked him: ‘What the devil did you drink?’

‘Some Prussic acid.’

‘Impossible, six drops would have killed you in a jiffy.’

‘Well, they told me it was Prussic acid.’

‘Who sold it to you then?’

‘The little chemist on the Quai de Saône.’

‘But usually you get your prescriptions made up at Girard, your neighbour right across the street here, the best pharmacist in Lyons!’

‘That’s true, but the last time I bought some medicine from him, I had the impression he was overcharging me.’

The Plastinator

ON THE ETHICS AND AESTHETICS OF A TRAVELLING ANATOMY EXHIBITION

In 1997, in the space of four months, more than three-quarters of a million people—the highest attendance for any post-war exhibition in Germany and more than the famous annual Dokumenta art review in Kassel has ever attracted—queued to be admitted to Mannheim’s Regional Technical and Industrial Museum. The exhibition attracted similar attendance figures when it moved to Japan, reportedly receiving more than a million visitors, and to the traditional European capitals of death, Vienna and Basel, where I caught up with it. It is now showing in Cologne; here, too, it is drawing in the crowds.

This is no ordinary exhibition, and not the display of fossilised machine tools from Germany’s long and unfinished history of industrial achievement that might have been expected from the museum’s name. What is on show, in fact, is a collection of about two hundred human anatomical specimens including the usual kinds of body sections, slides of diseased and healthy tissues, organs in glass cases, and so forth. These are standard objects in an exhibition of this kind. More controversial, and certainly more spectacular, are the eighteen ‘plastinated’ cadavers—Ganzkörperpräparate, or whole-body preparations.

Anatomy exhibitions have gone on the road before, though you might have to go a long way back, to the living human exhibits in the freak shows of the Victorian circus era, to find an exhibition which has aroused so much curiosity and controversy. Many of the anatomy museums in Europe’s famous medical schools are either accessible to the more intrepid kind of tourist or can be consulted by appointment: I spent a long afternoon a few years ago in the mote-filled hall of the University of Montpellier’s junk room, examining one of its famous series of wax impressions of syphilitic buboes and chancres from the nineteenth century. Montpellier’s anatomy tradition goes back to 1315, when the body would be opened for inspection by two barbers under the instruction of a magister reciting the appropriate Galenic text.

It is a tradition that has been revived in several books by Frank Gonzalez-Crussi, a professor of pathology in the Children’s Memorial Hospital at Northwestern University who has created a literary subgenre of his own: portrayals of the unusual and the monstrous drawn from his professional life and given a savant veneer that places them somewhere between Jorge Luis Borges and Sir Thomas Browne. In one of his essays, ‘Bologna, the Learned’ (in the book Suspended Animation, 1995) he reminds us how popular public dissections were in the fourteenth century when they were advertised by being posted in Latin, the language of the dissections, on the columns of the Archiginnasio days before the event. Public dissections became routine only at the beginning of that century. Prisoners were condemned pro faciendo de eo notomia—to make an anatomy of them. The cutting, rending and division of a body was a chance for the demonstrators to show the ‘image of the universe’ to the audience, and for learned members of the audience to engage in heated disputatio; it was above all an event in the social calendar. Hogarth’s ‘Four Stages of Cruelty’ offers a very sarcastic visual commentary, in the disembowelment of poor hanged Tom Hero by a pack of doctors, on how the poor were always being held up for scrutiny by their social betters.

In those days, anatomists had to work fast to avoid the deliquescence of the body. The French surgeon Ambroise Paré (1510–90) was already recommending the use of alcohol to preserve tissues, but it was ceroplasty, or wax modelling, as developed in northern Italy—especially Florence—in the seventeenth century, that became the prized method; Gaetano Zummo’s technique was brought to a fine art under the abbot Felice Fontana (1730–1805), who was able to convince artists and anatomists to work together on his waxes.

Ceroplasty was a highly skilled procedure requiring an intermixture of purified bees’ wax and spermaceti, as hardener, which was then pigmented to the desired hue; special techniques such as dipping silk threads in hot wax were used to achieve the effect of fine structures—that of the lymphatic vessels or nerves for instance. Fontana’s waxes were shown to great acclaim in 1780, when he was commissioned to prepare a series of obstetrical specimens for the Emperor Joseph II: these can still be seen in glass cases, as a permanent exhibit, in the palatial Josephinum in Vienna. It was hoped that they would educate Viennese doctors in the use of forceps as advocated by two pioneering Scots, Hunter and Smellie; Tristram Shandy, written at about the same time, descants knowingly on the optimal fulcrum placement of this new technology for use by man-midwives. Along with gross anatomy, or the study of the body as it presents itself to the naked eye, wax models were an important means of advancing the evidence of things seen when so many concepts in medicine had been hitherto deductive, reasoning from the general to the particular.

To understand the body, the body was enough—it is a very modern thought. Prior to William of Ockham, who is generally credited with giving primacy to the particular over the universal, that modern clincher ‘whose body is it anyway?’ would have been an inconceivable thought. Indeed, to have a body (a possession rather than an attribute, something like Locke’s ‘first property’, extending its domain by assimilating what it can grasp) would have been a novel and disturbing heresy five centuries ago. Visiting Melanesia in the 1940s, the anthropologist Maurice Leenhardt was startled to be told by an elder that the Europeans had ‘brought them the body’. Perhaps it was the body itself, as Durkheim suggested, that served to organise the personality. But the epistemological strain is evident enough: after the Middle Ages, an anchorite contempt for the flesh allies itself with the Cartesian doubt that underwrites modern analytical medicine; the body loses its place in the great panpsychia of the cosmos, and the very idea of its incarnating the divine comes to seem absurdly aggrandizing. What is universal in man is now a sign.

Ceroplasty and the vascular injection of fixatives and dyes remained mainstays for teaching anatomical structure into the twentieth century. There is clearly a difference between the two methods: the first is an imitation of nature, a distancing technique, the other an attempt to preserve the corruptible body. This was not to spare the anatomist’s feelings; it was to protect him from the dangers of putrefaction. The lifelikeness of prepared wax specimens can be such as to acquire a ‘terrorizing’ quality, as Gonzalez-Crussi puts it, although the technique met with Goethe’s approval: his youthful enthusiasm for anatomy classes in Strasbourg in 1770 gave way to a suspicion that anatomists were cads of the worst kind.

On the other hand, it is probably more accurate to say that what most medical students remember of their dissection classes is not a feeling of horror at having to cut up a body but an anticlimactic sense of how grey and shrunken the fixed cadaver is.

The illustrations from Andreas Vesalius’ De humani corporis fabrica ranged in the museum outside the dissection room at Glasgow University were more disturbing than the cadavers inside: even when subject to terrible violence—flensed like Marsyas or hanging by a cord to keep their jaws shut—Vesalius’ studies insist on comporting themselves in unmistakably lifelike ways: outrage is made complete, Baudelaire suggests in his poem ‘Le Squelette Laboureur’, by their being ‘tricked out to look like hired hands’. Tool, image, grave: the three artifacts that take the measure of, and surpass, our ordinary human condition are assembled in the poem, yet Baudelaire’s slave labourer goes on digging even after he has cut the turf for his grave, refusing to move into the immaterial. Concerning Vesalius’ series, Roger Caillois remarked in his essay ‘Au Cœur du Fantastique’ that ‘more genuine mystery crops up in such documents, in which precision is of the essence, than in the wildest inventions of Hieronymus Bosch.’

In the dissection groups of six to a table that were a feature of my days in the anatomy department of Glasgow University, imagination was stilled by the unpleasantness of the task and the pedagogic imperative: learn, learn, learn. Rote learning is drudgery: even surgeons don’t need to know all the sulci, tuberosities and foramina of every bone, nor every pulley and conduit of the softer parts as detailed by Alexander Monro in his The Anatomy of the Humane Bones (1726). What isn’t clinically important tends to be forgotten. Cynicism beckons, or you come to grief. My own enduring memory of the anatomy class is its smell, the pungent odour of formalin; it penetrated clothes and gloves, and lingered in the hair, a kind of olfactory ectoplasm from a cold place in which people no longer mattered.

Enter Professor Doktor Günther von Hagens (the ‘von’ is an affectation), who describes himself as ‘inventor, anatomist, physician and synthetic chemist’. In the mid 1970s, at the University of Heidelberg, he developed—and patented—a new technique for preserving biological tissue called plastination. It had taken him fifteen years of experimentation with industrial solvents.

Plastination is now used by medical schools across the world for the teaching of gross anatomy. It requires tissues, or whole bodies, to be fixed in the standard way with formaldehyde or some other preservative. Specimens are then dehydrated, a process in which the fluid in the tissues is replaced with a chilled organic solvent such as acetone. The next, and central, step of the process is forced impregnation: the solvent is replaced under vacuum with a polymer, silicone or epoxy resin, producing an object which can then be manipulated in ways that were quite impossible with previous preservation techniques. The final stage involves hardening of the polymer. Tissues can be rendered pliable or hard, and with a high degree of realism. The essential organic architecture of the body is preserved, although it is now about eighty percent plastic. In all, the process takes 500–1000 working hours. It is undoubtedly an elegant technique, and produces specimens which are much more resistant to oxidation and decay than the old formalin-phenol injected bodies. Plastination can give a body 500 years of postmortem standing.

This technique, for instance, allows the skeleton to be guddled out, leaving the rest of the body, once the muscles have stiffened after absorbing the polymer, as a self-supporting ‘shell’. Hagens has exploited this feature in one of his dissections on show at the Mannheim museum, where the menacing musculature of the Muscleman is displayed a step ahead of his skeleton. The skeleton has been ‘shucked’ of its muscles, which have been left to stand free, their bloatedness no doubt resulting from the sheer difficulty of extricating the cranium, rib cage and long bones—of outing the inner man. It is a virtuoso piece of dissection work, but the raised left arm and flailing triceps conjure up a film image: Boris Karloff as Frankenstein’s monster.

Several other of the whole-body preparations in the exhibition are similarly ‘exploded’ to show the relationships between the internal organs, or the arterial system. Nearby, the Orthopaedic Body is decorated with twelve different prosthetic devices, and sponsored by Johnson & Johnson.

Another preparation suggests that the association between the Muscleman and Frankenstein was not fanciful: a standing figure has been defrocked of his skin which he holds in his right hand, all of a piece, with an imploring gesture. It is a direct ‘quote’ of the famous flayed man published by the Spanish anatomist Juan Valverde in Rome, in 1560.

Yet other dissections have ‘windows’ cut into the bodies at various levels indicating important internal landmarks which have to be located or avoided during surgery. One of them is a young woman with a 5-month old foetus in her uterus, the overlying rectus abdominis muscle opened in the midline to reveal the dome of the uterus pressing upwards on the intestines. Another figure, posed like a chess-player, has been pared to the ribs to show the central and peripheral nerves as they exit in pairs from the spinal column and innervate the skeletal muscles, a feat of dissection beyond the means of the traditional anatomist. The organs of a ‘longitudinally expanded’ preparation, which has been made to squat, shoot upwards out of the body, and are held in space by threads. ‘I create space for the viewer to see the parts clearly’, says Hagans, ‘so that he can close the space up in his imagination.’ One preparation is dissected in bands and partitions, like Dali’s famous painting ‘Woman with Drawers’; another is caught in the act of running, all the muscles freed from their insertions and splayed outwards. It is a dramatic portrayal of a body in motion, but it nods at the pioneering artists of the early twentieth century: the Anatomical Angel, a woman with her trapezius muscles cut and suspended like wings, in Jacques Gautier d’Agoty’s atlas Myologie complète en couleurs, of 1746, was a fetish image for the Surrealists. Hagens’ dissection is, in fact, a p(l)astiche restatement of Umberto Boccioni’s visionary bronze ‘Unique Forms of Continuity in Space’ (1913).

Hagens is unbothered about blurring the distinction between art and dissection. He seems to thrive on it, never being seen in public himself without his Joseph Beuys fedora hat. His method of personal self-promotion stands in sharp contrast to the impersonality of his exhibits.

The Plastinator (not the plasticator, the epithet given to Prometheus in Ovid’s Metamorphoses) is quick to point out that some of the best early anatomists were artists, like Leonardo da Vinci, who is thought to have dissected thirty corpses; nor is he the first anatomist to model his dissections on works of art. Honoré Fragonard’s famous eighteenth century dissection of a rider on his horse, both stripped to the bone, recapitulates Dürer’s ‘Tod und der Reiter’, and can still be seen in all its lacquered glory at the National Veterinary School at Alfort, near Paris. Frederik Ruysch (1638–1731), professor of anatomy in Amsterdam and famous for his vascular injection technique (he used a secret combination of wax, resin, talc and cinnabar which had to permeate the entire vascular system before it hardened), had five rooms in his town house at the Niewe Zijds Achterburgwal converted into a Wunderkammer for display of his meticulously prepared specimens and mummies. They were baroquely adorned and placed in allegorical scenes: playing a violin with a bow made of a dried artery, weeping into handkerchiefs made of mesentery or meninges, or abandoned to bewail their fate on a stage constructed out of gallstones and other body casts. Peter the Great bought the lot for the huge sum of 30,000 Dutch guilders in 1717, and had it shipped to Russia. Only half of the collection survived the journey.

Both Fragonard and Ruysch were decidedly odd characters, brooders who took their discipline to a pitch well beyond the necessary degree of scientific precision or desired illusion. In the Mannheim exhibition catalogue, however, Hagens attempts to play down the aesthetic element, suggesting that ‘the art is in the beholder’s eye’.

Yet the subtitle of the exhibition itself—‘die Faszination des Echten’—spells out the nature of the confusion: what status do these exhibits have? What does real mean here, and why should it be so fascinating? Organs and body sections aren’t really that interesting unless you know what you’re looking at: without the whole-body preparations, the exhibition would hardly be such a scandalous success. Heated television debates accompanied the first exhibition. Hagens was arraigned for bad taste and lack of respect for human dignity: the Mannheim theologian Johannes Reiter said, ‘the person who styles human corpses as works of art no longer respects the importance of death.’ Protests about its tastelessness were made by the heads of both main churches to the minister president of Baden-Württemberg, though a cool-headed sixteen-year-old pointed out in the visitors’ book that the Church has a long tradition of putting its own holy mummies on display. Hagens has recruited Luther as his alias: everyone should have a chance to see the plastinated body, just as everyone should be able to read the Bible without mediation. He is ‘democratizing’ anatomy. ‘We are not putting dead human beings on public show. The whole-body preparations on display have been anonymised and are no longer dead human beings because they are no longer the object of piety and mourning.’ Article 168 of the German Strafgesetzbuch (on Disturbing the Peace of the Dead) has no legal force since all these former persons donated their bodies to the Institute for Plastination, thereby relinquishing their right to burial.

True enough: we don’t know who these people are. We won’t know their names, or the stories of their lives; even their features have been smoothed out by anatomical preparation, and the insertion of glass eyes makes them look vacuous. We may be able to guess their age, give or take a few years. Their sex is apparent. Organ deformation may give a clue as to the cause of death. That’s about all that can be guessed of them in their singularity as social beings. They are empty testaments. But how can we address them except as social beings? Hagens believes that his exhibition satisfies a great longing for what he calls unadulterated originality (‘unverfälschte Originalität’)—a clumsy expression which might translate more simply as authenticity. What does he mean? A plastinate is not a mimetic object, like one of those glossy wax models of the seventeenth century which, by virtue of being a representation, keeps its distance. In the museum catalogue a whole-body plastinate is defined as a structural model of the cadaver (it lacks most of the water that makes up four-fifths of the human body). But an artefact can’t be authentic, since an artefact is always the view of a thing, not the thing itself; nor does a cadaver have any innate structural aptitude for self-display. Hagens has to give it form by plastinating and then modelling it before hardening, a procedure ethically comparable to the partial intrusion on autonomy that occurs when a plastic surgeon reconstructs a face or body.

It is a peculiar form of playing to the gallery to insinuate, as Hagens does, that visitors to the exhibition can, in a day’s viewing, locate the meaningful turnings of the very tradition which has made it possible to strip a body: a medical education is a long apprenticeship in which the discipline required to be a physician is itself re-appropriated, precept by precept. It demands participants, not onlookers.

Twenty years ago, having to dissect a body twice-weekly over nine months in the cold hall of Glasgow University’s anatomy department was, as far as I was concerned, a chore; it seemed odd that a sense of medicine’s embodied realism was acquired by destroying the evidence. Yet the cadaver was, in a sense, our first patient. The six of us around the table were dimly aware of the ambivalence of what we were doing: the body in front of us was no longer a human subject, but neither was it wholly in the realm of the senseless (the same cleavage attends the removal of organs from cadavers for transplantation: the sense of ‘material’ being cannibalised sits uncomfortably with the prospect of the ‘harvested’ organs sitting inside a another person). Our apprentice knowledge of anatomy had already been informed by allied disciplines, and was broadened by twice-weekly lectures on form and function delivered before we entered the cold dissection room. It was hard to appreciate then, raking someone’s gizzard, that being a good doctor would entail getting beyond the old Indo-European conceptual metaphor ‘knowing-is-seeing’: knowing in medicine is just as much listening and touching. (Sniffing patients is not common practice these days, though diabetes can sometimes be diagnosed from a whiff of acetone in the consulting room; as for urine-tasting, it has fortunately become totally obsolete.)

But what can a ‘laterally expanded’ whole-body preparation convey to an observer whose only previous sense-impressions of lateral expansion have been in gore movies?

The difference between Hagens’ hard plastic bodies and a simple skeleton, bereft of the conceptually rich flesh it supports, is clear enough: imagination is at work, as Hagens knows it is bound to be; which is why it is disingenuous of him to pretend that the aesthetic aspects of his preparations are only institutional and second-order, ‘in the beholder’s eye’.

Joseph Beuys could have told him why. Art is predicated on the exclusion of death, which obliterates the aesthetic. The only art form I can think of which meaningfully includes it—a spectator sport which culminates in an animal being put to death—is the bullfight. There the risk of failure, of being impaled on the ‘bull’s keen horn’, is a mortal one, as noted by that restrained masochist Michel Leiris in L’Age d’homme; he thought it saved the torero-writer (himself) from an art of mere affectation.

The argument is one of authenticity and performance: those same strategists of liberation who had applauded the Anatomical Angel thought the process of self-discovery was a tauromachy. In fact, writing his autobiography while living his life did not elevate Leiris to the level of what Nietzsche had once called ‘the dignity of a great matador’; it was to become a lifelong mortification.

The exhibition offers no new scientific discoveries: gross anatomy’s heyday was long ago. The number of autopsies performed annually in hospitals has been declining for years to what pathologists regularly say are ‘worryingly low levels’. Professors of anatomy these days may well be molecular biologists or biochemists, not structural anatomists.

It is ironic too that our state-of-the-art perception of the body is airier and less solid even than that of the medieval medici: it is a composite representation made up of vector forces, atomic energy and sound waves. The body is as permeable as it is resonant. The more we see through it, the more its substance eludes us. It is a progression that would no doubt have appealed to medieval philosophers who believed all its fleshiness was, in any case, accidental to our true essence. ‘Thus we are men,’ wrote Sir Thomas Browne in Religio Medici, ‘and know not how: there is something in us that can be without us, and will be after us; though it is strange that it hath no history what it was before us, nor cannot tell how it entred in us.’

Evacuation and resurrection: the Greek word exanastasis means both—the body cannot be resurrected unless rid of its matter—or as the unshakeable Job puts it: ‘And though after my skin worms destroy this body, yet in my flesh shall I see God’. Hagens’ exhibition might just conceivably be a hunt for a tertium quid. It seems to be searching for it in the same places as the contemporary Brit Pack artists, who could well be defined as school-of-life rather than art school. It is, let it be said, a diminished life in which to go to school: reality alone counts, and reality knows nothing of representation—as if human history were an animal history.

Besides, if the body is always a symbol of society, as the anthropologist Mary Douglas insists, then society itself must be exploding at the seams. We can’t expect to lay the world bare, cognitively speaking, and not feel the draught: hard knowledge after Bacon’s time has meant going in fear of anatomists. Even if we were to adopt a minimal ethic with regard to the people who have donated their bodies to Hagens’ institute by seeing them as in some way performers, the grand master of anatomical ceremony and director of the performance has an obvious responsibility not to degrade or humiliate them in their unheeding act of self-exposure.

I seem to be in a minority: most visitors to the body show actually seem to applaud the idea behind it. No objections were raised by the churches in Vienna and Basel, both of which have a long tradition of socializing their own exquisite dead. Hagens now claims to have a waiting list of a thousand ‘donors’, and plastination will no doubt provide an ultimate fate for some of them. Perhaps some of them are down at the gym already, shaping up for the new symbolic order.

Knock! Knock!

A STUDY IN MEDICAL CYNICISM

Mundus vult decipi, ergo decipiatur

– Petronius

The perfect role

In August 1923, Jules Romains (Louis Henri-Jean Farigoule), PEN activist, friend of Stefan Zweig, and one of France’s most famous and popular writers between the wars, wrote a play in three acts called Knock. It was to prove his most enduring literary creation. In those days Romains’ theatre pieces, along with those of Luigi Pirandello and Bernard Shaw, were being staged everywhere, which only goes to show that no literary reputation is ever entirely vouchsafed. Indeed, the only other work for which Romains is remembered today is his colossal ‘unanimist’ fiction Les hommes de bonne volonté, which appeared in instalments between 1932 and 1946, when he he returned from war exile in New York and Mexico. It runs to 8000 pages, and is published in 27 volumes. I have yet to read it all or meet anyone who has, although Richard Cobb is right to assert, in his essay Maigret’s Paris, that the first volume contains some finely evocative scenes of the outskirts to the French capital.

Romains first thought of asking the Comédie-Française to stage his piece. That idea came to nothing, but a copy of his play ended up in the hands of the actor Louis Jouvet who was bowled over by its ‘formal perfection’. A pharmacist before he became an actor, Jouvet was for three decades one of the best-known actors of the Parisian theatre-world, a star of many classic French films including the famous Hôtel du Nord. With his widow’s peak and suave demeanour, he looks like a svelte version of Jack Nicholson. One of his witticisms has deservedly been anthologised: ‘there are performances where the public is quite without talent.’

After several rehearsals, Romains insisted that Jouvet play the character close to his own persona, without caricature—‘Vous avez une occasion magnifique d’être vous-même’—but with an added touch of courtesy, sarcasm, and self-assurance. Jouvet worried that the play was going to be too ‘black’ to attract the public. He was wrong. On its opening night at the Comédie des Champs-Elysées on 15 December 1923, André Gide went backstage to congratulate Jouvet on his performance. From then on Jouvet was Knock. The play was a great success. Jouvet played the role throughout his acting life, and after the war played Knock at the Athénée no fewer than eight hundred times. Two film versions were made: one in 1933, directed by Roger Goupillières with the screenplay written by Romains himself, and a better known version, directed by Guy Lefranc, in 1951. Such was Jouvet’s status that he was allowed to supervise casting. In the event, his brilliant performance proved to be the ultimate record on film of a remarkable acting career: he died on stage at the Athénée (which is now named after him) rehearsing Graham Greene’s The Power and the Glory, just months after the film’s release.

The farce and the farceur

The film opens in the early years of the twentieth century with Knock, the aspirant to a medical practice, sitting in the back of an old jalopy—the kind of automobile the French used to call a torpédo—with Dr Parpalaid and his wife. Knock has just purchased Dr Parpalaid’s practice in the small town of Saint-Maurice, which, from the references to hilly country and the nearby presence of Lyon, would seem to indicate a sleepy hollow somewhere in the foothills of the Massif Central or the Alps. Somewhere deep in dear old France, in other words: the kind of place lost to the world that the worthy Dr Benassis decides would be suitable for his ministrations in Balzac’s novel The Country Doctor. All the business has—unusually—been concluded in advance by letter, and Knock is exercising his right to be introduced to the clientele. Dr Parpalaid is a decent old duffer—un homme de l’art, as the French used to call their doctors—a man of predictable knowledge or even of ‘good intent’ in Romains’ terms, his wife a formidable matron who seems to have far more of a head for business than her husband. Dr and Mme Parpalaid have decided, after careful consideration, to move on to better things in Lyon—she has rheumatism and her husband ‘swore he would finish his career in a big city’. Urban aspirations notwithstanding, they extol the virtues of the canton to Knock: a railway far enough away for the clientele to stay put, no competitor, a chemist who doesn’t try to do the doctor’s job, no major overheads. Knock seems uncommonly interested in what kind of diseases his prospective clients might suffer from, and is put out to discover that the local people generally come ‘only for a single consultation’. There are no regular patients: it’s not like the baker or the butcher, exclaims Madame Parpalaid, who takes him for a bit wet around the ears. Knock is forty, Faust’s age; though he admits to having completed his thesis only the summer before. Its title? ‘On imaginary states of health’, with an epigraph from Claude Bernard: Les gens bien portants sont des malades qui s’ignorent. Well people are sick people who don’t know it yet.

This is a motto about the unwitting patient in all of us, and it turns out, ominously, to be the most telling line in the play.

There are already some subtle worrying signs about Knock. He doesn’t know the church feast-days, not even Michaelmas, which is when Dr Parpalaid’s patients are in the habit of paying him. (Dr Parpalaid has roguishly sold the practice just after this date, thus giving Knock grounds for accusing Parpalaid of attempting to fleece him—but when did a doctor ever buy a practice without seeing it first?) As a child he was apparently an avid and precocious reader of the information slips tucked around bottles of pills: at nine he could recite entire pharmacopoeias of side-effects. He has already been a ship’s doctor, he informs Madame Parpalaid, and for the duration of the voyage had crew and passengers confined to the sick bay: only the expediency of a roster kept the ship manned and the engines running. In short, Knock has a vocation and no ordinary one at that; and he has a ‘method’.

Knock arranges visits with the other members of the cabal: the teacher Mr Bernard and the pharmacist Mr Mousquet. His language is fulsome and ingratiating. He bludgeons the former with the modern horror of microbes. He describes the presentation material that will amplify the effect of his public lectures: ‘All of this illustrated with superb pictures: bacilli enlarged thousands of times, typical stool patterns of typhoid patients, infected nodes, intestinal perforations, and not in black and white, but in colour: all the pinks, browns, yellows and pale greens you can imagine.’ Poor Mr Bernard, who is an impressionable type, is overwhelmed, and protests that if he gets involved he won’t be able to sleep himself. ‘That’s how it should be’, retorts Knock, ‘what I mean is: that’s exactly the kind of fright we have to deliver. We have to shock the audience to its core […]. Because their fatal error is to sleep the sleep of false security—then disease wakes them like a thunderclap, but it’s too late, too late.’

Historically in France, pharmacists occupied the subsidiary role of marchands-épiciers; they were the money-hungry apothecaries and suppliers of unicorn’s horn who inspired Molière to create Purgon and Fleurant. Knock flatters Mr Mousquet with talk of collegiality. A physician who can’t rely on a first-class chemist is ‘a general who goes into battle without artillery’. They discuss the low volume of trade generated by Dr Parpalaid, and Knock wonders ‘whether he really believed in medicine’. This, for Knock, is a scandalous state of affairs when all the inhabitants of the district are potential clients.

With teacher and pharmacist now on his side, Knock engages the local odd-job man, who doubles as town-crier, to tell the country folk that consultations are to be given free of charge at the surgery on Monday mornings. When he asks the town crier what the townspeople used to call his predecessor, he discovers it was never ‘Monsieur le docteur’, but often a soubriquet—Ravachol. Romains is enjoying a little joke with his audience. Ravachol was a notorious anarchist in nineteenth-century France (his actual name was Kœnigstein) who ended up losing his head to the guillotine, though one of his ditties, Le Bon Dieu dans la Merde, was resurrected by the Situationists in the 1960s. His name marks Dr Parpalaid out as an old-fashioned believer in anarchism as against the power of capital and the State, though it has to be remembered that nineteenth-century anarchism was not irrationalist, and largely eschewed violence: it was the most serious utopian alternative to Marxism. It still finds some expression among French doctors who, rather than acknowledge the unwelcome fact that the medical profession needs the state to safeguard its monopoly in providing treatment, defend what they call ‘liberalism’ as a solid defence against the intrusions of government into private life. What had been hotly discussed issues in the 1840s were taken up again, though with a weary acerbity, after the debacle of the Great War. Romains rather vaguely defined his own philosophy of unanimism, which opposed liberalism’s concept of the individual in the belief that it simply handed even more power to state bureaucracies, as ‘a natural and spontaneous harmony within a group of people who share the same emotion’. His platform was a form of syndicalism. What is interesting about all this is that Kropotkin’s cooperatives and Proudhon’s theory of ‘mutual aid’—not unlike unanimism—leaned on Darwin’s law of natural selection just as much as Spencer’s competitive model of evolutionary sociology and the eugenic movement that followed it, suggesting that there is no straightforward leap from scientific to political ecology. Indeed, Dr Parpalaid’s anarchism—of the utopian, non-bombing, moralistic kind extolled by Tolstoy—looks mostly like a practical philosophy for smallholders.

All of this is old hat to Knock. His ideal of social organisation is a form of hygiene organised around himself as ‘continual creator’ and saviour. His method is finely calculated and carefully organised. He assiduously acquaints himself with the incomes of his clients. Blackboard, anatomical chart and reflecting laryngoscope are used to devastating effect in his surgery. Patients are stripped of their defences, beginning with the flimsy mantle of insouciance which has hitherto protected them from worrying about their health. ‘Est-ce que ça vous chatouille, ou est-ce que ça vous gratouille’, he inquires of the town crier, hilariously mangling the language, splitting hairs and echoing Hamlet all in the one phrase: ‘do you have a tickling feeling, or is it more a kind of prickling?’ If it’s an itch the poor man thinks he has, it must be a mortal one. The Lady in Violet, a certain ‘dame Pons, née demoiselle Lempoumas’, gets the shock treatment: her insomnia, which Dr Parpalaid had never taken seriously—he used to tell her ‘to read three pages of the civil code every evening’—may now be the result of a ‘pipestem deformity’ of the intracerebral circulation or perhaps even a ‘sustained neuralgiform crisis of the substantia nigra’. Or perhaps, as Knock adds in an undertone, it’s just a big black spider sucking on her brain.

Knock’s use of ‘big words’ to terrorise the Lady in Violet is one of the oldest medical tricks: think of Molière’s cod Latin-spouting Sganarelle in the most famous predecessor farce le Médecin malgré lui (1666), or the nuciform sac, a structure unknown to any anatomy textbook but wielded to good effect by the surgeon Mr Cutler Walpole in George Bernard Shaw’s play The Doctor’s Dilemma (1906). The description of Walpole in Shaw’s stage-directions even resembles Jouvet’s portrayal of Knock in the film: his face, according to Shaw in his stage directions, looks ‘machine-made and beeswaxed; but his scrutinizing, daring eyes give it life and force. He never seems at a loss, never in doubt; one feels that if he made a mistake he would make it thoroughly and firmly...’ It may be scandalous to admit it, but dissembling has long been part of medicine’s therapeutic arsenal: Knock proffers big words, not for the sake of the cure but for the rather more pertinent issue of reinforcing his authority.

The nuciform sac turns up in another guise in Axel Munthe’s hugely successful, if hugely self-regarding, volume of reminiscences from the same decade, The Story of San Michele (1929), in which he tells how, when working in a private practice, the fashionable diagnosis of colitis, invented precisely to save patients from the scalpels of surgeons like Mr Cutler Walpole, ‘spread like wildfire all over Paris’. Munthe, a young Swede who qualified in Paris at the unheard-of age of twenty-two, was once called ‘the most fascinating man in Europe’: his persuasive bedside manner brought him a large clientele of largely wealthy patients whom he believed should be made to pay for the poorer (Knock has a system of ‘means-testing’ too).

Several chapters of Munthe’s memoir, a best-seller in its time, are devoted to Jean-Martin Charcot, with whom he trained at the famous Paris hospital La Pitié-Salpêtrière. Patients, doctors (most notably Sigmund Freud, in 1885), and the public flocked to see the great man in action in the auditorium where his mostly but not exclusively female patients obligingly assumed, when prompted, all the dramatic postures of florid hysteria. Charcot took hypnosis seriously as a technique for healing, though the psychoanalytic movement as a whole, fearing that transference and counter-transference would contaminate the psychoanalytic method, shied away from suggestion techniques; even then, hypnosis was to stay in the bag of tricks of many psychoanalysts. Munthe’s thumbnail sketch of Charcot speaks volumes for the magical function of the medicine-man in an age that proclaims itself thoroughly rational: the following passage was actually omitted from the French translation of San Michele, presumably because its hint of diabolism failed to flatter the reputation of the Maître who had dominated French medicine for more than a generation. ‘Charcot for instance was almost uncanny in the way he went straight to the root of the evil, often apparently only after a rapid glance at the patient from his cold eagle eyes.’ This is a description of a magician, not a scientist.

Once Knock has made it explicit, danger is like the house dust mite: everywhere. One might call it Getting the Fear. Knock encourages the local schoolteacher, Mr Bernard, to indulge his little obsessive-compulsive tic—‘Do you think, doctor... I may be a carrier of germs?’ Mr Bernard’s phobic reaction testifies to the power of a mystery—the invisible germ—caught in the full glare of scientific explanation. No other scientific figure stands with such emblematic clarity in republican France’s sense of itself as the bacteriologist Louis Pasteur—‘le bienfaiteur de l’humanité’. It was, after all, the French Revolution that gave rise to the belief that where a physician worked his cures there could be no clergy, and that illness was a matter for the common weal. The evil of profiteering doctors would disappear once equality, freedom and fraternity had borne their true fruit. Diseases would be classified; statistics collated; clinics built. Pasteur is emblematic because he embodies so well the due process of the positivist formula: theoretical research plus application of acquired knowledge makes for general well-being.