Iain Bamforth A Doctor’s Dictionary: Writings on Culture & Medicine
2015 Manchester: Carcanet ISBN: 978 1 784100 56 8
Reviewed by Professor Alan Bleakley
Emeritus Professor of Medical Education and Medical Humanities
Plymouth Peninsula School of Medicine, Plymouth University UK
Iain Bamforth, by his own admission, is a writer who practices medicine. Indeed, while he appears to gorge on writers, essayists and philosophers, he gives medical education short shrift:
“doctors undergo a crammed, often dogmatic training in thrall to clinical ‘bosses’, which tends to hinder critical thinking. Then one fine day they wake up to find themselves as soteriological salesman in the Valley of the Shadow of Death. And they hate to lose face by admitting they don’t know.”
While many doctors I know would cringe in self-recognition at this description they would also think ‘hang on a minute, there’s more to medical education than this’ (simultaneously reaching for their dictionaries to check on ‘soteriogical’). ‘Country’ doctors come off worse, where “Doctor-baiting has long been a clandestinely popular activity in country regions. … my grandmother in Glasgow used to say ‘that’s but ae doctor’s opinion’” for in “country areas, where people have long memories, it is still remembered that doctors themselves were once a source of plague.” Bamforth should know – he worked for a year as a country GP in Scotland and has extensive experience working in a number of areas of medicine, including a long stint in his current practice as a GP in Strasbourg with “twenty-two different nationalities”. Bamforth can afford to be self-effacing about his medical career, for he is first and foremost a talented and dedicated writer, and a jobbing translator on the side. In this collection, he brings a literary sensibility to bear on the, often uncomfortable, recognition that much of medicine is an art rather than a science requiring high tolerance of ambiguity and recognition of personal limits to knowledge and ability. Medicine is a performance whose script has been crafted historically and culturally.
A Doctor’s Dictionary: Writings on Culture & Medicine is a collection of 26 essays and book reviews previously published in medical and literary journals, many of which were gathered together to form the core of the author’s manuscript Medicine and Imagination, submitted to Glasgow University (where Bamforth originally studied medicine) for the degree of Doctor of Letters by publication. The collection represents two decades’ worth of industrial strength and erudite commentary. The essay titles follow the letters of the alphabet in order, from ‘Anecdote’ to ‘(meta-) Zoology’, via ‘Depression’, ‘Happiness’, ‘Posture’, and ‘Vertigo’ amongst others. The title ‘A Doctor’s Dictionary’ refers to this conceit of an abecedarium. These single word titles serve less as signposts than welcome glades amongst thick forest, for Bamforth’s prose is baroque and relentless, providing little respite for readers who crave more minimalist approaches to the essay. Those who know the author’s poetry – he has published five collections – might not expect such convolutions and digressions within the essay form. His poetry is leaner than his prose. Certainly, he is not a writer who wears his learning lightly.
Where Bamforth provides no connecting thread from one essay to another this collection is more lucky dip than pearls on a string. And sometimes – despite the promise of the subtitle ‘Writings on Culture & Medicine’ – the links with medicine are tentative. A more honest subtitle would have been ‘Writings on Culture & on Medicine’. For example, a riveting essay ‘Emergent properties’ – relating to Joseph Needham’s masterwork Science and Civilisation in China – is linked to medicine only by the fact that Needham was a developmental biologist and his father was a Harley Street doctor specialising in anaesthetics. Further, it is not until you read the Endnotes that you find out this essay is in fact a 2009 ‘review’ of Simon Winchester’s biography of Joseph Needham. The reader is left not knowing how much is Bamforth’s original insight and how much is gleaned from Winchester’s biography.
A book review of Ziyad Marar’s (2003) The Happiness Paradox and Carl Elliott’s (2003) Better Than Well (first published in a literary and not a medical journal) contains a few lines on the treatment of depression – otherwise there is again no developed linking of culture with medicine. This leads me to ask just what audience the publishers have in mind for this book. Doctors in general are pragmatic and resist complex ideas (Bamforth quotes from a Robert Lowell poem referring to doctors: “We are not deep in ideas, imagination or enthusiasm – how can we help you?”), so I suspect that the primary audience for this book will be humanities scholars working within the health/medical humanities, although, in an ideal world, medical schools would adopt texts such as Bamforth’s to support the teaching of so-called ‘communication skills’ and ‘professionalism’ and to encourage the kind of liberal education that gives insight into the human condition.
Bamforth’s book has its weak spots. A review of Carl Elliott’s Prozac as a Way of Life (under ‘D’ for ‘Depression’) tells us little new where the author notes that depression is a cultural disorder and that many mental health symptoms are manufactured to sell drugs that supposedly treat such symptoms. While we are introduced to a stream of writers who have formed high culture, there is little reference to either popular culture or everyday people, in particular Bamforth’s patients. Are some of these not also extraordinary? Do any of them inspire, or is that just for high art?
But mainly, Bamforth offers us industrial strength prose. ‘Galen’ is a model of the essay form – pithy, humorous and insightful. Informed by his long experience of practicing medicine in Strasbourg, Bamforth dwells on the ‘folk illness’ of a crise de foi – a crisis of the liver. The essay is a generous meditation on a French national trait – the liver as embodied metaphor. Bamforth’s most recent (2015) essay ‘Tell Me About Teeth’ (under ‘M’ for Mouth) is a very funny meditation on the American obsession with good teeth (equating with good character). Bamforth takes up Elias Canetti’s challenge to ‘write about teeth’ and produces the best line of the book: ‘How can you believe the soul is a butterfly when the human breath is so foetid?’ There is cheek in the essay – Bamford, a doctor, looks down on dentists who cannot have a proper conversation with their patients “with a drainage pipe, cotton wool and gloved fingers in the mouth”.
Bamforth’s conversation with his readers, however, is more like the reality of doctors’ ‘conversations’ with their patients – the consultation is actually one-way traffic: Bamforth does not pose questions, he informs, and his information is more torrential downpour than light drizzle. Read psychoanalytically, Bamforth’s rather suffocating attention to detail might be seen as a desire to impress and to control. There is a clue in the Endnotes to this collection of essays, where referring to the essay on teeth, Bamforth notes that while many writers earn their living as doctors, the same cannot be said of dentists. Reading this, I immediately thought of the Egyptian dentist and novelist Alaa El Aswany’s The Yacoubian Building that I read a few years ago. I was interested in this novel because at the medical school where I used to work we had long established a medical humanities programme, and had just implemented a ‘dental humanities’ programme in the dental school. Aswany was recommended reading. I was pleased to see that Bamforth could afford an error, a relief from his parade of learning. But then I read the after-note to these essays, where Bamforth apologises to the reader for an oversight – dentists do indeed write novels, amongst them Alaa El Aswany’s The Yacoubian Building. The rent in the fabric of the essay is neatly repaired without losing face.
But Bamforth should not be worried about the occasional slip – after all, it is in such minor imperfections that humanity shows through (Nietzsche’s Human, All Too Human) and this is, paradoxically (and properly), how he describes the work of doctors. Little ‘holes-in-the-day’ or ‘holidays’ (as the late poet Peter Redgrove described unconscious slippage) allow both writer and reader a mini-break away from the relentless search for perfection. Indeed, such a hole-in-the-day does appear in Bamforth’s collection and is not retrospectively repaired in his Endnotes. It is an omission that also provides an insight into limitations to the author’s writing style.
While the psychoanalyst Jacques Lacan is referred to (on p.71), he is not included in the index of names that stretches to an eye watering close to 400 entries (with only a dozen women amongst them). Oddly, the publishers have not included an index of topics – a major omission in a book of this kind that is to be dipped in to and not read cover to cover. I pick up on Lacan because it was this psychoanalyst who famously suggested that the unconscious is structured like a language and shapes experience through metaphor and metonymy. Metaphor (the substitution of one word for another for effect: ‘time is money’), suggests Lacan, serves to repress (often in the form of denial). Metonymy functions to combine, where one word or phrase leads by association to another (such as ‘wand-sceptre-king-ruler’) and is then a form of displacement (often in the form of scapegoating). Bamforth’s writing is characterized by a particular use of displacement and contiguity as a rhetorical strategy. Let me give some examples.
There is a rather irritating ‘rock hopping’ technique, where reference to one author or thinker jumps quickly to another. The essay on ‘Happiness’ referred to above – a review of Ziyad Marar’s and Carl Elliott’s books – is only seven pages long yet manages to reference Freud, Plotinus, Nietzsche, Bentham, de la Rochefoucauld, Auden, La Mettrie, Diderot, Holbach, St-Just, Stendhal, Dr Johnson, Rousseau, Robert Burns, Tom Wolfe, Dostoevsky, Veblen, Wittgenstein, Theodor Fontane, de Sade, Montaigne, Aristotle, Erving Goffman, Robert Reich, Georg Christoph Lichtenberg, Alexander Pope and Jane Austen. Bamforth’s technique is not to simply list authors – that would be too crude. Rather, he metonymically links them. But these linkages are often arbitrary.
The essay ‘Ethics’ is actually about insomnia. Bamforth reminds us that the sleep state is ethically neutral. An anecdote about Vladimir Nabokov is neatly linked to one about the Romanian philosopher and writer E.M. Cioran. Both were insomniacs – so far, so good. But then, linking Kafka, W.H. Auden, Nietzsche, Freud and James Joyce, we are brought to a discussion of the merits of The Epic of Gilgamesh – a paragraph tells us how Rilke and Elias Canetti were both bowled over by Gilgamesh. But what has this got to do with sleep deprivation and what medicine and science might do about it as well as what literature has to say about it? What about sleep deprivation in junior doctors – a well-known source of medical error – rather than passing reference to Gilgamesh? Digressions and diversions are symptoms of the abuse of metonymy. A discussion of Proust and sleep leads into a section on the Irish writer Flann O’Brien with the link “Proust was unfamiliar with rural Ireland though”. The link is forced – a lazy metonymy. Here, Bamforth’s Baroque style reminds me of billiard balls flying haphazardly around the baize, or a pinball machine.
The essays contaminated by this rhetorical style tend to be lacking in narrative and resort rather to lists of events. Where narrative is strong – for example in Bamforth’s marvellous essay on ‘integrity’ – the writing seems to me to be so much stronger and engaging. Here, Bamforth turns a review of Emmanuel Carrère’s novel The Adversary into a meditation on lost identities that confounds notions of moral integrity. The essay is subtitled ‘An Empty Plot’ and this is a double-play on the fact that Carrère writes a novel about a French doctor whose whole life was literally an enacted fiction and then hollow. Jean-Claude Romand was (supposedly) a doctor living in France on the border with Switzerland and working as a researcher at the World Health Organization. In short, he turns out to be a fraud – he never completed his medical degree and lived a life of duplicity in which he pretended to have a prestigious job, convincing everyone, including his family and even a best friend Luc Ladmiral, a general practitioner working in a nearby town. Romand systematically embezzled money to maintain the lifestyle of a successful profession where his profession was in fact mute. At the point of his ruse being uncovered, he murdered his wife and two children. Carrère visited Romand in prison to piece together the story. Here, Bamforth returns us to a fundamental discomfort within medicine where doctors walk into roles prepared for them historically and culturally, and this may jar with their non-medical identities. Where then, to find solace or a moral compass? Bamforth’s suggestion is that such touchstones for reality can paradoxically be found in well-wrought fiction.
Readers of Medical Humanities will warm to Bamforth’s topics, but not necessarily to his style. A good editor would have rejected the rather forced abecedary structure of this collection to provide an alternative framework for linking otherwise disparate essays, prefaced by a different kind of Introduction illuminating Bamforth’s thought process and style of engagement. The book reviews sit rather awkwardly amongst the essays. The metonymic name-game could have been tempered. An index of topics would have helped the reader to better navigate around what is important writing in the field of the medical humanities. Finally, there are a couple of cheeky gestures: Bamforth is multilingual (he works as a translator into English from German and French), but it is rather high-handed to preface the book with a quote from the German poet Friedrich Hölderlin that is given in German with no English translation. Later, in an essay on ‘Posture’, a “famous couplet” from Ovid is given in Latin but again not translated. ‘Famous’ perhaps for Bamforth, but he is expecting high standards from his readership. The essays then expose the reader’s ignorance rather than engage her interests, and do not educate as much as lecture. It is a shame that the style sometimes taints the content in what is unquestionably an impressive collection.