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In search of A Fortunate Man
LITERATURE AND MEDICINE
Literature and medicine
In search of A Fortunate Man J S Huntley
J S Huntley
The patient left the consulting room quietly and the door fortunate enough to obtain in 1999, Berger said: “The swung itself shut. “Well, what do you think?” asked the remarkable thing, looking back at it now is that, as a book, middle-aged general practitioner (GP). I told him what I it mixes a whole series of approaches: in places storythought. “There you go again, imposing your middle-class telling, in others analytic, sociological, pictorial—and in values on your patients”, he replied, smiling but this respect is resembles Sassall, who was incredibly uncompromising. versatile”. I am reminded of the central tenet of Gestalt At the end of the clinic, as he packed his briefcase, he theory: that the whole is different from the sum of its parts.4 continued: “The book you should read is A Fortunate Man Berger continues: “Not only was he [Sassall] a wonderful by Berger and Mohr . . . about a GP in the Forest of Dean storyteller, he was also a brilliant met-a-scene—a stage . . . about a GP anywhere . . . if you can find a copy . . . director—he was able to orchestrate theatre, and he had God knows why, but it went capacity as an actor . . .”, out of print years ago instantly Berger negates the . . . and bear in mind the word actor, as if people irony of the title, given that would (mis)interpret this its subject, the ‘fortunate’ GP term as implying insincerity, later committed suicide.” “. . . and Sassall was always I tapped a second-hand sincere, aware of the dream book search and for £18 was of life”. In describing the life treated to a 1968 hardback and work of Sassall, the book edition.1 It is a beautiful and also depicts the life of this isolated community, in affecting work, bearing cultural terms an island examination again and again, where development is stilted in different moods, under and stunted. different lights. Berger admires Sassall— It is the story of a general praise indeed from an author practitioner, John Sassall, whose output encompasses who worked in an isolated fiction (and a Booker prize5), community in the west of Sassall’s surgery, now a family home England. It is poetic and pictorial: the text by John Berger essays, art criticism (in particular Ways of Seeing6), film, and the photographs by Jean Mohr are conjoined and poetry—besides being an artist. Berger’s output continues counterposed. The authors, as a condition of publication, from his position as a contented exile in France.7 Sassall retained the right to the minutiae of the book’s layout: the was of course his friend. I am intrigued as to how they position of the text on the page, the position of the pictures might have met. Because of the honesty of the prose, the within the book, the combination of text, page turn, and depth of the treatment of Sassall’s analysis and selfpicture. It is a successful mixed form of narrative that the analysis, I conjecture that they must have been friends from authors later used elsewhere.2,3 early life, from childhood even. I am wrong. Berger had lived in a neighbouring village The book acts at several levels. It is analytical, but the and went to consult Sassall about intermittent abdominal text also elicits emotional reactions and meditations, pain, thinking he had an ulcer. He didn’t, and the two men juxtaposing various pictures with text. For instance: “We became friends in the following years. It was, however, only give the doctor access to our bodies. Apart from the doctor, when Berger moved away to Geneva that he had the idea of we only grant such access voluntarily to lovers—and many doing the book, an offer accepted by Sassall. So for are frightened to do even this. Yet the doctor is a 6 weeks, Berger and Mohr lived on Sassall’s shoulder, in comparative stranger.” On the facing page, Sassall his house, in his surgery, and on his night calls. examines a patient’s extended neck. Several pages on, In attempting to describe the doctor’s life, you quickly Sassall examines a lady’s abdomen. A firm hand palpates a run up against the symbolic and the metaphysical. This left upper quadrant. Her eyes are wide but trusting; she parallels the tendency of Sassall, through life, to become watches him watching her. increasingly philosophical, increasingly reflective. The It is a difficult book to analyse or summarise. It is challenge may be in recognising the crossroads of human multifaceted and uncompromising. It moves by turn experience and endeavour. Doctors are human too. If you through case histories, through Sassall’s feelings and react to the misfortune of a friend, or a comrade, or a concerns, to the philosophy underpinning the GP and his patient by assuming their very distress, then you will not place in the community. In an interview, which I was last long. By contrast, if these experiences leave you unchanged then you have lost humanity. In a letter to The Lancet,8 Burns-Cox uses a passage of Lancet 2001; 357: 546–49 George Eliot (from Adam Bede) to illustrate the possibility of growth from experience of loss and tragedy. This is good Department of Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh EH3 9YW, UK (J S Huntley DPhil) so far as it goes. The danger is overdose. The GP bears
546
THE LANCET • Vol 357 • February 17, 2001
For personal use only. Reproduce with permission from The Lancet Publishing Group.
LITERATURE AND MEDICINE
witness to his patients’ lives—their hopes, aspirations, struggles, and failures. He is their “clerk of the records”. He has the challenge of reacting appropriately in any of a variety of charged situations—5 minute chat to a new and proud father; 5 minutes later to a bereaved daughter. The GP is a repository of trust. He has a unique passport to all classes, access to many fears and struggles, but is left to cope with his own humanity, his own propensity to failure. Sassall fails in the opening two stories of A Fortunate Man. He fails to save the leg of a man trapped by a falling tree, and he fails to gain the confidence of a girl traumatised by a previous affair. The landscape assumes historical significance in these studies. “There is a bend in the river which often reminds the doctor of his failure.”
How different it is for the hospital doctor, who takes but a snapshot of the patient’s life. He is less obliged to live with his failures. How numbing must be the feeling of failure over decades—to see plants never break bud, grown in the dark, in the wrong soil. Sassall delivered a girl in the cottage near the surgery. 16-years later, “nubile in everything except her education and her chances”, she is crying in his surgery, without knowing why—except that she wants more from life. She has no qualifications and no real aspirations. After the consultation Sassall is left staring out of the window. You are shown his closeness to his patients, to the community as a whole, to death. You are shown his ability to self-identify and his ability to be almost all things to all people. He became pre-occupied with the value of life, and the value of the moment in time. This idea centred on the value of lives in modern society. “Talk of the ‘bad old days’ before the war can encourage a certain superficial belief in progress. But faced with the young—and the prospects before them—it is hard to maintain any such belief. Sassall is forced to acknowledge that, by his own standards, they are having to settle for a fifth best.”
This is not a message confined to rural communities at the end of the 1960s. This is a message for our place and our time now. The definitive paediatric textbook, Essential Paediatrics,9 under the heading of social paediatrics states: “Certain inner city areas, deprived by most material and social standards, have a higher incidence of most medical problems and the children who live there are, in general less physically, mentally and socially able. At a disadvantage from birth, these children are ‘born to fail’. . .”
This is the measure of failure of our advanced civilisation. A doctor’s work is dependent on disease, inequality, morbidity—a doctor’s role is to struggle. Maybe it is fanciful to liken the task to the stone of Sisyphus, he the legendary soul doomed to roll a stone up a mountainside for eternity. Even when he approached the summit, the stone would fall backwards. Who would Sisyphus be, without his stone? In Le Mythe de Sisyphe,10 Camus concludes: “The struggle to the top alone will make a human heart swell. Sisyphus must be regarded as happy.” It is important to fight the war—against disease, misery, disability, infirmity, and deprivation—but ultimately it remains unwinnable. We must celebrate those few victories in battles and skirmishes along the way. It is necessary to reframe our aspirations but not decrease our efforts. The aim of a life in medicine—whether as GP, nurse, surgeon, or whatever is, in the words of Balint “to cure sometimes, relieve often, comfort always.”
THE LANCET • Vol 357 • February 17, 2001
Berger professes that Balint11,12 had a profound influence on his thinking, in particular through his book The doctor, his patient and the illness.12 Balint quotes have become legendary, not least: “Regard your patients as human beings. While never forgetting that they are your patients.” When involved with true empathetic depth, how does one maintain this necessary Balint perspective? Perhaps with a balance of one’s own life outside medicine, one’s own loved ones. The converse must also be true—poor relationships and bad life events within one’s family circle may be devastating. I talk to a GP friend about the problem of empathetic perspective, and (without prompting) he volunteers his wife and family as rather more than a support, dragging him out of introspection. A Fortunate Man does not explore this relationship. Perhaps it was considered too private, perhaps rightly so. However, the book is dedicated to both “John and Betty [Sassall] whom it concerns . . .”. It is not surprising that GPs are prone to melancholia. “Sassall’s depressions are maintained by the material of the two problems we have just been examining: the suffering of his patients and his own sense of inadequacy”.
Though earlier, “To a large extent, Sassall has achieved his ideal. As much as a man can on land, dealing with illness and not the sea, and living in the middle of the twentieth century, he has achieved a position which is comparable to that of a master of a schooner”.
John Sassall read the manuscript and accepted it with only a few minor changes. Obviously, the entire project would never have been possible without his enthusiasm, consent, and frank cooperation. Did the book have any direct impact on Sassall or the community he served? Berger replies: “The villagers, no. But . . . in retrospect, it had an important effect that I hadn’t foreseen, it defined what his work was there—and later he actually wanted to stop his practice there and go to the Third World . . . but his family were against this . . . and eventually he ceded to them. I have the feeling that if the book had not happened, he might not have had that wish. Certainly, after the book, Sassall travelled a lot more, and extensively through China in the 1970s”. Sassall suffered from depression before the book was started, and it is given frank treatment in A Fortunate Man. After the book was published Sassall continued his work, and continued his life. He endured personal tragedy and further depressive illness. Undoubtedly he gave himself to his patients: time, effort, thought, money, and spirit. The picture that one builds of this small (physically), agnostic, decent, and intense doctor is larger than the book. If ever he needed objective justification of his life, it was there in text and pictures. Another question the book leaves unanswered concerns Sassall’s sense of humour. What was it like? Doctors often take refuge in a blunt, black, or bleak humour that shocks their public. Did Sassall have a sense of humour? Berger is surprised that I even have to ask, and is keen to talk of it: “it was evident particularly when frustrated; it functioned, I think, as a kind of safety valve. And perhaps he used it less, except when applying it ludicrously to himself, when he was depressed.”
A neat and tidy man, he always sported a red handkerchief so that if he coughed up blood (he was a heavy smoker) he need not notice. In 1981, in a postcard to a friend, he remarked “Nous sommes dans le merde. I have always been in it.” In another letter, he finishes: “The
547
For personal use only. Reproduce with permission from The Lancet Publishing Group.
LITERATURE AND MEDICINE
J S Huntley
J S Huntley
patients are roaring with laughter in the waiting-room but given the beast a name, confirmed its existence, made it when they come in their faces will be as long as your arse”. real. Doctors see the noblest and the worst of humanity, These are sentiments that must (at times at least) be and both impact. Berger continues, “When faced with common ground to all doctors. Indeed some seem to revel what doctors face every day it is quite surprising how many in just keeping their head above . . . merde. Why include maintain a normality.” these phrases if they constitute common experiences? Two I go back to the village to find Sassall’s place. The truth reasons: precisely because they are common experiences, is that I do not know what I am expecting to find. I just go. and because they were his particular phrases. They belong Near the top of the hill is Sassall’s surgery, recognisable to his picture. from the photographs in A Fortunate Man. It is a surgery Generally, people outside of medicine have a poor idea no more; simply a house with an extension. A couple live about life as a doctor. I am at a meal with schoolfriends. there, with a small daughter. The young mother looks at They ask me about life as a junior doctor. I reply “Oh you me with some suspicion, then more helpfully as I explain, know . . . to cure sometimes, relieve often, comfort always” somewhat haltingly, why I am here. Yes, she knew a doctor [Balint’s dictum] and they just look at me wisely. They had lived here once. No, she didn’t know a book had been think they know better. written about him. Certainly, it is fine to go to the land Medicine is increasingly dominated by technology, below the house to try to take a photograph from the same economics, and litigation. The profession is in the throes of angle as in the book. embracing evidence-based medicine. It is encouraging that However, the path is gone, the field below is no longer a there has also been a surge of interest in the role of field, rather a young wood. It is impossible to gain an narrative in medicine,12 sociology, and the lives of our unobstructed view. But the two photographs, then and now, have common lines and patients. Furthermore there angles—roof-edges, window, is the possibility of writing telegraph pole, and watermaking us more reflective trough at the top of the field. and complete practitioners.13 Later I learn from the Horton14 outlined a proposal landowner that the villagers for a core canon of medical were against the planting. literature but this focused on The medieval castle in the biomedical papers. As he village still has the moatnoted: “Space must be set garden, the genesis of which aside by students and doctors is described in A Fortunate alike for solitary reading, Man. It is Sassall’s wife since reading forces one to whose name appears, open a window onto the alongside many others, on private self ”. This is as true the Moat Society board. The for texts of a humanistic The countryside close to Sassall’s surgery garden looks well. Now, nature. Other commenthere is a profusion of small taries15–17 highlighted the hotels in the village, and a overlap of literature and number of holiday cottages. medicine—in particular the The village is quiet, then benefit of ethical reflection, another lorry rumbles down when medicine is forced to its one main road. I wonder if consider increasingly complex the village is as isolated as the moral issues. cultural island of the 1960s. “What about the mistakes It is odd, given the central doctors make?” I ask. Berger identification of Sassall as immediately (and happily) witness, as the clerk of the expresses his lack of formal records, that I end up looking medical education, but goes for some lasting evidence of on to say: “Two things seem his identity in the church. I obvious to me: (1) everyone find the gravestone of is fallible, and (2) people do Sassall’s wife. There is a not accord normal fatalities plaque commemorating the with life”. Both comments life and work of Sassall’s are truisms lying at the core predecessor. But no stone for of what is difficult about Sassall. I wonder what modern medicine. In the dogma the Church lays down words of a former boss and about suicide today, and accident-and-emergency what it dictates about bodily consultant: “If you make no remains. Must they still be mistakes, you’re not seeing buried outside the enough patients”. Necessity churchyard? The churchyard dictates. Secondly, people has in any case overflowed— expect medicine and its but there is no stone for him practitioners to deliver. outside either. People have higher Sassall bore witness to this expectations. So who can be community—he was a blamed for a diagnosis, a confidante, elemental elder, disease, a condition? Medical psychologist, and guide. staff are there, and they have Sassall’s village church 548
THE LANCET • Vol 357 • February 17, 2001
For personal use only. Reproduce with permission from The Lancet Publishing Group.
LITERATURE AND MEDICINE
What then bears witness to Sassall’s life? Not his patients (too mortal), not his surgery (a surgery no more), and not the churchyard. The witness to his place and life is the book itself, A Fortunate Man. When considering the man, his work, and the apparent paradox of his suicide, the final words belong to Berger, who added this afterword to the recent German edition: “When I wrote the preceding pages—and I’m thinking particularly of the last ones which speak of the impossibility of summing up Sassall’s life and work—I did not know that 15 years later he was going to shoot himself. Our Instant-Hedonist culture tends to believe that a suicide is a negative comment. What went wrong? it naively asks. Yet a suicide does not necessarily constitute a criticism of the life being ended; it may belong to that life’s density. This was the tragic Greek view. John the man I loved killed himself. And, yes, his death has changed the story of his life. It has made it more mysterious. Not darker. I see as much light there as ever. Simply more violently mysterious. This mystery makes me feel more modest, as I stand before him. And standing before him, I do not search for what I might have foreseen and didn’t—as if the essential was missing from what passed between us; rather I now begin with his violent death, and, from it, look back with increased tenderness on what he set out to do and what he offered to others, for as long as he could endure”.
THE LANCET • Vol 357 • February 17, 2001
Grateful thanks to John Berger for his encouragement and frank discussion, and Robin Boyd, Tony Walsh, Mike Robinson, and Jeremy Hall for their help, advice, and input.
References 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
Berger J, Mohr J. A fortunate man, Readers Union edition. London: Penguin Press, 1968. Berger J, Mohr J. A seventh man, Middlesex: Penguin Books, 1975. Berger J, Mohr J. Another way of telling. Cambridge: Granta Books, 1989. Rock I, Palmer S. The legacy of Gestalt psychology. Sci Am 1990: 48–61. Berger JG. G. Middlesex: Penguin Books, 1973. Berger J. Ways of seeing. London: British Broadcasting Corporation and Penguin Books, 1972. Wroe N. The Guardian Profile. John Berger: contented exile. Guardian Review 1999. Feb 13: 8–9. Burns-Cox C. Positive potential of a sad experience. Lancet 1999; 354: 344. Hull D, Johnston DI. Essential paediatrics, 4th edn. Edinburgh: Churchill Livingstone, 1999. Camus A. Le Mythe de Sisyphe. Paris: Gallimard, 1942. Norrell J. Balint medicine. J Roy Soc Med 1993; 86: 435–36. Balint M. The doctor, his patient and the illness, 2nd edn. Old Woking: Unwin Brothers, 1964. Bolton G. Stories at work: reflective writing for practitioners. Lancet 1999; 354: 243–45. Horton R. A manifesto for reading medicine. Lancet 1997; 349: 872–74. Hudson Jones A. Literature and medicine: an evolving canon. Lancet 1996; 348: 1360–62. McLellan MF, Hudson Jones A. Why literature and medicine? Lancet 1996; 348: 109–11. McLellan MF. Literature and medicine: some major works. Lancet 1996; 348: 1014–16.
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For personal use only. Reproduce with permission from The Lancet Publishing Group.
Literature and medicine
In search of A Fortunate Man J S Huntley
J S Huntley
The patient left the consulting room quietly and the door fortunate enough to obtain in 1999, Berger said: “The swung itself shut. “Well, what do you think?” asked the remarkable thing, looking back at it now is that, as a book, middle-aged general practitioner (GP). I told him what I it mixes a whole series of approaches: in places storythought. “There you go again, imposing your middle-class telling, in others analytic, sociological, pictorial—and in values on your patients”, he replied, smiling but this respect is resembles Sassall, who was incredibly uncompromising. versatile”. I am reminded of the central tenet of Gestalt At the end of the clinic, as he packed his briefcase, he theory: that the whole is different from the sum of its parts.4 continued: “The book you should read is A Fortunate Man Berger continues: “Not only was he [Sassall] a wonderful by Berger and Mohr . . . about a GP in the Forest of Dean storyteller, he was also a brilliant met-a-scene—a stage . . . about a GP anywhere . . . if you can find a copy . . . director—he was able to orchestrate theatre, and he had God knows why, but it went capacity as an actor . . .”, out of print years ago instantly Berger negates the . . . and bear in mind the word actor, as if people irony of the title, given that would (mis)interpret this its subject, the ‘fortunate’ GP term as implying insincerity, later committed suicide.” “. . . and Sassall was always I tapped a second-hand sincere, aware of the dream book search and for £18 was of life”. In describing the life treated to a 1968 hardback and work of Sassall, the book edition.1 It is a beautiful and also depicts the life of this isolated community, in affecting work, bearing cultural terms an island examination again and again, where development is stilted in different moods, under and stunted. different lights. Berger admires Sassall— It is the story of a general praise indeed from an author practitioner, John Sassall, whose output encompasses who worked in an isolated fiction (and a Booker prize5), community in the west of Sassall’s surgery, now a family home England. It is poetic and pictorial: the text by John Berger essays, art criticism (in particular Ways of Seeing6), film, and the photographs by Jean Mohr are conjoined and poetry—besides being an artist. Berger’s output continues counterposed. The authors, as a condition of publication, from his position as a contented exile in France.7 Sassall retained the right to the minutiae of the book’s layout: the was of course his friend. I am intrigued as to how they position of the text on the page, the position of the pictures might have met. Because of the honesty of the prose, the within the book, the combination of text, page turn, and depth of the treatment of Sassall’s analysis and selfpicture. It is a successful mixed form of narrative that the analysis, I conjecture that they must have been friends from authors later used elsewhere.2,3 early life, from childhood even. I am wrong. Berger had lived in a neighbouring village The book acts at several levels. It is analytical, but the and went to consult Sassall about intermittent abdominal text also elicits emotional reactions and meditations, pain, thinking he had an ulcer. He didn’t, and the two men juxtaposing various pictures with text. For instance: “We became friends in the following years. It was, however, only give the doctor access to our bodies. Apart from the doctor, when Berger moved away to Geneva that he had the idea of we only grant such access voluntarily to lovers—and many doing the book, an offer accepted by Sassall. So for are frightened to do even this. Yet the doctor is a 6 weeks, Berger and Mohr lived on Sassall’s shoulder, in comparative stranger.” On the facing page, Sassall his house, in his surgery, and on his night calls. examines a patient’s extended neck. Several pages on, In attempting to describe the doctor’s life, you quickly Sassall examines a lady’s abdomen. A firm hand palpates a run up against the symbolic and the metaphysical. This left upper quadrant. Her eyes are wide but trusting; she parallels the tendency of Sassall, through life, to become watches him watching her. increasingly philosophical, increasingly reflective. The It is a difficult book to analyse or summarise. It is challenge may be in recognising the crossroads of human multifaceted and uncompromising. It moves by turn experience and endeavour. Doctors are human too. If you through case histories, through Sassall’s feelings and react to the misfortune of a friend, or a comrade, or a concerns, to the philosophy underpinning the GP and his patient by assuming their very distress, then you will not place in the community. In an interview, which I was last long. By contrast, if these experiences leave you unchanged then you have lost humanity. In a letter to The Lancet,8 Burns-Cox uses a passage of Lancet 2001; 357: 546–49 George Eliot (from Adam Bede) to illustrate the possibility of growth from experience of loss and tragedy. This is good Department of Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh EH3 9YW, UK (J S Huntley DPhil) so far as it goes. The danger is overdose. The GP bears
546
THE LANCET • Vol 357 • February 17, 2001
For personal use only. Reproduce with permission from The Lancet Publishing Group.
LITERATURE AND MEDICINE
witness to his patients’ lives—their hopes, aspirations, struggles, and failures. He is their “clerk of the records”. He has the challenge of reacting appropriately in any of a variety of charged situations—5 minute chat to a new and proud father; 5 minutes later to a bereaved daughter. The GP is a repository of trust. He has a unique passport to all classes, access to many fears and struggles, but is left to cope with his own humanity, his own propensity to failure. Sassall fails in the opening two stories of A Fortunate Man. He fails to save the leg of a man trapped by a falling tree, and he fails to gain the confidence of a girl traumatised by a previous affair. The landscape assumes historical significance in these studies. “There is a bend in the river which often reminds the doctor of his failure.”
How different it is for the hospital doctor, who takes but a snapshot of the patient’s life. He is less obliged to live with his failures. How numbing must be the feeling of failure over decades—to see plants never break bud, grown in the dark, in the wrong soil. Sassall delivered a girl in the cottage near the surgery. 16-years later, “nubile in everything except her education and her chances”, she is crying in his surgery, without knowing why—except that she wants more from life. She has no qualifications and no real aspirations. After the consultation Sassall is left staring out of the window. You are shown his closeness to his patients, to the community as a whole, to death. You are shown his ability to self-identify and his ability to be almost all things to all people. He became pre-occupied with the value of life, and the value of the moment in time. This idea centred on the value of lives in modern society. “Talk of the ‘bad old days’ before the war can encourage a certain superficial belief in progress. But faced with the young—and the prospects before them—it is hard to maintain any such belief. Sassall is forced to acknowledge that, by his own standards, they are having to settle for a fifth best.”
This is not a message confined to rural communities at the end of the 1960s. This is a message for our place and our time now. The definitive paediatric textbook, Essential Paediatrics,9 under the heading of social paediatrics states: “Certain inner city areas, deprived by most material and social standards, have a higher incidence of most medical problems and the children who live there are, in general less physically, mentally and socially able. At a disadvantage from birth, these children are ‘born to fail’. . .”
This is the measure of failure of our advanced civilisation. A doctor’s work is dependent on disease, inequality, morbidity—a doctor’s role is to struggle. Maybe it is fanciful to liken the task to the stone of Sisyphus, he the legendary soul doomed to roll a stone up a mountainside for eternity. Even when he approached the summit, the stone would fall backwards. Who would Sisyphus be, without his stone? In Le Mythe de Sisyphe,10 Camus concludes: “The struggle to the top alone will make a human heart swell. Sisyphus must be regarded as happy.” It is important to fight the war—against disease, misery, disability, infirmity, and deprivation—but ultimately it remains unwinnable. We must celebrate those few victories in battles and skirmishes along the way. It is necessary to reframe our aspirations but not decrease our efforts. The aim of a life in medicine—whether as GP, nurse, surgeon, or whatever is, in the words of Balint “to cure sometimes, relieve often, comfort always.”
THE LANCET • Vol 357 • February 17, 2001
Berger professes that Balint11,12 had a profound influence on his thinking, in particular through his book The doctor, his patient and the illness.12 Balint quotes have become legendary, not least: “Regard your patients as human beings. While never forgetting that they are your patients.” When involved with true empathetic depth, how does one maintain this necessary Balint perspective? Perhaps with a balance of one’s own life outside medicine, one’s own loved ones. The converse must also be true—poor relationships and bad life events within one’s family circle may be devastating. I talk to a GP friend about the problem of empathetic perspective, and (without prompting) he volunteers his wife and family as rather more than a support, dragging him out of introspection. A Fortunate Man does not explore this relationship. Perhaps it was considered too private, perhaps rightly so. However, the book is dedicated to both “John and Betty [Sassall] whom it concerns . . .”. It is not surprising that GPs are prone to melancholia. “Sassall’s depressions are maintained by the material of the two problems we have just been examining: the suffering of his patients and his own sense of inadequacy”.
Though earlier, “To a large extent, Sassall has achieved his ideal. As much as a man can on land, dealing with illness and not the sea, and living in the middle of the twentieth century, he has achieved a position which is comparable to that of a master of a schooner”.
John Sassall read the manuscript and accepted it with only a few minor changes. Obviously, the entire project would never have been possible without his enthusiasm, consent, and frank cooperation. Did the book have any direct impact on Sassall or the community he served? Berger replies: “The villagers, no. But . . . in retrospect, it had an important effect that I hadn’t foreseen, it defined what his work was there—and later he actually wanted to stop his practice there and go to the Third World . . . but his family were against this . . . and eventually he ceded to them. I have the feeling that if the book had not happened, he might not have had that wish. Certainly, after the book, Sassall travelled a lot more, and extensively through China in the 1970s”. Sassall suffered from depression before the book was started, and it is given frank treatment in A Fortunate Man. After the book was published Sassall continued his work, and continued his life. He endured personal tragedy and further depressive illness. Undoubtedly he gave himself to his patients: time, effort, thought, money, and spirit. The picture that one builds of this small (physically), agnostic, decent, and intense doctor is larger than the book. If ever he needed objective justification of his life, it was there in text and pictures. Another question the book leaves unanswered concerns Sassall’s sense of humour. What was it like? Doctors often take refuge in a blunt, black, or bleak humour that shocks their public. Did Sassall have a sense of humour? Berger is surprised that I even have to ask, and is keen to talk of it: “it was evident particularly when frustrated; it functioned, I think, as a kind of safety valve. And perhaps he used it less, except when applying it ludicrously to himself, when he was depressed.”
A neat and tidy man, he always sported a red handkerchief so that if he coughed up blood (he was a heavy smoker) he need not notice. In 1981, in a postcard to a friend, he remarked “Nous sommes dans le merde. I have always been in it.” In another letter, he finishes: “The
547
For personal use only. Reproduce with permission from The Lancet Publishing Group.
LITERATURE AND MEDICINE
J S Huntley
J S Huntley
patients are roaring with laughter in the waiting-room but given the beast a name, confirmed its existence, made it when they come in their faces will be as long as your arse”. real. Doctors see the noblest and the worst of humanity, These are sentiments that must (at times at least) be and both impact. Berger continues, “When faced with common ground to all doctors. Indeed some seem to revel what doctors face every day it is quite surprising how many in just keeping their head above . . . merde. Why include maintain a normality.” these phrases if they constitute common experiences? Two I go back to the village to find Sassall’s place. The truth reasons: precisely because they are common experiences, is that I do not know what I am expecting to find. I just go. and because they were his particular phrases. They belong Near the top of the hill is Sassall’s surgery, recognisable to his picture. from the photographs in A Fortunate Man. It is a surgery Generally, people outside of medicine have a poor idea no more; simply a house with an extension. A couple live about life as a doctor. I am at a meal with schoolfriends. there, with a small daughter. The young mother looks at They ask me about life as a junior doctor. I reply “Oh you me with some suspicion, then more helpfully as I explain, know . . . to cure sometimes, relieve often, comfort always” somewhat haltingly, why I am here. Yes, she knew a doctor [Balint’s dictum] and they just look at me wisely. They had lived here once. No, she didn’t know a book had been think they know better. written about him. Certainly, it is fine to go to the land Medicine is increasingly dominated by technology, below the house to try to take a photograph from the same economics, and litigation. The profession is in the throes of angle as in the book. embracing evidence-based medicine. It is encouraging that However, the path is gone, the field below is no longer a there has also been a surge of interest in the role of field, rather a young wood. It is impossible to gain an narrative in medicine,12 sociology, and the lives of our unobstructed view. But the two photographs, then and now, have common lines and patients. Furthermore there angles—roof-edges, window, is the possibility of writing telegraph pole, and watermaking us more reflective trough at the top of the field. and complete practitioners.13 Later I learn from the Horton14 outlined a proposal landowner that the villagers for a core canon of medical were against the planting. literature but this focused on The medieval castle in the biomedical papers. As he village still has the moatnoted: “Space must be set garden, the genesis of which aside by students and doctors is described in A Fortunate alike for solitary reading, Man. It is Sassall’s wife since reading forces one to whose name appears, open a window onto the alongside many others, on private self ”. This is as true the Moat Society board. The for texts of a humanistic The countryside close to Sassall’s surgery garden looks well. Now, nature. Other commenthere is a profusion of small taries15–17 highlighted the hotels in the village, and a overlap of literature and number of holiday cottages. medicine—in particular the The village is quiet, then benefit of ethical reflection, another lorry rumbles down when medicine is forced to its one main road. I wonder if consider increasingly complex the village is as isolated as the moral issues. cultural island of the 1960s. “What about the mistakes It is odd, given the central doctors make?” I ask. Berger identification of Sassall as immediately (and happily) witness, as the clerk of the expresses his lack of formal records, that I end up looking medical education, but goes for some lasting evidence of on to say: “Two things seem his identity in the church. I obvious to me: (1) everyone find the gravestone of is fallible, and (2) people do Sassall’s wife. There is a not accord normal fatalities plaque commemorating the with life”. Both comments life and work of Sassall’s are truisms lying at the core predecessor. But no stone for of what is difficult about Sassall. I wonder what modern medicine. In the dogma the Church lays down words of a former boss and about suicide today, and accident-and-emergency what it dictates about bodily consultant: “If you make no remains. Must they still be mistakes, you’re not seeing buried outside the enough patients”. Necessity churchyard? The churchyard dictates. Secondly, people has in any case overflowed— expect medicine and its but there is no stone for him practitioners to deliver. outside either. People have higher Sassall bore witness to this expectations. So who can be community—he was a blamed for a diagnosis, a confidante, elemental elder, disease, a condition? Medical psychologist, and guide. staff are there, and they have Sassall’s village church 548
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For personal use only. Reproduce with permission from The Lancet Publishing Group.
LITERATURE AND MEDICINE
What then bears witness to Sassall’s life? Not his patients (too mortal), not his surgery (a surgery no more), and not the churchyard. The witness to his place and life is the book itself, A Fortunate Man. When considering the man, his work, and the apparent paradox of his suicide, the final words belong to Berger, who added this afterword to the recent German edition: “When I wrote the preceding pages—and I’m thinking particularly of the last ones which speak of the impossibility of summing up Sassall’s life and work—I did not know that 15 years later he was going to shoot himself. Our Instant-Hedonist culture tends to believe that a suicide is a negative comment. What went wrong? it naively asks. Yet a suicide does not necessarily constitute a criticism of the life being ended; it may belong to that life’s density. This was the tragic Greek view. John the man I loved killed himself. And, yes, his death has changed the story of his life. It has made it more mysterious. Not darker. I see as much light there as ever. Simply more violently mysterious. This mystery makes me feel more modest, as I stand before him. And standing before him, I do not search for what I might have foreseen and didn’t—as if the essential was missing from what passed between us; rather I now begin with his violent death, and, from it, look back with increased tenderness on what he set out to do and what he offered to others, for as long as he could endure”.
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Grateful thanks to John Berger for his encouragement and frank discussion, and Robin Boyd, Tony Walsh, Mike Robinson, and Jeremy Hall for their help, advice, and input.
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Berger J, Mohr J. A fortunate man, Readers Union edition. London: Penguin Press, 1968. Berger J, Mohr J. A seventh man, Middlesex: Penguin Books, 1975. Berger J, Mohr J. Another way of telling. Cambridge: Granta Books, 1989. Rock I, Palmer S. The legacy of Gestalt psychology. Sci Am 1990: 48–61. Berger JG. G. Middlesex: Penguin Books, 1973. Berger J. Ways of seeing. London: British Broadcasting Corporation and Penguin Books, 1972. Wroe N. The Guardian Profile. John Berger: contented exile. Guardian Review 1999. Feb 13: 8–9. Burns-Cox C. Positive potential of a sad experience. Lancet 1999; 354: 344. Hull D, Johnston DI. Essential paediatrics, 4th edn. Edinburgh: Churchill Livingstone, 1999. Camus A. Le Mythe de Sisyphe. Paris: Gallimard, 1942. Norrell J. Balint medicine. J Roy Soc Med 1993; 86: 435–36. Balint M. The doctor, his patient and the illness, 2nd edn. Old Woking: Unwin Brothers, 1964. Bolton G. Stories at work: reflective writing for practitioners. Lancet 1999; 354: 243–45. Horton R. A manifesto for reading medicine. Lancet 1997; 349: 872–74. Hudson Jones A. Literature and medicine: an evolving canon. Lancet 1996; 348: 1360–62. McLellan MF, Hudson Jones A. Why literature and medicine? Lancet 1996; 348: 109–11. McLellan MF. Literature and medicine: some major works. Lancet 1996; 348: 1014–16.
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