Medical Cultures

Have doctors lost their culture? I will ignore the smart student in the back row who whispers loudly “Did they ever have one?” Let me answer that medical student, who may well be the young Oliver Gogarty. Yes, Mr. Gogarty, there was indeed a time. I remember sophisticated cultural chatter over the operating table; occasional visiting physicians who knew more than a bit about music. That time (early 1950s, Mater Hospital, Dublin) was a kind of end of days. For the great 19th century tradition of the physician and surgeon who hobnobbed with musicians and writers (not so much with artists) was already past. Do such contacts matter? If your surgeon reads Proust, does that mean he’ll operate on your gallbladder better than someone who doesn’t? Not necessarily, but at least you have something beside your missing gallbladder to talk to him about when convalescing. Do I mention this to make an easy score against busy practitioners? Certainly not! But the reasons for the evolution of the acultural doctor are clear enough.

As the profession became increasingly technological, the patient a client, the doctor a service provider, is it fair to say any doctor’s eagerness to appreciate or even practice an art form has declined? It is, as often with doctors, a matter of time you don’t have. More importantly, the rise of technology has inversely paralleled the decline of clinical medicine; the old Hippocratic trinity of ‘Observe, Record, Reflect’ has been dispelled. The laying on of hands is now fairly rare among practicing physicians. The clinical tradition of the three great 19th century schools of empirical medicine (Edinburgh, London, Dublin) has been lost. The book under review, Eoin O’Brien’s The Weight of Compassion & Other Essays prompts these thoughts as surely as if the author were whispering in your ear. For the book is not just a book, it is an occasion, in which we are not only presented with the rare figure of the doctor as cultural gentleman, but one who has made important contributions in every field he has touched, in and out of medicine. Cultural gentleman? The phrase is now quaint. Let us define this rare creature: one who possesses an easy grace with colleagues (difficult) and patients (not always easy), who is humble in his wide knowledge, sympathetic but not sentimental, humane is his treatments, who moves easily among artists and writers, actors and musicians and, if we are fortunate, has wit—and oh, in O’Brien’s case, what wit! O’Brien replaces this fictive paragon with a living person.

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The Weight of Compassion is divided into four parts. The first fifty-two pages record the friendship between O’Brien and Samuel Beckett, prefaced by a photograph of Beckett laughing, a startling corrective to the iconic images of depressive genius. The second retrieves, with supple prose and shrewd wit, a vanished Dublin intellectual life with a special feeling for what turns men into characters. Then a brief meditation on the great Dublin doctors of the classic era (the 19th century) and on the profession, which like other monopolies is not noted for self-criticism. The final section presents the critic and reformer of Irish medicine as it is presently practiced (always a lonely task). The book concludes with O’Brien’s campaign against the Bahrain government’s brutal treatment of the medical professionals who gave succor to protesters who were themselves savagely abused. The range is wide, the prose excellent, the wit always at the ready, and the moral center never mislaid.                                   

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O’Brien’s great tome, The Beckett Country: Samuel Beckett’s Ireland (1986) was a key document in reclaiming the self-exiled writer from being assimilated by French culture. Paris seems to make “French” those who stay long enough, especially if they write in French. Cioran stayed long enough to blur his Romanian origin. Nabokov stayed too briefly. But to the French, Beckett was becoming “Frencher” every year. O’Brien was not alone in reminders of Beckett’s origins. “No one, however, is sufficiently aware of the background to notice the Irishness of the Godot tramps.” The writer was O’Brien’s friend, A.J. (Con) Leventhal, writing in 1969. Leventhal, who succeeded Beckett as lecturer in English at Trinity College, was one of those brilliant literati, like Niall Sheridan and Stephen MacKenna, effortlessly produced by a post-war Dublin rife with argument and literary lawsuits.

This second section of The Weight of Compassion retrieves some of the most fascinating characters in a distant, smaller Dublin, among them, as well as Leventhal, the artist Nevill Johnson, the playwright Denis Johnston, with asides on Micheál Mac Liammóir and some unusual medical characters, including the waspish eccentric extraordinaire, Dom Peter Flood, doctor, surgeon, monk, misogynist, economist, and, for some years, Professor of Moral Theology in Rome. He was described by one of his contemporaries, Leonard Abrahamson, as having “more degrees than a thermometer without the same capacity for registering warmth.”

The essay written by O’Brien in 1981, “From the Waters of Zion to Liffeyside” is a sustained fugue on the Jewish influence on Dublin’s character. The Jewish presence, once very significant, has dwindled both in number and quality, but was intrinsic to the cultural matrix of Dublin. O’Brien traces a line from Bethel Solomons, rugby international and Master of the Rotunda Maternity Hospital, to Robert Briscoe, a patriot in difficult times and later Lord Mayor of Dublin (1956). Briscoe, in 1922 New York, occupied the Free State’s Consular Office for the Republican opposition, to be gently removed by New York cops “on the directive of my (O’Brien’s) grandfather, Timothy Smiddy.” The asides in this book, of which this but one example, are always fresh, informative, sometimes antic and often hilarious.

Bethel Solomons, a remarkable Dublin Jew, whose sister, the painter Estella and her husband, Seamus O’Sullivan bridged my divided loyalties (to the two trades, medicine and art) around 1950. For O’Sullivan, a name adapted by James Starkey, edited the luxurious Dublin Magazine where he (far too kindly) published my (hopefully forgotten) juvenilia and invited me to tea. I remember a curtained drawing room, a moustache over a pipe and two lines from one of my host’s poems: “Foaming with amethyst and rose/Fades once again the old blue flower of day.” His wife I met with pleasure, for I knew her paintings well—forceful, compositionally daring, overdue for revaluation.

A sense of otherness, it seems, is inseparable from what is called “the Jewish experience”—not unknown to outsiders and minorities of every kind. The otherness was probably emphasized during the reign of Archbishop John Charles McQuaid (1940 – 1973) who proscribed the faithful from studying at the Queen’s College, Trinity (including, by virtue of parental conformity, me). The contribution of distinguished Jews to Dublin culture is a remarkable section in a remarkable book.

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O’Brien’s friendship with the painter Nevill Johnson is a model of retrieval and post-mortem care (of the departed subject’s reputation). There is no more touching record of artist and patron. Johnson, in my student days, was one of Victor Waddington’s stable in his gallery at South Anne Street. The others were Colin Middleton (a searching, brilliant talent), Daniel O’Neill (romantic effusions, à la Vlaminck), Gerard Dillon (a pungent faux-primitive—I remember a priest hearing confessions through a very enlarged, pink ear) and, of course, Jack B. Yeats, whose celebrated biennial exhibitions in the late 1940s and early 1950s flowed from an endless cornucopia.

O’Brien was Johnson’s friend, counselor, admirer, collector, curator, physician, patron—multiple roles which came into play as O’Brien followed Johnson’s erratic peregrinations. O’Brien savors, as one fine writer to another, Johnson’s meditations on place, his trade, and his departure from Dublin: “I broke away from Waddington and jettisoned the bait; I brushed away the dust of Dublin and set off again for London—to be an exile in my birth land, to be an oddball in that country of class and compromise, that well-swept catacomb of logic and commonsense. ‘Why don’t you give up painting and get a proper job’ they would say.’” O’Brien’s story ends at Johnson’s London bedside and with a promise made to retrieve and preserve as much work as he (O’Brien) can find. Johnson died in 1999. With truly Roman virtue, O’Brien sponsored a Johnson retrospective exhibition on November 2008 and continues relentlessly to awaken interest in the oeuvre of this remarkable artist.

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Medicine, law, and the performing arts generate endless stories and tales of folly and wit, many of them passed down, embellished. Dublin medicine incubates its share. O’Brien takes particular relish in doctors who combine medical inspiration with character and sometimes its attendant quirks. He is an outstanding researcher and historian of Irish medicine. He places, as is proper, the founding of the Golden Age of Irish medicine with the great Victorian physicians and surgeons, who were masters of clinical prose and whose eponyms are part of contemporary medical parlance, among them: Graves’ disease (thyroid enlargement or goitre); Colles’ fracture (of the wrist), Corrigan’s pulse (aortic regurgitation); Cheyne-Stokes respiration (intermittent terminal respirations); Stokes-Adams syndrome (from a slow heart). It is an immortality O’Brien has joined. For many, “The Eoin Factor” is an international standard in discussions about hypertension, to which I was first introduced by an African doctor.

The work of one of these Victorian predecessors converges with O’Brien’s professional passions: cardiology and hypertension. His book on Dominic Corrigan (1802 – 80) is based on individual enterprise and original research—searching for and finding Corrigan’s papers slumbering in the Royal College of Physicians of Ireland archive. The outstanding characteristics of the great Irish doctors were their empiricism and downright common sense. O’Brien places great emphasis on the medical history of each case, which may often yield a diagnosis before the formal examination

Stokes’ vision of student training, appeals to O’Brien, the sophisticated humanist: Stokes wrote “the neglect of general education, the confounding of instruction with education, and the giving of greater importance to the special training than to the general culture of the student [...] Let us emancipate the student and give him time and opportunity for the cultivation of his mind so that in his pupillage he shall not be a puppet in the hands of others, but rather a self-relying and reflecting being.” O’Brien adds, “He (Stokes) would be saddened by medical training today and in particular he would deplore the neglect of the humanities and the suppression of cultural development with the emergence of the narrow-minded super-specialist.”

Arguably, the greatest figure of the Dublin School is Robert Graves (1796 – 1853), who “while making the usual continental tour, had such adventurous experiences as being arrested as a German spy in Austria on account of his fluency as a linguist, and of successfully quelling a mutiny on board ship during a storm in the Mediterranean, afterward assuming command and saving the vessel through his pluck.” Graves must have been a charming companion. O’Brien, who has the true historian’s tropism for original sources, adds this fact to the Graves mythos: In his journey across the Mont Cenis pass in the Alps in 1819, Graves travelled with a young artist “who looked like the mate of a trading vessel” (a shrewd observation any art historian will confirm). “Both sketched what they saw.” O’Brien quotes Graves writing to his friend Stokes: “When our work was done, we compared drawings; the difference was strange. I assure you there was not a single stroke in Turner’s drawing that I could see like nature; not a line, not an object, and yet my work was worthless in comparison with his. The whole glory of the scene was there.” In terms of observation, this is sophisticated criticism. Graves and J.M.W. Turner stayed together all the way, by slow stages, to Rome.

 How do people learn? How do you teach them? “Education” is a word that seems to bear with it an intrinsic flaw. O’Brien’s revisions: get to the patient early, cut the long six years to four. He believes that pre-med (botany, zoology, physics, chemistry) privileges somewhat irrelevant disciplines over clinical training. O’Brien has stirred these somewhat brackish (medical training) waters, a dangerous role with few if any rewards. But he brings an unimpressed lucidity to his points, and he has the professional distinction to back them up. So much of his discourse has been international, where as a writer of rare succinctness and clarity he can direct the aim to problems with arrow-like precision. He is thus frequently uncomfortable to have around, however gracefully his points are made. His persistence is legendary and he will not yield to threats and embrace unnecessary discretion.

Let us posit a quasi-colonial medical dilemma. A major medical center, eager to introduce unyielding standards of education and thereby spread its influence, works with a remote country to create a joint teaching situation—a medical school—to train the local populace in the profession. A great majority of that populace has little or no voice in the affairs of their country, which is ruled by authoritarian fiat. Repeated street protests from the excluded majority, looking for fair representation in government, are violently suppressed with the usual doleful sequelae of imprisonment, further deprivation of rights (which were never granted), and torture. Witnessing this, does the proxy parent raise its voice in protest?

The place is Bahrain, the institutions are Royal Colleges of Surgeons and Physicians of Ireland, distinguished bodies founded in 1784 and 1654 respectively. They have jointly created medical colleges in Bahrain’s capital. In terms of wealth, Bahrain could buy and sell Ireland many, many times. The oppressed majority is Shia; the rulers are Sunni. We are immediately projected into the toxic relationship of Sunni and Shia, which is dimming the promise of the Arab Spring.

When the demonstrators were suppressed, with the help of imported Saudi enforcers, the wounded and injured ended up—if they were fortunate—in Bahrain’s hospitals. The story doesn’t end there, as it usually does. Instead, it begins. The Sunni government extended its persecution to the doctors and nurses who had treated, as their professions demands, the sick and injured. Charged with treason and arrested, they received the same medicine as the protesters—imprisonment, beatings, torture, and either no trials or parodies of trials. The U.S. State Department was not heard from for a very good reason; the U.S. 5th Fleet is snugly ensconced in Manama Bay—for which the U.S. pays Bahrain substantial fees

 The dilemma: Would the Royal Colleges protest these actions against the profession? Several of those arrested were trained in and some are Fellows of the Royal College of Surgeons.

Dr. O’Brien took two unprecedented steps. He confronted the highest officers—the President and Vice-President of his alma mater, the Royal College of Surgeons, and advised that the principle of medical neutrality and the right to freedom of speech should override all other considerations; they refused to heed him. He resigned his Fellowship of the Royal College of Physicians to protest at its silence, a wrenching decision, since his love for both institutions has been proven again and again. O’Brien’s action stung many who hold the College of Surgeons as close to their hearts as does O’Brien. He was a leading member of a delegation to Bahrain, which demonstrated to the families of imprisoned doctors that someone cared about the injustices being done but the delegation failed to obtain Royal pardons for the accused doctors. So we might ask—how effective has O’Brien been? He has, by virtue of his reputation, made Bahrain’s repression an international problem, successfully influencing the Royal Colleges of Physicians and Surgeons in the UK to make representation to the Bahraini authorities (in contradistinction to the Royal College in Ireland) on behalf of the accused doctors. He and others in concert have succeeded in mitigating to some degree the abuse of the doctors and nurses who were simply doing their jobs. If I ever end up in jail, please send for O’Brien.

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Throughout the book there is an ongoing subtext that often becomes salient: How do you make a good doctor? And what is a good doctor? Of the many points O’Brien makes on this subject, one of the most inspiring is the way he conceives the doctor’s role in the broadest terms—to think not just locally, but broadly and internationally, to exercise, as he put it, his humanitarian instincts so as to mould his “attitude to the broader dimensions of medicine.”

Is this a discipline in the making? Yes. The profession of trained human rights activists. I must over-stress the value of this book. If ever there was such a thing as “essential reading” in and out of the profession this is it. It is written by a great humanist, a great doctor, a man of literature and culture, in cadences Addison and Steele would have admired. There is something else about his prose and persona that nagged at me until I learned that the good doctor every day, bitter winter and summer, crosses the road from his Monkstown house to the Irish sea fondling the stones which do duty as a beach and throws himself in as fully as Leander did in the Hellespont, which is fairly warm water. A Greek reference, yes, but here is a splendid fortitude, more noble, more Roman.