Letterman, by Will Self

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October 2022 Issue [Report]

Letterman

The surgeon who signed his work

Illustrations by Jeffrey Decoster

[Report]

Letterman

The surgeon who signed his work
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In January, it was reported that an English hepatic surgeon who had inscribed his own initials at least twice on the livers of patients was finally—after nine years, a criminal proceeding, and two disciplinary tribunals—banned from practicing medicine for life. In Britain, doctors facing this form of censure are said to have been “struck off the medical register,” and this seemed highly appropriate given that Simon Bramhall’s crime consisted of making his own mark, like some sort of graffiti-tagger—or, indeed, like a writer or an artist who signs his work.

Bramhall’s actions had been a cause célèbre since they were revealed in 2013. Something about this particular instance of writing in rather than on the body grabbed everyone’s attention—mine included. The headlines were typically sensationalist: Bramhall had severally “marked,” “branded,” “burned,” or even “seared” his initials into the exposed organs of these vulnerable patients, using an instrument that sounded appropriately sinister: an argon beam coagulator.

All these headlines implied permanent marking—and possibly concomitant damage. But when one read the body copy (another suggestive term in this context), it became apparent that Bramhall’s mark-making had been both evanescent and superficial: the diathermy cauterized the tissue only to a depth of a millimeter, and that tissue was the fatty layer that encompasses the liver, not the liver itself. Moreover, surgeons using this instrument invariably need to test it, and usually do so by making a small pattern of dots on the surface of the exposed liver.

As I say, the Bramhall case was widely reported. And while many—including one of his victims, who in her impact statement at the surgeon’s criminal proceeding in 2017 compared his actions to rape—portrayed him as a monster or a sociopath, there was an alternative view. Former patients spoke of him as a highly empathetic and conscientious doctor; former colleagues attested to his surgical skills and his excellence as a clinician, pedagogue, and promoter of best practices.

Then there was my own reaction, which was amusement bordering on wild hilarity. Bramhall’s behavior summoned this exclamation from my own mental lexicon: Whatever next! (Who among us can claim never to have responded in such a way to the peculiar predicaments of others?) Did I find the story so diverting because I was a writer, hence an etcher and a marker by vocation, or because, such is my nature, I secretly admired this insouciant behavior? Or was it perhaps because, as someone whose life had been saved by surgery on two occasions (and whose physical well-being had been both preserved and promoted by the practice on at least four others), I was able to see Bramhall’s initials in their correct proportions?

Immediately upon the initial revelation, Bramhall resigned from his senior position. After a guilty plea, he received a non-custodial sentence, a hefty fine, and a five-month suspension from practice. But the case simply wouldn’t go away. And so in the end, Bramhall himself had to disappear. A new hearing was ordered and Bramhall’s banishment completed. It happened that when I heard about his ultimate fate, I was myself recovering from one of those four life-altering surgeries: the fixation of an intracapsular hip fracture. Undergoing what is arguably the most extreme physical experience many of us have in our quotidian lives made me feel both a renewed gratitude to the surgical profession and a burgeoning curiosity about what goes on once the patient is unconscious and the doctors set to work.

There was this, and there was Bramhall himself: his behavior may have been bad, but the prolonged public shaming seemed excessive. No one disputed that his surgery had been impeccable in both cases, and no one argued that the initialing had injured the patients. Frankly, I was worried for the man, and contacted him as much to offer some support as to ask whether he’d be willing to talk about his experience. At first, Bramhall was understandably suspicious. He’d been the cynosure of a media feeding frenzy for almost a decade; a journalist was the last person he’d trust. I think he was swayed by my genuine sympathy as well as my curiosity—and perhaps also by my assurances that I was interested in telling his story in his own words, rather than inscribing my own initials on the corpus of his former career.

In August 2013, Simon Bramhall was a hepato-pancreato-biliary surgeon working at the cutting edge of his profession. “Cutting edge” is not only a cliché, but in this context reads as a rather weak pun. But that’s the way it is with surgery: it induces pointed idioms—as if while at a conscious level you’re calmly considering orderly and aseptic procedures, your unconscious is performing decoupage on a meat puppet.

Anyway, the fact remains: in August 2013, Bramhall was a senior consultant surgeon in the liver unit at Queen Elizabeth Hospital in Edgbaston, the leafy university quarter of Birmingham, England’s second city. He was forty-nine years old and, in his own words, had “reached the sort of pinnacle” of his career. “By the time I was on the liver unit I think there were probably only twenty-two or twenty-three other consultants in the United Kingdom in liver transplantation,” he told me. “And even fewer doing the combination of liver transplantation and hepato-pancreato-biliary surgery I was.”

Bramhall had performed around three hundred transplants, and had been involved in some spectacular cases, including one in which a liver was still viable for transplant after the aircraft that was carrying it had crashed. “You’d be flown in a helicopter to another part of the country to retrieve an organ and then flown back,” he explained, “and you’d come charging in—well, not charging in, you’d come into the theater with an ice bucket.” Bramhall’s enthusiasm for big entrances conforms neatly to that term “theater,” used to describe the room where operating takes place. Not only was he a fiendishly hardworking—even obsessive—surgeon, he also acted the part, driving a luxury SUV and wearing flamboyant Duchamp ties.

But back to that day in August: “I was on call and there was a nurse who was from Warwick, not far from Birmingham, who’d been referred in with fulminant liver failure. . . . We used to do fifteen or twenty of those sorts of fulminants every year. So, she came in, and by definition she had a seventy-two-hour window. The U.K. rules on listing somebody for super urgent liver transplant were that there is an expectation that they would be dead within seventy-two hours without grafting. . . . So, she gets listed as super urgent and a liver becomes available. And it’s a good donor. . . . And it was retrieved by one of our own surgeons.”

I hadn’t encountered this use of the past participle of “retrieve” before I began reading about surgery and talking to surgeons. But then unless we’re medics ourselves, or work in a field that borders the medical hinterland, we don’t normally inquire too deeply into the mechanics of surgery—the exception, of course, being when it’s a procedure that’s going to affect us personally. Yet even then, the bodily reality of what’s about to transpire is mediated by someone else’s professional expertise. We may be conscientious enough to find out how experienced the surgeon is, we may even scan the consent form before signing, but as with the pesky small print on any contract, it’s extremely unlikely we’ll read it all. And it seems to me this skimming correlates to a perception of the body that’s scarcely skin-deep. Henry Marsh, a distinguished brain surgeon who has become something of a media star in Britain as a result of two candid memoirs and a celebrated documentary, describes a colleague’s obtaining “consent” like this: having warned that the risks of the operation include “death, a major stroke, major haemorrhage, or serious infection,” he “handed the consent form—a document that has become so complicated of late that it even has a table of contents on its front cover—to the patient with a pen and the man quickly scribbled his signature without looking at it.”

Atul Gawande, the American writer and surgeon who has had a career as a public health policymaker, casts light on the notion of informed consent from the surgeon’s perspective like this:

Do we ever tell patients that because we are still new at something, their risks will inevitably be higher, and that they’d likely do better with others who are more experienced? Do we ever say we need them to agree to it anyway? I’ve never seen it. Given the stakes, who in their right mind would agree to be practiced upon?

The answer is: we, the willfully ignorant. As Marsh says, patients “will try to overcome their fear by investing the surgeon with superhuman abilities.” We may know a little bit—or even quite a lot—about anatomy, yet as laypeople we go about the world giving scarcely any thought to the skull beneath our skin, let alone the jellied mass of brain matter coddled inside it. And as it is to the thinking organ, so it is to all the rest: we know the liver and lights are within, and we may even have some sense of their distribution and interrelation. Yet as it is to the automobile, so it is to the self-driven human body: we require no knowledge of what’s under the hood in order to get from point A to B, or even to negotiate the myriad sharp corners and hairpin turns involved in our interactions with the world and all those other self-driven, fleshy vehicles. Until we crash, that is.

Perhaps the significance of Bramhall’s behavior is that it forced a lot of people to contemplate just this: the interior of themselves; and furthermore, to confront the degree of objectification required on the part of those we ask to heal us by slicing into it. The analogy between the automobile and the autonomous human is a facile and not especially illuminating one, but at least it captures the workaday Cartesianism of a culture that is determined to hive off the mind from the body so the former can cheerfully disregard the latter—and has developed a whole range of technologies, medical and otherwise, to make this increasingly possible.

Right up to the moment when patients are wheeled onstage from the wings where they’ve been anaesthetized, they retain their individuality; the surgical team addresses them solicitously—one hopes—by name, and otherwise extends the personalized care befitting those about to undergo a significant ordeal. The trouble is, once the mind that believes it has a body rather than simply being one is rendered unconscious by Propofol, paralyzed by curare derivatives, and made insensate by still other opioid painkillers, it has for all intents and purposes become synonymous with the inert flesh housing it. Depersonalized in this fashion, the patient is no longer referred to by name—to do so would be too disturbing for those who, while they may intend to make the kindest of cuts, nonetheless could cause the most profound harm. Even Shakespeare’s Brutus felt compelled to stab Julius Caesar in the back. But then he, like Bramhall by reason of his notoriety, was, is, and will evermore remain, a character.

For as long as there’s been surgery, there’s been surgical satire. Writing in the mid-nineteenth century, Herman Melville drew on his experiences as a seaman aboard the frigate USS United States to fashion White-Jacket, in which he skewered the pretensions of a risibly named surgeon of the fleet, Cadwallader Cuticle. Cuticle necessarily operates with great dispatch, given that he is ministering before effective anaesthesia is in widespread use. As he prepares to amputate a sailor’s leg, the young surgical assistants look on with awe:

“They say he can drop a leg in one minute and ten seconds from the moment the knife touches it,” whispered one of them to another. “We shall see,” was the reply, and the speaker clapped his hand to his fob, to see if his watch would be forthcoming when wanted.

Speed may have been of the essence, but Cuticle keeps breaking off from the matter at his “ensanguined hands” to deliver a series of instructional homilies and dewy-eyed reminiscences to the audience gathered around the hapless patient—who, once dealt with, is expeditiously removed. Cuticle, pleased with his work, tells the young assistants to reconvene the following morning so he can use the severed limb for anatomical instruction:

“To-morrow at ten, the limb will be upon the table, and I shall be happy to see you all upon the occasion.

Who’s there?” turning to the curtain, which then rustled.

“Please, sir,” said the steward entering, “the patient is dead.”

“The body also, gentlemen, at ten precisely,” said Cuticle, once more turning round upon his guests. “I predicted the operation might prove fatal; he was very much run down. Good-morning,” and Cuticle departed.

Yet greater dispatch is enjoined by William S. Burroughs’s creation, the infamous Dr. Benway who, in Naked Lunch, instructs his students thus:

Did any of you ever see Dr. Tetrazzini perform? I say perform advisedly because his operations were performances. He would start by throwing a scalpel across the room into the patient and then make his entrance like a ballet dancer. His speed was incredible: “I don’t give them time to die,” he would say.

It’s the subordination of the patient to the process implicit in surgery that seizes the attention of both satirists. If we think of a physician as a sort of spy, scoping out the interior of the patient’s body with a variety of intelligence sources, then the surgeon, by contrast, is a warrior who attacks disease and injury head-on. But it took a long time for surgeons to establish their bona fides as medical professionals, rather than mere workaday barbers who did a little bloodletting and kidney stone removal on the side; while physicians parlayed their bedside manner into emolument, surgeons depended on demonstrable skills—hence that ascription “theater,” for no self-respecting surgeon went to work without an audience.

Writing and surgery have many odd congruences: each activity depends for its success on counterfactuals, since there can be no satisfying conclusion to a plot without a potentially unsatisfying one, and no sense of a life being saved unless it could have been lost. Moreover, while any writer may mutilate a text, so any physician may create complications rather than cures. But among medical specialties, only surgery entails such injury by its very nature: you wound patients, with the hope that they’ll both recover from those wounds and benefit from what this wounding has enabled you to do.

I asked all the surgeons I spoke to for this piece about squeamishness—which is the baseline reaction laypeople have to the dissection of the living. Those who professed a vocation for the work were the least troubled, even in the initial stages of their career. Pasquale Giordano—a colorectal surgeon who had the pleasure (as he’d undoubtedly see it) of correcting my prolapsing piles by performing an operation of his own devising called a transanal hemorrhoidal dearterialization with Anolift—spoke of having slightly queasy feelings when he was a junior in the operating room: “The one thing I remember and which I will never forget is the strange smell of human tissue being burned. It was a little bit like roast chicken, and that was a bit of a surprise. I didn’t expect that.”

But having wanted to be a surgeon since he was a child, Giordano didn’t experience revulsion once he was looming over the objectified patient; instead, he felt frustration. One of his principal reasons for relocating to the United Kingdom from Italy was retrograde training, which meant that some surgeons ended up only assisting throughout their careers. While still training in Italy, however, his consultant offered him the opportunity to amputate a patient’s leg. Did he enjoy it? “From a surgical point of view, yes,” he said, “I totally enjoyed the fact that I could do something.”

It’s surely this ability to “do something” that ensures surgeons, far from being traumatized by their work, actively enjoy it—in some cases to a point where they view it quite as much aesthetically as they do ethically. Bramhall speaks of “a line between surgery and art.” He explains: “Surgery is definitely an art form of some kind, although not in a conventional way. When it goes well and it looks beautiful at the end—especially something like a liver transplant or a major resection—it really is a thing of beauty.” The writer-surgeon Gabriel Weston even went so far as to paraphrase Oscar Wilde’s notorious remarks on literature: “There’s no such thing as a good or a bad operation.”

Weston is the author of an award-winning memoir about her surgical training in which she pitilessly dissects her experience of dissection as a medical student. “When I had separated the two legs,” she writes,

I carried one of them to the sink—it was very heavy—and washed ancient, desiccated feces from inside it. The strangest aspect of this event was how it passed like any humdrum other, without shrieking or comment from anyone in the room.

Cutting up a cadaver helped Weston realize the peculiar status of the surgeon, who is at once exalted and yet also belongs with those professions always viewed as unclean: sewer and slaughterhouse workers, refuse collectors and gravediggers. “How odd it was that my relatively arbitrary medical student status sanctioned an activity that in any other place would be construed as mad or evil,” Weston muses. Along with this form of license comes, she argues, another: “What I think dissection chiefly gave me was a sound training in the crucial skill of distancing oneself from a patient.”

Like Weston, Bramhall is of the last generation of surgical trainees who dissected cadavers, and he described a similar distancing. “I thought of them as a person,” he told me. “Because you did get a little synopsis about their life, and any health issues they had. . . . But I was able to put that aside in an academic way and think of this as a learning procedure, and of course it’s what the person wanted; they donated their body to medical science for that reason. I wouldn’t say it was a particularly pleasant thing, but it was more unpleasant because of the smell . . . and the grease, y’know, a lot of grease.”

This was because the cadavers were preserved in formaldehyde. The expense of this method of preservation, Bramhall says, was largely responsible for the discontinuation of the practice. While still at Birmingham, Bramhall witnessed the introduction of new methods of instruction: “What they did is, they had some—if you like—professionally dissected bits, anatomical structures, and they plastinate them.”

This technique, developed by the medical showman Gunther von Hagens to preserve human remains, suggests an underlying continuity in attitudes toward the bodies we have, if not the ones we actually are. Von Hagens’s exhibitions have toured the world since the mid-Nineties, featuring cadavers partially dissected and plastinated so as to expose their anatomy. The mode of dissection is often fanciful as much as instructional: nervous systems are teased out to form cloaklike reticulations; a pregnant woman is bisected, complete with her fetus; corpses are arranged to engage in a supernatural chess game; and so on. Von Hagens has vigorously defended his practices against both public protest and legal injunction, always claiming they are as much educational tools as entertainment. In 2002, he performed the United Kingdom’s first public autopsy since 1832, wearing his trademark fedora, a reference to Rembrandt’s painting The Anatomy Lesson of Dr. Nicolaes Tulp.

In The Rings of Saturn, W. G. Sebald anatomizes this depiction of a celebrated anatomy lesson, observing the improbably formal clothing of the men surrounding the prone cadaver, who wear opulent lace ruffs, while Tulp himself sports a wide-brimmed and high-crowned hat. Sebald also suggests an inaccuracy of representation that’s difficult to square with the artist’s otherwise exacting forensic eye: rather than actually looking at the corpse of Aris Kindt, a petty thief who had been “hanged for his misdemeanors an hour or so earlier,” Tulp’s colleagues are rather staring “just past it to focus on the open anatomical atlas in which the appalling physical facts are reduced to a diagram, a schematic plan of the human being.”

There’s this discrepancy, and also the fact that Tulp has commenced the dissection with the offending hand, rather than by “opening the abdomen and removing the intestines, which are most prone to putrefaction.” Furthermore,

this hand is most peculiar. It is not only grotesquely out of proportion compared with the hand closer to us, but it is also anatomically the wrong way round: the exposed tendons, which ought to be those of the left palm, given the position of the thumb, are in fact those of the back of the right hand.

For Sebald this “crass misrepresentation” is itself a comment, by Rembrandt, on the depersonalization implicit in this exercise:

That unshapely hand signifies the violence that has been done to Aris Kindt. It is with him, the victim, and not the Guild that gave Rembrandt his commission, that the painter identifies.

Once you’ve read this, it becomes impossible to view the painting any other way. It’s as if the mutilated hand has come to life, and is beckoning you toward your own final disincorporation. Surely, we’d expect nothing less of Rembrandt, the painter most unswervingly committed to depicting the bodies we truly are, as evinced by his poignant self-portraits.

Bramhall sees an analogy between contemporary medical students’ insufficiently visceral introduction to the viscera, and the way the hands-on approach to examining patients has been abandoned: “The young doctors just fill in a form and send them for a CT scan.” Not only is there an unwillingness to engage with the patient, there’s also, Bramhall thinks, a squeamishness when it comes to what’s called open—as opposed to laparoscopic—surgery.

Talking to Bramhall, reading books by older surgeons such as Marsh, and then talking to younger ones, I found it hard not to accept what the older generation said and wrote. I believed Bramhall, because his thinking seemed to be in line with a general shift to render the body plastinated in life quite as much as death. The rise in cosmetic surgery, supplemented by the rise of social media, tyrannically regresses us toward an imagined mean of physical appearance at once aseptic and aesthetic. These attitudes toward the human body seem echoed even in the way meat is presented to us in supermarket freezers: filleted and shrink-wrapped, so that any trace of its anatomical origin is erased.

But in that operating room in August 2013, nothing carnal was being camouflaged: “So, the liver came in—liver looks beautiful on ice. . . . Everything looks fine. . . . So I start the liver transplant, and the liver transplant goes well. The old liver comes out without any particular event and the new liver goes in. . . . So, the first thing we stitch is the vena cava to vena cava so the venous outflow of the new liver is secured. And then you stitch portal vein to portal vein. . . . Again, that goes well, no particular problem. At this point you’ve left a little drainage pipe in the vena cava and you flush out all the bad—all the potassium, mainly—out of the donor liver by pouring dextrose through the portal vein. . . . When that’s complete you finish the vena cava hole where the plastic tube’s gone in and you finish the portal vein anastomosis, and you carefully monitor the blood coming back in and check the blood pressure doesn’t drop, because obviously once the old liver’s out that’s about a fifth of your body’s circulation. . . . The body acclimatizes to not having it—so then by opening it up you can drop the pressure. . . . So that all went well and there was no particular problem there.”

Besides the names of those unfamiliar parts that nonetheless are part of us, perhaps the only term with which a layperson will be unfamiliar is “anastomosis”: the joining together of two blood vessels, sections of intestine, or indeed any two channels in the body. To give Bramhall some credit here, the lucidity and comprehensibility of his account suggests he possesses the ability to describe complicated procedures effectively to patients and students. As a writer, I perform anastomoses all the time: linking together two channels of meaning so that the prose can flow in new (and hopefully healthy) directions.

Descartes—who Sebald suggests may have been present at Dr. Tulp’s anatomy lesson—thought that ideas became self-evident, and thus “true,” when they were “clear and distinct.” The philosopher had the greatest respect for anatomical knowledge: throughout his twenty-year sojourn in the Netherlands during which he perfected his ideas, he hardly read at all, preferring to conduct experiments in optics and physiology. He also purchased carcasses from butchers in order to dissect them; once, when a visitor asked to see his library, he simply indicated the flayed body of a calf and said, “There are my books.”

By his own admission, Bramhall was not a great reader before the incident that ended his surgical career. But since then, in partnership with a former patient, Fionn Murphy, a retired high school English teacher, he has created a literary imprint called Scalpel Stories. Together they’ve written and self-published five novels. The books draw heavily on Bramhall’s medical knowledge, but the one based on the initialing incident remains unpublished; its title is Letterman.

Murphy told me unequivocally that Bramhall had saved her life: she had been wrongly diagnosed with pancreatic cancer before Bramhall discovered and removed a benign but vast tumor that had been hidden by her pancreas and liver. Of the medical staff she’d dealt with, Murphy said that Bramhall was the one who engaged most fully with her as a person, and committed to telling her the truth about her condition. Ten years after her radical surgery, with her circulatory system reconfigured by Bramhall’s brilliantly extemporized anastomoses, she remains one of his greatest fans. And perhaps because she had been under her collaborator’s knife, the writing she enjoys most is describing operations: “I get quite excited just thinking about it, and when I’m thinking of the surgery bit I’m looking in and I’m imagining it, and pulling out and seeing the bits—and the great thing about talking to someone like Simon is I can say to him: ‘What does it smell like? What does it feel like? Is it hot? Is it warm? What’s it like to touch? Is it squidgy?’ And he’s not been asked these questions before, and says, ‘Oh, I don’t know; it smells like bacon frying.’ ”

I wasn’t looking for such sensory portraits. I wanted Bramhall to explain the context within which his controversial amendments had been made: “And the next step is the arteries. So, the artery is the Achilles’ heel really of liver transplantation, hepatic artery thrombosis occurs in about two and a half percent, or that sort of region, of liver transplants. . . . And when it happens it’s a disaster. . . . You need to replace the liver, and if it’s a fulminant and the artery goes then it’s pretty much. . . . Well, it’s probably good night. . . . So, I did a conventional arterial anastomosis, I used the same bits of donor and recipient vessel that I always use, and the anastomosis looks good. . . . Clamps come off and it just doesn’t perfuse—the artery doesn’t pulse, and I wasn’t quite clear on what had gone wrong at this point, so I clamp it off again, flush it out with heparin, redo the anastomosis. . . . Same thing happens. And I did this about four times until I realized what the problem was.”

We are such stuff as dreams—and the reveries about those dreams we call literature—are made of; but there comes a point (!) when all metaphors have to be abandoned, and a scalpel is a scalpel, while a letter is something either incised, imprinted, or otherwise described on a surface. Surgeons, however, are quite as liable to metaphorize the body as anyone. Giordano said burnt human flesh smelled like roast chicken; Bramhall mentioned bacon. It’s surely no accident that the first surgical-sensual experience Murphy alighted on to express her enthusiasm for this kind of descriptive writing should be this one: what smells “like bacon frying” is the application of argon beam diathermy to the human liver.

Enthusiasm for the raw facts of anatomy seems intrinsic to the surgical vocation. All the surgeons I spoke to had it; and when it’s united with an ability to write good prose, it becomes a strange sort of organic lyricism. Here’s Weston describing an attempt to repair a leaking abdominal aortic aneurysm, a tear that’s fatal unless addressed with utmost alacrity: “The operation began with the swiftest laparotomy incision I have ever seen . . . in one concerted movement, the attending literally sliced Mr. Cooke open, from xiphisternum to pubis. His proficiency was marvelously apparent to me: his decisiveness, his knowledge of exactly how much pressure to apply to the large blade to penetrate skin and subcutaneous tissue without harming any important underlying structures.” Following this, Weston and another colleague end up holding the guts of the disembowelled patient: “Arms outspread like goalposts, we held its writhing bulk, and I will never forget the eerie movements it made, vermiculating in our joint embrace.”

And here’s Marsh, with a very different approach, yet also rhapsodizing corporeal realities that would make the layperson retch, as he explores the interior of a patient’s brain through his beloved operating microscope: “I was descending a ravine or negotiating a narrow crevice, with the shiny, silvery-gray surface of the falx to the left and the pale surface of the brain, etched with thousands of fine blood vessels, glittering in the microscope’s brilliant light, to the right. . . . The white corpus callosum came into view at the floor of the chasm, like a white beach between two cliffs. Running along it, like two rivers, were the anterior cerebral arteries, one on either side, bright red, pulsing gently with the heartbeat, which you must not damage under any circumstances.”

Of all the surgeons I spoke to for this piece, Weston seemed the most alive to the false distinction between the subjective apprehension of incarnation, and the objective sense of oneself as a body in the world; she told me it wasn’t credible, for example, that Marsh had metaphorized the thinking organ while he was actually slicing into it. Proficient surgery depends on a flow state involving phenomenal levels of concentration, and all my interviewees concurred that this was one of its major appeals: time is annihilated, the world beyond the operating room, with all its quotidian irritations, is abandoned. All you have to do is operate.

Poised between the older and younger generations of surgeons, Weston is old enough to have experienced behavior by colleagues that would now be anathema, but which once was tacitly if not actively accepted; and yet she is young enough to believe that changes in surgical practice reflect social and moral progress in the wider world.

Cutting into the body, cutting bits out of it, and sewing it back together again may well be as old a practice as making fire, which, for millennia before the invention of electrocautery, provided the means for stanching bleeding. And surgical practice has always reflected the milieu within which it takes place. If you like, there’s a phylogeny of surgical techniques, just as there is of the human body itself, such that their evolution reflects our changing conceptions of the individual and its embodiment. Underlying our functional conception of our bodies is a childlike wonder at—and a childlike repulsion from—an interoception which was once all too piercing. For champions of progress, who often cite painless dentistry as the summum bonum, the surgery of the premodern period is nothing but a vile species of Grand Guignol. Yet before the advent of the three A’s (anesthesia, antisepsis, and antibiotics), a surgeon had to deal with a patient as a sentient being rather than an inert object. And if, as Gawande suggests, an individual surgeon’s expertise proceeds by means of a calculated willingness to make mistakes, then the profession marches forward only by trampling over a hecatomb of nameless victims.

We’re all familiar with accounts of men violently hacking off limbs or savagely excising tumors. The one that upset me most as a young reader, falling in love with literature, was Flaubert’s pitiless (and painfully detailed) description of Charles Bovary’s pathetically inept attempt to rectify the clubfoot of the aptly named Hippolyte Tautain, the hostler at the local inn, in Madame Bovary. That Bovary is urged on to exceed the ambit of his modest competence by his vain and snobbish wife, Emma—in cahoots with the publicity-seeking pharmacist—adds a layer of situational irony to what constitutes, prima facie, an abuse:

Charles incised the skin. A brisk crack was heard. The tendon was incised, the operation was over. Hippolyte was astounded. He fell upon Bovary’s hands and covered them with kisses.

Read one way, the operation is a timeless parable of vaulting ambition. But considered in context, it becomes an indictment of surgical methods that may, in theory, be technical improvements, but which, in practice, negate older forms of practical wisdom, including those that respond to the patient’s individuality. Hippolyte was perfectly happy, nimbly trotting about on his clubfoot, and had no need of Bovary’s ministrations. After the procedure, he succumbed to gangrene—and, as Bramhall might metaphorize it, it was good night.

Fortunately this wasn’t the case for the thirty-five-year-old woman on Bramhall’s table: “And then I realized that what had happened was that in the donor operation there’d been a traction injury on the artery—something called an intimal tear. . . . An artery is made of three layers, so the intima is the inner layer. . . . And if you get blood flowing, if you fracture the intima, you can get blood flowing up in the wrong passage which occludes the artery immediately. . . . It became obvious to me after a number of attempts that was the issue—so the problem I had then was I had to cut it right back to the point where the intimal deflection stopped. . . . So, I was now back to the bifurcation of right and left hepatic arteries. . . . So, I was back to very small vessels, and of course this is now under some degree of tension because I haven’t got enough arterial length to do it. It’s extremely stressful for the whole theater team, they all know what’s happening. . . . I don’t shout and I never have shouted or sworn or anything, some of my colleagues do but I’ve never done that. . . . It’s obvious to everyone that I’m under a degree of pressure here, trying to pack the liver down to reduce the tension and so on and so forth. . . . So, in the end I do the anastomosis, and this is the fourth or fifth go now . . . and it’s running. . . . The relief is palpable—absolutely palpable.”

In over five hours of interviewing Bramhall, I never got any closer to an explanation of his behavior than this: the palpable relief that attended the realization that it wasn’t good night, or good evening, but a new morning for the patient. He hasn’t helped himself by failing to come up with an explanation that employs one of the usual tropes of depth psychology, such as childhood trauma. When I put it to Bramhall’s literary collaborator, Murphy, that he was a man who perhaps found introspection difficult to a near-pathological degree, she agreed. For others, of course, that was precisely the point: Bramhall’s actions proved him to be the archetypal toxic male ego, devoid of emotional intelligence. A significant part of his mea culpa has been to accede to this; to me, as well as to the officials called upon to judge him.

Nevertheless, such an acknowledgment doesn’t really seem to have been accompanied by any planned operation on Bramhall’s ego. Rather, the protracted public shaming seems to have resectioned at least part of this malignant growth, while what remains—in my view, understandably—still adheres to the benefits his patients accrued from his technical expertise: “So, the next step is to complete the bile anastomosis, which is straightforward. There wasn’t a problem with that, it was easy enough to do. . . . My practice was always to do a real-time biopsy, so I use a Menghini needle to do a biopsy which a pathologist will then assess, which gives people down the line an idea about how that liver will behave. . . . Not everyone did it, but I did it routinely. . . . What I used to do then is hold the liver in my left hand, because there’s a hole there now that’s bleeding. . . . I used to squeeze it, pick up the argon beam diathermy. . . . So, argon beam diathermy is transfer of electric current between a plate on the patient, down a beam of argon gas on to the tissue—and it gives a very superficial diathermy burn. . . . It doesn’t go in deep, it didn’t cause any damage. It was originally designed for brain surgery. . . . And the liver, of course, is covered by a capsule which is about two millimeters thick, so the only thing it’s doing is coagulating the protein in that capsule. . . . So, I’m there, holding the liver and pointing the argon diathermy at it, and when the bleeding stops, I just flick my wrist and sign sb. . . . And I don’t know why I did it to this day, but I did.”

When does a pattern of dots coalesce into a letter? When does a test become a signification? And should all initialing—whether it’s on a contract, or the title page of a book, or a body—be interpreted as an expression of entitlement, of ownership? Bramhall didn’t help himself by allegedly saying, when challenged by one of his colleagues after the liver-initialing, “I do this”—implying both that it was his usual practice, and that it authenticated an act of artistic creation. He didn’t help himself either by doing it at least twice. The earlier incident, in February 2013, emerged at the same time as the second. I say at least because, although Bramhall denies any other instances (and also says he cannot remember the February one, but admitted to it in order to streamline his guilty plea), he continues to argue that this unorthodox use of argon beam diathermy was, if not exactly widespread, common enough.

On two occasions, Bramhall told me how one of his surgical mentors would not just initial a patient’s liver but would “play noughts and crosses” on the exposed organ. Giordano told me he’d witnessed a visiting American surgeon autograph an incision during a novel procedure to correct an inguinal hernia, and then ask a member of the surgical team to take a photograph of him with the portion of the patient that had been signed in this way. Other surgeons were coyer on this matter: one such was Adam Kay, a writer and former obstetric and gynecological surgeon whose bestselling account of his medical career, This Is Going to Hurt, was also a hit when his adaptation was screened this year. In the television drama, the character who shares his name deliberately makes the incision for a caesarean through the tattoo of a woman who made racist remarks about a midwife. I was interested to talk to Kay about this because, of all my interviewees, he was the most emphatic about both Bramhall’s malpractice and the fitness of his punishment: “I remember hearing about it and feeling sick that someone would do that. . . . The fact that someone loves themselves so much they feel the need to brand a patient, even temporarily, just goes against all my innate feelings as the doctor I was.”

Having deployed the highly emotive term “branding,” Kay wasn’t going to admit any such liability himself. When I asked about the tattoo incident, he obfuscated—“if it happened”—while conceding that, if it had taken place, this act and Bramhall’s initialing “would be equally reprehensible.” In Bramhall and Murphy’s fictionalized account of the initialing incident, the hospital’s head of surgery asserts that some ophthalmic surgeons had been known to laser their initials on patients’ retinas, and other orthopedic ones to inscribe them in the cement used for bone reconstruction. When I asked Bramhall if he knew this to be true, he told me he did.

But he would, wouldn’t he? In Britain, the Bramhall case may well come to be seen as a watershed, the event that publicly marked the end of a working culture typified by unfettered macho behavior, and underscored by an ethos that not only demands of surgical practitioners a willingness to work punitively long hours, but valorizes it. Although Bramhall couldn’t remember the first of the incidents, what he could recall is that on the day it allegedly occurred, he had performed two liver transplants and had been operating for ten hours. Yet he remains convinced that this almost frenzied level of surgical activity is precisely what enables surgeons to acquire the intuitive anatomical knowledge required to get in the flow and do exceptional work.

British surgery is also the product of the elite schools many of its senior figures attended. In these establishments, the humiliation of the weak and defenseless is not only seen as ineradicable, it’s figured as desirable and “character forming.” Weston told me about being “beasted,” or hazed, by older colleagues: “Obviously, in the early days people were throwing instruments at you and beasting you, and trying to make you cry, and obviously that sort of thing is not okay. . . . But I think, for me, what was so wonderful about surgery was that once you’ve hung around enough that people stopped throwing eggs at you—once they’d basically moved on to the next vulnerable person—was this feeling of being in this ungendered world. You walk around in your scrubs, and no one can see if you’re a boy or a girl.” Weston—who while resiling from her own deification still views surgeons she admires as “gods”—maintained firmly that “what surgery gave me as a world, as a woman, was much greater than what it took away.”

Another female surgeon, who asked to remain anonymous because she didn’t trust the complaints procedure and worried that speaking out could hamper her prospects, told me of an incident early in her career. Like every surgeon I spoke to, she was once a trainee desperate for hands-on experience. During an operation to reconstruct a patient’s wrist, the consultant orthopedic surgeon offered her the opportunity to “do the plating” (affixing a metal plate to the broken bones to secure them in position). This was a considerable step for a junior surgeon. The only proviso was she had to sit on his knee while she did it. My interviewee told me that no one in the operating room reacted, that she did as her superior bade her, and that she sat on his lap for five or ten minutes while she did the plating. She told her husband about it when she got home that evening. Neither of them thought much of it, but in retrospect she agrees the request was “not acceptable.”

This surgeon worked at the Queen Elizabeth Hospital in Birmingham at the same time as Bramhall but before the initialing incidents. She told me there was already talk about him “having an ego slightly larger than life,” though “he wouldn’t have been the only one who had that reputation.” Most significant for me was that both she and Weston figured this behavior as something that essentially tempered their steely determination to become surgeons—and both women told me the worst bullying they’d experienced had come from female colleagues.

Although herself a younger surgeon, my anonymized interviewee laughed when I told her about Bramhall’s mentor allegedly playing noughts and crosses. “We have laughs and jokes,” she admitted. “When we have patients that come in, say, with all four fingers amputated, and we have to put them back, there’s a joke: ‘Don’t put it back the wrong way round.’ ” When I put it to her that such remarks would probably have been just as traumatic as Bramhall’s behavior if the patient had learned about them, she readily agreed. She also told me about a legalcase where a patient, having recorded the chitchat in the operating room, successfully sued the surgical team. So a fair degree of self-contradiction was exhibited, even among those who seemed emphatic in their condemnation of Bramhall.

Perhaps the only surgeon I spoke to who was resolute in his view both that Bramhall’s actions had been wrong and that the culture which had sustained them was a thing of the past was Gerard Doherty. He was also the only American surgeon I spoke to for this piece, and while I didn’t put Giordano’s story of his countryman “autographing” an operation to him, he was at pains to describe a working culture far removed from this. A cynic might suggest this is to do with his eminence: surgeon-in-chief at Brigham and Women’s Hospital and Dana-Farber Cancer Institute and the Moseley Professor of Surgery at Harvard are just a few of his job titles, and a holder of such positions learns to weigh his words accordingly. Nonetheless, Doherty basically agreed with Bramhall’s contention that surgeons need to be “alpha personalities”: “I think in order to do surgery—to do this very unnatural act—it requires someone to have a certain amount of hubris, and when things don’t go the way we plan, or want or desire them to go, because not all operations work, it’s a devastating thing for the surgeon as well as the patient,” he said. “And to be able to go and do it again also requires that certain personality type. I think that characteristic personality can be taken too far; frankly, I think that’s what he’s been punished for—not for harming those two patients, but for reputational harm to the profession.”

Women now make up half of Doherty’s surgical trainees at Brigham and Women’s, and he believes that “there’s less tolerance for this kind of paternalistic behavior.” He added that if he wrote his initials on something during surgery, “I would be reported to the hospital authorities before I left the operating room.” According to Doherty, even the practice of initialing the felt-tip marking of the portion of the patient due for surgery to show that it has been registered has come to be viewed negatively by his colleagues: “Some of them actually made a parallel to the branding of slaves.”

Doherty told me that he hadn’t heard about any similar cases in the United States. But at least two came to light readily enough: one concerned Allan Zarkin, an obstetrician at Beth Israel in New York, who earned the sobriquet Dr. Zorro, after it was revealed that he had “carved” his initials into the belly of a patient whose child he’d delivered by caesarean section. The other involved a gynecologist in California accused of writing his patient’s name in inch-high letters on the uterus he had removed.

The first of these cases took place in 1999; the second about a decade later. The Beth Israel swordsman has disappeared from view, but the alleged uterus-tagger—whose charges were dismissed—appears to be practicing in Laguna Beach. Bramhall didn’t write his initials an inch high, and even Doherty believes the punishment has been disproportionate. His undoing came, in part, because of bad luck. Through no fault of Bramhall’s—and certainly not as a function of the initialing—the patient’s transplanted liver failed. When one of his Birmingham colleagues performed the second emergency surgery required to replace the defective liver, he found the organ massively engorged—and Bramhall’s initials massively enlarged.

Bramhall cites the photographing of the initials and the circulation of this image among staff at the hospital, then its leaking to the media, as the proximate causes of his disgrace. This may be the case, and certainly in our specular culture, in which all public debate takes place within a hall of electronic mirrors, what’s seen inevitably synergizes with the requirement that justice appear to be done. But I’m not particularly interested in the precise details of how his initialing was first exposed to a few readers and then published in the wider world; nor am I overly concerned with the ins and outs of the trial or the professional tribunals he underwent. No, what has preoccupied me from the first time I heard about Bramhall is why I find it so very hard not only to condemn him but even to view the act as particularly reprehensible.

I wasn’t alone: Murphy also found herself transported. “My first reaction when I heard about it was that I laughed,” she told me. “I thought it was hilarious.” Once she realized that the man who’d saved her life was facing serious ramifications, she set up a Facebook page that became a repository for hortatory testimonials from other former patients and even colleagues. The most popular comment, she reports, was “an artist signs his work.” (The judge in Bramhall’s trial viewed these testimonials as significant mitigation, and they helped keep him out of jail.) While acknowledging that Bramhall’s actions were in a sense wrong, Murphy nonetheless maintains that when it comes to her own insides, “I don’t care if he’d written his telephone number and his whole life story.”

Contemplating Bramhall’s fate—which was to be a marked man, who carried on being marked for nine years before his sentence was fully enacted—I was reminded of Kafka’s story “In the Penal Colony.” In this characteristically enigmatic narrative, the master-fabulist imagines a machine equipped with a mechanical “harrow” that delivers verdict and punishment simultaneously, carving into the malefactor’s back the commandment he has transgressed. A visitor to the eponymous colony is shown the hateful machine and watches a malefactor await his fate in the blazing sun. “Does he know his sentence?” the visitor asks the corrections officer. “There would be no point in announcing it to him,” the officer replies. “You see, he gets to know it in the flesh.”

Of course, Bramhall’s victims got to “know it in the flesh” as well, although arguably the greater sources of trauma were the coincident and critical surgical interventions that had to be made in order to save their lives. But as I said at the outset: I have no wish to make anyone into a character save those who have volunteered themselves. When Murphy asked me what I thought of her and Bramhall’s literary efforts, I muttered something non-committal. In truth, there’s nothing that bad about their novelizing. But there’s not much good either. These are amateurish offerings, and it’s not hard to see why the Scalpel Stories books are self-published. An aspect of the novels that seems, in my experience, to be shared with a lot of such fictions, is a view that can only be described as animist: for Murphy, the world and everything in it is potentially sentient, such that cardboard boxes are “on friendly terms” with wastebins; a middle-aged woman witnesses dark roots “sneering back at her”; and even a small key hung on a chain in the same woman’s décolletage can be characterized as “warm and cosy, coming up for air only when it had a date.”

Is it perhaps a stretch to see this attempt to vivify everything as a strange sort of counterpoint to surgeons’ need for patients to be insensible things before they can start work? Writing about people, quite as much as doing surgery on them, always runs the risk, in psychological terms, of becoming decoupage performed on a meat puppet. I certainly hope this isn’t what I’ve done to Simon Bramhall: his actions may have been wrong, but his punishment has been considerably more prolix than his crime, and when it comes to being a letter man, I think it’s probably me who has the edge.

’s most recent essay for Harper’s Magazine, “A Posthumous Shock,” appeared in the December 2021 issue. His latest book, Why Read: Selected Writings 2001–2021, will be published next year.


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