While the prospect of entering old age, say beginning when we hit seventy, comes with some serenity, so too does it come with fear. Those of this age group have seen the ravages and indignities that could befall themselves having witnessed the experiences of their families and friends, as well as their exposures to cultural and social representations (movies, novels, art, TikTok, Facebook). Their fear ranges from mild concern to outright panic, and their reactions range correspondingly. Those with mild to moderate fear might take up exercising or some brain work, see their doctors regularly, and adopt wearables. Those in utter panic will consider much more drastic actions. In all cases, the reactions to these fears boil down to fighting destiny. 

Lionel Shriver, in her novel, Should We Stay or Should We Go, takes on the case of the panicked, and imagines what they might be willing to do to avoid the horrors that can attend old age and how their actions could turn out. She does this through the story of Cyril and Kay Wilkinson.  

The Pact 

Cyril Wilkinson and his wife Kay make a pact. On Kay’s eightieth birthday, when Cyril is already eighty-one, they will commit suicide together. Cyril, a physician in the British National Health Service (NHS) secured a supply of secobarbital as the means to their ends. It was 1991. They have planned well ahead; another twenty-nine years will pass before Kay’s eightieth in 2020. 

Motivating the pact was the death of Kay’s father after “a good four years of steady deterioration, followed by a solid ten of nothing but degradation” from dementia. (p. 7) Kay recalls “how he was physically so unpleasant,..managing the nappies alone was such a trial, because he fought and kicked a great deal, and sometimes, which was mortifying, got a soft little erection—honestly,  my own father.” (pp. 2-3) Then “the chasing and corralling and undressing…I was halfway between a daughter and a sheepdog. And in between these and many like events, pictures of Kay’s father kept popping up in her head, such as one showing him “naked below the waist, purple with rage, and covered in feces.” (p. 9) 

They had just arrived home from his funeral service and were reflecting on what they had been through. At one point, Cyril says, “Your father frankly made me suicidal—or homicidal—or both. Half an hour in his presence passed like a mini ice age,” and then promises Kay, “I will do almost anything to keep the two of us from acceding to such a fate.” (p. 12) Kay is dubious. 

That’s what everyone says…Everyone looks at what happens to old people and vows that it will never happen to them…Somehow they’ll do something so their aging will proceed with dignity…Everyone thinks they have too much self-respect to allow a stranger to wash their private parts…Then it turns out that, lo and behold, they’re exactly like everyone else! And they fall apart like everyone else, and finish out their miserable end of their lives like everyone else. (pp. 12-13) 

Cyril counters, “in order to retain agency over your own end of life, you have to be willing to give up some small portion of it that’s not particularly rubbish.” (p. 31) But, he admits the plan amounts to “placing a high-stakes wager.” (p. 32) Kay dithers over the next few months, but then her mother begins showing signs of dementia; “I’m all in,” she tells Cyril. (p. 17) 

The Pact Wobbles 

Cyril and Kay proceed through the subsequent twenty-nine years, with Kay raising their three children, retiring, finding new work and passions; Cyril going on and on about politics, the NHS, old people; and both watching their remaining parents pass on, traveling to far-flung locations, becoming grandparents, aging. Then the day arrives; happy birthday, Kay? 

The four years preceding Kay’s eightieth birthday overlap both the decision of the United Kingdom (UK) to leave the European Union (“Brexit”) and the Covid-19 pandemic. Thus, during the time Cyril and Kay are beginning to wonder whether they will actually leave or remain on Earth, the UK is deciding whether to leave or remain in the European Union. And while Cyril and Kay are seemingly willing to die rather than fight the ravages of old age, millions of people are willing to fight the ravages of Covid-19 rather than die. These juxtapositions pop up often giving the Wilkinsons’ decision added poignancy, and play a part in their newly manifesting doubts about the pact as the established date of its execution nears.  

At this juncture, Shriver conjures twelve different endings that still take the form of high-stake wagers. Through these alternative paths, we see if the wagers are well placed. We also gain insights on common and contemporary issues concerning aging, as well as on some hypothetical and futuristic possibilities. Among them are these: 

• The surprises still left between people after more than forty years of marriage 
• The possibility of a person with dementia as happy 
• Whether being sensible and prepared for old age is always rewarding 
• The prospect of outliving enjoyment, purpose, or interest in life 
• What life might be like when a drug reverses aging and makes elderly people twenty-five years old again, forever 
• Elder abuse within an institution and within a family 
• The adventurousness and desperation people approaching old age can exhibit 

Though each of the alternative endings comprise individual chapters, they are not wholly independent of one another as they each borrow ideas, paragraphs, dialogs, and sentences from the others. Some of them peel off into separate tales. Shriver does not limit these through lines to just those within the book. In one case Shriver samples another of her books, So Much For That, and in another, she riffs on an American in England who bloviates on BBC 4 and in a widely-circulated newspaper, who happens to be Shriver in real life. These interminglings make for more dynamic prose, and add some coherency to all the different alternatives presented. 

Destiny’s Grandparents 

None of the alternative endings stand out as the one they should follow. Shriver, though, offers other ways of accommodating the challenges and frights of approaching old age. Throughout the chapters, and with mostly dialog between Cyril and Kay as they think through their choices and decisions, she puts an emphasis on destiny, risk, and bravery.  

When Kay is arguing against the pact, she tries to impress upon Cyril that destiny has a part in what becomes of them, and that they cannot control all of it. “Our destiny isn’t wholly in our hands. I realize you don’t like that about the world, but there’s an upside: our destiny isn’t wholly our responsibility, either. Or, if we end badly, our fault.” (p. 241) Shriver emphasizes the point by making destiny a component of each alternative path they take. Destiny can’t be completely controlled, so embrace it, or at least accept it, Shriver may be saying.  

As they did with their original plan for Kay’s eightieth, the Wilkinsons would have to wager that the outcomes of any of their alternative paths would be more preferable than the status quo. Kay acknowledges that this reality has been the case throughout their life when she asks Cyril, “every decision we make is a gamble, isn’t it?” (p. 202) So, why not give them a go? 

The pact Cyril and Kay make can seem brave, but Shriver is not having it, and especially not when compared to the bravery needed in old age. “Real bravery and nobility,” Kay tells Cyril, “entail losing everything you love by degrees like everyone else, and taking what comes like everyone else, and dying when you least expect it and when you don’t want to, like everyone else.” (p. 75) “Buck up,” Shriver could have added. 

We should stay: it’s destiny, with risks, be brave, eat your ice cream.  

Should We Stay or Should We Go
HarperCollins, 2021: 266 pages 

Image Credit
Title: The Voyage of Life: Old Age 
Artist: Thomas Cole, 1842 
Source: Obelisk Art History  Public domain 

For a growing number of artists whose work falls under the umbrella of graphic medicine—and the readers who make up their audiences—words and drawings in short- or long -form works, the genre provides an effective platform for not only exploring these questions, but for understanding and education, advocacy and activism. In publications that include single frame cartoons, self-published zines or “floppies” (comic-book-style publications) as graphic memoirs and novels, the message is often both less and more complex than text alone. In a single cartoon frame portraying, for example, the relaying of a prognosis, the expression on the face of a patient, the body language of a physician, and even the choice of lettering in the thought or speech bubbles that accompany the drawing, can create an emotional impact that resonates deeply and immediately. (For some graphic medicine cartoonists, what’s left unsaid appears to be just as important as the language they include.)

Those newer to the art form, may find the Graphic Medicine Manifesto (Pennsylvania State University of Press, 2015 and 2025) a fine place to start. Authored by a group of six creators* made up of clinicians and caregivers as well as those working in the medical humanities, the volume serves as a kind of bible for the community. Co-author Ian Williams, a physician and graphic novelist, coined the term graphic medicine to describe comics and graphic novels with medical content. The field is variously described by other members of the informal collective behind the manifesto as including, but not limited to, “the intersection of the medium of comics and the discourse of healthcare”, a “movement for change that challenges the dominant methods of scholarship in health care offering a more inclusive perspective [on medicine and caregiving]” and comics that “give voice to those who are not often heard”. While a significant segment of the work produced focuses on the physical and emotional aspects of illness, medicine, and caregiving, graphic medicine also serves as a means of demystifying disease and injury, professional and lay education, and even patient advocacy.

Creators in the broader graphic medicine community frequently cite its reputation for friendliness and inclusivity; numbered among their ranks are clinicians, researchers, allied health professionals, educators, public health experts, patients, medical illustrators, and others.

A quick survey of the virtual or actual graphic medicine bookshelves reveals the seemingly inexhaustible array of subject matter, with entire sub-genres devoted to specific diseases and conditions. For those on either side of the healthcare divide – providers and patients—these documents can create a bridge to understanding.

Drawing styles employed in graphic medicine are as various as in other art forms. Political cartoonist Peter Dunlap-Scholl, for example, uses a “jangly” drawing style in My Degeneration, which depicts life with Parkinson’s and the effect the illness has had on the way he makes art. Moka Onmae’s graphic novel, Good Morning, Good Night, and See you Tomorrow, based in part on her experience as a cancer patient, adheres to many of the conventions of manga (Japanese comic books and graphic novels with distinctive visual characteristics) to great effect.

Complementing the vast body of patient narratives is an abundance of graphic medicine content that focuses on medical education and clinical practice, including memoirs specific to illnesses that were once thought to be untreatable and diagnoses/conditions that have recently emerged or been identified. Graphic medicine pioneer, MK Czerwiec’s Taking Turns, for example, describes her experience as a nurse in a Chicago hospital caring for patients on an AIDs unit, and includes oral accounts from patients, family members, and staff. The book serves as a historic document as well as a memoir. Palliative care physician Nathan A. Gray’s forthcoming graphic memoir, The Human Remains: Drawing Out Compassion in Medicine, addresses the author’s efforts to maintain his humanity through residency in a system that doesn’t always allow the time and space to do so, and his continued striving while working with patients approaching the end of life.

Use of graphic medicine in the medical school setting has also grown in recent years. Penn State physician and bioethicist Michael J. Green, was among the first group of educators to teach graphic medicine; in his case, introducing the curricula to fourth year medical students in 2009. Writing on this topic in the Graphic Medicine Manifesto, Green elaborated, “[Comics] can tell compelling stories about illness and demonstrate the complexity of medical culture. Reading comics can help students think critically about the environment in which they learn and work, and making their own comics can help students communicate more clearly and precisely.” Moreover, Green wrote, “Being challenged to tell a story by drawing pictures can be an uncomfortable and often daunting exercise…. a reminder that they (and doctors in general) seldom have all the answers or skills to solve every formidable problem that comes before them.”

The relatively recent explosion of graphic medicine comics, zines, novels and memoirs, notwithstanding, it’s worth noting that there’s also a much earlier tradition of cartooning that centered on illness, the medical profession and the public. British caricaturist James Gillray’s The Cow-Pock—or—the Wonderful Effects of the New Inoculation (1802) memorably depicts the wildly imagined consequences of inoculation against smallpox among contemporary anti-vaxxers. William Hogarth (1697-1764), who famously skewered politicians, the upwardly mobile, and the morally dissolute, did not spare physicians his merciless critique in his engravings. In A Consultation of Physicians, or The Company of Undertakers, the artist depicts a gathering of doctors led by three notorious “quacks”, including John Taylor, the “oculist” said to have performed botched eye surgeries on Handel and JS Bach. More on Hogarth and his role as a member of the board of governors and muralist at St. Bartholomew’s Hospital in London, can be found on www.drawing-blood.org, a website associated the Billy Ireland Cartoon Library & Museum at Ohio. Those wishing to go even farther down the rabbit hole on the history of medical cartoons, may be fascinated by Professor Jared Gardner’s piece on the Gumps (a long-running comic strip from 1917 to 1959) in which family members contend with the threat of the Spanish flu epidemic.

State of the Art

Among those graphic medicine creators approaching the complexity of the human body, disease, and delivery of care from a distinctive perspective, are Kriota Willberg and Gianna Paniagua. Willberg, who has worked as a dancer, massage therapist, and anatomical illustrator, and holds certificates in bioethics, medical humanities, and gerontology, is the creator of numerous pieces including the Cadaver Diaries, in which she documents her experience as a student and later as a co-teacher of a drawing class for medical students in a cadaver lab. The booklet not only offers a nuanced description of this work, but also explores how Willberg grew to view bodies in other contexts, as when she sat at her father’s bedside at the end of his life, her understanding of anatomy and physiology making his death more real. “Learning …from textbooks and models taught me perfect anatomy. Dissection taught me how a body’s anatomy can vary and survive illness,” she notes in Cadaver Diaries.

Currently a part-time adjunct professor at Parsons School of Design and an instructor for Art and Anatomy at NYU Langone, Willberg’s time as the Artist in Residence at the New York Academy of Medicine led to the creation of her comic, Silver Wire. Placing herself in the story as a character, a technique that allows her to represent the naïve and curious layperson, Willberg gets a hands-on lesson on ligatures and suturing techniques (her use of fruit as “patients” makes for some intentionally humorous moments) from her friend Mollie, a palliative care physician. Throughout this section, Willberg draws the parallel to stitching techniques used for centuries by needleworkers.

The narrative then advances to a discussion of medical knowledge acquired via unethical and sometimes deeply disturbing practices over the centuries, including experiments on servants, enslaved people, and prisoners by Galen, Paré, and Bell. Willberg’s focus on J. Marion Sims and his experimentation on enslaved women—which included surgeries performed without anesthesia—in his work on vesico-vaginal fistula, serves to illustrate how the surgical techniques and advances that benefit so many women grew out of this history. The title of the comic refers to the silver wire Sims used during surgery to reduce infection. “Because Sims findings were shared internationally, individuals of all genders in countries where there was no legacy of slavery benefited,” Willberg notes. “In fact, he probably saved the lives of some of my ancestors. I think it’s important to share this information.”

Gianna Paniagua, an artist who has been both a painter and a papercutting sculptor, and is a two-time heart transplant recipient, is making another unique contribution as a graphic medicine cartoonist and patient advocate. In both mini-comics and several pieces published in Bonus Days, a magazine by and for transplant patients, among other publications, Paniagua has documented her complicated history. After receiving an initial transplant at 14 months of age due to hypertrophic cardiomyopathy, she then required another as a young adult to address transplant coronary artery disease that developed after a period of non-compliance with her treatment.

Finding an institution that would approve her for a second surgery proved challenging, and it took a great deal of perseverance to find the team at Vanderbilt University where her second transplant surgery was performed. Even with the highly supportive team in place, Paniagua says, “I thought I would die in the surgery, because it was very high risk. I was trained for years not to expect something good to happen [and] I was trying to find something where I could quickly leave a legacy and tell a story others could learn from.” Although she had focused on oil painting as an art major at the University of Pittsburgh, it was important to avoid exposure to toxins in the medium. Paper cutting was also too strenuous at the time. Graphic medicine turned out to be the natural fit for someone who had spent much of her childhood drawing. Her comic about life after surgery and the expectations of others regarding her health are powerfully shown in “Are We Ever Really Recovered?” published in Literature and Medicine in 2023.

With her second heart surgery now five years behind her, Paniagua is still immersed in the transplant world, not only as an artist, but as a patient coping with chronic pain and the demands of remaining vigilant against rejection. Her work as an advocate for other young adult heart transplant patients also takes center stage. “Dealing with the side effects of immunosuppressive drug regimens and noncompliance remain major concerns [for this population]”, Paniagua says. She also notes the importance of adequately educating female transplant recipients about issues specifically related to gender, including the impact of their condition on childbearing.

“I think there are creative solutions for this. It’s important to hear true stories about other transplant patients. It’s a way of feeling less isolated. Graphic medicine breaks barriers of education and language,” Paniagua adds. “If you see an image, it can cling to you. There’s a magic in it.”

Her commitment to helping clinicians communicate clearly and empathetically to those in their care is another driving force behind her comics. When possible, she attends conferences and participates on panel discussions on graphic medicine as well as on care for young heart transplant patients.

Paniagua also acknowledges the role of graphic medicine comics in helping her process a lifetime spent in the medical world. While enrolled at Columbia University in the Narrative Medicine program, Paniagua conceived of a capstone project depicting a heart transplant surgery for a Medical Education comic that would benefit other young transplant patients. Already in the process of founding a support group for this population, she had maintained a connection to her own transplant team and with strict adherence to HIPAA guidelines she was granted permission to be present during a transplant surgery. Although one of her advisors had expressed some reservations, thinking that Paniagua might be unsettled by the experience, she was amazed and inspired and plans to co-create more work in the future with other transplant recipients. She is also deeply gratified to know that the patient whose surgery she observed is doing well.

Owing in great part to the efforts of Graphic Medicine International Collective (www.graphicmedicine.org), comic artists like Willberg and Paniagua, among numerous others, continue to receive exposure and opportunities to network with their peers in cities around the world, both through the organization’s conferences and on their website. The widely attended Comic-Con in California has also hosted programs in graphic medicine, bringing awareness to mainstream comics audiences, while smaller conferences hosted by universities and professional societies are proliferating.

As many in the graphic medicine community will acknowledge, there is still resistance to the value of the genre in some quarters. But this, too, appears to be changing, as demonstrated by the online exhibition maintained by the National Library of Medicine: Graphic Medicine: Ill-Conceived and Well Drawn! With the imprimatur of the National Institutes of Health lending support for graphic medicine – and a growing number of published titles by physicians and other healthcare professionals receiving glowing reviews, there’s surely more widespread acceptance to come.

Selected Notes and Resources
The book alluded to in the beginning of this article is Memento Mori by Tiitu Takalo, which chronicles the artist’s recovery from a ruptured cerebral aneurysm, its effect on her life as an artist and on her personal relationships. In her introduction she also notes that citizens in her home country of Finland are spared the added burden of medical debt as they recover from a serious medical event.

The Graphic Medicine Manifesto was authored by M.K. Czerwiec, Ian Williams, Susan Merrill Squier, Michael J. Green, Kimberly R. Myers, and Scott T Smith

More of Kriota Willberg’s work can be viewed at http://kriotawelt.blogspot.com and on Instagram at @kriotawillberg. Her full-length memoir, Over My Dead Body, will be published in 2027 by Fantagraphics.

Gianna Paniagua’s website, https://giannapaniagua.squarespace.com, showcases her work in various media. She is on Instagram as @tragicdarling.

Web image created by Medhum.

AIDS in the Comics: The Graphic Memoir Taking Turns with MK Czerwiec

Russell Teagarden 08.27.26 125

A nurse’s graphic memoir reveals the human stories, suffering, and compassion behind the AIDS crisis.

Despite Virginia Woolf’s (12) famous proclamation that a “poverty of the language” exists in the description of illness, the most common form of pathographies is likely literature. Woolf’s essay On Being Ill argues that illness, compared to topics such as grief and love, remains rarely written into narratives due to the vocabulary itself. Yet, Carel’s work focuses on a more acute limitation. Language in books inherently offers limited bearing on temporality and pacing. While it is true that skilled authors can decide the pace of paragraphs, quickening tension with staccato and parataxis, the reader is ultimately given control regardless. As Roland Barthes (11) writes in The Pleasure of Text, “the author cannot predict tmesis: he cannot choose to write what will not be read.” In other words, the writer’s intentions matter little if a reader decides to skim over what they deem to be unimportant. Thus, the act of writing itself involves a willful relinquishment to the reader, and this act of surrender betrays a core tenet of the illness-experience: removal from control, particularly over time and space.

Video games complicate this dynamic, since some strip the very control Barthes describes back out of the player’s hands. Perhaps no game better exemplifies this removal of player control, especially over time, to depict illness than Before Your Eyes, released in 2021 by GoodbyeWorld Games. Before Your Eyes is not a typical video game. At no point does the player use their hands to control the game. Rather, the opening minutes require the player to set up an eye-tracking system, which lends itself to a simple conceit: with each blink in real life, once a metronome-object appears, time passes rapidly within the video game.

The first half of the game acts as a type of memory play. The main character, Benjamin, whose eyes the player inhabits, awaits judgment after death and must recount their life story to a mythical Ferryman to continue to the afterlife. The scenes begin playing out. Blink – Benjamin, as a baby, playing with rubber ducks. The scene plays out, then a metronome begins ticking down. Blink – watching parents argue about money. Blink – a piano recital. Blink – nervousness about talking to a crush. Evoking how memories work in real-life, each of these moments has a fleeting quality to them, as these scenes can only last if the player does not blink. Life goes by in a blink of an eye, literally.

While this perspective on memory alone makes Before Your Eyes an intriguing musing on memory, the second half of the game recontextualizes what comes before it in the context of medical humanities. As the scenes continue to play out, eventually Benjamin becomes a highly successful musician and artist, garnering worldwide acclaim. Yet, the story increasingly becomes fantastical, until it’s revealed that the story up to this point has been false. Rather, Benjamin died at 12 years old due to an unspecified terminal illness. The game plays out again; this time, the scenes are of Benjamin confined to his hospital bed. Blink – a growing illness. Blink – his parents visiting him at the hospital. Blink – dreaming of playing the piano. Blink – a fading interaction. In this second half, the scenes become ever more fleeting as the metronome signaling the scene is ready to pass appears more rapidly, triggering in the player a desire to avoid blinking. Often, before a moment can conclude, one blinks; time progresses, closer to death.

Before Your Eyes demonstrates the ability of other mediums, particularly video games, to use interactivity to disrupt typical temporality. This technique is not unique to Before Your Eyes by any means; the works of Samuel Beckett employ a similar technique of stripping audience control to simulate the constricted present Carel describes. For example, Beckett’s Not I (1972) features a disembodied mouth that delivers a fragmented monologue about past trauma at a pace too fast for an audience to fully process, let alone control. In video games, Red Dead Redemption 2’s protagonist, Arthur Morgan, develops tuberculosis over the game’s final chapters, which alters gameplay mechanics, including reducing stamina. As Marshall McLuhan famously argued, a medium’s structure shapes the way it delivers experience, independent of its content. Removing description of illness in favor of depicting its phenomenology, whether that is through Beckett’s compression of time or Red Dead Redemption 2’s diminishing of gameplay abilities, aims to cause the audience to experience illness. Before Your Eyes heightens both of these experiences, for time and space are tied to the player’s physical body, as occurs in sickness. In binding the passage of time to the player’s own involuntary blinking, the player’s body becomes a mechanism of failure. Thus, the player is made to inhabit Carel’s claim that illness is lived from within the body rather than observed from outside it. While literature can recapitulate the experience of symptoms, it cannot impose the conditions of it. Before Your Eyes suggests that the truest representation of illness may not be a representation at all, but an imposition of the phenomenological conditions of illness.

References:

Barthes, Roland. The Pleasure of the Text. Macmillan, 1975.

Carel, Havi. Phenomenology of Illness. Oxford University Press, 2016. Silverchair,
https://doi.org/10.1093/acprof:oso/9780199669653.001.0001.

McLuhan, Marshall. Understanding Media: The Extensions of Man. MIT press, 1994. Google Scholar,
https://scholar.google.com/scholar?cluster=4603169387763961023&hl=en&oi=scholarr.

Woolf, Virginia. “On Being Ill.” Family Business Review, vol. 6, no. 2, June 1993, pp. 199–201. SAGE Journals,
https://doi.org/10.1111/j.1741-6248.1993.00199.x.

Web image by medhum.org

The book became, unwittingly it seems, the first of a trilogy ultimately concerned with what conscious is and does. The second book, This is Your Mind on Plants (2021), extends Pollan’s project to three mind-altering compounds found in plants: opium, caffeine, and mescaline, and the third, A World Appears (2026), is his attempt to discern consciousness itself. Here I cover Pollan’s investigation into consciousness across the three books, the results of which frustrated him and required a reconciliation.

The Trips Begin

In How to Change Your Mind, Pollan gives a brief summary of the bumpy history of psychedelics. He recounts how the intense and well-supported interest in them as therapeutic agents during the 1950s was almost completely snuffed out in the 1960s when “a moral panic about LSD engulfed America, and virtually all psychedelic research and therapy were either halted or driven underground” (p. 185). The panic reached its apogee when counterculture movements and their leaders, among them Timothy Leary of “turn on, tune in, drop out” fame, were seen as threats to mainstream society in general. The few remaining embers, though, reignited in the 1990s and by 2006 serious interest in psychedelics revived and research into clinical use resumed through legal means. Structures were in place allowing psychedelic use for specific purposes, opening the way for Pollan’s investigation.

Pollan arranged three separate “trips,” one each for the psychedelics LSD, psilocybin, and 5-MeO-DMT (i.e., “The Toad”). He carefully chose a tour guide for each one. He came through these sessions with what he interpreted as a dissolution of his ego, which made more room for his consciousness: “I was present to reality but as something other than my self” (p. 264). After these experiences and interviews with many scientists, psychologists, counselors, and users, Pollan constructed an argument about how the altered consciousness states psychedelics produce can offer benefits to individuals who are healthy or sick, and to societies that are stable or fractious, by sending “a life or culture down a new path” (p. 407). He is inspiring, vague, and fantastical at times; he gets more so in his follow-up book, Your Mind on Plants.

There’s No Place Like Home

Pollan expands his investigation of consciousness-altering substances by marrying it with his passion for plants and gardening. Therefore, he need not look further than his kitchen and garden for sources serving his interest at this stage: opium (poppy), caffeine (coffee and tea), and mescaline (San Pedro cacti). He explained his rationale for choosing these three mind-altering agents:

Taken together, these three plant drugs cover much of the spectrum of the human experience of psychoactive substances, from the everyday use of caffeine, the most popular psychoactive drug on the planet; to the ceremonial use of mescaline by Indigenous peoples; to the age-old use of opiates to relieve pain. (p. 4)

Pollan received guidance and supervision for his trials of opium and mescaline. As a self-described “heavy caffeine user,” he withdrew from it by giving up coffee and tea, thinking he could make inferences about caffeine effects through reverse engineering the experience.

While Pollan describes the effects these three agents had on his consciousness, he went further morphing from his role as an investigative journalist into roles of historian and anthropologist. Pollan covers how opium, caffeine, and mescaline altered the consciousness of millions of people through the millennia, and in doing so, says they figure in world history and human development, often in rather breathtaking terms. Opium spurred “the Romantic revolution in poetry” (p. 31). “Caffeine was the perfect drug not only for the age of reason and the Enlightenment but for the rise of capitalism, too” (p. 119). “The sins of slavery and imperialism, in a global system of production…could only have been fueled by caffeine” (p. 138).

While he does not credit mescaline with having contributed to human progress in such grand scales, Pollan speaks of its power in healing the most devastating wounds. But insofar as affecting consciousness, for him, mescaline does “what all psychedelics do—not so much change how we feel inside as imbue the world around us with never-before-appreciated qualities” (p. 217).

Pollan may have imbibed too much caffeine while writing this book judging from some of the conclusions he makes, but it may have fueled his subsequent quest to understand just what consciousness is rather than just what it does to his mind and its impact on world history. What he found on this quest, or more appropriately, what he didn’t find, became the basis for his next book, A World Appears.

Pollan Trips into a Cave

If psychedelics and mind-altering plants can change consciousness, then, as Pollan surmises in describing his objective with A World Appears, “consciousness is, at its core, a material phenomenon…[or there is] at least some credence to the idea” (p. xx). So off he goes on more trips, this time to experts working on finding a discernible form of consciousness, a trip that in the end fails, but still produces some value towards the way we think about artificial intelligence.

Pollan’s trips takes him to four ports of call, or “four different dimensions of consciousness” (p. xxxi). His first stop is “sentience,” which refers to consciousness as where in living beings sensations are perceived and responses to them generated. The next stop is “feelings,” the awareness of biological phenomena, the communication link between the body and the mind, serving homeostasis, for example. “Thought” is Pollan’s third stop, accounting for “the stream of thoughts that all of us experience every waking moment” (p. xxxii). His trip ends at “self,” or the ’I’ that takes in all of our experiences.

Each trip constitutes a chapter comprising what is known about consciousness from a particular dimension. Pollan describes and evaluates them with the help of people involved in their development. Across the four dimensions, he consults or references a wide range of experts including among others: neuroscientists, physicists, biologists, philosophers, psychologists, screenwriters, novelists, poets, and Buddhists. He combs through their theories, constructs, data, analogies, stories, and metaphors. Pollan, nevertheless, comes up empty, and is “abashed to say I know less now than I did when, naively, I set out to unravel the mystery of consciousness” (p. 225). It took several days in a cave at a Buddhist retreat high in the mountains of New Mexico for Pollan to reconcile with this outcome, “to let go into not-knowing.” He wound up accepting consciousness “as less a scientific or philosophical puzzle to be solved and more as a practice…Consciousness is a miracle, truly, and remains the deepest of mysteries” (p. 239).

So be it, but what then are we to make of the artificial intelligence industries’ determined attempts to integrate or discern consciousness in their machines? Pollan might say they will need a miracle.

Citations:
Pollan M. How to Change Your Mind. Penguin Books; 2019. 464 pages
Pollan M. This Is Your Mind on Plants. Penguin Press; 2021. 288 pages
Pollan M. A World Appears: A Journey into Consciousness. Penguin Press; 2026. 320 pages

Links:
My blog post elaborating on Pollan’s How to Change Your Mind is here, and on Your Mind on Plants is here.

Along with cohost, Dan Albrant, here’s a link to our podcast episode in which we focus on: consciousness, spirituality, and mysticism as what is at work in the effects psychedelics produce, and how they may delineate limits to biomedicine (rational or not), that is, how they brighten or blur the line between classic biomedicine and whatever isn’t. 

Edited by Lucy Bruell.
Web Image: Cave Man, Tim Brown, CC BY 3.0 <https://creativecommons.org/licenses/by/3.0>, via Wikimedia Commons

The hand’s importance in daily activities is often overlooked even as I look down at my fingers typing these very words. Rudimentary at first glance, the expansive nature of the hand is as complicated as its anatomy and not in the palm reader sense. Its complexity manifests in the intricate duties it performs when acted upon by the user’s brain, and yet there is so much to learn by its simple examination in its resting splendor. The beautiful dichotomy of the hand is illustrated in the simple gesture of hand-holding, a parent’s single finger grasped in their infant’s small palm contrasted with the loose grip of the dying parent with their child. It is in the soft caress that hands are capable of, but also the solid fist of a hard punch, and the complexity of playing instruments, weaving, programming AI and painting.

My office visits begin and end with a post-COVID handshake if the patient is agreeable. The essential job of the clinician begins with listening followed by thorough examination. For it is in examination that the patient map unfurls. From the initial handshake, to how one holds their hands during the visit, little clues are imperceptibly directed at me. The wringing of the patients’ hands is the tip off for anxiety, along with tightly picked nails or scars. The slight hand tremor can be the giveaway of Parkinson’s disease, alcohol withdrawal or thyrotoxicosis. Then there is the yellow-stained thumb and index finger of the habitual smoker. The tiny muscle fasciculations below the skin are the tip off for advanced carpal tunnel syndrome, advanced neck arthritis, amyloidosis or the more devastating amyotrophic lateral sclerosis. The feel and look of the callus distribution on the palm of the construction worker as opposed to the soft and supple feel of the secretary’s palm or those of the computer programmer are all documented subconsciously, while noting the fissuring and hyperkeratotic papules and scale of the mechanic’s hand, or the similar changes on the non-mechanic’s hand suggesting dermatomyositis or anti-synthetase syndrome. Tell me how AI could perceive most of this without the input of touch and observation?

Whether in the office, grocery store or at dinner, examination proceeds whether the person is willing or not, or even aware. Examining the hand is like picking up an oak leaf in the fall with its midrib, venules and variegation all telling you about the health of the tree from which it has fallen. We won’t discuss ornaments that adorn the hands such as rings or nail paintings as this is quite illustrative in and of itself. Rather, I am more interested in scars, irregularities and deformities. Each small finger joint so intricate and important in function, working simultaneously together like the worker bees in a hive or an orchestra.

From the fingertip alone, Terry’s nail, with its loss of the crescent half-moon, ground glass white appearance, and the darker line at the very tip of the nail, suggests underlying liver issues. Move that line of demarcation proximally to affect half of the nail, it transitions into Lindsay’s nail and communicates underlying kidney dysfunction. Should that half-moon crescent change to a blue tinge or even completely change to blue, the patient may be being slowly poisoned by silver or copper. The pale nail bed alone is a tip-off for anemia. A murky longitudinal dark stain, like a comet and its tail tracing from the cuticle to the free nail edge, can be the forewarning of a melanoma. Smaller dark stripes distributed throughout the nail are the potential signs of endocarditis, lupus or vasculitis. Should the patients’ nails look like a pock-marked battlefield, the likelihood of psoriasis as a verdict is greater, especially if they are accompanied by joint aches or a reddish-silver raised skin rash. If the same patient did not choose to paint their nails yellow, and it spontaneously occurred, my pondering moves to lung pathology or autoimmune issues. Lastly, horizontal linear grooves on the nail, named after our friend Joseph Beau, tells me the patient is zinc deficient or enduring chemotherapy. While AI can certainly catalogue each of these physical exam signs and what they indicate, my examination can transpire on a soccer field, train or exam room and without the need for a computer.

Ascending from the fingertips, I look at the profile of the fingers. Do they keep their standard characteristic orientation, straight as an arrow or do they angle? Simply the direction of that angle can tell me so much, as the rearrangement of the interphalangeal joints offers countless clues. Should the patient get angry at all the meddling with his finger and point that finger at me, does his finger hyperextend backwards from the middle joint while the fingertip itself bends forward? Quickly I am carried pondside to see the swan neck of rheumatoid arthritis, lupus or scleroderma. However, should that fingertip hyperextend while the middle joint flexes, this represents the boutonniere deformity of injury or other connective tissue disorders. Moving from the quaint pondside to the opera house, I consider the shortened collapsing finger joints crumpling in a telescoping manner like an erstwhile opera-glass. This is the finger joint destruction of arthritis mutilans or advanced psoriatic arthritis. Now envision that same finger, fat and round like a sausage, and you have the less than delectable exemplar of dactylitis, which may be another sequelae of psoriatic arthritis, lupus or even tuberculosis.

Lest we forget the palm, it can serve as a mirror into superficial and deeper matters both physically and professionally. If there are a collection of cords slowly stealing a digit’s extension, you’ll find the fascial condensations of Dupuytren’s contracture. This patient has either had a long career of intense work with their hands or has been long afflicted with diabetes or may just have one more thing to thank a parent for. Should one of the fingers flex and become locked, trigger finger is now the diagnosis, although no marksmanship is required.

Both AI and I could go on for pages with the exam findings of the hand if necessary, particularly if we wanted to discuss congenital hand deformities or telltale characteristic findings on x-rays such as the appropriately named boxer’s fracture or the hand surgeon’s bane of the scaphoid given its peculiar blood supply. Oh, the many amusing mnemonics to remember the bones of the wrist can be quickly recited, both from AI and by the medical student! Ultimately, the power of observation is vital and a trusted companion of the doctor alone. The world is the clinician’s exam room and once one puts on these glasses and truly observes, it is hard to unsee the pathology vexing us humans. So, I say go forth and learn. Always start with a handshake as this key unlocks so much during the visit and then sit and watch. We physicians are a fortunate few beholden in full to our patients, who are granted access to this vast vocational milieu and this is what sets us apart from machines.

Web image by Medhum.org

Shame is the capacity to suffer under the gaze of the other. The other can be anyone, even oneself; we’re perfectly able to feel wounded by our own perceptions. There’s also a certain pride in shame—as proof of moral rectitude, of earnestness, or of competence. A patient learns that he will eventually go blind; it takes a year for him to confess this news to his family. He feels ashamed, and at the same time, he feels proud to suffer in silence. Shared emotion brings relief to the afflicted, yet it propagates his suffering; and by what right do I pass on my pain to my loved ones?

I think about this on a park bench, with a bottle of pineapple juice on one hand and no intention of calling my family. Not wanting to propagate my suffering is an excuse; if I die, my family’s pain will be far greater.

It’s the loser’s shame, then. If I pass out, I lose. Who am I if I can’t keep my blood sugar under control? You shouldn’t have eaten that bowl of ramen. It’s your responsibility. There’s this dog lying on a patch of grass in front of me, and he’s still yawning, and I desperately want to pet it. I want to tend to a garden. I haven’t been able to get out of the city yet; I’d love to go for a hike, to lose myself on some trail, to be part of a nature-driven epiphany that makes me understand how the world works and calms me down and makes me accepting of my illness, turns me into a placid, kind-eyed monk.

But I’m sitting on this bench and I can’t feel my legs, I’m sweating and panting and I can barely see. How am I supposed to play cool independent adventurer in the woods? I hear there are bears. I picture a bear yawning, and I hoist my two-liter bottle of juice to take another swig.

An illness is also a healing balm, an unguent—especially if it is socially accepted. It serves as fertile ground; it mothers your identity; it bears fruit and takes root. One benefits immensely from one’s illness; indeed, some are so eager to have one that they craft their own. They build slowly, with care. They decorate. They perform. To be ill is to be a victim, and that notion proves delightfully relaxing. Guilt is drawn out of you and replaced by a certain calmness that feels as protective as it feels alienating.

My diabetes is my greatest, most beloved excuse. It never fails. My diabetes removes me from the equation, cancels me out. My diabetes drops me inside a limbo, a liminal space. Why do I call it mine? It punishes and rewards me. It’s my biggest bet against shame; whenever the dreaded feeling bubbles up, I can use my glucose levels to run and hide, to defend myself, to set up a smokescreen.

It’s part of the intricate fabric of my body-mind, perhaps even of my soul. Yet there was a time, nebulous and distant, when I was not diabetic. I barely remember it. Was that truly me back then? Have I been two different people? I’d feel naked without my glucose monitor and my insulin pump. Every shift within my mind, every movement of my body, every lighting up of every neuron affects my illness, and my illness, in turn, influences every cell that thinks and feels. I cannot exist separately from my hypoglycemia.

Even worse so: will I ever be able to exist without shame? Shame precedes even my autoimmunity; shame has always been there. If everything’s interconnected, then I’m forced to admit that shame played a defining role in the development of my illness. It’s also playing a role in my losing consciousness; it gives and takes away.

I drink and stare at the dog. I think I’d like him to be the last thing I see. It’s a good final image. But then… what if I’m exaggerating? Maybe this is nothing and I’m making a complete fool of myself for believing I’m about to drop dead and miss out on all the beauty of life—oh, the tragedy!—and maybe this yawning dog is just a dog and not my last impression of the world and the epitome of tender simplicity.

Those who are ashamed are very good at being victims, but they will also try their best to be caregivers. Helping another wounded soul proves I’m not quite so miserable myself. Service to others is a weapon I can wield; to fight against the meaninglessness of my existence and to show I have a right to be here. My diabetes grants me the people’s pity, and unlocks a new perspective, that of the chronically ill: a vantage point to which the majority have no access. Illness touches us all, just as life does; yet autoimmunity and degenerative ailments, inevitable and relentless, are not, fortunately, a shared experience for our species. This means that there are certain things, certain feelings or ways of coping, that only us, the permanently sick, can understand. Cold comfort, I know. But to carry the bodily wisdom of a chronic ailment, to feel it, deeply and daily, carving and scarring, should also make me capable of great empathy, of great compassion.

It does not. I’d be a wonderful caregiver if I wasn’t wholly corrupted by the urge, the desperate desire to exist solely within the gaze of others. The image in their minds is more powerful than the present moment in which I live, and stronger than the reality I could build for myself. Shame is the guiding factor in all this; it turns real people into members of an audience, and one cannot fail in front of an audience. One cannot show oneself, one needs to win approval. To really care for someone includes, necessarily, that you be vulnerable and open, genuine and honest. If what I want is for others to perceive me as a caregiver, then I’ll never actually become one.

Once again, the problem lies in my inability to step outside myself.

Web image by Riley Revell 

Narrative

Isles

José Luis Marín Aznárez 05.11.26

Illness, emotion, story, and the interconnectedness of it all; a meditation on a park bench, on the verge of death

Two hidden stories by two famed authors written decades apart in two countries eventually became widely known. One, Anton Chekhov’s, At the Pharmacy, was translated into English in 1998, about one-hundred years after it was published in Russia. The other, Raymond Chandler’s, It’s Alright–He Only Died, was unearthed from its unpublished state by Strand Magazine in 2018, about sixty years after it was written. Though written in different times, and using different scenarios, both stories warn of the barrier money creates to urgent and necessary health care, and of the corrosion in professionalism it causes in providers. They tell of what was to become a defeating feature of Western health care because of financial incentives, social prejudices, and human folly.

Six Kopecks or Your Life

Peter Constantine reached back from the 1990s into the 1880s to assemble a translated anthology of some Chekhov short stories not available to English-speaking audiences. Among the chosen stories in The Undiscovered Chekhov: Thirty-Eight New Stories, is At the Pharmacy.

The story begins when Egor Alexeyitch Svoykin becomes sick. His physician prescribes medicine that a pharmacy would need to prepare. Svoykin felt some relief being in a large Russian city during the late nineteenth century that would have pharmacies he could count on. This feeling of relief dissipated just after entering the pharmacy and coming before the imperious pharmacist there. 

The pharmacist eventually raises his head from a newspaper, looks at the prescription, shouts instructions to his assistants, and then returns his gaze to the newspaper while at the same time informing Svoykin the prescription will be ready in an hour. Svoykin is the only person waiting at such a late hour as it was, and he was deteriorating.

His mouth was on fire; there was a drawn-out pain in his arms and legs; foggy images tumbled about like clouds and shrouded human figures in his heavy head. He looked as if through a veil at the pharmacist, the shelves of jars, the gas burners, and the cabinets. The monotonous pounding in the marble mortar, and the slow ticking of the clock seemed to him to be coming not from the outside but from inside his head. (p. 129)

When Svoykin reports to the pharmacist that he is becoming feverish and feeling weaker, “the pharmacist “remained stock-still and, leaning his head farther back, kept on reading his newspaper. He didn’t respond to Svoykin with word or movement—it was if he hadn’t heard him.” (p. 130) When Svoykin subsequently approaches the pharmacist pleading with him to hurry the prescription, the pharmacist again brushes him off saying, “It’ll be ready soon enough…excuse me, but there’s no leaning on the counter.” (p. 131)

The next half hour was “unbearable” before the prescription came and then made more so by the dubious rituals the pharmacist performed in adorning the prescription container. The pharmacist charged one ruble and six kopecks, but Svoykin was short the six kopecks. 

Under the circumstances…I would be grateful if you would let me bring you, or maybe send you, the six kopecks tomorrow…

I’m sorry, we don’t accept credit here.

What am I supposed to do?

Go home, get the six kopecks, and then you can have your medicine.

But…I’m having difficulty walking, and I don’t have anyone I can send…

That’s your problem.

pp. 132-133

Svoykin returned home, though with difficulty. The Kopecks were there on the table, but his illness kept him from returning to the pharmacy.

Just Drunk

Strand Magazine is a source for “unpublished works by literary masters.” The October-February (2017-2018) issue includes an unpublished Raymond Chandler short story. Chandler wrote crime fiction for the most part, and the stories usually involved the fictional detective, Phillip Marlowe. This story, however, written between 1956 and 1958, is about a person brought to a hospital emergency room and denied service for financial and social reasons.

As the story opens, a man who has been hit by a truck is brought into the emergency department at General Hospital. He arrives just before shift change and so the admitting clerk is already annoyed about having to assess him. The clerk checks the patient’s pockets for the required $50 deposit and finds nothing, so she could now send the patient to the county hospital, and that would be that. But, before she initiates the transfer, she asks a passing private attending physician to look at the patient. He sees that the patient is dirty, smells of alcohol, and would cost a lot to work up. Mindful of an admonition from a major donor that the “hospital is not run for charity,” the physician surmises the patient is “just drunk,” and agrees the patient should be moved to the county hospital. Off the patient goes.   

The next day, the same admitting clerk at General Hospital gets a call from the county hospital. She’s informed that the patient they transferred had a head injury requiring surgery, and that the patient had $4,000 in a money belt inside his undershirt. The patient couldn’t be saved, however, because of the delay involved in the transfer to the county hospital. “It’s all right—he only died.”

Fast Forward

If they could have foreseen the current time when they wrote these stories, 140 years ago for Chekhov and 70 years ago for Chandler, they would have realized that the scenarios they created became commonplace and institutionalized in many ways.

Pharmacists may not go unseen behind a newspaper as Chekhov’s pharmacist did, but they may be buried under insurance company paperwork or piles of prescriptions needing to be filled. And certainly in a few situations, perhaps only independents, do pharmacists have ways to cover costs when patients are short on cash, credit, or insurance coverage. They are very likely to send patients away to get money even when they are very sick.

Hospital personnel do not now actually reach into the pockets of unconscious patients to see if there’s enough cash for admission as Chandler conjures in his story, but he would see them still check for money in the form of insurance cards or proof of sufficient financial means. He would also see that the scenario he described in which patients without money get transferred to county hospitals had progressed to a degree that people are moved around among different health care providers based on health care insurance plan coverage or lack thereof. But the poor treatment of patients in need of emergency care can even occur in the “right” hospitals when they are held for hours to days in hallways or holding wards for beds to become available.

Scenarios such as these can and have been addressed to varying degrees through government welfare programs, regulatory requirements, technology advances, and professional practice standards among other responses. The two stories, though, also expose human folly not so amenable to these actions. What can be done about the pharmacist who won’t put the newspaper down to address the needs of a person seeking help for an acute illness? What can be done about the physician who after a cursory evaluation brushes off an unconscious patient as “just drunk?”

Chandler makes an attempt at addressing the human folly he and Chekhov reveal by describing how it fails humanity on both professional and personal levels, and in shaming the character, who is ostensibly standing in for those behaving as this doctor in the story did.

All he had done was disgrace himself as a person, as a healer, as a saviour of life, as a man required by his profession never to turn aside from anyone his long–acquired skill might help or save…Why should a doctor in such circumstances be better than other men? The answer is simply, that if he isn’t, he is not a doctor. The $4,000 would have made quite a difference in this case, wouldn’t it?  Should it?  

Chekhov and Chandler are perhaps hoping that those in the care of others will exhibit more humane and professional behaviors when they ask themselves many decades later: “Am I a doctor?”“Am I a pharmacist?” “Am I a human being?” Would it make a difference? Should it?

Notes

Title image:
A young girl waiting for a pharmacist to make up a prescription.
Photogravure, 1912, after J. Jendrassik, 1896
Licensed under the Creative Commons Attribution 4.0 International

End image:
Nurse Aide Rocky FordHospital CO
Mennonite Church USA Archives, No restrictions, via Wikimedia Commons

Daudet tried all sorts of therapy, including mashed bulls’ testicles and elixir of guinea pig. Nothing worked, with the exception of large quantities of morphine and chloral hydrate, which made his life bearable. Daudet also coped with his intractable pain by writing about it. He planned to write a complete memoir of his life with pain, but by the time of his death in 1897, he hadn’t gotten farther than 60-odd pages of notes and reflections. About twenty-five years ago, the English author Julian Barnes translated and collected these fragments into a small jewel of a book called In the Land of Pain.¹

The title is illustrative. Those who suffer from chronic pain live in a different country from the healthy, and they gradually find themselves speaking a language that others don’t understand. At first, Daudet introduces details of his discomfort into conversation but soon realizes how repetitive and boring this is to his friends. “Pain is always new to the sufferer,” he writes, “but loses its originality for those around him. Everyone will get used to it, except me.” (p. 19) Daudet finds himself living in a land where suffering is pervasive, “Pain finds its way everywhere, into my vision, my feelings, my sense of judgment; it’s an infiltration.” (p.23) Toward the end he writes, “I’ve passed the stage where illness brings any advantage or helps you understand things; also, the stage where it sours your life, puts a harshness in your voice, makes every cogwheel shriek.” (p. 65)

Although Daudet was not known as a poet, many of these presumably random notes are, in fact, miniature poems. Consider this example: “In the dining room: the man who quite suddenly finds himself unable to read the menu. His wife bursts into tears and leaves the table…” (p. 63) And here is another: “The hotel. The bell-board. The bath times. / Solitude. / Encroaching darkness.” (p. 65)

One of the more depressing aspects of medicine today is the fact that many doctors are still “very poor at discerning things,” at least when it comes to pain. I get a knot in the pit of my stomach whenever I hear a resident discussing whether a patient’s pain is “real” or “imaginary,” or making a cynical comment about drug seeking behavior, especially when the resident herself has prescribed a grossly inadequate course of analgesia. Some of my colleagues believe that a person has to be visibly anguished before they take seriously his reported experience of severe pain. And others get exasperated with patients who describe having more pain than their condition (according to the doctor) warrants, and tell them, “You’re overreacting,” or “It’s all in your head.” When I hear this, I want to shake the physician by their shoulders and yell, “Of course it is! All pain, no matter what causes it, exists in the head. Where else could the experience be generated?”

In the Land of Pain illustrates that chronic pain sufferers can live calm, productive lives despite constant agony. Daudet continued writing, publishing, and socializing until the end of his life, even though he wrote, near the beginning of his journal, “My friends, the ship is sinking, I’m going down, holed below the water line.” (p.7) At the same time, the author’s strength, compassion, and humor illuminate his little book. He emerges as a generous person, who was well loved by his contemporaries. If you were his physician, what would your assessment be?

Would you accuse him of exaggerating his pain because he doesn’t appear desperate?

Daudet refers to his pain as an “unwanted guest,” to whom he intends to give “no special attention.” (p. 79) At another point he reflects on “the ingenious efforts a disease makes in order to survive.” (p. 26) The writer never questions his enemy’s ultimate victory, but neither does he turn in upon himself. He remains a source of joy to others, especially his family, as indicated in this note: “I only know one thing, and that is to shout to my children, ‘Long live life!’ But it’s hard to do so while I am ripped apart by pain.” (p.49)

Chronic pain remains challenging for doctors to treat. One set of barriers are the moral and legal concerns about overuse of opioid analgesics. Questions about the threat of addiction, or the possibility of being manipulated, favor resisting the patient’s suffering, rather than responding with compassion. Many are uncertain about how to proceed because they lack knowledge of treatment protocols that include nonpharmacologic modalities, or referral to pain control clinics for invasive procedures. Alphonse Daudet’s little book invites us to imagine ourselves living, at least for a little while, in the land of pain.

1. Daudet A. In the Land of Pain. Edited and translated by Julian Barnes. New York, Alfred K. Knopf, 2002. (page numbers indicated in the text).

Photo of Alphonse Daudet from Wikicommons.

Back when I was doing my internship at Pennsylvania Hospital, I was so surrounded by history I felt like I was working in a museum. Even the china we dined on in the hospital cafeteria sported the original historic pattern. And when we finished our training, a brass plaque with our names went up on the same wall as the plaques of our predecessors going back to the 18th century.

At the time, none of this was widely known. But fortunately, Pennsylvania Hospital now has an actual museum, open to the public just in time for the nation’s 250th anniversary. The Pennsylvania Hospital Museum is compact yet chock-full of art, architecture, artifacts, and documents, and has at once become a must-see destination in Philadelphia.

Although Bellevue Hospital has roots that go back to 1736, it started out as an almshouse. Pennsylvania Hospital was the first institution in the colonies founded specifically as a hospital, established in 1751 by Benjamin Franklin and Thomas Bond. The 1756 building housing the museum is a National Historic Landmark. Not only is it considered an important example of Georgian architecture, but its cornerstone even bears an inscription by Franklin referring to King George II.

The landscaped grounds are a serene oasis in the middle of Philadelphia’s Society Hill neighborhood and include a Physic Garden containing herbs and plants used for medicines in the 18th century.

As one enters the building, the first room encountered is the pharmacy, which remained in use until 1927 and now contains interactive displays. A fire engine purchased in 1803 sits in the foyer at the base of a grand staircase. After ascending to the second floor, visitors enter America’s first medical library, a handsome wood-paneled room containing more than 13,000 volumes from floor to ceiling, including one of the nation’s most complete collections of medical books published between 1750 and 1850.

The third floor houses the nation’s oldest surgical amphitheater. In the era before electricity, it was illuminated by skylight, so surgeries could only be performed on sunny days. (I must confess that we interns used to sneak into this room when on call. It was spooky in the middle of the night!)

For me, as a psychiatrist, the highlights of the museum were the exhibits on mental health. I have previously written in MedHum about Benjamin Rush, often called the father of American psychiatry, whose portrait is on view here. Rush served on the staff at Pennsylvania Hospital from 1783 until 1813 and was known for his groundbreaking and humane treatment of the mentally ill. Metal shackles once used as restraints are also on display, although hopefully they predated Rush’s tenure.

Another psychiatric pioneer whose portrait hangs in the museum is Thomas Story Kirkbride, who came to Pennsylvania Hospital for residency training in 1834. When the psychiatric wards exceeded capacity and a satellite facility was built on 101 acres in West Philadelphia, Kirkbride was named superintendent. His ideas about the layout and design of mental institutions became highly influential, leaving an imprint on hospitals throughout the country.

Initially called the Pennsylvania Asylum for the Insane, the new campus eventually became known as the Institute of Pennsylvania Hospital. I completed my residency training there, but over time it was no longer financially viable, and it closed in 1997.

How fascinating to learn that Francis Scott Key, of “The Star-Spangled Banner” fame, wrote a poem titled On Visiting the Pennsylvania Hospital. And to see 18th-century anatomical casts used for teaching at a time when formal dissection was illegal.

There is so much history in this museum that I could not absorb it all in one visit. With its addition, Philadelphia further demonstrates its role as the cradle of American medicine. Indeed, one would have to travel to London to find a larger assemblage of medical historical sites.

In one very busy day—or a more leisurely two-day trip—a visitor can now experience this museum, plus the College of Physicians of Philadelphia and its famous Mütter Museum, while also stopping to see The Gross Clinic by Thomas Eakins. (The painting alternates between the Philadelphia Museum of Art and the Pennsylvania Academy of the Fine Arts, but will spend 2026 at the latter.)

Bravo, Philadelphia!

Benjamin Rush:  Reflections from a Psychiatrist 

Guy Glass 09.02.24 0

A founding figure in American psychiatry, known for pioneering reforms, but also controversial for his treatments and complex contradictions in beliefs and practices.

For more information about the museum, visit Pennsylvania Hospital Museum.
Web image from Wiki Commons

Hypoglycemia can kill you fast. The brain, our most self-centered organ, is also the greatest consumer of glucose. If blood sugar levels drop, it starts to shut down the rest of the body, in a desperate attempt to save fuel —it will drink every last drop of sweet sustenance before collapsing.

That’s how it feels; like parts of me slowly go dark. If I collapse, right here, in the middle of this park, I won’t have had a chance to say goodbye.

It’s a beautiful day outside. Beneath the trees, the filtered light takes on a greenish hue. A dog yawns on a patch of grass in front of me. I’ve found a spot on the corner of a bench facing a fountain—I can barely see it though, given the sheer number of people coming and going, dodging one another and getting in the way. I rub my right hand against my thigh, starting from the knee, pressing down with my thumb. I look around and crane my neck, trying to scrunch it down over my shoulders like an accordion.

I need to drink this entire bottle of pineapple juice. I bought it at a street stall the moment my alarm went off. Something must have gone wrong—with my meal, with the heat, with my nerves, or with who knows what, but my blood sugar is draining away, slipping right out of my body. Within the nebula that is my mind, clusters of stars begin to vanish. Suddenly, in a corner, the light goes out. A void emerges in the upper-left quadrant; I lose an immense cloud of hydrogen, and, along with it, all sensation in my feet. Blinking becomes a conscious task that demands effort; I don’t want to make it, so I simply close my eyes as I drink. There dies a sun, leaving its entire solar system in complete darkness. My hand has already made a hundred trips up and down my thigh. It occurs to me that all this back-and-forth motion is burning glucose, but the movement helps keep my anxiety at bay. Fighting this panic is costing me the very sugar I don’t have; I am living proof (at least for now) that sometimes, resisting the inevitable only makes things worse. If you fall into quicksand, stay still.

Someone shouts, somebody laughs and claps; there’s people making music, but it’s all distorted, as if the hot air were making the sounds bubble. I hear the beep of my insulin pump. It hasn’t stopped vibrating; I pull it out from my pocket and imagine it’s screaming at me, threatening me. My sugar levels are very low, and they’re still plummeting. The app on my phone—connected to the glucose monitoring patch on my arm—picks it up, too: my screen turns crimson, filled with arrows pointing straight down. I don’t have much time.

At least I’m sitting down, though I doubt I could stand. I think about calling an ambulance, but I suspect that if I had to start speaking to explain the situation, my voice would sound like a soaking-wet mop dragging across a school hallway floor. Besides, wouldn’t it be better to call my mother? Or my father, or my siblings—or the girl I dated a couple of years ago? Because I’ve only ever managed to fall in love once, with her; what a waste it would be if I died here, alone in a park bench. I’d lose the chance to experience that feeling again.

I should tell my mother that I love her, but there’s a six-hour time difference between New York and Madrid, so she’ll be asleep; and honestly, I don’t think I have the time or energy left to unlock my phone and make the call. I ought to keep drinking. The more pineapple juice I gulp down, the higher my chances of survival. I’ve never really known exactly when a person loses consciousness and slips into a coma—I don’t know how close I am to that edge. I don’t know how far away those thresholds lie, or how quickly they’re being crossed. I want to call someone, or cry out for help, or at least make sure that someone sees me losing consciousness—if only so I can say that someone was there, that someone witnessed it. That they saw the sun go out.

I don’t do it. I move only my arm; I bring the juice to my lips. My fingers tingle. I tremble.
A blink of an eye lasts longer than before.

I stare at a shapeless, unfocused mass of people. There’s this phase in hypoglycemia in which I feel myself reverting to something animalistic, primitive, a beast between two palm fronds; I’m in awe of the certainty I feel that nothing matters except my own survival.

An example: I drag my body to the fridge, haul myself forward, shove everything into my mouth without thinking; juice and Coca-Cola drip down my chin; I mix bread and fruit and cheese and sauces and whatever else I find; I use my hands—tearing, shredding, and stuffing it all into my mouth—barely chewing, coughing and spitting, then swallowing again; my fingers slick with grease. A ravenous urge burns across my forehead, and I breathe with incredible depth, as if someone were pumping oxygen into me through a funnel embedded in my throat.

I remember having done that several times.

I exhale, emptying myself out, and sparks fly from between my teeth. I can’t see clearly. Things—people? —move before me, but they’re terribly blurred. It doesn’t matter; I’m the center of the universe. I’m like a child. I drink my juice.

The feeling of losing control is a curious one, for it seems to be well-organized. From the bottom up, my limbs go numb. Mental fog seeps in through my nose and settles in my glabella. It concentrates; crystallizes. My thoughts cease to be mine—though I wonder if they ever truly were—and questions of this sort—like the one about love—begin to bubble up. Flashes.

Suddenly, I find myself wondering if I have ever truly been rebellious. I don’t know. My mother used to say that as a baby, I never cried—that I was pure tenderness. The thought of dying fills me with distress, for tenderness makes everything interesting, and I long to hold a little girl in my arms—to know that she’s my daughter, to watch her cling to me, burying her fingernails into my skin, like tiny half grains of rice. I tell myself that this is my life’s dream and purpose; for a moment, it feels as though my body might finally be able to relax—but it doesn’t. There remains a starry corner of my mind that still clings to the juice, to the park, to the yawning dog, and to reality itself. I take another sip.

A sudden flash: a line from a John Ashbery poem that says the bedroom of the soul is our moment of attention. I force myself to pay it— I tell me that, in doing so, I’m bringing myself back to consciousness. A minute’s passed? Or is it already the next day? I can’t tell.

Tachycardia is the worst part, for it forces itself upon me. It tramples my chest, imposing a rhythm of time from which there’s no escape. The only thing I can feel is my heart.

A hundred beats.
Hundred and twenty.
Hundred and forty.

Panic and tachycardia are close allies —and panic is a diabetic’s sworn enemy. It wants to trick me, it whispers, tells me everyone’s watching me, says all can hear the frantic hammering in my chest. Random clusters of thought dissolve, giving way to a single, definitive question. It is here that my illness bifurcates, and I ask myself (as I’ve been doing for years): which comes first, diabetes or shame?

I don’t dial 911, I don’t call my family, and I don’t ask for help, because I am ashamed. Right now, on the verge of losing consciousness, nothing should matter except staying alive. I ought to scream, to make a scene; for if I simply let myself fade away while sitting on a bench in the middle of Washington Square Park, no one is going to stop and help me. New Yorkers are more than used to seeing people sprawled on the ground, asleep on benches, or passed out in the subway; they won’t be the least bit fazed to stumble upon a twenty-something year old with his head lolling and his eyes closed, sitting upright, back straight, clothes clean, beard neatly trimmed. I need to grab their attention—my life’s slipping away, my blood feels as if it’s being pulled downward—I have to do something, right here, right now, but I can’t.

Asking for help means intruding on another person; it means meeting their gaze, making demands, stepping out into the spotlight to take a bow before the entire audience. It is here, in this theater of interaction, where human beings are made and molded. In my case, the guiding emotion is shame. The gaze of the other is the place where we all live and die. What is it, then? What’s about to kill me? Hypoglycemia, or my own inability to step outside myself?

Web image from Wiki Commons.