DAVID HSU: What do you think is the importance of medical humanities to you at this point? 

JACKIE DUFFIN: I think it is a very satisfying way of filling in the gaps that are generated by traditional medical training and medical experience. It invites reflection, and it invites growth, and it especially encourages criticism. And those things were certainly not there in my training. Therefore, it is comforting and inspiring, both of those things for me.  

When you say it that way, there’s a certain subversive quality to medical humanities. Am I catching your answer right?  

Yes, I guess that is exactly right. Subversiveness goes with the territory of what we do as historians as well. Everyone thinks that history is about the past, but the questions that we ask of the past are generated by the present and also the inherited wisdom that we have. And there has to be curiosity and a willingness to admit that the trajectory might not have been as straightforward as is sometimes pretended.  

How do you respond to the saying that basically history is written by the victors? 

That statement is also a reminder that what might be out there as the master narrative isn’t exactly the truth or isn’t exactly the whole story. And the losers will have their own story. And sometimes that’s worth exploring. Of course, my view of medical humanities is very much affected by the fact that I am a historian. And more than any other aspect of medical humanities … that’s what interests me the most. In fact, I don’t mind admitting that the medical humanities boom that we’ve witnessed in the last decade and a half or so has been a wonderful vehicle for enhancing the presence of history in medical schools​,​ and our visibility. I’m happy to hitch my wagon to it, but I don’t claim any expertise in all the other disciplines that participate.  

One of the things I think is useful for history with respect to ​present and ​future doctors is how history is a mirror image of the clinical process and the scientific process. And that’s something that I raise​d​ with my students all the time when I was teaching, that you begin with a question. As medical practitioners, you ​also ​have a question​;​ ​i​t is the chief complaint of the patient. What is wrong with me? Why do I feel this way? And as a doctor, you consult the patient, you explore the history, you do the physical examination, and then you touch base with the clinical wisdom that’s available to you through ​the medical ​literature. And you come up with a diagnosis, which ​​determines the direction of action. As a historian, you have the question​:​ where did this come from? Or why do we do this? Or what happened then? And with your question, you interrogate the past, looking at all of what has already been published, which is the equivalent of the medical literature, but also looking at things that have been ignored, like the stories of the losers, for example. And you come up with an interpretation. And that is a direct parallel with the ​process of ​diagnosis. You can push this even further to make an analogy with a scientific experiment where you have the hypothesis, the method, et cetera, and you come up with a conclusion. I think that demonstrating history as a discipline to healthcare professionals opens up their imaginations to seeing the practice of what they do is something that’s malleable, that’s anchored in time, that’s affected by culture and society. So, my role in the medical school was to do that. It was a privileged position. But I had no idea how successful I ever was. I have a sneaky suspicion that a lot of my faculty colleagues and maybe a large number of the students just thought I was there for comic relief and entertaining stories to be told in the meantime. That’s okay. I accept that if that gave me permission to weasel my way into the curriculum or introduce new ideas. 

Tell me a little bit about this medical humanities boom over the last 15 years. What’s going on?  

As you know, medical schools are evaluated. They’re accredited by committees. And things come along that are the flavor of the month. ​P​rior to the medical humanities boom, there was an ethics boom. Many medical schools didn’t have ethics, but they looked around and they thought, oh, we better get ethics because everyone has ethics. If they got ethics, it made them look ethical. That happened in the 90s. I saw that as a real problem for people teaching history of medicine. I got along great with our ethicist at Queen’s. It wasn’t her fault, but she was my biggest enemy. Because if the school had to devote some time to what they called ​“​soft science,​”​ they would rather have the ethicist than the historian because the ethicist got them brownie points on the accreditation. ​​ 

​​T​here was a time when the American Association for the History of Medicine was meeting in Chicago in May 2014. And we happened to be meeting at the same time as the Academy for Professionalism in Healthcare. So the brass of the American Association asked to have a meeting with their leaders to find out how they managed to convince all the medical schools they needed ethics and in particular succeeded in having questions about ethics education in the exit surveys. They did not really understand our problem. I think ethics had the media going for it and the power of a number of ​high-profile​ malpractice cases that had come along. ​It​ became obvious that patients wanted to make sure their doctors were legal and ethical, and ​t​he schools wanted to give the students tools to address these concepts. It became almost urgent. 

In fact, I did some Medline searches on this at the time. The number of articles addressing history of medicine basically tanked. And the number of articles addressing medical ethics soared. There was always an interest in medical ethics. It goes way back. Hippocrates even talks about this. And then there was codification in the 18th century. But what ​arose ​in the late 20th century was this concern that it should be transferred to the students as some kind of rubric that would help them in their future to ​educate them and help them ​behave ​ethically. ​And then that sort of plateaued and along came medical humanities. 

Accreditation saw ​​this as very good for student life. They saw it as very good for student education. If you could enhance the possibility of getting a positive accreditation of your medical school, then you would acknowledge that you should have something called medical humanities. But under that umbrella, there could be just about anything. And that’s the problem with it as a discipline. It doesn’t really have a single method. It embraces so many other sorts of​ fields​. That’s the beauty of it, but it’s also the confusion of it when it tries to make its way in a curriculum that is as rigid as a medical school structure. 

In Canada we now have a society for ​Medical Humanities, the Canadian Association for Health Humanities​. I’ve attended some of the meetings but the disappointing thing about it from my perspective is there’s almost never anything about history. 

I’m curious. If history is not emphasized as part of medical humanities what is? 

Presumably it’s ethics again and reactions to technology. I think ethics underpins a lot of it​,​ but medical ethics is a very distinct discipline​,​ as is history. We’re not the same thing. We respect each other but we’re very different. So medical humanities usually include, at the Canadian meetings at least, a lot of literature, of readings, both fiction and nonfiction. It includes the arts, music, poetry, visual imagery, trauma, drama, dance, etc. And often the papers in the meetings that I’ve attended are​ almost all​ about individual case studies​: ​e.g, “We tried this at our medical school​;​ and then we did an after​-​survey about whether it worked or not. Of course, our students loved it because it was fascinating​,​ and it wasn’t memorizing the elements in the periodic table. It was something that took them out of themselves.” Often medical students have other hobbies before they get to medical school, which are sadly neglected because there’s no time for anything else. And these activities provide an outlet for them to recover their previous selves and their identity.  

I think another agenda of ​Medical Humanities ​is to raise awareness of the differences between peoples — the difference between your patients, for example, and yourself, and to be prepared to tolerate it. So that’s a subliminal message of many of these things, causing you to see the world and other people in a different and more tolerant way. That’s basically what goes on in the medical humanities conferences. People get very excited about these opportunities, a drama presentation, a collect​ive​ reading, something that they might have done together, or artwork that medical students do based on their clinical learning and then having a show about it. That kind of thing gets reported. And then … it sort of sinks into an oblivion until the next meeting comes ​​​​along.  

So it sounds like the way you’re describing it, there’s a little bit of the study of history of medicine versus medical humanities. The two are not fully in sync in your mind.  

No, they’re not fully in sync in my mind, but I accept and welcome history being seen as part of ​ ​medical humanities. I think it’s an opportunity for us as historians to maintain our place and our credibility in medical schools.  

The presence of history in medical education has gone up and down over the centuries. There have been full-fledged chairs in History of Medicine. In a distant past, they went away​ and​ they came back. What is expected of it has probably also changed through time. But now, since it seems medical humanities is an easier way​ ​to open the door to medical schools, history can be part of it. I don’t know. It would be really interesting to find out if ethicists feel the same way as I do about it. I find that some medical humanities programs are peopled by or run by doctors who are so well-intentioned​–​ very, very well-intentioned​–​ but they really don’t have any expertise in anything but medicine. The best of them, obviously, are experienced clinicians who’ve had a lot of encounters and are thoughtful and reflective about those encounters. But there’s no method. It’s not a single discipline. It’s a quilt with a whole bunch of different patches in it.  

What do you think about medical humanities and maybe more specifically the history of medicine as a vehicle for the broader mass of people out there?  

I’ve written ​11 ​books and the most recent one to get published is this one. [She holds up a copy of ​Covid-19: A History​]. What I was doing was getting it down for everyone. It’s a history for everyone. It’s not aimed at medical students or doctors or anybody in particular. It’s aimed at Canadians basically, but it talks about the whole pandemic from a global perspective. What I want to do is remind people of the personal stories that go with the pandemic, about the dilemmas of decision-making and policy choices, about the scientific endeavors that are so easy to mock or make fun of. And ​clearly,​ I’m revealing my colors. I believe in vaccines. I believed in the public health measures. I point out in this book about the value of quarantine. When you don’t know what the pathogen is and you haven’t got a clue what the incubation time is because it’s a previously unknown pathogen, quarantine is not a stupid thing to do​,​ because you are waiting to find out how dangerous it ​might ​be and put some parameters around it. I think​–​ and again, I’m speaking only from a history perspective, not medical humanities in general​–​ I think it was important to unpack what was behind those decisions that many people got so angry about. And yet they were lifesaving decisions in many cases. Sometimes perhaps it was over the top, but it was because we didn’t know what we were confronting. 

During that book writing, I served as a volunteer contact tracer at the Kingston ​[Ontario] ​Public Health Unit. I had to phone up citizens all over our area and get them to quarantine because they’d been in contact with someone who had COVID. That was very eye-opening for me because I realized at what level you had to pitch why it was a good thing to do. And at the outset, when we didn’t know what the parameters were, we were telling people who’d been exposed to COVID to stay home for 14 days. Kingston was the only health unit to use volunteer contact tracers, but we worked really hard and Kingston had the best ​​outcomes of COVID cases in the country for a brief time. It didn’t last forever, but it was like a flagrant, on-the-spot demonstration of something that has been known for years, since at least 14^th-century plague.  

What do you make of that now that we’re in 2025 and people are so over this stuff now​,​ that​ ​there’s this feeling I get that people are saying we will never go into quarantine again? 

That’s why I wrote the book. Actually, I was invited to write it, and I had to think about whether I wanted to or not. One of the reasons I decided to write about it was that my thesis advisor, Mirko Grmek, wrote a history of AIDS right at the beginning of the pandemic. And I thought, well, I can’t write a history of COVID because it isn’t over and it may never be over. We may always have COVID. And then I remembered that Grmek had written that history of AIDS at the beginning of the AIDS epidemic. He set down where it came from. He studied the historical possibilities. He had the science too. I realized he was at the end of his life, and I’m at the end of my life. And I thought, OK, maybe this is what I need to do​,​ to accept the task of writing it as it is, right now. Now ​I’m very depressed​ by these negative attitudes. But I do hope that when the next pandemic comes-​-​and there will be another pandemic​,​ with a new pathogen that we haven’t seen before​,​ and there will be conspiracy theories about where it came from​–​ I hope that the public health agencies will remember that quarantine from 14^th-century plague worked really well​,​ and that’s what we need to do again if we don’t want to overwhelm our finite resources in hospitals and health care units to look after people. The more you implement those measures, the fewer people die. It makes a huge difference​,​ and you can actually see it. So the story is there. Whether or not it will be believed, whether or not the argument can convince the naysayers, I have no idea. All I did was set it down and hope.  

You have a historian hat, which is the critical, sometimes subversive side and then you also have the medical doctor establishment side, the scientific side. It gives you a unique lens to look at the COVID pandemic and the consequences that came afterwards.  

It’s been the story of my life. I worked in cancer care at the end of my career at Queen’s and patients would tell me really interesting things​.​ I loved talking to them and hearing what they thought about what was going on. And some of them held what I would think of as wacky ideas or they’d utter doctor​-​blaming ideas. Then the doctor in me would feel very defensive about their accusations of the mistakes or the neglect of my colleagues, even colleagues I’d never met. But when it comes to the history of medicine, I feel terribly responsible for the bad things that doctors may have done, even if it was not deliberate, but out of ignorance, because they didn’t know what was going to be discovered next​;​ or ​due to ​misplaced enthusiasm for something that turned out not to be as great as everybody thought it would be. And I’ve seen that with respect to certain drugs in my career. I’m old enough to remember thalidomide babies​;​ I was a child when that happened. But the impact of it was enormous​: ​what pills could do to us and how they might harm us. There’s a new biography out that I ​reviewed for ​Medhum of Francis Kelsey, the Canadian​-​born American health official who spared the United States from the damages of thalidomide. An amazing and courageous decision because there was great pressure on her to approve the drug and she didn’t. So we had the tragedy in Canada and they didn’t in the United States​,​ which was fascinating for me to learn at this stage of my life, because I remember being so horrified and ​thinking, ​how could doctors let us down? 

There are also other procedures that were once considered important to do that we have done away with, not because they shouldn’t ever have been used, but because something so much better came along. The most striking example of that that I remember are pneumoencephalograms. Pre-CT scans, if you thought there might be a space​-​occupying lesion in the brain, you put the patient under a sort of an anesthetic. You took out a modicum of CSF and injected the same volume of air. And then you strapped them to a chair and you ​​rotated them around, taking x-rays while the bubble of air moved all around the brain to see if there was a space​-​occupying lesion. It was brutal, painful, but it was the only way to find out if there was a space​-​occupying lesion in there. And of course, you could tell only if it was bulging on the surface of the brain. It took days for patients to recover with headache and vomiting. Every medical student in my class of​ ​1974 was required to go and witness one of these so that we would not order it frivolously. And in that same year, CAT scans were introduced and nobody would ever do a pneumoencephalogram again. Ever, ever, ever. But does that mean that all the doctors who were involved in ordering pneumoencephalograms or taking the x-rays were evildoers? I don’t think so. They were trying to help. They were trying to make a diagnosis. But it was excruciating.  

If you could fix medical education and its relationship to history, what would you want done?  

I’ve written about this for a long time. I was so lucky at Queen’s; I really was. They let me get away with a lot. From my hire in 1988 until I retired, I thought the best way to bring history into medical education was to infiltrate it. The historian has to be very tolerant and very flexible. But what you do is you introduce the history of whatever it is they’re studying at any given time. History of anatomy in anatomy if they’re doing the anatomy course. History of physiology in physiology. History of pathology (essentially is the history of disease) in pathology. The timing really is everything because it’s synergistic with what they’re learning at the same time.  

With that method, you are preceded by a guy in a white coat, and you’re followed by a guy in a white coat. It gives you credibility vicariously by the people who are around you. But it makes it seem relevant in a way that otherwise it ​wouldn’t be​. If you make ​it ​an optional, elective course, the students automatically know that it’s not important. So, I refused to teach electives when I got hired at Queens, which meant that I had to meet every department head to beg for time to do a history session. There were 25 departments at the time, and only three said yes. They were​–​ anatomy, pathology, and obstetrics; I’m forever grateful.  

Early on, faculty members of those departments would come to my inaugural class on the history of their discipline. I think they were slightly checking out how “nice” I would be to their field: the history of obstetrics, for example. But they approved the approach. The most willing departments were those units in the medical school with a lot of curriculum hours​,​ ​s​o they were able to feel generous. ​“​We will give her an hour.​”​ 

But one department head said to me, “I can’t do that. History, I love history. You’d be invited to give an ​after-dinner​ speech at our annual meeting. That would be really good. But we only have 80 hours in the curriculum. And if I gave you one of those hours, they might miss something important and kill somebody.”  

I said, “Oh, thank you​,​” ​a​nd I ​went​ back to my office feeling rejected. Only later did I think of the right reply, “If you don’t give me one of your 80 hours to make them skeptical about everything else you’re going to teach them in the other 79 hours, then they really might kill somebody.” That was the answer I should have said.  

It’s about the time constraint; you can’t offer an entire course. Medical students are not going to be historians. They’re going to be doctors. So what you want to do is sensitize them to the fact that what they see as knowledge now is something that has evolved through time, through human endeavor, something that is destined to change in the future. So history is a reminder of life-long learning. And if you time it right, then it is relevant and interesting. Not all students are going to like it, but they don’t all like pharmacology either. 

And the other thing that the medical school let me do, bless their hearts, is to grant my wish for one question on every exam.  

I remember this actually.  

It was a question of credibility; a way of forcing the medical school to commit to the idea that history was important.  

All right. To wrap up, we’ll get back to Medhum. what would you like to see us do in the months and years to come? 

I’m really a special interest voter on this because I was for 25 years involved with the Literature Arts and Medicine Database. And I contributed hundreds of annotations to that database​. ​I hope MedHum is a place where people who want to use literature–mostly literature is what I think of, but there​ are ​other things there, ​for example ​film​ reviews​–in a way that will deepen their understanding of a situation, or for enhancing education, or for whatever purpose, because that’s how the database was used, that it will be there, accessible to people who want those things.  

​​​​So for me, I get to go there when I feel like it. I get to browse. I get to pick around. I already knew some of the people and from our meetings, I’ve gotten to know new ones. I think you, people of your vintage​,​ should be deciding its purpose, in terms of determining the direction and the flavor of this entity, which hopefully will have a big reach and get to the people who need to see i​​t​. You​ ​​have a better sense. You’re closer to the users. I’m not trying to be gloomy about it. I just know that it’s entirely possible that it needs to go someplace that I can’t even imagine. 

Dr. Jacalyn Duffin was the Hannah Chair of the History of Medicine at Queen’s University from 1988 to 2017. She was also a practising hematologist. In 2020, she was awarded the Order of Canada. 

More importantly, she’s one of my favorite people in the world. Medical school wouldn’t have been the same without her gentle encouragement and unending enthusiasm. Dr. Duffin, thanks for everything. 

Web image by Medhum.org

Posts Written by Dr. Jacalyn Duffin

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Esther, daughter of a native healer who has some familiarity with and respect for Western medicine, envies and longs for Antonia’s Western training and attaches herself to her as a disciple. In her encounters with patients, Esther finds that she has an inexplicable gift for healing which baffles her as well as Antonia and complicates their already tenuous relationship. Esther’s gift forces Antonia to reexamine some of her most basic assumptions about what constitutes healing. 

The novel raises complex questions about the cultural, religious, and institutional contexts of medicine in a delicately drawn portrayal of relationships among characters whose divergent frames of reference complicate trust and understanding. One of the questions the novel addresses is not only how to heal the body, but how to heal the breach between cultures. In the development of the friendship between the American doctor and the African healer these questions are worked out in concrete particulars that fully honor both the pain and the hope involved in authentic cross-cultural dialogue. 

Antonia Saw the Oryx First
Maria Thomas 
Soho Press, New York 2007: 296 pages 

A previous version of this review was published in the NYU Literature, Arts, and Medicine Database.  
Web image by medhum.org.

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Hours later, after she has tried all the methods known to her, Agnes is asleep next to Judith’s pallet. Hamnet, overwrought that he is about to lose the “other side to him,” crawls from his pallet to Judith’s side, beginning to feel poorly also. He arranges himself next to Judith in a way that made it almost impossible for people to tell them apart, hoping as Death came to take her, it would be fooled into taking him instead. “And if either of them is to live, it must be her. He wills it. He grips it…He, Hamnet, decrees it. It shall be.” (p. 169) 

When Agnes awakens, she eventually discerns that “her daughter has been spared…but, in exchange, it seems that Hamnet may be taken.” (p. 208) She reinitiates the treatments she had tried on Judith, but nothing works. Hamnet takes his last breath. Agnes wonders how she could have saved him, how she could have missed Hamnet being at risk before she is able to comprehend: “he is dead, he is dead, he is dead.” (p. 219) 

From this event on, O’Farrell constructs the trajectory of the family’s grief with a particular focus on Agnes. Her grief is amplified by resentment and incredulousness over her husband’s return to London soon after the burial because he feared his work as an actor and playwright would lose irretrievable ground with a prolonged absence. These emotions and grievances reach a crescendo over a period of years before understandings are reached and catharsis experienced. 

The Plague Comes for the Twins 

Easily lost in the gripping story O’Farrell tells and the emotional torrents she evokes is the chapter explaining how the plague reached the twins. She takes the modern-day, biomedical understanding of the complex chain of events involved in the spread of plague and weaves it into how she imagines it could happen amidst everyday life in the countryside outside London during the 1590s.  

A basic biomedical reference O’Farrell could have consulted in piecing together a credible sequence of events leading to the twins’ infections would likely include the same details provided in a summary of plague spread published in the 2021 volume of the American Journal of Medicine*: 

An ancient disease, its bacterial agent (Yersinia pestis) is an aerobic, gram-negative coccobacillus in the family Enterobacteriaceae. Its primary vector for transmission is the Xenopsylla cheopis flea, although roughly 80 species of fleas can carry it. During the Black Death, the flea was transported by the black rat or Rattus. A controversial new theory argues that ectoparasites such as human fleas and lice also spread the disease during the second plague pandemic [1347-1665]. Fleas can also survive in infected clothing or grain. The bacteria multiply in infected rodents and block the fleas’ alimentary canal, causing the fleas to regurgitate the Y. pestis bacteria into its animal host…Plague transmission is generally from infected fleas by rodent vectors or, rarely, in clothing or grain but may also occur through ingesting contaminated animals, physical contact with infected victims, or direct inhalation of infectious respiratory droplets. 

O’Farrell could also find plenty of well-researched historical accounts of the plague impacts at the time and place she set the novel. The plague affecting Stratford then is thought to have first entered England in 1348 from ships docking in cities along the southwestern coastline. England struggled with it almost constantly for more than 300 years until it dissipated after 1665. From this biomedical and historical background, O’Farrell created a realistic framework for the story, and a reasonable representation of the all the factors needed for the infection to find the twins in 1596 Stratford.   

She starts her explanation of how the twins got infected by specifying that,  

two events need to occur in the lives of two separate people, and then these people need to meet. The first is a glassmaker on the island of Murano in the principality of Venice; the second is a cabin boy on a merchant ship sailing for Alexandria on an unseasonably warm morning with an easterly wind. (p. 140) 

The glassmaker is filling an order for decorative glass beads received from a dress shop in Stratford, England. But, because of a recent hand injury, a fellow worker is given the job of packing the order. This worker doesn’t know that the glassmaker “usually pads and packs the beads with wood shavings and sand to prevent breakage. He grabs instead a handful of rags from the glassworks floor and tucks them in and around the beads.” (pp. 140-141).  

Meanwhile, the merchant ship has docked in Alexandria, and the cabin boy has been sent ashore for provisions. He quickly encounters a man with a monkey, and the monkey quickly jumps on the cabin boy, and then all over the boy, passing along three infected fleas. One of them accompanies the boy back onboard ensconced “in the fold of the red cloth tied around the boy’s neck, given to him by his sweetheart at home.” (p. 144) The flea doesn’t stay there long. It jumps into the fur of one of the ship’s cats the boy picks up and nuzzles. Soon after the cat is sickened by its passenger and seeks comfort on the hammock of a midshipman, who upon approaching his hammock for a night’s sleep, finds a dead cat. The flea, now needing a new place to live “makes its way, by springing and leaping, to the fecund and damp armpit of the sleeping, snoring midshipman, there to gorge itself on rich, alcohol-laced sailor blood.” (p. 144) Three days later, the midshipman is dead. 

The ship arrives in Murano to pick up cargo including the glass beads. The cabin boy and the glassmaker come eye to eye as the glass beads are loaded onto the ship. And at that moment, the monkey flea, which had found a way back to the boy after time with some of the ship’s rats and its chef, leaped onto the glassmaker. He and many others in his factory subsequently succumb to “a mysterious and virulent fever.” (p. 149) 

In the hold of the ship now heading to England, the progeny of the monkey flea leap from dying rats to cats lying on top of the boxes filled with the glass beads until the cats die. The fleas eventually “crawl down into these boxes and take up residence in the rags padding the hundreds of tiny, multi-coloured millefiori beads (the same rags put there by the fellow worker of the master glassmaker…)”. (p. 148) The ship arrives in London and the boxes of glass beads are taken to a wharfhouse where they are stored for about a month before picked up for further transport. 

O’Farrell ends her tale of how the plague found the twins through the delivery of the box with infected fleas to their final destination. The box of beads “still wrapped in rags from the floor of the Venetian glassworks” is transported to an inn located near the northern reaches of London. (p. 149) Then, a messenger collects the box and takes them by horseback on a two-day journey to another inn near Stratford. O’Farrell adds how during this ride the mass of infectious plague vectors and organisms intensifies. 

The fleas in the rags crawl out, hungry and depleted by their hostless stay in the wharfhouse. Soon, however, they are recovered, rejuvenated, springing from horse to man and back again, then out on to the various people the rider encounters along the way…By the time the rider reaches Stratford, the fleas have laid eggs: in the seams of his doublet, in the mane of the horse, in the stitching of the saddle, in the filigree and weave of the lace, in the rags surrounding the beads. These eggs are the great-grandchildren of the monkey flea.  

The box with the beads and the fleas is now in the town where the twins live. An innkeeper there has it, and gives a boy a penny to deliver the box to the dress shop that ordered it many months before. The fleas have found Hamnet. 

Judith is at the dress shop helping out when the box is delivered.  

The seamstress holds aloft the box. ‘Look,’ she says to the girl, who is small for her age, and fair as an angel, with a nature to match. 
        The girl clasps her hands together. ‘The beads from Venice? Are they here?’ 
        The seamstress laughs. ‘I believe so.’ 
        ‘Can I look? Can I see? I cannot wait.’ 
The seamstress puts the box in her counter. ‘You may do more than that. You may be the one to open them. You’ll need to cut away all these nasty old rags. Take up the scissors there.’ 
 She hands the girl the box of millefiori beads and Judith takes it, her hands eager and quick, her face lit with a smile. (pp. 150-151) 

The fleas have found Judith. 

When Literary Narrative Serves as Biomedical Text 

O’Farrell’s narrative, fictional model of plague spread embedded in her story imagining what could have caused the death of an eleven-year-old boy in 1596 takes into account both the virulence of the infection and the many and varied ways it can spread. To make that point, she, much as would any epidemiologist, tells of others killed as the fleas made their way from Murano to Stratford, such as workers in the glassmaker’s factory, midshipmen on the boat, and various people encountering land-based messengers carrying the box of beads to those awaiting it. In that way, her model also explains how the mortality estimates of one-tenth to one-third of the populations from frequent plague visitations over three centuries could be generated. 

O’Farrell could have left this part out of the novel without losing much of the core storyline or emotion and drama of it. Indeed, the movie version gives it only a few seconds of attention showing the twins’ father walking by a street puppet show during a scene representing the spread of and death from plague delivered from a ship. By including the chapter, however, O’Farrell compounds the drama and emotion, and reveals the complexities involved in our fates.  

And, as I recall the drudgery of reading and mastering the intricacies of infectious disease spread and pathology such as those of bubonic plague, I wish I had O’Farrell’s novel Hamnet at the time. The experience would have been enjoyable and memorable where the experience with biomedical texts were not in either way. Perhaps this application was not in O’Farrell’s mind for the book, but it could go a long way in ridding us of the plague of turgid, mind-numbing, and indecipherable biomedical prose. Whether or not she knows it, O’Farrell has in this novel brought attention to a plague of another house.  

Hamnet
Maggie O’Farrell
Alfred A Knopf; 2020

*From: Glatter JA, Finkelman P. History of the Plague: An Ancient Pandemic for the Age of COVID-19.  American Journal of Medicine 2021; 134(2): 176–181. 

Image Credits

The path of infection of plague from rats via fleas to man, by A.L. Tarter from the Wellcome Collection. Attribution 4.0 International (CC BY 4.0). 
A rat on board a ship, carrying the plague further afield, by A.L. Tarter from the Wellcome Collection. Attribution 4.0 International (CC BY 4.0) 
The word plague hovers above a victim’s face, by A.L. Tarter from the Wellcome Collection. Attribution 4.0 International (CC BY 4.0) 

While only in nascent forms, organizing a method for understanding artificial intelligence (AI) as it’s currently structured for broad application is important but daunting. Shannon Vallor, a philosopher and ethicist, suggests using a mirror as a metaphor in her book, The AI Mirror. The book stems from her work as both an academic philosopher and as an AI ethicist at Google.  

Vallor describes her book as a “polemic,” and that it is when she says AI “in its dominant commercial form, endangers our humanity.” (p. 4) I’m leaving her polemics aside, mostly. My interest is her use of the mirror as a metaphor for AI, large language models (LLMs) in particular, and how she constructs the metaphor, some of the consequences of AI seen through her metaphor, and some suggestions she makes based on what the metaphor reveals about AI and ourselves.  

Reflections on the Mirror Metaphor  

The mirror as metaphor for AI came to Vallor based on its content source, that is, us: our words, our computations, our images, our sounds, and all the other digestible forms of our creations. What AI regurgitates from our prompts is based on an algorithmic mixing and matching of the collective creations it ingests.  

We often think of a “mirror image” as an exact replica of what faces it, and so the mirror metaphor for AI could convey that AI outputs are true and objective. To the contrary, Vallor hastens to caution, “mirrors do not merely reveal things as they are: mirrors also magnify, occlude, and distort what is captured in their frame. Their view is always both narrower and shallower than the realities they reflect.” Consequently, her metaphor is as much about what “AI mirrors do not show us: what they hide, what they diminish, what humane possibilities for self-engineering are lost in their bright surfaces.” (pp. 13-14)  

Throughout the book, Vallor emphasizes how nothing much of the human essence is to be found behind the AI mirrors, especially that which could contribute to AI analytical output.   

An AI mirror is not a mind. It is a mathematical tool for extracting statistical patterns from past human-generated data and projecting these patterns forward into optimized predictions, selections, classifications, and compositions…Minds depend upon the brain for their reality…[but] our mental lives are driven by other bodily systems as well: our motor nerves, the endocrine system, even our digestive system. (pp. 38-40)  

Vallor extends the metaphor when adding the myth of Narcissus. In the myth, Narcissus catches his image in a pool and becomes so enamored with its reflected beauty he can’t extricate himself before he wastes away into oblivion. Vallor worries that we risk the same fate when AI has us “fixated, confined, immobilized, held captive.” (p. 5) Vallor points to another character from this myth that makes it more poignant yet. Echo, a nymph, only parrots the last few words she’s heard. In applying Echo’s trait to AI, Vallor contrasts how Echo returns the words she has taken in while “a large language model returns to us not our own recent utterances, but a statistical variation on the collected, digitized words of untold millions.” (p. 34) This trait of large language models underlies some of the consequences the metaphor reveals. 

Truth of Consequences 

The metaphor helps us see that what we get from AI results is based on statistical probabilities of words occurring in a certain order without regard to how true any of it is. So, to Vallor, AI models are “like the human bullshitter. They aren’t designed to be accurate—they are designed to sound accurate.” (pp. 120-122) She does not use the term bullshit blithely. She refers to Harry Frankfurt’s treatise on the subject in which he distinguishes bullshit from lying by its indifference to the truth and its indiscriminate application. AI users often see this consequence in the form of the erroneous answers they get, which are referred to colloquially as “hallucinations;” Vallor calls them, “fabrications.” These consequences range from humorous and annoying to unproductive and deadly.  

As the AI source for content is mainly us, Vallor warns it’s not all of us who contribute content, but rather just a small subset of us, and certainly not a subset of us that is representative of the human race in all its variations. Referring to her metaphor, then, a mirror cannot reflect what it cannot see, which produces consequences around what we can expect from AI predictions. The complete reliance on what it has seen limits its predictions to what can be inferred from the historical data that exists and it can reach, “what humans valued enough to describe or record in data. But not all humans.” (p. 133) And, with no input from broad-based human experience, wisdom, imagination, and purpose, she wonders how we can have any “hope of making ourselves more than what we have already been.” (pp. 90-91) There’s nothing new under the mirror. 

The consequences of AI Vallor details that are polemical concern the commercial entities controlling what the mirror sees and what it shows. In particular, given the weakening of regulatory functions over the previous decades, she sees how “the rise of the behemoths of ‘Big Tech’” has transformed them “from intermediaries of social power to its primary executors.” (p. 175)  

All this to Vallor “is a calamity—a betrayal of life and its possibilities,” (p. 36) but she does not go so far as to say we’re doomed. She allows how huge benefits could accrue to societies and individuals if the AI mirrors become more reliable and objective sources of information, that is, amidst a pile of bullshit, the optimist in her is saying there must be a calf in it somewhere. She offers suggestions on how we unearth the calf. 

How to be the Fairest of them All 

Vallor’s suggestions for managing AI applications call upon the wherewithal of users for now—DIY quality control required. Many of her suggestions center on comprehending how AI output is constructed and accounting for the implications of that construction. 

When we do catch sight of our past in the AI mirror, it is essential that we do not mistake those patterns for destiny or allow them to become self-fulfilling prophecy…If we mindlessly replicate what we see in the mirror of history, we will never build upon that knowledge, never be free to try new and better approaches. (p. 101) 

She speaks of knowing “data provenance,” and of knowing when “algorithmic predictions and profiles are scientifically credible, ethically justifiable and politically accountable, and when they are not.” (p. 52) Although that may seem like asking a lot from even advanced AI users, we need to go through the same processes for our own analyses. And from these analyses, we also at times produce hallucinations, distortions, and slanted results. In this way to a degree, the AI mirror metaphor applies to humans. But we can incorporate aspirations, imagination, wisdom, and morals into our analyses. That differentiation is key to seeing how Vallor’s AI mirror metaphor situates AI as a “powerful amplifier of human ability,” not as a substitute for it. (p. 28) 

Vallor S. The AI Mirror. Oxford: Oxford University Press, 2024. 
Frankfurt H. On Bullshit. Princeton: Princeton University Press, 2005. 

Web image by Medhum.org.

Literature mirrors the general culture. There has been a recent explosion of books in which AI is the central plot device moving the narrative forward to endings that range from a utopian fulfillment of human destiny to the catastrophic collapse of civilization and the annihilation of humankind. But AI infiltrated the literary space several decades ago. Philip Dick imagined a world in Do Androids Dream of Electric Sheep? where cyborgs were being hunted down because of fear that they might take over the world. In 2001: A Space Odyssey by Arthur C. Clarke, a robot named Hal murders nearly all the crew of a spaceship on a planetary mission because of a programming error. 

Speak by Louisa Hall is more recent addition to the AI library. But it was published several years before large language models became a routine tool to plan a vacation or write a letter of recommendation. Is it still worth reading in 2025? 

The novel is a composite narrative centered around five interwoven stories spanning the time period from 1663 to 2040. In the first narrative, a young Puritan girl who finds herself in an unwanted marriage, records her thoughts in a diary that she is writing on a treacherous ocean voyage to America. Fast forward to the 20^th century and we meet Alan Turing who is writing letters to the mother of young man to whom he was emotionally attached and who died prematurely. He is troubled by his inability at times to communicate with people. A decade later we meet Karl and Ruth Dettman, a couple whose families escaped Nazi Germany but under vastly different circumstances. The husband, Karl, is a computer scientist who has developed a program named MARY to enable computers to interact with humans. Ruth, his wife, is a historian who has built a career centered on the publication of old diaries like the one written by the young woman traveling to America. She is trying to convince Karl to expand the memory of his computer program and enrich it with more human material, but Karl stubbornly refuses because he is concerned about the power of his program to overwhelm its users if its database is expanded. Finally, we jump ahead to 2040, and we read the transcripts of the trial of Stephen Chinn, a man who is being prosecuted for the production of robots that are too life-like. Chinn is being accused of causing physical and psychological harm to the people who have used his robots and of weakening normal relationships between people. A young adolescent named Gaby, who was given a doll powered by a version of MARY, is one of his alleged victims. His own personal recollections are folded into the trial proceedings, as he tries to describe his intentions, justify his actions, and make amends for where they may have gone awry. 

Taking stock of our world today, there is clear evidence that AI can improve the day-to-day lot of people, make life more convenient and efficient, and promote better health outcomes. However, much of the current angst that permeates discussions of AI is focused on the potential economic and sociopolitical consequences. There is fear that systematic adoption of AI will lead to widespread loss of jobs and financial distress for people left behind. The generation of false data and uncontrolled dissemination of unfiltered information may, it is feared, foster social unrest and destabilize democratic institutions.  

All of these predictions, for good or for bad, center on the word “intelligence.” If it is defined as the creative use of information towards a specific goal– my definition, to be sure — then it exists along a gradient and there is not an opposing term. In that case, the mixed picture about the future of AI seems accurate. Humans can process information to both noble and destructive ends. If machines are provided information by humans, then it is likely that there will be worthy and flawed outcomes. It is not a reflection of the logical structures or neural networks that are built into us as humans or artificially placed into machines. It simply is the nature of intelligence. Information is agnostic and it can be processed in a limitless number of ways; there is no guarantee of what will happen when it is processed. 

On the other hand, if we center our predictions on the word “artificial,” there is an opposing term, namely “genuine.” Speak looks beyond AI as intelligence and forces us to think about its impact on interpersonal communication and interactions. The design of the robots that are being created in fiction and in our world of 2025 is steadily improving. The voices become more lifelike, the reactions more emotionally appropriate, the reactions more convincing. They display keen intelligence and manifest seeming empathy with their handlers. Like the artificial friend in Klara and the Sun by Kazuo Ishigura, the robots may even appear to have more feelings and awareness of the ever-changing psychological state of their owners than family members and friends. But it will always remain artificial. Speak forces us to ponder whether interactions between human beings have an element that cannot be programmed, that is not simply manipulation of information. It is that piece that accounts for the genuine nature of relationships between people and it is that component that is vital for human growth and maturation. The interconnected stories in Speak raise the concern that reliance on AI, in whatever embodied form it takes, to provide support and companionship may inevitably fail and leave damaged humans in its mechanical wake. The intelligence of AI may not be sufficient for humans to thrive. It remains difficult to put into words exactly what to call this additional component of human interaction. Thankfully, there is literature, and creative novels like Speak, to help us grapple with what it might be and to help us steer a course where AI is developed thoughtfully with full awareness of its limitations and potential for good and harm. 

SPEAK  
Louisa Hall 
EccoPress, New York 2016, 356 pp 
Web image by Medhum.org

On the one hand, if the doctor is physically unable to treat, then he is not responsible for withholding treatment. On the other hand, by being rendered professionally helpless, perhaps he is being punished for not taking a moral stance against his patient. This interpretation seems to have validity because the last line recalls Psalm 137, which warns, “If I forget thee O Jerusalem, let my right hand forget her cunning.” 

For drawing attention to the biblical reference, I am grateful to Dr. Danielle Ofri (clinical professor) and Lara DeLong (Class of 2001), both at NYU School of Medicine. Dannie Abse (1923-2014) was a practicing physician and poet. 

Reading by Dannie Abse

Case History
‘Most Welshmen are worthless,
an inferior breed, doctor.’
He did not know I was Welsh.
Then he praised the architects
of the German death-camps–
did not know I was a Jew.
He called liberals, ‘White blacks’,
and continued to invent curses.

When I palpated his liver
I felt the soft liver of Goering;
when I lifted my stethoscope
I heard the heartbeats of Himmler;
when I read his encephalograph
I thought, ‘Sieg heil, mein Fuhrer.’

In the clinic’s dispensary
red berry of black bryony,
cowbane, deadly nightshade, deathcap.
Yet I prescribed for him
as if he were my brother.

Later that night I must have slept
on my arm: momentarily
my right hand lost its cunning.

Commentary

“Sometimes it’s very difficult to like some patients. Patients imagine that they’re always likable, but in fact there are some one has great difficulty with, I think. And indeed there was one patient that bugged me so sufficiently that I wrote two poems about him.”

A previous version of this review was published in the NYU Literature, Arts, and Medicine Database.
Web image created by Medhum.org

When he arrives, he finds that the hospital is an expropriated village church overrun by rats and ravaged by typhus, and he is the only physician. The hospital is run by a nun, Sister Margarete, assisted only by orderlies, and the patient load runs the gamut from fractures and gunshot wounds to gangrenous legs and massive head trauma. The front is only a few kilometers away, and the wounded arrive continuously; the quiet and formal Sister Margarete confidently and unobtrusively guides him through rounds, surgeries, and battlefield medicine. Lucius is initially wary of her, perhaps a bit awed by her, and ultimately falls in love with her.  

The transforming event is the arrival of the “winter soldier,” Jozsef Horvath, brought in from the snow mute and shell-shocked, but with no visible wounds. For Lucius, who is fascinated by diseases of the brain and mind, this patient presents a tremendous challenge. Lucius is sure that Horvath has “war neurosis,” what the British physicians of the time were calling shell shock and what we today would call PTSD, and he is determined to understand and heal him. Lucius and Margarete make slow progress with their patient, but his attempts to care for the patient have unintended effects, and Lucius must then deal with the consequences of his actions.

The war, and the hospital routine, go on. One day, while Lucius and Margarete are relaxing in the woods, Margarete runs off; Lucius returns to the village, but Margarete is not there. While Lucius and the staff search for her, Lucius gets lost; he stumbles onto a battlefield and is dragooned into service with a regiment of the Austrian infantry. He ultimately escapes and tries to make his way back to the field hospital, and to Margarete, but Lemnowice has fallen to the Russians. The hospital has been evacuated—and Margarete has disappeared.  Lucius’ search for her will take him across the war-torn remnant of the Empire.

The Winter Soldier is a war story, a doctor story, and a romance, and it also poses a wrenching question of medical ethics. This is a lot to ask of any novel, but Mason pulls it off with aplomb. The writing is lyrical; the author’s descriptions of the variation of the seasons in the Carpathian forests are poetic and beautifully detailed, and his characterizations are finely drawn. We can not only clearly see, but also feel that we know, these people, not only the major figures of the doctor and the nurse, but also the orderlies, the Austrian soldiers, Lucius’ somewhat bemused Professor Zimmer, and Lucius’ parents (who are marvels of characterization: the retired military officer father who lives on past glory and cannot see his son for who he is, and the controlling, clever, acid-tongued society grande dame mother who can only see her son for who she thinks he should be). Lucius and Margarete feel real, and their interaction feels real…and complicated. The historical setting comes alive with detail, and the reader truly feels that they are in that place at that time, whether at a formal dinner in a Viennese mansion or treating war casualties in a Galician backwater. And the medical details are correct, not just the medical terms but even the way in which they are used in dialogue, which is not surprising, as Mason is a physician; it isn’t always easy to get this right, but Mason does.  

But the true heart of the medical story here is the ethical quandary in which Lucius finds himself—the complex nature of the doctor-patient relationship, the motivations which drive it, and the decisions we make. Although this takes up a relatively short page count, its repercussions continue throughout the novel.

The novel has a particular, though minor, resonance for the time of COVID-19 (though it was released two years before the pandemic occurred). The action of the novel is set in motion when, due to a war-induced doctor shortage, medical schools decided to allow upper-level students like Lucius to graduate early and become doctors, and then immediately posted them, often with little practical experience, to field hospitals near the front lines.  Several American medical schools took a superficially similar action in Spring 2020 when doctors were desperately needed to help staff hospital units during the coronavirus pandemic, although this only applied to fourth-years who were but a few months short of graduation and would have already had the clinical experience which Lucius lacked. So while the situations aren’t entirely analogous, the concept of students opting into a trial by fire is.

The Winter Soldier can be appreciated for its historical perspective, its story of human relationships, the ethical dilemma it poses, and the beauty of its prose. Or enjoyed for what it is—a great read.

The Winter Soldier
Daniel Mason
New York, Little Brown & Co., 2018; 318 pp.

A previous version of this review was published in the NYU Literature, Arts, and Medicine Database.
Web image created by Medhum.org

The artist depicts Chekhov as he was in the early 1890’s, soon after he had purchased a small, dilapidated estate and moved there from Moscow with his family. In addition to serving as country doctor and public health official in Melikhovo, Chekhov at that time was composing many of the stories and plays that made him one of Russia’s most well-loved writers and a major influence on 20^th century literature. How was he able to pursue two such different and demanding careers? Several years earlier, at the height of Chekhov’s early literary success, his friend Alexi Suvorin had urged the young writer to give up medicine. Don’t spread yourself too thin, he said. You’ll never reach your potential unless you concentrate on writing. In response, Chekhov wrote, “You advise me not to chase after two hares at once and to forget about practicing medicine. Well, I don’t see what’s so impossible about chasing two hares at once… Medicine is my lawful wedded wife and literature my mistress. When one gets on my nerves, I spend the night with the other. This may be somewhat disorganized, but then again, it’s not boring, and anyway, neither loses anything by my duplicity.” (1) In this famous passage, the 28-year-old writer dances lightly over a fundamental truth of his life and identity. In fact, Chekhov’s career was not so much a matter of jumping from one bedroom to another, as was the case perhaps with the poets Wallace Stevens and T. S. Eliot, or the composer Charles Ives. Rather, Chekhov thrived on the effective, if not always seamless, integration of the arts of medicine and writing, which reinforced one another throughout his creative life. This essay explores that integration, and the manner in which Chekhov’s cold eye (objectivity) and warm heart (compassion) reveal themselves in his medical and literary lives. 

DOCTOR CHEKHOV  

“Medicine Is My Lawful Wife” 

When he graduated from the Moscow State University School of Medicine in June 1884, Chekhov was already earning his living as a professional writer. The grandson of serfs, Anton was the third of six children in a poor merchant family from Taganrog, a southern provincial town on the shore of Sea of Azov. His father had moved the family to Moscow after going bankrupt in 1877. By the time Anton entered medical school on a scholarship in 1879, the Chekhovs were living in squalor. His father had a dead-end job. His older brothers were alcoholics and generally unemployed. Anton soon discovered that he could ameliorate the situation by selling comic sketches to local magazines for eight kopecks per line. This was a type of moonlighting he loved. He wrote obsessively, often knocking off a story or two each night, after spending the day listening to lectures or working in the hospital. Chekhov ultimately published more than 200 pieces while a medical student, most of them under his preferred pseudonym, Antosha Chekhonte. 

Chekhov was a natural storyteller. Thus, it wasn’t surprising that the newly minted Doctor Chekhov continued to write, even after he opened his office and patients began to arrive. “Continued to write” is an understatement. Chekhov published 54 stories in 1885, 76 in 1886, and 57 in 1887. His work evolved from humorous sketches to longer, more serious stories for leading literary journals. In 1888 Chekhov won the prestigious Pushkin Prize and published “The Steppe,” his longest and most innovative story to date. Ivanov, his first full-length play, had a successful premiere in St. Petersburg in January 1889. By that time the young doctor had become one of the best known writers in Russia. 

Yet Chekhov always saw himself as a physician, even though in 1889 he did, in fact, retire from a normal paying practice; after that, he offered his medical services at no charge, even though the generous Chekhov often found himself financially strapped. He took care of the peasants near Melikhovo (as depicted in the painting), donated his services to the government as a district physician, and engaged regularly in public health initiatives. In less than five months in 1891, Chekhov reported seeing 453 patients at a district health center and making 576 house calls, in addition to his home practice. (2) Throughout his life, Chekhov also was heavily involved in grass roots activism, building schools for peasants, raising funds to help famine victims, and, later, near the end of his life, supporting the establishment of a sanitarium for tuberculosis victims at Yalta.  

“My Debt To Medicine” 

One of the best known of these public health efforts was his 1890 epidemiological survey of health and social conditions in the prison colonies on Sakhalin Island. Traveling by himself, Chekhov journeyed six weeks by train, steamboat, and horse-drawn carriage across Siberia to reach the 1000-km long Pacific island on which the Czarist government had recently established a notorious gulag. There, he embarked on a one-man, three-month survey of the population, tenaciously picking his way from settlement to settlement and from house to house, often by foot.  

Biographers have long tried to pinpoint his motivation for this perilous journey. During the year prior to the trip, Chekhov had undergone a crisis of confidence. In a letter to Suvorin, he opined, “I don’t love money enough for medicine, and I lack the necessary passion—and therefore talent—for literature. The fire in me burns with an even, lethargic flame; it never flares up or roars… I have very little passion. Add to that the following psychopathic trait: for two years now, seeing my works in print has for some reason given me no pleasure.” (3) He reported symptoms suggestive of clinical depression, perhaps precipitated by grief over the death of his brother Nicholas from tuberculosis. There was also a literary issue. The master of the short story had promised himself that he would create a Tolstoy-like novel that would confirm his status as a serious writer. But he was unable to do so.  

Undoubtedly a major factor for choosing Sakhalin was Chekhov’s desire to pay his debt to medicine. He had recently developed a scientific interest in penology and had read about the dismal conditions in the Siberian gulag. He saw an opportunity to influence this situation by obtaining accurate data on the health status of Sakhalin convicts. He had never completed the research thesis (the equivalent of a Ph.D.) that would make him eligible to be a medical specialist or professor. Hence, his notion of “my debt to medicine”—he would perform a survey, write his thesis, and become a teacher. 

Ultimately, Chekhov claimed to visit every settlement and survey every household on Sakhalin Island, using a 12-item data collection form. He said he completed over 10,000 of these forms in three months, a feat that (if true) qualifies Chekhov as the speediest shoe-leather epidemiologist of all time. After his return to European Russia, the author found it difficult to organize his data into a coherent study. While he had planned to write a strictly scientific monograph, his creative spirit struggled with the limitations of science. What about his personal experience? What about the interesting stories? After struggling for years, in 1895 Chekhov published The Island of Sakhalin, a curious (but engrossing) mixture of journal, geography, history, medicine, statistics, and travelogue. (4) Unfortunately, the faculty of the University of Moscow was unimpressed.  

“As I Grow Older, the Pulse of Life in Me Beats Faster” 

Picture the mature Chekhov—a middle-aged bachelor, longish face, rather neatly trimmed beard, a prince-nez clipped to the bridge of his nose. His household included his aging parents and his sister Masha, an unmarried schoolteacher who had become his confidant and secretary. His three surviving brothers looked to him for guidance and financial help. Anton was popular, witty, and generous. Among the guests at Melikhovo, there were frequently female admirers. Chekhov’s encounters with women were flirtatious and obviously enjoyable. He had teasing, sexually charged relationships with several women, but whether any of these liaisons are actually “affairs” is uncertain.  

The doctor in the painting already suffered from the tuberculosis from which he would die at the age of 44 years. In fact, he first coughed blood as a medical student. Yet, Chekhov dismissed that episode and each subsequent episode that occurred with disheartening regularity as “influenza” or “bronchitis,” steadfastly refusing to label himself consumptive. As a physician Chekhov must surely have understood the meaning of his symptoms. Was his denial simply a face to show others? Or was his denial so great that it made him unaware? The cat finally came out of the bag in early 1897. While dining at a restaurant in Moscow, Chekhov had a violent spell of hemoptysis that left him critically ill. For the first time, he sought medical treatment and entered the clinic run by Dr. Ostropov, one of his medical school professors. Chekhov’s chronic illness progressively worsened. At the insistence of his doctors, Chekhov left his beloved Melikhovo after 1898 and lived mostly at a new home in the sunny Black Sea resort of Yalta. 

It was also during these last years that the bachelor writer courted and married Olga Knipper, an actress with the Moscow Theater Arts Company. Even after their marriage in 1901, Olga remained at work in Moscow during much of the year, while the invalid Chekhov lived in Yalta, theirs being perhaps one of the earliest examples of the modern two-career commuter marriage. Chekhov found himself able to devote less and less of his waning energy to writing, especially since he refused to give up his social and philanthropic activities. Nonetheless, between 1898 and his death in 1904 Chekhov completed some of his greatest work, including several stories, two novellas (“Peasants” and “In the Ravine”), and his last plays, The Three Sisters (1900) and The Cherry Orchard (1903).  

COLD EYE, WARM HEART 

Chekhov’s Doctors 

Several characteristics of Chekhov’s work reveal the influence of medical training and practice. He used clinical knowledge to lend accuracy to his descriptions of disease and medical situations. This characteristic is perhaps most clearly seen in the characterization of mental disorders. For example, the title character in Ivanov is a subtle portrait of a man suffering from clinical depression, who eventually commits suicide. The young heiress in “A Doctor’s Visit” presents symptoms we would now label as generalized anxiety or panic disorder. The title character in Uncle Vanya appears to have a neurotic depression, a condition that meets today’s DSM 5 criteria for Persistent Depressive Disorder. In the peculiar story called “The Black Monk,” Chekhov describes a psychotic condition, presumably schizophrenia.  

Chekhov also drew from his medical experience in creating a multitude of physician characters. Doctors play significant roles in nearly 30 stories and in all of his major plays, except The Cherry Orchard. The author’s sensibility as a medical insider gives insight and poignancy to these characters, who range from committed altruists to lazy bureaucrats to burned out cases. Chekhov knew too much about the contemporary state of medical science to portray his doctors as curing many people. Thus, they often appear impotent. Yet, at their best Chekhov’s doctors convey the seamless fabric of tenderness (compassion) and steadiness (detachment) that lies at the heart of good medical practice. They also demonstrate courage, altruism, and self-effacement. For example, in “The Grasshopper” (1892) Dr. Dymov dies as a result of contracting diphtheria from a patient. Dr. Kirilov in “Enemies” (1887) demonstrates extraordinary devotion to duty by leaving his distraught wife and dead son in order to make an emergency house call.  

Perhaps Chekhov’s most textured portrait of a good physician appears in “A Doctor’s Visit” (1898). The protagonist, Korolyov, is a young doctor substituting for his boss, the professor of medicine. During the course of the story he moves from being a careful observer (detached concern) who ascertains that his young patient has nothing wrong but a “case of nerves,” to making an imaginative leap by which he connects more deeply with her. This empathic connection allows him to relieve some of her suffering by re-framing her illness. While he cannot solve her existential problems, his demonstration of solidarity leads her to trust him and to gain insight. Korolyov is like Chekhov himself. Dr. Pavel Archangelsky, who supervised Chekhov’s first job as a physician, captured the author’s ability to listen carefully when he later commented: “… he did everything with attention and a manifest love of what he was doing, especially toward the patients who passed through his hands. He listened quietly to them, never raising his voice, however tired he was and even if the patient was talking about things quite irrelevant to his illness.” (5)  

At the other end of the spectrum, some of Chekhov’s doctors are insensitive, incompetent, or impaired. Mayer, the callous medical student in “A Nervous Breakdown” (1889) is a disaster. Mayer can rattle off statistics on the number of whores in London and Moscow, but he is unable to “see” (empathize with) the suffering of the living-and-breathing whores he encounters. Shelestov in “Intrigues” (1883) and the public health doctor in “Darkness” (1887) are examples of self-centered physicians a little further along in their professional lives. The former is superficial and pompous; the latter is narrow-minded and detached.  

Chekhov’s most complete insensitive and acquisitive social climber is found in “Ionych” (1898). Dr. Startsev, when the reader first meets him, is a young physician setting up practice in a provincial town. After surviving an unrequited infatuation with the daughter of a wealthy townsman, Startsev devotes himself entirely to work. His practice prospers and he branches out into real estate. As he grows corpulent and wealthy, Startsev loses touch with his patients (and his own humanity): 

“Probably because his throat is covered with rolls of fat, his voice has changed; it has become thin and sharp. His temper has changed, too; he has become ill humored and irritable. When he sees his patients, he is usually out of temper; he impatiently taps the floor with his stick, and shouts in his disagreeable voice: ‘Be so good as to confine yourself to answering my questions! Don’t talk so much!’” (6) 

“Ionych” traces the progressive destruction of a medical practitioner who finds that medical affluence is more to his liking than the emotionally and physically difficult path of medical virtue.  

Some of Chekhov’s most interesting doctors are tortured by existential or spiritual conflict. Chekhov accurately depicted professional burnout, a syndrome characterized by depletion, detachment, depersonalization, denial, and depression. (7) Dr. Kirilov, who chooses to “go to the office” instead of mourning with his wife, may illustrate the relatively early phase of emotional detachment. Dr. Ovchinnikov in “An Awkward Business” (1888) demonstrates the more advanced symptom of depersonalization when he slugs his assistant in response to the man’s incompetence. The overworked Ovchinnikov reacts to his personal depletion by objectifying and dehumanizing his assistant, a response that compromises the medical care he is trying to protect. Chebutykin in The Three Sisters (1900) illustrates the extreme of alcoholism. Though still employed as a military physician, Chebutykin convincingly asserts that he has forgotten all the medicine he ever learned.   

Ragin in “Ward #6” (1892) and Nikolai Stepanovich in “A Dreary Story” (1889) are complex characters in whom depression and burnout are superimposed on a deep sense of existential failure. Like many of Chekhov’s characters, these physicians suffer from a lack of self-knowledge; they move through life relying on one form of self-deception or another. When they were younger, they committed themselves to noble ideals—Stepanovich to teaching and Ragin to practice in a provincial hospital. But in the long run they never “found” themselves. Professor Stepanovich yearns for a unifying moral principle that would knit together the fragments of his life. Dr. Ragin experiences his failure as emotional numbness. He yearns to suffer, assuming that if he experienced pain, he would be freed from his inability to feel. Thus, the academic physician pines for salvation in the cognitive sphere; the practitioner yearns for emotional redemption. In each case the focus remains inward, rather than turning outward to others, in whom salvation might actually be found.  

Medical Sensibility 

Medical attitudes and methodology play a larger role in Chekhov’s work than does medical knowledge. He believed that his duty as a writer was to present his observations clearly and accurately; in other words, to lay out the data in an objective fashion and allow readers to reach their own conclusions, rather than providing an author’s interpretation. He wrote, “The artist should not be a judge of his characters and what they say, but only an objective observer.” (8) 

This objective attitude put him in conflict with most other Russian writers of the time. It was a major source of conflict with Tolstoy, who was widely revered at the time as a living saint. The two men enjoyed a close personal bond but approached writing with radically different philosophies. After his mid-life religious conversion, Tolstoy viewed literature as a way to communicate his moral vision. He preached the gospel of a radical Christianity, in which all men work together to achieve economic and social equality. However, he rejected the concept of material progress and was particularly skeptical of medicine and doctors. Chekhov, on the other hand, strove to be objective, to present people as they are and the world as it is. His medical training taught him to be a careful observer; his medical attitude made him leery of judging others.  

Other Russian writers and intellectuals spoke out against the czarist government’s repressive social institutions. While this protest was disguised in various ways in order to satisfy the state censors, late 19^th century Russians (like their 20^th century counterparts) learned to speak and understand a subtle code of insurrection. The intellectuals addressed “big issues”—democracy, education, social revolution. They wrote articles, organized meetings, and gave speeches. Here again, Chekhov found himself on a different wavelength. He rarely engaged in theoretical discussion and did not advocate radical social change. Rather, he preferred a pragmatic, case-based approach. His goals were relatively limited, but achievable. Treat the sick patient. Document and publicize the abysmal condition of prisoners. Contain the cholera epidemic. Provide financial assistance to keep farmers afloat during the famine. Raise money for a new school. On and on, but always specific and personal.  

In “About Love” (1898), the narrator speculates on the essence of love. Are there universal characteristics that identify love wherever it occurs? “What seems to fit one instance doesn’t fit a dozen others,” the narrator concludes. “It’s best to interpret each instance separately in my view, without trying to generalize. We must isolate each individual case, as doctors say.” (9) Indeed, Chekhov’s stories and plays rigorously follow this dictum. While many of his Russian contemporaries used fiction to advance moral or social theories, Dr. Chekhov focused on the complexities of human interaction. In Chekhov’s world, biology and circumstance constrain freedom. People often do not listen. Acts performed with good intentions frequently result in hurtful outcomes. And yet occasionally and in unexpected places, one finds a glimmer of love, courage, spirituality, or healing. “Never generalize,” Chekhov tells his readers. “Never theorize. Pay attention to the particulars. Focus on the concrete.” In this respect, the 19^th century physician-storyteller presages the 20^th century physician-poet, William Carlos Williams, who coined the aphorism, “No ideas but in things.”  

In the long run, Chekhov’s objectivity and aversion to theory played a major role in the development of modern literature, as 20^th century writers followed Chekhov in attempting to describe the world of human character and relationship objectively, and allowing that world to speak for itself. To the extent that Chekhov’s “lawful wedded wife” contributed to his sensitivity, skills, and attitudes, perhaps medical education and practice played an unanticipated role in the history of literature, his delightful “mistress.” 

Adapted in part from Coulehan J. (Ed.) Chekhov’s Doctors, Kent State University Press,  2003

Sir Luke Fildes’ “The Doctor,” is in the Tate: File:The Doctor Luke Fildes crop.jpg – Wikimedia Commons 

Portrait of Chekhov: File: Chekhov 1898 by Osip Braz.jpg – Wikimedia Commons 

REFERENCES 
1, Chekhov A. The Selected Letters of Anton Chekhov, translated by Sidonie Lederer, New York, The Ecco Press, 1984, p.  
2, Coope J. Doctor Chekhov. A Study in Literature and Medicine, Chale, Isle of Wight, Cross Publishing, 1997, p.  
3, Chekhov A. The Selected Letters of Anton Chekhov, translated by Sidonie Lederer, New York, The Ecco Press, 1984, p. 81. 
4, Chekhov A. A Journey to Sakhalin, translated by Brian Reeve, Cambridge, Ian Faulkner Publishing, 1993.  
5, Coope J. Doctor Chekhov. A Study in Literature and Medicine, Chale, Isle of Wight, Cross Publishing, 1997, p. 27. 
6, Chekhov A. Ionych. In: The Tales of Chekhov. Volume 3, translated by Constance Garnett, New York, The Ecco Press, 1972, p. 91. 
7, Coulehan JL. Being a Physician. In: Mengel MB, Holleman WL (Eds.) Fundamentals of Clinical Practice. A Textbook on the Patient, Doctor, and Society, New York, Plenum Medical Books Company, 1997, pp. 73-101. 
8, Chekhov A. The Selected Letters of Anton Chekhov, translated by Sidonie Lederer, New York, The Ecco Press, 1984, p. 54. 
9, Chekhov A. About love. In: The Tales of Chekhov. Volume 5, translated by Constance Garnett, New York, The Ecco Press, 1972, p. 290.

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