The novel follows Martin Arrowsmith from a small Midwestern town to the upper reaches of American research science. As a boy in Elk Mills he reads anatomy in the town doctor’s office, and at the University of Winnemac he falls under the spell of Max Gottlieb, a German bacteriologist who teaches him to distrust easy answers and love the laboratory above the clinic. Martin’s career moves quickly from medical practice into research as a vaccine discovery vaults him from a small-town practice into a prestigious New York institute, and finally to a Caribbean island where bubonic plague is raging. There he faces an ethical conundrum: whether to withhold his unproven cure from half the population to prove it works, or whether to save as many as he can without conclusive evidence. When his wife Leora dies in the experiment, Arrowsmith throws caution to the wind and immunizes everyone, sacrificing his chance at greatness. In the aftermath, he walks away from money, marriage, and fame to chase pure science in a rural cabin, leaving the reader to decide whether he’s really a hero or just a reclusive crank. 

Lewis wasn’t the first American writer to champion medical science. Willa Cather and Oliver Wendell Holmes laid some of this ground first. But biographer Mark Schorer isn’t wrong in saying that “Martin Arrowsmith was a new hero, scientific idealism a new subject, and scientific individualism a new (and rather unscientific) perspective.” And Lewis was probably the first American writer to coauthor a major novel with a scientist, the bacteriologist Paul de Kruif. 

Arrowsmith won the Pulitzer in 1926 (though Lewis refused to accept the award), and the novel was a major factor in the Swedish Academy’s decision to award Lewis the Nobel Prize in 1930. It represents a hard-fought accord between science and art that has vanished from the literary scene today. But it’s hardly a one-note celebration of science. Lewis suggests that once scientific medicine withdraws from public view, the ominous tropes of the nineteenth century may creep back in. 

Like most of Lewis’s novels,  Arrowsmith is filled with overwritten scenes and dialogue riddled with slang. But I’d be curious, if I could teach it to medical students today, how much of themselves they might see in the character of Martin Arrowsmith, a boy from flyover country who nearly rose to medical immortality but crashed, Icarus-like, on his own hubris. 

A Novelist and a Whistle-Blower 

Lewis was immersed in medical culture throughout his young life as the son of a rural physician, but he was not a scientist himself, and never aspired to a career in medicine. His father, Edwin J. Lewis, began his medical training at Rush Medical College in 1875, graduating two years later as an M.D. and eventually opening a small practice in Sauk Centre, Minnesota, where he advertised himself as a physician and surgeon. Memories of his father provided a general basis for the opening scenes of Arrowsmith, set in rural Winnemac (or Minnesota), but Lewis needed to grasp both the passion and methodology of real scientists to create his medical hero. 

Lewis met his coauthor, Paul de Kruif, at a meeting arranged by his publishers. De Kruif held a Ph.D. in bacteriology from the University of Michigan. He had also worked as a researcher at the Rockefeller Institute in New York, but had been fired after the director discovered that de Kruif had published an anonymous exposé of the Institute’s financial corruption and premature publication of scientific results. He was an ideal partner for Lewis, whose satires of the American Midwest elevated skepticism to an ethical ideal. As E. L. Doctorow observes, “Expecting his countrymen to be more than they were, looking for a resonant truth and righteousness, Lewis had found an American spiritual life that could elicit from him nothing more than bitter derision.” Lewis and De Kruif counterbalanced one another professionally, one steeped in medical science, the other in literary art, but they were both truth-seekers, through and through. 

De Kruif was professionally destitute when he met Lewis, having recently lost his position at the Rockefeller Institute. He had seriously jeopardized his chances of finding work in his field, as university bacteriology departments and pharmaceutical companies balked at hiring known whistle-blowers. He needed Lewis and the stimulus of a major literary project as much as the author needed his expertise. 

Lewis gave De Kruif “assignments” during their travels, such as writing a fictional biography of Gottlieb, Arrowsmith’s mentor. The apprenticeship would later pay off for De Kruif, who became a bestselling author of scientific history just one year after the publication of Arrowsmith. His book The Microbe Hunters, which sold over one hundred thousand copies in 1926, alone, was one of the major nonfiction books of the decade. 

Indeed, De Kruif learned literary craft so well that it’s impossible to know who wrote certain passages in  Arrowsmith. Take, for instance, the scene where Martin realizes that he is about to make a potentially groundbreaking scientific discovery about the behavior of bubonic plague. Late at night, alone at the McGurk Institute (the fictionalized Rockefeller Institute), Arrowsmith simply can’t wait to process his lab results: 

At a hectic run, not stopping for lights, bumping corners and sliding on the too perfect tile floor, he skidded down the stairs and galloped through the corridors to his room. […] 

Then he forgot…war, night, weariness, success, everything, as he charged into preparations for an experiment, his first great experiment. He paced furiously, rather dizzy. He shook himself into calmness and settled down at a table, among rings and spirals of cigarette smoke, to list on small sheets of paper all the possible causes of suicide in the bacteria. 

Lewis and De Kruif collaborated so intimately that the scientist began to write like the novelist and the novelist began to think like the scientist. They should have shared the honors that followed, but Lewis insisted on crediting De Kruif more as a fact checker than as his equal. 

Cruelty or Cure? 

It’s hard to imagine language like this from a doctor now, but Martin Arrowsmith dedicates himself to the search for “the Why that made everything so.” Impatient with memorizing facts, he “wanted to look behind details and impressive-sounding lists of technical terms for the causes of things, for general rules which might reduce the chaos of dissimilar and contradictory symptoms to the orderliness of chemistry.” Arrowsmith believes in precise technique, but he’s also emotionally invested in the work, demonstrating an almost fanatical belief in the scientific method. 

His defining characteristic is his curiosity, which helps him crack riddles others see as mere aberrations. Lewis writes, to this effect: 

Now in Martin Arrowsmith there were no decorative heroisms, no genius for amours, no exotic wit, no edifyingly borne misfortunes. He presented neither picturesque elegance nor a moral message. He was full of hasty faults and of perverse honesty; a young man often unkindly, often impolite. But he had one gift: curiosity whereby he saw nothing as ordinary. 

When he sees something weird in his test tubes, he says, “Now there was some cause for that, and I’m going to find out what it was.” This is how Arrowsmith discovers the X Principle. He tells his wife Leora that it could lead to the cure of every germ disease, which overstates the case, but it is a major scientific breakthrough—not only for Martin, but potentially for humankind. 

Arrowsmith’s X Principle is a remarkable development in the novel. Perhaps for the first time ever in American fiction, Lewis invites a reader to participate in the euphoria of scientific discovery, rooting for the medical scientist as he plugs away in the laboratory. Later he causes a stir among the farmers in Wheatsylvania, the little town where he briefly sets up a private practice, by curing a seemingly unstoppable blackleg epidemic with an original vaccine prepared in the makeshift laboratory at the back of his doctor’s office. The vaccine requires several experimental dry-runs, but Martin works on the project after hours, glad to be searching for the root cause—the Why—of the disease. 

Later, Arrowsmith travels to St. Hubert, a fictional Caribbean island, to test the X Principle on a population besieged by bubonic plague. Verifying the efficacy of his bacteriophage would require a control group, which would mean denying the remedy to a portion of the populace. Is it more compassionate to inoculate everyone with an unproven (but promising) remedy or to withhold treatment for conclusive proof, thereby guaranteeing the health of future generations? It’s an important ethical question, but one that politics ignores. It’s hard to name a doctor today who is both publicly promoting scientific knowledge and defending human rights in quite this way. 

Arrowsmith develops a high-stakes debate over humanitarianism. One doctor argues that temporary cruelty does not justify eventual compassion; accordingly, he refuses to receive the preventive bacteriophage inoculation until the entire population of St. Hubert has been immunized. Arrowsmith’s mentor, Gottlieb, insists that true humanitarianism requires establishing irrefutable scientific facts. Gottlieb corners Arrowsmith before he leaves for St. Hubert and delivers one of his longest speeches of the novel. The St. Hubert experiment is Martin’s chance to become a “Great Man,” and Gottlieb intensifies the pressure: 

Be sure you do not let anything, not even your own good kind heart, spoil your experiment at St. Hubert. I do not make funniness about humanitarianism as I used to […]. So many men, Martin, are kind and neighborly; so few have added to knowledge. You have the chance! You may be the man who ends all plague […]. 

You must not be just a good doctor at St. Hubert. You must pity, oh, so much the generation after generation yet to come that you can refuse to let yourself indulge in pity for the men you will see dying. 

As I write this,  doctors are taking to Instagram to protest insurance companies who deny patients coverage for life-saving procedures. We’re having a hard enough time helping people now; no one is talking about the generation after the generation yet to come. But this is what Lewis imagines in Arrowsmith’s unorthodox heroism: by withdrawing from society into the laboratory, as he does to prepare his blackleg serum or to discover the X Principle, Arrowsmith has a chance to become a legendary benefactor of public health. But is the greatest degree of human compassion possible only through momentary cruelty? 

Arrowsmith’s heroism might have been lost on the popular audience had Lewis seen the St. Hubert experiment through to the end. Instead, Lewis creates a strategic compromise. First, he sets up the conditions of the experiment, outlining arguments for and against denying the vaccine to portions of the St. Hubert population; this lends credibility to Martin Arrowsmith as a scientific physician by highlighting the complexity of his choice. Then Lewis derails the experiment with the accidental death of Arrowsmith’s wife Leora, who dies suddenly of plague. Stricken with grief and guilt (because he had been entertaining adulterous thoughts at the time of her death), Martin begins administering his serum indiscriminately to the people of the island, compromising the scientific integrity of his results, but demonstrating his capacity for emotion. 

After Leora’s death, he returns to the self-destructive behavior of his vagrancy during medical school, drinking heavily and acting as if he no longer cares about knowledge or the accompanying reward of fame. Lewis writes: “[…] all day, Martin injected a line of frightened citizens, in the Surgeon General’s office,” during which time he “had a bitter satisfaction in throwing away all his significance, in helping to wreck his own purposes.” In the end, no one knows whether the plague disappears from St. Hubert as a result of “phage or rat-killing or Providence.” The result is tragic by Gottlieb’s standards, but it further endears Arrowsmith to readers, whom Lewis manages to educate about the ethical quandaries of research science while introducing the research scientist, himself, as a man of passion and human weakness. 

Arrowsmith loses his chance to enter the historical record alongside scientific greats such as Pasteur, but Lewis reinforces his heroic stature on the human level. Alongside characters like Hawthorne’s Rappaccini who becomes so obsessed with science that he forgets humanity, Arrowsmith’s capacity for emotion in the heat of his greatest experiment is extraordinary. In fact, I’d like a little more evidence that grief, for today’s doctors, is as powerful as scientific curiosity, profit, or personal branding. We could use more reminders that science happens in social contexts and that it is vulnerable to the weaknesses and biases of those who do it and the systems that support it. 

A Flawed Hero 

Arrowsmith is a bildungsroman—the first to show how an ordinary person becomes a scientific hero—but it borrows from other literary forms, such as the epic and the portrait of the artist. 

Martin is raised in a small town called Elk Mills, where he is the “unofficial” assistant to Doc Vickerson, the self-styled “plug doc” and alcoholic who has managed to compile the first museum of natural history in the county. In a drunken speech, Vickerson tells the young Arrowsmith to get all the training he can in the sciences in order to realize his full potential as a physician. “Set a high goal,” he admonishes Martin. “Don’t let things slide. Get training. Go college before go medical school. Study. Chemistry. Latin. Knowledge!” A nice little pitch for the liberal arts, even if it sounds quaint to us now. 

The University of Winnemac is Arrowsmith’s portal to opportunity, where preparation for medical school consumes his life. His entire identity revolves around his education, where “the purpose of life was chemistry and physics and the prospect of biology next year.” Arrowsmith’s junior year of college is set in 1904, and the descriptions he hears of Gottlieb, his professor of bacteriology, reflect lingering stereotypes of the medical scientist as a rogue. Rumors about Gottlieb suggest that “he was doing terrifying and costly experiments which probably had something to do with human sacrifice. It was said that he could create life in the laboratory, that he could talk to the monkeys which he inoculated, that he had been driven out of Germany as a devil-worshiper or an anarchist.” 

Gottlieb, whose name translates literally from German as “Godlove” and more accurately as “Beloved God,” recalls the master-apprentice relationship typical of the bildungsroman through his mentorship. From his introduction in the Winnemac scenes, Gottlieb remains the dominant influence on his young protégé throughout the remainder of the novel. When Arrowsmith asks to be admitted into his course before having taken all of the prerequisites, Gottlieb says: 

There are two kinds of students the gods give me. One kind they dump on me like a bushel of potatoes. […] The other kind—they are very few!—wish a liddle [sic] bit to become scientists, to work with bugs and make mistakes. Those, ah, those, I seize them. I denounce them. I teach them right away the ultimate lesson of science, which is to wait and doubt. Of the potatoes, I demand nothing; of the foolish ones like you, who think I could teach them something, I demand everything. (11) 

He goes on to tell Arrowsmith that he must take physical chemistry before he will be ready for bacteriology; this is the difference between true scientists and imitators. Gottlieb’s first public experiment, an inoculation of guinea pigs with anthrax repulses many of Arrowsmith’s classmates, but the young Martin later imagines himself repeating experiment: “as he remembered Gottlieb’s unerring fingers, his hands curved in imitation.” 

But Arrowsmith needs flaws if he is to be taken seriously as a character, and he nearly destroys himself at several crucial moments in the narrative. The same restlessness that fires his curiosity is also his potential undoing—binge drinking makes him careless in the laboratory and lack of sleep makes him belligerent. When Gottlieb reprimands him for a series of avoidable errors, Arrowsmith’s defiant response nearly ends his medical career. The medical dean decides to suspend rather than expel him, and Martin is temporarily exiled from the University that has been the primary touchstone for his identity as a young adult. 

But Arrowsmith’s flaws show that the most promising benefactors of public health sometimes seem the most misanthropic by nature. For Lewis and De Kruif, two idealists who effectively replace religion with science, pure science requires complete devotion. This is a high standard that none of Lewis’s characters fully attains; it’s in their failings that he endears them to readers, unveiling the joys and heartaches of a scientist, making the doctor’s emotional life known. 

Back to the Lab, Out of the World 

If the novel were to end in St. Hubert with Martin Arrowsmith doling out medicine to everyone in sight, it might be a story about compassion defeating cold-hearted science. Leora would be a martyr and Martin would be a widower, unselfishly serving humanity. But the story doesn’t end there: Martin marries Joyce Lanyon, a wealthy woman from New York, and briefly celebrates the birth of a son before divorcing Joyce, abandoning his son, and withdrawing to a remote cabin to dedicate his life to research. Arrowsmith is hard to like as a deadbeat father and cultural isolationist. Why, after taking such pains to help us understand the beauty and importance of science through Arrowsmith’s life, would Lewis turn his hero into such a miserable person? Is that really what science does to the heart? 

Lewis leaves us with a paradox. Nearly all of Arrowsmith’s flaws are scientific virtues: his brutal honesty, his distaste for wealth, his comfort with solitude. But  Arrowsmith’s  most troubling implication is that the medical scientist might give up trying to communicate with the public at all, choosing, instead, the uninterrupted calm of the laboratory, where discoveries happen unseen. When that happens, we’re thrown back to the distrust of the nineteenth century. Are the researchers devoted to unlocking the great Why beneath physical things today doing it for themselves or for humanity? Are they Arrowsmiths or Rappaccinis? 

The public story of medicine is a balancing act. It requires careful translation of facts into culture. It’s hard work, and it never ends. It’s much easier for suspicion to prevail. 

That’s why I see  Arrowsmith as a miracle. Think about what it took for that book to exist. It took a Paul de Kruif: a researcher with enough integrity to sacrifice financial gain for truth-telling. And it took a Sinclair Lewis: a kindred spirit who was willing to make an artist of a lab scientist. 

In Martin Arrowsmith, the scientific physician comes of age as a character, no longer a shadowy villain, but an artist in his own right: a figure whose potential for greatness or failure extends the medical narrative to the full scope of human experience. 

Web photo: Wiki Commons

DAVID HSU: Tell me a little bit about this half-marathon business. What’s going on with that?

TONY MIKSANEK: I’ve been running for a number of years, which I truly enjoy, and I’ve done ten full marathons, one ultra marathon, and God knows how many half-marathons. But as I get older, I’m leaning more toward the half-marathon as the longest distance I like running.

DH: So how did this one go? Was it good?

TM: Yeah. This one was in Florida. The weather was beautiful. There were about 20,000 people, and it was at Disney World. So you run through the Cinderella Castle, you’ve got all the characters high-fiving you on the course. It’s great. I think I originally got into running as a sort of release from medical practice, where you can be outside, mindful of your surroundings and your breathing and your foot striking the pavement. Since then, it’s become just short of an obsession. A good one, a good obsession. But I’ve often thought about the similarities between running and medicine. The greatest similarity is that both endeavors require a pair of comfortable shoes because you’re on your feet all day practicing medicine. There’s also a rhythm to running, which is a very individual, personalized thing. And, of course, there’s a rhythm to our practice. The flow of taking care of patients and our style in interacting with them. In running, you have to build up a core. We call it a core of mileage that your body gets acclimated to. In practice I think that core is sort of like developing trust in the physician-patient relationship. You have to work on that. You know that saying, “trust is hard to earn but easy to lose?”

DH: Let’s talk a little bit about medical humanities. You mentioned that running was something that you did to put your head in a different space from your regular work. I assume that medical humanities would also be something that gives you a diversion from your regular work. Is that accurate?

TM: Most of my career was spent as a small town, rural area, solo family practitioner in a former coal mining town with a population of right around 8,000 people. So medical humanities, for me, for most of my life, has always been an individual thing. I read and tried to be involved in whatever peripheral way I could with medical humanities. And I did and still do derive a lot of satisfaction, enjoyment and learning from reading great literature. We can debate what the adjective “great” means when it applies to literature, but I feel there’s so much to gain from literature. When a patient comes into our office, they usually want to tell us a story. Sometimes they’re reluctant, but usually they want to tell us a story. And my belief is that most people, to be healed, need to tell that story. But equally important is they need somebody who is invested in listening to that story, that confirms their importance. and the validity of their illness or what they’re going through. And I think literature is a really great tool to help us learn how to listen intently to patients, more fully understand their stories of life and illness, and to enhance our empathy.

So again, my entry into medical humanities is probably unlike most of the people on our MedHum group. It’s mostly been kind of a solo route for a long time. Currently I’m an associate editor and a book editor for the Journal of Medical Humanities. I don’t know how far back you go with your practice, but once upon a time, the American Family Physician Journal, the AFP, had a regular column called “Diary from a Week in Practice.” And there were four contributors. I was one of them. I guess I was the token rural small-town doctor, because there was somebody from an urban practice and somebody from an academic practice. I forget what the fourth one was. And so we would take turns writing a column that was basically a chronicle of a week of practice like “what were the highlights, what were the lowlights.” I think that was important for me, because at the time, that was probably my version of reflective writing, even though it was produced in a form that would be published. You know, being a doctor is tough, albeit a wonderful, often joyful, profession. Running gave me an opportunity, I think, to kind of put myself in a place where I can sustain joy and the dedication that was required, especially being a small-town doctor where your patients are your neighbors. You run into them at church or the grocery store. The land is the connecting fabric for a small-town doctor. I mean, your kids’ friends are almost always your patients. So it’s a very vivid, organic, dynamic relationship.

DH: How big was your practice? How many patients did you have?

TM: I practiced in our town for a little over 30 years, as a solo family physician, 24/7, unless it was time for vacation or a meeting. And then, you know, I had an agreement with a couple other physicians for coverage if we were gone, but it was a very full practice. The only thing I didn’t do as a family physician was OB.

I loved to make house calls. I used to make them in my Jeep Cherokee. And I’ll never forget the first house call I made. I brought my nurse with me because I was new to town, and I didn’t really know where the address was. And we pulled up in front of this very, very small, weathered house. And I remember as they opened the door to let us in, the floor was dirt. It was a dirt floor. And having been born and raised in Chicago and then later some of the suburbs, I was dumbfounded. That was really my experience — people that were really struggling to make a living. But the dirt floor was, I mean, it sounds like an oxymoron, but it was clean. And the home was well-kept. There were a lot of eye-opening experiences being in a small town.

DH: What’s the name of the town?

TM: Benton. Illinois. Wonderful town. Great people.

DH: How did you stumble across the humanities and arts connection to medicine? Was this something that you were aware of as a student or at some point as you started working you started to realize that novels had something to do with your job? How did you make that connection working solo?

TM: I’ve always been an avid reader, as I think most physicians are. And actually, I got a head start because our medical school, the medical school I attended and where I am now a volunteer faculty in the Department of Medical Humanities, was one of the first medical schools in the country to actually have an independent medical humanities department. So as a student, I was already interested in medical humanities. I guess as a prelude to that, as an undergraduate student at the University of Chicago, we had what they called a core curriculum when that was not a popular thing. Every student, no matter what your major was, had to have competence in basically all the major disciplines. So, if you were going to be a biochemistry major, you still had to take the History of Western Civilization, Art Appreciation, etc.

I’ve always been involved with literature. Once upon a time, JAMA and the New England Journal had book review sections, and I did book reviews for those two journals. The sad thing is, they haven’t had a book review section for a number of years now. There’s no interest, I presume? I don’t know. They just kind of vanished in the night. So, during my early years of clinical practice, I was writing reviews mostly for JAMA. They would send me all kinds of books, some of which were very peripherally connected with medicine. And so I think maybe when they had a book that looked interesting, they would say, “well, we’ll just send it to Tony.” Which was great. But that was in the days even before internet. I remember I would be sitting at my kitchen table with a typewriter typing these reviews to mail to JAMA or New England Journal. And it was kind of wild. But life was so much simpler then, too, on the other hand. Anyway, I would say that medical school, a love of literature, getting involved in book reviewing from early in my career was kind of the springboard for me, into medical humanities.

DH: Can you give us a few medical humanities book titles that we can spotlight for the audience?

TM: One book that I really was impressed by was Do No Harm. There’s an aphorism in medicine, “do no harm.” That’s the title. And it was written by a neurosurgeon in England by the name of Henry Marsh. It’s a beautiful book because like the very best memoirs, he presented his vulnerability as an individual and as a physician, a surgeon, so beautifully. You couldn’t help but be moved by his sincerity. In fact, he had a line, I’m paraphrasing it, but the line was something like, “I am a vessel for my patients to pour their misery into.” And you know, on the one hand you can say, “well, that sounds a little pontificating, a little arrogant,” but on the other hand, it’s like, “isn’t that part of the job description?” So that would be one: Do No Harm. Another by a physician author is Cutting for Stone.

DH: By Abraham Verghese.

TM: He’s out at Stanford and he’s written a lot. The Tennis Player, and others, but Cutting for Stone is one of these lengthy novels that you’re reading and you’re like, “this author’s all in.” He’s not saved any good stuff for another book. It’s just all there. So that’s another one I would recommend to people.

I’m also a very big fan of Richard Selzer because first of all, most are short stories or short essays you can read in a single sitting. I’ve met him a number of times and he admits that he lies, because these are not true stories necessarily, and they may have had their genesis in some kernel of truth. So there is a lot of exaggeration and hyperbole but there’s still something that he’s able to successfully impart to the reader about a doctor’s vulnerability. When I trained, we were told to suppress our emotions and have clinical detachment. You can’t survive if you get too involved with your patients. And of course there is truth to that. It can get to the point where you lose yourself in someone else’s situation and it’s not healthy for you or them. But I think we’re in a renaissance of saying, “Okay, maybe you can’t be too empathetic, but it’s okay to be vulnerable.” We’re not superheroes. I still struggle with that.

I had a lot of older folks in my practice who were huggers. Early on, I was always like taking a step backwards as they were lunging toward hugging me. But then my nurse, in her wisdom, said, “You know, they need to hug you.” That’s how they’re acknowledging your value to them and what you mean to them. I’ve done a lot of thinking about vulnerability and physicians. What is the optimum amount of being vulnerable? In the old days, if we had a very difficult situation, we would just go in our office, close the door, and have a cry. I mean, we would weep. We would never think of demonstrating our sorrow in front of a patient or something. And I think that comes from the training back then. But as you know, there’s no template for being a good physician. And it’s kind of a learning experience for all of us.

DH: It has something to do with how to be a good human being.

TM: Yes, exactly. And I think the whole point of medical humanities, as I alluded to earlier, is about that soul, that spirit of medicine, which is not just about how we practice medicine and interact with other people, but also with being self-aware of who we are, what we can offer, what our strengths and our weaknesses are, and trying to embrace both. Understanding that there are things we don’t do as well as we’d like, things we could do better. But again, it goes to that understanding of our vulnerability and accentuating our strengths and trying to minimize our weaknesses, while understanding that all human beings are some unequal combination of both.

DH: Switching gears a little, as a retired family physician, what’s your view of medicine today? Is it pessimistic? Is it optimistic? Do you think we’re moving in the right direction or are things worse than they were back when you were going through it?

TM: I think medicine is a completely different enterprise now than it used to be. I remember the joy of holding a paper chart and writing my notes with a pen on paper. I think my notes were adequate or good, but they had just the right amount of information that was necessary. There was nothing superfluous when you had to write your own note because you had a certain amount of time that you wanted to get the note done in. And I understand the utility of the electronic health record and its portability. But I think there’s something about looking a person in the eyes, giving them 100% attention, and even though back in the day I used to scribble down some notes so I wouldn’t forget certain things, 90% to 95% was just one-on-one. And then after the visit, I would write the note in the chart, or later I had the ability to dictate a note, which was great. So I think the electronic health record, on balance, has been a detriment to the practice of medicine.

Also, the amount of time you spend with a patient has become very restricted. For example, I was very cognizant of people waiting in the waiting room. Back at my peak, I was seeing 30 to 35 people a day in the office. In addition, I admitted and cared for all my patients requiring hospitalization. The local hospital that we have, 50 beds, still does not have a hospitalist. And so you had to make rounds. You took care of people in the ICU. You saw your patients in the ER. It was a full-service experience for patients and the physician. It was hard. There’s no question. But there was something very gratifying about being able to do all those things right and being a small-town doctor. People just called you at home. We had one rule in the house, and the rule was that as a family — we had three children — we would all have dinner together and that one hour was just for us. What happened with the kids during the day at school and their activities and how work for my wife went. And I just remember laughing and laughing, but we carved out that time. But otherwise, it was all hands on deck all the time. SoI think medicine is different. Whether it’s better or worse, I don’t know.

I really do feel sad that we’ve become such a technological profession. You hear students saying, “Well, what’s the point of trying to listen to a murmur? We’ll just get an echocardiogram.” Back in the day, you relied on your clinical acumen and you formulated your differential diagnosis. And then you thought, “well, what is the most likely diagnosis?” And then you would do testing to support that diagnosis or refute it and move on. And now I feel it’s like people immediately get tested.

We used to have to listen to people. You probably have the same experience. I think all medical students do. You have some wise professor that says 90%, 80%, 85% of the time, the patient will tell you exactly what’s wrong. You just have to listen to them. You may have to nudge them a little bit to give you more information. But now I don’t know that we’re giving people enough time to tell us what is really wrong with them before we kind of take the leap to do these tests. And I think, unfortunately, patients are getting so comfortable with the notion of getting tests that that is all they want. I’ve had patients that say, “Well, can we do a CAT scan? Can we do this or that?” Of course we can do it, but tests come with risks. False positives, incidentalomas, radiation exposure in some cases and so on. So on balance I’m going to say, although it was not Nirvana or Eden back in the day, and we had our own issues and problems, it seemed closer to the aim of healing.

DH: Well said. What would you like to see MedHum do in the coming months and years?

TM: I think what I would like to see is just MedHum continue on its trajectory and grow to become a go-to resource for people interested in medical humanities or just people that are curious about medicine in general. I would like to see the website continue to grow and become a valued resource where people, if they’re interested in the depiction of medicine in the humanities and in the culture of medicine, they can read articles, they can listen to podcasts. There’s a lot of interesting material on the website already. I think as we grow and expand and include more contributors, the possibilities are limitless for what it can become.

DH: That was great. I had a good time. We should do this again.

TM: Me too. We’ll look forward to talking again.

Posts Written by Dr. Tony Miksanek

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The trajectories of tuberculosis (TB) and opera met in the mid-nineteenth century most notably with the production of La Traviata in 1853, and then La Bohème near the century’s end. With eminent scholars Linda and Michael Hutcheon, we talk about how these trajectories converged and how these resulting two operas then brought attention to the medical effects of the infection and the sociocultural influences on its spread. We also discuss how the discovery of germ therapy during the time between the staging of these operas affected the way social behaviors changed accordingly, that is, from understanding TB as hereditary to understanding it as infectious. We play audio clips from parts of the operas pertinent to perspectives provided. 

A big thanks to Drs Linda and Michael Hutcheon who in addition to providing their expertise and perspectives during the podcast, also contributed ideas for the production. 

Links
– The combined bio for Linda and Michael Hutcheon.
– The New York Metropolitan Opera on-demand video service where you can get access to high-quality video productions of La Traviata and La Bohème among many other operas and performances. (There could be a 7-day free trial available).
– Homer Simpson performing as Rudolpho in La Bohème singing Oh Dio! Mimi!
– We covered the effects of TB as an aesthetic ideal of beauty during the nineteenth century as represented in paintings earlier in episode 5.

Audio Credits
La Traviata
Preludio (National Philharmonic Orchestra; Richard Bonynge cond London Records 1979)
Prendi, Quest’È L’Immagine (Orchestra of the Opera House, Rome; Tullio Serafin cond; Victoria de los Angeles (Violetta); EMI Records Ltd 1960; digitally remastered 1992)

La Bohème
O Soave Fanciulla (Berlin Philharmonic; Herbert von Karajan cond; Mirella Freni (Mimi); Luciano Pavarotti (Rudolfo); Rolando Panerai (Marcello); London Records 1972)
Si. Mi Chiamono Mimi (ibid)
Mimi È Una Civetta (ibid)
Mimi È Tanto Malata! (ibid)

La Bohème photo from wikicommons

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

A Most Unexpected Path Laid by a Most Unexpected Disease

Dr. Ross Slotten chose family medicine to serve patients from cradle to grave. But, as he was entering practice, the AIDS virus was entering the community where his practice was situated, and he found himself serving patients much closer to the grave than the cradle. 

In June 1981, a few weeks before I began my internship in family practice [at Saint Joseph Hospital in Chicago], the Center for Disease Control in Atlanta had published the first report of a strange lethal infection among a cohort of gay men in Los Angeles. I had no clue then that the disease would soon kill friends, former lovers, colleagues, and patients; devastate tens of millions of people and their families worldwide; and consume my entire professional life and more than half my chronological one. (p.14)

From both the circumstance of time and place he found himself in, and the sense of necessity and compassion that claimed him, Slotten’s professional trajectory unexpectedly shifted away from traditional family medicine towards specializing in AIDS. His interest in AIDS, however, extended to personal considerations, because as a gay man, he was part of the population at risk, and harbored the same anxieties and fears he saw in his patients and throughout his social circles. His patients were principally gay men because of his geographic location in an established gay community and the resulting referral patterns. The book chronicles both his experiences as a physician taking care of gay men with AIDS, and his experiences as a gay man at risk for AIDS. For Slotten, these experiences were not independent of one another, which makes for rich insights on the complexities of both. 

Slotten spent a lot of time at Saint Joseph Hospital because his patients required intense medical support and specialized services. He tells how he and his practice partner pushed for establishing a specialized AIDS unit in the hospital. They bumped up against usual bureaucratic obstacles, plus a few more concerning issues specific to AIDS patients, but they ultimately prevailed. Slotten “was to spend the next fifteen years there, often heartbroken, occasionally inspired.” (p. 109) In contrast to his commitment, he recounts how some specialists he called for help with particular patients refused when told they had AIDS. Those occurrences stuck with him: “I couldn’t forgive those other physicians for abandoning me and my patients in the hours of our greatest need.” (p. 108)

With whatever little time he had left for volunteer and advocacy work, Slotten stayed local. He talks about the volunteer-run health clinics where he worked (e.g., the famed Howard Brown Clinic), and the housing facility he helped set up for homeless people with AIDS. He left protesting at the Food and Drug Administration, the National Institutes of Health, and the annual International AIDS Conference to others while he focused on his patients, his studies, his volunteer work, and his own safety.

The 2020s are approaching when Slotten writes about the preceding three-and-a-half decades. As he finishes the book he is still caring for people with HIV, but the horrible complications of AIDS are now infrequent since the availability of effective medications. His practice had been reliably stable and predictable for some time, a circumstance he could only dream of when he first started. That dream ended abruptly just as the book was released on July 15, 2020: Covid was surging.

Moments of Horror, Relief, Calm, and Then…

Slotten’s perspectives correspond with the trajectory of AIDS over the thirty-five years his memoir spans. Particular periods are discernable, beginning when gay men were presenting with illnesses associated with profound immunodeficiency of unknown cause. Another is the time of peak AIDS death and destruction represented by the moment in 1992 when Slotten hears from the Chicago Board of Health, “that no one had signed more death certificates in Chicago than I had.” (p. 122) The next moment arrives at the turning point when highly active antiretroviral treatment (HAART) became available, transforming HIV/AIDS for him “from a universally fatal disease…into a chronic one like diabetes…it was almost beyond belief.” (p. 186) Then the prolonged period of relative calm when AIDS became controllable—even preventable—with Slotten noting during a moment in 2016 that, “It had been almost a decade since I’d cared for someone with advanced HIV infection, and I hadn’t lost a patient to AIDS since 2004.” (p. 202)

The AIDS epidemic is known for and measured by the number of deaths that occurred. Slotten wants us to remember the misery the disease causes.

For those who didn’t experience that terrible time, or who’ve forgotten how terrible it was, let my chapters serve as a warning to the complacent and the ignorant: untreated HIV is as ruthless as any terrorist and as destructive as a nuclear device. (p. 3)

He drives this point home when he recounts the stories of individual patients tortured by Pneumocystis carinii pneumonia, Kaposi’s sarcoma, cytomegalovirus retinitis, herpes simplex infections, cryptosporidium dysentery, AIDS wasting syndrome, AIDS dementia complex, and progressive multifocal leukoencephalopathy among other medical horrors, and who often suffer many at the same time. And, all the while, he had little to offer but his wits and his compassion. 

Both attributes would be called upon again in 2020 as Covid struck. Though those with Covid did not produce nearly the fatality rate of AIDS, not nearly the severe comorbidities of AIDS, not nearly the stigma and prejudice as AIDS, and not any of the governmental insouciance seen with AIDS, it still caused a lot of death, suffering, grief, and misinformation at a time when only supportive care was available. Like AIDS, though, the Covid pandemic was transformed into a manageable syndrome with the availability of an effective vaccine, new antiviral agents, and better clinical management regimens.

Complacency remains a threat to the reemergence of any infectious disease. Indeed, AIDS is reportedly rising in poor and developing countries in 2026 as funding for AIDS treatment and prevention programs has been withdrawn from donor countries, mostly that from the United States. Lessons from Slotten’s book may thus be called upon again.

Notes

Book citation:
Slotten, Ross A. Plague Years: A Doctor’s Journey through the AIDS Crisis. University of Chicago Press, 2020. 224 pages

Plague Years is a good companion to the documentary film, 5B, which reports on how San Francisco General Hospital coped during the early years of the AIDS epidemic, and Rebecca Makkai’s novel, The Great Believers which features the stories of a group of gay men in Chicago also during the early years of the AIDS epidemic.

Dr. Slotten was a guest on an episode of The Clinic & The Person podcast to discuss his experiences during AIDS epidemic as he reported them in his book, and how well they match up with what we see in 5B and read in The Great Believers.

Web image by Medhum.org

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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Henry’s severe illness and his difficulties accessing treatment prompted Green to contemplate the horrifying statistics of tuberculosis and the paradox of our extensive knowledge about it. More than one million people still die every year from this ancient disease; yet the bacterial cause was elucidated a century and a half ago, and effective treatments have been around since the 1950s. Barring eradication, the germs mutate and become resistant. Given dire living conditions, it spreads. Effective therapy can be prohibitively expensive. “The cure is where the disease is not, and the disease is where the cure is not” (p. 5). People die where cures cannot be obtained. 

History is woven though Henry’s story, but so are politics, culture, and economics: the discoveries, the 19^th-century romanticization of ‘wasting away,’ the hard realities of pharmaceutical development and delivery. Henry has survived, become healthy and an inveterate TikToker and youtuber. He even has an episode on the power of storytelling. But other people that we encounter through this tale have died. 

We still have tuberculosis because statistics de-personify it, and geography allows ignoring it. Green uses Henry’s story to invite us to ‘[t]hink about how rare and precious humans are, and how many of them you get to worry for and care about. Then if you can, find a way to multiply that 1,250,000 times’ (p. 189).  

The book flows easily in language that is clear and accessible, a tribute to Green’s experience in writing young-adult fiction. In the end, without denying the benefits of medical interventions, he calls for a focus on the real cause of tuberculosis: injustice—tolerated and unchallenged. ‘Ultimately,’ he writes, ‘we are the cause’ (p. 184).  

Everything is Tuberculosis: The History and Persistence of Our Deadliest Infection
John Green
New York: Penguin/Crash Course Books
2025
ISBN 9780525556572 

Web image created by Medhum.org

The time has come when the existence of a private pestilence in the sphere of a single physician should be looked upon, not as a misfortune, but a crime; and in the knowledge of such occurrences the duties of the practitioner to his profession should give way to his paramount obligations to society.

— Oliver Wendell Holmes, “The Contagiousness of Puerperal Fever”

It would have been cold on February 13, 1843, when the Boston Society for Medical Improvement convened. But anyone who heard Oliver Wendell Holmes’s fiery speech about puerperal fever would have forgotten about the chill outside immediately.

Holmes stood just 5’ 3”. And he was young, only 34 years old. But he was hot with moral authority. He was so sure that puerperal fever was contagious that he accused his skeptical colleagues of murder. He knew that in order to make them listen, he had to do more than lay out the facts. He needed a persuasive story.

As I’ll show presently, it was precisely this approach that allowed Holmes to win Nathaniel Hawthorne’s trust as personal physician to the great author near the end of his life. No mean feat, since Hawthorne was terrified by medical science.

The Crowd Puller

In those days, you had to speak well publicly to make a name for yourself. Oratory was required in school. In New England, the rhetorical standard was set in the pulpit, and public discourse followed. So it wasn’t an insult if someone said your speaking or writing felt sermon-like. Good sermons could awaken, convict, inspire, and transform even the most uneducated souls. The best professors and the best doctors fit the ministerial mold.

In New England, good speakers were a dime a dozen. But Holmes stood alone.

One of Holmes’s students recalled how he could hold a crowd:

He always makes people attentive, and I have been told that there is no professor whom the students so much like to listen to. In one of his books he says that every one of us is three persons, and I think that if the statement is true in regard to ordinary men and women, Doctor Holmes himself is at least half a dozen persons. He lectures so well on anatomy that his students never suspect him to be a poet, and he writes verses so well that most people do not suspect him of being an authority among scientific men.

This was also a time when science was retreating from the public sphere. Hawthorne was writing short stories about the terrors of the lab, where Rappaccinis and Chillingworths played God. As Michel Foucault said, it was a time when some doctors took the patient into account “only to place him in parentheses.”

Holmes was a scientist, but he hated how science made some of his peers “think only in single file.” And so he tried to wake his colleagues up on that cold day in Boston with facts, but also with panache and metaphor.

The Case for Contagion

Attention spans were different in 1843. The full text of Holmes’s speech, which he later published in essay form, was over 12,000 words. It would have taken him at least an hour to deliver it. He had to review many cases in depth, not just spin fetching tales.

But that’s why everyone in the Boston Society had gathered that day. They wanted to get better as doctors, for medicine itself to improve. So they listened.

Holmes points out that William Dewees’s A Treatise on the Diseases of Females, published in Philadelphia in 1833, explicitly denies that puerperal fever is contagious and that the Philadelphia Practice of Midwifery (1838) omits mention of the disease entirely.

Unthinkable now, but it was commonplace for a doctor or midwife to deliver one baby and then move to the other without washing their hands. Holmes’s words for such a physician? A “death-carrying attendant.”

He also opens with a logical list, a kind of syllogism, something he’d have learned from his humanities education. If all these things are true, then there’s no room left for opposing views.

1. Not all forms of puerperal fever may be equally contagious. But evidence shows the disease appearing again and again among patients of a single practitioner, even when no epidemic is present. That pattern demands explanation.
2. Whether infection travels through the air a physician carries into the sick-chamber or passes directly from his unwashed hands, the practical result is the same. We need not settle the question to act on it.
3. Contagion does not guarantee infection. Even the smallpox vaccine, fresh and carefully administered, sometimes fails. Same for scarlet fever. But no one doubts those diseases are contagious.
4. Seasonal and regional influences may trigger or worsen the disease. But smallpox follows the same patterns of rise and fall, and no one doubts it spreads by contagion. Why should puerperal fever be different?
5. If physicians can be shown to carry death instead of health, no excuse will absolve them. “[W]henever and wherever they can be shown to carry disease and death instead of health and safety, the common instincts of humanity will silence every attempt to explain away their responsibility.”

It made Holmes angry that colleagues could explain the deaths of new mothers as Providence, using God’s will as an excuse for their own failures to stop preventable deaths. 

We do not deny that the God of battles decides the fate of nations; but we […] are particular that our soldiers should not only say their prayers, but also keep their powder dry. We do not deny the agency of Providence in the disaster at Norwalk, but we turn off the engineer and charge the Company five thousand dollars apiece for every life that is sacrificed. Why a grand jury should not bring in a bill against a physician who switches off a score of women one after the other along his private track, when he knows that there is a black gulf at the end of it, down which they are to plunge, while the great highway is clear, is more than I can answer.

I’ll not reprise Holmes’s full review of cases (he painstakingly covers more than half a dozen). You can read the full text that he reprinted in Medical Essays here.

What I want to emphasize is how storytelling was much more than a way to “sell” science for Holmes. He knew that story piqued an emotional understanding of science, which was how doctors could be persuaded to act, and also how public trust could be earned and held.

Here’s his passionate conclusion in full:

It is as a lesson rather than as a reproach that I call up the memory of these irreparable errors and wrongs. No tongue can tell the heart-breaking calamity they have caused; they have closed the eyes just opened upon a new world of love and happiness; they have bowed the strength of manhood into the dust; they have cast the helplessness of infancy into the stranger’s arms, or bequeathed it, with less cruelty, the death of its dying parent. There is no tone deep enough for regret, and no voice loud enough for warning. The woman about to become a mother, or with her new-born infant upon her bosom, should be the object of trembling care and sympathy wherever she bears her tender burden or stretches her aching limbs. The very outcast of the streets has pity upon her sister in degradation when the seal of promised maternity is impressed upon her. The remorseless vengeance of the law, brought down upon its victim by a machinery as sure as destiny, is arrested in its fall at a word which reveals her transient claim for mercy. The solemn prayer of the liturgy singles out her sorrows from the multiplied trials of life, to plead for her in the hour of peril. God forbid that any member of the profession to which she trusts her life, doubly precious at that eventful period, should hazard it negligently, unadvisedly, or selfishly!

I read recently that we respond much more powerfully to troubled characters in fiction than we do to stock types who move from one adrenaline-spiked obstacle to the next. That’s because our deepest emotional responses are driven by three chemicals (dopamine, cortisol, and oxytocin). These brain responses are strongest when we truly care about someone else.

Holmes was trying to do something similar by creating a moral dilemma within the physicians he addressed. The doctor who cared nothing about exposing his patients to risk had no soul. But the doctor who could imagine a family’s grief and wrestle with his own culpability was more complex, more colorful, more worthy of trust.

If you’d been listening to Holmes on that February day, you know which doctor you’d have wanted to be.

Converting the Chief Skeptic

Despite his charms, it took time for Holmes to push his reforms. People thought he looked too young. One woman ordered him out of her house when he accompanied a senior physician during his medical training. “Take him away!” she cried. “This is no place for boys.”

Holmes’s colleagues respected his medical skill, but thought him “impaired” for writing poetry. And not all readers of The Atlantic loved him. To some he was a “tiresome little man.”

As one biographer explains, Holmes “disarmed criticism…by courageously persisting in the same method which had originally produced it, namely, by the most fearless intimacy with his audience, never keeping back any jest or any expression of confidence.” In a word, he was not afraid to make himself vulnerable in his writing. 

Holmes and Hawthorne shared pages in The Atlantic Monthly and also knew each other through the Saturday Club, a gathering of literary celebrities that included Ralph Waldo Emerson, Henry Wadsworth Longfellow, and Harriet Beecher Stowe hosted by the publisher James T. Fields. Hawthorne was quiet and shy, brooding around the edges, but Holmes loved to regale the group. As Annie Fields recalled, “with Dr. Holmes sunshine and gayety came into the room.”

The two writers developed a close intellectual relationship, commenting on each other’s manuscripts and commiserating with one another over the dangers of pseudoscience and careless experimentation. So it was no surprise that when he grew ill in 1864, Holmes was the only doctor that Hawthorne would see. Hawthorne had watched a friend die of pneumonia while a quack prescribed a variety of ineffective drugs, poultices, even cupping and blistering, to no avail.

As the two men walked the Boston streets, Holmes conducted a “talking exam,” listening while Hawthorne reported his symptoms of indigestion and fatigue. Holmes recognized that Hawthorne suffered from a profound sense of despondency which signaled imminent death, that there was no cure but compassion. This was an intimate moment—as vulnerable as the introverted Hawthorne had ever allowed himself to be with anyone—and it illustrates Holmes’s ability to reassure even this great skeptic of his good intentions. 

Hawthorne’s simultaneous fear of alternative medicine and medical science left him nowhere to turn as his own death approached. On the one hand were the mesmerists who sought to control the individual through pseudoscientific means. On the other were the Rappaccinis whose misappropriation of science was equally hostile to the privacy of the soul.

Only Holmes could rescue Hawthorne from those two nightmares. He did it as a man of science, as an indefatigable optimist, as a caring friend, and, yes, as a storyteller who knew that passion is one form of understanding.

Web image of A young Oliver Wendell Holmes from PBS.