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

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

The Pact 

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

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

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

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

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

The Pact Wobbles 

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

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

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

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

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

Destiny’s Grandparents 

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

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

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

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

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

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

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

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

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

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

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

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

References:

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

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

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

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

Web image by medhum.org

The Sick Child

The sick child is thought to be the artist’s sister. She is not a child but rather a young girl who is lying down or seated, with a blanket over her lower body and she faces a woman who is seated beside her, clutching the child’s left hand. We cannot see the woman’s face – it is turned down as she is bent over in apparent grief. While the painting’s title names the girl as the subject of the painting, it is the grieving woman and her attention to the girl that is particularly striking.

Death and the Child

Death and the Child depicts the anguish of a child who has been confronted with the corpse of her mother lying in bed. The child faces the viewer, hands pressing against her ears – she cannot bear to “hear”/ absorb what she has encountered; her face has an expression of fear and despair

Death in the Sickroom

In Death in the Sickroom several adults are scattered about, some standing, one woman sitting in the foreground; behind her another woman stands facing us. In the back of the room a figure sits on a chair, a blanket draped over her lap – presumably this is Munch’s sister. With his back to the wall an elderly man has both hands pressed to his chest. These individuals have come to help and mourn but they are isolated from each other, which adds to the grimness of the scene.

Image credits: wiki commons

Painting with Empathy: The Expressionist Art of Edvard Munch with Curator Øystein Ustvedt

Russell Teagarden 12.28.23 1971

Edvard Munch’s emotional portrayal of illness and suffering offers profound insights for health professionals and…

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

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

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

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

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

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

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

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

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

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

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

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

Web image by Riley Revell 

Narrative

Isles

José Luis Marín Aznárez 05.11.26

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

Most chapters are titled after a medical condition (exceptions are “Hubris” and “Melodrama”). Some of the headings are familiar – Trauma, Infarct, Aneurysm, Meningioma. Other chapter titles flaunt delicious medical terminology that mingles the mysterious and the poetic with nomenclature such as Angor animi, Neurotmesis, Photopsia, and Anaesthesia dolorosa.

Included are riveting accounts of both mundane and seemingly miraculous patient outcomes. One success story involves a pregnant woman losing her sight due to a brain tumor that compresses the optic nerves. Her vision is restored with an operation performed by the author. Her baby is born healthy too. But tales of failure and loss – malignant glioblastomas that are invulnerable to any treatment, operative calamities including bleeding of the brain, paralysis, and stroke – are tragically common. The author describes his humanitarian work in the Ukraine. He admits his aggravation with hospital bureaucracy and is frequently frustrated by England’s National Health Service.

Sometimes the shoe falls on the other foot, and the doctor learns what it is to be a patient. He suffers a retinal detachment. He falls down some stairs and fractures his leg. His mother succumbs to metastatic breast cancer. His three month old son requires surgery for a benign brain tumor.

As his career winds down, the author grows increasingly philosophical. He acknowledges his diminishing professional detachment, his fading fear of failure, and his less-hardened self. He becomes a sort of vessel for patients to empty their misery into. He is cognizant of the painful privilege it is to be a doctor.

The title of Do No Harm is spot-on. After all, this commandment is a crucial caution to all doctors. And for neurosurgeon Marsh, it signifies the restraint he must exercise in his medical decision-making. His approach to the doctor-patient relationship features a gentle medical paternalism that incorporates plenty of honesty and kindness. He writes about his struggle (and occasional clumsiness) with breaking bad news.

His professional life is portrayed as paradoxical – constant anxiety and contagious confidence, phases of futility and strings of inspiring operative accomplishments. The gift of forgiveness, how uncertainty tortures doctors, and the process of dying are significant topics for Marsh. In the last few decades, there has been a proliferation of medical memoirs. Do No Harm rises above them all. The book informs doctors that it’s okay to be vulnerable and fallible, as long as they are also compassionate, truthful, and caring. 

Primary Source Do No Harm: Stories of Life, Death, and Brain Surgery 
Publisher Thomas Dunne Books/St. Martin’s Press 
Place Published New York 
Edition 2015 
Page Count 288 

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

In her second collection, “I Watched You Disappear” Silver’s poems invited us to accompany her on her journey through treatment, anger, despair, determination, and faith. This third collection (her penultimate) continues the author’s beautifully written illness narrative, again presenting moments of joy and of despair, and always of hope. 

Silver places her title poem, “From Nothing” (pg. 1), before Section I as an epigraph to the entire collection. “Each death I witness makes me more my own,” she writes, and although the poem sees “muscle shredded” and “bone sheared,” the poem’s last lines lift, as do many of Silver’s poems, into hope and faith: “and my molecules will vault, emerging. / From darkening days, the light will surge and flee.” Section I begins with poems of memory–“Summers in Vermont” with her family (pg. 5)–and “Coincidence,” when her sister’s child is born on the same day that Silver holds her breath and presses her “shorn chest” to an X-ray machine (pg. 7). The memories here are of family moments, both the joyful and those tinged with such “darkening days.” In “Luzerne,” she recalls when time was “consigning” her to such darkness, but two things saved her: her son, the poet’s hand touching his “damp blond hair,” and poetry, “offering itself like a pair of velvet shoes” (pg.13). Silver develops the idea of poetry as a special entity, a gift that enables her to walk forward in her journey, in “Raven” (pg. 15). She imagines a raven lifting her, holding her, and then setting her down in her home, where, she says, “dawn drove a pen into my hand.” This sense of urgency and necessity pervades all of Silver’s poems, as if she has been commanded to write her story.  

Section II begins in “Anguish” (pg. 19) a stunning poem about the loss of her first child, a daughter, but the section ends in joy with “After a Favorable PET Scan” (pg. 38). It might be difficult to find another poem by any author that offers such resounding relief and happiness. This poem, especially, speaks to how terrible every test is for those who are suffering, for those whose test results might mean more medication, more surgery, or less time to live. The celebratory release felt by patients when results bring good news must be a special kind of joy: “Oh world, I will give you all my love. / I will race like a child through the fields, / I will chase off the unkindness of ravens. / My words will grow thick as marshes, / sheltering nests in salty steams.” The poems in Section II are some of the most beautiful and moving poems in this collection. See especially “Tenebrae” (pg. 21), a plea for life; “Poise” (pg. 26), a rant against giving in to cancer; “Snow White” (pg. 30), a poem of mourning for self and others; and “Four Prayers for Forgiveness” (pg. 34-35), a poem that turns illness into beauty: “–the scattered lumps in my lungs / become church domes roofed in green mosaics, / my bones’ fissures fill in with grass-green yarn. / . . . I open my eyes and all is golden.” 

Section III seems to present a corrective reaction to the joy expressed in the final poem in Section II. The poems in this last section are short, mostly one stanza, a catalog of things that are broken, cracked, ripped, or chipped. The warning that nothing lasts forever is implied in poems such as “Partings” (pg. 44) and “Woman with a Hole in Her Stocking” (pg. 45), in “Red Never Lasts” (pg. 47) and “Autumn” (pg. 57). Yet, as always in Silver’s poems, the warning is tempered by the beauty of her words and the depth of her insight into what it is to suffer over the course of an illness that has remissions and recurrences, that sees the body changed and relationships altered. In “Ideal Speech” (pg. 58), she writes “Listen to the Holy Ghost. She blows through you, / she blows her poems right through you.” Even when days seem darkest, the ideal speech for Silver is poetry, and she is the “you” through which the Holy Ghost speaks these auricles. In the book’s final poem, “Three Roses” (pg. 59), the author once again works her spell, turning illness into beauty and despair into hope. “Where only my scar line remains, a red rose blooms. / Luscious, full, so open that if it dropped a single petal, / it would not be as lovely as it is this very moment.” And in the poem’s final lines, “Lay her hands on my chest–here, I give it to you. / Feel your palm on my skin heat and spark,” What is the “it” she gives us? I believe that Silver invites us, as Whitman did, to merge with her and to live within her words, which are her flesh, the poems she writes and then gives us to read and ponder.  

Miscellaneous 

In my annotation of Silver’s second collection, “I Watched You Disappear,” I wrote that her poems might be difficult for some to read: “These poems are beautifully crafted, often primal, and they touch the deepest reaches of personal illness and the shadow of mortality. Readers who have breast cancer or who have family or friends living with breast cancer, might find these poems difficult to read–others under the same circumstances might find them difficult and yet, at the same time, essential.” The poems in this collection can be as raw as they are hauntingly beautiful. But, as do her other books, this one again opens to us a world apart, one we cannot enter unless we share this author’s diagnosis and illness trajectory. If we are caregivers or care receivers, if we suffer or we watch loved ones suffer, these poems plunge us into emotions that we ignore at our peril.  

Publisher Louisiana State University Press 
Place Published Baton Rouge 
Edition 2016 
Page Count 65 

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

Among the scores of essays Montaigne wrote, while occasionally serving in various government roles, are accounts and commentaries concerning many of his infirmities. Kidney stone attacks in particular plagued Montaigne, and so they became subject matter for several essays. His focus on “the stone,” as he called this condition, generally concerned the physical and mental suffering acute attacks caused him, his work at reconciling a life with intermittent attacks, and from these two features, the profit his attacks afforded him. (N.B. I have drawn Montaigne’s words from the Everyman’s Library collection of Montaigne’s essays.)

Attack of The Stone

Pain from acute kidney stone attacks always ranks amongst the worst humans suffer from diseases, injuries, or various conditions. Montaigne’s vivid and horrifying descriptions of his kidney stone attacks lend credibility to these rankings: “I am at grips with the worst of all maladies, the most sudden, the most painful, the most mortal, and the most irremediable.” (p. 698)

To others looking on during one of his attacks, Montaigne says: “They see you sweat in agony, turn pale, turn red, tremble, vomit your very blood, suffer strange contractions and convulsions, sometimes shed great tears from your eyes, discharge thick, black, and frightful urine…” (p. 1019) No observer could doubt the intensity of pain kidney stone attacks produce after reading Montaigne’s accounts; no current sufferer would contradict them. 

A Life Accommodated

The pain and agony kidney stones inflict are never forgotten. And, the fear of knowing they will strike again is ever present, with good reason; they often return time after time. Indeed, this threat is a form of suffering of its own. Montaigne was cognizant of this reality, and writes about how he learned to live with the inevitability of a next attack. 

In the eighteen months or thereabouts that I have been in this unpleasant state, I have already learned to adapt myself to it. I am already growing reconciled to this colicky life; I find in it food for consolation and hope. So bewitched are men by their wretched existence, that there is no condition so harsh that they will not accept it to keep alive. (p. 697).

His primary approach was adopting a mentality allowing him to maintain as much function as possible while under frequent sieges of the stone: “I have kept my mind, up to now, in such a state that, provided I can hold fast, I find myself in a considerably better condition of life than a thousand others, who have no fever illness but what they give themselves by the fault of their reasoning.” (p. 701) Montaigne advises these thousand others they would do well to adjust their reasoning because the problem “occupies in us only that much room as we give it.” (p. 47) As for how much room to give the stone, he says, “we have no cause for complaint about illnesses that divide the time fairly with health.” (p. 1020)

With his reconciliation of a life with the stone, Montaigne carries on as close to a normal life as possible and not being obsessed with his condition: “Do not expect me to go and amuse myself testing my pulse and my urine so as to take some bothersome precaution; I shall be in plenty of time when I feel the pain, without prolonging it by the pain of fear.” (p. 1023) 

Profitable Kidney Stones

“I have in [my] time become acquainted with the kidney stone through the liberality of the years. Familiarity and long acquaintance with them do not readily pass without some such fruit.” (p. 697) The fruit is the profits he gains with kidney stones. The profits derived mainly from lessening his fear of death, better appreciating the health he had, and getting on with his life more easily. As such he has profited from receiving benefits exceeding the costs he incurred through suffering. 

“I’m not dead yet.” Montaigne wrote that when the stone visited him, he felt he was “so far forward into death that it would have been madness to hope, or even to wish, to avoid it, in view of the cruel attacks that this condition brings.” (p. 771) He had come face to face with death on those occasions only to survive. What he gained from these encounters he eventually appreciated as a form of profit. 

I have at least this profit from the stone, that it will complete what I have still not been able to accomplish in myself and reconcile and familiarize me completely with death: for the more my illness oppresses and bothers me, the less will death be something for me to fear. (p. 698) 

“What a feeling.” The perception of good health is created mostly either by various metrics like physical fitness standards (e.g., weight, strength, endurance), medical diagnoses, and other empiric findings, or by contrasts to states of bad health. Montaigne claimed great profit because his kidney stones reminded him how good his health is generally when he’s not in the midst of an attack. 

But is there anything so sweet as that sudden change, when from extreme pain, by the voiding of my stone, I come to recover as if by lightning the beautiful light of health, so free and so full, as happens in our sudden and sharpest attacks of colic? Is there anything in this pain we suffer that can be said to counterbalance the pleasure of such sudden improvement? How much more beautiful health seems to me after the illness, when they are so near and contiguous that I can recognize them in each other’s presence in their proudest array, when they vie with each other, as if to oppose each other squarely! (p. 1021)

Montaigne also perceived profit from the finite nature of kidney stone attacks. He points to the abrupt resolution of an attack followed by a quick return to good health in contrast to other diseases causing their victims continuous suffering: “My sickness has this privilege, that it carries itself clean off, whereas the other always leave some imprint and change for the worse that makes the body susceptible to a new disease.” (p. 1022)

“Brush off the clouds and cheer up.” To Montaigne, kidney stone attacks are gruesome and can make the sufferer wish to die. But, by their nature, and as a form of profit, they can make life better between attacks than it would be otherwise. Montaigne sees this profit in the certainty that any attack will end and lives can go on as planned, because the stone is “a disease in which we have little to guess about. We are freed from the worry into which other diseases cast us by the uncertainty of their causes and conditions and progress—an infinitely painful worry.” (p. 1023) This means for Montaigne, that the stone “almost plays its game by itself and lets me play mine. (p. 1022)

The idea that there can be profit or any form of benefit from having kidney stones is likely preposterous to modern day sufferers, especially when effective analgesics and surgical techniques for acute attacks and methods for preventing them are available. Many people, however, still struggle with chronic kidney stones making Montaigne’s observations and advice relevant yet. Drawing from a cultural analog, he might tell them to look for the profit kidney stones generate, and when found, they will see that gray skies are going to clear up, so put on a happy face. Alas, his admonition would likely be met with stony silence. 

Kidney stone image from the gallery at KidneyStoners.
Title image credit: Three Kidney Stones Highlighted in Red. Sanderlewis, CC BY-SA 4.0 https://creativecommons.org/licenses/by-sa/4.0, via Wikimedia Commons

But medically assisted death is not new. It has been present and debated since at least Greco-Roman antiquity and probably much earlier. However, its current status in various countries and within them is fraught with controversy even after legalization. For their involvement, euthanasia providers have been celebrated – and they have gone to jail. They have been portrayed as heroes or as villains, prominent among them American pathologist, Jack Kevorkian (1928-2011). Sometimes, health care workers are wrongly accused of killing their patients, especially when an unusual cluster of deaths arises – one example being the vicious prosecution of Canadian pediatric nurse Susan Nelles in 1981 for having murdered unhealthy neonates. She was later vindicated, absolved of all blame.  

Yet those of us who have worked with seriously ill people on the hospital wards know that a therapeutic choice to help suffering can run the risk of shortening those few remaining days. I recall more than half a century ago, a diminutive, elderly patient, writhing in agony on her bed. A much-respected senior clinician on his rounds demanded to know why we had not given “enough” morphine. “But chief!” we protested, “to raise the dose could stop her breathing!” “Why are you giving morphine?” he asked. “To relieve the pain.” “Have you succeeded?” “No.” “Then give enough; enough to make her comfortable” We did. She stopped moaning and died soon after. Unforgettable. We realized that decisions like this must be happening everywhere, but they occur within a cloud of trepidation, as bereaved family members might choose to make accusations. 

Prior to Canada’s 2016 legalization of medical assistance in dying (MAiD), people seeking help to end their lives with dignity would sometimes go to Switzerland. There, providing assistance to a person able to voluntarily self-administer lethal drugs had been legal (with variations) since the 1940s. In 1998, the Swiss non-profit organization Dignitas was founded to offer assisted death (or assurances thereof) to its members. In 2010, 89-year-old Kay Carter of Vancouver, who was suffering from spinal stenosis, went to Switzerland to end her life. It seemed outrageous that “death with dignity” was available to citizens who could afford to leave the country– yet everyone else was deprived. After her death, the Supreme Court decision that struck down Canada’s law against assisted suicide is known as “Carter vs Canada.” Considering that ordinary suicide had been illegal in Canada until 1972, these changes reflect a remarkable and relatively rapid shift in attitudes to death and dying.  

But the controversies are not over. And Canada is far from alone. Religious objections can be found in many communities. Vulnerable and disabled people together with their caregivers worry that they could be targeted or urged to accept assisted suicide by institutions wanting to save money. The prohibitions on access for children or the mentally ill are repeatedly challenged and have been overturned in some jurisdictions. Psychiatrists argue that assisted suicide would rarely be contemplated if more mental health services were available. Palliative care doctors resent the implication that they should be the administrators of euthanasia; they saw themselves as purveyors of comfort for life, not death. They pointed to the World Health Organization emphasis on the global need for more palliative care, and they complained that the new law made patients even more hesitant to accept their help. Swirling throughout these debates is the well-intentioned question about how a society should treat the least of its members: humane treatment or humane killing. 

It is scarcely surprising, then, Assistedlab.ch comes out of Switzerland; nor is it surprising that it finds a rich supply of sources. Launched in 2023, it claims to be “a living archive of assisted dying” that strives neither to endorse nor criticize the movement. Led by Anna Elsner, a professor of French Culture and Medical Humanities at the University of St Gallen whose 2011 doctorate from Cambridge focused on mourning in the work of Marcel Proust. Her polyglot team includes three other investigators and a manager, all with doctorates in either history or literature, all with Swiss affiliations. They are supported by ten assistants, mostly graduate students, seven from Canada and one each from the Netherlands, Switzerland, and the United Kingdom. They rely on an advisory board of four distinguished scholars from Montreal, Glasgow, London, and Garrison, New York (the Hastings Center).  

Funded in part by a starting grant from the European Research Council for five years (2023-2028), assistedlab.ch also acknowledges support from several other universities. It is active on Bluesky with 1400 followers and, in mid-2025, launched a newsletter to feature the latest entries and events of interest. 

Aside from its specific subject-matter, assistedlab.ch has many features in common with our own Medhum, the most obvious being the preparation of reviews by team members. The site is plain but attractive and color-coded for analysis of textual, performance, visual and audio sources, the majority being textual sources. Each menu entry sports a black and white image, which sometimes turns to color upon clicking. The sources – fiction and non-fiction books, short stories, essays, films, plays, artwork, podcasts, memoirs, news reports, and farewell letters from the recently deceased. Most sources are linked from the articles describing them, most from recent decades but some dating back to the 1990s. A bibliographic list of further reading in print or other media accompanies each entry. Keyword tags and an efficient search function make exploration easy. 

At the time of writing, assistedlab gathers more than a hundred articles, all in English, although the works examined can be in other languages. In addition, a news section, similarly color-coded, provides information about upcoming and recently past events: lectures, theatre, conferences, workshops, interviews and new publications. Thoughtful description takes precedence over hyperbolic criticism or praise, making the site welcoming for anyone approaching this dire matter with curiosity for themselves or their loved ones in terms of personal or professional life. It will be fascinating to learn usage statistics for assistedlab.ch, not only the numbers, but also the geographic origins and user traits, for it should serve a wide array of human beings as we wrestle with the most fundamental of existential questions facing us all.  

Web image from Assistedlab.ch.

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

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

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

The Plague Comes for the Twins 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The fleas have found Judith. 

When Literary Narrative Serves as Biomedical Text 

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

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

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

Hamnet
Maggie O’Farrell
Alfred A Knopf; 2020

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

Image Credits

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