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.

​​​Public reactions to t​he fatal shooting of a health care insurance company executive in front of a hotel in Midtown Manhattan on December 4, 2024, revealed a deep, seething antipathy across the country directed at the health insurance industry​, an antipathy that has existed for at least thirty years. ​Its ​persistence brings to mind four movies​: As Good as It Gets, Critical Care, and Rainmaker​, released in 1997 and ​John Q ​in 2002, ​each depicting scenarios where rage against the healthcare system play a key role. ​​​​​​ 

​As creators in the arts often do, the makers of these movies were picking up on trends and signals before they were appreciated throughout society, and envisioning how they might play out in real life​ 

How it starts 

“Fucking HMO bastards, pieces of shit…sorry.”  

This is how Carol reacts to the pediatrician who tells her the HMO should have covered certain tests for her suffering, asthmatic son. “Actually, I think that’s their technical name,” is the doctor’s response. This is from a scene in the 1997 movie, As Good as It Gets, directed by James L. Brooks. The movie won major awards from the Academy of Motion Picture Arts, Hollywood Foreign Press Association, and Screen Actors Guild​. It​ also ​drew ​attention from the mainstream press for revealing a building rage about to boil over.  

Ruthe Stein, from the San Francisco Chronicle, sensing the importance of the scene, wrote on December 23, 1997, 

As Good as It Gets may be the first movie to take on HMOs…Brooks strikes a chord when he has Carol use four-letter words to describe the HMO that has mangled her son’s case. The audience hoots and claps its approval.  

​​Then- ​President Clinton pointed to the scene as representative of real life while speaking at an event involving the Health Care Bill of Rights. 

Movies Raging Against the Managed Care Machine 

As Good as It Gets (1997, director – James L. Brooks). The movie mostly concerns the relationship between an author with obsessive compulsive disorder and a waitress whom the author depends on for a routine set of practices around his breakfasts. A side story involves the waitress’ young son who has severe asthma. At one point he needed certain tests done, but his health plan refused coverage. This situation led to the scene in which the boy’s mother reacted to this news in a way that attracted widespread public attention. The scene lasted for less than a minute, yet its effect on the image of managed care activities continued for years.  

The Rainmaker (1997, director – Francis Ford Coppola). The movie plot involves a scam operation posing as a health insurance company. A young lawyer, fresh from passing the bar exam, takes on the company through the case of a plaintiff. The plaintiff is a young man who has a form of leukemia that can be successfully treated but will kill him otherwise. The insurance company denies coverage for the needed treatment and denies seven subsequent appeals. The lawyer eventually ascertains that the company denies all claims as a matter of course. Although a judgment is made against it, the company declares bankruptcy and goes out of business, thereby vitiating the settlement awarded. The patient dies. The movie is perhaps best-known for a line said by the lawyer’s assistant which fueled the growing public sentiment at the time: “There’s nothing more thrilling than nailing an insurance company.”  

Critical Care (1997, director – Sidney Lumet). The setting for the movie is mostly in a hospital critical care unit. As in As Good as It Gets, a particular scene feeds the fury to come about managed care. A resident physician taking care of a terminal patient who has been clear about not wanting to continue treatments that only prolong suffering, argues with a senior physician and mentor about the advisability of putting the patient through yet more futile interventions. With his guard down from a combined state of inebriation and dementia, the senior physician tells the resident that the patient is fully insured and is thus a source of guaranteed revenue. He goes on to explain the economics (and immorality) driving these decisions.  

[With HMOs] we get paid not to perform medical procedures. It’s a little like when the government pays the farmers not to grow crops. However, with insurance we get paid to perform medical procedures. Do you understand the difference?  

On that basis, and that basis alone, he demands that the resident proceed full speed ahead. 

With this scene, the moviemaker is going further than pointing to just the managed care organizations as the source of rage, but also to the health care providers who can spot opportunities for self-dealing. Viewers already sensitized to managed care activities could become even more worried, incensed, or nihilistic about the situation.  

John Q (2002, director – Nick Cassavetes). About the same time John Q. Archibald’s full-time factory job is cut in half, along with his health insurance, his son collapses from heart failure while playing in a Little League baseball game. After a cardiologist tells John about his son’s need for a heart transplant and the financial requirements which he can’t meet, a nurse he asked why his heart condition had not been detected before tells them, “HMOs pay the doctors not to test. That’s how they keep costs down.” This comes up again when John asks the cardiologist how it could be that his son’s condition had never been discovered. An accompanying intern chimes in saying,  

HMOs pay their doctors not to test. That’s their way of keeping costs down. Let’s say Mike did need additional testing and insurance says they won’t cover them. The doctor keeps his mouth shut and, come Christmas, the HMO sends the doctor a fat-ass bonus check. 

The surgeon qualifies the intern’s assertion as possible but unlikely.  

Try as he might, John Q cannot come up with the $75,000 down payment. The hospital administrator will not put his son on the transplant list, and he is released to be taken home where he will die. John pulls out a gun and takes the emergency room hostage. No one is killed, no one is shot, and a solution is found in the end. However, the movie raised the level of rage to one that produced the possibility of gun violence.  

How It Ends? 

Nearly thirty years have passed since these first movies depicted the rage that came in response to aggressive measures directed at managing health care costs, especially when they involved restrictions on certain products and services health care providers ordered and patients expected. Did these movies get it right? In large measure, they did. Management activities got more aggressive over the years and indeed many of those portrayed that were particularly egregious became a reality for some. As a medical affairs executive in a large pharmacy benefit company before, during, and after these movies were released, I witnessed (and fought against) the scenarios they depict as well as many others as bad or worse (with the exception of gun violence).  

Where the movies helped to identify the problems early and possibly stoked the existing rage by bringing attention to them, they, along with professional health organizations, news media, and consumer advocates, pushed legislatures and regulatory agencies into creating laws and rules concerning how these activities are managed. These measures helped some, but media stories, books, and movies highlighting the problems appear regularly, keeping the rage alive, and maybe even intensifying it to the level anticipated in John Q. Maybe, even, to the level that played out on an early morning Manhattan street in December 2024.  

Podcast: The Clinic & The Person

Film Trailers

As Good as It Gets Trailer

John Q Trailer

The Rainmaker Trailer

Critical Care Trailer

Web photo by Christian Harb