John Last, MD. FRACP, FRCPC; University of Ottawa; Ottawa, Canada
Text based on a talk in a Symposium on “The role of the medical humanities in education and healing”, McMaster University, Hamilton, Ontario, May 19, 1999.
A complete physician needs insight transcending the knowledge, skills and attitudes that professional training provides. How can this be achieved? Personal experience of illness and suffering, or that of a close family member or a loved one, can do it. It is painful, but it can be a good way to comprehend the complexities of life, and of human nature.
Another way is through the humanities -- a rich source of insight into the human condition and the role of healers. The ethical, moral, and spiritual dimensions of sickness and healing are eloquently displayed in the creative arts -- in music, painting, sculpture, and most of all, in literature -- drama, poetry, fiction. Here I can only skim over the surface, touching without penetrating into the immense variety and richness to be found in literary works. (I mean real literature, not what authors of journal articles commonly call “the medical literature” -- a phrase that is almost always an oxymoron).
Our understanding of the complexities of society and human nature, and our values, come from good literature as well as from our medical experience. Fiction can portray social conditions brilliantly, as Charles Dickens did, for instance in Oliver Twist (1837) Dombey and Son (1848) and Little Dorritt (1855). Good writers often reflect on life and the values of their time. HG Wells, in Kipps (1905) and Anne Veronica (1909); JB Priestley, in The Good Companions (1929); Sinclair Lewis, in Babbitt (1922); John Steinbeck, in The Grapes of Wrath (1939); George Orwell, in Down and Out in Paris and London (1933), and The Road to Wigan Pier (1937); and legions of others in many countries have upheld this tradition through all the wars and turbulent events of the 20th century. John Updike’s four books about Harry (“Rabbit”) Angstrom, which dissect the life and values of an “average” American man and his family over the four decades from the 1960s to the 1990s are a good contemporary example. 1
The workings of the mind, and the whole range of emotions are another fruitful field for novelists -- and for poets. James Joyce's Ulysses (1922) perhaps the greatest novel in the English (or any other) language may be the best textbook ever written about how the mind works. Sylvia Plath and Anne Sexton revealed their tormented souls in their poems. Moran Campbell, a former chairman of the department of medicine at McMaster University, movingly described his bouts with the peaks and troughs of manic-depressive disorder in his autobiography, Not Always on the Level.2 The 19th Century Scottish poet James Hogg captured the personality of a paranoid psychopath in The Private Memoirs and Confessions of a Justified Sinner (1824), a work of fiction that reads chillingly like fact.
And the works of Shakespeare, of course, are the human mind laid bare, displayed in all its glory, misery, squalor, high spirits, splendour, imaginative sweep. Shakespeare's plays are at the highest pinnacle of a tradition that began with Homer and the Greek tragedians and continues through Samuel Beckett and Arthur Miller. Shakespeare is the undisputed master. If you would understand humanity, heed Hamlet, know Lear, love Rosalind, roister and frolic with Falstaff.
You can learn about the human dimensions of many aspects of disease and medical care from literary accounts:
Passion, compassion, confusion, and other emotions encountered in medical practice have been described by many creative writers, including some doctors.
In The Use of Force, William Carlos Williams, a family doctor, and a lyrical poet and short story writer in depression-era Paterson, New Jersey, described the passion of anger. He absolutely had to look at a little girl's throat because he suspected she had diphtheria. She fought him every step of the way. Her throat was hers! No busy body doctor was going to see it. She knocked his glasses off, kicked, scratched, and bit him. He got really angry. Here, abridged a little, is William Carlos Williams in New Jersey in the 1930s:
... now I had grown furious -- at a child. ...the worst of it was that I too had got beyond reason ... I could have torn the child apart. It was a pleasure to attack her... The damned little brat must be protected against her own idiocy ... in a final unreasoning assault I overpowered the child's neck and jaws... I forced the heavy silver spoon back of her teeth and down her throat till she gagged. And there it was -- both tonsils covered with membrane. She had fought valiantly to keep me from knowing her secret. She had been hiding that sore throat for three days at least and lying to her parents to escape just such an outcome as this. Now truly she was furious. She had been on the defensive before, but now she attacked. Tried to get off her father's lap and fly at me while tears of defeat blinded her eyes. 3
I’m sure this is a true story. Not long before I first read it, I had slapped a girl about that age, in front of her mother too, because I was fed up with her tantrums. (It was the act in my professional life that I am most deeply ashamed of, but at the time, more than 40 years ago, it felt satisfying and amply justified -- and it worked. Now it would be a criminal offence).
William Carlos Williams's gritty, real-life Doctor Stories are beautifully written accounts of real events and real people, but they are not comfortable reading. They explore the most powerful emotions a doctor can experience in dealing with sickness and suffering, birth and death.
Samuel Shem had just finished his internship year when he wrote The House of God about 20 years ago. Its black humour has been compared to Catch 22 and Mash but it is more obscene, scatological, cruelly callous -- yet also it is compassionate, sometimes very funny, and it can be deeply moving. A few scenes are unforgettable. One is the suicide of an intern who can't take it any more. Well, that's the facile, superficial explanation. The reality is that premonitory signs notwithstanding, no one, including the narrator, Samuel Shem’s alter ego, attempted to intervene as the unfortunate Potts slid into irretrievably profound depression. Another is a brief scene, sketched in just a few lines, of a young married woman who is brought in by the police for a medical examination after being raped. Her husband joins her. In a few lines about their body language, Shem describes how their lives and their loving relationship have changed forever:
“Have you called your husband yet?”
“No... I’m too ashamed,” she said, and she lifted her head up for the first time and looked me in the eyes, and first her eyes were dry cold walls and then, to my relief, they broke apart into wet pieces, and she screamed and screamed out, sob after sob ... after I did the workup for rape I called [her husband]. He’d been worried stiff and was glad she wasn’t dead. He could not know, yet, that part of her had died. [Her husband comes to collect her]... I watched them walk down the long tiled passage. He went to put his arm around her, but with a gesture I knew was disgust at the ruination of her body by a man, she pushed it aside. Separate, they walked out into the savageness...4
They never will touch one another again as they did before that night's evil was done. Vignettes like this elevate Shem above the brutal obscenity and ribaldry in the rest of this excellent book.
Doctors are often confused. The Yale surgeon Richard Selzer, a superb writer who ultimately quit surgery to write full-time, described how he once was transported back to the Middle Ages, confused, fearful, possessed by a devil, when on opening an abscess he was confronted by something alive, a hideous face with antennae and eyes staring at him. Reading this makes the hair on the back of my neck bristle. He managed to snare this unearthly beast with a pair of forceps, got it into a bottle of formalin. It was the maggot of a bot-fly, the abscess a common one in cattle, rarely seen in people. It was a deeply disturbing, confusing experience.
Confusion? Pity Emma Bovary’s cuckolded husband, poor Charles Bovary! In medical school he didn't even begin to understand what he was being taught, and when he became a country doctor he could not apply any of it. He lurched and staggered from crisis to crisis, reaching the depths with a major medical disaster, a badly botched diagnosis, at the same time as his marital disaster. He was dazed and constantly bewildered as a medical student:
The curriculum that he read on the bulletin board staggered him. Courses in anatomy, pathology, pharmacy, chemistry, botany, clinical practice, therapeutics, to say nothing of hygiene and materia medica -- names of unfamiliar etymology that were like so many doors leading to solemn shadowy sanctuaries. He understood absolutely nothing of any of it. He listened in vain; he could not grasp it. Even so, he worked. He filled his notebooks, attended every lecture, never missed hospital rounds. In the performance of his daily tasks he was like a mill-horse that treads blindfold in a circle, utterly ignorant of what he is grinding. 5
I can recall feeling a little like that once or twice when I was a medical student, but not all the time, thank goodness. I can also think of one or two students like Charles Bovary whom I’ve tried in vain to teach...
Confusion and disaster go together in Isabel Allende's account of the tragic death of her daughter, Paula -- brain dead in an episode of acute porphyria, and a long, slow death in deep coma. No one should read Paula as an account of a personal family tragedy due to a medical misadventure, though it is that too. Paula is about much else -- the Allende family, the culture and politics of Chile, lovemaking and childbirth as well as death, the evil of the Pinochet era and the good that overcomes that evil (themes that recur in Isabel Allende's other books) and her own passionate nature and the magic reality of her own life. And the long-term home care of a comatose patient with a tracheostomy... Paula is a celebration of life, and I think it will become a classic.
I am an epidemiologist, so I like books about epidemics. Berton Roueche’s Annals of Medical Detection in the New Yorker7 aroused my interest when I was a medical student, long before I thought of becoming an epidemiologist myself. Two and half thousand years later we puzzle, over Thucydides’ meticulous account of the epidemic that struck the Athenians at the end of the first year of the Peloponnesian War. Now we debate its possible cause, because we can't identify it despite the details Thucydides gives us. Daniel Defoe described in fiction 60 years after the fact the outbreak in 17th century London in Journal of the Plague Year (1722). Samuel Pepys who was in London in the plague year described it too, made it come to life so you can feel the fear and fatalism that infected Londoners even when the plague bacillus did not. Albert Camus's La Peste (1948) is ostensibly about the outbreak of bubonic plague in Oran, Algeria, in 1946; but it is really an allegory of how people become infected with evil ideas and beliefs like fascism. Camus fought in the French Resistance, and knew what he was talking about. Alexander Solzhenitsyn's Cancer Ward is another allegorical novel, a treatise on the cancerous onslaught of Soviet communism on the body and soul of Russia.
There is plenty of humour in fictional works about the doctor's trade. Much of it is satirical, deflating the egos, pricking the pomposity that prevails among too many of us. Shakespeare and Dickens let doctors off lightly considering the professional shortcomings of their times. Not Moliere or Laurence Sterne though: Dr Slop in Tristram Shandy (1759-64) is contemptible as well as a figure of fun. Proust’s description of one of his many doctors, who could discretely palm his fee like a magician, makes me smile ruefully. I had a partner like that when I was in practice... Sir Roderick Glossop, the brain surgeon in P G Wodehouse's novels, is a ludicrous caricature with no medical credibility. George Bernard Shaw was merciless, sceptical about the irrational behaviour of doctors in the first half of the 20th century. In Doctors’ Dilemma, which Shaw called a tragedy, he reserved his most savage criticism of medical customs and mores for the Preface8 which is salutary reading for everyone in the medical profession who is beginning to suffer from hubris. If Shaw were writing now, would he think we have improved? Have we improved?
It takes a real doctor to display our profession in ways that make me laugh out loud. Has there ever been an account of how to treat a belly-ache that can top A Cure of Serpents? Alberto di Pirajno’s treatment regimen was not only unorthodox, it was highly unethical.9 But it was very effective! (You must read his book to find out what it was; I won’t reveal it here). Richard Gordon and Colin Douglas, two pseudonymous modern British light novelists can make us laugh out loud too. Gordon's Doctor in the House (1952) and Doctor at Sea (1953) ring hilariously true. I find Doctor at Sea especially satisfying, having been a ship's doctor myself a few times, and had experiences like some of those that Gordon describes.
We have fictional portrayals of noble and good doctors too, like Tertius Lydgate in George Eliot’s Middlemarch. (1871). One “fictional” character from the early 20th century was a real person, the anthropologist and psychiatrist W H R Rivers, who treated shell-shocked soldiers in the Great War. He is brilliantly and sympathetically brought back to life in Pat Barker’s superb Regeneration 10trilogy.
The honour roll of doctors who deserted their calling to become writers is long and impressive. But some marvellous writers stayed on. It is a deeply satisfying aesthetic pleasure to read them. William Farr's success as a social reformer owes as much to the power of his language as to the facts he displayed in his Annual Reports (in Vital Statistics, part of his job as Compiler of Abstracts to the newly created Office of the Registrar of Births and Deaths in England and Wales). He held that office for over 40 years, from 1839 until near his death in 1883. Not a year went by without his beautifully crafted, rich and rolling phrases tugging at the emotions and the sensibility of his political masters. In his Report in 1874, he addressed the dramatic differences in health levels among English towns:
Take for example the group of 51 districts called healthy… turn to the district of Liverpool.. Here it is evident that some exceptional causes of death are in operation in this second city of England. What are these causes? Do they admit of removal? Is this destruction of life to go on indefinitely? Of 10,000 children born alive in Liverpool, 5396 live 5 years, a number that in the healthy districts could be provided by 6554 annual births. This procreation of children to perish so soon, the sufferings of the little victims, the sorrows and expenses of their parents, are as deplorable as they are wasteful. In Liverpool the death of children is so frequent and dreadful that a special system of insurance has been devised to provide them with coffins and burial ceremonies. The mother when she looks at her baby is asked to think of its death, and to provide by insurance not for its clothes but for its shroud and other cerements. 11
Farr’s contemporaries wrote well too. Read Florence Nightingale's Notes on Hospitals (1863) or her better-known but slight and slim volume of Notes on Nursing (1859). Read John Simon on Filth Diseases (1876) or on English Sanitary Institutions (1890) or go back to 1798 and read Edward Jenner’s Inquiry into the causes and effects of the variolae vaccinae, which describes his experiments with cowpox vaccine -- probably the most important advance in public health sciences of the past thousand years.
William Osler's Principles and Practice of Medicine, published in 1892 was a tour de force the like of which we will never see again, because it is no longer possible for the mind of one person to encompass and write about the entire body of medical knowledge. Osler's textbook is worth reading today, not only for the timeless clinical wisdom (clinical signs haven't changed) but also for Osler’s graceful, elegant prose style.
Alas, as every medical editor knows, such gifts that once were common among learned people are rare nowadays. Far too many authors of papers in contemporary medical journals are like cuttlefish, hiding in their own ink. Pitifully few can communicate an important medical or scientific message in good prose -- the verbal equivalent of a musician with perfect pitch. Lewis Thomas did it, in sparkling essays, many of them published as “Notes of a Biology Watcher” in the New England Journal of Medicine. Collected in book form they won two Pulitzer Prizes.12 Peter Medawar13 did it, and Oliver Sacks14 can do it too. But the little company of medical writers whose prose is like music or poetry is shrinking. I can count on my fingers the ones who give me pleasure as I read, and whose thoughts I admire.
You too can make life more pleasant for medical editors and for those who read what you write: learn to write well by following these examples! Even the good writers among you can become better. But of course this is not the real reason to read books like those I have mentioned here. The real reason is to enrich the mind and spirit, and to experience the pleasures of reading.
I am grateful to Dr. Karen Trollope-Kumar for inviting me to speak on this subject, and thereby stimulating me to think about the pleasures of reading; I probably owe my lifelong love of literature to my English teachers at St Peter’s College in Adelaide, Australia, in the early 1940s; and as always I am grateful to my wife, Wendy, for critical comments. This paper is based on a presentation at a Symposium on “The Role of the Medical Humanities in Education and Healing” at McMaster University, Hamilton, Ontario, May 19, 1999
1. Updike J: Rabbit, Run (1960); Rabbit Redux (1971); Rabbit is Rich (1981); Rabbit at Rest (1990). New York: Knopf; also available in Penguin.
2.Campbell E J Moran: Not Always on the Level. London: The Memoir Club (BMA Books), 1988.
3. Williams W C: The Use of Force in The Doctor Stories. Compiled by Robert Coles. New York: New Directions Paperbacks, 1984; pp 56-60.
4. Shem S: The House of God. New York: Dell, 1978; p 246.
5. Flaubert G: Madame Bovary. Translated from the French by Francis Steegmuller. New York: Vintage 1957; p 11.
6. Allende I: Paula; a memoir. Translated from the Spanish by Margaret Sayers Peden. New York: Harper Perennial, 1995.
7. Roueche B: Eleven Blue Men and Other Narratives of Medical Detection. Boston: Little, Brown & Co, 1954.
8. Shaw G B: The Doctor’s Dilemma. London: Constable, 1913; Preface on Doctors, pp 3-79.
9.di Pirajno A: A Cure of Serpents; a Doctor in Africa. London: Andre Deutsch 1955.
10.Barker P: The Regeneration Trilogy (Regeneration, The Eye in the Door, The Ghost Road). London: Penguin.