Posts Tagged 'medical history'

Solzhenitsyn’s Cancer Ward: “A definite opinion has been established.”

I should start by explaining that Alexander Solzhenitsyn’s Cancer Ward is about a cancer ward. The reviewers, like this one in the New York Times, 1968, are going to tell you that the ward symbolizes the Soviet Union, and the cancer the moral rot eating away at the souls of the Soviet people:

As “One Day [in the Life of Ivan Denisovich]” stands for the agony of all Russia under Stalin, so “The Cancer Ward” irresistibly conveys an image of the immediate post-Stalin period when both victims and executioners were confined, all equally mutilated, in the cancer ward of the nation.

…and that Solzhenitsyn was just being cagey when he told the secretariat of the Union of Soviet Writers – who had declined to approve his book for publication – that,

The fact is that the subject is specifically and literally cancer, a subject avoided in literature, but nevertheless a reality as its victims know only too well from daily experience.

alexander solzhenitsyn cancer ward

In that meeting (a transcript is included as an appendix in the Bantam paperback edition of Cancer Ward), whenever Solzhenitsyn was invited to speak he made a point of disavowing his earlier, more explicitly political play Feast of the Conquerors, which had particularly upset the bigwigs. He told them that he now regarded his play as “very dangerous”. [1] He could’ve told them to stuff it – one kind of wishes he had – but at this point he still had hopes of pestering them into greenlighting his new novel.

(They never did. They kicked him out of the union a couple years later.)

So sure, he was being cagey. But I think he meant what he said about Cancer Ward. He must have known that his subject would invite all kinds of speculation about its symbolic significance, but it really is a book about life in a cancer ward. That seems to have been a big part of what annoyed the commissars from the Union of Soviet Writers. Why cancer, comrade? Isn’t it just kind of gratuitously depressing? As a member of the secretariat named Kerbabaev put it,

Why does the author see only the black?

This line of criticism echoes one of the debates within the novel, which begins when a patient named Podduyev, a man of rude and unreflecting vitality, is given a book of short stories. To his surprise, one of the stories seems to answer a question that’s been haunting him for weeks, as he has grappled with the reality of his disease. He decides to share his revelation with the others in the cancer ward:

“Listen, here’s a story,” he announced in a loud voice. “It’s called ‘What Men Live By’.” He grinned. “Who can know a thing like that? What do men live by?”

Treating the title as a riddle, he challenges the other patients to offer their speculations. One suggests that men live by air, water, and food. Another, by their pay. Another, by their professional skill.

In the bed across from Podduyev is a self-satisfied little man called Rusanov, a person of some political influence – for instance, rather than wearing the ill-fitting pyjamas assigned by the hospital, he’s been allowed to bring in his own. Later we’ll learn that Rusanov has acquired his position through the strategic denunciation of neighbours and co-workers.

Relaxing his customary aloofness toward the other patients, Rusanov decides to settle the debate:

“There’s no difficulty about that,” he said. “Remember: people live by their ideological principles and by the interests of their society.”

Discomfited by Rusanov’s tone of certainty, Podduyev attempts to summarize the story in his own words. It’s a fable about a poor cobbler who takes as an apprentice a mysterious beggar who, it soon emerges, may have the power of prophecy.

Rusanov has no patience for such mystical nonsense. He interrupts Podduyev, demanding that he skip to the end and tell them what, in the author’s opinion, men live by.

“What do they live by?” He could not say it aloud somehow. It seemed almost indecent. “It says here, by love.”

“Love? . . . No, that’s nothing to do with our sort of morality.”

Upon being demanded to tell who wrote this sentimental tripe, Podduyev haltingly enunciates the author’s name: “Tol . . . stoy.” Not, it soon emerges, Alexei Tolstoy, winner of the Stalin Prize, but “the other one” – that old pious fraud whose ideological errors had been settled long ago by Lenin, who wrote in 1908 that,

The contradictions in Tolstoy’s works, views, doctrines, in his school, are indeed glaring. … On the one hand, the most sober realism, the tearing away of all and sundry masks; on the other, the preaching of one of the most odious things on earth, namely, religion[.]

Having reminded his listeners of these facts, Rusanov retires complacently from the debate.

But the topic comes up again some days later. Along with Podduyev and Rusanov the ward contains a romantic character called Kostoglotov, a former political prisoner subsequently exiled to a remote village in Central Asia. (The location of the hospital is never spelled out, but is presumably Tashkent, where the author was treated for cancer after his stint in prison.)

A cynic with a long scar on his cheek from a brawl with urkas in the Gulag, [2] Kostoglotov inevitably winds up at odds with the doctrinaire Rusanov. But they have in common a sermonizing bent, which one evening inspires Kostoglotov to hold forth on the healing properties of optimism:

“So I wouldn’t be surprised,” Kostoglotov continued, “if in a hundred years’ time they discover that our organism excretes some kind of cesium salt when our conscience is clear, but not when it’s burdened, and that it depends on this cesium salt whether the cells grow into a tumor or whether the tumor resolves.”

[Podduyev] sighed hoarsely. “I’ve mucked so many women about, left them with children hanging round their necks. They cried . . . mine’ll never resolve.”

“What’s that got to do with it?” [Rusanov] suddenly lost his temper. “The whole idea’s sheer religious rubbish! You’ve read too much slush, Comrade Podduyev, you’ve disarmed yourself ideologically. You keep harping on about that stupid moral perfection!”

“What’s so terrible about moral perfection?” said Kostoglotov aggressively. “Why should moral perfection give you such a pain in the belly? It can’t harm anyone – except someone who’s a moral monstrosity!”

“You . . . watch what you’re saying!”

[Rusanov] flashed his spectacles with their glinting frames; he held his head straight and rigid, as if the tumor wasn’t pushing it under the right of the jaw. “There are questions on which a definite opinion has been established, and they are no longer open to discussion.”

“Why can’t I discuss them?” Kostoglotov glared at Rusanov with his large dark eyes. […]

“If you wish to state your opinion, at least employ a little elementary knowledge.” [Rusanov] pulled his opponent up, articulating each word syllable by syllable. “The moral perfection of Leo Tolstoy and company was described once and for all by Lenin, and by Comrade Stalin, and by Gorky.”

“Excuse me,” answered Kostoglotov, restraining himself with difficulty. He stretched one arm out toward Rusanov. “No one on this earth ever says anything ‘once and for all’. If they did, life would come to a stop and succeeding generations would have nothing to say.”

[Rusanov] was taken aback. The tops of his delicate white ears turned quite red, and round red patches appeared on his cheeks.

In a realistic twist, Kostoglotov soon finds himself contradicting himself – he started out arguing for optimism and now finds himself arguing for facing up to the grim facts:

“Why stop a man from thinking? After all, what does our philosophy of life boil down to? ‘Oh, life is so good! . . . Life, I love you. Life is for happiness!’ What profound sentiments. Any animal can say as much without our help, any hen, cat, or dog.”

And as the other patients jump in with their own opinions, and Rusanov is distracted by a twinge in his tumor, the discussion veers off in another direction.

***

One of the ironies of this scene is that the more sympathetic figure in the quarrel is arguing for what we would now describe as some kind of holistic “alternative medicine” approach to cancer treatment – the kind that many of us, myself included, would wave off as pseudo-scientific quackery. Shortly after proclaiming his right to think and speak freely, Kostoglotov is invited by another patient to elaborate on a folk remedy to which he’d previously alluded:

“Friends!” he said, with uncharacteristic volubility. “This is an amazing tale. I heard it from a patient who came in for a checkup while I was still waiting to be admitted. I had nothing to lose, so straightaway I sent off a postcard with this hospital’s address on it for the reply. And an answer has come today, already!”

Kostoglotov’s correspondent is a country doctor near Moscow, who (the letter explains) observed that cancer was rare among the peasants he treated. Deducing that this immunity was derived from their consumption of a tea made from a birch tree fungus called chaga, the doctor now promotes the fungus as an anti-cancer remedy. His letter contains a recipe for drying the fungus and preparing the tea: Kostoglotov reads the instructions aloud, and the other patients eagerly copy it down.

The catch is that the chaga can only be found on certain birches in northern forests, far from the Central Asian plain:

“He says here there are people who call themselves suppliers, ordinary enterprising people who gather the chaga, dry it and send it to you cash on delivery. But they charge a lot, fifteen roubles a kilogram, and you need six kilograms a month.”

Rusanov is, of course, outraged by such profiteering:

“What sort of a conscience do they have, fleecing people for something that nature provides free?”

But his Communist principles don’t prevent him from joining the other patients in importuning Kostoglotov for the address of the supplier of the miracle cure. Kostoglotov, however, resolves to share the secret only with a few of his closest friends among the patients.

After this, the chaga is mentioned only in passing; one of the patients gets his hands on some, but we never find out whether it helps him.

Equally unknown is whether Solzhenitsyn tried chaga in the treatment of his own cancer – though some seem to think he did. Lately chaga, which also grows in Canadian forests, has been promoted as a “superfood”, leading to overharvesting of the rare fungus. Whether it actually does anything is open to question.

There is another herbal treatment mentioned in Cancer Ward – “the root from Issyk Kul”, an infusion of aconite in vodka. When Kostoglotov’s doctor discovers that he’s been treating himself with the highly poisonous compound, acquired from a medicine man in the country, she insists that he hand the bottle over to her. He resists:

“When I leave the clinic I’ll want the root extract to treat myself with. I don’t suppose you believe it works?”

“No, of course I don’t. It’s just a lot of dark superstition and playing games with death. I believe in systematic science, practically tested. That’s what I was taught and that’s the way all oncologists think. Give me the bottle.” […]

“Oh, I know about your sacred science,” he sighed. “If it were all so categorical, it wouldn’t be disproved every ten years!”

Former president of the American Cancer Society Vincent T. DeVita described how in the early 1970s one of his patients, a former U.S. ambassador to the Soviet Union, was told by Solzhenitsyn that he credited a similar infusion – not of aconite, but of mandrake root – for the remission of his cancer.

The ambassador, suffering from advanced cancer of the pancreas, brought Dr. DeVita a handful of mandrake root and some 80-proof vodka and asked for his help preparing the medicine per the author’s recipe. DeVita declined – this wasn’t “systematic science, practically tested” – but gave the ambassador leave to try it on his own.

After the ambassador’s death – from cancer, not self-medication – his wife brought DeVita the remainder of the medicine they’d prepared, and asked him to have it analyzed:

I called the chief of our natural products branch, told him the story, and asked if he would do it. His interest was piqued. “Sure,” he said.

A month later he called me, expressing his amazement: “Vince, this stuff contained two cancer drugs we have had under development, VP-16 and alpha peltatin.” […]

“Not only that,” he continued, but the exact concentration of alcohol needed to extract the alkaloids from the roots is the concentration in 80 proof vodka. “And, you’re not going to believe this, but there is enough drug in eight grams of root to provide a therapeutic dose of VP-16,” he said. In other words, Solzhenitsyn’s root-and-vodka recipe had neatly created a version of the medication strong enough to treat cancer.

***

There are two ways to read Solzhenitsyn – well, there are hundreds, I suppose, but let’s stick to the two. You can read him as an uncompromising evangelist for Truth – the Truth that goes on happening while academics and bureaucrats squeak contrary pronouncements from within their clockwork models of ideological clarity. This is the reading typified by the social conservative author and blogger Rod Dreher, who has named his upcoming book Live Not By Lies after an essay Solzhenitsyn wrote in 1974 – shortly before he got kicked out of his country:

If we did not paste together the dead bones and scales of ideology, if we did not sew together the rotting rags, we would be astonished how quickly the lies would be rendered helpless and subside.

That which should be naked would then really appear naked before the whole world.

So in our timidity, let each of us make a choice: Whether consciously to remain a servant of falsehood … or to shrug off the lies and become an honest man worthy of respect both by one’s children and contemporaries.

Whereas I tend to read Solzhenitsyn as an evangelist of Uncertainty. The last time I wrote about him I quoted this passage from The First Circle. The setting is a prison – once again, Solzhenitsyn’s own experiences formed the basis of the story – and the character being described is the prison’s security officer, Major Shikin:

If Shikin had been told – though he never was – that he was an object of hatred because he maltreated people, he would have been genuinely indignant. He had never found pleasure in any form of cruelty or thought that it was an end in itself. It was true that there were such people: he had seen them on the stage and in films. But they were sadists who loved to torture people, and had lost all human feeling. In any case they were always White Guardists or Fascists. Apart from doing his duty, Shikin was concerned only to prevent people committing wrongful acts or thinking harmful thoughts.

Like Major Shikin, Rusanov in Cancer Ward is secure in his own well-meaningness: he only wants to protect his fellow patients from being exposed to dangerous falsehoods. We might scoff at his statement that “There are questions on which a definite opinion has been established, and they are no longer open to discussion” – and yet few of us would argue for absolute open-mindedness. The idea that Tolstoy’s supposed ideological errors, as defined by Lenin, should be one of those undiscussable questions strikes us as absurd, just as it would strike Rusanov as absurd that – well, choose your own article of contemporary dogma.

I’m afraid that if I were in that Tashkent cancer ward listening to Kostoglotov prattle on about herbal remedies, I would react much as Rusanov did: “If you wish to state your opinion, at least employ a little elementary knowledge.” (Although I wouldn’t say it out loud.) While Kostoglotov dosed himself with mysterious rural potations, I would defer to the scientific opinions of the doctors. And if I’d been brought up believing that Lenin had scientifically settled the question of Tolstoy’s literary merit, I suppose I’d defer to that opinion too.

M.

1. If Solzhenitsyn’s Feast of the Conquerors has ever been translated into English, it seems not to be online. Nowadays it usually goes by the name Feast of the Victors or The Victors’ Feast. Russian readers can find it here: Пир победителей.

The author made a triumphant appearance at the play’s belated world premiere in Moscow in 1995.

2. The urkas or urki were thieves (my edition of Cancer Ward translates the term as “hoods”) who, as “socially friendly” elements – enemies of private property – were given an easier ride in Soviet prison than the “politicals”. As Solzhenitsyn explains in Part III of The Gulag Archipelago:

Here is what our laws were like for thirty years – to 1947: For robbery of the state, embezzlement of state funds, a packing case from a warehouse, for three potatoes from a collective farm – ten years! (After 1947 it was as much as twenty!) But robbery of a free person? Suppose they cleaned out an apartment, carting off on a truck everything the family had acquired in a lifetime. If it was not accompanied by murder, then the sentence was up to one year, sometimes six months.

Conscious of their privileged status, the urkas would rob and tyrannize the political prisoners while the guards did nothing:

[I]t was much better for the business of oppression; the thieves carried it out much more brazenly, much more brutally, and without the least fear of responsibility before the law.

Much like convicts in American prisons who take it upon themselves to dole out extra punishment to sex offenders, the urkas regarded their abuse of the politicals as a matter of honour. Solzhenitsyn quotes an ex-convict:

I was even proud that although a thief I was not a traitor and betrayer. On every convenient occasion they tried to teach us thieves that we were not lost to our Motherland, that even if we were profligate sons, we were nevertheless sons. But there was no place for the “Fascists” on this earth.

The “Fascists” included reprobates like Kostoglotov in Cancer Ward, sentenced to eight years, followed by permanent exile to Central Asia, for participation in a non-approved university discussion group.

For more on the urkas, this undergrad thesis by Elizabeth T. Klements is worth reading: “Worse Than Guards:” Ordinary Criminals and Political Prisoners in the GULAG (1918-1950)

There must be something about that “Major Shikin” passage from The First Circle that really speaks to me. I first used it in a discussion last year of Jordan Peterson, and a few months later I trotted it out again in a critique of the movie It: Chapter Two. Having used it three times, it’s probably time for me to retire it.

 

The media vs. the populists.

In June I published a long essay inspired by the memoirs of John Diefenbaker, Canada’s prime minister from 1957-63.

It’s kind of rambling and haphazard and I wouldn’t say it has a thesis, exactly. But to my mind its various digressions share a common theme, which is how in many ways Diefenbaker presaged modern populist conservatives like Trump, FarageLe Pen, Salvini, Orban, etc. – not in his policies, which were particular to mid-century Canada, nor in his rhetoric, which was pompous and long-winded by modern standards, but in the intense allergic reaction he provoked in the establishment, especially the media.

For those unfamiliar with Diefenbaker’s career (and not quite up to tackling my 6,000-word essay): in 1957 his Progressive Conservatives edged out a Liberal government that had been in power seemingly forever; the following year he won what was up to then Canada’s largest ever parliamentary majority; and in 1963, fatally wounded by a mutinous cabinet, a hostile media, and an opposition Liberal Party openly in cahoots with the U.S. administration of John F. Kennedy, he was defeated.

He made many unforced errors during his six years in office, and his bristly, paranoid personality alienated many allies. But the specific issue that led to his downfall was his resistance to accepting American nuclear warheads for the Bomarc missile system his government had over-hastily purchased a few years earlier to contribute to continental defence against Soviet bombers.

Diefenbaker seems initially to have been happy to take the nukes, subject to negotiations to ensure that Ottawa would have a meaningful say if it ever came to launching them. He dragged his feet for a few years, attempting to reconcile his cabinet’s hawks and doves, but was finally won over to his foreign minister’s position: that there was no formula for hosting U.S. nukes that would preserve Canada’s military sovereignty, that a nuclear-armed Canada would lose the moral authority to argue for disarmament, and that the Bomarcs were pretty much useless anyway, with or without nukes.

I’m neutral on the nuclear issue. I can see how Diefenbaker might have accepted the need to sacrifice a degree of sovereignty in order to preserve a strong NATO front against the Soviets. I can also see how nuking up might have seemed to him a provocation more likely to lead to war than to deter it.

But as a Generation Xer who has spent his whole life steeped in a media culture that portrayed the arms race as little better than a case of collective hysteria, and the pro-nuclear side as a mob of sinister psychopaths and spittle-spraying buffoons, I was surprised by the consistently negative spin mid-’60s journalists put on Diefenbaker’s anti-nuke stance. They called it incoherent, divisive, anti-American, and most of all, the word that shows up again and again in nearly every account of the Diefenbaker years, indecisive.

(Then they praised Liberal leader and secular saint Lester B. Pearson for, uh…decisively repudiating his previously held position, and announcing that he would take the nukes Dief had refused.)

It’s not searchable on Google Books and I’m too lazy to confirm by re-reading the whole thing, but I’d guess that the words indecision and indecisive appear on every fifth or sixth page of Peter C. Newman’s bestselling critical account of the Diefenbaker years, Renegade in Power; and that if I threw in synonyms and near-synonyms like hesitate, prevaricate, waffle, etc., I’d find a reference to Diefenbaker’s indecisiveness on every other page.

Indecision was to the Diefenbaker years what chaos has been to the Trump years – the lens through which journalists observe their subject, bringing certain events and narratives into focus while reducing others to an irrelevant background blur.

Take this editorial by John Ivison in the National Post back in June, in which President Trump’s reluctance to blame the Iranian leadership for an attack on oil shipping in the Persian Gulf was cast as an instance of Trumpian chaos:

Trump had his own theory about what might have happened. “I may be wrong but I may be right and I’m right a lot,” he said, positing that someone down the chain of command had ordered the strike. “I find it hard to believe it was intentional.”

It was a classic example of Trump’s political improv – a stream of consciousness, informed by his own narrow experience, based on evidence that conforms to his own prejudices and rejects evidence that contradicts them. War and peace; life and death, all governed by the chaos theory that permanent destabilization works to America’s advantage.

While there are any number of U.S. actions in recent years to which the description “permanent destabilization” might reasonably apply, surely declining to launch missiles at Iran isn’t one of them. But when evaluating Trump, Ivison’s instruments of punditry are permanently set to “chaos”, so that’s all he’s capable of seeing.

***

Speaking of Ivison, I chuckled at his quixotic attempt a couple weeks ago to paint Canada’s relentlessly progressive prime minister as a populist:

[T]here are few more capable exponents of populist techniques than Justin Trudeau. He is clearly not an authoritarian right-wing demagogue, playing on the insecurities created by cultural competition that have left many voters feeling estranged from the predominant values in their own country.

But even if his causes are more cosmopolitan – globalism, diversity, women’s empowerment – they are similarly tribal and, at times, equally disdainful of divergence from their orthodoxy.

Trudeau and his team have been adept at using polarizing rhetoric, symbolism and identity issues, even while accusing his opponents of adopting “the politics of division.”

What is a populist, anyway? In his memoirs Diefenbaker recalled challenging a Conservative Party bigwig who’d dismissed him as a “western populist” to explain what he meant by the phrase:

He thought it was some kind of erratic radicalism. When pressed further, he wasn’t certain what his new term encompassed, except that it did encompass those things he disapproved of.

Diefenbaker’s “western populist” government relaxed immigration rules, expanded social welfare programs, made liberal reforms to the criminal justice system, and took modest steps to make government more accessible to linguistic and ethnic minorities. But none of that mattered. What mattered was that Diefenbaker refused to go along with the agenda of a glamorous Democratic president who was beloved by the media. Therefore he could be dismissed as an uncultured bigmouth from the sticks.

(I suspect that if Diefenbaker had stayed in office long enough to quarrel with the unloved Lyndon Johnson, he’d have a much better reputation today.)

Nowadays, the populist agenda includes restricting immigration, using targeted tariffs to protect blue-collar jobs, and bringing the troops back home. These are currently associated with Donald Trump and the American right, but until a few years ago the latter two causes were largely the province of the left.

(Through the Bill Clinton era, the left also harboured a significant anti-immigration constituency; Bernie Sanders was playing to this vanished audience as recently as 2015.)

In 2016 Hillary Clinton won more votes than Donald Trump; her agenda was, arguably, more popular than his. And yet it was Trump, and not Clinton, who was labelled a populist. Clearly this had less to do with Trump’s popularity than with his unpopularity among those with the power to label him.

As Diefenbaker put it, populism encompasses all those things the influential people disapprove of. Or to be more precise, it’s whatever is currently popular among ordinary folks and unpopular among the elite.

***

At the local level, populism often entails citizens rebelling against plans imposed by a remote and unresponsive city hall – plans like paving over beloved green spaces, plunking social housing in sleepy suburbs, and rezoning low-density neighbourhoods to permit apartment blocks. Such rebellions also tend to jumble left-right ideological alignments.

Think of the writer Jane Jacobs, who rose to local fame organizing the opposition to a planned Lower Manhattan Expressway. As described by Alex Mazer in The Walrus,

Backed by her own lack of formal training (she left Columbia University after two years of undergraduate study) and her grandmotherly demeanour, she cast herself as an underdog in a world of credentialed experts – be they economists, traffic engineers, civil servants, or professors – and her attacks on them could be unrelenting. Like a populist politician, she cast her opponents as out of touch with reality, ignorant of plain facts, and dismissive of regular folks.

The urban model Jacobs advocated – bustling, pedestrian-friendly mixed-use streets like those of her beloved (1960s-era) Greenwich Village – is now generally associated with the progressive left, and opposed by the kind of populists who rail against bike lanes and gas taxes. And yet her most famous book, 1960’s The Death and Life of Great American Cities, is a paean to small businesses and bottom-up organization.

Nowadays she’s as likely to be lauded in right-wing publications like The American Conservative and City Journal as in left-wing ones like Salon and Slate; if anything, she gets rougher handling on the left, where the woke vanguard kvetches that she was white and out-of-touch.

Death and Life lambastes the practices of her era’s urban planners, under whose guidance cities were diligently bulldozing poor but functioning “slums” and replacing them with brand-new public housing projects that quickly became cesspits of crime and decay.

They pursued these ruinous policies in the name of an academic fad Jacobs mocks as “radiant garden cities”, combining aspects of Le Corbusier’s Ville radieuse and Ebenezer Howard’s Garden Cities of To-Morrow into a glossy vision of urban life with all its noise and disorder banished to the margins.

The trouble was that in the real world, banishing noise and disorder also entailed banishing street life and economic diversity, creating at best well-manicured dead zones, and at worst unfenced reservations for street punks to roam.

While some of Jacobs’ modern fans would like to believe that her foes were villains “oozing arrogance and reptilian cunning”, she’s clear in Death and Life that the “radiant garden city” vision was pursued by intelligent men with a sincere desire to improve the lives of the people whose neighbourhoods they were wrecking. Jacobs compares them to an earlier movement of self-confident blunderers:

And to put it bluntly, they are all in the same stage of elaborately learned superstition as medical science was early in the last century, when physicians put their faith in bloodletting, to draw out the evil humors which were believed to cause disease. With bloodletting, it took years of learning to know precisely which veins, by which rituals, were to be opened for what symptoms. A superstructure of technical complication was erected in such deadpan detail that the literature still sounds almost plausible.

However, Jacobs goes on, the practice of bloodletting was “tempered with a certain amount of common sense”, until in the United States it was pushed to new levels of recklessness by the brilliant and revered Dr. Benjamin Rush, under whose instruction the technique was applied “in cases where prudence or mercy had heretofore restrained its use”:

He and his students drained the blood of very young children, of consumptives, of the greatly aged, of almost anyone unfortunate enough to be sick in his realms of influence. His extreme practices aroused the alarm and horror of European bloodletting physicians.

And yet, as late as 1851, a committee appointed by the State Legislature of New York solemnly defended the thoroughgoing use of bloodletting. It scathingly ridiculed and censured a physician, William Turner, who had the temerity to write a pamphlet criticizing Dr. Rush’s doctrines and calling “the practice of taking blood in diseases contrary to common sense, to general experience, to enlightened reason and to the manifest laws of the divine Providence.” Sick people needed fortifying, not draining, said Dr. Turner, and he was squelched.

Jacobs doesn’t mention that Dr. Turner’s opposition to bloodletting derived from his adherence to a then-trendy form of alternative medicine known as the “chrono-thermal system”, brainchild of the Scottish doctor Samuel Dickson.

Dr. Turner wrote the introduction to the American edition of Dickson’s jeremiad The Principles of the Chrono-thermal System of Medicine, which had been ridiculed in the British and Foreign Medical Review:

The plain truth is, as every one must see, the whole book is a farrago of nonsense; a hash of a few old truths and many fantastic speculations, made piquant by the most amusing self-laudation on the part of its author, and the most extravagant abuse of his professional brethren and imagined rivals.

I’m no doctor, but from what I can glean of his system, Dickson was indeed some kind of crank. However, if you submitted to his treatment, the worst that was likely to happen was he failed to cure you; whereas a doctor who stuck to the conventional wisdom as represented by the British and Foreign Medical Review might very well open your vein and kill you.

The 1960s urban planning consensus has held out a little better than the 1850s medical consensus. While doctors rarely bleed their patients these days, planners continue to blight cities with roads that hinder the movement of pedestrians while doing little to improve the movement of cars. Still, Jacobs’ critique has been so successful that it no longer qualifies as populist: it has been absorbed into the establishment against whom the anti-density, pro-freeway rabble hoist their pitchforks.

I won’t make a fool of myself by attempting to predict which wacky idea currently disdained by the academy, the media, and most of the people reading this essay will in a half-century be seen as so obvious that only fools and villains could ever have opposed it. Today’s populism will become tomorrow’s establishment, and a new populism will burble up to be snickered at and hand-wrung over.

M.

The medical men of Middlemarch.

There must be two dozen books on my shelves that I’ve never read, but recently, after coming across a couple references to how dauntingly unreadable Middlemarch is, I decided to verify my hazy impression that I’d found it absorbing from the start.

george eliot middlemarch

Maybe “absorbing” is the wrong word. Victorian novels demand sifting, extracting, unpacking. Many sentences need to be double-read: once through to sort out how the clauses relate to each other and again to determine how they relate to the story. You’d think I’d find it tedious. I’m not enchanted with complexity for its own sake. My eyelids tend to droop when I read poetry, for instance, even stuff I know I should admire, like Shakespeare. George Eliot begins each chapter with an epigraph, usually poetical; I skim them. But the story is interesting enough that I don’t mind unravelling the prose when it gets knotty. Clive James once disparaged another literary pretzel-twister, Edward Gibbon, for “the kind of stylistic difficulty which leads its admirers to admire themselves, for submitting to the punishment.” Perhaps liking Middlemarch is a kind of masochism.

The other day, awaiting the inevitable callback from my garage to upsell me from a routine oil-and-lube to major repairs, I found myself wondering why mechanics can’t operate the way Mr. Lydgate does in Middlemarch. I know that sounds unbearably pretentious but it’s what I was thinking.

Most readers remember Middlemarch for the thwarted romance of widowed Dorothea Casaubon and the passionate but aimless Will Ladislaw. Mr. Lydgate is the hero of what a screenwriter would call the “B-plot”; to quote the rear cover copy on my Signet Classic paperback, Lydgate is “an ambitious young doctor who is betrayed by his wife’s egoism and his own inner weakness.” The rather haughty surgeon-apothecary, newly arrived in Middlemarch, offends local custom by acting on the principle that a doctor should “simply prescribe, without dispensing drugs or taking percentage from druggists.” He explains that,

it must lower the character of practitioners and be a constant injury to the public if their only mode of getting paid for their work was by their making out long bills for drafts, boluses, and mixtures.

This explanation gets rather muddled in third-hand transmission to a competitor:

The next day Mr. Gambit was told that Lydgate went about saying physic was of no use.

“Indeed!” said he, lifting his eyebrows with cautious surprise. (He was a stout, husky man with a large ring on his fourth finger.) “How will he cure his patients, then?”

“That is what I say,” returned Mrs. Mawmsey, who habitually gave weight to her speech by loading her pronouns. “Does he suppose that people will pay him only to come and sit with them and go away again?”

This business about Lydgate and his rivalry with the town’s other “practitioners” is one of those subtle questions of class and custom that gets lost on the modern reader. On first reading Middlemarch I failed to notice that Lydgate is referred to as “Mr.”, never as “Dr.” The latter honorific is reserved to those, like the town physicians, Dr. Minchin and Dr. Sprague, who have “been to either of the English universities and enjoyed the absence of anatomical and bedside study there”. In other words they have been more expensively though not more comprehensively educated. Mr. Lydgate, by contrast, after his apprenticeship to a country apothecary, has studied at Edinburgh, Paris, and London, there picking up numerous progressive and unsettling ideas.

Middlemarch is set just before and after the accession of William IV in 1830, a time of much reformist ferment. A decade and a half earlier, Parliament had made a stab at straightening out the chaotic system of medical accreditation which then prevailed in the United Kingdom. As S.W.F. Holloway explained in the July 1966 issue of the journal Medical History (“The Apothecaries’ Act, 1815: A Reinterpretation: Part II“) , the new system effectively defined nearly all medical practitioners as apothecaries, and regulated them as such. Traditionally apothecaries had filled a role roughly analogous to pharmacists today, but the lines between the different classes of medical practitioners had become blurred. As Holloway quotes a contemporary source:

In London, and some of our other great towns, there are physicians and surgeons who do not compound or vend medicines; but in the country this distinction of the three branches of the profession does not exist. Except in a few of our largest towns, every man who practises medicine at all, likewise deals in drugs, and must do so … If he were not to supply [patients] with medicines, there is nobody else from whom they could procure them. The consequence is … that over all England the medical practitioners are also apothecaries, within the meaning of this act.

Physicians were an exalted class who could afford to forgo the unseemly necessity of seeking licensure as apothecaries, which required a five-year apprenticeship as an apothecary. Men of substance who could afford a degree from Oxford or Cambridge, physicians attended the sickbeds of the titled and propertied; the customary fee for a consultation was one guinea. All other medical men, known inclusively as general practitioners, were traditionally forbidden to charge an attendance fee. Their sole source of income was the “drafts, boluses, and mixtures” they peddled. As Holloway explains:

This system led not only to [the general practitioner] being considered a tradesman in an age when trade was regarded as a debased occupation: it also exposed him to the accusation of over-charging and over-prescribing. The apothecary, it was said in 1703, “makes the deluded Patient pay very extravagant Fees by the intolerable Prices he puts on all the cheap Medicines, and by passing upon him very many more Doses than the Disease requires or the Constitution can bear”.

(You can see why my mind ran to Lydgate as I sat awaiting the call from my mechanic, to pass upon me a Dose my Constitution could not bear.)

By charging for doctoring and not for drugs, Lydgate is offensive not only to the physicians on whose exclusive prerogative he is trespassing, but to his fellow general practitioners Mr. Wrench and Mr. Toller, to whom he appears to be trying to overreach his station:

“I say the most ungentlemanly trick a man can be guilty of is to come among the members of his profession with innovations which are a libel on their time-honoured procedure. That is my opinion, and I am ready to maintain it against anyone who contradicts me.”

“My dear fellow,” said Mr. Toller, striking in pacifically and looking at Mr. Wrench, “the physicians have their toes trodden on more than we have. If you come to dignity it is a question for Minchin and Sprague.”

“Does medical jurisprudence provide nothing against these infringements?” said Mr. Hackbutt with a disinterested desire to offer his lights. “How does the law stand, eh, Hawley?”

“Nothing to be done there,” said Mr. Hawley. “I looked into it for Sprague. You’d only break your nose against a damned judge’s decision.”

What decision is this? Holloway again:

The first step came in 1829 when Chief Justice Best, in Towne v. Gresley, held that an apothecary might charge for his attendance, provided he made no charge for the medicines furnished. But in the following year Lord Tenterden ruled that an apothecary might recover for reasonable attendance as well as for medicines.

Per this judgement, there’s nothing stopping Mr. Lydgate from charging a consulting fee and also pushing lucrative potions on his patients. But he refrains as a matter of principle.

Perhaps an idealistic thinker of the Lydgate type will one day reform the automotive repair industry so that garages are no longer incentivized, as apothecaries once were, to over-prescribe service. A consulting mechanic would examine our car and determine which fluids really needed flushing, which gaskets really needed replacing, then write out a prescription which we’d take to a practicing mechanic up the road, who’d actually carry out the repairs. I’m sure the first such practitioner would arouse much resentment and resistance among his fellow tradespeople. It would make good drama for a novel. Not the main story, probably. A B-plot.

M.

Update, July 28, 2020: Added cover image and linked to Bibliography page.


Michael A. Charles is a writer, animator, and musician currently living in the Vancouver area. He used to be the singer and guitarist for the band known as Sea Water Bliss.

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