The Spouter-Inn: let’s see what’s inside

Photo courtesy of Tony Sun
Photo courtesy of Tony Sun

The third chapter of Moby Dick, “The Spouter-Inn,” is all about how to interpret new things. Ishmael, who settled on staying in the hotel called “The Spouter-Inn:–Peter Coffin,” tells readers about what he sees upon entering the hotel. Let us compare Ishmael to a medical student, first entering a new floor, say the neurology floor of a hospital. Ishmael and student are both faced with the task of making meaning from whatever presents itself. On that floor, the student wonders: who are the people sitting in the center of the floor? What is the meaning of the NPO signs next to some room entranceways? On entering Spouter-Inn, Ishmael wonders: what is this painting I see? What are the “monstrous clubs and spears” doing on the wall? I draw this comparison between Spouter-Inn and the neurology floor because I remember thinking about Ishmael’s first visit to that inn when I entered the neurology floor, where my physical diagnosis practice took place. I wasn’t sure what to expect, and there is not much to do for preparation. Like Ishmael, I just walked in and did my best to make sense of what I saw. If there was any “preparation” on my part, it was reading Moby Dick and knowing about the analogous situation of walking into a foreign Spouter-Inn.

For Ishmael, a painting hanging on the wall caught his attention, though he couldn’t make sense of what the painting was about. However descriptive he was about what he saw in the painting, he couldn’t give readers a definite sense of what the painting was. While you might see a painting at the Metropolitan Museum of Art and text your friend what you saw (Washington crossing the Delaware, or the like), Ishamel tells readers this:

A boggy, soggy, squitchy picture truly, enough to drive a nervous man distracted. Yet was there a sort of indefinite, half-attained, unimaginable sublimity about it that fairly froze you to it, till you involuntarily took an oath with yourself to find out what that marvellous painting meant. Ever and anon a bright, but, alas! deceptive idea would dart you through.–It’s the Black Sea in a midnight gale.–It’s the unnatural combat of the four primal elements.–It’s a blasted heath.–It’s a Hyperborean winter scene.–It’s the breaking-up of the ice-bound stream of Time…But stop; does it not bear a faint resemblance to a gigantic fish? even the great Leviathan himself?

Remembering Ishmael’s struggle to make sense out of that painting, I felt a comfort of familiarity, the best feeling I think that someone can feel when thrust in a new situation. It’s OK that Ishmael couldn’t make sense of the painting he saw on the wall, just as it’s OK that I didn’t know what to make sense of the labels telling me: NPO, or D5 0.45 NS. It’s no big deal to look those acronyms up on my smartphone, or just simply ask someone, the latter of what was done in Ishmael’s time: “based upon the aggregated opinions of many aged persons with whom I conversed upon the subject. The picture represents a Cape-Horner in a great hurricane.” This comfort of familiarity I mentioned earlier arises not necessarily from previously seeing the acronyms “NPO” and “D5 0.45 NS,” though seeing them before certainly does add to familiarity–no, this comfort comes from knowing that it’s not uncommon for someone, someone even as smart as Ishmael, to see something and be entirely uncertain what it is and to have several guesses as to its meaning.

Featured Image:
Silver Bank Outtakes by Christopher Michel


The carpet-bag: what to bring with me?

In the first chapter of Moby Dick, “Loomings,” Ishmael gives his reasoning for going on a sailing journey. He is anxious, irritable, and needs to find an escape from his current life, symbolized by the land, so he plans on going to sea as a sailor. In my previous post, I likened his narrative in the first chapter, redolent of the famous Shakespearean monologues, to an exchange between a patient and a physician. I noted that understanding Ishmael’s narrative is analogous to understanding a patient’s story. In chapter two, “The Carpet-Bag,” Ishmael prepares for his sailing journey and leaves Manhattan island, but he faces a problem:

Quitting the good city of old Manhatto, I duly arrived in New Bedford. It was a Saturday night in December. Much was I disappointed upon learning that the little packet for   Nantucket had already sailed, and that no way of reaching that place would offer, till the following Monday (Ch. II)

Ishmael realizes he must look for a hotel to spend the cold December weekend. He surveys the area and finds several hotels: The Sword-Fish, The Crossed Harpoons, and The Trap. Finally, he stumbles upon one that seems reasonable, at least by its name:

Moving on, I at last came to a dim sort of light not far from the docks, and heard a forlorn creaking in the air; and looking up, saw a swinging sign over the door with a white painting upon it, faintly representing tall straight jet of misty spray, and these words underneath- “The Spouter Inn:- Peter Coffin.”Coffin?- Spouter?- Rather ominous in that particular connexion, thought I. But it is a common name in Nantucket, they say, and I  suppose this Peter here is an emigrant from there (Ch. II).

Here, Ishmael’s response to something seemingly as simple as the name of a hotel illustrates an important point—that the perception of language shapes how one feels about what one’s exposed to in life. This is a vital issue in science and medicine, one that deserves more attention in medical education. A few weeks ago, Dr. Mary Simmerling of Cornell University gave a lecture to first year medical students about the ethical, social, and economic issues surrounding kidney transplantation, and in her lecture, she talked about “how much language matters.”

As someone trained in philosophy, I’m very attuned to how the choices we make about words have a huge impact… And I think it’s so true when talking to patients. When I was in graduate school, we called what we now call ‘deceased donors,’ ’cadaveric donors’. So, who wants an organ from a cadaver, and who wants an organ from a deceased donor? Right? So, every word counts. And, it’s really important that we are careful in how we talk about things and describe them because it makes a big difference in how people think about things and how receptive they are, and how willing they are to do things. For example, ‘harvesting’ versus ‘recovering’ an organ—all these things that you might not think really make a difference… The way we talk about things has a huge impact on how the public thinks about them, how we think about things, and most importantly, about how the patients that you care for are going to understand and think about what you’re saying to them.

I’ll take Dr. Simmerling’s point one step further with a personal example. I recently participated in a small group discussion about taking a complete patient history, and the question came up of whether or not to ask about religious identification as part of the social history. I noted that asking about this issue is relevant but can be difficult to bring up in conversation. But there are ways to ease into this conversation. For example, asking patients what support groups they turn to in times of trouble is a better way to start this topic than asking directly about what religion they identify with. How can physicians be more conscientious about how they present information and ask questions? There are two ways, and the first is simply keeping this issue in mind while speaking to patients, students, or colleagues. The second way is to read more, and particularly imaginative literature and poetry, because such works are written in ways that require readers to be attuned to how language is used. Moby Dick gives readers a poem and play clothed in what appears to be a novel, but it really is an enormous prose-poem, and the dialogue between characters very much resembles interactions in Shakespeare’s plays. Reading Moby Dick is great practice for physicians and very much deserves to be alongside Bates’ Guide in a student’s carpet-bag.

Featured Image:
Moby Dick by Mal Jones


Ishmael’s narrative: an emotional response

“Call me Ishmael” is the first line in Moby Dick and probably the most famous opening line in all of American Renaissance era literature. Taken in a different context: “Call me Ishmael,” or perhaps: “My name is Ishmael,” could also be a first exchange between a doctor and patient. Coincidentally, our Ishmael in Moby Dick tells readers something that resembles what a patient might say to a doctor following initial greetings:

moby dick
Photo courtesy of Tony Sun

[So doc,] Some years ago—never mind how long precisely—having little or no money in my purse, and nothing particular to interest me on shore, I thought I would sail about a little and see the watery part of the world. It is a way I have of driving off the spleen, and regulating the circulation…whenever my hypos get   such an upper hand of me, that it requires a strong moral principle to prevent me from deliberately stepping into the street, and methodically knocking people’s hats off—then, I account it high time to get to sea as soon as I can.

So, translation? That is to say, can a physician translate Ishmael’s opening account into a chief complaint and past medical history? Here is my attempt: Ishmael is a middle-aged male (his age is not given) who complains about feelings of boredom and tiredness. He also describes a history of behavioral symptoms that suggest underlying feelings of anger. Ishmael mentions he looks for ways of “driving off the spleen”—the most fitting definition of “spleen” given by the Oxford English Dictionary is: “irritable or peevish temper.” Imagine now, if a patient used that exact phrase, “driving off the spleen,” to describe his anger and how he tries to rid it. As a student, I encountered patients during my preceptorships that mentioned similar behavioral symptoms including becoming “more irritable” and “losing their temper.” I found it challenging but helpful to imagine such feelings and consider them in the context of the patient’s chief complaint and past medical history. This allowed me to move with the patient’s sorry and avoid awkward moments and responses. As an exaggerated example, responding with a huge smile to a patient saying they’re “irritable” is not an ideal reaction and creates a difficult situation. Many times, these problems may not even be apparent until later reflection. To give students more chances to reflect, some medical schools such as Weill Cornell Medical College offer students recorded sessions of them interviewing mock patients. As a student, taking complete patient histories is not an easy task, and we can use all the practice we can get.

To wrap the above discussion into the ongoing theme of my posts—how reading imaginative literature is useful to doctors and scientists—I would suggest that my classmates, and also upper years and residents, make time to read poems and imaginative fiction that elicit a wide range of emotions. To this end, I can give the example that reading Othello and King Lear elicits very different emotional responses than reading, say, A Midsummer Night’s Dream and As You Like It. Yes, readers should read deeply into the variety of emotions in these plays, but they must remember to feel those emotions within the characters of Othello and Lear, or in our case, Ishmael and Ahab. This reading followed by feeling is a practice that physicians can use while taking a patient history: read and hear the patients’ situation, and then feel with the patient. Importantly, students and doctors can practice this even outside the clinic, while reading a poem, play, or novel.

Coming back to Melville’s novel, Ishmael announces his decision to go on a whaling journey at the end of Chapter 1: “By reason of these things, then, the whaling voyage was welcome; the great flood-gates of the wonder-world swung open.” Ishmael’s decision to “get to sea” then brings readers into Ahab’s infamously mad pursuit of the white whale.

My future posts will follow Ishmael’s narrative and bring to light elements that relate to medicine and science.


Featuring image:
Sea and sky by Theophilos Papadopoulos

General Literature

Moby Dick and Medicine

Last weekend, my classmates and I went on a ski trip to a most excellent resort in Vermont. This trip was partly a literature retreat for me, as I chose to reread a large portion of Herman Melville’s Moby Dick on the drive there and back. Upon arriving at the resort, I was inspired to write this post for two reasons. Firstly, the main room had a scenery that I felt to be most conducive to writing (see photo). Secondly, I had been thinking during the drive up to Vermont about how rereading Moby Dick, or any other piece of imaginative literature, is related to rereading texts in medicine, including our current lung unit’s clinical cases (as some of my classmates had been doing in the van), or even re-“reading” a real-life scenario during a pulmonary ward rotation. I realized that there are many similarities, some of which I will share in this post. Again, my central question is: what is the usefulness of reading imaginative literature for the progress of science and medicine?

Photo courtesy of Tony Sun
Photo courtesy of Tony Sun

First, I’d like to introduce, or for some readers, re-introduce Melville’s Moby Dick, a supreme example of American Romanticism. The Romantics were involved in a movement that affected Western art, music, and literature, primarily in the 19th century. In America, the chief Romantic writers were R.W. Emerson, N. Hawthorne, H. Melville, W. Whitman, and H.D. Thoreau. These writers wrote about the art of rereading texts, created characters that had to re-experience situations, and presented the meaning of redoing what has already been done or experienced. The last is of crucial importance and is what unifies the first two themes: rereading and re-experiencing. For any belated reader or writer, there is naturally an anxiety of comparison with precursor writers and readers. Belated individuals may ask themselves: how can I read in an original way, or, how can I write original ideas? For Melville, his question might have been: how can I create and write an original character that embodies vengeance, when Shakespeare had already done so with Iago, or John Milton with his Satan. But Melville overcame this anxiety. He created Ahab, a fusion and reworking of the characteristics found in Iago and Milton’s Satan.

You may ask: how does Ahab and Melville relate to science and medicine, and how is Romanticism related to the art of medicine? I see two main links, one being that reading the Romantics enables one to be more knowledgeable about the issue of originality, and two being that observing how the Romantics handle the art of redoing enables one to redo something and still retain originality. These two links are not mutually exclusive, and the second naturally follows the first—learning what originality is enables one to redo things in original ways. Take this for example: a pulmonary intern (keeping the lung theme) sees a case of fibrotic lung disease that had been presented recently at grand rounds. Now, repeat this situation maybe ten times, that is to say, the intern sees ten more patients with fibrotic lung disease and goes to ten more grand rounds on fibrotic lung disease. Could such repetitiveness lead to boredom for the intern? I can’t answer this from experience, as I’m only a first year student, but I’ve heard the answer to be: “Yes.” A bit of originality could help the intern out here, so here I invoke the experience of reading and rereading Melville: when I reread Moby Dick, or reread any other book, I remind myself to be more aware of where I reread, how long I reread, and how I feel when I’m rereading. And then I compare these to my previous experiences of reading Moby Dick, that is to say, where I first read it, or, where I previously read it. I would argue that the intern can try something similar with clinical cases and grand rounds: where did I last see this case of fibrotic lung disease? And how did I feel when I last saw this case? These questions can make each case of fibrotic lung disease original and interesting.

To finish this post, I’d like reflect on my previous post. In my first post titled “Imaginative Literature and Medicine,” I laid out my objectives and motivations for writing in this blog, and I identified three focal points that I can discern in the medical humanities: 1. a literary focus, in which writers identify characters in literature that are scientists and doctors and write about these characters; 2. a medical focus, in which doctors and scientists reflect on personal anecdotes and write about them creatively in the form of poems or short stories; and 3. a practical focus, in which writers identify links between literature and medicine and argue for the usefulness of reading imaginative literature in practicing medicine and science. My interest is in the third category, and admittedly, I think this is the most underdeveloped of the three categories. This second post on Melville, Moby Dick, and medicine (a convenient alliteration, I might add) is meant to not only continue where I left off in the first post, but also to start a trend for future posts, in which I will be drawing more links between medicine, science, and the American Romantic writers: R.W. Emerson, N. Hawthorne, H. Melville, W. Whitman, and H.D. Thoreau.

Featured image:
Ahab reloaded by José María Pérez Nuñez

General Opinion

Imaginative literature and medicine

What is the usefulness of imaginative literature to the practice of medicine and science? This question continues to intrigue me, and according to Weill Cornell’s admissions dean Dr. Charles Bardes, it is an important question that “remains unanswered.” I approached Dr. Bardes in mid-November this year after being impressed and intrigued by the physicianship lectures he gave as part of our first-year Essential Principles of Medicine curriculum. One of his most memorable lectures was the October 9th presentation on how to take vital signs. His lecture started out with an introduction to taking body temperature. As many readers know, body temperature is often measured first when vital signs are being taken, and it’s one of the easiest measurements to take. But the meaning of a particular body temperature is not always so simple. In the course of his lecture, Dr. Bardes reminded students of the possible meanings of an increased or decreased body temperature relative to the average normal range. He then proceeded to explore one interpretation of a decreased body temperature: dying and death. He presented a historical (Socrates) and a literary (Falstaff) example of decreased body temperature as it relates to dying and death. Importantly, how Dr. Bardes chose to explore this relation was more interesting than what he chose (though I do share with Bardes a common fascination with the character of Falstaff). I quote, below, from his October 9th lecture:

Here you see a representation of the death of Socrates, as narrated by Plato, and painted by David. And the text describes how Socrates, after drinking hemlock—he’s just about to do so here—becomes cold. And he becomes cold beginning with his feet, and it gradually ascends up his body, and Plato says that when the cold has reached the level of the thorax, that’s when Socrates breathed his last. You can see here a combination of biologic observation, that is, that this sort of ascending coldness does in fact occur, but also a little bit of literary fiction—there’s nothing magical that when the cold reaches your chest, you die; that was another little bit of medical folklore. [Also] Here we have the death of Falstaff, which actually happens offstage in the play, but onstage in the Laurence Olivier movie, and Mistress Quickly describes how Falstaff becomes cold, ascending from toe to chest, until he is, in her words, as cold as any stone. Those are the meanings of…decreased temperature.

The Death of Socrates
Jean Francois Pierre Peyron (1744-1814), The Death of Socrates, 1787. kms7066, photo courtesy of SMK Statens Museum for Kunst (officiel)


Certainly, there are numerous ways to provide details and anecdotes on how changes in body temperature are related to changes in physiology. A keyword search in PubMed of “body temperature changes” reveals more than fifty-thousand articles on that subject. Dr. Bardes didn’t choose this path to present his lecture. Yes, one can learn a great deal about body temperature changes by reading any of the articles on PubMed, but what do such articles on case studies and molecular pathways not tell us? They don’t provide the human and historical context to the medical condition. Yes, case studies no doubt can include anecdotal material, but such material provides a limited perspective. What about the vast historical and literary contexts that are available to us? Why should we not look through such material and mine them for gems related to our subject matter? Socrates in human history experienced death and dying, as did Falstaff amongst Shakespeare’s universe of characters. Dr. Bardes wonderfully brought in such contexts to give each of us diverse tools to make meaning, and to quote again from the lecture: “these things [increased and decreased temperature] have meaning. Why do we do them, because they have meaning.” How we make meaning, then, and the tools we choose to do this, is up to us.

I continue, every day, to explore literature, medicine, and science; for me, they are just variations of the same thing: a desire to better understand and describe life, and to make meaning in life. Though the methods and jargon differ between those fields, their objectives should be common and coherent. If the objective, then, is to make meaning in life, then each field ought to be practiced daily with the same enthusiasm and joy we give to life itself. I practice all three–literature, medicine, and science—daily and with joy because I have fallen in love with all three. The best works in all three fields have been produced when their creators have fallen in love with their works, a cliched but true notion (on this note, I’ll cite Josh from the new-age Broadway musical I recently saw, If/Then, when he affirmed to viewers that “it’s cliche, which means it’s true”—indeed, it’s true that the best works were created by those who loved what they were creating). On this theme, the late Yale poet and professor John Hollander said this of Professor Mark Van Doren’s sublime book on Shakespeare, that he “enlightens us, not because he has any special knowledge or private advantages, but because his love of Shakespeare has been greater than our own.” A love of making meaning in life, then, I propose, will be found in the greatest physicians and physician-scientists, because they will produce the best works when they love what they do. I will, on this note, go out on a limb to surmise that if Falstaff had been trained as a physician, and not as a knight, he would have been an excellent doctor, though he clearly—and we love him for this—fails in his duties as a knight. He loves living, however, and making meaning as he lives. Harold Bloom, most certainly our best reader of Shakespearean in the last half century, said this of Falstaff, that “if you crave vitalism and vitality, then you turn…most of all to Sir John Falstaff, the true and perfect image of life itself.”

For The Medical Student Press, I have two main objectives I hope to achieve in my blog posts. Like Dr. Bardes, I’d like to share how reading imaginative literature, focusing on Shakespeare, has provided contexts and insights for my medical training. Secondly, and this will simply be an extension of my first objective, I’d like to share my enjoyment of literature, medicine, and science with colleagues and readers. In this manner, I’d like to fill what I think is a gap in the medical humanities canon. There has already been much written about medicine and medically-related themes in poetry and fiction, but such pieces seem too literary and theoretical for my taste. Another category of writing within the so-called field of medical humanities involves poems or short stories that seek to communicate personal anecdotes in medicine or reflect upon them. But there is a third category of writing, one that I think has been under-appreciated, and the goal for these writers is in describing the relevance and usefulness of imaginative poetry, fiction, and drama to scientists and physicians. This relatively unexplored third category is what interests me and what I like to write and think about. I end this post by echoing what Weill Cornell’s Dean Laurie Glimcher shared with us in her holiday greetings:

Do not go where my path may lead, go instead where there is no path and leave a trail. -Ralph Waldo Emerson Warm wishes for the holidays, Laurie H. Glimcher, M.D. Stephen and Suzanne Weiss Dean


Fetured image: and read all over by Jonathan Cohen