Tolstoy on Medicine

From the best novel ever, War and Peace:

“Natasha’s illness was so serious that, fortunately for her and for her parents, the consideration of all that had caused the illness, her conduct and the breaking off of her engagement, receded into the background. She was so ill that it was impossible for them to consider in how far she was to blame for what had happened. She could not eat or sleep, grew visibly thinner, coughed, and, as the doctors made them feel, was in danger. They could not think of anything but how to help her. Doctors came to see her singly and in consultation, talked much in French, German, and Latin, blamed one another, and prescribed a great variety of medicines for all the diseases known to them, but the simple idea never occurred to any of them that they could not know the disease Natasha was suffering from, as no disease suffered by a live man can be known, for every living person has his own peculiarities and always has his own peculiar, personal, novel, complicated disease, unknown to medicine—not a disease of the lungs, liver, skin, heart, nerves, and so on mentioned in medical books, but a disease consisting of one of the innumerable combinations of the maladies of those organs.

This simple thought could not occur to the doctors (as it cannot occur to a wizard that he is unable to work his charms) because the business of their lives was to cure, and they received money for it and had spent the best years of their lives on that business. But, above all, that thought was kept out of their minds by the fact that they saw they were really useful, as in fact they were to the whole Rostov family. Their usefulness did not depend on making the patient swallow substances for the most part harmful (the harm was scarcely perceptible, as they were given in small doses), but they were useful, necessary, and indispensable because they satisfied a mental need of the invalid and of those who loved her—and that is why there are, and always will be, pseudo-healers, wise women, homeopaths, and allopaths. They satisfied that eternal human need for hope of relief, for sympathy, and that something should be done, which is felt by those who are suffering. They satisfied the need seen in its most elementary form in a child, when it wants to have a place rubbed that has been hurt.

A child knocks itself and runs at once to the arms of its mother or nurse to have the aching spot rubbed or kissed, and it feels better when this is done. The child cannot believe that the strongest and wisest of its people have no remedy for its pain, and the hope of relief and the expression of its mother’s sympathy while she rubs the bump comforts it. The doctors were of use to Natasha because they kissed and rubbed her bump, assuring her that it would soon pass if only the coachman went to the chemist’s in the Arbat and got a powder and some pills in a pretty box for a ruble and seventy kopeks, and if she took those powders in boiled water at intervals of precisely two hours, neither more nor less.

What would Sonya and the count and countess have done, how would they have looked, if nothing had been done, if there had not been those pills to give by the clock, the warm drinks, the chicken cutlets, and all the other details of life ordered by the doctors, the carrying out of which supplied an occupation and consolation to the family circle? How would the count have borne his dearly loved daughter’s illness had he not known that it was costing him a thousand rubles, and that he would not grudge thousands more to benefit her, or had he not known that if her illness continued he would not grudge yet other thousands and would take her abroad for consultations there, and had he not been able to explain the details of how Metivier and Feller had not understood the symptoms, but Frise had, and Mudrov had diagnosed them even better? What would the countess have done had she not been able sometimes to scold the invalid for not strictly obeying the doctor’s orders?”

“You’ll never get well like that,” she would say, forgetting her grief in her vexation, “if you won’t obey the doctor and take your medicine at the right time! You mustn’t trifle with it, you know, or it may turn to pneumonia,” she would go on, deriving much comfort from the utterance of that foreign word, incomprehensible to others as well as to herself.

What would Sonya have done without the glad consciousness that she had not undressed during the first three nights, in order to be ready to carry out all the doctor’s injunctions with precision, and that she still kept awake at night so as not to miss the proper time when the slightly harmful pills in the little gilt box had to be administered? Even to Natasha herself it was pleasant to see that so many sacrifices were being made for her sake, and to know that she had to take medicine at certain hours, though she declared that no medicine would cure her and that it was all nonsense. And it was even pleasant to be able to show, by disregarding the orders, that she did not believe in medical treatment and did not value her life.

The doctor came every day, felt her pulse, looked at her tongue, and regardless of her grief-stricken face joked with her. But when he had gone into another room, to which the countess hurriedly followed him, he assumed a grave air and thoughtfully shaking his head said that though there was danger, he had hopes of the effect of this last medicine and one must wait and see, that the malady was chiefly mental, but… And the countess, trying to conceal the action from herself and from him, slipped a gold coin into his hand and always returned to the patient with a more tranquil mind.

The symptoms of Natasha’s illness were that she ate little, slept little, coughed, and was always low-spirited. The doctors said that she could not get on without medical treatment, so they kept her in the stifling atmosphere of the town, and the Rostovs did not move to the country that summer of 1812.

In spite of the many pills she swallowed and the drops and powders out of the little bottles and boxes of which Madame Schoss who was fond of such things made a large collection, and in spite of being deprived of the country life to which she was accustomed, youth prevailed. Natasha’s grief began to be overlaid by the impressions of daily life, it ceased to press so painfully on her heart, it gradually faded into the past, and she began to recover physically.

I use this excerpt in my health econ class.  HT to Steven for the link.

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  • Ralph

    Ah, yes; Tolstoy was quite the medical expert.

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  • Matt

    It seems to me Natasha suffered from a rare but serious condition known as fibromyalgia. She should have asked her doctor about Lyrica.

  • http://entitledtoanopinion.wordpress.com TGGP

    Maybe its describing something real, but let’s keep in mind the logical fallacy of generalization from fictional evidence.

    • fenn

      I do miss EY’s presence on this blog, but I don’t miss those darn links

  • Benquo

    @Ralph:

    You don’t have to be a medical expert to know that all else equal, new evidence that increases P(A|~B) (in this case, the use of medical treatment even when it won’t work, on account of the impulse to “do something” and make people feel taken care of), should increase P(~B|A).

    The discovery of additional motives for medicine (aside from curing someone directly) should lower our confidence that any actually applied medical procedure works.

  • Andrew

    One of the things I recall about “Anna Karenina” is that it has a paragraph describing the employment of the Atkins diet in the same context it is used today. If Wikipedia is to be believed, that makes it one of the earliest descriptions of the metabolic impacts of switching to low carbohydrate diets, but Tolstoy writes it as though it was common knowledge in the 1870s.

    • Matt

      Well, it’s certainly an old idea. I remember the main heroine in “For Whom the Bell Tolls” saying she would stop eating potatoes so she could stay skinny. Everything is cyclical. There’s nothing new under the sun.

    • http://williambswift.blogspot.com/ billswift

      I don’t remember the exact source and year, and I’m too lazy to go look it up, but Taubes in “Good Calories, Bad Calories” traced an explicit low-carb diet back into the middle to late-middle 1800s.

  • Doug S.

    Today, we’d probably be giving Natasha Prozac or other such pills.

    Incidentally, I’ve read that Charles Dickens’s novels contain detailed descriptions of what are now recognized as various medical disorders, long before they were known to be medical problems. For example, a character in “The Pickwick Papers” exhibits textbook symptoms of severe sleep apnea, and one in “Bleak House” has dyslexia.

  • Tracy W

    This is why modern medicine’s gold standard is double-blind randomised trials.

  • tonyf

    Swedish television showing a documentary on health professor Hans Rosling
    http://svtplay.se/v/1654393/dokumentar/rosling_s_world?sb,p103479,2,f,-1
    Available until September 18, 2009. Actually this documentary is more concentrated on Rosling as a person, more of his views on the factual matters of medicin and social and economic developement can be found on e.g. TED, but it’s still somewhat interesting.

    As for the War and Peace example, probably social concerns can never be completely be separated from medicine per se, although of course Tolstoy’s example is to the extreme. The overt point there is of course that Natacha’s “illness” makes it possible to save face in the social scandal. Good that the doctors could be of help to the Rostovs in also that. But bacteria in drinking water that kill babies is a bit different matter.