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Shelby Foote, The Civil War

Herman Melville, Moby-Dick, or the Whale

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Bill Bryson, Notes from a Small Island



The contents of this website are for contemplative purposes only. No medical advice will be given, and emails asking for medical advice will be ignored.

Although patient vignettes are based on my experiences with real individuals, I liberally change details to maintain patient confidentiality.

I also reserve the right to change old postings to correct errors, and to delete comments that include obscene language or that I deem abusive to me or other commentators.  If you are looking for a open mind, I suggest you consult a neurosurgeon.


Dylan the Laureate

Almost lost in the inexcusably bad news about the presidential election is a bit of truly good news: Bob Dylan has won the Nobel Prize in literature. For me, this was a true shock — not because I doubt Dylan’s talent, but because I have not known the Nobel committee to ever give the literature award to anyone who didn’t write books. Yes, I know Dylan has published a memoir, a novel, and even a children’s book, but he is primarily a songwriter, and the poetry he won the Nobel for is almost exclusively  song lyrics. This is like a huge departure from typical Nobel awards, and a profound statement about the importance of Dylan’s work on worldwide music.

Being the only songwriter ever to win a Nobel for lyrics is an unexpected achievement.

I must admit I have not always been a fan. I didn’t have anything against Dylan, but his music never appealed to me. That changed a few years ago when I started exploring the music of the 1960s rock band the Byrds, who, like most people, I best knew for the song “Turn! Turn! Turn!,” a folk-rock rendering third chapter of Ecclesiastes.

While listening to the Byrds’ first album, I was struck by the beauty of the lyrics to “Chimes of Freedom.” My first thought was, this sounds like Bob Dylan. Bob Dylan’s phrase style and language are so distinctive that even I, the most casual of fans, had a sense of it.

And of course it did, because it was. The song was a cover from Dylan’s 1964 album Another Side of Bob Dylan. This should not have been a surprise, since the album I was listening to was entitled Mr. Tambourine Man, which is of course another Dylan cover.

So it turned out that, while Dylan recordings didn’t appeal to me, I liked the songs very much when they were done by other artists. For me, a different performance brought out the quality of the songwriting. As is sometimes true with great art, seeing a work in a new light changes its appeal, remaking it entirely.

So I went back to Dylan. Gave Highway 61 Revisited a revisit, then checked out Blonde on Blonde, and The Freewheelin’ Bob Dylan. Yes, I had to concede there was something there.

But it didn’t change a basic fact — I prefer Dylan in translation. When someone else performs his songs, to my ear, it usually sounds better. Dylan, God bless him, is a poor singer. While I can appreciate the many who say his vague mumblings that pass for vocals are interesting and give a certain wildness to his music, I still don’t like it. I don’t like mumbling. I like singing: Go figure.


Why shouldn’t I prefer better performance? Would I insist that Bach play his own violin concerto, or Mozart take the role of the Don himself in Don Giovanni? Who said the artist has to be the best renderer of the material?


We all know that Shakespeare was an actor, and probably acted in many of his own plays. And while seeing Shakespeare play Hamlet would probably be an interesting and even illuminating experience, Sir Laurence Olivier would have wiped the floor with him in an act-off. I’ve never seen the Bard on stage, but have seen Sir Laurence on film, and  am satisfied that I got the better part of the deal.


And so it is with Dylan. As a musician and singer he has his merits, but the Byrds did it better. I prefer music that is precise and, um, melodic, and Dylan can’t do that. His recordings are good, interesting, and even cast a useful light on his work, but Dylan would benefit from a Laurence Olivier.


He needs to find one. Plenty of great musicians have recorded entire artist catalogs. Some have recorded all of Beethoven’s symphonies, others entire cycles of opera, pianists have done complete sets of concertos, actors have done all the major Shakespeare plays. We need a truly great musician to do the Dylan cycle. To give all that Nobel-winning poetry the platform it deserves, so stuck up elitists like me can appreciate him for all his glory.


It would be fitting to close with a few lines of Bob Dylan. So: The opening stanza of “Chimes of Freedom.” I am especially mesmerized by the third line, “As the majestic bells of bolts struck shadows in the sounds,” a bizarre mix of sound and visual imagery. What in the world does “shadows in the sounds” mean? Nuance, perhaps?


Far between sundown's finish an' midnight's broken toll
We ducked inside the doorway, thunder crashing
As majestic bells of bolts struck shadows in the sounds
Seeming to be the chimes of freedom flashing
Flashing for the warriors whose strength is not to fight
Flashing for the refugees on the unarmed road of flight
An' for each an' ev'ry underdog soldier in the night
An' we gazed upon the chimes of freedom flashing



Donald Trump: Birtherism Is Racism. Period.

In two years of ceaseless presidential campaigning, the candidates have insulted the intelligence of the voters many times. But no insult has quite equalled Donald Trump's recent claim that Hillary Clinton is responsible for birtherism, and that he, Trump, is responsible for ending it.

The assertion is so colossally false that facts are useless against it. It’s like arguing against the existence of unicorns — since no one has ever seen one, it's difficult to disprove them, because the very thing you are trying to disprove has no definable characteristics. There isn't enough substance in the assertion "unicorns ate my homework" to disprove it. What does a unicorn look like? Is it invisible? Does it eat homework? If so, does it eat only math, or other subjects as well? So it is with Trump: If Donald Trump was not a birther since 2011, who was? Was anyone? Did birtherism even exist?

If Trump did not, as he now says, ever promote birtherism, it is hard to see why he would need to renounce it. He now says that the thing he didn't promote for 5 years never existed anyway, and that it was never supported by the people who voted for him, even though they voted for him for because he supported it.

At this point, it doesn’t matter if Clinton ever considered or even listened to anyone who considered birtherism. Or if she had a friend who did, or passed someone in a department store and who did and rubbed elbows with her. Since Trump is arguing that he never was a birther, perhaps birtherism never existed at all. (Except that Trump now says it did, but only long before he never supported it.)

Facts? Who needs facts. Since facts never had anything to do with birtherism, any claim is as good as any other. Birtherism could have been invented by Houdini. Maybe Pope Urban IV wrote about it in Klingon in the year 1024. It could be that Neil Armstrong found Obama’s birth certificate while he walked on the moon. Any of these are just as plausible as the idea that Trump was never a birther.

Birtherism isn’t even what it claims to be. It isn’t constitutionalism. It isn’t reasonable doubt. It isn’t even unreasonable doubt. It is fiction. No, worse, it is an impostor.

Birtherism is racism in disguise. Since no one, not even racists, will admit to racism anymore, when you try to attack birtherism as racist all you hear in response is a roar of denial from a mob that then feels free to turn around and vote exclusively on issues that imply ethnicity — immigration, fictitious voter fraud, taking America back.

The assertion that Barack Obama was not born in the U.S., and specifically was born in Kenya, even though he can produce a certified birth certificate, is founded on the principle that he is too alien-appearing to be American — that is, he fails the eye test. What eye test is there to fail skin color? Therefore, racism.

When Donald Trump says Clinton started it, he is making an indefensible position even more indefensible. Racism isn’t something you blame on someone else. You can’t say, I was only racist because George Wallace was racist in 1961.

In the same way, it is preposterous to argue that a racist point of view that you held until about a week ago was something you believed only because someone else first thought it years ago. It makes about as much sense as an arsonist, caught fleeing a house fire with a gasoline can, arguing that he only did it because the woman across the street had a match in 2007.

Who cares? No one should care. If it was a dumb idea in 2007, how much dumber is it 8 years later, with 8 more years of proof that it is wrong?

How stupid does Trump think we are? Three weeks ago, when pressed on the birther issue, he refused to deny it. He is on record suggesting it might be true in January. Are we're supposed to believe the guy we see now and think the guy who looks like Trump on tape is a liar and impostor, or should we believe the guy we see now is a liar and imposter and believe the real Trump on tape? If it goes one way, it could just as easily go the other.

It is hard to imagine anyone swallowing such nonsense. Hard to imagine how stupid he must take the voters to be. “I love the poorly educated,” indeed.

But while what Trump is doing certainly is outrageous and belittling to voters, it is an old script that Southern politicians have been following for decades.

Down in the South, we know how racism works. We never acknowledge it, but everybody knows how to play the game. You pursue business as usual, and substitute some other word for racism, like law and order, justice, freedom, or (my favorite) small government. For instance, in Mississippi, our current governor campaigned on illegal immigration in a state that has no foreign border and where very few immigrants come, because Mississippi is just as poor as the Mexican towns they left in the first place. There is not and never has been a problem with illegal labor in Mississippi. The only problem is the color of the vanishingly few Mexicans who call Mississippi home.

Or another example: Despite being the poorest state in the nation, Mississippi sets Medicaid eligibility for adults at 22% of the federal poverty level, leaving over 330,000 citizens without healthcare and incidentally excluding twice as many blacks as whites. Or another: voter ID laws in a state where you have to drive long distances to get to a place that can make a valid ID, which means people who don’t have a car have a greater difficulty voting -- a group once again overrepresented by black people. That kind of thing.

And you skirt the past. When people ask to have the Confederate symbol taken off the state flag, you point to a referendum in 2001 that chose to keep it, and state that the Confederate flag is “history.” Whose history, we don’t know. That’s a blank that doesn’t get filled.

You can do all these things without reference to race, and that means it has nothing to do with race. Right? Just because blacks represent 37% of the population and 62% of prisoners doesn’t mean the justice system is rigged. If you take a microscope to the justice system, you won’t find any specific prejudice. No obvious reference to blacks, no segregation. Just a little injustice here, a little there, and somehow it all adds up to 3.5 times the incarceration rates for blacks over whites.

Nobody knows how it happens. Somebody else started it. The Washington Democrats must be responsible somehow; as for us, we are just interested in law and order.

But here is how it happens. You close the book on a racial policy, attitude, law, and you turn away and pretend it didn’t happen. You name your airport after Medgar Evers and forget why he is famous, and that his murderer didn’t face justice for 31 years. Or name a road after Emmett Till, no explanation required. History with an unfilled blank.

These changes are not all bad; some things are better than they used to be. But everyone knows what happens when an idea goes into “history.” In the public consciousness, it petrifies, it fades, it becomes part of the landscape. And we don’t forget about it, but we forget most of the facts, which is almost the same thing.

Of course we have to move on, but we don’t get to move on until the right discussion, and even settlement, has taken place. The guilty don’t get to turn the page. Only victims get to do that. And that’s where the South, and Donald Trump, have gone horribly wrong. They think once they swear off drinking, all the drunken days are over. Never mind who was hurt while they were drunk.

In Mississippi, this plays out every day. Because people think of the Confederate flag, or the Freedom Riders, or Medgar Evers, or the murders of two civil rights activists in Philadelphia, MS as history, no one has to deal with it. And so the state government can continue to discriminate against the poor on the supposition that they are lazy, without applying a moment of thought to why they were born into poverty in the first place. Deny one history, create another. Perfect way to guarantee that things stay the same.

Move to a more expensive neighborhood. Get gates for your community. It’s all about crime, the causes of which are known only to “history.”

So when Donald Trump says he is “ending” birtherism, “period,” he is plagiarizing a very old script that has harmed many millions of people. He gives himself the power to end a racist idea and turn the page, even though he is not the one that was hurt by it, and therefore not the person allowed to call it “history.”

He wants to put it in the past, talk about it no more, and move on. Is it his right to move on? No. Moving on is what the racists do.


Quote of the Week

Is it not curious, that so vast a being as the whale should see the world through so small an eye, and hear the thunder through an ear which is smaller than a hare's? But if his eyes were broad as the lens of Herschel's great telescope; and his ears capacious as the porches of cathedrals; would that make him any longer of sight, or sharper of hearing? Not at all. -- Why then do you try to "enlarge" your mind? Subtilize it.

                           -- Herman Melville, Moby-Dick

                               Chapter 74, "The Sperm Whale's Head"


A Few Words About Mother Teresa. And Burqas.

Mother Teresa was canonized today, September 4. Officially she is now St. Teresa of Calcutta,* but I suspect she will always retain the name she was known by in her lifetime, Mother Teresa. This sometimes happens -- a few Catholic saints are known by their non-saint names, such as Father Damien, Padre Pio, John-Paul II. So I will call her Mother Teresa, or MT, and I don't think anyone will take offense. So much for names.

Mother Teresa is the most acclaimed religious figure of our time. While most Catholics accept her sainthood without question, there are a few people who have voiced doubts. Was she really as great as people say she was?

Perhaps it is fitting that a woman Father James Martin calls “the saint of doubters” inspires doubt in a few people. I sympathize. Like a lot of people, when acclaim reaches near-unanimity, the contrarian in me sees a sheep stampede. Is she as great as she is cracked up to be? Let's look at a few of the criticisms.

One criticism of Teresa was that she collected millions of dollars for her cause, but has very little to show for it. Almost all the money she collected she turned around and gave to the Vatican. When she started her ministry, all she had was a small building in Calcutta that she used to deliver care to the dying. A hospice. By the time she died, she barely had anything more than that.

She ran a hospice, but from what I can gather, it was not a perfect one. Dying patients were taken care of by nuns who had little or no medical training. There were stories of re-used needles, of people suffering from conditions that might have been better managed in a hospital. Some have asked why, given MTs resources and the amount of money she collected, couldn’t she have built a real medical facility and practiced a bit of real medicine? Wouldn't that be a better use of the cash than turning it obediently over to the Pope?

Being a physician, I can’t fully dismiss this criticism. But I don’t see that I need to. MT was not perfect. Saints are not perfect. On the contrary, Church history is littered with stories of saints doing unsavory things. It is probably true that if you took all the marvelous things saints did and wrote them in one book, and all the bad things they did and wrote it in another, the books would be about the same size.

Sainthood does not mean perfection. It never did. God is perfect. The rest of us struggle. What we are supposed to get from the lives of the saints is not that they are perfect, but that the struggled and sinned just as we did. They just did a better job of struggling.

It can be a hard thing to embrace. But we have to remember that most saints lived before the media age. We don’t have pictures of St. Paul, or video of St. Thomas Aquinas giving a homily. Mother Teresa’s life is well-documented, and that makes her imperfections more clear. Although I seldom would presume to speak for MT, in this case I will. She almost certainly would say, “Look at my imperfections! Learn from them!” She would be fine with her imperfections known as long as they helped another person towards God.

In all likelihood, she did not build a Mayo Clinic because she did not think that medical technology was the path to heaven. She was not a doctor, and did not want to be one. What she wanted was to show compassion for the suffering, and that is what she did. India had hospitals, then as now, and it had doctors, then as now. I know many doctors who were trained in India. There is nothing deficient about Indian medicine. They may lack our money, but they do not lack knowledge and sophistication.

MT wanted to provide what she thought medicine did not — compassion. She thought that the goal of living was to get to heaven. She did not think this world was an end of itself. That is to say, she did not think humans should be striving to make earth a heaven. She was a knowledgeable Catholic, and knew the teaching of Original Sin, that humans are all flawed, and that we are all born into a sinful world and will all sin eventually if given the chance. She thought that trying to perfect the world is a task bound for failure. We cannot perfect ourselves.

Given this, MT thought that the goal of life on earth was to spread love and compassion, nothing more. I don’t think she objected to doctors or thought what they were doing was evil, but she did think that love and compassion were more important than curing. Her hospice was set up that way. It delivered love and compassion first, medical care second.

One can argue with this way of running a hospice. As a doctor I would not run a hospice quite that way. But that does not mean what she was doing was wrong. Her hospice was not a prison. People could go to the hospital if they wanted to. But they chose MT because they preferred to die in love than live in indifference. In that sense, MT was holding the world to a harsh standard. What does it mean that a person would rather be loved than cured? This question has never, to my knowledge, been completely addressed in the medical profession. We just plow on with our new technology and techniques, and fail again and again to wonder if we are leaving humanity behind.

Mother Teresa insisted that we never leave humanity behind. Or God. Her insistence stands as the same challenge it did in her lifetime. Build a Mayo Clinic? Sure. But will the gleaming new building be a monument to loving kindness, or to human ambition? MT had her answer. Not in words, but as usual, in her actions.

I will be the first to say that her devotion to low-tech medicine was a fault. But again, saints are not perfect. She provided love for the dying, and that has to overshadow her shortcomings as a medical administrator. Let’s remember that we all have to die someday. No doctor ever saved a man’s life — death can only be postponed. MT would say there is no need to postpone death if you are prepared for it.

This is a very difficult challenge to Western values, especially Western medical ethics. And we are not meeting it on its own terms. We in the West have an idea what heroism is, and it usually involves social change and overcoming barriers or saving fellow soldiers or landing a plane safely in the Hudson river. These may all be examples of heroism, but is this really all it is to be a hero?

Isn’t being a hero loving other people? Isn’t it human concern, basic and quiet, and not necessarily an act that will turn the world on its ear? People can criticize MT or any saint, but MT did not ask to be world famous. A few critics, most notably Christopher Hitchens, considered her a self-serving media star, a charge that is ridiculous. If I wanted to be a global celebrity, there are many ways I might go about it, but none of them involve wandering the slums of India, looking for dying people to take care of.

There is a jealously in accusing her of seeking celebrity, an anger that she got so famous by being so small, which flies in the face of almost everyone else, who seek fame by becoming larger and larger. No wonder such people distrust her -- she short-circuited the entire business of becoming a world leader.

If she had never been world famous, she would have toiled out her entire life in Calcutta, doing what she was famous for anyway. And God might have opened the doors of heaven to her at her death, as He does for many unknowns, and she would have been a saint nonetheless, except we wouldn’t have known it.

If there is a testimony to her greatness, it is this: She probably would have been exactly the same woman, Nobel Prize or not. Fame or not. She was devoted to compassion, your approval and my approval not needed, and whether we approved of her methods or not didn’t matter either. She wanted to please God and save the souls (not the lives) of her patients. She did that, no matter what we think.

Mother Teresa has also been criticized for her wholehearted support of the Catholic Church and the papacy, which is sometimes seen as a male-dominated organization. She was a simple woman who lived in a time when women’s liberation was in full swing. Although she was probably the most revered Catholic of her time, she submitted to the Church in every way. She was never able to say Mass, or even preach a homily. She remained either silent or completely supportive of the Papal position on many women's rights issues of her day, including birth control, divorce, and the role of women in the Church.

Many would argue, what kind of woman leader submits herself completely to a male hierarchy? Didn’t she owe the women in the world more than silence and complicity?

This is not a question I can completely answer. Mother Teresa would have to answer that question herself, but on that subject she was characteristically silent. She was not the kind of person to challenge sacred authority.

This can be discouraging, but it is worth remembering that after her death a series of her letters was published, under the title “Come Be My Light,” in which it was revealed that Teresa profoundly struggled with what theologians sometimes call “spiritual dryness,” or the feeling that God is absent. And while she struggled with this mightily, she remained unwavering in her public commitment to the Church. Some have even argued that this meant she was a fraud, a secret atheist who enjoyed her celebrity and played it for all it was worth.

Poppycock. Mother Theresa was devoted to her work. One must ask — how do you judge someone, by their words or by their actions? Clearly actions tell more about what is in the heart than words. We can all think the right things, and usually do, but acting on our convictions is much more difficult, and much less common. We can be distracted by the day-to-day anxieties in her letters, or we can look at her almost 90 years of devotion to her Church and weigh that more heavily. An easy choice.

The truth about her spiritual struggles is that she believed in God, but for long stretches she didn’t “feel” God’s presence. She said so, quite literally, several times in her letters. She didn't say God didn't exist, she said she did not feel His presence. This is not the same thing. Floating in water, I can say that I don't feel the force of gravity. This cannot be taken to mean I am denying gravity. When MT said she didn't feel God's presence, she meant precisely that. She didn't feel Him there, but that didn't mean she didn't believe He was there. To ignore this distinction is to ignore everything that she ever said, and more importantly, everything she ever did, her life's work. Which one can do. But then one is taking issue with an imaginary Teresa, not the real one.

But back to the letters: The letters tell us something else interesting about Mother Teresa. Her inner spiritual life was very different from her public persona. We tend to forget that about famous people. We tend to forget that about practically everyone. What goes on inside people is not necessarily what we think is going on. So how can we know or judge what Mother thought about the Church? Can we really know that she had no qualms, ever, about the role of women in it? Not really. To say that we do is to be unjust to her. We know she supported the Church wholeheartedly. But that does not mean there was no nuance in her thinking.

Sometimes when I think of MT and her fidelity to the Church I think about Muslim women and the burqa. There are many Muslim women who would not wear a headscarf if given the choice. They are forced by circumstance to do so. But there are many who wear because they want to, it out of reverence to God. As a Westerner I have some problems with that, as many Westerners do, but I need to hold my tongue.

Why is it that when a woman stands up to the limitations of society, when she bucks the system and fights back against sexism, we see her as a hero, but when she decides, completely of her own volition, to conform to a religious or social requirement (by wearing a burqa or staying at home with the kids), we see this as weakness? It isn’t fair. Part of the outcome of social freedom is that some people will choose traditional roles for themselves. This is no more or less an act of feminism than any other, provided the woman does so freely.

This applies to MT as well. She chose to adopt a very traditional role in the Church. That she did so freely is beyond question. She moved thousands of miles from her birthplace in Albania to serve as a nun, leaving her family life and traditions behind. She moved to India and started her religious order all alone, her own choice, and did so despite some resistance from her bishop. There is no question she chose to be what she was. In that sense, she is as much a feminist as anyone ever was. We have to honor her decision, and set aside our expectations of what a feminist is or should be. She chose her life and did so with an informed and free conscience. Our right to say she was not the feminist leader she ought to have been is extremely limited here. She chose her burqa. Which in her case, was a nun's habit.

* The official spelling now Kolkata, which was changed in 2001 by the city to closer approximate the Bengali language. Since Teresa died in 1997 and was known her entire life as Mother Teresa of Calcutta, the Catholic Church has retained the old spelling when attached to Teresa. Seems reasonable to me.


Katrina: Eleven Years


One thing I learned: what is really important. I lost virtually everything, from every childhood picture I ever had, down to my socks. All my clothes, all my books, every letter I ever received, all my furniture.

Today, in my house, everything in sight I have acquired since August 29, 2005.

And yet I am surprised to find that I lost nothing. I got out with my wife and children, that's what mattered, and the rest of it -- who cares?

Although I have replaced much since that day, my relationship with everything I own is profoundly changed. I see that don't own anything, really -- my possessions amount to a handful, a small pile of junk that makes up my personal empire -- things that have passed into my caretaking for awhile.

And one day, one way or another, they will pass out of my care.

What I have besides that -- myself, those I love, hope, faith, purpose -- those are the things I cannot lose.

So let the winds blow. Let the waters come. All they do is enable me to distinguish what is truly mine, and what will never be mine.

What is truly mine can never be washed away.