God is in the Details

On Alan Rickman, George Orwell, and Paying Attention

The other day I read a New York Times book review of actor Alan Rickman’s posthumous diaries, Madly, Deeply.

The review is a pan, which is always more fun to read than a rave – why is it that reviewers write so much better when trashing than when praising? I guess that’s why we call them critics.

The main complaint is that Rickman’s diaries are almost completely devoid of interesting details or insight. Rickman was rich, famous, and well-connected. He knew everyone and was invited everywhere. And yet, in more than a million words of entries, he had almost nothing to say beyond, as the reviewer puts it, the “fantastically dull.”

For example, here is his entry after having dinner with Mick Jagger, in 2002: “Mick Jagger’s dinner party.” That’s it. And lest you think the fault lies with his boring companions, check out Rickman’s diary entry upon getting a terminal diagnosis of pancreatic cancer: “Dr. Landau, Harley Street. A different kind of diary now.”

“If Rickman had written The Metamorphosis,” quips the reviewer, “it would have been one line: Woke as a bug.”

So there I am, sitting at the kitchen counter at the break of dawn, enjoying a final moment of stillness before waking up the kids for school, sipping a glass of Turkish coffee and chuckling over witty put-downs of poor Alan Rickman (who probably never intended for his diaries to be published), when suddenly it hits me.

Why am I laughing? Of the countless pieces of writing that I have read, one that remains stuck in my mind, written by George Orwell, is exactly this kind of diary entry.

Let me set the stage.

It is November 1938. The dark clouds of WWII are gathering over Europe after the Spanish Civil War, where Franco, backed by Hitler, crushed the democratically elected Republicans – a motley crew of Socialists, Anarchists, and Communists – and established a Fascist dictatorship allied with Nazi Germany.

The Western powers mostly sat back, wringing their hands piously as they watched Spain fall, claiming neutrality while Hitler armed Franco to the teeth (in return for their passivity, of course, Hitler’s guns would shortly be turned against them).

Meanwhile, young, freedom-loving idealists and adventurers from around the world, including many writers and artists, flocked to Spain to join the International Brigades and the fight against Fascism.

Hemingway was there. So were Arthur Koestler, Andre Malraux, John Dos Passos, and Emma Goldman. And George Orwell.

The Spanish Civil War was the defining political experience of Orwell’s life. It was there that his hatred of totalitarianism crystallized – not just against the Fascists but also against the Communists, his treacherous so-called allies.

In May 1937, in a trench near Huesca, Orwell was shot through the throat by a sniper, the bullet missing his carotid artery by millimeters, where it would have instantly ended his life. He returned to England and was advised by his doctors to relocate to a warm climate to recuperate (why don’t we recommend that anymore?).

In September of 1938, Orwell and his wife Eileen arrived in Morocco and moved into a little house with a garden and chickens, where he kept a diary.

Here are some sample entries:

November 3, 1938: Yesterday one egg. Fine sunset, with green sky.

November 4, 1938: One egg.

November 5, 1938: One egg.

November 6, 1938: Two eggs. Fairly considerable rain recently at nights.

Orwell is known mostly for his books Animal Farm, a political satire written in 1944 toward the end of WWII, and 1984, a dystopian novel written in 1948. Together they account for his reputation as a writer of moral clarity and political vision.

Those are the books we reach for when we want to sweep away the complexities of the world and the moral confusion that comes with it. Orwell gives us the language to distill muddy waters into clear, Manichean streams: good v. evil; freedom v. slavery; democracy v. tyranny.

Why do you think Animal Farm and 1984 are always assigned in middle school? They are perfect for the adolescent stage of psychological development where everything is black and white (I still remember my daughter Georgia’s powerful and righteous indignation at Napolean’s piggish behavior).

But much as I appreciate them, those books are not why I love Orwell.

I love Orwell for his first-person account of his time in Spain, Homage to Catalonia, where we see his youthful idealism collide headfirst into the harsh reality of war.

I love Orwell for his essay Politics and the English Language, where he shows how language can be used as an instrument for concealing or preventing rather than expressing thought (and which rivals Strunk and White’s Elements of Style as an essential guide for how to write well).

I love Orwell for his essay, Shooting an Elephant, where he writes about being a young British official in Burma, where he was forced to shoot an innocent elephant – something he knew was wrong in every moral fiber in his being – purely in order not to lose face in front of a crowd of natives.

I love Orwell for his little-known novel, Keep the Aspidistras Flying, where he elevates simple domestic duties, pleasures, and responsibilities over grand, selfish artistic ambition.

And I especially love Orwell for his essay, Reflections on Gandhi, where he criticizes Gandhi not for being human as opposed to saintly, but for being saintly as opposed to human.

Those who are quick to knock cultural and historical heroes off their pedestals because they fall short of modern standards, or even because of contemporary failings, have a lot to learn from that essay. In Orwell’s estimation perfection – moral or otherwise – only counts against you.

Orwell was the most humane of writers, which I suspect is related in some way to the attention he paid to the quotidian details of ordinary life. To eggs, skies, and rain. He wrote nothing much about them. He simply noted them in his diary.

But those entries show how Orwell was a writer who lived in the world, not just in his head. He laid his life on the line in Spain and looked for the eggs his hens laid each day. He tried to see things truly and relate them clearly.

The problem with living in the world, however, is that what you see can break you – as almost happened to Orwell in Spain.

This may be a stretch, but I like to think that the flaws of the world opened Orwell to those in human nature; and conversely, made him suspicious of people and ideologies that seem too perfect – like the utopian theories of Communism, for example, of which his contemporaries were so enamored.

Furthermore, I like to think that Orwell wrote so well about the big picture in his later works thanks in part to the attention he paid to the little picture in his earlier works. That his affinity for little human lives attuned him to how big forces like politics and language can conspire to crush them.

People say, “don’t lose the forest for the trees”, but it can also work the other way around; sometimes paying attention to each tree is the only way to find the forest.

It’s an idea that applies in many areas, including medicine.

Clinical reasoning is the process of arranging bits of information – symptoms, signs, and studies – like a jigsaw puzzle, where each piece fits just right. But what about a piece that doesn’t fit? Maybe it’s just noise and needs to be discarded. Or maybe it’s the key to the correct diagnosis.

When I was an intern I had a patient with community-acquired pneumonia, which is usually caused by a virus or certain typical bacteria. His sodium level was a little lower than normal, which turned out to be a clue to the culprit, an atypical bacteria called Legionella. I would have overlooked this if not for my astute senior resident.

Just last month I had a patient with swollen neck glands, usually the result of a viral infection. In this case, it came up that he had eaten a kebab from the street on a recent trip to Mexico. That put Toxoplasmosis on the differential – which is what it turned out to be.

Closer to home, when my six-week-old daughter, Georgia, got sick in the Dominican Republic, all signs pointed to a common illness like bronchiolitis. It ended up being congenital heart disease.

“The heart border looks a little bigger than normal on the chest X-ray,” said Dr. Robert Best, at the end of his long shift in the Columbia peds ER (the eponymous Dr. Best). “I’m sure it’s nothing, but let’s get another view to make sure…”

Don’t get me wrong. I still say when you hear hoofbeats, think horses, not zebras. But pay attention, too. It’s the little details – rarely flagged, sometimes noted, often overlooked – that can help you spot the zebra in the herd.

Anyway, I’m an M.D., not a Ph.D., so even if I’m right about the medicine I may be wrong in my analysis of Orwell. And while I find those egg entries to be inspiring, that may just be because I love Orwell’s work.

Shall we extend the courtesy to Rickman of contending that the boring diary of his enchanted life can be similarly inspiring?

I think I’ll leave that question to his fans.

Dr. Bertie Bregman
Dr. Bertie Bregman
Full Stack Family Medicine is a newsletter about what it’s really like to practice medicine and run a medical practice in New York City.
This blog will be a mix of stories, advice and discussion – topics will diverge widely, but they will all share a point of view!