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'To Write Down the Whole Particulars': Narrative Competence in R. L. Stevenson's Medical Doctors.

It is surely no small feat that Robert Louis Stevenson should have succeeded in creating two of the most memorable physicians in Scottish literature: David Livesey in Treasure Island (1883) and Henry Jekyll in Strange Case of Dr Jekyll and Mr Hyde (1886). Certainly, the frequently ill author had extensive interaction with doctors, yet it is intriguing that the medical profession should occupy so central a 'character space' within his major novels. This article explores how Stevenson's physicians may be read as literary enactments whose demonstrations of narrative competence, or lack thereof, have far-reaching implications for their patients and themselves. Such a reading reflects an increasing narrative emphasis within contemporary medical education, which is perhaps hardly surprising given Stevenson's penchant for being so uncannily ahead of his time. (1)

Narrative competence refers to the ability to construct meaning from individuals' stories, adjusting one's perceptions and actions accordingly. In recent years, the value of narrative competence has been the subject of much critical interest within academic medicine, insomuch as it fosters empathy, communication skills, and the ability to navigate the ambiguities and complexities intrinsic to clinical decision-making --all of which are essential to the delivery of more holistic patient care. (2) Renowned physician-educator Rita Charon notes:
a scientifically competent medicine alone cannot help a patient grapple
with the loss of health or find meaning in suffering [...] physicians
need the ability to listen to the narratives of the patient, grasp and
honor their meanings, and be moved to act on the patient's behalf. This
is narrative competence, that is, the competence that human beings use
to absorb, interpret, and respond to stories. (3)


Such a conceptualisation of storytelling as a humanising act and integral component of bioethics informs the healthcare framework of narrative medicine, which involves both a philosophical and practical understanding of the ways in which storytelling profoundly affects clinical practice. Indeed, the Oxford Concise Medical Dictionary defines narrative ethics, from a clinical perspective, as 'an approach to ethical problems and practice that involves listening to and interpreting people's stories.' (4)

In order to engage with narrative medicine in the broadest sense, physicians must cultivate others- and self-awareness as a means of understanding and interpreting how their own narratives operate in symbiosis with the broader 'story' of the world. Significantly, the act of engaging with the narrative process can be beneficial to clinicians as well as to patients: amidst the daunting physical and psychological pressures faced by physicians in turbulent social and economic times, narrative medicine offers hope for alleviating burnout and compassion fatigue. (5) As Emily Silverman observes, in addition to humanising the doctor-patient encounter, in the current 'environment of physician burnout, storytelling may actually help to humanise the physician' as well. (6)

In considering the success of Stevenson's fictional doctors in relation to their respective demonstrations of narrative competence, it is important to note Jekyll and Livesey's commonalities: both are intelligent, educated, and enjoy good social standing. Comparing the two characters is particularly interesting when their narratives are contextualised in the Scottish literary tradition within which Stevenson so consciously wrote. Variations on this motif (doubles, duality, and multiple perspectives) are of course intrinsic to Scotland's cultural history. Much has been written on Stevenson's almost obsessive interaction with this tradition, which finds embodiment in the characters of Livesey and Long John Silver in Treasure Island, (7) David Balfour and Alan Breck Stewart in Kidnapped (1886) and Catriona (1893), The Tale of Tod Lapraik' embedded within Catriona, James and Henry Durie in The Master of Ballantrae (1889), Henry Jekyll and Edward Hyde in Strange Case of Dr Jekyll and Mr Hyde, and Adam and Archie Weir in Weir of Hermiston (1896). Thus, it is intriguing to engage in an intertextual reading of Stevenson's most famous medical characters as doppelgangers.

Livesey, whose decisions are consistently life giving, and Jekyll, whose choices ultimately lead to tragedy, comprise a fascinating fictional case study. What can be learned from these clinicians if we view them as literary enactments of medical norms, as Stevenson would have perceived through his frequent interactions with physicians? Might the outcomes of their stories hinge upon innate or learned abilities to employ narrative competence as a means of recognising, communicating, and acting upon an authentic construction of reality? Do the texts offer implicit opportunities for reverse-mapping from fiction to life? (8) These inquiries will be explored as significant events from the two novels are analysed to reveal correlations between key turning points in the doctors' expressions of narrative competence and the ensuing impact upon plot trajectories.

STEVENSON AND HIS DOCTORS

Stevenson's poor health attained nearly mythic quality even during his own lifetime, presenting a significant, although hardly singular, contributing factor to his nomadic wanderings through Europe, North America, and the South Seas. Manuel J. Rowen recalls how, 'Born in the harsh cold blustery climate of Scotland, [Stevenson] suffered attacks of chills, fever, cough, weakness, and malaise, which recurred with erratic regularity throughout his life. With this type of medical background it followed that he knew doctors, many of them, from a very early age.' (9) Alan E. Guttmacher and J. R. Callahan, present an intriguing clinical overview, concluding that, 'whatever the identity of Stevenson's chronic illness, it left a deep mark on his life.' (10) Ruth Richardson lends additional insight to this observation with her assertion that Stevenson's 'view of doctors was complicated, as one might expect of a man who had suffered much illness since childhood.' (11) Indeed, his writings and correspondence highlight a mixture of positive and negative experiences regarding his interactions with physicians, as the following examples demonstrate.

Even in his youth Stevenson engaged in subconscious 'explorations' that seem inextricably related to that culture of academic medicine which permeated the intellectual climate of nineteenth-century Edinburgh. After all, he 'grew up in the most medical of all British cities, [...] surrounded by doctors and medical students.' (12) Writing of himself in the third person, Stevenson recalls how: 'while he was yet a student, there came to him a dream--adventure [...] he passed a long day in the surgical theatre, his heart in his mouth, his teeth on edge, seeing monstrous malformations and the abhorred dexterity of surgeons.' (13) Clearly, medicine both fascinated and terrified the young author. Years after his student days in 'Auld Reekie, while attempting to convalesce in Switzerland in December of 1881, Stevenson informed P. G. Hamerton: Almost immediately after I last wrote to you, I had a hemorreage (I can't spell it), was badly treated by a doctor in the country, and have been a long while picking up--still, in fact, have much to desire on that side.' (14) The following February he told W. E. Henley, 'My knee never gets the least better; it hurts tonight, which it has not done for long. I do not suppose my doctor knows any least thing about it. He says it is a nerve that I struck, but I assure you he does not know.' (15) A letter to James Payn from Samoa reveals similar distrust: 'I'll tell you the worst day that I remember. I had a haemorrhage, and was not allowed to speak, then, induced by the devil, or an errant doctor, I was led to partake of that bowl which neither cheers nor inebriates, the castor-oil bowl. [...] The waves of faintness and nausea succeeded each other for twelve hours.' (16) This recollection of ineffectual treatment ordered by a physician who Stevenson facetiously categorises alongside 'the devil' hardly presents a glowing commendation of the medical profession.

However, there were also positive interactions. Stevenson's volume of Scots poetry, Underwoods (1887), is dedicated thus:
the physician [...] is the flower (such as it is) of our civilisation;
and when that stage of man is done with, and only remembered to be
marvelled at in history, he will be thought to have shared as little as
any in the defects of the period, and most notably exhibited the
virtues of the race. [...] He brings air and cheer into the sick-room,
and often enough, though not so often as he wishes, brings healing. (17)


The book's introduction proceeds to express Stevenson's gratitude to an international roster of physicians who had come to his aid on various occasions, including a special word of thanks to Bournemouth doctor Thomas Bodley Scott. In a letter to Edmund Gosse, Stevenson noted:
I have been very, very sick; on the verge of a galloping consumption,
cold sweats, prostrating attacks of cough, sinking fits in which I lost
the power of speech, fever, and all the ugliest circumstances of the
disease; and I have cause to bless God, my wife that is to be, and one
Dr. [William] Bamford (a name the Muse repels) that I have come out of
all this, and got my feet once more upon a little hill-top, with a fair
prospect of life and some new desire of living. (18)


He also sent Dr. Bamford a copy of Travels with a Donkey (1879), and the following is excerpted from his note on the book's half-title:
But for your kindness and skill, this would have been my last book, and
now I am in the hopes that it will be neither my last nor my best.
You doctors have a serious responsibility. You recall a man from the
gates of death, you give him health and strength once more to use or to
abuse. I hope I shall feel your responsibility added to my own, and
seek in the future to make a better profit of the life you have renewed
to me. (19)


The connection that Stevenson draws here between renewed physical health and creative (in this case, narrative) output promotes an implicit understanding of healing as a broadly conceived concept involving both body and mind. He similarly wrote to Charles Baxter that, despite 'feeling very seedy, utterly fatigued, and overborne with sleep; I have a fine old gentleman of a doctor who attends and cheers and entertains, if he does not cure me.' (20) Once again, Stevenson here associates medical success with the physician's ability to cultivate meaningful communication with patients, even when the provision of physical relief is beyond the healer's ability in a given situation. This is the essence of practicing medicine with a high degree of narrative competence.

A TALE OF TWO NOVELS

Stevenson's first major work to feature a medical protagonist--or co-protagonist, since the narration is shared between Livesey and Jim Hawkins--is Treasure Island, initially conceptualised as a serialised story for Young Folks magazine called The Sea Cook. (21) When considering this novel, it is essential to realise its nuances. Peter Hunt notes, 'Treasure Island transcends the boundaries between children's books and adults' books just as it transcends the boundaries between the novel and the romance.' (22) As is the case with all Stevenson's best fiction, the deceptively simple children's tale in fact is rife with moral ambiguity. Lucio De Capitani notes that 'his major works--Treasure Island, The Strange Case of Dr Jekyll and Mr Hyde, The Master of Ballantrae, his South Sea writings--involve unreliable narrators, polyphony, multiple perspectives, or an ambivalent dislocation of ethical standpoints.' (23) Julia Reid likewise refers to Treasure Island as 'an equivocal work, celebrating and enacting the resurgence of primitive romance, but at the same time exploring its darker side--its implication with bellicose imperialism and a ruthless creed of heroic manliness.' (24) On a similar note, Duncan Milne contends that here Stevenson began 'to darken the romance with the realities of violence and the truth of colonial appropriation, which would have its climax in the deeply effective "colonial naturalism" of The Ebb-Tide.' (25) Certainly, in Treasure Island mixed motives and ethical quandaries are presented unapologetically, demonstrating Stevenson's conceptualisation of narrative worlds in which morality is consistently problematised, particularly by the standards of popular nineteenth-century adventure narrative. (26) Interestingly, his early plans for the story mention more than one doctor, (27) and revisions to Livesey during the re-writing process were extensive, demonstrating this character's centrality to the narrative. (28)

Published just three years after Treasure Island, Strange Case of Dr Jekyll and Mr Hyde provides an ever-relevant cautionary tale. Jekyll's desire to cultivate the veneer of an upstanding citizen whilst simultaneously indulging vice has typically been considered his hamartia. However, it is possible to view Jekyll's tragedy as also resulting from his inability to perceive and contextualise a balanced narrative. In particular, the doctor exhibits a singular reliance upon science as an isolated mechanism for solving psychological and physical quandaries. MacDuffie points out that 'Stevenson frequently compared the methods and representational practices of science and literature.' (29) Indeed, Stevenson's seemingly clairvoyant depiction of Jekyll reveals how 'the scientific revolution of the 20th century required a profoundly wider base of technical knowledge than ever before. Yet the transformation marked a departure from medicine's rich tradition of valuing and relying on literature as a unique tool.' (30) This impending 'transformation' is evident in the text, where Jekyll's edited narrative vision is one in which quantifiable scientific achievement takes on a quasi-redemptive mantle in a bid to redefine the parameters of moral agency. The dangers inherent to such an ideology are addressed by a principal assertion of narrative medicine: that physicians' ultimate 'success as a profession, as healers, depends on [the] ability to integrate [...] patients' stories with the evidence. Otherwise, [they] become slaves to technology.' (31) A narrative framework helps to interrogate the allure of absolute reliance upon scientific discovery and biomedical innovation, even if such questioning is regarded as a subversion of the technological status quo.

STEVENSON'S FICTIONAL DOCTORS

From quite early in Strange Case of Dr Jekyll and Mr Hyde, we find clues that Jekyll's ambitions involve the creation of a narrative specifically tailored to his purposes: 'I saw that, of the two natures that contended in the field of my consciousness, even if I could rightly be said to be either, it was only because I was radically both; and from an early date, even before the course of my scientific discoveries had begun to suggest the most naked possibility of such a miracle, I had learned to dwell with pleasure, as a beloved day-dream, on the thought of the separation of these elements.' (32) This 'day-dream', as Jekyll calls it, relies upon an alternate version of reality--one in which the desirable and undesirable elements of a person's psyche might be violently rent asunder. In Jekyll's case, this scenario enables a situation wherein 'the unjust might go his way, delivered from the aspirations and remorse of his more upright twin; and the just could walk steadfastly and securely on his upward path [...] no longer exposed to disgrace and penitence by the hands of this extraneous evil.' (33)

Sadly, not until he is deep into a 'clinical trial'--engaged in the act of transforming into Hyde through the vehicle of ethically dubious pharmaceuticals--does Jekyll recognise the dangers of such experimentation. (34) Once this initial realisation has been attained, he makes a serious error in judgment by choosing to disregard the 'larger story' of reality in an improbable hope that his virtuous side will ultimately remain unaffected by the artificial separation of vice, which is amalgamated into that thoroughly vicious character of Edward Hyde. Given the medical/scientific context of Jekyll's story, his decision may be conceptualised as an employment of clinical judgment, which refers to the informed conclusions that lead to decisions regarding patient care. (In a fascinating display of Stevenson's sleight of hand, Jekyll occupies the dual role of physician and patient.) Clinical judgment has been defined as, the 'Cognitive or thinking process used for analyzing data, deriving diagnoses, deciding on interventions, and evaluating care.' (35) Clinical judgment may be conceptualised as being 'developed through practice, experience, knowledge and continuous critical analysis. It extends into all medical areas: diagnosis, therapy, communication and decision making.' (36)

Although for a time Jekyll's story appears idyllic, providing a convenient separation of his professional image from unscrupulous inclinations, eventually the fabrication devolves into a nightmare as the act of physical transformation slips beyond his cognitive control: 'I was slowly losing hold of my original and better self, and becoming slowly incorporated with my second and worse.' (37) Finally, Jekyll's narrative competence seems to awaken: he realises a preference for 'the elderly and discontented doctor, surrounded by friends and cherishing honest hopes [... rather than] the liberty, the comparative youth, the light step, leaping impulses and secret pleasures, that I had enjoyed in the disguise of Hyde.' (38) Attempting to be rid of this ignominious alter-ego, he realises, to his horror, that he has lost the efficacy to accomplish transformation at will. (39) As his ability to exert volition destabilises, he is decreasingly able to communicate and empathise with others. His actions and habits become marked by hypochondria and an ever-loosening grip on reality. Jekyll's inability to perceive his flaws, imperfections, and vices has dreadful implications: just as his chemical potions transform him into the worst version of himself, so his flight from reality has ultimately destructive consequences. (40) Patricia Comitini and Thomas J. Reed have written thoughtfully about the text's subliminal commentary on addiction, and such a reading evokes uncanny parallels with the current epidemic of physician burnout, which is associated with drug and alcohol abuse as means of self-medicating. (41) Given that Jekyll's chemically-induced psychological 'unraveling' results in his suicide, it may certainly be considered a clinical failure of the most devastating sort, as well as a haunting commentary on the tragically high rates of physician suicide in our own era. (42)

Interestingly, it is only through his written account, 'Henry Jekyll's Full Statement of the Case', that readers witness the doctor's ultimate reconciliation with the reality of his situation. That this account is presented as a medical case gives additional credence to reading a substantial correlation between Jekyll's poor narrative competence and his diminishing ability to effect sound clinical judgment, even when (or perhaps especially because) he is both practitioner and patient. Jekyll's eventual use of a written confession as a medium for coming to terms with reality reinforces the significance of narrative practice for processing experience. The writing process, whether its mode takes the shape of confessional text, creative prose, or poetic musing, has a unique ability to activate a pensive attitude. Perhaps this is why, as Rishi K. Goyal, et al. assert, 'when a clinician is encouraged to write, in ordinary language, about a situation with a patient, the very writing reveals aspects of the encounter otherwise left in the dark.' (43) Reflective writing thus possesses a unique ability to enhance narrative competence within medical practice.

Sadly, for Jekyll genuine self-awareness lies dormant until the final chapter in his story, when he at last acknowledges the intractability of his own psyche--but this revelation comes too late. The monstrous Hyde has gained control and is intent on destroying the physical embodiment of Jekyll's epiphany by the most visceral means possible: 'for if my narrative has hitherto escaped destruction, it has been by a combination of great prudence and great good luck. Should the throes of change take me in the act of writing it, Hyde will tear it in pieces.' (44) So the case closes badly, due as much to failure to perceive and interpret reality as to the dangers of simultaneously repressing and indulging our vices. The tragedy, of course, lies in the fact that Jekyll truly has much good in him--surely as much (perhaps more) than any of us. Thus, in the character of this ill-fated physician, we come face to face with humanity's insatiable need to construe, and justify, a narrative portrayal according to our own preferences, in which the flight from self-awareness can have profound consequences for the self and others.

Fortunately, in the character of Livesey, Stevenson has provided us with an alternative. From the onset of Treasure Island, we encounter a physician who appreciates the art and significance of storytelling. Hawkins opens his account with the memorable explanation of how: 'Squire Trewlaney, Dr. Livesey, and the rest of these gentlemen having asked me to write down the whole particulars about Treasure Island, from the beginning to the end, keeping nothing back but the bearings of the island, and that only because there is still treasure not yet lifted, I take up my pen.' (45) Livesey is thus introduced as a man who appreciates the value of employing narrative. When an intoxicated Billy Bones begins to croon his piratical sea-song, the doctor correctly interprets its menacing nature and refuses to tolerate this 'text' as a tactic of intimidation aimed towards the inn's patrons. Indeed, with the exception of a half-hearted effort by Black Dog, Livesey is the only character to resist Bones's oral bullying, and he does so with an appeal to civil law (embodied in written form: another narrative). In an encounter that sets the tone for our perception of Livesey, he faces the old villain's death-threat with admirable composure, remaining,
perfectly calm and steady:--'If
you do not put that knife this instant in your pocket, I promise,
upon my honour, you shall hang at the next assizes.'
Then followed a battle of looks between them; but the captain soon
knuckled under, put up his weapon, and resumed his seat, grumbling like
a beaten dog.
'And now, sir, continued the doctor, 'since I now know there's such a
fellow in my district, you may count I'll have an eye upon you day and
night. I'm not a doctor only; I'm a magistrate; and if I catch a breath
of complaint against you, if it's only for a piece of incivility like
tonight's, I'll take effectual means to have you hunted down and routed
out of this. Let that suffice.' (46)


The interaction is brief but memorable, bringing swift emotional relief to the victims of Bones's intimidation. While the doctor has come to the Admiral Benbow Inn to visit an ill patient, his decisions in this setting extend beyond the sickroom to the surrounding context. That is, Livesey's astute perception transcends the boundaries of his profession, and his narrative competence enables him to accurately assess a perilous situation and exercise the appropriate judgment to diffuse it.

Livesey's verbal ownership of his identity as a holistic entity can be mapped onto a broader psychological understanding of self. Unlike Jekyll, whose self-awareness and narrative competence appear so painfully limited throughout his persistent attempts to alter his physical and psychological state, Livesey embraces multiple aspects of himself. We sense no fragmentation of the man's psyche: he is simultaneously a medical practitioner, a neighbor, and a civil servant. Stevenson creates a doctor who embodies the exact opposite of Jekyll: where the latter fragments his psyche into 'not truly one, but truly two' the former integrates diverse elements of his identity into a unified person. (47) Rather than eschewing his less desirable or socially acceptable characteristics, Livesey accepts all facets of his multidimensional self. (48) He appears disinterested in construing that idealised image which is so evident in Jekyll--and so prominent a contribution to the latter's downfall. This is readily apparent on the island, when Livesey accepts a rather humbling role in camp life: that of cook. (49)

The doctor's cohesive identity is once again demonstrated when Hawkins and his mother seek assistance from residents of the nearest hamlet. Although the townspeople recoil in fear from returning to the inn with the threat of pirates looming, they are (somewhat humorously) 'willing enough to ride to Dr. Livesey's, which lay in another direction.' (50) When help arrives in the form of Supervisor Dance and his men, Dance refers to Livesey as 'a gentleman and a magistrate.' (51) The doctor's personal and professional roles exist in harmony, devoid of that disjunction which marks Jekyll's increasing cognitive dilapidation. When Hawkins delivers the oilskin packet containing Flint's map to Livesey, 'The doctor looked it all over, as if his fingers were itching to open it; but, instead of doing that, he put it quietly in the pocket of his coat.' (52) Symbolically, the ultimate adventure narrative lies within Livesey's grasp, yet he demonstrates the restraint to delay movement until the moment is right. He adroitly perceives the situational context and realises that the packet's contents must be valuable (and likely dangerous).

The ensuing scene, in which Trelawney, Livesey, and Hawkins open the packet and examine Flint's map, is notable for being the first in which we glimpse Livesey assuming yet another facet of his professional identity: that of a teacher and mentor. Hawkins recalls how, 'Dr. Livesey had kindly motioned me to come round from the side-table, where I had been eating.' (53) Interestingly, we find no pedagogical references regarding Jekyll: indeed, quite the opposite seems to be the case, if we go by the description of his workplace, a 'dingy, windowless structure [...] the theatre, once crowded with eager students and now lying gaunt and silent, the tables laden with chemical apparatus.' (54) Ever the dexterous narrative craftsman, Stevenson leaves readers to draw what conclusion we will from Jekyll's abandonment of the art of teaching, which implies an inherent narrative aspect.

Despite Livesey's keen intuition, he falls prey to one of the most charismatic tricksters of adventure literature: Long John Silver. In retrospect, an older and less naive Hawkins recalls how Silver 'was too deep, and too ready, and too clever.' (55) Nevertheless, despite being deceived, Livesey demonstrates a high level of interpersonal awareness by acting as a mediator between Trelawney and Smollett, who engage in a heated argument regarding the quality of their new-found crew: "Stay a bit; said [Livesey], "stay a bit. No use of such questions as that but to produce ill- feeling. The captain has said too much or he has said too little, and I'm bound to say that I require an explanation of his words. You don't, you say, like this cruise. Now, why ?"' (56) The doctor's artful use of words to defuse the tension between his colleagues is characteristic of his behavior throughout the novel. Tellingly, it is Livesey who Hawkins seeks out following that memorable scene in which he overhears the pirates' mutinous plans from within an apple barrel: '"Doctor, let me speak. Get the captain and squire down to the cabin, and then make some pretence to send for me. I have terrible news." The doctor changed countenance a little, but next moment he was master of himself.' (57) This brief description of Livesey's response provides a key insight into his employment of narrative competence.

While Livesey's professional training, judgment, and instincts--his practical 'know how'--can be readily translated beyond the clinical space, his ability to perceive narrative context is most evident within medical contexts. After Bones has lost consciousness following Black Dog's mysterious appearance, the Hawkins family is understandably alarmed:
It was a happy relief for us when the door opened and Dr. Livesey came
in, on his visit to my father.
'Oh, doctor; we cried, 'what shall we do? Where is he wounded?'
'Wounded? A fiddle-stick's end!' said the doctor. No more wounded than
you or I. The man has had a stroke, as I warned him.' (58)


By interpreting the broader historical context of his patient's situation, Livesey is empowered to make a swift and accurate diagnosis based on knowledge beyond the immediately apparent facts.

As the plot moves forward, Livesey consistently demonstrates fluency in interpreting his circumstances:
There was not a breath of air moving, nor a sound but that of the surf
booming half a mile along the beaches and against the rocks outside. A
peculiar stagnant smell hung over the anchorage--a smell of sodden
leaves and rotting tree trunks. I observed the doctor sniffing and
sniffing, like some one tasting a bad egg.
'I don't know about treasure, he said, 'but I'll stake my wig there's
fever here.' (59)


Not unlike a sick patient, the island's unique ecology presents a story that the doctor must accurately 'read' and interpret--and the health of the ship's crew depends entirely on his ability to do so. This keen perception is echoed in Livesey's narrative account: 'the nasty stench of the place turned me sick; if ever a man smelt fever and dysentery, it was in that abominable anchorage.' (60) A solid scientific knowledge base, coupled with narrative competence and keen intuition, impels Livesey to discourage his colleagues from making camp on the swampy ground near shore. Later, when the pirates situate themselves there, he accurately reckons that 'camped where they were in the marsh, and unprovided with remedies, the half of them would be on their backs before a week.' (61) Similarly, following the initial battle at the stockade, Livesey notes that, 'The captain and Gray were already examining [a wounded man] ; and I saw with half an eye that all was over.' (62) By contrast, we hear never a hint of Jekyll correctly diagnosing and treating a patient: we are simply left to assume that his high standing in London society must involve some measure of clinical success.

The disjunction in narrative competence between Stevenson's physician-protagonists is reinforced when, whilst returning to the Hispanolia on a surreptitious mission to recover the ship from the pirates, Hawkins notices that, 'One of the doctor's medical books lay open on the table, half of the leaves gutted out, I suppose, for pipelights' by the pirates. (63) Livesey's obvious respect for narrative knowledge, embodied here by the books that he was forced to leave behind when fleeing the ship, stands in stark opposition to Jekyll, who apparently spends the his time engrossed solely in chemicals, which might be read as a representation of science divorced from narrative competence. Conversely, Livesey's keen communication skills engender his discovery of the truth from the marooned Ben Gunn, who--to everyone's surprise--long ago found and removed Flint's treasure from its original hiding place.
When the doctor had wormed this secret from [Ben Gunn], on the
afternoon of the attack, and when, next morning, he saw the anchorage
deserted, he had gone to Silver, given him the chart, which was now
useless--given him the stores, for Ben Gunn's cave was well supplied
with goat's meat salted by himself--given anything and everything to
get a chance of moving in safety from the stockade to the two-pointed
hill, there to be clear of malaria and keep a guard upon the money. (64)


Time and again, Livesey 'saves the day'--sometimes through sheer scientific acumen but more frequently by his application of an artful blend of medical knowledge, self-awareness, and expert communication. Perhaps this is exactly what physician-author David J. Hellerstein refers to when he writes that 'a life of narrative allows one to explore and report upon of the complex worlds of doctoring. [...] By grappling with the narrative method, [physicians] encounter its inherent complexities, the conflicting obligations that come from being both a healer and a bearer of witness.' (65)

CONCLUSION

Given the correlation between narrative competence and character trajectory enacted by Stevenson's fictional doctors, it is hardly surprising that the physician most concerned to 'write down the whole particulars' of a story should, in the end, achieve a higher degree of personal and professional success. Readers are left to speculate as to whether Jekyll's tale may have evaded tragedy if he too had taken greater pains to perceive and reflect upon reality before it was too late. Jekyll's empathy certainly seems to recede in direct proportion to his loosening grip on his story. Perhaps an expansion of this physician's capacity for reflective practice might have negated the very possibility of Hyde before this fearful entity could inflict as much damage as he did.

The juxtaposition between Jekyll's lack of others- and self-awareness (not to mention the ruthless crimes committed by his unleashed alter-ego) and Livesey's consistent altruism is clearly evident in that last, fateful glimpse of Treasure Island, viewed from the departing Hispanolia. Three mutineers stand on shore, begging dolefully to be taken aboard ship, and Livesey alone expresses pity: 'But if I were sure they were raving--as I am morally certain one, at least, of them is down with fever--I should leave this camp, and at whatever risk to my own carcass, take them the assistance of my skill.' (66) Surely this empathic response is the ultimate mark of the 'good doctor', that healer bridging the mysterious boundary between physiological knowledge and an innate perception of the soul's strange journey.

Notes

(1) See, as a few examples: Daniel Marchalik, 'The Return to Literature--Making Doctors Matter in the New Era of Medicine; Academic Medicine, 92.12 (2017), 1665-67; Samir Johna and Simi Rahman, 'Humanity Before Science: Narrative Medicine, Clinical Practice, and Medical Education; The Permanente Journal, 15.4 (2011), 92-94; Arno K. Kumagai, 'Beyond "Dr. Feel-Good": A Role for the Humanities in Medical Education; Academic Medicine, 92.12 (2017),1659-1660; and Tzipi Weiss and Marci J. Swede. 'Transforming Preprofessional Health Education through Relationship-Centered Care and Narrative Medicine, Teaching and Learning in Medicine, 31.2 (2019), 222-33.

(2) See, as a few examples: Sarah Barber, and Carlos J. Moreno-Leguizamon, 'Can Narrative Medicine Education Contribute to the Delivery of Compassionate Care? A Review of the Literature, Medical Humanities, 43.3 (2007), 199-203; Rita Charon, Narrative Medicine: Honoring the Stories of Illness (Oxford: Oxford University Press, 2006); and Megan Lemay, et al.,' Writing Well: The Long-Term Effect on Empathy, Observation, and Physician Writing through a Residency Writers' Workshop; Journal of Graduate Medical Education, 9 (2017), 357-60.

(3) Rita Charon, 'Narrative Medicine: A Model for Empathy, Reflection, Profession, and Trust; Journal of the American Medical Association (AMA), 286.15 (2001), 1897-902 (p.1897). Charon is widely considered the founder of the narrative medicine discipline. Indeed, along with collaborators at Columbia University, she asserts that the 'capacity to perceive events or persons fully and to inspect one's perceptions for accuracy are prerequisites for delivering attentive and empathic clinical care.' Rita Charon, et al., 'Close Reading and Creative Writing in Clinical Education', Academic Medicine, 91.3 (2016), 345-50 (p. 346).

(4) Narrative ethics', in Oxford Concise Medical Dictionary, ed. by Elizabeth Martin. Oxford University Press (2015) www.oxfordreference.com [accessed 18 July 2057]

(5) There is currently much work to be done in rigorously evaluating the efficacy of narrative interventions for compassion fatigue and burnout, but existing studies show some potential. See, as examples, Tim Cunningham, 'The Use and Role of Narrative Practices to Mitigate Compassion Fatigue among Expatriate Health Workers During the Ebola Outbreak of 2013-2016' (unpublished doctoral thesis, Columbia University, 2016) and Abigail Winkle, et al., 'Narrative Medicine Workshops for Obstetrics and Gynecology Residents and Association with Burnout Measures; Obstetrics and Gynecology, 128.Suppl 1 (2016) 27s-33s. For further reading on the current epidemic of physician burnout and its consequences, see Tait D. Shanafelt, et al, 'Burnout and Satisfaction with Work-Life Balance among Us Physicians Relative to the General Us Population; Archives of Internal Medicine, 172.18 (2012), 1377-85 and Tait D. Shanafelt, et al., 'Changes in Burnout and Satisfaction with Work-Life Balance in Physicians and the General US Working Population between 2011 and 2014; Mayo Clinic Proceedings, 90.12. (2015), 1600-13.

(6) Emily Silverman, 'Sharing and Healing Through Storytelling in Medicine; JAM/ Internal Medicine, 177.10 (2017), 1409-10 (p. 1410).

(7) Livesey and Silver may be read as doubles functioning as oppositional paternal figures for Hakwins.

(8) In considering the intersections between fiction and life, we ought to keep in mind Stevenson's famous remarks so eloquently delineated in his 'art of fiction' debate with Henry James. Here, Stevenson reveals his conviction that the 'monstrous, infinite, illogical, abrupt and poignant' aspects of 'life' can be realised and contextualised by human beings through the 'neat, finite, self-contained, rational, flowing' nature of 'a work of art; with which readers imaginatively engage. Robert Louis Stevenson, 'A Humble Remonstrance; Longman's Magazine, 5 (November 1184--April 1885), 139-47 (p. 142.).

(9) M. J. Rowen, 'Doctors and Robert Louis Stevenson', The Journal of the Medical Society of New Jersey, 75.6 (1978), 482-83 (p. 482.).

(10) Alan E. Guttmacher and J. R. Callahan, 'Did Robert Louis Stevenson Have Hereditary Hemorrhagic Telangiectasia?; American Journal of Medical Genetics, 91.1 (2000), 62-65 (p. 65).

(11) Ruth Richardson, 'Silent Pirates Of The Shore: Robert Louis Stevenson And Medical Negligence; The Lancet, 356. 9248 (2000), 2171-75 (p. 2172).

(12) Theodore Dalrymple, 'The Strange Case of Robert Louis Stevenson', The Telegraph, (2014) www.telegraph.co.uk/culture/9135680/The-strange-case-of-Robert-Louis-Stevenson.html [accessed 18 July 2.017].

(13) Robert Louis Stevenson, 'A Chapter on Dreams; Random Memories, Second Vailima edn, 12. (New York & London: Scribner's / Heinemann (in association with Chatto & Windus; Cassell & Co., and Longmans, Green & Co.), 1921-1923), 231-49, p. 235.

(14) Robert Louis Stevenson, The Letters of Robert Louis Stevenson, ed. by Bradford A. Booth and Ernest Mehew, 8 vols (New Haven: Yale University Press, 1994-1995), 3, p. 259.

(15) Stevenson, Letters, 3, p. 285.

(16) Ibid, 8, p. 387.

(17) Robert Louis Stevenson, Underwoods, Second Vailima edn, 8 (New York & London: Scribner's/Heinemann (in association with Chatto & Windus; Cassell & Co., and Longmans, Green & Co.), 1921-1923), p. 93.

(18) Stevenson, Letters, 3, p. 77.

(19) Ibid., 3, p. 73.

(20) Ibid, p. 397.

(21) Stevenson's short story, 'The Body Snatchers' (first published in the Pall Mall Christmas Extra in December 1884), also features medical protagonists, but it is beyond the scope of this project.

(22) Peter Hunt, 'Introduction; in Robert Louis Stevenson, Treasure Island, Oxford World's Classics Edition, ed. by Peter Hunt (Oxford: Oxford University Press, 2011), pp. vii--xxxi (p. x).

(23) Lucio De Capitani, 'The playwright, the moralist and the poet: a Brechtian reading of Stevenson's writings on Francois Villon; Journal of Stevenson Studies, 11 (2016), 53-79 (p. 75).

(24) Julia Reid, Robert Louis Stevenson, Science, and the Fin de Siecle (Houndmills, Basingstroke, Hampshire: Palgrave Macmillan, 2006), p. 41.

(25) Duncan Milne, 'Realism and romance: Henry James, Robert Louis Stevenson and the Victorian literary form', Journal of Stevenson Studies, 12 (2016), 96-117 (p. 112).

(26) For further discussion of moral ambiguity in Treasure Island, see Christy Di Frances, 'Motion and Agency in Robert Louis Stevenson's Treasure Island', eSharp. Special Issue: Spinning Scotland: Exploring Literary and Cultural Perspectives (2009), 51-66 (pp. 61-64) and Jefferson A. Singer, 'Disobedience Dreamed by a Loyal Son', in The Proper Pirate: Robert Louis Stevenson's Quest for Identity (Oxford: Oxford University Press, 2017), 67-88.

(27) 'Will you be surprised to learn that [the story] is about Buccaneers, that it begins in the Admiral Benbow public house on [the] Devon Coast, that it's all about a map and a treasure and a mutiny and a derelict ship and a current and a fine old Squire Trelawney [...] and a doctor and another doctor, and a Sea Cook with one leg, and a sea song with the chorus "Yo-ho-ho and a bottle of Rum" (at the third Ho, you heave at the capstan bars)--which is a real Buccaneer's song, only known to the crew of the late Captain Flint.' Stevenson, Letters, 3, p. 225-26.

(28) Hardesty, et al., 'Doctoring the Doctor: How Stevenson Altered the Second Narrator of Treasure Island', Studies in Scottish Literature, 21 (1986), 1-12.

(29) Allen MacDuffie, 'Irreversible Transformations: Robert Louis Stevenson's Dr Jekyll and Mr Hyde and Scottish Energy Science', Representations, 96.1 (2006), 1-20 (p. 10).

(30) Marchalik, p. 2. For perspectives on Stevenson's interaction with Victorian science, see Reid.

(31) Mark H. Ebell, 'Foreword', in Integrating Narrative Medicine And Evidence-Based Medicine, ed. by James P. Meza and Daniel S. Passerman (London: Radcliffe, 2011), pp. x-xi (p. xi).

(32) Robert Louis Stevenson, The Strange Case of Dr Jekyll and Mr Hyde, The Works of Robert Louis Stevenson, Second Vailima edn, 7 (New York & London: Scribner's / Heinemann (in association with Chatto & Windus; Cassell & Co., and Longmans, Green & Co.), 1921-1923), p. 430.

(33) Stevenson, JaH, p. 430.

(34) Ibid, p. 432.

(35) Thomas Lathrop Stedman. Stedman's Medical Dictionary for the Health Professions and Nursing, 7th Ed (Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2012), p. 346.

(36) Gunver S Kienle and Helmut Kiene, 'Clinical Judgement and the Medical Profession; Journal of Evaluation in Clinical Practice, 17.4 (2010), 621-27 (p. 621).

(37) Stevenson, JaH, p. 441.

(38) Ibid, p. 442.

(39) Ibid., p. 442, 446.

(40) Ibid., p. 446.

41 Patricia Comitini, The Strange Case of Addiction in Robert Louis Stevenson's Strange Case of Dr Jekyll and Mr Hyde, Victorian Review, 38.1 (2011) 113-131; Thomas J. Reed, The Transforming Draught: Jekyll and Hyde, Robert Louis Stevenson and the Victorian Alcohol Debate (London: McFarland & Co., 1006). For further information on burnout and substance abuse, see, as examples, Lisa J. Merlo, et al, 'Reasons for Misuse of Prescription Medication among Physicians Undergoing Monitoring by a Physician Health Program, Journal of Addiction Medicine, 7.5 (2013), 349-53 and Michael R. Oreskovich, et al., 'Prevalence of alcohol use disorders among American surgeons, Archives of Surgery, 147.2 (2012), 168-74.

(42) See, as examples, Catherine M. Kuhn and Ellen M. Flanagan, 'Self-Care as a Professional Imperative: Physician Burnout, Depression, and Suicide; Canadian Journal of Anesthesia, 64.2 (2017), 158-68; Matthew L. Goldman, Ravi N. Shah, and Carol A. Bernstein, 'Depression and Suicide Among Physician Trainees: Recommendations for a National Response', JAMA Psychiatry, 72.5 (2015), 411-12 and Eva Schernhammer, 'Taking Their Own Lives--the High Rate of Physician Suicide; New England Journal of Medicine, 352.24 (2005), 2473-76.

(43) Rishi K. Goyal, et al., "'A Local Habitation And A Name": How Narrative Evidence-Based Medicine Transforms The Translational Research Paradigm; Journal of Evaluation in Clinical Practice, 14.5 (2008), 732-41 (P. 737).

(44) Stevenson, JaH, p. 453-54.

(45) Robert Louis, Stevenson, Treasure Island, The Works of Robert Louis Stevenson, Second Vailima edn, 5 (New York & London: Scribner's / Heinemann (in association with Chatto & Windus; Cassell & Co., and Longmans, Green & Co.), 1921-1923) p. II.

(46) Stevenson, TI, p. 19.

(47) Stevenson, JaH, p. 429.

(48) At one point, we glimpse Livesey's self-admitted arrogance: 'That man Smollett [...] is a better man than I am. And when I say that it means a deal, Jim: Stevenson, TI, p. 171.

(49) Stevenson, TI, p. 171.

(50) Ibid., p. 41.

(51) Ibid, p. 55.

(52) Ibid, p. 58.

(53) Ibid, p. 60.

(54) Stevenson, JaH, p. 381.

(55) Stevenson, TI, p. 78.

(56) Ibid, p. 83.

(57) Ibid, p. 110.

(58) Ibid, pp. 26-27.

(59) Ibid., p. 120.

(60) Ibid, p. 145.

(61) Ibid., p. 173.

(62) Ibid., p. 160.

(63) Ibid., p. 222.

(64) Ibid, p. 305.

(65) David J. Hellerstein, "The City of the Hospital": On Teaching Medical Students to Write; The Journal of Medical Humanities, 36.4 (2015), 269-89 (p. 2.74).

(66) Stevenson, TI, p. 312.

Boston University School of Medicine

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Title Annotation:CHRISTY DIFRANCES REMEIN
Author:Remein, Christy Difrances
Publication:Scottish Literary Review
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Date:Sep 22, 2019
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