As I struggled to examine Johnny, an 8-year-old boy who refused to let me see into his mouth, yelling and screaming and spitting his defiance, I thought of another doctor who wrote of his own struggles examining a child’s throat more than 80 years ago.
In 1938, doctor, writer, and poet William Carlos Williams wrote a short story entitled “The Use of Force” in which he painted a disturbing picture of the mix of emotions — frustration, anger and more — that boiled inside of him as he tried to examine a recalcitrant young patient during one of the diphtheria epidemics of his time.
Nowadays, diphtheria is archaic in the United States. But it was once a major cause of illness and death among children, until a vaccine developed in the 1920s helped prevent this bacterial infection. One look into a child’s mouth is all it takes to reveal the leathery gray plaques covering the mounds of the tonsils and lining the throat. The name of the disease derives from diphthera, the Greek word for leather. The buildup of dead tissue in a child’s throat could obstruct the airway and produce a horrific death by suffocation.
The field of modern laryngology emerged at the turn of the 20th century as doctors developed long metal instruments to remove these mortal plaques before they grew too large. But to be treated, patients needed to open their mouths, something that Williams’ patient refused to do.
As a pediatric ear, nose, and throat specialist with decades of experience trying to put children — and their parents — at ease, I knew just how difficult was the task Williams wrote about.
My patient Johnny was a pale, thin boy whose mother had brought him to see me because she was concerned about his frequent sore throats and fevers. I understood the root of Johnny’s mother’s concerns, especially during this latest wave of Covid-19. No school wanted children with fevers or coughs to be in the classroom. It’s a global phenomenon: We have become a people scared of each other, viewing each other as vectors rather than neighbors and classmates, and convinced that our children, ourselves, and our elders can and will be invaded.
Did Johnny have straightforward recurrent streptococcal infections, a common and treatable infectious process that has afflicted children for generations? Or did he harbor the enemy, something everyone in the room — perhaps with the exception of Johnny — was worried about?
Amy, the nurse who was assisting me, and I were protected by the N95 masks pinching our noses and the plastic protective shields awkwardly sitting on top of our glasses. Even so, it was impossible not to imagine a steady stream of viral soldiers emerging from Johnny’s mouth, breaching our eye protectors and masks, sticking to our scrubs and searching for crevices of exposed skin, as Johnny defied every effort of mine to use a tongue depressor so I could see his tonsils.
I closed my eyes for a moment and guiltily remembered bringing Covid-19 home to my wife and children while caring for patients during the first wave of the pandemic.
Williams’ words echoed in my ear: “The damned little brat must be protected against her own idiocy, one says to one’s self at such times. Others must be protected against her. It is social necessity … But a blind fury, a feeling of adult shame, bred of a longing for muscular release are the operatives. … In a final unreasoning assault, I overpowered the child’s neck and jaws.”
How shocking those words had been when I first read them. How I had bridled at any doctor labelling or handling any patient in such a way. Yet now, as I imagined wave after wave of aerosolized droplets envelop me, I understood the boiling of blood.
I forced myself to step back from Johnny and his mother and take a breath (and remind myself that such a breath was indeed drawn from within my protective mask). I had cared for many similarly scared Johnnies before. The only difference now was the presence of overwhelming fear: for Johnny, for his mother, and for Amy and me.
Modern science has produced better and better protective gear as well as the miracles of vaccines that prevent dread diseases, some created on previously unimaginable timelines. It has yet to cure fear, to quell the human predisposition to divide “self” from “other” and produce an antidote towards the tendency of such fear to lead toward anger, dehumanization, and isolation, when the best hope might well lie in accepting each other and working together.
I reminded myself that there have been pandemics before and there will be others in the future. I recalled the words of another doctor, Eric Cassell, who once wrote that “the test of a system of medicine should be its adequacy in face of suffering … bodies do not suffer, humans suffer.”
Johnny was not an invader. He was just being Johnny, and acting and suffering as countless other Johnnies had before him and will continue after him. I encouraged his mother to give him a hug, had Amy hold the iPad playing his favorite cartoon next to him so he could watch, and gently encouraged him to open his mouth. Distracted and calmed, he did.
I thought once more of Williams and his so very honest recounting of his thoughts, feelings, and actions, and of the experiences of doctor, parent, and child during that long-ago epidemic. I thought of Matilda’s father’s “dread that she might have diphtheria,” of Williams’ helpless frustration and shame, and of Matilda herself, who “fought with clenched teeth, desperately!” Where was the idiocy in this story? In the young patient’s actions? In the doctor’s? In our current time of widespread fear and distrust it seems so much more idiotic to refuse to acknowledge the feelings that gave rise to those actions — the same feelings that now threaten to drive us all toward our own shameful — and unhelpful — actions.
As a grateful reader of others now turned actor in my own story, I recognized I had a second chance: to take a breath before reacting, not to resort to force (despite the temptation), and not to dehumanize and overpower, but to confront the powerful urges that I and so many others are feeling, and then let them go, searching and finding a more peaceful path forward.
Christopher Hartnick is an otolaryngologist; director of pediatric otolaryngology and director of the Pediatric Airway, Voice and Swallowing Center at the Massachusetts Eye and Ear Infirmary in Boston; and a professor of otolaryngology at Harvard Medical School.
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Using force crossed my mind when examining a defiant young patient. A short story made me take a breath - STAT
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