Sherwin (Shep) Nuland is the author of the National Book Award winning How We Die: Reflections on Life's Final Chapter. He has also written The Wisdom of the Body, The Origins of Anesthesia, Doctors: The Biography of Medicine, Medicine: The Art of Healing, The Mysteries Within and Leonardo da Vinci. He is a clinical professor of surgery at Yale where he teaches bioethics and medical history. Besides being a regular contributor to medical journals he has also written for The New York Times, The New Yorker, The New Republic, The New York Review of Books and Time. Sherwin Nuland also writes "The Uncertain Art," a regular column for The American Scholar. His newest book is Lost In America: A Journey with My Father. Shep Nuland lives in Connecticut with his family and is working on a biography of Moses Maimonides.
Robert Birnbaum: Sometimes I read a book and think, "Why did the writer write the book?" In this case I didn't have any difficulty in understanding why you wrote the book. But I do question why you wanted to publish it.
Sherwin Nuland: That's the question I had for myself after I wrote the book, "Am I out of my mind to publish this book?" I realized several things. One of them was in a conversation I had with my old friend Vittorio Ferraro, who is the twenty-seven-year-old psychiatrist who kept me from having my brain divided in two. He looked at me when I questioned whether I should publish it, and he said, "Are you crazy? You're a doctor, you have to publish this book. Do you realize how many people there are who have either suffered from depression or from some tremendous insult to their lives, to their futures, to everything that they stood for?" And this is a kind of Horatio Alger story, from the depths to the heights. That was one factor. Also, I realized although I had written it to try to figure out, to understand how I felt about my father, I was also in a sense writing to see whether people still loved me. Very strange. My daughter, who is a very wise young woman—forty-one now—said to me, "Dad, if you are expecting to be validated by this book forget about it. There are going to be some supercilious and snide reviewers and they will make you feel awful." I said, "I understand that." But I didn't understand it. I still needed to be told, "Look, it's okay that your name was Nudelman. It's okay that you almost had a lobotomy and you had twenty electric shock treatments. It's okay that as early as age fifteen you were having episodes of depression. It's okay that you were for so many years trying to hide your Jewishness from certain people. All of these things are okay because what counts is the arc of a life. And not what happened along the way." And I needed that. But I was terror stricken at what the snide or supercilious reviewer might say. So far it hasn't happened. Which is a kind of an amazement to me.
RB: The terror is about having opened up your life to the world, people will be unkind about what you have offered as the truth of your life?
SN: There is a word my wife invented that I find very useful. The word is "blech." It's an onomatopoeia.
RB: (Both laugh) She didn't invent that word.
SN: Of course she didn't. She is a Quaker girl from Baltimore, and it's not the kind of word I would expect from her. But what she actually said to me, "You are really worried that someone will blech on your life, will blech on you and what you have done with your life and on the people you love." And that was exactly it. It was that snideness and superciliousness that I was so terribly concerned about. And I will never forget when I was sent the first three pre-publication reviews and every one of them was a starred review, and every one of them seemed to understand what I was trying to do. Publisher's Weekly even called it "breathtaking." I thought, "My god, they do understand. A reader will understand." And so far, nobody has bleched. That gave me courage at the last moment.
RB: You graduated from Yale Medical School. Clearly, you have accomplished a lot. I am reminded of my mother talking to me at various points in my life, "You are this and you are that. Why do you let some things bother you? Where's your confidence in yourself?" So let me ask you, where's the confidence that would protect you from what people say?
SN: Oh you are much more perceptive than that. (both laugh) The past is always with us. Who was it who said, it's not even past? We are made of memories. Everything we are is constructed of all of the early insecurities, the uncertainties. We never rid ourselves of those. One of my purposes in writing this book for myself was not just to understand my father but to understand those uncertainties that stay in me, and the major uncertainty that stayed with me was, "Will they still admire me? Will they still respect me? And in certain ways will they still love me if they know where I have come from?"
RB: I seem to be on a tear of reading psychologically interior books. I just read Frederick Busch's A Memory of War, about a middle-aged psychotherapist whose life is falling apart. When I talked to Busch, he related that early in his school career, he had a teacher who he thought hated him, and then he wrote a poem that she loved, and the message to him was that if he kept on writing, people wouldn't hate him and want him to die. This is from a memory of him at eight years old.
SN: I can believe that. This is the vehicle in which we carry ourselves forward.
RB: Where does the standard of strength come from that we are encouraged to have and often admonished if we don't?
SN: "Find closure." All of those lies that we tell ourselves. You never find closure. You never put things behind you. Instead, you carry them with you. If you somehow have been able to assimilate them into what you are, you come to some reconciliation with these problems—if you want to call them problems. I end the book with one sentence which is almost my motto, "There is no end to it." All through life we are trying to figure this out and we are trying to figure that out. We are trying to put everything into the context of what we are and make sense of it and try to justify to ourselves everything we have done. But there is no end to it. It just keeps on going. Only in the movies does someone step away and now they are a fully created man.
RB: And in literature.
SN: That Rosebud is always there.
RB: Tell me about the title. When I read the title I took it as a simple description of your father's plight. He comes to this country and can't seem to or doesn't assimilate. Then I saw more nuances after I read the book.
SN: Oh yeah. Well, there are ambiguities for him and for me. There are two Yiddish words for lost, one is ferloren, "Ich hab ferloren meine shich." I lost my shoes. The other word is ferblunget which means not just lost but puzzled and confused and unable to find your way out. And that's the lost that I am talking about in this title. Because my father simply did not understand. So he remained lost all through his life. And I too was lost. My life in certain ways—you would have to look at it as an attempt to find America—find myself in America. I was thinking, I was on a radio show last night. And I while the host was talking I started to think about assimilation. We didn't talk about it. We were talking about something else. But mind was going one way and my host was going another way. It was great fun, but I came away thinking about the fact that immigrants talk about assimilating, nobody ever talks about the fact that we assimilate the society into ourselves. He was talking about how immigrant children will consciously re-pattern themselves. The fact is a lot of that process is not conscious. It's unconscious. You are assimilating the outside world into yourself and so that becomes part of this mix of what you eventually become. Ralph Lauren wants to be a cowboy and a lord of the manor at the same time—I don't know enough about him, I haven't read the new books. But all I set myself for was becoming an American and the answer was language. To be, to have the language as my own. To make it to belong to me was to be liberated. That was my way out. And so I became fascinated with the language.
RB: That doesn't seem like the usual strategy for assimilation. Not to mention that pop culture seems the last place to have any reverence for language.
SN: But if I was going to succumb to what drives movies and television I would not be the peculiar odd guy that I am. I've always courted being an oddball. It was a little painful as an adolescent and in my twenties, but the older I got, the more I realized that there was something very valuable to me in it, and that enabled me to certain kinds of things that maybe others weren't able to do. I began to glory in it and that's one of the reasons that my writing is so personal. I'm a big fan of Michel Montaigne. I have three volumes of his essays. They are all the same, different translations, but I read them from time to time. In the introduction to his essays as they are in the original 16th century French. "Je suis moi-meme la matiere de mon livre"—I am myself the substance of my book. And if you look at anything I have written, it's me. I'm there. Even the very first book, Doctors, which was a history of medicine, I keep interweaving my medical experiences.
RB: David Shields' book Enough About You is concerned about the intermingling of autobiography into various narratives. I am inclined to think, "So what if the writer brings their own life into their writing?"
SN: That's right. So what? As a matter of fact, that becomes the perfect prism through which you see the world. I am not a writer. I never took a course in my life, and if I had to teach someone else to write I wouldn't know here to begin. But one of the things that I learned early on, after How We Die came out—is that the more personal and intimate, the more you are willing to see outside events through your own particular perspective, the more universal you are. It's an astonishing thing. My wife is in the theater and we often talk about what in the theater has really lived? Sophocles. Aeschylus, Euripides. Shakespeare. In modern times, Eugene O Neil, the early Arthur Miller. It always has to do, not with intellectual things—for whatever intellectual content it has—and it certainly has plenty—it's the audience's heart and understanding of the heart of this character. They keep doing Medea, one after the other. There is almost never a time when if you went to London or New York you couldn't see a production of Medea. None of us have ever killed our children, but we have all had the kinds of rages and emotions that that woman went through. That's the essence of literature. It’s this unknown unconscious thing that a reader feels—that if he tries to articulate it, maybe if he is good with words he might be successful, but usually not.
RB: I had a dumb moment and then maybe a not-so-dumb moment after I completed Lost in America. I wondered what was so unusual about this story?
RB: Then I realized, not much. But that would be the compelling reason to tell it.
SN: You put your finger right on it. There are unusual aspects to my story. But this is the story of an immigrant son that could be duplicated by virtually any immigrant group, even East Asian immigrants. As a matter of fact one of the first people who called me was the daughter of a Chinese immigrant. She is my agent's wife. And she is a literary lawyer, and her father was an unreconstructed Chinese immigrant and she says, "It's like my father. He didn't have syphilis. He didn't do this or that, but essentially there it is." I've gotten so many letters from people unlike me. Different places and different ethnic groups saying, "I see pieces of so my father here. I see pieces of myself here." That's what I mean by the whole notion of, if you're really going to reach to the heart of people and really give something of value to readers, you have to be intimate and personal. And you have to be absolutely dead truthful because people intuit things that aren't true. There is a certain emotional inconsistency when you read something that's not true.
RB: I was puzzled by the section where you describe being a camp counselor one summer and a period when you are having the time of your life. Seemingly you were liberated in some way. I didn't understand how that happened.
SN: I went to a junior high school, a high school, and a college that had no girls. So from sixth grade, it was all boys. It was a completely male atmosphere. I knew very few girls. About every six weeks I would have a very awkward date with someone I would never see again. That kind of thing. I had no sense of myself as a social being, no sense of myself with women. I had no sense of myself as someone who could be creative in a atmosphere of my peers, that reflected the real world. In the sense that there were men and women. And I come into this place, and I discover partly because I could speak fluent Yiddish and it was Yiddish camp, and partly because I find I have certain talent for dealing with adolescent boys. They were thirteen in my bunk. And partly because for reasons unknown, people looked to me for counsel. That had never happened before. And partly because I am very popular with these girls, which was just an amazement to me. So in that place I felt like I was some god who had descended from Olympus. I never had that feeling before, and granted it would have lasted exactly eight weeks and I would have come down to earth later anyway. But of course it stopped dead in the middle. But it was such an Olympian height for me that when the crash came it was devastating. I found that I reacted in ways that alienated the very people around who had most admired me and one of the things that it did to me, for me, against me, was that it made me think I am not this Olympian fellow. I am really a shit. I am really someone that when the chips are down and there are strains, gives in to his own hostility, his own insecurity. My thirteen-year-olds had a minor revolt against what they conceived of as my authoritarian rule and I lost some friends. It was a real crash for me.
RB: So this is a landmark event in your life. In the book you don't say that…
SN: Yeah, I don't elaborate or emphasize anything. I just tell a story. And hope that the story will emotionally speak for itself. Yeah. It was really an important event in my life because it was almost typical—it was typical, it was the epitome in the sense of summary, of so many times in my life when I had been at the height and lost it. It's fascinating to me that in my medical history research, all but one of the people whom I have extensively studied have been personalities who self-destructed. People who had everything. The world was sitting right in front and they made some really dumb move that took everything away from. I didn't realize what I was doing until after the third biography. I just finished a biography of Ignatz Semmelweis who was a 19th century obstetrician who essentially found germ theory before Pasteur and did some dumb awful stupid things and ended up in an insane asylum and lost his position. So I seem to follow this pattern of being way up at the top and exalted in my own eyes and pow!. So part of what I have gone on this journey for, in writing this book was to figure out enough of it so maybe I wouldn't have to do it anymore. At the age of 72.
RB: You were hospitalized in your late 30's?
SN: Well, I got sick in my late 30's and gradually it built up, and I was forty-one when I was hospitalized.
RB: Have you manifested self-destructive behavior since then?
SN: No, no because part of getting better once I got all the jangled connections cleared out by the electroshock therapy was standard face-to-face psychotherapy. I have never had any medications. They had failed when I went in the hospital so I have never done them again. And I have had psychotherapy when one would think I didn't need it. I have just stayed with it because there were so many puzzles I was trying to solve and just kept getting closer and closer. One doesn't want to get too psychoanalytic in an ordinary discussion but—sure the seeds of self destruction, the seeds of "I free myself from my father and I am up in the clouds and I come crashing down and become my father again, over and over again…"
RB: You mention that Vittorio Ferraro saved you from a lobotomy. Where were you that such a drastic operation was being considered?
SN: You look at me disbelieving and there is good reason for that.
RB: Even at McLean, they were quite restrained about doing lobotomies, in the heyday of lobotomies.
SN: That's right. This was at the Institute of Living in Hartford, Connecticut. The theoretical basis for lobotomy was actually developed at Yale by a man named John Fulton who influenced Munoz who got the thing going and another man, Walter Freeman. The first large number of lobotomies were done at the Hartford Hospital by a neurosurgeon named Scoville and they were doing tons of them. You know the old thing by Alexander Pope, "Be not the first by whom the new is tried nor the yet the last to cast the old aside," Well they were the first by whom the new was tried and the last to cast it aside. So, all of these major psychiatric moguls at the Institute of Living—and there were some big names there—were influenced by the enthusiasm of the neurosurgeons. By that time, which was 1973, when also nobody was still doing this, they were still doing a few. Yeah. (laughs) Close.
RB: You had mentioned that your publisher was not particularly enthusiastic about this book. How is it doing?
SN: It's pretty early and I really don't know figures, but I have been getting letters—an awful lot of letters. At this point I have gotten more letters for this book than for How We Die, in the first month. How We Die sold a half a million copies in the United State alone. So I would think that sales are good. And they are thoughtful letters, indicating that people have really read the book and thought about it.
RB: What was the rationale for the publisher's hesitation about publishing Lost in America?
SN: There were several. The first one was, "Look, you have a genre, which is explaining medical things to the general public. That's what you are identified with when people see your books. That's what people expect. That's what they want. That's what has been selling books for us." That was number one. Number two was, "There are too many memoirs. There is an epidemic of memoirs. Why do you want to do this? Stay away from it." What was unspoken but implicit in everything was "Who would care?" I was immune to who would care.
SN: There was a reason for it. When I was writing How We Die, I get to chapter three, which was a chapter on old age. I write without any plan, without any outline. I have a 2.5 Eberhard Faber pencil and a pad of paper and I write sentence by sentence, whatever. I write the first few paragraphs and in the book I had I always used a patient I had seen to illustrate the kind of death that I am describing. Suddenly it hit me like a bolt out of the blue. I spent the first eighteen years of my life watching my grandmother slowly die at the age of 96 with all of the physiological and mental changes that occur. Perfect, perfect, perfect. So I go into the kitchen, my wife was home that day. And I say, "I really want to write about my bubbeh. But who the hell would care about this four-foot-ten-inch Jewish bubbeh who couldn't speak a word of English?" And I remember what I said, "I'm going to narrow my readership down till I have six readers and they are all aged Jewish boys from the Bronx." She laughed at me, she said—there words that changed everything for that book, "Don't censor yourself. You have an editor. "Of those thousands of letters the most common topic in those letters was my bubbeh. (Searches into his jacket pocket.) Should anybody ask me this, I brought one. A pig farmer form Iowa. I'll read it for you. He writes a four-page letter in long hand, "Finally, but far, far from least, thank you so much (underlined) for sharing your beloved bubbeh with us. I now love her too, as I have known her by another name, in another time, in another place. Peace, love, joy, family prosperity, may you enjoy them all. Sincerely yours, Jim Barnes" A pig farmer in Iowa named Jim Barnes! Everybody loves their grandmother. That's what I mean by the more intimate, the more universal you are. So I was not bothered when they said, "Who will care?" I figured everybody would care.
RB: It seems to me the good answer to "Who cares?" is "How do you know?"
SN: (Laughs) Maybe a better answer is "You don't know." Of course, who was to know that a book that dealt with death graphically, in detail would do what this book [How We Die] translated into seventeen languages did. Including Arabic, of all things. Who would predict such a thing?
RB: A best seller about a horse, Sea Biscuit. Or a novel about dead fourteen-year-old protagonist [The Lovely Bones].
SN: Oh yeah. (laughs)
RB: All this focus on so-called bottom line certainly inhibits the gut calls, the intuitive decisions of editors.
SN: Oh yeah. But it’s interesting the term you used, 'gut call'. This is just what I am talking about. If it appeals to the gut of the publisher because of the way it is written they ought to just go ahead and publish it and stop thinking that no one is going to want to read this. I think the style in which the writer can present his story is much more important that what the story is about.
RB: This reminds me of The New Yorker story I read years ago, that was an extended essay on tomatoes. At the time I had no particular interest in fruits and vegetables. But it was compelling.
SN: I think every writer is looking for something and if he can engage a reader in looking for something—it may not be exactly the same thing —but they are both on this journey toward whatever it is, they are trying to find and they are engaged with each other.
RB: You are ambivalent about whether you are a writer?
SN: (Laughs) I'm not ambivalent. My wife and I have this argument all the time. I keep saying, "I'm not a writer." She says, "What the hell are you talking about, you idiot?" Well, I am a guy who has been fortunate to have been so sick that he has had to spend a very long time in accessing his unconscious mind, in trying to free up all of the entanglements to get to what he really thinks. Somehow in doing that, I have been enabled to just write spontaneously. And that has been how I do it.
RB: So why doesn't that make you a writer?
SN: (laughs again)
RB: Putting aside the stereotype of image of what a writer is, it is a skill that probably everyone can do, can access.
SN: Much more than they think. If they are only willing to not think about style, not think about how it's going to sound to the person reading it. But just go ahead and do it.
RB: There is the old saw that everyone has at least one book within them.
SN: I think it's true. Whenever people ask me, "Should I do this?" Yeah do it, do it. You have no way of knowing how wonderful this might be for you, for a reader, whatever. Another reason I say I am not a writer, when I die there is going to be an obituary in the Times and there is going to be a picture. I won a prize. I noticed that National Book Award people get their pictures there when they die.
SN: The headline will say "Author of How We Die and/or Lost in America." You know what I want the headline to say? (long pause) I need a moment for this. I want it to say something about the fact that this man spent thirty-five years of his life…taking care…of sick people the best way he knew how. That's what I want it to say. (long pause, while SN struggles to control his emotions) Ridiculous. Uh, because that's what I have done. That's what my life has been about. I don't want to be thought of as a writer. I want to be thought of as a doctor. Surgeon, yes, but a doctor. I know that it sounds self-exalting but a healer. Because that's what I tried to be. Some of it, of course, comes from the story I tell in the book, about going to the clinic with my father and how awful that was —for everybody, not just for him.
RB: It could sound self-exalting, but current medical practice makes it sound rare…introducing the word 'healing' into the discourse ought to be commended. I remember having a family doctor who made house calls.
SN: Sure. And who knew who you were.
RB: Being Jewish, I have always had friends who are doctors, who would intercede for me to get an appointment with someone who when I called was booked three or four months in advance…
SN: That's a great line. (laughs) Isn't it awful that we are in this situation were you have to have a personal contact to make that happen.
RB: Being a healer sounds like a lost or dying art. Is it possible that you may be the last generation of physicians who understand what healing means…
SN: I'd like to think that we finally reached the point as medical educators we're beginning to figure out how to stop leaching the humanity out of these young people who come to us. They come to us idealistic, by the time…
RB: Do they?
SN: Well, fewer than before. No question about it. Some come, I might even say many come idealistic. By the time we are through with them at the end of four years and more years of training we've really screened all that stuff out. We have made them just like us in the generic sense of us. Especially surgical training—it's like six years of Marine boot camp. We are replicating ourselves. The real problem nowadays has to do with the admissions committees. Years ago these committees were composed of people who really took care of the sick. They were clinicians. If you look at the composition of the Boston University or Harvard admissions committees, these are researchers. Even those who call themselves surgeons or internists, they got to be professor because of their research work. So they are looking for people very much like themselves. They are already selecting the kids that are more focused on science, more focused on distancing from human problems.
RB: Were there courses in medical ethics when you were training?
RB: So we have a rise in academic concern with values concomitant with the decline in compassion in medical practice.
SN: We are talking about the laws of thermodynamics here. To every action there is an equal and opposite reaction. In the late '70s people began to realize, "Look what we are turning out here. A bunch of scientific automatons." I'm sure that's why the ethics movement started in reaction to this dreadful situation.
RB: You're still teaching?
SN: I teach ethics (laughs) and I don't teach surgery anymore.
RB: What is the routine of your life composed of?
SN: I get up in the morning and my wife and I have breakfast together and read the Times together and talk a little bit. By a quarter of eight I am up stairs—all of my books are immediately available to me in two rooms. I just sit down with that tablet of paper and I write till about one. I start to get fuzzy in the head. Or might go to the gym or might read for a while. Or run errands and maybe by four or five I write a little more. Maybe not. And in the evening I read magazines, newspapers, books. That's what I do virtually every day. I have to do a lot of traveling I probably give twenty talks a year in far away places. That has to do with things like Death and Dying and Ethics, sometimes, History. Very often to medical schools or universities, sometimes lay groups.
RB: When you are writing is for a specific project?
SN: There are two kinds of writing. The writing of a book and the writing on assignment. For example, right now I am working on a book review for the New York Times on the history of the Food and Drug Administration. I've reviewed for the Times, The New Republic and The New York Review of Books…
RB: And for the American Scholar?
SN: That's right I have a column four times a year. Those are specific projects, and I give myself a couple of weeks to do each one and they are done. But I am always at the same time working on a book.
RB: What's next for you?
SN: I'm in the midst of beginning a biography of [Moses] Maimonides. You are familiar with the Viking Penguin series? I did one on Da Vinci. Pantheon/Shocken is doing a series on Jewish personalities.
RB: I like that approach. I'm beyond a time when I can regularly read eight hundred page biographies of Mao or whomever. Biographical essays are more helpful. I liked Nicholas Lehmann's observation recently in a New Yorker piece that the trouble with studying US History was that there was too much of it. That is, was it necessary to master every tariff and piece of legislation to grasp the history?
SN: My son who lives in China, has lived there for twelve of the last sixteen years and lives there now. He read Jonathan Spence's book on Mao. He learned more about Mao in that little book than in all the years of trying to figure that man out.
RB: There is a gap here in your reflections. Are you planning on filling it in?
SN: (Chuckles) Of course there is. There is a huge gap. Not right now. So much that it has to do with concerns a first marriage that was beyond disastrous and I don't t talk in the book about that contribution to my final breakdown. It was a dreadful period of time for everybody. So, I am not quite prepared to do something like that. One of the things that made it possible to write this book was that everybody is dead. It's interesting that my nephew and niece are a little unhappy with me because they never knew their father [Nuland's older brother] as this very troubled young man after his rheumatic fever. He would never talk about his childhood. He would talk only about his father once in a while. He would talk only about how difficult and mean his father was. And my nephew Seth refers to my father as "that old bastard." Now they find there was a period of about fifteen years where their father was completely in the wilderness and couldn't find himself. My cousin Arlene, who lived with us in that little apartment, called me after she read the manuscript and she said, "This is amazing. This is just the way I remember it. This is bringing everything to life for me." There is a pretty big character assassination of her father in the book but that's the way she remembers him.
RB: On a totally different note, what are you reading these days?
SN: About a year and a half ago I was reading Harold Bloom's book How to Read and somewhere early in the book Bloom says, "Every year until recently I used to read The Pickwick Papers." So I thought to myself, "Well, if he can read The Pickwick Papers forty times, I can read it once." I started on a train ride to Boston—it's a wonderful train ride because you are on the water most of the way—by chapter three I was hooked. So I started reading Dickens. I've read about a dozen Dickens' novels. I decided I needed a moratorium, so I haven't done it in a bit. I've just started Don Quixote.
RB: I try to read one of two Garcia Marquez books every year—A Hundred Years of Solitude or Love In the Time of Cholera…
SN: I had the experience about seven or eight years ago rereading three books—because the Boston Globe asked me to do it—All Quiet On The Western Front, The Red Badge of Courage and The Bridge of Saint Luis Rey. But Holy Christmas, what an experience that was. They were totally different books from what I had remembered, having read them when I was in my teens.
RB: I read the Wilder book recently. I couldn't believe that a New Englander wrote that story.
SN: Yeah, he lived down the block and across the street from me. Yeah, a very waspy background, yeah…and of course the way that book ends, about memory and love. In all three of them I saw things. I had read them for the story when I was fifteen and sixteen. All through your life you are building an intellectual and emotional framework and it gets bigger and bigger and the more there are places where books and experiences can latch.
RB: Well, thank you.
SN: A great pleasure…
Copyright 2003 by Robert Birnbaum
All photos by Red Diaz / Duende Publishing