Summary:

Dick and Nicole Diver are a sparkling 1920’s expatriate couple with two small children. They are whiling their life away on the French Riviera. Dick is a psychiatrist who, when we first meet him, is not practicing. Nicole had been his patient at an exclusive clinic where she had been admitted after a "nervous breakdown" (schizophrenia) occasioned by an episode of incest with her father.

The first section of the book presents the Divers through the eyes of Rosemary Hoyt, a young actress who is vacationing with her mother and develops an ambiguous relationship with Dick. Later, in a long flashback section, we learn the story of Nicole’s illness and treatment, culminating in Dick’s marriage--with the support of her family--to the incredibly wealthy Nicole. In the interest of Nicole’s health, her sister (“Baby”) helps Dick purchase an interest in the clinic. The remainder of the novel describes a gradual role inversion, whereby Nicole grows strong, healthy, and sympathetic; while Dick gradually weakens, succumbs to alcohol, divorces Nicole, and is finally left drifting from practice to practice in upstate New York.

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Doctor Richard Diver is a young neurologist already gaining great respect for his work. One day, he visits his friend Franz in Zurich. Franz is treating a young American girl, Nicole Warren, who was sexually abused by her father and has suffered a breakdown. Nicole is attracted to Diver and writes him letters after he leaves the clinic. When she is almost cured, Diver returns to the clinic and decides, rather haphazardly, to marry her. Nicole comes from a wealthy family and the couple begin to travel around Europe.

They settle briefly in a cabin by the French Riviera and aim to live quietly so that Dick can finish his great treatise. Nevertheless, Dick's easy-going, giving nature attracts a band of followers. When Rosemary, a budding American film star visits their town, she too is drawn to him. She tells him she loves him but Dick remains true to Nicole.

Several years pass during which Dick still does not finish his writing and indeed does very little towards that end. Nicole suffers several relapses. When Dick runs into Rosemary again, they have an affair. Nicole also takes a lover and finally leaves Dick who has become increasingly dissolute. He drinks most of the day and does nothing.

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Osler’s famous essay was first delivered as a valedictory address at the University of Pennsylvania School of Medicine in 1889. Osler urges the graduates to develop two qualities or virtues. First is the "bodily" virtue of imperturbability or "a judicious measure of obtuseness." This means the outward expression of calmness and coolness, even under difficult circumstances. This virtue suggests that physicians should be relatively "insensible" to the slings-and-arrows of patient care, always maintaining a degree of detachment from their patients.

The complementary "mental" virtue is aequanimitas, which is the personal quality of calmly accepting whatever comes in life. These virtues, however, should not lead to "hardness" in dealing with patients. Osler also urges his students and colleagues to develop the other gentlemanly virtues of courage, patience, and honor.

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Scarlett writes about the tradition of medicine in a recognizably British (Canadian) voice. He presents a definition of a profession that features social responsibility and duty to serve others, and notes that "an organized profession does not seek to advance the money-making feature of professional activity." Scarlett identifies seven "pillars" (principal qualities) of the physician, or any other professional: technical skill, social responsibility, knowledge of history, knowledge of literature and the arts, personal integrity, faith that there is some meaning and value in life, and "the grace of humility."

Scarlett critiques the medical profession in two ways. First, physicians are not skeptical enough and willing enough to correct their errors. Secondly, professional qualities have declined "at the hands of the scarcely literate pushing public . . . . " As a result of this, some physicians now believe that "all this rhetoric about the essential nobility of the medical profession is a load of old rubbish" (p. 129).

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A young doctor, just graduated, arrives at the country hospital to which he is assigned. He is fraught with anxiety because of his inexperience, especially when he meets the seasoned feldsher and midwives, who sing the praises of his predecessor. During the night his first patient arrives: a girl who was caught in a brake (a machine for threshing flax) and is now mangled and near death. No one expects her to live. The feldsher whispers, “She'll die now.” Yet the doctor feels compelled to try to save her, despite his ignorance. He amputates a leg, he continues treatment, the girl hangs on. Eventually she recovers. The new doctor has established his reputation in the district.

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This novel was inspirational for several generations of pre-medical and medical students. It follows the hero, Martin Arrowsmith, from his days as a medical student through the vicissitudes of his medical/scientific career. There is much agonizing along the way concerning career and life decisions. While detailing Martin’s pursuit of the noble ideals of medical research for the benefit of mankind and of selfless devotion to the care of patients, Lewis throws many less noble temptations and self-deceptions in Martin’s path. The attractions of financial security, recognition, even wealth and power distract Arrowsmith from his original plan to follow in the footsteps of his first mentor, Max Gottlieb, a brilliant but abrasive bacteriologist.

In the course of the novel Lewis describes many aspects of medical training, medical practice, scientific research, scientific fraud, medical ethics, public health, and of personal/professional conflicts that are still relevant today. Professional jealousy, institutional pressures, greed, stupidity, and negligence are all satirically depicted, and Martin himself is exasperatingly self-involved. But there is also tireless dedication, and respect for the scientific method and intellectual honesty.

Martin’s wife, Leora, is the steadying, sensible, self-abnegating anchor of his life. In today’s Western culture it is difficult to imagine such a marital relationship between two professionals (she is a nurse). When Leora dies in the tropics, of the plague that Martin is there to study, he seems to lose all sense of himself and of his principles. The novel comes full circle at the end as Arrowsmith gives up his wealthy second wife and the high-powered, high-paying directorship of a research institute to go back to hands-on laboratory research.

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For forty years, James Langstaff (1825-1889) practiced medicine in a small town near Toronto. He witnessed the advent of anesthesia, antisepsis, new drug remedies, germ theory, and public health. Chapters are devoted to his management of surgery, obstetrics, and diseases, especially in women and children, his finances, and his role and that of his suffragist wife in the political and social fabric of their community. A reformer and temperance advocate, Langstaff was quick to adopt medical innovations, but slow to abandon familiar practices.

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Helen van Horne, the good doctor, has left her solitary practice as a physician in rural East Africa to become chief of the Department of Medicine at City Hospital. She is a tough, hard-as-nails woman who has given up the comforts of marriage, family, and human indiscretion for her profession. While the folks in South Bronx initially "hate" her because of her skin color, they soon learn that van Horne is a model of rectitude, dedication, and compassion. The Hispanic chief resident becomes her disciple.

Van Horne's yearning for human comfort and sexual gratification brings her into intimate contact with a lazy, irresponsible, but charming male student. Out of weakness, she tells the failing student that he will pass the rotation, but is later challenged by the chief resident, who has left her own lazy husband and dedicated herself to be "just like you." Van Horne realizes her own weakness, allows the failing grade to be recorded, then contemplates (but rejects) suicide.

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A physician stands in the laundry, folding her baby’s diapers, and thinks about Mr. Dantio, who died of wildly metastatic cancer. She reflects on the development of her relationship with Mr. Dantio during the time that she was pregnant. Toward the end, he developed a lung infiltrate, maybe a type of pneumonia. There was a chance that a biopsy might have helped--perhaps he had a treatable infection--but she recommended against it. Now she wonders about this decision. She wonders also about what the other physicians think of her: "you don’t really want to be a doctor anyway, you must be conflicted to have a child . . . . " She remembers seeing Mrs. Dantio in the supermarket shortly after her husband died, and crying with her. She asks herself: Will I ever be a REAL doctor, "because in moments of great stress I revert to my native tongue."

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A medical student at Lincoln Hospital in the south Bronx is called to the Emergency Room, where a gang war is going on. She plunges through fighting bodies in the waiting room to reach the treatment area, where she is enlisted to ride an ambulance with a critically injured and intubated patient. During the trip, the ambulance jerks, the tube comes out, and the student tries but fails to ventilate him with mouth-to-mouth respiration. At the other hospital, she is turned away from the cafeteria because her clothes are blood-soaked. The patient dies. Although she feels terrible, her friend Marie, a practical nurse, comforts her with a touch of ordinary love, a photo of her new grandchild.

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