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Esteve Foundation

Television fiction viewed from the perspective

of medical professionals
Medicine in Television Series
House and Medical Diagnosis. Lisa Sanders
Editor: Toni de la Torre
The Knick and Surgical Techniques. Leire Losa

The Sopranos and Psychoanalysis. Oriol Estrada Rangil

The Big Bang Theory and Aspergers Syndrome. Ramon Cererols

Breaking Bad and Methamphetamine Addiction. Patricia Robledo

Mad Men and Tobacco Addiction. Joan R. Villalb

The Walking Dead and Epidemics in the Collective Imagination. Josep M. Comelles and Enrique Perdiguero Gil

Medicine in Television Series

Angels in America, The Normal Heart and Positius: HIV and AIDS in Television Series.
Aina Clotet and Marc Clotet, under the supervision of Bonaventura Clotet

Nip/Tuck, Greys Anatomy and Plastic Surgery. Mara del Mar Vaquero Prez

Masters of Sex and Sexology. Helena Boadas

CSI and Forensic Medicine. Adriana Farr, Marta Torrens, Josep-Eladi Baos and Mag Farr

Homeland and the Emotional Sphere. Liana Vehil and Luis Lalucat

Olive Kitteridge and Depression. Oriol Estrada Rangil

True Detective and the Attraction of Evil. Luis Lalucat and Liana Vehil

Polseres vermelles and Cancer. Pere Gascn i Vilaplana

ISBN: 978-84-945061-9-2

9 788494 506192

Medicine in Television Series

Editor: Toni de la Torre
Cover illustration by Suxinsu (

English version: Kevin Booth for ANKER Traductores

This edition expresses the opinions of its authors,

which are not necessarily the views
of the Fundacin Dr. Antonio Esteve

2017, Fundacin Dr. Antonio Esteve

Llobet i Vall-Llosera 2. E-08032 Barcelona
Phone: 93 433 53 20

ISSN print edition: 2385-5053

ISSN e-edition: 2385-5061
ISBN: 978-84-945061-9-2
Legal deposit: B-10216-2017
Printed in Spain
The Fundacin Dr. Antonio Esteve (Esteve Foundation), established in 1983, has the main aim of encour-
aging progress in Pharmacotherapy through communication and scientific discussion.

The Foundation wishes to promote international cooperation in pharmacotherapeutic research and, to

that end, organizes international multidisciplinary meetings where small groups of researchers can discuss
the results of their work. Such discussions find an outlet in various publication formats such as the Esteve
Foundation Symposia and the Esteve Foundation Discussion Groups.

Other Esteve Foundation activities include organizing meetings to discuss problems of a more local
scope, published as monographs or notebooks. The Foundation also participates in conferences, sem
inars, courses and other forms of support of the medical, pharmaceutical and biological sciences, not
least among which is the Research Prize, granted biennially to the best article published by a Spanish
author within the field of pharmacotherapy.

Striking among the variety of publications that the Esteve Foundation promotes is the series Pharma-
cotherapy Revisited, which compiles the main articles that laid the foundation of a specific discipline in
several volumes, in facsimile edition.

Notebooks of the Esteve Foundation N 42


Toni de la Torre............................................................................................................................. 1

House and Medical Diagnosis

Lisa Sanders................................................................................................................................. 11

The Knick and Surgical Techniques

Leire Losa..................................................................................................................................... 19

The Sopranos and Psychoanalysis

Oriol Estrada Rangil...................................................................................................................... 29

The Big Bang Theory and Aspergers Syndrome

Ramon Cererols............................................................................................................................ 35

Breaking Bad and Methamphetamine Addiction

Patricia Robledo........................................................................................................................... 49

Mad Men and Tobacco Addiction

Joan R. Villalb.............................................................................................................................. 55

The Walking Dead and Epidemics in the Collective Imagination

Josep M. Comelles and Enrique Perdiguero Gil............................................................................ 61

Angels in America, The Normal Heart and Positius: HIV and AIDS in Television Series
Aina Clotet and Marc Clotet, under the supervision of Bonaventura Clotet.................................... 69

Nip/Tuck, Greys Anatomy and Plastic Surgery

Mara del Mar Vaquero Prez........................................................................................................ 75

Masters of Sex and Sexology

Helena Boadas............................................................................................................................. 85

CSI and Forensic Medicine

Adriana Farr, Marta Torrens, Josep-Eladi Baos and Mag Farr................................................. 93


Homeland and the Emotional Sphere

Liana Vehil and Luis Lalucat.......................................................................................................... 97

Olive Kitteridge and Depression

Oriol Estrada Rangil...................................................................................................................... 103

True Detective and the Attraction of Evil

Luis Lalucat and Liana Vehil.......................................................................................................... 111

Polseres vermelles and Cancer

Pere Gascn i Vilaplana................................................................................................................ 117

Notebooks of the Esteve Foundation N 42


Josep-Eladi Baos Josep M. Comelles

Doctor in Medicine Specialist in Psychiatry
from the Universitat Autnoma de Barcelona Founder of the Masters in Medical Anthropology
Specialist in Clinical Pharmacology and International Health, and of the Doctorate
from the Hospital Clnic de Barcelona in Medical Anthropology
Lecturer in Pharmacology at the Experimental at the Universitat Rovira i Virgili
and Health Sciences Department (CEXS) Professor Emeritus at the Medical Anthropology
at the Universitat Pompeu Fabra Research Center of the Universitat Rovira i Virgili
Barcelona Tarragona

Helena Boadas
Toni de la Torre
Sexologist and relationship therapist
Critic of television series
Writer and columnist for the Diari de Girona
Author of the books Series de culto
and J.J. Abrams: la teora de la caja
Ramon Cererols Collaborator in El Mn a RAC1, Arucitys
Author of Descubrir el Asperger and La Vanguardia
Conference speaker on Autism Spectrum Lecturer in Scripting Series
Disorders at ICE of the Universitat de Barcelona, at the Universitat de Barcelona
Universitat Internacional Menndez Pelayo in Member of the jury of the Ondas Awards
Barcelona, Mental Health Unit at the Consorci Barcelona
Sanitari de Terrassa, Confederacin Autismo
Espaa and several associations Oriol Estrada
LAmetlla del Valls (Barcelona) Graduate in Psychology
and holds a Masters in East Asian Studies
Aina Clotet
Founder of the Espai Daruma
Culturally disperse writer and educator
Graduate in Audiovisual Communication
Matar (Barcelona)
from the Universitat Pompeu Fabra
Adriana Farr
Bonaventura Clotet Researcher at the Instituto de Neuropsiquiatra
Director of IrsiCaixa y Adicciones (INAD) and in the Neurosciences
Head of the Infectious Diseases Service Program at the Institut Hospital del Mar
at the Hospital Germans Trias i Pujol dInvestigacions Mdiques (IMIM)
Badalona (Barcelona) Barcelona
Marc Clotet
Graduate in Company Administration and
Management; holder of an MBA from ESADE


Mag Farr Lisa Sanders

Researcher at the Instituto de Neuropsiquiatra Associate Lecturer
y Adicciones (INAD) and in the Neurosciences at Yale University School of Medicine
Program at the Institut Hospital del Mar Columnist for the New York Times Magazine
dInvestigacions Mdiques (IMIM) and Well Blog
Lecturer in Pharmacology Inspiration and technical consultant
in the Faculty of Medicine for the series House MD
at the Universitat Autnoma de Barcelona New Haven (CT), USA
Head of the Clinical Pharmacology Service
at the Hospital Universitari Germans Trias i Pujol Marta Torrens
Badalona (Barcelona) Researcher at the Instituto de Neuropsiquiatra
y Adicciones (INAD) and in the Neurosciences
Pere Gascn
Program at the Institut Hospital del Mar
Director, Molecular and Transnational Oncology
dInvestigacions Mdiques (IMIM)
Laboratory at the Institut dInvestigacions
Biomdiques Agust Pi i Sunyer
Head of the Medical Oncology Service
Mara del Mar Vaquero
at Hospital Clnic de Barcelona
Doctor in Medicine and Surgery
Specialist in Plastic, Aesthetic and Repair Surgery
Luis Lalucat Editor of the magazine Ciruga Plstica Ibero-
Doctor and Psychiatrist Latinoamericana
Director of the Les Corts Mental Hygiene Center Sociedad Espaola de Ciruga Plstica,
Barcelona Reparadora y Esttica (SECPRE)
Federacin Ibero-Latinoamericana de Ciruga
Leire Losa Plstica (FILACP)
Graduate in Medicine and Surgery Madrid
from the Euskal Herriko Univbertsitatea
(University of the Basque Country) Liana Vehil
Specialist in General and Digestive Surgery at Clinical Psychologist
the Hospital de Sant Joan Desp Moiss Broggi Coordinator of the Rub Community
Barcelona Rehabilitation Service,
Consorci Sanitari de Terrassa
Enrique Perdiguero Gil
Terrassa (Barcelona)
Senior Lecturer in History of Science
at the Universidad Miguel Hernndez de Elche
Director of the University Masters in History Joan R. Villalb
of Science and Scientific Communication Head of Quality and Processes
at the Universidad Miguel Hernndez de Elche at the Barcelona Public Health Agency
Elche (Alicante) President of the Tobacco Consultation Council
at the Health Department of the
Patricia Robledo Government of Catalonia
Senior Scientist Associate Lecturer in the Experimental and
on the Neurosciences Program at the IMIM- Health Sciences Department
Hospital del Mar de Investigaciones Mdicas at the Universitat Pompeu Fabra
Barcelona Barcelona

Notebooks of the Esteve Foundation N 42

Toni de la Torre

Medicine and television series have been sym- of representation on television, with the doctors
biotically conjoined for more than half a cen- white-coated figure most commonly identified as
tury. Of all dramatic genres in serialized fiction, the hero in TV series.
the medical genre is the one most firmly rooted This popular perception was also consolidat-
in the origins of televised fiction. It is one of the ed by the fact that the presence of the medical
foundational genres of the series and, in contrast drama in serialized format has been a constant
to the western (inherited from film), and the sit- for decades. The genre had its premier in 1951
com (hailing from radio), medical drama formed, with City Hospital1 on CBS, the first series in the
alongside police series and legal drama, a type of genre. Since then, there has always been a medi-
fiction inherent in series, that came into existence cal series on air in the US, with the sole exception
with the medium. These are known as workplace of a four-year period from 1956 to 1961 (from the
programs (fictions set in the workplace), whose last episode of NBCs Medic to the premier of Dr.
structure arose with the earliest television series. Kildare on the same channel). From 1961 to the
Their construction is closely linked to the creation present, US viewers have always had reference
of the narrative language of this new medium, to a fictitious hospital, making the medical pro-
which until recently was considered a lesser me- fessional a constant figure in the collective imagi-
dium, albeit highly popular. Doctors, the police nation created by television2. The genre, far from
and lawyers were the main stars in this format becoming jaded, has managed to reinvent itself
of televised fiction, and doctors tend to be more over time as we will see in this book and its
frequently identified with the world of TV series. popularity remains strong even in the new era of
Such an association is due to two reasons. TV series, in which they have achieved unheard-
Firstly, it is a question of clarity. Lawyers and of prestige. The arrival of new ideas and risky cre-
police have often shared a screen in the same ative series have not shouldered medical dramas
series, both genres frequently overlapping (a aside. In the midst of this creative revolution in
paradigmatic example is that of Perry Mason, TV series, as many as three medical series have
who practices as both a lawyer and detective), been on air at one time. From 2005 to 2009, the
while the medical drama has rarely mixed with veteran show ER, the recently launched House
other genres, remaining more sharply defined. and Greys Anatomy, still on air, were being
The second reason can be found in the medi- broadcast on NBC, FOX and ABC respectively.
cal dramas preference for the serialized format. All three attracted a large and loyal audience,
While police drama has had a prolific presence good reviews in the press and the recognition of
in film (even more so than on the small screen), the television industry, the three shows collecting
medical practice has found its foremost means 32 Emmy Awards between them.

Throughout this volume, italics will not be used for the names of series, since there are too many and this would interfere with com
fortable reading of the book.
On the next page, see the chronology of the main medical series broadcast in the US from 1953 up until the present.


General Hospital

The Doctors
(1963-1982) Greys Anatomy
(1972-1983) ER
St. Elsewhere
(1982-1988) House M.D.
Quincy M.E. Northern Exposure

(1976-1983) (1990-1995) Nurse Jackie
Marcus Welby M.D.
China Beach
(1969-1976 Chicago Hope
(1994-2000) Nip/Tuck
Medical Center (2003-2010)
Medic (1969-1976)
(1954-1956) Dr. Quinn

City Hospital Dr. Kildare The Knick

(1951-1953) (1961-1966) (2014-Present)

1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 2015
Notebooks of the Esteve Foundation N 42

Medicine in Television Series

Of all three fictions, ER tends to be consid- tious series Prescription Passion, which is a par-
ered the medical drama of reference, not simply ody of General Hospital) and others which have
for the number of awards it has reaped during nothing to do with the genre, such as Friends.
its lifetime (of those 32 Emmys, it won 23) but (The character Joey, who is an actor, gets the
because, furthermore, it is the fiction in its genre part of a doctor called Drake Ramoray, who is
that has been longest on air in the US, with 15 simultaneously a parody of one of the doctors in
seasons and 331 episodes. Its figures lag be- General Hospital, Dr. Noah Drake, and a parody
hind the British program Casualty, which is the of another soap, Days of Our Lives, broadcast
longest-running medical drama: it was launched on NBC, the same channel as Friends.) When
on the BBC in 1986 and is still on air. In its time, all is said and done, General Hospital is the se-
it was the English answer to the North-American ries that most helped consolidate the hospital as
St. Elsewhere3, a founding medical drama that a fictional setting, consequently shoring up the
standardized the forms of the genre in the eight- medical drama genre in the North-American tele-
ies. Nevertheless, Casualty is less able to exert vision tradition.
influence than North-American medical dramas,
which are exported to numerous countries and
The hospital as a dramatic setting
end up playing a greater role in forming collec-
tive imagination concerning medicine worldwide The medical drama has its basis in the very foun-
than television generates. (In this respect, it is no dations of serial fiction, characterized by offering
different to other genres since the predominance viewers an episodic narration that develops over
of the North-American television industry is abso- time (a far longer period than in other media, and
lute in terms of fiction exports.) naturally much greater than in film) and follows the
Only General Hospital surpasses both ER and lives of specific characters in a stable universe. Its
Casualty in duration, but they are not generally serial nature is defined to a certain extent by rep-
compared like to like given that General Hospital etition: In each fictional episode, viewers encoun-
is a soap set in a hospital rather than a medical ter a number of repeated elements, starting with
drama, a crucial difference for many reasons. (The the same theme music (the repetition of which
technical expertise, acting quality and creativity fulfils a ritual function), the same characters, the
in the soap opera genre are far below drama in same place and often, moreover, the same man-
terms of quality, and in fact, the manner of film- ner of resolving plot conflicts. This repetition has
ing and broadcasting are completely different, as soothing effects on viewers who enjoy witness-
well as viewers perception of them.) Neverthe- ing the development of what they already know,
less, that does not mean that this medical soaps something which has elements they can more or
resilience in US programming, where it launched less predict and constitutes the key to the cre-
on ABC in 1963 and still airs (over 13,000 epi- ation of a fictional universe that is stable in time.
sodes broadcast), is not a good example of the The universes created in TV series have fea-
ongoing presence of hospital fiction on television, tures that tend to seek viewers well-being, be-
or of the unquenchable popularity that medical ing spaces in which viewers want to lose them-
stories have among viewers4. selves. One of the fundamental rules of classic
General Hospital is also the most referenced series is the use of resources that aim to encour-
medical series, to the point where it even appears age viewers to return each week to see the next
in other hospital series such as House M.D. (Dr. episode. That means creating universes one
House never misses a single episode of the ficti- wants to be a part of at least for the duration

Broadcast in Spain under the name Hospital and in Catalonia with the title A cor obert. In Latin America it was called Hospital San Eligio.

This is in contrast to other founding genres in TV series, such as the western, which despite the huge popularity it enjoyed in the

fifties, sixties and seventies, ended up being shunned within the medium. Nowadays westerns hold a residual position, the main
contemporary examples of the genre being Deadwood, Hell On Wheels and Justified.


of the broadcast and characters one wants to professional work. In medical dramas, the cen-
get to know. Naturally, I am referring, above all, to tral character in this plot type is a patient, whose
the series from the fifties and sixties, which was story is presented, developed and resolved in an
when the medical drama was created. In later episode. Meanwhile the storylines of the hospi-
series, the techniques for capturing the audi tal medical team evolve. They are the true main
ences attention were adapted to other ways of characters, but their plot lines often have more
understanding serial fiction. So, the cliff-hanger to do with their personal than their professional
or change of direction in the script are two of the life. Sometimes, a patients storyline may have a
most popular in contemporary series, where the stronger influence on one of the stars, acting as
repetition of elements and stable universes have the detonator to a conflict, serving as a parallel to
given way to the fiction of innovation. something that is happening in the doctors per-
These stable universes have their origins in sonal life, or showing a new facet of his or her
the television sets domestic nature, prompting personality, especially when dealing with medical
the medium to create fictions that seek viewers cases with an ethical conflict. In specific cases,
comfort. In such universes, audiences find a sec- the episodic storyline can transform the protag
ond home of which they form part every time they onist, but that is not its main function.
sit down to watch. The universes in traditional se- This division between professional and private
ries are Arcadias boasting an established order life has been a feature of medical dramas since
that can definitively be altered only with difficulty. their beginnings: Part of the interest generated
Viewers know that a conflict that endangers the from exploring the daily goings on in a workplace
nature of the universe in question is possible (for is in getting to know the workers intimately (not
example, an argument between two characters), just their occupational side). Nevertheless, the
but they also know that in most cases the con- use of spaces has varied over time. In series in
flict will be resolved to ensure that the universe the fifties and sixties, the universe of the medi-
remains unaltered. In the classic serial structure, cal drama was divided in two: One part of the
such universes have a huge capacity for resist- story evolved in the hospital and another part at
ing change (to the extent that time appears sus- the medical professionals home, a legacy of the
pended, without characters progressing on in family series, which was very popular in its day.
their lives as they would were they real), while This was the structure followed by one of Spains
the contemporary series take more risks and most successful medical dramas: Mdico de Fa-
introduce changes over the seasons that alter milia. Its storylines in Doctor Nacho Martns hos-
the series universe. Whenever an event of this pital were blended with the characters daily life at
nature occurs, such as the death of one of the home as a father and head of the family. The hos-
protagonists, it is traumatic for viewers because pital as a space for fiction gained in prominence
the fiction in which they live through the television in medical dramas from the eighties onwards,
set changes for good. with the North-American series St. Elsewhere.
The medical drama (and other variants of Here, the building became a place with its own
workplace programs) use a story type that in life, another character in the series through which
television script slang is known as episodic to hundreds of peoples lives circulated. So it en-
introduce dramatic events that do not greatly af- joyed a life independent of its protagonists. This
fect the main characters and so do not alter the new structure, more focused on the setting where
universe of the fiction. Normally, they tend to be the medical profession was practiced, is what the
related to non-habitual characters, used only in a series Hospital Central adapted to Spain. This is
specific episode, and arise from the characters the latest successful medical drama in Spain5.

Note that the trends governing TV series tend to reach Spanish television late, since Mdico de Familia was launched in 1995 and
Hospital Central in 2000, both much later than the international series that inspired them.

Notebooks of the Esteve Foundation N 42

Medicine in Television Series

The growing importance of the hospital space westerns or the detective in police series. This
in medical dramas is reflected in the treatment says a lot about the way the television medium
it receives in fiction. It goes from being a neutral has traditionally represented doctors: as heroes
space that could be any hospital (from standard- who save lives, but who, instead of using a re-
ization) to a place with its own personality (per- volver or showing a sheriffs badge, wield a
sonification). It is easy to mention the names of scalpel and white coat as symbols of authority.
some of these fictitious institutions and for view- Doctors perfectly fit the definition of the clas-
ers to know perfectly well which series we are sical television hero in the sense that their cause
speaking of. Names such as St. Eligius, County is noble and their nature altruistic. They tend to
General Hospital, Princeton-Plainsboro Teaching value others above themselves, sacrificing them-
Hospital and Seattle Grace have become associ- selves to long working days and always doing
ated with medical dramas that used the hospi- everything possible to save their patients. The
tal as the epicenter of its fictional universe. The archetype of the healer notably underscores the
North-American series St. Elsewhere was the portrait of the television doctor, whose capacity
first medical drama to foreground the hospital in- to heal those who need it makes them a figure to
stitution, in a change that formed part of a trend admire and in whom viewers can blindly lay their
in televised fiction that had begun a year earlier faith. The sheriff protects us from the Indians, the
with Hill Street Blues both series were by the police inspector from criminals and the doctor
same producer, MTM Enterprises. The focus on from diseases. At heart, they all look out for our
the hospital enabled the medical drama to sink its safety. This is an idea that connects with comfort
roots into a particular neighborhood with a spe- fiction, which we mentioned above, converting
cific socio-economic situation, broadening the the medical professional into a character with a
type of comment that could be made as a genre. friendly and understanding disposition.
This point will be developed below. The protagonists of the early medical dramas,
Within series set in workplaces, there is no such as Dr. James Kildare (from Dr. Kildare), were
doubt that a hospital is a unique venue to create the prototype of a doctor for whom a reassur-
scenarios that hold narrative possibilities. This is ing smile and a slap on a patients back were
not just because it is a space through which an in- enough to gain their trust. Itll all be fine was
finite number of anonymous individuals may pass what the character played by a young Richard
(meaning an infinite number of possible story- Chamberlain conveyed. His faculties surpassed
lines), but because, furthermore, the stories un- those of a medical professional. Despite his men-
folding in such a setting tend to have great dra- tor, Dr. Leonard Gillespie, warning him that he
matic potential. It is also a setting that appealsto should limit himself to the sphere of medicine, the
viewers of all kinds because conflicts linked protagonist in this classic medical drama often
tohealth connect to a broad audience. Health is took his medical practice further and became his
a common concern among audiences that area patients advisor, such was the sense of security
priori highly diverse. The doctors and medical he transmitted. So we are dealing with an author-
team are at the dramas epicenter and are the ity figure to whom are attributed knowledge and
heroes and heroines ensuring that these anonym- wisdom in the sphere of life in general that exceed
ous stories cheat their final destiny, delivering a the competencies of a medical qualification, who
happy ending that causes an emotional catharsis generates respect around him yet at the same
in the TV audience. time is intimate enough for the sick to come to
him with problems outside the health sphere.
The figure of the friendly doctor was perpetu-
The figure of the doctor in series
ated and was the prevailing view until the end of
From the very beginnings of serialized fiction, the seventies. Dr. Marcus Welby, the star of Mar-
the figure of the medical professional has been cus Welby M.D., better personifies than anyone
placed in the same category as the sheriff in that doctor who does his utmost for his patients,


and who we often see holding vigil at his patients find in series such as Breaking Bad or Dexter. In
bedside. One of the central pillars of this series the medical drama, the adoption of this model of
was the conflict between the protagonist and protagonist has led to the emergence and popu-
Dr. Steven Kiley, since they often disagreed on larization of a model of doctor characterized by
what methods to use. This friction would become a disagreeable nature and a dehumanized ap-
a habitual type of conflict in medical dramas, but proach to medicine.
in this case, despite one tending to adhere to the If traditional fictitious doctors were essentially
letter of the medical books and the other follow- noble and altruistic, always at the service of their
ing less orthodox paths, they both have the pa- patients, whose well-being they considered a pri-
tients well-being as their central concern. They ority (reassuring manner included), the new doc-
are simply heroes with different approaches with tors in fiction would be egotists who would not
regard to medical practice. take their patients into account. They would con-
The figure of the doctor began to mutate in sider patients an obstacle in their profession and
St. Elsewhere, a series cut in a far more realistic treat them unpleasantly. Lack of orthodoxy would
mode, where we find Dr. Mark Craig, a charac- be another key element. Anti-heroes in the medi-
ter who puts his own interests above medicine. cal drama would be reticent to follow the hospital
He abandons St. Eligius for a better-paid job and rules, would make decisions that risked the lives
only returns to the center when he is promised a of others, including patients, and generally scorn
pay rise and better equipment. He is portrayed as any other opinion. Their priorities would have
a medical star, an easily irritated, irascible genius, moreto do with the personal satisfaction of be-
who has the habit of ridiculing his colleagues with ing able to solve a puzzle (the patient) than with
ironic comments. His risky operations, such as curing a person who needed their help. Leading
a heart transplant, make him a significant asset this trend of the medical anti-hero is the afore-
to the hospital, demonstrating to viewers that en- mentioned Dr. House, who was and remains the
during his personality is a fair exchange for his skill most popular of this new type of medical pro-
as a doctor. The profile is similar to Dr. Gregory fessional, though the character, who premiered
House, expert diagnostician in the series House on North-American television in 2004, has sev-
M.D. The difference between them is that Mark eral precedents. It is worth mentioning Doctor
Craig is just one character in a fictional chorus John Becker, from the series Becker, played by
of other doctors who personify the view of the Ted Danson, who in 1998 was already a bad-
kind-hearted doctor of earlier decades, while tempered politically incorrect doctor, or Doctor
Gregory House is the protagonist in his series and Vilches, from the Spanish series Hospital Central,
the absolute star of the show, personifying a new which the actor Jordi Rebelln began to play in
type of doctor corresponding to the anti-hero 2000 (though in this case in a supporting role,
archetype. like Dr. Mark Craig). The incursions of the North-
The emergence and popularity of the anti- American cable channels into medical drama
hero is not exclusive to the medical drama. have bequeathed other hospital anti-heroes,
Houses success should be read within the such as the pair of surgeons in Nip/Tuck (2003),
context of the transformation experienced by Nurse Jackie Peyton, in Nurse Jackie (2009), or
TV series due to the ground-breaking US cable Doctor John W. Thackeray, in the historical medi-
channel phenomenon, which introduced fictions cal drama The Knick (premiering in 2014).
that, among many other aspects, featured mor- Whether heroes or anti-heroes, all the doc-
ally complex characters. Tony Soprano, in The tors in medical dramas are characterized by their
Sopranos, is the archetypal modern television huge talent and skill. They are all extraordinarily
anti-hero, a subversion of the classical heros well-prepared and capable of resolving high-risk
values yet one who manages to connect with situations and extremely complex operations. To
viewers through his anxieties and weaknesses, find inefficient or irresponsible doctors, one has
and a basic influence in modern anti-heroes we to abandon medical drama territory and go to

Notebooks of the Esteve Foundation N 42

Medicine in Television Series

comedy, where series such as Scrubs, Green reality than in fiction6. Both features are resources
Wing or Childrens Hospital use precisely the re- of the medical drama for imbuing greater heroism
sponsible, idealized image that doctors tend to on the protagonists. No one wants to see doc-
have onscreen in order to subvert it humorously. tors in fiction whose patients are not cured, or
These comedies signal a break with an excess of who die on the operating table too often. Though
seriousness and drama in medical series, and as these situations occur in medical dramas, they
such constitute a healthy exercise of demystify- are not particularly abundant because at heart
ing the figure of the doctor. they are fictions that convey, as we said above,
feelings of comfort and security that are agree-
able to viewers. The same occurs with medi-
Relationship with the medical community
cal instruments, which are more spectacular in
One of the attractions of fictions set in workplaces these series, running the risk of recreating ultra-
is their ability to operate as a testament to the technological hospitals that do not reflect patient
reality of professions that viewers find attractive, reality. Nevertheless, it is also true that medical
but of whose secrets they know few. Professions dramas exist that have made the realistic recre-
such as police officer or doctor are a mystery to ation of medical equipment one of their features.
viewers, who are curious to see the reality of daily So, series such as ER or House M.D. portray
life for these professionals and how their work hospitals with the latest technology, whereas
dynamics operate. This factor is also key in other St. Elsewhere or Nurse Jackie show the reality
series that do not delve into traditional television of a lack of resources and waiting lists, taking the
professions, such as the west wing of the White medical drama into the terrain of social drama. In
House, enabling viewers to see how a fictitious this sense, criticism by the medical community
version of a US presidential cabinet functions; or that medical drama creates false expectations in
Mad Men, which shows the creative work behind viewers is valid, but only partially, since it cannot
advertising spots and slogans, taking us from the be applied to all series.
initial meetings with the client to the final version For medical dramas to be as realistic as pos-
of the advert to be approved. In all these fictions, sible, studies often employ medical profession-
viewers assume that what they are watching is als as consultants who work in close collabor
faithful and based on reality. So, they construe ation with the scriptwriters. The first chapter
through these series an image of the reality of of this Notebook you are reading is written by
such professions. Dr.Lisa Sanders, who was consultant on the se-
The medical drama is no exception to this rule ries House M.D. However, as she herself says,
and wields inevitable influence in creating the col- there is an agreement between reality and fiction:
lective imagination about the medical community Professional consultation, which is the medical
and day-to-day hospital life. Even if such series communitys channel of influence on the fictions
make a realistic approximation of the profession, representing it, is strictly adhered to only until it
the mechanisms of fiction make certain license clashes with the cause of fiction. In such cases, a
inevitable. Such license leads to one of the trad decision by the scriptwriter of the episode or the
itional criticisms made of these series by the series showrunner will choose between the real-
medical community: they can create unrealistic istic option and the one that works dramatically.
expectations in viewers insofar as the medical Since the medical drama is no documentary, no
instruments they are liable to find in hospital are such strict standards of realism can be enforced,
concerned. The same goes for the death rate so it is logical that what works best in the script
inspecific situations, which tends to be higher in carries more weight than what is more realistic.

A 2008 report of the Organizacin Mdica Colegial (Spanish Medical Association Organization) gave the example of cardiopulmonary

resuscitation, whose results in fiction tend to be positive to a much greater degree than in real life.


The connection between medical dramas channel. Medical dramas are often crossed with
and the medical community has existed since controversial moral dilemmas that enjoy diverse
the genres origins. The series Medic, launched acceptance according to society at the time, but
in 1954, was the first to pay special attention to the pressure of advertisers often acts in a censor-
medical procedures. Since then, scriptwriters ing role. Despite this, throughout medical dramas
have worried about showing the work of medi- history, scriptwriters have managed to tackle
cal professionals with detail and exactitude, often difficult-to-swallow medical questions, thereby
relying on consultation with doctors to ensure becoming (thanks to their large audiences and
they are correctly representing reality. Initially, the the publics involvement in the fiction) a more ef-
scripts were sent to medical institutions to be re- fective vehicle for influencing public opinion than
viewed. So, Dr. Kildare, the most popular medical documentary programs.
series of the sixties in the US, welcomed the ad- The arrival of the seventies saw a sea change
vice of the American Medical Association, which in this sense, with social realism opening a breach
was credited at the end of each episode. And in the traditional series genres. In the medical
in the seventies, the series Marcus Welby M.D. drama, this gust of fresh air translated into fic-
had members of the American Academy of Fam- tion such as M.A.S.H., whose political comment
ily Physicians correcting errors in the scripts. Re- on the Vietnam War, then in progress (though the
cently, independent consultants have been popu- series was set in the Korean War to camouflage
lar, employed by the studio or production house. its intentions), offered a previously unconsidered
They work continuously with the scriptwriters, reading of the genre. The series, created by Larry
offering constant feedback and even suggesting Gelbart from the novel and film that preceded
ideas for new storylines. As well as Dr. Lisa Sand- it, broadcast from 1972 to 1983, and was suc-
ers on House M.D., others in this category in- ceeded by China Beach, which premiered in
clude Dr. Karen Lisa Pike and Nurse Linda Klein, 1988 and this time was set in an evacuation hos-
who works for the series Greys Anatomy. A third pital in the city of Da Nang during the Vietnam
possibility is that the scriptwriters are knowledge- War. In the eighties, the medical drama of refer-
able about medicine. This is notable in ER, which ence was St. Elsewhere, which was striking for
Michael Crichton wrote based on his own experi- its realist approach and humble socio-economic
ence as a resident doctor at Boston City Hospi- context: St. Eligius was the hospital where pa-
tal, and which used scriptwriters with experience tients turned up who had been rejected by other
in the profession, such as Joe Sachs, a general hospitals of greater prestige with better equip-
practitioner, and Neal Baer, a pediatrician. ment. The series, created by the duo of Joshua
Consultation with the medical community was Brand and John Falsey (who years later created
crucial in introducing diseases unknown in fiction, another iconic medical series, Northern Expo-
which is one of the most interesting characteristics sure), dealt with previously taboo themes such as
of medical drama as a genre. Throughout history, breast cancer. St. Elsewhere was the first series
scriptwriters in many of these series have sought to tackle AIDS, in a 1983 episode entitled AIDS
to introduce medical conditions with little or no & Comfort. In it, the father of a family is diag-
previous screen time into their storylines, thereby nosed HIV-positive, which causes a certain ner-
helping to raise awareness of them. Dr.Kildare, a vousness in the hospital. He is led to reveal to his
classic series, was the first to introduce epilepsy family the secret homosexual relationship he has
and the problems deriving from drug addiction. with another man. St. Elsewheres example was
It would have been the first to treat other mat- followed in 1987 by the English series Intimate
ters, such as sexually transmitted infections or the Contact, which was the first series whose theme
contraceptive pill, had the NBC Board of Direc- revolved exclusively around this syndrome, hav-
tors not decided to reject the scripts of these epi- ing a protagonist who contracts the AIDS virus
sodes written by Jack Neuman, despite the fact during a business trip when he has relations with
he was supported by the then-president of the TV a prostitute.

Notebooks of the Esteve Foundation N 42

Medicine in Television Series

The first doctor to practice euthanasia in a fic- more tools than those that the show itself aims
tional series was Dr. Roxanne Turner, also from to, since series do not set out to educate viewers
St. Elsewhere, though she did not do so in the but to entertain them.
original series but in Homicide: Life on the Street.
Actress Alfre Woodard recovered the character,
Transformations of the medical drama
who had abandoned St. Elsewhere in its fifth
season, who we re-encounter working in a Bal- Television series are currently experiencing one of
timore hospice. In the episode, entitled Mercy, the most interesting creative periods in their histo-
from 1998, she is accused of having practiced ry. The medium has managed to achieve prestige
euthanasia on several terminal patients. Notwith- that was unimaginable years ago. It is the result
standing that ER was also a courageous series of changes in the television industry that have led
in this regard, it took far longer before it tackled to the recognition of scriptwriters as authors and
the question of assisted suicide. It was not until a the creation of series with artistic ambitions that
2004 episode, entitled Twas the Night, in which go beyond what was formerly considered mere
Dr. Jing-Mei Chen practiced euthanasia on her entertainment. This transformation has also made
own father, as he had requested in one of his few itself felt in the structure of the medical drama,
lucid moments. Dr. Pratt covers for her. She per- which in the last decade has combined the re-
forms the act successfully and afterwards disap- alization of a traditional formula of workplace
pears, returning to China to bury her dead father programs with the exploration of new ideas that
and leaving her job at the County General Hospital aim to innovate the genre. Among the most rel-
for good. In the nineties, ER also covered topics evant changes are an interest in barely explored
such as organ transplant or barely recognized disciplines in the medium, such as plastic sur-
mental illnesses, while it also dealt with themes of gery (the Nip/Tuck series, 2003), gynecology
a social nature like people trafficking or the rights (the English fiction Bodies, 2004) and sexol-
of the gay community. ogy (in the series Masters of Sex, 2013), which
Lastly, it is worth highlighting the value of broaden the viewpoint of the traditional medical
medical dramas as educational tools. Despite the drama, often centered on general medicine.
fact that they often adapt reality to the conven- Fusions with other genres have also occurred,
tions of fiction, the depiction of the work done with mixed results. Making the doctor an ac-
in a hospital is accurate enough to be used in tion hero by imposing a fast pace on the medi-
an illustrative manner by medical students. Joe cal drama is something that has been tried sev-
Sachs, the scriptwriter and producer of ER, ex- eral times with rather unpromising results. This
plains it in this way: A medication that would is the case of the 2009 North-American series
take ten minutes to work [in real life] might take Trauma, focused on a group of paramedics, and
30 seconds instead. We compressed time. [...] of the 2015 British series Critical, which prom-
But we learned that being accurate was impor- ised operations in real time. Neither of these were
tant for more reasons than just making real and well-received, either by the critics or by viewers.
responsible drama. To viewers, medical dramas In contrast, the merging of medical drama and
can also be a source of useful knowledge. In historical drama in The Knick, the Steven Soder-
2011, a woman suffered an asthma attack that bergh series that premiered in 2014, stood out as
left her unconscious and her ten-year-old daugh- one of the best televised fictions in that year. Set
ter practiced cardiopulmonary resuscitation as in an early-twentieth-century hospital, the series
she had seen on Greys Anatomy, a series she revisits some of the genres key features, such as
used to watch every week with her mother. This the figure of the anti-hero, rivalry between doc-
anecdote cannot be generalized nor should one tors, ethical conflicts and episodic cases, be-
deduce from it that a course in first aid may be fore a background that enables the creation of
substituted for a television series, but it does tell a historical portrait depicting social conflicts like
us that watching a medical drama gives viewers racism and class differences, practices such as


the sale of corpses, or surgical techniques that protagonist. The fourth chapter asks in what way
to modern-day viewers are extremely rudimen- the TV series The Big Bang Theory has helped to
tary. All this with a suitable taste for blood and raise awareness and popularize Aspergers syn-
arresting images that governs much of current TV drome, virtually unknown to the wider public until
fiction. recently. Chapter five is an essay on drug addic-
However, the most interesting element in the tion as shown in the series Breaking Bad while
current transformation of the medical drama is the sixth chapter looks at how tobacco addiction
that its themes are appearing in series that are is treated in a period series like Mad Men. Chap-
not framed within the archetype of the genre. ter seven covers The Walking Dead as if it were
Medical questions, for years contained within a medical series, treating the problem of zom-
hospital series, are now appearing in series of bies as a traditional epidemic. The eighth chap-
all kinds. This volume contains essays on trad ter looks at how the social problem of AIDS has
itional medical series such as those we have dis- been dealt with in three very different fictions. The
cussed in this introduction, but also on series that ninth and tenth chapters are devoted to the two
a priori do not qualify as medical yet still contain medical disciplines most recently depicted on TV:
enough elements from the genre to be analyzed firstly, an analysis of plastic surgery in Nip/Tuck
here. The expansion of this content outside of and Greys Anatomy; then we focus on sexology
the limits of hospital fiction in the last instance and the stars of Masters of Sex. Chapter eleven
benefits medicine. And medicines presence in deals with forensic medicine, one of the most
the collective imagination shaped by TV series is frequently recurring specializations on television,
increasingly stronger. In any case, we believe that analyzing CSI, the series which popularized it. In
a detailed analysis of certain key cases is over- the following three chapters, we explore the emo-
due. This analysis we leave in the hands of the tions of three characters: Carries bipolar disorder
true medical professionals: the experts in each in Homeland, Olives depression in the mini-series
of the medical disciplines who have participated Olive Kitteridge, and Rusts path towards evil in
in this book with their reflections concerning how True Detective. The final chapter is concerned
the series reflect their profession. with cancer as shown in the series Polseres ver-
The first chapter contains an analysis of the se- melles (Red Band Society), closing this Notebook
ries House and its view of medical diagnosis. The of the Esteve Foundation. Our aim is to give medi-
second postulates whether The Knick is as rigor- cal professionals a panoramic view of how their
ous as it seems with a passionate journey through profession is reflected in TV series, and to give
the history of surgery. The third chapter analyzes fans of the series a fresh viewpoint, one that is
how a series as prestigious as The Sopranos has unexpected, interesting and enriches their favorite
made psychoanalysis the key to the creation of its fictions.

Notebooks of the Esteve Foundation N 42

House and Medical Diagnosis

Lisa Sanders

Gregory House marked a before and after within the genre of medical series. The concept of an anti-hero
as hero did not merely transfer with remarkable success onto the cable TV networks, but furthermore it
managed to earn the interest and respect of many health professionals. After eight seasons on the FOX
network (20042012), 177 episodes and numerous awards, among them two Golden Globes for Hugh
Laurie as Best Actor, House continues to be studied in the university sphere and in prestigious medical
journals such as The Lancet.

The doctor turns his piercing blue eyes to the in this meeting the readers first encounter with
strangely discolored middle-aged man seated the detective in A Study in Scarlet. Within minutes
before him. Peering over his long, thin nose, the of his introduction to future amanuensis, Dr. John
physician had the look of a predator examining Watson, Holmes announces, You have been in
prey. Unfortunately, he informs the man coolly, Afghanistan, I perceive. He does not reveal his
you have a deeper problem. Your wife is having route to this deduction for several weeks and
an affair. nearly a dozen pages. When Watson begs for an
What?!? the man exclaims, astonished by explanation, Holmes traces the observations and
this strange and unsought diagnosis. The doc- thought process which makes this, like all deduc-
tor casually twirls his cane as he considers his tions, seem so simple, at least in retrospect.
patient, who had come to see him with skin the Here is a gentleman of a medical type, he
color of a carrot, but complained only about a tells the eager Watson, but with the air of a mili-
pain in his back following a vigorous golf game. tary man. Clearly an army doctor, then. He has
Youre orange, you moron, he explains irritably. just come from the tropics, for his face is dark,
Its one thing for you not to notice, but if your and that is not the natural tint of his skin, for his
wife hasnt picked up on the fact that her hus- wrists are fair. He has undergone hardship and
band has changed color, shes just not paying sickness as his haggard face says clearly. His left
attention. arm has been injured. He holds it in a stiff and
This is the first exchange between Dr. Gregory unnatural manner. Where in the tropics could an
House and a patient whos come to him for help English army doctor have seen much hardship
in the first episode of the Fox Television program, and got his arm wounded? Clearly in Afghani-
House MD. And right from the start we are tipped stan.
off to the link between House and his inspiration, Arrogant, observant, intelligent; a little testy,
the most famous consulting detective of all time, perhaps, but a master of deduction, who clearly
Sherlock Holmes. has a flair for dramatic revelation though per-
From our initial encounter with the character, haps a little less ruthless. The parallel between
House establishes himself as an observant, intelli- the two was not accidental. Show co-creator,
gent, arrogant man. Prickly, even rude at times, he and executive producer David Shore, acknow
is nevertheless a master of deduction, equipped ledged the intentional homage from the start:
with a ruthless flair for the dramatic revelation. Anytime one says puzzle and brilliant deduc-
Those familiar with the Canon will hear echoed tion in the same sentence, one cant help but

House and Medical Diagnosis

think of the great fictional detective Sherlock tors Guild, the Writers Guild and many Peoples
Holmes and his trusty sidekick, Dr. Watson. And Choice Awards.
indeed, Holmes and the real-life physician that It is said that success has many fathers, and
inspired him, Dr. Joseph Bell were very much here I will make my bid for at least a small piece of
inspirations for House. that paternity, alongside Sherlock Holmes. Since
Echoes of the Canon are frequent within the 2002 I have written a monthly column for the New
show. The lead characters last name, House, York Times Magazine about medical mysteries. In
is a synonym of Holmes (a near homophone to my column, called Diagnosis, I tell the story ofa
homes). House has only one friend, James Wil- patient with mysterious symptoms who seeks
son, a parallel to Dr. John Watson. House plays a doctor to discover their cause. I take readers
the piano, the guitar, the harmonica; Holmes dis- into the diagnostic process and reveal the clues
tracts himself with the violin. House takes Vico- and deductions that lead the doctor/detective to
din, Holmes, cocaine and both occasionally inject discover the pathological processes causing the
morphine or a derivative. Holmes was killed at patients illness, and point the way to treatment
least temporarily by Professor James Moriarty; or even cure.
House was shot and nearly killed by Jack Mo- Its hard to remember, but at the beginning
riarty. Irene Adler was, to Holmes, The Woman. of this century before House was a household
The first patient we see House save is named af- name diagnosis was not a topic of popular dis-
ter her Rebecca Adler. House pretends to have cussion. Indeed, if you look at what was in the
cancer to achieve one of his aims, a clear refer- media and entertainment world as an indicator
ence to the story The Adventure of the Dying De- of what was popularly or widely known, a diag-
tective where Holmes pretends to have a deadly nosis wasnt a Holmesian process but a simple
infection to catch his man. answer to the complex question presented by
Holmes and Watson refer to everyone by the patient. In these shows diagnosis was merely
their last names. So too do House and Wilson. a springboard to the rest of the story. In programs
Holmes and House also share an unconven- from Dr. Kildare (19611966), to Marcus Welby
tional personality and, a certain brusqueness (19691976) to ER (19942009), you may have a
of manner, particularly when deep into an inter- patient who comes to the doctor or hospital with
esting case. Even in their spare time similarities some type of symptoms but the focus of the dra-
can be seen. Actor Hugh Laurie once likened ma occurs before or after the cause is revealed.
Houses obsession with television, video games, The diagnosis itself is a one-liner that gets you
and popular music to Holmes habit of listening from one scene to the next.
to classical music or reading dull monographs For example, in ER, one of the longest run-
for hours on end in order to relax his mind while ning medical series, one of the ER doctors tells
pondering a case. a patient, I have the results from your blood ex-
ams. They show you have leukemia. No fuss, no
muss. Blood is taken, a test is performed, the an-
A doctor inspires a detective who inspires
swer, leukemia, is revealed, and the story returns
a doctor who inspires a show
to what its really about. In these shows diagnosis
House MD ran on Fox Television from 2004 to is like math. Fatigue and abnormalities found on
2012. It was one of the most popular television blood tests equal leukemia. In fact, the diagnosis
shows of the decade. Indeed in 2009, it was the of this type of cancer is usually far more complex
most watched television show on the planet with than that. Were there clues in the physical exam:
a reported 51 million viewers. Along the way the a certain pallor in the face and eyes? An enlarged
show garnered three Emmys (Best Script, Best spleen? Perhaps there was some weight loss?
Directing, Best Make up), four Golden Globes None of it is important or even particularly mys
(Best Actor and Best Dramatic Series, twice each) terious when the diagnosis is just one small com-
and a Peabody. Plus awards from the Screen Ac- ponent of a different human drama.

Notebooks of the Esteve Foundation N 42

Medicine in Television Series

Actually, I think doctors liked to portray their the sitting room at 221B Baker Street but in the
profession that way. The crisp precision of the exam room that inspired it. In this modern ver-
science of illness and the certainty of diagnosis sion that I witnessed, the residents play the role
is a counterweight to the art of dealing with the of the young Conan Doyle physicians working
complexities of human behavior and emotion. hard to learn the basics of deduction and diag
The simplicity of this fictional representation of nosis, guided and corrected by the master
the process disguises the uncertainty that sur- Joseph Bell, here played by the senior doctors
rounds all but the most basic diagnoses. To ac- who correct and guide and amaze when the
knowledge this intrinsic lack of precision seems pupils go astray.
to make doctors uncomfortable. Indeed, one might well say that House is the
The first two years of medical school do noth- doctor Holmes might have been had Conan Doyle
ing to contradict the impression that I and many lived in the 21st century. It would have been im-
of my fellow students had about medicine. That possible for Holmes to be a physician at the end
there is a science to it; a precision and accura- of the 19th century when first penned by Conan
cy that puts it in the same class with all that we Doyle. Joseph Bell, the doctor Conan Doyle mod-
learned on the way to med school and in those eled his character after, was admired for his re-
first two years: chemistry, biology, anatomy, phys- markable skills as an observer, his mastery of the
iology. That it is well defined, well understood in ephemera of his time the local geology, regional
short, a science. accents, etc. his powerful deductive reasoning
That impression falls apart in the third year and his flair for the dramatic. Despite his mastery
ofmedical school when students are taken out of of these fundamentals of diagnosis, theywere vir-
the classroom and put into the clinic and hospital tually useless at that time. What good werethese
where real medicine is practiced and the mystery skills at the end of the 19th century? The sci-
of diagnosis is revealed and indeed, quietly cele ence of medicine then was rudimentary. Although
brated. many diseases had been described, few were un-
On my first day in my medicine clerkship I derstood. There were no tests to confirm a sus-
went to the daily meeting that everyone in that pected diagnosis. Moreover, even if those basics
specialty attends, called Resident Report. The had been available, there were almost no effective
meeting room was dominated by a large table. treatments for anything.
The doctor-trainees sat around the table. Stu- In contrast, the end of the 19th century saw
dents sat in the back with the wiser and more the first blossoming of the science of forensics.
experienced doctor-teachers. One resident, as The most basic tools of the detective were com-
such trainees are called, describes a patient ing into wide use. The first ballistics test was
who came to the hospital, sick and in need of a developed in 1835. Fingerprints were used in a
diagnosis and care. The case is laid out before criminal investigation for the first time in 1892.
theaudience of trainees as it revealed itself to the Mug shots were first used as a means of identify-
physician at the time: who the patient was; what ing those brought before the police in the 1870s
he or she told the doctors; what the examination in Paris. The widespread use of the telegraph al-
revealed; what the preliminary tests showed. And lowed 19th century detectives to communicate
then the residents are challenged to figure out quickly with police in other districts, near and far.
the diagnosis. They examine the data presented The ultimately unsolved case of Jack the Rip-
before them, ask additional questions, and try per was perhaps the most famous application of
to reason backward, from effect (symptoms) to the burgeoning forensic sciences at that time. In
cause (disease). this investigation, teams of policemen conduct-
In that first meeting, I watched in amaze- ed house to house inquiries throughout White-
ment as diagnosis revealed itself to be, not a chapel, the area where the murders were com-
math problem but a detective story. A Sherlock mitted and forensic material was collected and
Holmes story set in its original setting not in examined, suspects were identified, fingerprint-

House and Medical Diagnosis

ed, photographed and interrogated and featured that obviously. You dont have one germ framing
on front pages almost everywhere. another germ because he was sleeping with the
One can almost sense Conan Doyles frus- first germs wife.
tration with his own profession. Even given the Although what Fox wanted, and paid for,
remarkable skills picked up from his years of ob- was a reliable procedural the case-of-the-week
serving Bell, there was virtually nothing you could kind of crime show, like CSI, like Law and Or-
do to help anyone medically. So his fascination der, known and loved by the other networks it
with the process of observation and deduc- soon became clear to co-creators Attanasio and
tion and the accumulation of arcane knowledge Shore, that they werent going to get one. In-
the fundamental tools of diagnosis were easily stead, the show was becoming more of a serial
translated into this new science. The science of drama, a program that relies on story arcs span-
crime and detection. Sherlock Holmes traded his ning multiple episodes and relying heavily on the
newly invented stethoscope for a deerstalker cap development of the core characters. These are
and magnifying glass and the detective story was less profitable for the producing companies be-
invented. cause they are less flexible in reruns. And yet, it
was clear to Shore that the doctor as detective
structure required more of just about everything
Back to his roots
to make up for the lack of a bad guy. And that the
If Holmes was a detective inspired by a doctor, I doctor himself needed to embody the complex-
consider myself a doctor inspired by a detective. ity normally spread out over an entire cast. The
Indeed unravelling the diagnostic mystery has moreI worked on it, Shore explained, the less
been my obsession since that first Resident Re- able Iwas able to make it work as a procedural
port. In my practice, and in my column in the New [and] the more the character started to come alive
York Times Magazine. So, when I got a call from a for me. That character became the guy we now
Hollywood producer named Paul Attanasio who know as Gregory House.
told me hewas producing a show based on my Once the pilot was shot there was some con-
column, I wasintrigued. Would this legacy go full cern that the executives at Fox would be angry
circle? It was an exciting possibility. Attanasio de- that the show wasnt the case of the week type
scribed his new show as a Law and Order type show theyd bought and paid for. We pulled a bit
procedural, where in each episode the crimi- of a bait-and-switch, Shore acknowledged. The
nal would be an unusual disease, to be tracked team debated how to handle this when the time
down and brought to justice not by police but by came to show the pilot to the Fox executives who
a special team of doctors. would be making the decision about whether the
The show had initially been titled Chasing show would live or die. Attanasio suggested that
Zebras, a reference to the medical truism that they not tell Fox and let the show speak for itself.
when doctors hear hoofbeats, they should nor- And speak it did. The show was put in the sched-
mally think horses common diseases. In this ule for the following season.
show the hoofbeats would be made by zebras Thats when I got the call from Attanasio.
the rarities. The idea was immediately picked Would I work with the show to come up with the
up by Fox television and funding for a pilot was medical stories that would be at the heart of each
greenlighted. However, Attansio and his team program? Wow! I thought. My column in Hol-
partners Katie Jacobs and David Shore soon lywood. I could hardly speak.
realized that by focusing exclusively on the dis- Tell me more, I asked, trying to sound casual
eases, they were losing a key component of as if calls from studio executives came as of-
the drama the human complexity. Said Shore, ten as those from nurses. It was about, Attanasio
When you are dealing with a procedural police paused briefly, then continued carefully, a doctor
drama, youve got all these motives. Youve got who specialized in making difficult diagnoses. A
all these people hiding things. Germs dont do doctor who was, and Attanasio paused again,

Notebooks of the Esteve Foundation N 42

Medicine in Television Series

irritable, arrogant, and drug-addled. A physician A tall well-built young man greeted me as I
who hated patients, but loved diagnosis. wandered into a low-slung building that looked
The description triggered a brief war in my like an old warehouse. The carpets were indus-
brain. Thats not how I wanted my magnificent trial and well worn. The walls were marked and a
obsession to be shown as the product of some little dingy. But Dustin (as the young man identi-
jerk, some badly behaved monster. On the other fied himself) was cheerful and lively as he led me
hand, showing diagnosis as a mystery to be un- past a dozen or so small offices (This is where
raveled, as detective story, and to the world well the writers work.) into a large room that, though
beyond the reach of my column, had tremendous dominated by a large table, had the casual,
appeal. well-used look of a college dorm rec room. Paul
Of course, based on this description, I figured greeted me and introduced me to the writers
the show would be a flop. Normally Im in the Tommy Moran, Peter Blake, Larry Kaplow,
William Goldman school of thought about Hol- Sara Cooper, to the executive producer, David
lywood that nobody knows nothin. But not that Shore, and medical consultant, Harvard-trained
day. Hearing about a show centered on someone internist, David Foster.
that seemed impossible to like (remember, this We all sat down around the oversized table
was before Breaking Bad) I figured it would last a and just started talking. Several episodes of that
season, maybe. first season came from that conversation. In par-
Drowning the cacophony in my head, I said, ticular, I recall a discussion of how patients wish-
as casually as I could, why yes, Id love to work es have to be obeyed, even if you think they are
with the show. Once I saw the pilot, though, I wrong. And that if you treat someone who does
realized that I had been wrong. The show was not wish to be treated you can be charged with
brilliant. The actor theyd chosen to play House, assault. That discussion was brought to life in Epi-
a Brit named Hugh Laurie who had previously sode 9 called DNR about a jazz musician who,
been known for playing the dimmer partner in a believing himself to have a terminal degenerative
duo with comic actor Stephen Fry was mesmer- illness, asks that he not be resuscitated should
izing as the unlikely hero in this medical dramedy. his heart stop beating. House believes he has
On the surface, House was the horror Attanasio been misdiagnosed and so, when the mans heart
described arrogant, irritable, rude; in short, ut- stops, brings him back from the dead. Of course
terly intolerable. And yet, somehow, when you, House is found right eventually and the musi-
the viewer, looked into the eyes of actor Hugh cian lives. But not without first pressing charges.
Laurie, there was a sense that there was another I met Hugh for the first time during that visit.
House, a better House a sensitive and damaged We chatted briefly and I told him that being a
being lurking within that crusty outer layer. And doctor was my midlife crisis, after a successful
the two of them were riveting. stint in television news. Hugh told me that his fa-
ther had also become a physician as a second
career. His first career was in the military and only
Adventures in Hollywood
when he retired, did he consider going to medi-
After I signed the contract, Paul arranged for me cal school. Was he channeling his father in any
to come to LA and meet the writers and actors. way in this role, I asked too starstruck to even
Driving my rental car down West Pico Boulevard I hear what that implied about his father. Laurie
tried to picture who Id meet, how this would go. smiled kindly and said his father was a very dif-
My heart raced as I drove up to the guard house ferent kind of doctor. A general practitioner, he
at the entrance to the studio grounds and report- saw much more bread-and-butter medicine than
ed my arrival to a handsome middle-aged man House ever would. And, he added, it was odd to
(a failed actor?). I was given a map and pointed think that in one season of this show he would
toward the building where I was to meet writers, be making more than his father would make in
producers and actors. a year. Strange, isnt it? he added, thoughtfully.

House and Medical Diagnosis

Bicoastal production right environment for the bacteria. However, even

if it could, the infection would certainly not be
Over the 8 years run of House MD I tried to go
called bacterial vaginosis but something like bac-
to Hollywood to visit the set at least once a year
terial buccalosis (buccal of or pertaining to the
but that was mostly because it was fun. Most
inner walls of the cheeks). In medicine the name
of my job as technical advisor was done through
of a disease usually does not reflect where the
email and phone calls. Writers would call with the
infection came from but where it ends up.
character and overlying story and I (and eventu-
So, I wrote a lengthy email to Tommy explain-
ally two other doctor-consultants) would try to
ing this issue and suggesting several other pos-
come up with a disease and a story to fit.
sibilities. I got back a one-line reply from Tommy:
The other part of my job was to identify inac-
Yeah. My way is funnier. And so it was.
curacies in the script. It wasnt quite as much fun
as coming up with the stories themselves, but I
recognized that how medicine is seen by the pub- The Holmes-ian roots of House
lic depends at least in part, on how it is shown on
I recently called some of the writers from House to
TV. Very early on in season 1, one of the writers
ask them how they worked Sherlock Holmes into
had Houses team put something in the mouth
the character of House. Peter Blake, Liz Fried-
of a young man having a grand mal seizure to
keep him from having his airways blocked by his man, Sara Hess, Eli Attie were some of the best
tongue. That never happens in medicine. We are and most productive writers for the show.Most
taught from our earliest days in med school that were involved from the start of the show until the
putting anything into the mouth of someone who very last days. And their answers were identical.
is seizing will do more harm than good. While They were never told that House was based on
the intention may be to prevent the patient from Sherlock Holmes. Never. Indeed both Blake and
swallowing his tongue as I was told as a kid in Friedman said that until they went to work on the
highschool, a spoon in the mouth can block the show Elementary, a series based on the premise
patients airway and cause the patient to become that Sherlock Holmes is alive and working as a
hypoxic. When I pointed this out, the writer im- consulting detective in contemporary New York
mediately changed the scene. As a result, House City, they were unaware of how closely House
was one of the few programs that correctly rep- paralleled Sherlock Holmes. Only when they re-
resented the medical response to this very com- read the Canon did they see the links between
mon type of seizure. the two characters.
Of course, not all my advice was taken. In the Still, somehow Holmes is present in the stories
second season, I got a script that contained an and in the character of House throughout all eight
error that I felt needed to be corrected. Writer/ seasons. How? Clearly it didnt originate with the
producer Tommy Moran wanted to indicate some writers. Then who? It was Eli Attie who provided
(umm, insert embarrassed cough here) oral-gen- the clue to help me solve this mystery. Attie came
ital contact between two characters, so he had to House in the shows fourth season, after a long
the young man contract an infection that could run at the NBC hit West Wing. Attie was the writer
only be transmitted that way. House diagnosed who came up with the story line that ended the
the young man with bacterial vaginosis. As a series. In this 8th seasons long story arc, Houses
dramatic tool, the diagnosis got the job done. best friend Wilson has metastatic thyroid cancer
However, it would be an unlikely diagnosis for a and is dying. And House is about to go to pris-
man. As with so many of the names of the dis- on for driving his car into his old boss/girlfriends
eases in medicine, the location of the infection is house through the living room wall.
contained in the name it is bacterial vaginosis It seemed so unlikely so un-House-like that
(vagina + osis, meaning a state of disease.) This Wilson would just go quietly off to die as his friend
infection cannot move to the mouth; its not the sat in prison. So how were they to shape this set

Notebooks of the Esteve Foundation N 42

Medicine in Television Series

of events into an ending, a good solid House-ian detection and, between the occasional mystery,
ending? The challenge went out to the writers. tends his bees.
Who can come up with the exact right story to Like Holmes, House will retire from his old fa-
end the season and the show? miliar world. Since he has allowed himself to be
Attie had an ingenious twist. House disap- thought dead, hell have to come up with a new
pears just days before he is to go to prison. There identity, a new profession. But first he and Wilson
is speculation that he has run away. Instead, will ride their motorcycles through the country,
House has apparently been on something of a finding fun and adventures as they may, until Wil-
bender he doesnt remember clearly but wakes son finally meets his maker and House will start
up to find himself in an abandoned building in a life anew. Who knows maybe hell even take up
bad part of town, alone with a junkie who may beekeeping.
have overdosed. Oh yeah and the building is on Hearing Elis story, I finally understood that
fire. As House starts to pull himself together he Holmes was embedded into House through the
is visited by a woman who died a couple of sea- snark and sensibility of David Shore. Shore was
sons earlier. She serves as the ghost of Christ- channeling Sherlock Holmes, embedding his dis-
mas past and present confronting him with tilled essence into Gregory House. I asked Shore
deeds and misdeed from the past several years. about this. He was modest in his reply. Hed al-
In between bouts of what is probably a drug in- ways been a huge fan of Sherlock Holmes and
duced delirium House becomes aware enough felt strangely in tune with him. Shore, who was
to realize that if he doesnt get out of the burning a lawyer before he abandoned that profession to
building he will die. And he has to figure out how become a producer in Hollywood told me that
to get the other guy the overdosing junkie out when he was representing someone he was more
as well. House is able to get out, but by then the interested in seeking what he thought was the just
other guy has died from his OD. House leaves his outcome than in the people he actually represent-
ID next to the guy and escapes the building just ed and what they wanted. It was a problem in the
before it collapses into a fiery heap. Then he goes law. But that was what Holmes did, really. He pur-
into hiding. When the body and ID are found, it is sued his own ideas of justice. He had his own very
assumed to be House, giving him the chance to deep moral compass. Works a lot better on the
live on but with a new identity. page or the small screen than in a court room.
Attie was thrilled when David Shore chose his Are you then the medium by which Sherlock
story to end the series. It wasnt until after the Holmes was channeled into the heart and mind
show was shot and aired and the season finally of Gregory House? I asked.
put to bed that Shore told him why he chose his Well, Im not Holmes; Im not House. But
ending. That story arc paralleled the final chap- those words that come out of Hugh (Laurie)s
ter in the life of Sherlock Holmes. In The Adven- mouth I almost always agree with them. Im
ture of the Lions Mane, Holmes describes his writing them because I believe them. They are
life at that moment. The story occurred after my thoughts and my philosophy.
my withdrawal to my little Sussex home, when In an interview Shore expounded on that phil
I had given myself up entirely to that soothing osophy and for those who love Holmes, it has
life of Nature for which I had so often yearned a familiar feel to it: House could care less what
during the long years spent amid the gloom of people feel about what hes doing, good or bad.
London. Holmes has put away his deerstalker He could care less about whether people tried
and retired to the country where he takes regular their best. The only thing that matters to him is
walks through the countryside, writes his learned the result. Surprisingly, that makes him a bit of a
monographs on cigar ash and other aspects of rebel in our society.

Notebooks of the Esteve Foundation N 42

The Knick and Surgical Techniques

Leire Losa

The one thing Steven Soderbergh, winner of an Oscar for Best Director in 2001 for Traffic, had not de-
clared when he announced his withdrawal from the film world in 2013 was that he was transferring his
unique aesthetic to cable TV, to join a growing list of film directors who are investing their talent in this far
less interventionist medium. This is what he has done in this historical drama that takes us back to the
beginnings of modern surgery in a highly unconventional way. It is set in a New York hospital in the early
twentieth century, and has an even more unusual protagonist: a reputable surgeon who is addicted to co-
caine, played by Clive Owen (Closer, Children of Men). Its popularity has raised visibility for HBOs younger
sibling: the action channel aimed at the male Cinemax audience.

The Manhattan Dispensary was a hospital found- inition of a surgeon is attributed, along with his
ed in Harlem, New York, in 1862, which survived modus operandi: The things relating to surgery
until 1979. Throughout its history it received dif- are: the patient; the operator; the assistants; the
ferent names, but was known from 1913 onward instruments; the light, where and how; how many
as the Knickerbocker Hospital. This is where the things, and how; where the body, and the instru-
series action is set, in 1900, taking as its main ments; the time; the manner; the place. The op-
narrative referent the early steps of modern sur- erator is either sitting or standing, conveniently
gery and efforts to improve it technically. for himself, for the person operated upon, for
To understand this period, one needs to briefly the light... The nails should be neither longer nor
review the history of surgical evolution from its shorter than the points of the fingers; and the sur-
beginnings. Back then, surgeons were consid- geon should practice with the extremities of the
ered technicians, and were not always qualified, fingers, the index-finger being usually turned to
in contrast to doctors, who were the true healers. the thumb; one should practice all sorts of work
However, it could be said that both disciplines with either of them... endeavoring to do them
have always been closely related. well, elegantly, quickly, without trouble, neatly,
According to archaeological and anthropolog- and promptly.
ical studies, the earliest surgical techniques were Galen of Pergamon was known above all for
employed to treat wounds and injuries. They in- being the personal physician of Emperor Mar-
cluded rudimentary cauterization, amputations cus Aurelius. Nevertheless, he was considered a
and sutures, as well as cranial trepanning, dating famous traumatologist, who repaired gladiators
back before 3000 BCE. Evidence shows that ap- wounds and described new surgical techniques,
proximately 50% of individuals undergoing such such as reconstruction of a cleft lip or palate.
operations survived. Interest in surgery did not take root among
Hindu medicine developed surgical tech- Arabian doctors, except in the case of Al-Zah-
niques as diverse as methods for repairing the rawi, the author of a compilation treatise in which
auricula of ears, rudimentary reconstructive he included sections that referenced ophthalmol
rhinoplasty and even cataract operations. ogical, obstetric and odontological techniques,
In ancient Greece, Hippocrates was known as well as hernia repair and hemostasis (aimed at
as the paradigm of a doctor, to whom the def staunching hemorrhages).

The Knick and Surgical Techniques

The Middle Ages was not an especially kind clamps, which were modifications of the clamps
period for surgery, given that its theocentric world that Par used to extract bullets. Another great
view conceived of disease as Gods scourge, contribution was the study of coagulation and the
with healing depending on a patients repen- discovery of blood groups, which enabled trans-
tance. This made surgeons a second-best resort fusions to be made, as can be seen in the final
compared to Gods will. The founding of a guild episode of the first season of The Knick, Crutch-
of surgeons in London in 1368 is noteworthy. It field. In the field of infection, in 1861, Semmel-
aimed to separate these practitioners from bar- weiss conceived the antiseptic principle with his
bers, who were the surgical precursors of doc- work Etiology, Concept and Prophylaxis of Child-
tors truly specialized in surgery as such. Never- bed Fever, which would later be enlarged upon
theless, the latter profession would continue their by Lister with his pulverizations of carbolic acid
work of extracting teeth, blood-letting and minor (phenol) and by Bregan with the introduction of
surgery until the creation of the Royal Academy steam sterilization. In 1887, Mikulicz-Radecki, es-
of Surgery in 1731, when that guild was finally tablished the use of a cap, surgical mask and cot-
prohibited from carrying out surgery. The second ton gloves during surgical operations, substituted
episode of The Knick, Mr. Paris Shoes, makes from 1890 onward by rubber gloves. The fight
reference to this when Thackery turns to Chris- against pain is highlighted by the arrival of ethe-
tiansen and says You are legitimizing surgery, real anesthesia through inhalation. Later, less toxic
taking it out of the barber shops and into the fu- anesthetics would appear, and an important mile-
ture, in a clear allusion to its past. stone was the introduction of tracheal intubation
Already in the sixteenth-century Renaissance, by Trendelenburg in 1871. So many profession-
Vesalius gained fame as an anatomist, penning als from that period developed significant surgical
De humani corporis fabrica. The Spaniard Miguel advances that it would be tedious to list them all.
Servet, who discovered pulmonary circulation, And what can be said about the twentieth
necessary for the oxygenation of the blood, was century? It is characterized by significant prog-
no less well-known. All these anatomical discov- ress in diagnostic methods, such as diagnostic
eries were favored by the freedom to conduct aut sonography, endoscopy, magnetic resonance,
opsies, which had been prohibited by the church and so on, that enabled less aggressive surgery,
and were punishable with death in the Medieval which, along with minimally invasive laparoscopic
Period, should the practitioner be discovered. techniques, made it possible to reduce certain
In the Modern Period, a real expansion in complications in conventional surgery while im-
surgeons numbers occurred, bringing great proving patient recovery times.
progress to the specialization. The Frenchman
Ambroise Par is considered to be the father of
Characters that become blurred
modern surgery. He specialized in bullet wounds,
with reality
designed prostheses for amputees, and made
brilliant studies of Siamese twins. A curiosity from The series true protagonist and anti-hero, Dr.John
that period was the design of a special vehicle Thackery, or Thack, becomes the head of surgical
suitably equipped for the transportation of pa- staff upon Dr. Christiansens death.
tients (the rudiments of todays ambulance, iden- While Thackery is a brilliant surgeon, he is also
tifiable in The Knicks first episode, Method and arrogant and ambitious, and a user of opium and
Madness, as a horse-drawn carriage). cocane. He is obsessed with being remembered
Not till the nineteenth century did the recogni- in history for some innovative surgical procedure
tion and integration of medicine and surgery take that would bear his name, to be remembered by
place, with a victory over hemorrhaging, infection, future generations of surgeons for contributing to
and pain the major obstacles this science had medical advances.
faced since its birth. Surgeons successfully man- There is no doubt that this character is based
aged to control hemorrhaging using hemostatic on the figure of William Stewart Halsted (1852

Notebooks of the Esteve Foundation N 42

Medicine in Television Series

1922), with whom he shares a great likeness. Another character who is, perhaps, based on
This man belonged to the glorious epoch of a real person is Dr. Algernon Edwards. He is a
surgerys development. Thanks to his research black doctor, the top of his year, trained at Harvard
on physiology and pathology applied to surgi- and in Europe, who joins Knickerbocker Hospi-
cal techniques, he was considered the father tal as assistant chief surgeon, encouraged and
of modern surgery, specifically North-American supported by the hospital patrons, the Ro b
surgery. Trained in both the United States and ertsons. He must contend with the racism that
Europe under the most notable surgeons of that prevails in the hospital, both from his colleagues
time, upon returning to the US he joined the staff and from patients. Like Thackery, neither is he
of several hospitals, achieved fame and prestige, free from professional arrogance, which comes
and gave classes in surgery. He undertook trials to the fore when he must face the daily disdain of
in his pathology laboratory, perfected intestinal his colleagues. We could say that Edwards is the
suture techniques and experimented with dogs alter ego of Daniel Hale Williams (18561931).
to research the curing of wounds and thyroid Due to the racial discrimination reigning in that
surgery. In 1890, he was named first surgeon in period, Afro-American citizens were banned
chief of the recently inaugurated John Hopkins from entering hospitals and black doctors were
University Hospital, and in 1892, he was ap- not employed as health personnel either. In firm
pointed first professor of surgery at the school opposition to this situation, in 1893, he decided
of medicine. to open the Providence Hospital and a nursing
Halsted used cocaine as an anesthetic and school, which became the first medical center
even went so far as to take it, to the point where with interracial staff in Pennsylvania. Likewise, in
he had to undergo a detoxification cure in 1886, 1895, he co-founded the National Medical As-
just like Dr. Thackery. sociation, a professional organization for black
His assistant in the operating theater, Miss doctors as an alternative to the American Medi-
Hampton, suffered from dermatitis on her hands, cal Association, which did not admit Afro-Amer-
so Halsted commissioned the Good Year com- ican members. A similar activity led Dr. Edwards
pany to create some rubber gloves to preserve to open his clandestine hospital in the Knicks
them. Shortly afterwards, their use was extended basement. Another of his achievements was to
to surgeons and to their assistants hands to conduct the first successful open-heart surgery,
protect the surgical field. We will see whether without having the benefit of transfusion or mod-
in future seasons Dr. Thackery does the same, ern surgical procedures, by suturing the pericar-
since at the moment no trace of gloves or surgi- dium (the membrane enclosing the heart) of a
cal masks can be seen. man who had received a knife thrust in his thorax.
Both the real and the fictional character were It is not so clear that other characters have
innovators in several surgical techniques, notable been influenced by famous historic figures. The
among which is the repair of hernias. Further- women in the series are notable for their strength
more, the real person developed a technique to and individual determination: Cornelia Robert-
combat breast cancer, still known today as Hal- son, daughter of the hospitals patron, Captain
steds operation, consisting of a radical mastec- Robertson, who heads the Knicks social welfare
tomy of the gland and pectoral muscles, along office; Nurse Lucy Elkins, who keeps both her
with local and axillary ganglionic extirpation. relationship with Thackery and her addiction to
The post-operative swelling of the arm after the drugs secret; and Sister Harriet, a Catholic nun
aforementioned surgery is also known as Hal- who runs the orphanage affiliated with the hos-
sted Syndrome. There is an amusing situation pital, who also engages in clandestine nighttime
in the seventh episode, Get the Rope, where activity consisting of practicing abortions, which
Thackery and Halsted meet face to face in the were illegal at that time. The other characters,
operating theater anteroom and are introduced though not at all dispensable, have more of a
by Dr.Christiansen, the formers mentor. chorus role that gives the storyline solidity.

The Knick and Surgical Techniques

Premises of the series and subplots This was such a frequent deformity that a specific
prosthesis was invented for aesthetic reasons,
The main storyline follows Dr. Thackery, a racist
such as the one Abigail wears, since the damage
figure, addicted to cocaine and devoted to his
can extend to the total destruction of the nasal
work to the point of exhaustion. It allows us to ex-
pyramid. Such a stigma demanded an answer,
plore one of the golden periods of surgery in terms
that of covering the orifice with reconstructive rhi-
of medical advances, through Nurse Elkins, with
whom he establishes a relationship,and through
In India, as early as 500 BCE, a technique had
his colleagues, doctors Gallinger and Chickering.
been developed to repair the nasal pyramids am-
The latter two, who are innovative in spirit, admire
putated from thieves or enemies. It consisted of
Thackery unconditionally, and accompany him
constructing a frontal flap. Later, in the sixteenth
through several steps of this surgical revolution.
century, Gaspare Tagliacozzi described a flap that
Certain details worth highlighting throughout
was taken from the skin of the arm (nasobrachial)
the series are the scientific advances revealed,
and sutured to the nasal stump, maintaining a
for example, the application of x-rays for diag-
bridge with the arm, which provided nutrients and
nostic purposes, and the perfecting of surgical
was not cut until the flap had taken root. It is this
devices and techniques.
latest technique Thackery employs on the nasal
In parallel, the series explores other subplots,
reconstruction of his former lover. It is possible
such as xenophobia formulated as humiliations
that he chose this technique to avoid an obvious
of a racist nature that Algernon Edwards must
scar on the forehead of a beautiful woman such
bear throughout the entire series, and the need
as Abigail. In the nineteenth century, the German
to create a secret hospital to treat black people.
surgeon Karl Ferdinand von Graefe recovered
The difficulty of managing a hospital that is no
this technique and modified it, earning the title of
charitable institution, given that its patients pay
the father of modern plastic surgery.
yet come along because it services a population
sector consisting mainly of workers, means that
its manager, Herman Barrow, must invent Ma- Inguinal hernia
chiavellian schemes to correct his own errors. He
The repair of defects in the abdominal wall has
can think of nothing better than asking the mafia
been a surgical procedure that has raised interest
for help, resulting in innumerable problems.
since Antiquity. Papyri from Pharaonic Egypt de-
scribed the first technique for curing an inguinal
Analyzing surgical techniques hernia, consisting of bilateral castration. Without
being so radical, over the years the use of trusses
Syphilis and rhinoplasty
were recommended as a method of conserva-
Syphilis is a disease caused by a bacteria called tion to avoid surgery on the hernia, which was
Treponema pallidum which tends to be sexu- blighted by significant infection rates and the fail-
ally transmitted, as occurs to Abigail Alford, who ure of the procedure (relapse). Once again, it was
contracts it from her husband in the third epi- not until the nineteenth century that significant
sode, The Busy Flea. Syphilis patients can go advances were announced.
through several phases. In the series we identify Edwards develops a procedure in his clan-
the ravages caused by benign tertiary syphilis, destine clinic to correct this pathology, which
which appears from three to ten years after con- was the true work of the Italian Edoardo Bassini,
tagion and is characterized by the appearances based on strengthening the posterior plane of
of inflamed lesions, known as gummas, that the inguinal canal, with a low incidence of infec-
evolve toward the death of the affected tissue. tion and relapse. A single case of early relapse
The loss of ones nose was one of the most com- resulting in death takes place in the third episode,
mon effects of syphilis in the nineteenth century. The Busy Flea, due to the patient not having

Notebooks of the Esteve Foundation N 42

Medicine in Television Series

avoided physically strenuous activity as the doc- hernial sack is known by the eponym of Amyands
tor ordered. This encouraging result is what Ed- hernia). Later, appendicular inflammation was
wards reveals to Thackery in the sixth episode, known by the name of perityphlitis, and it was not
Start Calling Me Dad, when Thackery discovers until 1886 that Fitz, a professor of pathological
him in the basement. So a working relationship anatomy, recommended appendicular removal in
begins prompted by the interest he sparks. The the case of inflammation after analyzing the post-
technique is revealed in a meeting of the Met- mortem results of 257 patients suffering from this
ropolitan Surgical Society in the eighth episode, affliction.
Working Late a Lot. Halsted (once again) pro- The first extirpation is attributed to Thomas
poses a certain modification concerning Bassinis Morton, but we would have to wait for the ar-
reconstruction of the internal ring, which must rival of McBurney, in 1888, who would go down
be as snug as possible, and he argues: ...If we in posterity as being the first surgeon to describe
could artificially produce tissues of the density the clinical manifestations of such a popular path
and toughness of the fascia and tendon, the se- ology prior to its perforation, as well as the point
cret of radical cure of hernia can be discovered. of maximum abdominal hypersensitivity and the
Irving L. Lichtenstein took this idea and in 1986 incision that bears his name, which is the one
created a hernioplasty free of tension, where a employed today when it is carried out as an open
polypropylene mesh is implanted on the anterior procedure, radically contributing to decreasing
face of the internal oblique muscle and on the mortality, from 27% around 1900 to 0.6% today.
inguinal ligament, confirming its technical sim- In episode seven, Get the Rope, Thackery gets
plicity, early discharges and a lower incidence of into McBurneys skin: By drawing a line and di-
relapse. Currently, hernias can be repaired using vining the midway point between the anterior-su-
a laparoscope. perior iliac spine and the umbilicus, parallel tothe
This type of surgery constitutes one of the fibers of the external oblique, no matter what
most frequent operations a surgeon must under- the size or sex of the patient... you will always
take, and in all hospitals classic techniques such find the appendix. Christensen, who is assisting
as Bassinis and Lichtensteins are employed. him in surgery, adds: The Thackery Point never
misses, in clear allusion to McBurneys point.
If we had to halt our arrogant protagonist with
a but, it would be to point out that the most
The fourth episode, Wheres the Dignity?, precise location for making the incision is on the
makes reference to the difficulty of locating the line described, but two thirds of the way from the
cecal appendix and consequently performing an belly button, not at its mid-point.
appendectomy or extirpation of the appendix, a
procedure, viewers are assured, that nobody has
Cocaine: between anesthetic
survived to date. To our eyes this fact may seem
and addiction
curious, since acute appendicitis is the main
cause of acute or surgical abdomen nowadays, In parallel to the development of surgery, for
and therefore, a relatively common procedure. thousands of years humankind has experiment-
We have to go back to the sixteenth century ed with substances for anesthetic and analgesic
to find the first description of the cecal appen- purposes, never quite achieving an optimum re-
dix, given by Giacomo Berengaria of Carpi, and sult, making surgery a bloody and painful proce-
shortly afterwards the description of its inflamma- dure. Not until the early nineteenth century would
tion during an autopsy. The first extirpation was the time be right for the progress of anesthetics,
conducted in the eighteenth century by Amyand, provided by the development of sciences such
who removed an inflamed appendix located in an as physiology, physics and biology, as well as
inguinal hernial sack (nowadays the infrequent surgeons greater sensitivity to their patients suf-
situation of an acute appendicitis contained in the fering.

The Knick and Surgical Techniques

By 1831, three anesthetic agents were known pioneers in spinal anesthesia via medullary co-
and employed via inhalation: nitrous oxide, ether cainization. The latter also experimented on him-
and chloroform. self, and described the typical post-dural punc-
The first to apply nitrous oxide for anesthetic ture headache due to the loss of spinal fluid dur-
purposes was a dentist named Horace Wells, ing the anesthetic tap. This type of tap is given
who inhaled the gas and extracted a tooth with- in the first episode of The Knick, when a patient,
out feeling pain. However, a later exhibition before Mr. Gentile, previously operated on for second-
his colleagues resulted in failure, since the patient ary intestinal perforation of a polytrauma, pres-
began to scream and he was branded a fraud. ents septic shock due to the failure of the suture
One of his disciples, Morton, experimented with made, requiring a further surgical operation. As
ether both on animals and on himself, achieving the patient presents a respiratory infection, gen-
a loss of consciousness through inhalation. So eral anesthesia by inhalation is not recommend-
in 1846, the first surgical operation without pain able, so Thackery opts for a spinal block.
(the extirpation of an injury of a vascular nature lo- At this point, it is obvious that Thackery is ad-
cated in the neck) was successfully carried out by dicted to cocaine, as has been evident from the
a Dr. Warren, thanks to Mortons ether. A year lat- first episode. Cocaine, the natural alkaloid ex-
er, Simpson, in England, self-experimented with tracted from coca leaves that was isolated for the
chloroform with similar results, extending its use first time in 1859, has among the most powerful
in Europe, while in the US, ether was preferred, stimulating effects on the central nervous system
which is the gas used in the series. known, the devastating effects of which are now
John Snow, from Edinburgh, was responsible well-known today.
for the development of anesthetic as a specializa- Initially, it was successfully commercialized as
tion when he successfully administered chloro a remedy for specific common diseases: the flu,
form to Queen Victoria to ease her pain while giv- colds, toothache, etc. In this way, Mariani wine,
ing birth to Leopold. Until then, it was customary with a cocaine base, was bottled and sold with-
that the narcosis was administrated by the least out problems. Among this wines great defend-
expert member of the medical team. In fact, in ers and consumers were Edison and Pope Leo
the series, it is often controlled by the nurses. XIII. A glass of this wine could contain between
In 1844, a needle for injecting fluids was de- 35 and 70 milligrams of cocaine, the same as a
signed. A decade later, Wood sought for a way to line of cocaine. Coca cigarettes were also sold
alleviate the pain caused by the neuralgia his wife for throat afflictions, and drinks with cocaine and
suffered by injecting morphine. However, though alcohol, such as the well-known Coca-Cola, for
morphine was not successful as an anesthetic, it headaches, melancholy and hysteria (as can be
was as an analgesic. appreciated in the ninth episode, The Golden
Cocaine is the alkaloid extracted from coca Lotus). It was in 1909 when cocaine was substi-
leaves. It was in 1884 when Koller applied it for tuted by caffeine in Coca-Colas formula.
the first time topically onto his cornea, achieving Such was the furore unleashed by cocaine
anesthesia. Its use was soon extended to fields that even Sigmund Freud began to study its use
such as urology and gynecology. Halsted and for treating neurasthenia, leading to an essay
Hall managed a wide range of truncular blocks entitled ber Coca, in which he expounded its
through injecting cocaine. The practical demon- virtues for the cure even of alcoholism and opiate
strations were conducted on patients and even addiction. Only one German naturalist compared
experimenting on themselves, which brought cocaines secondary effects to opium, but until
tragic consequences due to cocaines highly ad- the second half of the twentieth century, cocaine
dictive power, causing alterations in their social was not classified as a narcotic substance.
and professional behavior. Cocaine acts by exciting the cerebral cortex
James Leonard Corning (18551923) and and producing a state of euphoria, which in-
Karl Augustus Gustav Bier (18611949) were creases wakefulness and physical performance

Notebooks of the Esteve Foundation N 42

Medicine in Television Series

because it decreases ones feeling of tiredness. unqualified staff, such as a hospital washerwom-
So Thackery employs it to avoid fatigue during an to act as a surgical nurse.
his long sessions of study and surgery. Habitual It is in the seventh episode, Get the Rope,
consumption does not create physical depen- when the cruelty with which black people are
dence, but definitely psychological dependence. treated is brought to the fore. The conflict is
Periods of abstinence are not common, though served with the death of a white patient who has
not impossible. been attacked by a black man for having treated
So we can conclude that Thackerys inclina the latters wife as a prostitute. Exhorted by the
tion to consume cocaine is a response to three family of the deceased, the white community
factors: firstly, its ubiquity in society of the time blames the black woman for events and a ver
(at the start of the ninth episode there appears itable revolt erupts in the city.
on screen, In 1900, cocaine was regularly sold
in pharmacies no prescription needed, so
Epidemiology and typhoid fever
easy was it to purchase); secondly, a lack of any
awareness of its negative effects combined with Ongoing mention is made through the episodes
the improved performance needed for his work; of a typhoid fever epidemic affecting some of
and thirdly, self-experimentation with the drug on New Yorks population of a higher social stand-
his own body. ing. This disease is caused by a bacteria called
Salmonella typhi, whose bacilli are evacuated
through the feces of asymptomatic carriers. They
Racism in the hospital institution
are disseminated through inadequate hygiene,
Despite slavery being eliminated in the United thereby entering the water supply and foodstuffs,
States in 1865, racial segregation continued as occurs in the series. The pathogens enter the
to be imposed in an unofficial yet real sense organism through the gastrointestinal tract, reach
throughout the nineteenth and until the mid- the bloodstream through the lymph vessels and
twentieth century. In cities such as New York, cause inflammation of the lower part of the small
black people were confined to specific neigh- intestine. All this generates fever, prostration and
borhoods, and could not live in affluent districts. abdominal pain which can sometimes be due to
Likewise, in the working sphere, black people an intestinal perforation, as happens with Cora
were relegated to less-qualified positions, given Hemming in the third episode, where she re-
that in most cases, they could not access uni- quires surgery to repair it.
versity education. In the series, it is clear that The investigative activities of Jacob Speight,
there were hospitals for whites and for blacks. an inspector from the Health Department, and
Dr. Edwards joins the Knick through the media- Cornelia Robertson, following the epidemiologic
tion of its patrons, the Robertsons, without hav- al clues left by the typhoid fever, lead to the as-
ing previously demonstrated his worth, albeit ymptomatic carrier: Mary Mallon, a cook who
insofar as Dr. Thackery has not allowed him to. spreads the disease (even though she does
Taking a black doctor onto the hospital staff also not suffer from it) through her peach Melba. So
meant many patients refusing to be treated by it makes those who eat it sick. We have three
him, losing customers, and thereby lowering the elements here the agent, host and environ-
income of the debt-ridden hospital. Faced with ment that comprise the epidemiological model
this situation, in the hospital basement, Edwards current in the period that fitted the explanation
attends several medical cases of black patients, of genesis of diseases in contrast to the simpli
creating a clandestine hospital where not only city that reigned in the eighteenth century, which
does he undertake surgical procedures but also explained the disease as the effect of a specific
research, managing to perfect a surgical vacuum agent in an erroneous unicausal model.
without the need to operate it using a crank han- This study of the distribution and determiners
dle. Likewise, the situation leads him to employ of health-related states or events in specific pop-

The Knick and Surgical Techniques

ulations, and its application in controlling health Zinberg and the intrascope
problems, is what we currently call epidemiology.
We have to wait until the eighth episode, Work-
This does not merely provide a causal explan
ing Late a Lot, to discover Dr. Levi Zinbergs lu-
ation of the disease and its distribution, but also
minous intrascope, the objective of which was to
emphasizes its prevention, among other, more
access the bodys different cavities with the least
complex objectives.
invasiveness possible.
This gadget was known about in 1805, in-
Diagnostic instruments vented by Bozzini, who used a candle as a light
source. But the invention passed unnoticed until
X-rays in 1853, Desormeaux rescued it from oblivion.
The German researcher, Rntgen, discovered Thirty years later, Nitze perfected it, though it was
this form of radiation by chance in 1895, when still a rigid instrument, which caused patients a
he detected a certain luminescence while he was lot of inconvenience. In this manner one could
handling vacuum tubes. He believed this was a view a bladder through the urethral channel with-
form of previously undiscovered radiation, which out the need for open surgery.
he called x-rays because of their unknown na- The instrument was refined little by little
ture, comparing them to an unresolved equation. throughout the twentieth century until it became
Before presenting this discovery to the scientific the flexible endoscope, which enabled doctors
to view the stomach. The next step was the
community, he conducted several experiments,
appearance of the fiberscope, made of a fiber-
exposing different objects to this new radiation,
optic bundle that allowed the transmission of light
among them a womans hand, which constituted
even if the end is curved, and to receive images,
the first human x-ray.
which was extremely useful for diagnosis, taking
X-rays are a type of ionizing electromagnetic
biopsies and conducting specific simple surgical
radiation to which continued exposure can be
procedures. The following step was miniaturizing
dangerous, although, as is well-known, they have
the system.
a wide application in medicine. Naturally, x-rays
signified a revolution in medical diagnosis, and
later, the science of radiation therapy was devel- Conclusions
Stanley B. Burns, a New York ophthalmological
Rntgen was awarded the Nobel Prize for
surgeon, was always interested in history, and
Physics in 1901 for this discovery, but declined to in 1975 he began to collect old photographs on
patent it despite Edison suggesting this course, medical subjects. His collection now constitutes
saying he was bequeathing his discovery for hu- the Burns Archive, one of the most significant pri-
manitys benefit. vate holdings of old images in the United States,
Nevertheless, Edison can be attributed with with over one million historical photographs. Mid-
manufacturing the first commercially available way between a circus show, due to the striking
fluoroscope, shown in the fifth episode, They nature of some of the images, and graphic docu-
Capture the Heat, in which the device is present- mentation of diagnostic means and treatments of
ed to the doctors and manager of the hospital. the period, it enables us to delve into the darker
Another innovation that came from the in- side of life in the nineteenth and early twentieth
exhaustible Edison was the roller phonograph, centuries. It has therefore been a source of docu-
an invention with no medical applications, but mentation on many occasions for film-makers,
which Captain Robertson shows off in a party at artists, editors, and so on, revealing a heroic age
his home, recording his own voice and playing it in medicine.
back later to the delight of his guests in the fourth In The Knick, Soderbergh uses Burns con-
episode, Wheres the Dignity? sultation, both personally, via collaboration on

Notebooks of the Esteve Foundation N 42

Medicine in Television Series

the TV sets, and through the contribution of this episode, a photograph belonging to Burns col-
graphic collection. Furthermore, he possesses lection can be seen.
a collection that covers all the articles published Director Steven Soderberghs manner of dis-
between 1880 and 1930 of magazines such as playing all this could be described as hard and
Annals of Surgery and Archives of Surgery, doc- grim, comparing surgery to something akin to
umenting both the huge successes of the sur- a butchers shop, through fairly explicit images.
geons of the period, and their failures. So the first However, one should bear in mind the difficult
time filming took place in the operating theater, times, for both doctors and patients, in which
he had to reorder the staff sitting on the benches the action develops, when such advances as we
as was done of old: in the first row sat the old and now take for granted did not exist. One should
distinguished doctors, and in the next sat the as- be aware of the need to experiment for surgery
sociate professors, assistants, etc. Another curi- to evolve, sometimes on the experimenters own
ous fact is that Burns had to teach the actors flesh, at others on patients, and often on animals,
how to correctly hold the different surgical instru- generally dogs. These were not easy times, and
ments such as the needle drivers, perform differ- they should be paid due merit.
ent suture types, and so on. Among other things, Even if it is true that the various discoveries
Burns has a photo that shows a device that was occurring throughout the series are real, we can-
employed to cool a persons head, dating from not say that the date on which these events took
approximately 1890. This consisted of a sort of place is likewise true. However, we understand
cape surrounded by a rubber tube that acted as that this is a resource of the scriptwriters, Jack
a type of coil, through which cold water was cir- Amiel and Michael Begler. Not only does it give
culated. Thanks to this, the sixth episode, Start the series greater entertainment value, but it por-
Calling Me Dad, shows this device for cooling trays the importance that this period had in order
a patients head used on little Lillian, who has for surgery to advance to its current state of the
meningitis. Furthermore, during the case of the art a state in which we now have far more con-
theft of a medical item in the series, in the second fidence than back then.

Notebooks of the Esteve Foundation N 42

The Sopranos and Psychoanalysis

Oriol Estrada Rangil

For many, this program is the pioneer of televisions so-called third golden age (the first, heralded in by
The Twilight Zone in the sixties while the second, by Hill Street Blues and St. Elsewhere, among others,
in the eighties). In 1999, the inner turmoil of a New Jersey mafia boss launched a new epoch in television
fiction, one which catapulted the cable chain HBO up to the highest standards of quality. Its six seasons,
which ended in 2007 with five Golden Globes and 21 Emmys, also showered well-deserved recognition
on the career spanning more than 30 years of its creator, David Chase.

Tony Soprano is nervous. He does not know Dr. Melfi in The Sopranos puts things into
where to sit when he enters the psychiatrists of- perspective and shows us how this therapy has
fice. I shouldnt be here, he has written all over evolved. While psychologists in general have
his face. It all began during a family barbecue been adopting new techniques and even aban-
when he fainted in front of his two families (his doned psychoanalysis as a valid method, for
blood relations and his in-laws). The diagnosis: a several years many psychiatrists have combined
panic attack. His doctor and neighbor suggested psychoanalysis with pharmacological treatments,
he visit a psychiatrist, Dr. Melfi, who also con- treating the patient in quite a different way to their
ducts psychoanalysis. founding fathers approach. For example, they
Despite fainting episodes being highly un push aside the divan and prefer to look their pa-
usual in panic attacks, we have to concede to tient in the eyes, actively participating in the dis-
the creators of The Sopranos that it is probably cussion.
one of the TV series that has best portrayed In Dr. Melfis psychiatrists office we see the
modern psychoanalysis. Proof of this is recog- famous divan, but Tony will not lie on it. Nor will
nition by the American Psychoanalytic Associa- he begin to make associations of ideas while his
tion, which awarded a prize to Lorraine Bracco, therapist nods occasionally (or that recurring
the actress who plays Tonys therapist, for hav- gag awaking with a start when the patient re-
ing portrayed the most credible psychoanalyst calls their attention). In fact, one of the main prob-
appearing on film or television. The truth is, until lems with the psychiatric process is that Mr. So-
then the image of the psychoanalyst had barely prano is a difficult patient who does not want to
changed from what it was in the early twentieth speak, one of those who thinks he is constantly
century: a Sigmund Freud type smoking a pipe wasting time. An added difficulty is that, if anyone
while a (hysterical) patient reclines on a divan, in his mafia environment finds out he is seeing a
raving incessantly. Directors such as Woody Al- shrink (even worse, a lady shrink), it could be
len have not strayed very far from that more clas- the end of his career as future capo of the New
sical idea when portraying psychoanalysis on the Jersey mafia. Tony is a challenge, but Melfi will
big screen. So it is understandable that her pop insist; while she risks her professional pride, he
psychoanalyst image was so out of step with may be risking his life.
the broader public (and despite her character, it One of the aims of any psychological therapy,
remains so). above all psychoanalysis, is to get to the root of

The Sopranos and Psychoanalysis

the problem, so it is worth recapping history and inhabit the tip of the iceberg, but not completely.
going back to late-nineteenth-century Vienna, to The ego is the part of us that must balance the
the celebrated neurologist Sigmund Freuds con- ids insatiable drives and the superegos morality,
sulting room, to understand what psychoanalysis and it is where internal conflicts arise that lead
is based on and what it aims to do. Freud de- one to seek consultation with a psychoanalyst.
fined the three aspects that comprise it as a dis- To understand it better, we can return to Tony
cipline: it is a theoretical and explanatory model Soprano. We can see that his problems come
of emotions; it is a research method; and, lastly, precisely from that internal struggle between the
it is a form of therapy. As a theory, Freud pos- different factions of his psyche. While in reality
tulated that the pillars of psychoanalysis have a they do not appear outside his mind, we accept
great deal to do with sexuality, stressing the well- that in the series they become visible to viewers.
known Oedipus complex, but also repression, His mafia side, that unscrupulous Tony, who is
resistance and the unconscious. In fact, some violent, promiscuous and a killer, that character
of the greatest criticisms, even schisms within with whom we cannot easily empathize, is the
psychoanalysis are due precisely to that excess manifestation of the id, an uncontrolled id that
of emphasis on the sexual question, which more neither his ego nor superego are capable of rein-
than once Tony Soprano will hold up for compari- ing in. But then we have that other Tony, who is
son in his sessions. sympathetic, who sometimes truly loves his wife,
But there is a theoretical model of the human who worries about his kids and wants to protect
psyche that did have a big impact, one crucial for them from that world dominated by the id. That
understanding Freudian theory, and the case be- is where we see this characters ego, the story
fore us, the dilemmas and problems that wrack of a man who looks after his own and leads an
Tony. This is the psychological structure formed apparently normal life. Yet his superego is there
of the ego, the superego and the id, which act to remind him that how he earns his living is not
on three different levels: the conscious, the pre- good. That is when the internal conflict arises,
conscious and the unconscious. A common causing those panic attacks. Naturally, such con-
metaphor that explains it more simply is the ice- flicts are fought on the unconscious plane, the
berg. The largest part is hidden underwater, cor- demesne of psychoanalysis and psychoanalytic
responding to the unconscious and the precon- techniques, which try to get all those submerged
scious, the latter sitting above the former. Only a issues to rise to the surface.
small tip, the conscious, pokes above the surface. On Sigmund Freuds divan, the subject would
Meanwhile that iceberg is divided into three parts lie back without seeing the therapist so as not to
with different functions. On one side we have the feel observed, and begin speaking barely without
id, completely submerged underwater, which is interruption or restrictions of any kind. It is what is
our most primitive, innate, undomesticated side, known as free association of ideas. This is the
which exists to try and satiate our most basic de- principal psychoanalytic technique to encourage
sires, the so-called drives: hunger, sex or aggres- the patient to talk about anything entering their
sion. Then we have the superego, which is the head, whether images, feelings, ideas, mem
largest part of the iceberg and is therefore almost ories, etc. Sometimes, the therapist might sug-
completely submerged, though its head remains gest a topic to the patient, or encourage them to
above water. The superego represents the moral focus on their dreams, but in general they try not
and ethical thought that reaches us through our to suggest anything and topics arise spontan
culture, and which is in constant struggle against eously. Freud believed that this was the best way
the id, like a sort of moral guardian. Finally, we of reaching the id, the unconscious, and the freer
have the ego, which resembles an intermediary the associations, the better the results would be.
between the real world, the demands of the id As mentioned, Dr. Melfi in The Sopranos is not
and the superego. It is perhaps most similar to our a traditional psychoanalyst. In fact, probably few
self-awareness, our visible face. It would mainly therapists still use free association of ideas in the

Notebooks of the Esteve Foundation N 42

Medicine in Television Series

purest sense. Yet traces remain in her approach, us famous books on dream interpretation and,
and we often see her intervene in response to one even if the content in most of these modern
of Tonys comments in order to keep unraveling books is highly doubtful, it was Freud himself who
a thread, trying to follow the associations almost in 1900 published a manual explicitly entitled The
without realizing it. And had she not taken more Interpretation of Dreams (Die Traumdeutung). As
of an active role, they probably would not have mentioned, the sexual question was one of the
gone beyond a first session, in which the ma- pillars (not to say obsessions) in Freuds theories,
fioso wonders where the strong and silent Gary and it seems he had a tendency to interpret many
Cooper types have gone. Historically, before ar- dreams from a festive or erotic viewpoint. How-
riving at free association of ideas, psychoanalysts ever, the creators of The Sopranos were clear
used rather more complicated methods that, that, nowadays, not everything can be linked to
nowadays, are seen as quite unscientific. I am sex. In the pilot episode, Tony explains one of his
referring above all to hypnosis and the cathartic dreams, where he undoes a screw and his pe-
method, both of which were discarded once free nis falls off. He goes, penis in hand, to visit the
association of ideas began to be used, since it mechanic to get it put back in place, but a bird
was thought that the other methods were unable takes it and disappears. Beyond the supposedly
to break down the barriers of the unconscious. clear sexual connection, the focus of attention is
Nevertheless, within the concept of catharsis lies centered on that bird and what it came to sym-
one of the theoretical and therapeutic pillars of bolize in that episode. It is a moment of revelation
psychoanalysis: the idea that to cure a patient (or call it a catharsis) when Tony becomes aware,
one has to recall that traumatic moment that among sobs, that one of his main problems is
caused the discomfort, which that person has re- the fear of losing his family (as he lost the ducks
pressed and forgotten. This is an idea which fic- that appeared at the beginning). So the episode
tion has used often to create a final climax, such closes, in a similar way to how Freud believed
as in Hitchcocks Marnie, a film in which psycho- cases were closed, when the patient is able to
analysis is likewise heavily present. discover what his or her problem is. And in the
But if there is any place where our unconscious same manner as todays psychology believes
moves with as free a rein as most New Jersey that discovering the problem is simply the first
gangsters, it is in the world of dreams. Dreams step and then one must work on it, this is where
were one of the resources that the scriptwriters the series truly starts.
of The Sopranos used to get directly inside Tonys In the first season, a moment arrives when
head, though they do not always make clear what Tonys mother finds out he is seeing a psychia-
each of the elements appearing signify. Why is it trist. Her first reaction, tremendously egocentric,
snowing? Why can we hear that constant creak- but not necessarily erroneous, is to think that
ing? What is Junior doing in that window? Why Tony is going to the psychiatrist to talk about
does he kill one of his most productive workers? her, to complain about his mother. This scene
Not even Tony has an explanation for the latter, perfectly illustrates some of the clichs about
so he asks Dr. Melfi: Why would I do something psychoanalysis in which the wider public believe:
like that? According to Freud, dreams represent If someone visits a mental health professional it
the realization of our desires, yet it is not so sim- is because when young they had problems with
ple. Despite being asleep, our conscious is still their mother. Once more, although psychology in
awake, and is not willing to accept certain drives general has gone substantially further than Freud,
that come from the id. So the unconscious must the influence he had on popular culture remains
camouflage such desires in some way in order strong and retains its hold in the collective imagi-
to overcome our censorship, thereby utilizing the nation. Part of the blame lies with one of his most
terrain of metaphor and symbolism. famous (and most parodied) theories, although
The idea that dreams send us camouflaged some of the merit should go to Greek mythology
messages has been used for many years to sell itself: the Oedipus complex was described for

The Sopranos and Psychoanalysis

the first time in his aforementioned manual The based on the mother of the series creator, David
Interpretation of Dreams. Yet before discussing Chase). Nevertheless, whether due to that Ital-
it, we should recap Freuds own theory on child- ian cultural heritage of the Mamma figure, or be-
hood sexual development, since he believed that cause that childhood desire postulated by Freud
right from birth children seek to satisfy their libido has not been fully overcome, Tony continues to
using different parts of their bodies. He divided worry about her and set her on a pedestal. He
the process into five stages: the oral, anal, phal- complains that it is his wife who refuses to bring
lic, latent and genital. It is the phallic stage (from her to live with them, which is supposedly what
three to six years old) when the so-called Oedi- a good son should do. In fact, after talking about
pus complex develops, which is defined as the how complicated his mother is, he goes to visit
presence of feelings of hate and love towards her with a bunch of flowers. Some of the most
the progenitors simultaneously. There can be two heated lines in Melfis office specifically concern
aspects: a positive Oedipus complex, in which questions relating to his mother and his incapac-
the child feels hatred towards the progenitor of ity to recognize that, as well as love, he also feels
the same sex, and sexual attraction toward the hatred toward her. Those who do seem to have
opposite sex, and a negative complex, which is taken these negative feelings toward his mother
logically the inverse. In the phallic stage it is the on board are Tonys sisters. Freud would explain
male sexual organ that focuses the boys interest, such a rejection as them blaming his mother for
and it seems that, in the case of girls, the clitoris their castration. In this case, they would not
is also equivalent to a phallus. In this phase, the have overcome the complex or moved on to
boy will feel sexual desire toward his mother, and identify with their mother. Bearing in mind Tonys
thus supposed hatred for his father (the Oedipal older sisters mental instability, it is clear that
tragedy), but by identifying with her and realiz- some trauma remains unresolved.
ing that girls do not have penises, the only ex- The figure of the father, Johnny Soprano, is
planation that occurs to him is that women have also worthy of analysis. Tonys identification with
been castrated. This fear of suffering the same him is clear. During the series we see flashbacks
fate leads him to abandon his incestuous desires of the relationship Tony establishes with him,
and identify with the father (according to Freud, midway between fear and admiration. From the
this is the logical path to follow). In the case of psychoanalytic perspective, it is obvious that
girls, they abandon their desire for their mother a significant problem exists in this relationship.
on believing that she is guilty of their castration Overcoming the Oedipus complex is considered
(through her they realize that their clitoris will not necessary for the psyches healthy functioning. It
grow like a penis), and from that fact, so-called is supposedly at that moment when the superego
penis envy arises, which will help them identify is born the moral force that declares incest is
with their mother again, since she has access to not good and boys should identify with the father,
one, the girls fathers (this is known as the Electra focusing on him. As mentioned, that is exactly
complex, which Freuds old colleague, Carl Jung, what Tony does, but the problem lies in that his
defined). father is the root and symbol of all his current an-
And if ever there were a tempestuous story guish. His father represents all those values, all
between mother and son on television, few could those attitudes that now clash with the ego and
beat that of Livia and her son Tony Soprano. superego. Added to all this is the figure of Cor-
Their relationship cannot be considered a clear rado, Tonys uncle, who, in Melfis office, takes
example of the Oedipus complex, but no doubt on a paternal role for him even before his fathers
it contains elements of the above. Firstly, Tonys death: When Dr. Melfi asks him for memories of
feelings toward his mother are difficult to explain, his father, one of the first that comes to mind is
since she is a sort of bitter ogre who since his playing baseball with his uncle, not his progenitor.
childhood has maltreated her child (and some And is their relationship not tempestuous? As-
of the toughest scenes of that childhood are sassination attempts, subterfuge to win power

Notebooks of the Esteve Foundation N 42

Medicine in Television Series

Another straw on the camels back of Tony So- patient has about their therapist, that facilitates
pranos Oedipal family drama. the transference process. According to modern
Another interesting love story occurs in Melfis psychoanalysts, the patient is transferring onto
office itself, from the first season, even from the their therapist such feelings and experiences as
pilot episode. Our protagonist shows signs of they recall, of which they speak, and addressing
having noticed this psychiatrist and psychoana- that empty vessel which is their psychoanalyst,
lyst of Italian heritage (My mother would have sometimes identifying them with their mother
loved it if you and I got together). Dreams come or father. The patient has not fallen in love with
into play again. He dreams of Melfi in bed, in the the therapist. The patient does not necessarily
shower, and finally tries to kiss her in the psychia- feel that their therapist substitutes their father or
trists office. He ends up making a confession: mother. The therapist is simply there at a moment
I love you. Im in love with you. Im sorry. ... when feelings arise, and therefore the therapist
I dream about you. ... I think about you all the is the figure the patient addresses. As Dr. Melfi
time. To which she responds: I know this may correctly states, this means the therapy is pro-
be very hard for you to swallow, but youre only gressing. Tony has progressed in terms of the
feeling this way because weve made such prog- trust he has in her, so his feelings and lack of af-
ress... Ive been a broad, generic sympathetic fection also begin to come to the fore. Caution is
woman to you, because thats what this work required, however, since the psychoanalyst must
calls for. Youve made me all of the things you feel be capable of recognizing that transference (al-
are missing in your wife... and in your mother. though for this psychoanalyst it was easy), and
Tony insists: Youre makin me out to be some stopping it from going further. Will she manage
mamas boy. Im a man... and youre a woman. this? I reveal no spoilers here.
End of story. And this crap about Freud and ev- Not everyone has praised Dr. Melfi: Some
ery boy wanting to have sex with his mother... therapists have raised their hands in horror at
thats not gonna fly here. ... You dont want me to certain details she reveals to Tony about her per-
come back any more, fine. But Melfi assures him sonal life, or for letting her control slip at times
it is quite the opposite, that his confession is a and losing that distance and impassiveness she
byproduct of his progress. Beyond the comment should maintain. Yet others have seen in all this
on the Oedipus complex, and even beyond the a reflection of the therapists true reality, making
lack of female affection that Tony seems tofeel, Dr. Melfi much more believable and plausible than
this falling in love is the perfect excuse to speak if the series had portrayed a textbook therapist.
of some of the phenomena associated with psy- Psychoanalysts are not perfect, and neither is
choanalytic therapy, in this specific case, trans- psychoanalysis. While it is probably the thera
ference. peutic technique/philosophical perspective on
Psychoanalytic therapy is a long process. the human psyche best-known worldwide, it is
It can last years. So a personal relationship is also one of the most criticized. Currently, it does
established with the therapist, somebody with not even form part of the mandatory or core con-
whom profound, intense experiences and feel- tent of academic programs in Spanish psychol-
ings are shared. In fact, psychoanalysts consider ogy faculties. Psychoanalysis was rejected by
that in any relationship, one attributes libido to many psychologists and psychiatrists decades
the other person, though they hasten to add ago (in fact, Freud himself experienced col-
that the term libido should not be interpreted leagues such as Jung disown some of his theo-
sexually. In fact, they consider it necessary for ries), and one of the main reasons is eminently
the therapy to progress, since it is primordial practical. Psychoanalysis requires the patient to
that the patient trusts their therapist. From their attend the consultancy for a long period of his or
side, the therapist must maintain an impassive, her life, years even, and that was considered inef-
distant stance (whenever possible). And it is pre- ficient. Neither was it ethical, since the patients
cisely that distance, the sparse information the financial commitment was enormous.

The Sopranos and Psychoanalysis

Nevertheless, some critics would blame the current approach considers that the therapeutic
decline in psychoanalysis in the late fifties and work is done together. It is a process that occurs
early sixties on drugs. In this, they are not refer- by listening one to the other, both what the pa-
ring exclusively to hallucinogenic drugs which tient and the therapist have to say. The patients
expanded ones mind in another direction (re- subjective reality is now relevant, so both parties
member that Freud felt a certain attachment to work more on how she or he sees the world, not
cocaine), but to advances in pharmacological how the psychoanalyst believes things should be
therapy. Here, the supposed benefit was almost (that is why Melfi is constantly asking Tony what
instantaneous, making it unnecessary to spend his dreams mean to him, what his feelings are).
months in therapy to begin noticing improve- Psychoanalytical psychotherapy keeps seek-
ment. In fact, advances regarding the neurologi- ing those unconscious processes that affect the
cal origins of certain psychopathologies led psy- patients life without the latter realizing, but is no
chology more toward the pill than the divan. In longer exclusively related to neuroses or phobias,
that period many of Freuds theories were also but can tackle the mental problems of our age
discredited, and often his own patients cases, (anxiety, depression, eating disorders, etc.). It is
the ones leading him to formulate his theories, perhaps shallower work, therefore requiring few-
were questioned. Accusations of having forced er sessions, on problems that may be less spe-
memories out of his patients or interpreting what cific. Nevertheless, the divan remains and, should
they told him in his own interest are criticisms that the patient so require, they can delve deeper into
Freud and psychoanalysis have weathered since their psyche.
the start. The Sopranos is considered one of the best
But despite everything, progress in this sci- TV series of our times, one of the pioneers that
ence, specifically neurobiology, seems to prove wanted to take its format beyond that of a pure
Freud partially right. Perhaps not in the inter- consumer product for filling television schedules.
pretation and reasoning of some of his theories, It was a series that was carefully produced in ev-
but definitely in terms of certain basic ideas that ery detail, one with artistic pretensions. The care
psychoanalysis proposed in its time, especially its creator took to create something special can
regarding unconscious processes. So it is time be seen not merely in its manner of approach-
to bring psychoanalysis up to date, in Dr. Melfis ing its protagonists psychological therapy, which
office, one that has no divan, and to discover earned it the recognition of psychoanalysis pro-
psychoanalytical psychotherapy. Some of the fessionals. One can truly say that the scriptwrit-
practitioners of this new discipline, while recog- ers put in great effort, since four out of five of
nizing that the origins and much of the method the main scriptwriters had undergone psycho-
still owe a great deal to Freud, consider that cur- analysis. Many of the series viewers were simply
rent psychoanalysis is as different from the origi- interested in stories about gangsters, so perhaps
nal as modern physics is to Newtonian physics. they did not understand that the main story its
Remember that in its early days, the patient had creators wanted to tell was of Tony Soprano, his
no visual contact with the therapist, and the latter family and his therapy. However, when one ana-
barely intervened in the discourse, except at spe- lyzes the series from a more psychological view-
cific moments to guide the patient a little. More- point, one discovers many things that perhaps
over, from that moment on, the psychoanalyst went unnoticed among so many beatings and
was the maximum authority: he, rather than the killings. In the end, the part of the iceberg we can
patient, decided what was important or not. The actually see is the smallest part.

Notebooks of the Esteve Foundation N 42

The Big Bang Theory and Aspergers Syndrome

Ramon Cererols

It is a mass phenomenon. Since its launch in 2007, this CBS comedy has not stopped winning fans
and is now first among the most-viewed television fictions in the US, having nearly 20 million viewers in
its eighth season. This sitcom starring two Caltech (California Institute of Technology) physicists, which
makes constant references to physics most complex theories and principles, has garnered extraordinary
success, thanks above all to its lead role. The character of Sheldon Cooper, who displays many of the
characteristics associated with Aspergers syndrome, has earned the actor Jim Parsons no less than four
Emmy Awards

In the field of scientific progress it is not unusual now Klekotiv, a village that belonged to Poland,
to find cases where two or more researchers but is currently in the Ukraine, in 1894), their lives
make the same discovery independently and al- led them on destinies far removed from each
most simultaneously, sometimes without either other. At thirty years old, Kanner emigrated to the
knowing about the others work. Among the United States, and a few years later was com-
best-known cases are those of Charles Darwin missioned to create the first childrens psychi-
and Alfred Russel Wallace (biological evolution atric service in the world at the Johns Hopkins
by natural selection), Isaac Newton and Gottfried Hospital, in Baltimore.1 Among the many children
Wilhelm Leibniz (infinitesimal calculus), and Eli- he treated there, several captured his attention.
sha Gray and Alexander Graham Bell (the tele- They displayed common symptoms differing
phone). This fact shows that any great leap in from any other disorder identified to date, and
the progress of science is due not just to a lucid had been classed as mental or schizophrenic
mind and great dedication, but also to the prior weaknesses. They all displayed an incapacity to
advances of many people who create a cultural relate to people in a normal manner, a preference
environment that fosters the development of for objects, a language having no communica-
new ideas. Even a figure as renowned as New- tive purpose, an excellent mechanical memory,
ton, citing twelfth-century French philosopher monotonous and repetitive behavior, rejection of
Bernardo de Chartres, recognized that If I have external intrusions or loud or sudden noises, and
seen further, it is by standing on the shoulders fear of change.
of giants. Kanner decided to call this syndrome ear-
One such concurrent breakthrough occurred ly infantile autism because its fundamental or
in the early 1940s. Its protagonists were the psy- pathognomonic characteristic is the childs iso-
chiatrist Leo Kanner and the pediatrician Hans lation in his own inner world. He borrowed the
Asperger. Though both men were born in what term autism from Swiss psychiatrist Eugen
was then the Austro-Hungarian Empire (Asperg- Bleuler, who had coined it in 1911 to define the
er, in Vienna in 1906, and Kanner in Klekotow, behavior of schizophrenic adults, withdrawn

 ere and below, I use a male gender to refer to both boys and girls. Nevertheless, Aspergers syndrome is around
five times more common in males than in females.

The Big Bang Theory and Aspergers Syndrome

and closed in upon themselves. In 1943, Kan- er (Autistic Psychopathy in Childhood), published
ner presented his conclusions, along with a in Switzerland in 1944, a year after Kanners ar-
detailed description of eleven case studies, in ticle. The coincidence in the naming of autism
an article called Autistic Disturbances of Affect as infantile autism by Kanner and as autistic
ive Contact, which became a classic of clinical psychopathy by Asperger is curious, given that
psychology. as far as we know, neither knew of the others
While Kanner was treating and studying studies.* The characteristics described were also
his patients in the US, Asperger was doing the similar, even if Asperger emphasized the posi-
same in his native Vienna, at whose university he tive aspects these children displayed, whom he
gained a doctorate in medicine and specialized in protected in the Aktion T4 program, which aimed
pediatrics. In 1932, he took over the special edu- to exterminate the Lebensunwertes Leben (life
cation section at the university childrens clinic, unworthy of being lived, according to the term
through which hundreds of children were treated. used in Nazi rhetoric).
During the Second World War, he was a medical Precisely because of the geopolitical circum-
officer and created a school that was destroyed stances of the time, Kanners and Aspergers
by shelling, in which he lost a large part of his articles suffered contrasting fortunes. While the
earlier work. In 1944, he obtained the chair of pe- formers was rapidly disseminated, Aspergers re-
diatrics at the University of Vienna, and two years mained unknown outside of certain limited, Ger-
later he was also named director of the childrens man-speaking circles. So the name Aspergers
hospital at the same university, both positions he syndrome did not appear in English until 1970,
would occupy until 1977. with the translation of a book by Gerhard Bosch
For his qualification thesis to the chair, As- originally written in 1962 (Infantile Autism: A Clini-
perger focused on a syndrome he had observed cal and Phenomenological-Anthropological In-
in his consulting room in the clinic, one which vestigation Taking Language as the Guide). Yet
had grabbed his attention. The children who dis- true international recognition would not arrive
played this syndrome he called the little teach- until 1981, thanks to British psychiatrist Lorna
ers since they were highly knowledgeable on a Wing.
particular topic, on which they could speak for As a result of the birth in 1956 of her daughter
hours. Despite this, their continuous, exclusive Susie, who had autism, Wing focused on study-
concentration on the subject of their attraction, ing this disorder, and founded the National So-
and their lack of interest in contact with other ciety for Autistic Children in 1962. Her husband,
people made their integration into society and John Wing, likewise a psychiatrist, discovered
into the standard education system difficult. Even one of Hans Aspergers studies from 1946 and
so, Asperger considered that in some cases, translated it for his wife, who became interested
these problems are compensated by a high de- in the syndrome, considering it a subcategory of
gree of original thought and experience, which autism. As a result of her research, in 1981, she
often led them to achieve exceptional successes published the article Asperger Syndrome: A Clini-
in adult life, and was convinced that autistic cal Account, which in the words of Wing herself
people had their place in the organization of so- opened the Pandoras box to the point where
cial community. over the next two decades 900 articles were
Asperger presented his work in an article enti- published on this disorder which until then was
tled Die Autistischen Psychopathen im Kindesalt- practically unknown.

* L
 ater, in his book Neurotribes: the Legacy of Autism and the Future of Neurodiversity, Steve Silberman documented
the history of autism. He says that Kanner knew of Aspergers work because one of Aspergers assistants, Georg
Frankl, had emigrated to the US and was working with Kanner. In fact, the observation and study of the first child
that Kanner diagnosed with autism (Donald Triplett, who is still alive) was done by Frankl, so it is inevitable that Kan-
ner knew of Aspergers studies.

Notebooks of the Esteve Foundation N 42

Medicine in Television Series

Two different disorders? Autism or as it was then called, infantile au-

tism was not considered a specific category
In Wings aforementioned article, the author
until 1978, in ICD-9, and 1980, in DSM-III (re-
emphasized the common characteristics of the
spectively 35 and 37 years after Kanners original
disorders described by Kanner and Asperger, to
article). Up until that moment it was considered a
the extent where she asserted one should ask
subgroup of schizophrenia. Fourteen years later,
whether they are varieties of the same under-
the new editions of both classifications divided
lying abnormality or are separate entities. Ten
autism into different categories (eight in ICD-10 in
years later, in 1991, Wing came down clearly on
1992, and five in DSM-IV in 1994), one of which
the side of the former, proposing the existence of
was Aspergers syndrome (according to the ICD)
a continuum from Kanners autism to Aspergers
or disorder (according to the DSM). It would
syndrome, as clinical cases showed, in which
thereby acquire official recognition for the first
the same individual was typically autistic in his
time, approximately half a century after publica-
early years, but made progress and as a teen-
tion of Aspergers original article. This status was
ager showed all characteristics of Aspergers
maintained for two decades, until in May 2013,
after intense polemic, a new edition of the DSM
Currently it is thought that this continuum or
(DSM-5) consolidated the autism group into a
spectrum is even broader, encompassing at one single category, autism spectrum disorder, with
end the most intense cases of autism, Aspergers three levels of seriousness according to the sup-
in the middle and from there a gradual evolution port required. With this decision, Aspergers no
toward normalcy otherwise termed neurotyp longer has its own identity in the DSM, being sub-
ical in which people display certain characteris- sumed into autism spectrum disorder according
tics on the spectrum to such a slight degree as to to the corresponding level in each case. We must
be considered simple facets of their personality. now wait and see what happens with ICD-11,
In this sense, Wing considers that autistic fea- publication of which is scheduled for 2017.
tures are present to a greater or lesser degree in There are five diagnostic criteria listed in
all people. DSM-5: A) persistent deficits in social commu-
nication and social interaction; B) restricted, re-
Official recognition petitive patterns of behavior, interests, or activi-
ties; C) symptoms must be present during early
The standard criteria for the diagnosis of men- childhood development; D) the symptoms cause
tal disorders are established and updated in two clinically significant deficiencies in social and oc-
publications: DSM (Diagnostic and Statistical cupational areas, or others that are important for
Manual of Mental Disorders, published by the current functioning; and E) such alterations are
American Psychiatric Association, currently in its not better explained by an intellectual disability
2013 DSM-5 edition) and the ICD (International or a retardation in overall development. However,
Statistical Classification of Diseases and Related in almost all cases these symptoms are accom-
Health Problems, maintained by the World Health panied by other varied manifestations that seem
Organization, whose latest edition, ICD-10, came to indicate that the autism spectrum disorder is
out in 1992). They agree in general, though with not confined to a cognitive module, but that it is
certain differences. So, for example, the As- found in the brains general architecture.
pergers disorder defined in DSM-IV receives the Given the widespread use of the DSM for
name Aspergers syndrome in ICD-10. psychiatric diagnosis, the new criteria of DSM-5

 The relationship between Aspergers syndrome and Kanners autism, in the book Autism and Asperger Syndrome,
edited by Uta Frith. The same book includes the first translation into English of Aspergers original 1944 article, un-
dertaken by Uta Frith.

The Big Bang Theory and Aspergers Syndrome

means that patients who until then had been most frequently presents significant disparities
diagnosed with Aspergers syndrome now have between one aspect or another of an individuals
a specific degree of Autism Spectrum Disorder mental faculties. So, you might have the case of
(ASD), or in some cases, no longer fall under an individual who is incapable of understanding
diagnosis. Some associations, family members the double entendre in an expression and yet
and patients are averse to this change, both for can construct complex scientific theories. Or one
the loss of specificity it implies and the fear that who may not remember a persons face, but can
this will signify a decrease in support received, memorize thousands of digits of the number Pi.
and for the negative connotations the term au- In general, people with Aspergers operate bet-
tism bears and loss of a certain mystique sur- ter in logical and methodical activities, and have
rounding Aspergers. difficulties with the ambiguities of social life (such
Increasing knowledge of the autism spec- as interpreting ironies and double meaning, intu-
trum, and improvements in diagnosis, have ition of implicit, unspoken social norms, etc.). Or,
meant that the numbers of people diagnosed as the father of one child with Aspergers com-
has increased progressively in recent decades. mented: To put it more simply, our son learns
While in 1974, a prevalence of one in every 2500 social skills with the same difficulty most people
(0.04%) was estimated, the most recent report learn math, and he learns math with the ease that
from the US Centers for Disease Control and most people learn social skills.5
Prevention raises this ratio to one in every 68 The progressive recognition of the compart-
(1.5%), 37 times higher.3 mentalizing of mental capacities, manifested, for
example, in interest in the multiple intelligences
proposed by Howard Gardner in 1983, has
Aspergers in society
spurred curiosity in the phenomenon of savant
Historically, mental disorders bore a social stigma syndrome in society people who combine def
that has waned in recent years, albeit slowly. The icits in diverse cognitive areas with a capacity far
Nobel Prizewinner for Economics in 2002, Ver- above the normal in a specific field. This curios-
non L. Smith, who has Aspergers, expresses it ity was picked up and emphasized by literature
thus: Weve lost a lot of the barriers that have and film, which highlighted the extreme aspects
to do with skin color and with various other char- of their natures to give them greater cinemato-
acteristics. But theres still not sufficient recogni- graphic charisma, at the cost of distancing such
tion of mental diversities. And we dont all have characters from the more common reality.
to think alike to be communal and to live in a pro- The first important milestone came in 1988
ductive and satisfying world.4 with the film Rain Man, winner of four Oscars,
The traditional view on mental disorders is that in which Dustin Hoffman interpreted an autistic
they form an integral part of the person, a totum savant. The character is partially inspired by Kim
revolutum that completely disables the person. Peek, a person with an exceptional memory, who
However, in most cases this is not so. Many could remember the contents of 8000 books and
great figures in history, art or science have been a huge amount of data on the most diverse sub-
so, despite and occasionally thanks to having jects (from a year and a half old he remembered
problems in some dimension of their mind. The all the books his parents had read to him, and
autism spectrum disorder is one of those that later he was able to read and memorize every

 ommunity Report on Autism 2014, available at:
Interview on CNBC News Channel, February 2005, available at: 31/ns/
From an article by Brian G. R. Hughes on the Massachusetts Institute of Technology Alumni Association blog, avail-
able at:

Notebooks of the Esteve Foundation N 42

Medicine in Television Series

page in around ten seconds). In reality, Peek was the death of his neighbors dog. Boone has vast
not autistic, but born with several brain defects, mathematical knowledge, but also difficulties in
principally an absence of the corpus callosum relating socially. Though the blurb of early edi-
(the band of white matter connecting the two tions of the book stated that he had Aspergers
hemispheres in the brain). syndrome, the author himself regretted this fact
In 2001, another film also won four Oscars. and confessed he knew very little on the subject.
A Beautiful Mind, based on the 1998 book of His intention was not, he says, to write a book
the same name, narrates the struggle against about Aspergers, but a novel about difference,
paranoid schizophrenia of mathematician John F. about being an outsider, about seeing the world
Nash Jr., who was awarded the Nobel Prize for in a surprising and revealing way.6 Among com-
Economic Sciences in 1994 for his work on non- munities linked to the disorder, the book received
cooperative game theory. In real life, Nash was highly varied criticism, from those who consider
interned five different times from five to eight it an adequate description of Aspergers to those
months each time in psychiatric clinics. Even who believe it offers a false and stereotyped im-
so, using the time between these involuntary age. It is from that date, both in film and literature,
commitments he managed to develop important that works began appearing that depict protago-
research. Gradually, Nash was able to learn to nists who are specifically identified with Asperg-
reject his delirium intellectually, until he reached ers. So in film, we have Mozart and the Whale
a level that he himself considered acceptable at (2005), Adam (2009), Mary and Max (2009) and
about 55 years old. Nevertheless, he regretted My Name Is Khan (2010), while in literature, The
that this return to normalcy caused him to lose Curious Incidents success was dwarfed by Stieg
part of himself. So, in his autobiography for the Larssons Millennium7 trilogy, which has sold
Nobel Foundation, he wrote: So at the present more than 70 million books and been made into
time I seem to be thinking rationally again in the films. Its co-star, Lisbeth Salander, is a talented IT
style that is characteristic of scientists. However expert with eidetic memory and social difficulties,
this is not entirely a matter of joy as if someone characteristics that the other lead, journalist Mi-
returned from physical disability to good physi- kael Blomkvist, associates with Aspergers.
cal health. One aspect of this is that rationality of
thought imposes a limit on a persons concept of And series made their entrance
his relation to the cosmos. For example, a non-
Zoroastrian could think of Zarathustra as simply During the last quarter-century, TV series have
a madman who led millions of naive followers to gone from a minor product (second-class film) to
adopt a cult of ritual fire worship. But without his overtaking film in the viewer interest they gener-
madness Zarathustra would necessarily have ate. Clearly, the decisive nature of this change is
been only another of the millions or billions of hu- due to a growing presence in the TV sphere of
man individuals who have lived and then been talented directors, scriptwriters and actors, but
forgotten. also because the mediums characteristics adapt
In current society, film has far more media im- better to the dynamism and connectivity of to-
pact than literature. So it is worth highlighting the days society. Add to the mix that the advances
relative success of the novel The Curious Incident made by series-phile culture coincide time-wise
of the Dog in the Night-Time, by Mark Haddon, with the recognition and public dissemination of
published in 2003. Its protagonist is Christo- awareness of Aspergers, then the time is ripe for
pher Boone, a fifteen-year-old who investigates the growing appearance of series with charac-

 s published on his website in July 2009:
The Girl with the Dragon Tattoo (Mn som hatar kvinnor, 2005), The Girl Who Played with Fire (Flickan som lekte med
elden, 2006), and The Girl Who Kicked the Hornets Nest (Luftslottet som sprngdes, 2007).

The Big Bang Theory and Aspergers Syndrome

ters having characteristics more or less resem- Table 1. Recent series with characters displaying char
bling the disorder, or who adopt certain of its acteristics related to Aspergers syndrome.
traits. Series Character
In real life, there are many cases of people
Alphas Gary Bell
who are difficult to diagnose with certainty, since
the border between a mild disorder and a sin- Bones Bones
gular personality is blurred. Such a diagnosis is Boston Legal Jerry Espenson
much tougher generally impossible in fiction,
Bron/Broen Saga Norn
except for those few productions in which this
point is explicitly stated in the script. So it be- Community Abed Nadir
comes impossible to draw up a definitive list of Criminal Minds Spencer Reid
series with characters having Aspergers. Those
CSI Gil Grissom
I list in Table 1 are characters from recent series
who best fit, fully or in some way, with the defini- Eureka Kevin Blake
tion of the disorder. Fringe Astrid (Alternate Universe)
The treatment given to the topic of Aspergers
Glee Sugar Motta
in each of these series varies greatly, and in
reality, the focus in many is not even suggested, Greys Anatomy Virginia Dixon
since the only thing they aim for is not to present Hannibal Will Graham
a character that fits a certain diagnostic, but
House Adam
one that is interesting, or funny, or encourages
some kind of empathy or curiosity in viewers. House Dr. Gregory House
Currently, the most popular character with most Law and Order: Wally Stevens
audience success displaying traits of Aspergers Criminal Intent
syndrome is Sheldon Cooper, the theoretical
Mr. Robot Elliot Anderson
physicist in the series The Big Bang Theory.
Below, I will analyze this character along with Orange Is the New Black Crazy Eyes
examples of different approaches adopted in Parenthood Max Braverman
other successful series by comparing several
ReGenesis Bob Melnikov
characters with Sheldon.
Rose Red Annie Wheaton

Sheldon Cooper and Aspergers Sherlock Sherlock Holmes

Skins JJ Jones
The Big Bang Theory is a sitcom that plays on
the contrasting perspectives of a group of friends Temple Grandin Temple Grandin
(Sheldon and Leonard, physicists; Howard, a
space engineer; and Raj, an astrophysicist) and
their partners (Penny, a waitress and later a sales trasts with many other traits commonly associ-
agent; Amy, a neuroscientist; and Bernadette, a ated with Aspergers syndrome.
microbiologist). The series began airing in 2007 Sheldon always performs every action identi-
and to date (February 2015) is in its eighth sea- cally, which tends to be peculiar. For example,
son, after more than 170 episodes. The shows whenever he calls at Pennys door, he does so
central figure is Sheldon Cooper, a theoretical using a sequence of: three knocks, Penny!,
physicist at the California Institute of Technology, three knocks, Penny!, three knocks, Penny!.
with two doctorates (the first obtained at 16) and Sheldon cannot cope with change, or hav-
a masters, with an IQ of 187, who at the age of ing anyone interrupt his routines. Every week, he
five was already writing scientific articles on his strictly follows the same program of meals and
notepad. This towering scientific intellect con- activities (according to him, change is never

Notebooks of the Esteve Foundation N 42

Medicine in Television Series

good). He always sits in the same spot on the build time machines, Sheldon disagrees: I dont
sofa (not his favorite spot, simply his spot). When, agree. Your lack of attractiveness predates your
in the first episode, Penny sits in Sheldons spot, work on the time machine, so your failure with
he complains: Um, Penny, thats where I sit. Penny is due to other reasons. And for Sheldon
Penny says: So, sit beside me. No, I sit there. it is clear: Why should I say sorry? I didnt say
Whats the difference? Sheldon is clear on that: anything that wasnt true.
Whats the difference? In the winter that seat is Sheldon needs to have everything regulated,
close enough to the radiator to remain warm, and stipulated. He has a Roommate Agreement with
yet not so close as to cause perspiration. In the his roommate that includes every last detail, and
summer its directly in the path of a cross breeze when he starts a relationship with Amy he estab-
created by open windows there, and there. It fac- lishes a Relationship Agreement that specifies
es the television at an angle that is neither direct, factors such as the frequency and type of meet-
thus discouraging conversation, nor so far wide ing, and the extent of physical contact.
as to create a parallax distortion. I could go on, Sheldon is probably the most popular char-
but I think Ive made my point. acter of all those displaying traits typical of As-
Sheldon interprets what is said literally, with- pergers. However, the viewpoint taken by The
out capturing the underlying sense in the other Big Bang Theory on this theme is one motivated
speakers words. So when he knocks on Pennys purely by humor. In fact, the series co-creator,
door in the early hours of the morning, and she, Bill Prady, claims that Sheldons personality is
annoyed, spits out: Do you know what time it not based on this disorder (which was not as
is?, Sheldon replies calmly: Of course I do. My well-known when he created the character), but
watch is synchronized with the Boulder atomic on computer programmers Prady used to work
clock, in Colorado. Its accurate to a tenth of a with. Furthermore, he believes it is better not to
second. assign the label of Aspergers to Sheldon be-
Sheldon does not understand the implicit rules cause, on one hand, this would limit the series
governing social relations, and he tries to study creative possibilities, and on the other, run the
them using rational logic. In episode thirteen of risk of other characters wisecracks about Shel-
the second season, The Friendship Algorithm, don being taken as wisecracks about someone
he wants to become friends with a colleague and with the disorder. However, whether voluntarily or
visits a bookshop for a book to show him so as not, Sheldon is a caricature of Aspergers syn-
to make friends. The only one he finds is one for drome.
kids, about a cockatoo that has just arrived in Was it a coincidence that the programmers
the zoo. From the information obtained, Sheldon who Prady was inspired by when defining Shel-
draws a flow chart for a friendship algorithm don had such a similar personality to a person
that is detailed, logical and yet totally useless in with Aspergers? Or rather, is there some relation
real life, since, as Sheldon himself recognizes, between IT and this syndrome? Before tackling
parts of the human experience escape me. this question, let us look at a series prior to The
Society values honesty highly. So we teach Big Bang Theory, whose star is in fact a computer
our children they must tell the truth. However, programmer often credited with having Asperg-
children soon learn intuitively that this is not al- ers syndrome (though in the series this is never
ways the best idea. All children? No, not Shel- explicitly stated). This is The IT Crowd, a British
don. He is honest, rudely and brutally so. When series that ran for four seasons (with a total of 24
Leonard, who is worried about his relationship episodes), broadcast from 2006 to 2010 (plus a
with Penny, comments: Penny thinks Im too final episode in 2013), which follows the ups and
smart for her. Thats ridiculous!, Sheldon has no downs of a companys IT department. As in The
problem answering: Youre right. Most of your Big Bang Theory, this is a situation comedy that
work is worthless. Or when Leonard is worried plays on the contrast between two very different
that girls like Penny dont end up with guys who personality types, embodied by two IT support

The Big Bang Theory and Aspergers Syndrome

technicians (Roy and Moss) and the department deeper underlying the persons cognitive archi-
head (Jen), who has no idea about computers. tecture.
To say that Moss is intelligent would only be The variety of symptoms observed on the
partially true. Moss has huge logical and math- autism spectrum has a common denominator:
ematical intelligence, which makes him suited to cerebral functioning that makes the brain better
IT work, but his interpersonal intelligence is prac- suited to understanding and interacting with ob-
tically nil. He can communicate perfectly with the jects than people. Objects follow specific physi-
computer, but not with the people around him. cal rules and are, therefore, predictable. On the
Within the department, the work that would be contrary, people act according to their own will,
best suited to him would be programming in- guided by interests and objectives that are hid-
stead of users technical support. He also lacks den from the outside and so are unpredictable.
common sense and the capacity to improvise The human brain is a complex computational
suitable solutions in unforeseen situations. In a mechanism that combines logical capabilities
famous sketch, his office catches alight. After (reasoning, algorithmic method, conscious atten-
some moments of doubt, Moss looks for the fire tion, mono-task processes, which are accurate
extinguisher, places it carefully on the table and but slow) and heuristic processes (intuition, imag-
starts to read the instructions: Stand vertical- ination, automatic, multi-task processes that are
ly. Moss interprets this to mean he must stand fast but prone to error). In fact, in recent decades,
straight, but when he does so, finds that the ex- some authors have suggested the existence of
tinguisher is no longer in his field of vision. Oh, two different cognitive systems in the human
no! Now I cant read it. Faced with this difficulty, brain.9 The relative level of each of these two sys-
he decides to go back to what he knows and tems varies in each individual; we all know people
write an email to emergency services. who are more intuitive and others who tend to be
Moss, like Sheldon, is a character whose be- more methodical.
havior has been adapted to the needs of the fic- So the characteristics observed in the autism
tion. Even so, what they share with Dr. Aspergers spectrum correspond to a brain in which a sig-
little teachers, and with the 107 million people nificant imbalance exists in favor of the former of
who fall within the Autism Spectrum8, is a cer- these two systems, the one we could call logi-
tain way of being and interacting with the world cal, in detriment of the latter, the heuristic sys-
surrounding them, which is displayed through tem. For this reason, patients with Aspergers are
widely differing characteristics. One specific dif- more skilled in subjects governed by clearly de-
ficulty in studying autism is finding the core of termined rules, and in methodical tasks or ones
the disorder that which constitutes its essence with careful attention to detail, such as informa-
and raison dtre. What does it really consist of? tion technology. This would explain their more
When Eugen Bleuler coined the term autism, populous presence in this field.
which Kanner and Asperger later used to define
this disorder, he took the Greek term to
Sherlock, Max, Hank and Saga
indicate that the individual was shut into them-
selves, because that was the trend he observed Below, I will look at other examples of television
in themost seriously affected cases. But even in characters related with Aspergers. The earliest
the cases where this occurs, the social isolation example would be Sherlock Holmes, who was
is no more than a manifestation of something initially a literary character based on the real-life

 he statistic comes from current world population numbers, around 7250 million people, and from the aforemen-
tioned report which detects a prevalence of autism of 1.47%.
See, for example, the article Dual-Processing Accounts of Reasoning, Judgment, and Social Cognition, by Jonathan
St. B. T. Evans, or the works of Shelly Chaiken, Seymour Epstein, Daniel Kahneman and Steven Sloman.

Notebooks of the Esteve Foundation N 42

Medicine in Television Series

figure of Dr. Joseph Bell (18371911), an eminent three episodes each in 2010, 2012 and 2014,
Scottish surgeon. He was the author of several with a fourth scheduled for 2016, present the
medical books (including A Manual of the Op- famous detective in the modern world, adding
erations of Surgery), as well as being a pioneer new technologies to his arsenal of investigative
in forensic science. He believed that every doc- resources. The image they present of Holmes re-
tor should base their diagnosis on painstaking inforces his character within the autism spectrum.
attention to detail, and he made every effort to Right at the start of the first episode, a morgue
encourage this trait in his students. So, it is said worker paints her lips and suggests a date: Lis-
that in one of his classes he showed his students ten, I was wondering maybe later, when youre
a vial containing a foul-smelling liquid into which finished I was wondering if youd like to have
he dipped his finger before licking it. He then coffee? But Sherlock does not capture the insin-
indicated that the students should do likewise. uation and responds coolly: Black, two sugars,
Once they had finished, Bell repeated the opera- please. Ill be upstairs. Later, when she returns,
tion, showing them that he had, in fact, dipped disappointed at his response, without the lipstick,
one finger and licked another. Through this, he he asks her: What happened to your lipstick?.
aimed to teach them the need to focus on ac- It wasnt working for me. Really? I thought it
curate observation of the facts. Bell himself was was a big improvement. Mouths too small now.
extraordinarily gifted in this capacity and in draw- Though this type of behavior is repeated
ing conclusions from the smallest details. So his throughout the series, the only time when such a
help was often required by the police in their in- diagnosis is explicitly proposed is in the second
vestigations. (Some claim that he even assisted episode of the second season, when Inspector
in the case of Jack the Ripper, but there is no Lestrade, annoyed at Sherlocks behavior, com-
evidence of this.) plains to Watson that it must be due to his char-
One of Bells students in 1877, and later his acter, and Watson confirms: His Aspergers?
assistant, was Arthur Conan Doyle, then a medi- The series in which Aspergers is explicitly
cal student at Edinburgh University, from where dealt with is Parenthood, in which two charac-
he would graduate four years later. Already, dur- ters have the disorder. The action is set with the
ing his studies, Doyle had begun to write works following scene: While eating in a restaurant,
of fiction, but those that made him universally Adam receives a call from his wife Kristina, who
famous were the stories starring the detective, in a worried voice asks him to meet her. When
Sherlock Holmes. Doyle admitted to Bell himself he arrives, Adam sees the concern on her face.
that he had created the character based on Bells Whats going on?. Um, I heard from the edu-
personality, a combination of his acute concen- cational therapist. And she said that she has
tration when at work, his passion for detail and some concerns about Max. She feels that Max
his capacity for logical reasoning. And it may be has some learning differences. Well, that isnt so
supposed that, although he did not include them serious, thinks Adam. They are both concerned
in the list, other of Holmess less praiseworthy about their sons strange behavior, but if it is just
characteristics, such as his lack of empathy, a an educational problem, it can be solved. Okay,
certain arrogance, and the anxiety he attempted listen, Ive given this some thought, I wanna
to counter with his addiction, also originated with contact the school, get Max a tutor to help him
Bell. All this encourages speculation on whether through this rough period. But Kristina knows it
Holmess character, and consequently Bells, cor- is more than this. Honey, she wasnt just talk-
responds to the profile of Aspergers syndrome. If ing about... academics. ... Honey, she thinks that
so, Doyle was describing a case almost 60 years he may have... Her voice fails her. She thinks
prior to Hans Asperger publishing his article. that he may have Aspergers. Adam is surprised
Among the many adaptations of the character and incredulous. Aspergers? Like autism? ...
for the screen (both the wide and the small), the Ive seen autistic kids. ... The Lessings kid with
BBC series Sherlock, with three brief seasons of the hand flapping... However, after the interview,

The Big Bang Theory and Aspergers Syndrome

Kristina is better informed. Its high-functioning Katims, has a son with this disorder, which led
autism. A lot of people with Aspergers ... live very him to research the subject thoroughly and to try
productive lives, Adam. ... [The therapist] said to represent it on-screen in the most exacting and
that if we get him the right tools to learn direct way possible. Virtually none of the series I
Parenthood is a series by the channel NBC included in Table 1 specify that the characters
which narrates the difficulties of three generations characteristics are due to Aspergers syndrome,
of the Braverman family: Zeek and Camille are the or at most, this is indirectly insinuated at some
grandparents, who have four kids, Adam, Sarah, point. Yet in Parenthood, the term Aspergers is
Crosby and Julia, some of whom have partners, pronounced 125 times (in addition to autism or
and kids. The fragment described, focusing on autistic 23 times, and spectrum another eight
Adam and his wife Kristina, is in the series first times, used in the sense of autism spectrum).11 In
episode, but could come from the real life of any of fact, after the second episode of the first season
the many families who have undergone similar sit- was aired, a curious event occurred. Though the
uations when they discover their child suffers from initial episode had mentioned Aspergers (in the
a disorder that they may never have heard about. fragment I copied above), the second episode
Parenthood is the series that describes Asperg- emphasized it with greater intensity (13 times), so
ers syndrome most explicitly and rigorously. The it seems to have lodged more firmly in viewers
scripts are assessed by experts on the subject, perception. Curiosity concerning a medical con-
and every two episodes the director, executive cept that people had not heard of meant that the
producer and the actor playing Max meet with an morning after the broadcast, the most searched-
Aspergers specialist to ensure that the perform for expression on Google was Aspergers dis-
ance mirrors the disorder. A singular feature of ease.
Parenthood that reveals its involvement with the The most idiosyncratic characteristics of As-
disorder is that the series runs a blog10 called The pergers as well as its repercussions for the
experts speak, where doctors and researchers individuals themselves and those around them
comment on episodes and offer families advice. (family, social network) were being projected
Max presents the social deficits and adher- from the very first episodes. Just two minutes
ence to routines that are the diagnostic clues to into the start of the series we saw the grandfather
Aspergers. He is also hypersensitive (to sound (Zeek) expressing his concern to Maxs father
and touch), is unable to understand facial expres- (Adam) because the child refused to play on
sions or implicit social rules, and suffers nervous the baseball team, preferring to stay home and
crises or tantrums when anything alters his plans. play alone. Adam, who knows that Max dislikes
However, one should not think that all children baseball (because of his lack of skill at sports and
with Aspergers are like Max, since each case can because he feels uncomfortable in groups), tries
be manifested in differentiated aspects and to to justify this, saying that the grandfathers insis-
varying degrees. The way in which each person tence on this score makes Max a little nervous,
reacts to their difficulties is also different. In reality, adding: Max is a sensitive kid, thats all. Zeeks
two people with Aspergers can be as different abrupt answer expresses an entire viewpoint
to each other as two neurotypical people might unfortunately, one that is pervasive of dealing
be, though this does not stop an expert profes- with human diversity: Well, you were sensitive
sional from detecting the disorder after observing too. I cured you. These few words allow us to
a childs behavior for a while. reflect on certain therapeutic methods that aim
The highly realistic treatment of Aspergers in more to adjust childrens behavior to the social
Parenthood is because the series creator, Jason standard than to help them develop their specific

Not counting the final episode, which had not been aired at the time of writing this paragraph.

Notebooks of the Esteve Foundation N 42

Medicine in Television Series

capacities and live fulfilling lives.12 And in case the Dr. Pelikan, gives advice to viewers who may find
idea, given its briefness, goes unnoticed by view- themselves in this situation: You will help to un-
ers, the next scene shows Maxs mother (Kris- cover Maxs gifts. You figure out how he learns.
tina) and sister (Haddie) wondering why baseball You get as much support for Max as possible.
is so important. Kristinas answer is clear: Well, Quite honestly, the research clearly shows the
because men feel the need to express their love greatest barometer of success for children with
through hitting balls, slapping butts, and discuss- Aspergers is their parents involvement.
ing meaningless statistics. And I think your father One aspect that concerns parents when they
thinks that if Max doesnt do these things hes receive such a diagnosis about their child and still
gonna grow up to be sad and alone. Haddie do not know much about Aspergers is the fact
concludes: Well, thats absurd. that it is not temporary, but a characteristic that
After the therapist indicates to them that Max will accompany their child all his life. Adam ex-
may have Aspergers, Adam and Kristina begin presses it like that when they return home after
to do research and get in contact with the par- their visit to Dr. Pelikan: I can deal with anything.
ents of another kid with Aspergers, who recom- I... I can deal with disease, with illness, with a
mends they follow a gluten-free diet: No wheat. broken bone. Give me something I can fix. But
No sugar. No chemicals. Casein-free too. Kris- I just... I dont know how to deal with this. This is
tina asks: Whats casein? A quick comeback: for life. True, autism spectrum disorder is for life,
I dont know. And immediately: We have a nu- but that does not mean that it always affectsthe
tritionist that you are gonna love. (This is a nod person in the same way as it does during the early
at the cures that are sometimes proposed in years of development at least not in most cases,
certain circles, arising from the impotence that especially if help is given early. Even without this
some parents feel at not finding a solution to their help, many people who were children when the
childs problem.) However, the next piece of ad- disorder was still unknown are now adults lead-
vice is useful: Youre going to need a behavioral ing apparently normal lives.
therapist. They say Dr. Pelikan is the best. ... [but] Children with Aspergers without abandon-
no one gets in to see Pelikan. Hes an elusive ass. ing the essence of what makes them like that
Hes like the Bob Dylan of autism. and constitutes the way they are and see the
Luckily, a chance situation gets them an early world can learn to integrate and relate with their
appointment with the doctor. After the visit, environment, and to become capable of contrib-
Pelikan tells them his diagnosis: Max is very high uting their special personal capabilities toward
functioning. But I do find that Maxs behaviors societys progress (as many of them have done).
are consistent with an Aspergers diagnosis. The Parenthood reflected this throughout the series,
confirmation falls like a piano on the parents, who showing Maxs progressive evolution in self-
were hoping it might be something temporary: control, his social relations and, in the sixth and
So how long is this going to take then? The re- last season, his first romantic crush on Dylan, a
ality is quite different: Unfortunately, there is no classmate suffering from attention deficit hyper-
cure for Aspergers. It is a syndrome that he will activity disorder.
always have. Kristina: What... what are we sup- Yet furthermore, to complete the life perspec-
posed to do for him? Then the series, through tive of the person with Aspergers, from the fourth

 Its important to value our children as individuals, even if they are not the children we expected them to be. The
tragedy of our society is the rush to services that are geared specifically at inculcating conformity as opposed to
helping the child develop into the unique adult they will eventually become. We easily forget that the goal isnt a
well-behaved child but a happy, successful and independent adult. An intervention is deemed successful when
the child appears to behave just like all of the other kids, but little attention is paid to the long term goal or the rami-
fications of forcing square pegs into round holes. Corin Barsily Goodwin and Mika Gustavson, 2011. Available at:

The Big Bang Theory and Aspergers Syndrome

season onward, the series incorporated an adult chance. For them all, the moment means finding
character: Hank, a man with few social skills. He the explanation for their past and perhaps be-
is a professional photographer who has a studio ingable to make peace with themselves.
where Maxs family goes to get a group portrait Parenthood is the series that deals with As-
done. Hank is looking for an assistant, and Sarah, pergers syndrome in the most explicit manner,
who is Adams sister and Maxs aunt, applies for closest to the situation of many families who
the job. Initially, Hank rejects her because of her have similar experiences. I will end this review
lack of technical knowledge, but he soon realizes with another quite different series. This one never
that Sarah has the skills for dealing with custom- even names the disorder, but I consider it highly
ers that he lacks and he hires her: Turns out the instructive, since both through its plot idea and
people at the shoot, they liked you. They, um, in the relationship it establishes between the
made a big stink about it. So it turns out youre two leading characters, and even symbolically
good at the schmooze. And I hate talking to cli- through the setting in which it takes place, and
ents. Truly, I hate it. I get a little sick in my stomach the series name itself, it sends a message that
sometimes. Yeah, so thats why I was gonna call is valid not just for the case of Aspergers syn-
you. Youre not as awful as I originally thought. drome, but for human diversity of any kind.
The relationship between Hank and Sarah, ini- Bron/Broen is a series co-produced by Swed-
tially a professional one and later romantic, puts ish and Danish public television along with the
Hank and Max in contact, who, because they German channel ZDF. To date, two seasons have
share similar character traits, become friends. been produced, with a total of 20 episodes.13 The
One day Max gets angry at Hank because he had bilingual title means bridge (Bron in Swedish,
promised to help him with some photos and, due Broen in Danish) and refers to resund (or re-
to work reasons, Hank could not. Max throws a sund) Bridge, an eight-kilometer-long architectural
tantrum, yells at Hank that he is a liar, and runs marvel that, along with a four-kilometer tunnel,
home to shut himself in his room. A few days links Sweden and Denmark. The bridge has a
later, Maxs father appears at Hanks studio to constant presence in the series, since it is on its
apologize for this behavior. He explains that Max central point, just on the line marking the border
has a disorder called Aspergers syndrome and between both countries, that a body appears. The
leaves him a book on the subject so that he can death must be investigated jointly by the police of
understand what happened. Sweden and Denmark, countries separated by a
Minutes later we see Hank at night, reading certain social and cultural distance. From that mo-
the book with growing excitement, turning pages ment onward, the characters are constantly forced
nervously and highlighting sections. He runs to to cross the bridge, both in a real sense, to pursue
Sarahs house. Seeing him so troubled, she asks: their investigation, and figuratively, by learning to
Whats this book? Whats up? Hank answers ex- understand and accept their differences.
citedly: I was reading this book for Max. And then In charge of the Danish side of the investiga-
all of a sudden, Im not reading about the kid any- tion is detective Martin Rohde, a man whose ap-
more. Im reading about me! This book is describ- parently calm and ample figure brings to mind a
ing me. Im seeing my life. My life. I can see every- polar bear. Yet he pursues his work with a pas-
thing, absolutely everything. That is why stuff hap- sion, to the extreme of taking justice into his own
pens to me. Im like him. Im like Max. How many hands. In contrast, on the Swedish side, we have
adults in recent years have experienced that mo- detective Saga Norn: a meticulous person, hard,
ment! Some, when their children have been diag- cold and humorless, who follows the rules scru-
nosed. Others, like Hank, when reading a book by pulously, is incapable of lying, and brilliant in her

 ntil August 2015. There has also been a US remake, The Bridge, that takes place on the border between the US
and Mexico, and another Franco-British version, The Tunnel, centered on the Eurotunnel.

Notebooks of the Esteve Foundation N 42

Medicine in Television Series

work, but with no skill at social niceties. No doubt accept Sagas way of being, and becomes her
the scriptwriters were guided by Aspergers syn- confidante and assessor in social questions, as
drome when defining her character, though at no through her he acquires a previously unknown
time during the series is explicit reference made view of the world. For her part, Saga learns to
to it.14 see Martin as the closest she has ever had to a
To a certain extent, Saga and Martin are the friend, something she confesses at the end of the
antithesis of each other, and so their initial con- last episode aired, when she discovers he has
tact causes mutual perplexity, incomprehension committed a punishable offense: I have ana-
and some rejection. Nevertheless, little by little, lyzed your motives and I have concluded you
they establish a bond, a form of male-female are my only friend.
friendship unrelated to sex or even external No doubt it is the lesson we should take away
shows of affection. I would venture to say it is from the series: acceptance of human diversity in
such a relationship as might exist between an all its variety, and collaboration to overcome any
understanding father and a daughter who is ex- differences (mental, nationality, culture, etc.) so
periencing certain difficulties. Martin manages to that we can all build a better world.

I would note the coincidence (or not) that means that in the sample of characters displaying Aspergers I have
chosen, there are five males (Max, Hank, Sheldon, Moss and Sherlock) and one woman (Saga). In other words, the
same ratio as in real life, according to the aforementioned CDC report.

Notebooks of the Esteve Foundation N 42

Breaking Bad and Methamphetamine Addiction

Patricia Robledo

If any series has garnered close to unanimous approval among both critics and viewers, it is without a
doubt the story told over five seasons about a common chemistry teachers descent into hell, a man who
becomes the largest methamphetamine distributor in New Mexico. Thanks to Bryan Cranstons outstand-
ing acting, the character of Walter White has become a TV icon. Having won sixteen Emmys, the series,
along with Mad Men, has turned cable channel AMC into a serious competitor with the all-powerful HBO.
After the shows 2013 finale, its creator Vince Gilligan presented Better Call Saul, based on a secondary
character from the original series.

The main theme of the series Breaking Bad is accidents, convulsions, agitation and hyperther-
synthesis and distribution of methamphetamine mia, and they are mostly the cause of abuse and
in a small US town on the border with Mexico. addiction to this substance as well.1 The subject
In a highly realistic way, the series depicts how of addiction presented in the series agrees with
the methamphetamine market can be a lucrative scientific evidence and clearly shows the addict
business, since there is huge demand for this ive process. So, according to one of the most
product and because its synthesis is inexpensive, influential theories, addiction to abusive drugs is
its chemical precursors being relatively cheap established by the interaction of a vulnerable indi-
and easy to purchase legally. Meanwhile, the vidual with the neurobiological changes the drug
series deals with two crucial problems linked to causes, which depend on the amount of expos
methamphetamine trafficking. The first is the vio- ure. Addiction is a recurring illness that consists
lence associated with the war for absolute market of different phases, including the intensification of
control, and the second, abusive consumption of consumption or escalation, increase in the need
this substance and its negative consequences. to consume, loss of control and relapse into us-
On the latter point, the series faithfully shows how ing even after prolonged abstinence.2
methamphetamine is a highly addictive abusive
drug which is mainly consumed for its long-lasting
The three faces of methamphetamine
euphoria-inducing properties. It produces its psy-
synthesis and distribution
chostimulant effects by increasing monoamine
extracellular concentrations in the brain. The fast, Jesse Pinkman is a young high school dropout
constant increase of noradrenaline is the cause with substance abuse problems, who is rejected
of its known toxic syndrome, characterized by by his family because he cannot get off drugs
tachycardia, hypertension, mydriasis, diaphoresis and back into society.
and psychomotor agitation. Prolonged release of Though he failed chemistry at high school, he
central monoamines and activation of the sym- has the formula for preparing methamphetamine
pathetic nervous system produce most of the or crystal meth as it is called on the streets
acute neurological complications associated with which he prepares in a secret lab in his garage.
methamphetamine use, such as cerebrovascular Jesses formula, which is based on chemically re-

Breaking Bad and Methamphetamine Addiction

ducing pseudoephedrine, is the method used in This method of methamphetamine synthesis is

real life. Jesses friends, Badger and Skinny Pete, shown in episode Seven Thirty-Seven of the se-
are also drug addicts and undertake to source ries, the first in the second season. Walters broth-
the raw material by buying the nasal deconges- er-in-law, who works for the US Drug Enforcement
tant Sudafed, which contains pseudoephedrine, Administration (DEA), is surprised to see the video
from different pharmacies. Once the pseudo- of a theft of methylamine and comments: P2P
ephedrine is extracted, it is reduced using iodine theyre cooking old school biker meth. His com-
and red phosphorus to form methamphetamine ment refers to the fact that during the 1970s and
or N-methylamphetamine. Jesses methamphet- early 1980s, methamphetamine was produced
amine distribution is small-scale, using his drug- by this method and distributed by the Hells An-
addict friends as pushers, who mainly sell the gels motorcycle club in northern California, until
drug locally. According to the Spanish National it stopped being used due to the classification of
Plan on Drugs, in Spain, methamphetamine is P2P on the list of controlled substances.3 By the
known by the names speed, meth, chalk, ice or mid-1990s, most P2P labs had been substitut
crystal, and is consumed by smoking. It can also ed by pseudoephedrine/ephedrine-based labs.3
be taken orally, inhaled or injected, which deter- However, the law relating to methamphetamine
mines the type and magnitude of the effects it precursors in the years 1993, 1995 and 2005 in
produces. the US meant that both ephedrine and pseudo-
Walter White is a highly intelligent man whose ephedrine also became controlled substances.4
creative aspirations in the chemistry field are This fact contributed to a decrease in the market
foiled, so he ends up as a high school chemis- and the recovery of the old P2P method of synthe-
try teacher. The situation makes him deeply bitter sizing the drug. So, in late 2010, 69% of American
because of the lack of incentive and his financial and Mexican samples examined showed that they
problems. Moreover, he has serious health prob- were produced using the P2P method.4
lems involving costly treatment. By chance, Wal- Some discrepancies between the TV fiction
ter finds out that Jesse, a former student of his, and reality have to do with the incredible purity
is synthesizing methamphetamine under danger- that the methamphetamine prepared by Walter
ous conditions. He decides to suggest a more seems to have. So one feature of Walters meth-
efficient manner of synthesizing a large quantity amphetamine is its blue color, which in strict
of extremely pure methamphetamine. His idea chemical terms does not agree with its claim to
is to earn a lot of money so that his family can be 99% pure, given that this color is a sign of im-
live comfortably after his death from lung cancer. purity. Another discrepancy with real life is related
Walter is a disciplined, well-organized man, with to the fact that the ultra-pure methamphetamine
an astonishing ability in chemistry, traits which that Walter prepares is found on the streets in
will serve him well to improve the purity of the equal purity, which does not normally happen
meth and set up a lab in a van that can travel because distributors tend to adulterate the drug
out to desert regions to effectively elude the citys with other compounds to increase its volume and
police controls. In the series, Walter stops using earn more profit.
the pseudoephedrine-based method because of Walter also changes the means of metham-
the difficulty of acquiring large quantities of this phetamine distribution to make the business more
precursor. Instead, he suggests using a meth- lucrative, associating with an extremely danger-
amphetamine preparation method known as ous Latin distribution network. These two means
reductive animation or 2P2 method, which of methamphetamine distribution are faithfully re-
consists of reducing phenyl-2-propanone (P2P) flected in the series. The first, on a small scale,
using phenylacetone and methylamine. Methyl- carried out locally by drug addicts, and the other
amine is used in industry, but it is a substance on a large scale, controlled by mafia.
that is tightly controlled by the anti-drug law en- Gustavo Fring is a Latin drug trafficker who
forcement agencies. controls the business in the American west in an

Notebooks of the Esteve Foundation N 42

Medicine in Television Series

organized way. He passes completely under the by dysphoria, restlessness and anxiety. Further-
radar because he has an infallible money laun- more, he displays bruxism (clenching or grinding
dering system. Walter and Jesse are associated his teeth for no reason) and the shakes. In the
with him to synthesize big amounts of meth in a series, Jesse is the typical meth addict who little
large secret lab that Fring sets up for them in the by little loses control of his life and the support of
city where they live. This fact is similar to the real- his parents due to his addiction. So, in Down,
ity of the so-called super-labs, that are known in the fourth episode in the second season, we see
Mexico and which probably also existed in the US how Jesse becomes homeless because his par-
at some point. In the tenth episode of the fourth ents have found out he has set up a meth lab
season, called Health, Gus Fring takes Jesse in the house he inherited from his aunt. In Jesse
to Mexico by force to make him try his hand at we see the relapse into seeking out the drug
synthesizing ultra-pure methamphetamine in the and returning to using after adverse situations
Jurez Cartel. There, he sees one of these super- or depressing episodes, such as in Mandala,
labs, run by this criminal gang. Fring is a dan- when he feels guilty and sad about the death of
gerous man who does not hesitate to eliminate his friend Combo and starts to shoot up heroin
the boss of the Mexican cartel, who is compet- with his addict girlfriend. This episode offers fair-
ing for the trafficking and distribution of metham- ly realistic scenes about the effects heroin has,
phetamine on American turf. The methamphet- in clear contrast to the effects of methamphet-
amine trafficking by Mexican criminal gangs as amine. Injected heroin induces a wholly pleasant
described in the series is plausible, given that sensation, characterized by a marked indiffer-
the decrease in methamphetamine production ence to internal and external stimuli. The peak of
in the US noted since 2003 was countered by euphoria occurs seconds after injecting the drug
an increase in Mexican production. The Mexican and tends to last several minutes, while the feel-
drug cartels became more involved in that traf- ing of well-being can last from four to six hours.
ficking, and the amount of methamphetamine However, heroin does not induce psychomotor
confiscated on the border between the US and action, given that it is a depressant of the central
Mexico increased considerably in 2003.4 In 2008, nervous system. Large amounts of heroin can
Canadian trafficking organizations increased their cause extreme drowsiness, with the risk of in-
participation in meth production worldwide, while ducing a state of coma or decreasing the cough
Mexican cartels invaded the market in the US.4 and expectorant reflex, which can cause one to
choke on ones own vomit. This is reflected in the
tragic case of Jane, Jesses girlfriend, who dies in
The different profiles of meth addicts
precisely this way.
The second season of Breaking Bad depicts in a On the other hand, methamphetamine also
fairly realistic manner some of the existing patterns induces a fast peak of euphoria that can last for
among methamphetamine users. On one hand, many hours, depending on whether it is inhaled,
Jesse and his friends generally sniff or smoke smoked or injected, through activation of the
the drug, so that moderate doses produce quick central nervous system by its effect of releasing
effects such as euphoria, heightened attention, monoamines. At the end of the second season,
a loss of appetite, increased libido and self-es- in episode thirteen, ABQ, Walter takes Jesse to
teem, and improved mood. Yet Jesse appears in rehab. We see his affective deterioration, feeling
the series as a true addict who does not limit the guilt at his girlfriends death. The situation Jesse
amount of methamphetamine he uses because finds himself in is no doubt because of the af-
he has unlimited access to it. In a scene from the fective deterioration characteristic of those who
second seasons eleventh episode Mandala, chronically abuse methamphetamine, who fre-
when Jesse meets Walter to talk business, we quently have problems experiencing pleasure
see the effects associated with consuming high (anhedonia) and fall into deep depression from
doses of methamphetamineas Jesse is stricken the exhaustion of cerebral reserves of dopamine

Breaking Bad and Methamphetamine Addiction

and serotonin in the neuronal terminals.1 Through they consume meth because it is cheaper. They
Jesses character, the series shows addiction will do anything to get the drug, even prostitute
truthfully, since the affective problems and possi- themselves, as Spooges girlfriend does. The epi-
ble cognitive deficit that Jesse experiences con- sode Peekaboo, in the second season, shows
tribute significantly to perpetuating the addict- the marginal conditions in which this couple
ive cycle, characterized by abuse, loss of control live, with a small child who is totally uncared for.
and relapse.2 These two characters suffer from serious side ef-
The third episode, Open House, in the fects that truly occur after chronic meth use; for
fourth season, shows how Jesse increasingly example, both show evidence of malnutrition and
loses control over his actions and seems quite poor dental health associated with serious cavi-
unbalanced when, after killing Gale, he throws an ties and the loss of teeth. The latter is due to the
interminable party in his house with other drug drugs acidic properties combined with a lack of
addicts, consuming huge amounts of metham- oral hygiene. Xerostomia (dry mouth) also adds
phetamine. The situation degenerates, evolving to the dental problems resulting from metham-
from dancing to violence. This episode shows phetamine use. Spooge and his girlfriend also
the reality of methamphetamine use inthe form have skin damage as a result of the compulsive
of binges, which can last several days, and scratching that accompanies methamphetamine
where the euphoric effects of the drug progres- use. Such injuries tend to get infected, resulting
sively decrease over time, while dysphoria and in a bacterial cellulitis that spreads to become
compulsive and repetitive behaviors increase. bacteremia and sepsis in some cases.
This use profile is perfectly captured by Jesses In addition to these examples of methamphet-
party, where after several days of euphoria and amine users in the series, two other individuals
dancing, the guests start to become violent and use the drug but do not become addicts. This
engage in risky sexual behavior. The behaviors aspect, which the series does not examine, is
described in the series (which Jesse dramatizes) linked to existing differences in the population in
are linked to pathological deregulation of the ce- terms of individual vulnerability of entering the ad-
rebral circuits involved in pleasure and motiva- dictive cycle after sporadic or recreational drug
tion caused by the addiction. So, taking most use. Experts believe that 12 to 20 out of every
abusive drugs, including methamphetamine, 100 people who begin to use drugs will develop
increases dopaminergic transmission in specific addiction. Yet the risk that these addicts relapse
cerebral centers that reinforce the behavior of into using the drug, even after prolonged per
seeking and consuming the drug, facilitating the iods of abstinence, is extremely high.2 In 2013,
reiteration of learned behaviors and encouraging the Washington Post6 published an article on the
addiction. From the uncontrolled need to obtain type of person, known as a functional addict,
the drug stems the relapse, the basis of which is who consumes methamphetamine and seems
a pathological form of neuronal plasticity in the able to remain socially active. Some of the exam-
excitatory glutamatergic system. Such deregu- ples mentioned were working mothers, or people
lation means that the individual addict places holding down several boring and poorly paid jobs
excessive motivational importance on stimuli who use meth to boost their energy and alleviate
that predict drug availability and it reduces his the tedium of their social and working conditions,
or her ability to stop using it.5 or university students wanting to improve their
Meanwhile we have the characters of Spooge cognitive capacities. As has been mentioned,
and his girlfriend, two addicts on the fringes of the addictive process depends on the drug use
and disconnected from society. These characters and its interaction with the individuals preexist-
show the reality of chronic methamphetamine ing genetic or behavioral vulnerability. So some of
addicts, who are often multi-drug addicts. But these people, perhaps the most vulnerable, enter
because they cannot pay for cocaine or heroin, the spiral of addiction and lose control over their

Notebooks of the Esteve Foundation N 42

Medicine in Television Series

drug use to the point of failing at work and dis- Republic and the Russian Federation, as well as
connecting socially. developing countries in Africa and Central Amer
ica.9 In Spain, methamphetamine consumption is
Could Breaking Bad encourage low due to its high price, and seems to be linked
methamphetamine use? above all to elitist use on the gay scene.7

Though the series deals realistically with meth-

amphetamine addiction and its devastating ef- References
fects, some believe that Breaking Bad may have
1. Rusyniak DE. Neurologic manifestations of chronic
encouraged consumption of this drug. In 2014, methamphetamine abuse. Psychiatr Clin North Am.
several articles appeared in the Spanish press in- 2013;36:261-75.
dicating an increase in the confiscation of meth- 2. Piazza PV, Deroche-Gamonet V. A multistep general
amphetamine in the UK and rising use in Ger theory of transition to addiction. Psychopharmacology
(Berl). 2013;229:387-413.
many in the past five years. For some, this fact 3. Drug Enforcement Administration (DEA). Metham-
could be related to the series, while others claim phetamine situation in the United States. Drug intel-
that it is more correct to say that the series has ligence report. Washington, DC: U.S. Department of
made people aware of this drug.7 On the other Justice; 1996.
4. Drug Enforcement Administration (DEA). Office of
hand, a report from the DEA indicated that the
Forensic Sciences, Special Testing and Research
number of methamphetamine-related incidents Laboratory. Methaphetamine profiling program, fourth
in the US in 2012 was the lowest since 2008, the quarter CY2010. Washington DC; 2010.
year the series started. So it does not seem to 5. Kalivas PW, Volkow N, Seamans J. Unmanage-
able motivation in addiction: a pathology in prefron-
have influenced in the consumption of this sub-
tal-accumbens glutamate transmission. Neuron.
stance. 2005;45:647-50.
Though methamphetamine use could be 6. Matthews D. Heres what Breaking Bad gets right,
dropping in the US, it remains high in Asia, and and wrong, about the meth business. The Washington
Post; 15 August 2013.
worldwide consumption has become an epi-
7. Navarro M. La devastadora droga de Breaking Bad
demic. According to the UN Office on Drugs and ya se toma en Catalunya. El Peridico; 21 November
Crime (UNODC), it is estimated there are 25 mil- 2014.
lion amphetamine users worldwide, a larger num- 8. UNODC. Annual Report 2008. Available at: www.
ber than cocaine (14 million) and heroin users
(11 million).8 Furthermore, studies indicate that 9. UNODC. Annual Report 2013. Available at http://
methamphetamine synthesis and distribution has
increased in countries such as Poland, the Czech World_Drug_Report_2013.pdf

Notebooks of the Esteve Foundation N 42

Mad Men and Tobacco Addiction

Joan R. Villalb

Don Draper is, in all likelihood, one of the most representative icons of the golden age that TV series are
currently enjoying. Set in a New York ad agency in the 1960s, the show is a true and elegant reflection of
a period characterized by social discrimination, and has reaped the most prestigious accolades since it
premiered on the cable channel AMC in 2008. It scored four consecutive wins as Best Drama in the Em-
mys, and three Golden Globes, totaling 20 awards over its seven seasons on air. Even before its finale, it
was considered one of the best series in television history.

Big tobacco companies have used different strat- eral exhibition. Internal tobacco industry docu-
egies to promote tobacco use for decades. Nat- ments revealed in North American court cases
urally, direct advertising is the most significant, document this, and the work of Stan Glantz and
and one of the most effective; billboards on the his collaborators at the University of California
street, seen by the general public in their daily provides ample evidence.
lives, is one of its favorite supports, as well as Mad Men is a successful TV series, which
adverts in the printed press and spots on radio many consider a work of art. In recent years,
and TV. In such adverts, it is common to show part of the creative talent that time back was em-
popular figures smoking, and the stars of film ployed in films has migrated toward TV series on
and TV were doing it from the 1920s onward. So channels like AMC and HBO. Mad Men is part of
Humphrey Bogart and Lauren Bacall starred in this process. Since the series is set in the 1960s,
tobacco adverts in the 1940s, but so did many when smoking was common in the US, tobacco
more US artists, until the practice was declared il- plays a significant role, leading to the formulation
legal in 1964. As governments in many advanced of this analysis from a double perspective: the
societies adopted policies to reduce the damage viewpoint both of a fan of the series, and of a
that tobacco was causing, for example prohib- public health professional involved for years in the
iting the advertising and promotion of tobacco, prevention of smoking.
the industry sought ever more subtle ways of
promoting itself. One of these was through its
The historical context of Mad Men
presence in films or on TV. In recent years, it has
come to light that both studios and artists signed The series Mad Men premiered in 2007 in the US,
contracts with tobacco companies that led to at- on the cable TV channel AMC, and ended in 2015,
tractive film stars visibly smoking, or even making after seven seasons. Set in New York throughout
favorable comments on tobacco brands. These the 1960s, it focuses on an ad agency located
tactics intensified in the 1980s, and it has been on Madison Avenue (hence the reference to Mad
documented that during the following decade men, the men of Madison Avenue in ad agency
the presence of smoking on-screen in Hollywood slang, since there were numerous agencies lo-
films increased, especially in films rated for gen- cated in the area at that time). The drama follows

Mad Men and Tobacco Addiction

the career of the creative Don Draper and the al public through the media. The detonators were
people in his personal and professional sphere, the 1962 report by the Royal College of Physi-
centering on ad agency business and the life of cians in London, Great Britain, and publication of
its stars during several years of frenetic changes the US Surgeon Generals Advisory Committee
in the US, up until the 1970s. This period allowed report in 1964. Statistics on tobacco use showed
the series, using images and dialog, to place sev- the impact of the Surgeon Generals report, which
eral themes center-stage: cigarette smoking, al- marked a clear turning point, since its publica-
cohol consumption, persistent sexism, budding tion prompted many desertions from tobaccos
feminism, frequent adultery and infidelities, hid- cause. So 1963 was the year of greatest tobacco
den homosexuality and homophobia, anti-Sem- consumption per capita in the US (this has been
itism, and signs of flagrant racism. Throughout estimated at 4345 cigarettes per inhabitant over
the series, events occur which pervade the ac- 18). After the Surgeon Generals report in 1964,
tion: Kennedy wins theelections,the contracep- many states and cities began to pass regulations
tive pill comes onto the market,theVietnam War aimed at reducing tobacco addiction. This pro-
breaks out, the damage that tobacco causes is cess led to the current situation, where 20% of
documented, and so on. Yet perhaps its major adult Americans smoke, a ratio that in New York
pillar, one of its main underlying themes, is the City drops to 14% of the population. In this city,
deception people weave and their projection of one cannot smoke in the workplace, on public
identity. We see characters living a lie, hiding key transport, in bars or restaurants, or on beaches
elements of their identities, lives and past, who or in parks. (The fine for smoking in a public park
are, moreover, constantly deceiving the people is $US50.) The cost of cigarettes is high due to
closest to them. A certain parallel exists between specific taxes (in New York, the average price for
a packet is $US12). Tobacco cannot be sold to
such aspects and the ad agencys core activity,
persons under 21 in the city. Lastly, messages
which builds an unreal image of the brands and
warning against smoking, offering reasons to
products it promotes to consumers.
stop smoking are everywhere.
In the early 1960s, tobacco use in the US had
reached its critical point. For decades most adult
men had smoked, and since the mid-1940s it The key tobacco moments in the series
had been widely taken up by women too. Its so-
Throughout the series, tobacco is constantly
cial acceptance was widespread. One smoked
present. The main character, his wife and many
at work, on trains, in bars and in restaurants.
of the adult characters are smokers. The ab-
Advertising frequently laid claim to the presump-
sence of tobacco regulation in the period means
tive benefits of one brand over another, and its
that they smoke in the office, in meetings, in bars
less irritant properties. It was not infrequent to
and in restaurants. The characters constantly
show health professionals on cigarette adverts. smoke. In addition to tobaccos omnipresence,
In 1965, the prevalence of smoking was 42.4% there are three key moments when tobacco is not
(51.9% of men and 33.9% of women). merely part of the atmosphere but plays a lead-
Early studies incontrovertibly showing the ing role in the show: in episode one of the first
damage caused by tobacco were published in the season (focused on tobacco advertising); in the
1950s. Foremost among them was Richard Dolls twelfth of the fourth season (when they talk about
pilot study in the UK and a study of cases and the damage tobacco causes); and in the final epi-
controls by Ernest Wynder in the US. This knowl- sode of the seventh and last season (where lung
edge began circulating in professional circles and cancer affects one of the main characters). We
had a certain impact in the press, but it was not should review these moments.
until the early 1960s that the relationship between In the first episode (named, like The Platters
tobacco, lung cancer and other diseases became song, Smoke gets in your eyes), the agency is
generally accepted and reached the wider gener- trying to win an important contract with the com-

Notebooks of the Esteve Foundation N 42

Medicine in Television Series

pany that manufactures the cigarette brand Lucky York Times entitled Why Im Quitting Tobacco,
Strike. They must combat a growing social per- in which he proclaims he is happy to stop pub-
ception that tobacco is bad for ones health (an licizing a product that kills its users, and that
opinion the Readers Digest has just published), henceforth he will not accept tobacco companies
as well as a prohibition by the Federal Trade as clients. Furthermore, he publishes the letter as
Commission from evoking health benefits in ad- a full-page advert. Naturally, everybody keeps
vertising as was previously common (the tobacco smoking in the office, while the agency has seri-
company executives rant about these marketing ous financial difficulties and must lay off staff. Yet
obstacles, with references to Russia and com- in the next episode, it wins new accounts and
munism). To prepare for the meeting, Don Draper begins talks with the American Cancer Society,
holds apparently trivial conversations with the which is possibly interested as a client, from the
smokers around him, delving into their reasons for result of Don Drapers advert against tobacco
smoking and for choosing a brand. He also has a companies.
meeting with a medical consultant, a psychoana- In the seventh season, at the end of the series,
lyst, who indicates that an underlying element for the attractive Betty (Don Drapers ex-wife), an ex-
smokers is a death wish. In his meeting with the model and heavy smoker, undergoes tests after
tobacco company executives, which develops suffering health problems and receives the diag-
in rather an insane manner, where naturally any nosis of lung cancer. They tell her the prognostic
concern about the damage tobacco may cause is is grim: she has a few months left, though she
rejected or ignored (though as committed smok- may survive for a year if they undertake aggres-
ers, they are visibly coughing), Don Draper, who sive treatment, which she refuses. So she pre-
was creatively blocked, is struck by sudden inspi- pares for her death, notifying the people around
ration and proposes an ad campaign that differs her, while she organizes her childrens future...
from those that have been typical up to that point. and keeps on smoking. Furthermore, in the last
He suggests ignoring any concern about tobacco episode, Roger Sterling also appears. He is the
and health, and seeking connections with their character who indulges in every excess, with
customers aspiration to happiness: based on heart attacks in his past since the first season.
the smokers stories and identity. He advocates And he continues smoking, drinking and order-
building the brand image based on colors, logos ing lobster and more champagne, along with his
and slogans. Pure advertising: Lucky Strike. Its young partner.
toasted. While Lucky Strike was already a brand
that used a play on words, Its toasted refers
Tobacco use in the series and during
to the fact that during manufacturing, this tobac-
the period
co is toasted instead of just dried (other brands
also do this, but they decided to make a feature of As mentioned above, tobacco use in the series
it). Simultaneously, they sought a connection with reflects reality throughout the 1960s. At the start
the customer by evoking the morning toast and of the series, set in 1960, smoking is common
relaxed daily life. A surefire success. (In fact, this among adult men and women, except for old
story is pure fiction, since the slogan Its toasted people. Smokers smoke everywhere: naturally
was coined decades earlier.) athome, but also on the train on the commute,at
At the end of the fourth season, Lucky Strike the office, in bars and restaurants. Naturally, this
abandons the ad agency after 25 years of con- means that smokers smoke heavily. Early data
tracts and signs with another agency. In epi- tell us that in 1965, many smokers smoked more
sode 12, Blowing smoke, the agencys survival than a packet a day. So the levels of tobacco
seems threatened by the consequences of this consumption shown in the series are in line with
change, which affects its image. An attempt to contemporary reality.
capture Philip Morris as a substitute client fails. Another element to note is that Don and
Don Draper reacts and writes a letter to the New Bettys adolescent daughter begins smoking in

Mad Men and Tobacco Addiction

secret, a detail that also seems to reflect with cer- rather unreliable due to the publication of his let-
tain realism the process by which some people ter on tobacco.
began smoking back then. Equally shocking is
how her mother, wanting to improve their rela-
Tobaccos consequences:
tionship, offers her a cigarette in one scene, an
reality and image
act in which she seeks to create complicity. For
people of my generation, this was not an unusual Tobaccos negative consequences appear in the
event in the family circle, or with certain teachers. series. Bettys lung cancer, diagnosed at a sur-
Nowadays it would clearly clash with our current prising age due to her youth, is probably the most
sensibilities. striking (though it appears only in the final two
The series is set in an ad agency, so this oc- episodes of the last season, among a number
cupies a relevant space. There were no limits on of episodes). Roger Sterlings heart attacks are
tobacco advertising in those days. The federal there from day one, and tobacco shares its caus-
prohibition against tobacco advertising on elec- al role along with other risk factors. But this does
tronic media (radio and TV) came about in the not stop Roger smoking and he generally gives
1970s. The reality was that advertising expenses an impression of doing everything he can to en-
for the tobacco industry were then far lower than danger his health while continuing to have a good
in the early twenty-first century. What the series time. In the later seasons, Dons cough emerges
shows is fairly true to life, tobacco being one (as well as his problems with alcohol), which does
ofthe important accounts for an ad agency. Until not stop him smoking. There are mentions of oth-
the early 1960s, ad campaigns did not hesitate er risks linked to smoking. Perhaps one should
to evoke the presumed benefits of smoking, us- highlight that the explosion that unleashes one
ing doctors and other health professionals in of the main plot strands (Dons false identity after
ads. Facing concern about the damage caused the war) is the result of him dropping his lighter in
by tobacco, advertising was reoriented to trans- spilled fuel. There is even a scene in which Me-
mit feelings of happiness, relaxation and daily gans mother falls asleep in bed with a lit cigar
life linked to their customers identity and aspi- ette, posing a risk that her daughter discreetly re-
rations. Initially, no mention was made of luring solves. In general, the consequences of tobacco
adolescents towards smoking, or of market seg- are present, but given little space. So, while it
mentation by gender or race (though in later epi- is true that the series does not flinch from such
sodes set in the late 1970s, a Philip Morris cam- consequences, they are barely communicated to
paign did appear aimed specifically at the female viewers. Regarding tobacco, Mad Men viewers
market). In my understanding, it is probable that basically receive many images of people smoking
advertisings omnipresence, along with consum- a lot, which sends out a message that smoking is
er reality in 1960, made any segmentation un- normal behavior. This was the social perception
necessary. In the fourth season, in the episode in the 1960s, but fortunately nowadays this is not
described above, set in 1965, when Don Draper so, neither in the US nor in Spain. From this, a
makes public that the agency will not accept any certain dissonance arises.
more tobacco advertising because it is a prod-
uct that harms its customers, he is trying to turn
Tobacco and freedom of expression
the loss of his largest account to his advantage,
to position himself favorably in the light of publi- As other TV series and films, Mad Men poses
cation of the Surgeon Generals 1964 report. In certain dilemmas. As mentioned earlier, it is well-
later episodes, the American Cancer Society or- known that for years the big tobacco companies
ganizes an event in his honor and it seems like a paid the film and television industry to guaran-
good opportunity to win new clients, but we are tee its presence on-screen as a form of promo-
informed that the executives of the large com tion. Tobacco is overwhelmingly present in Mad
panies attending the dinner consider Don Draper Men, and naturally the Lucky Strike brand fea-

Notebooks of the Esteve Foundation N 42

Medicine in Television Series

tures. Throughout the series, many other prod- demarcate. My values are also in favor of free-
uct brands appear, many of which remain on dom of expression, even when this challenges
the market today (Jack Daniels, Gillette, Play- hegemonic opinions. I can confirm that every
tex, Maidenform, Cadillac, Volkswagen, etc.), so time I see a rerun of Die Hard showing Bruce Wil-
there has been a lot of speculation about product lis smoking with gusto, I curse the tobacco com-
placement. According to Matthew Weiner, the panies, which paid to ensure its inclusion. And
series creator and executive producer, only three yet, when I see the third film in the The Godfa-
companies paid for placement: Jack Daniels, ther trilogy, which also received funds from the
Heineken and Unilever (and also the Hilton, which tobacco industry, I cannot do so. Perhaps the
apparently made a payment after appearing in an difference is in the distinct pleasure that one and
episode, as an expression of gratitude). The oth- not the other give me, but maybe this is simply
er brands and products that appear (up to a hun- a reflection of the dilemmas that we perceive life
dred) were placed to give the series more realism, throws at us at certain ages.
with no commercial agreements. One should not Like many other complex works, Mad Men
forget that there are storylines, especially in cer- can be read on several levels. For a superficial
tain periods and places, where the absence of and occasional viewing of the series, I think it
tobacco could affect their authenticity. This is not transmits a favorable message about smoking
just true for tobacco, but also for alcohol, for sex that which is visible. On another level, of full
and, in reality, for many human behaviors and as- viewing, the message is more complex. And on
pects of daily life that can be related to health or yet another, a fuller and perhaps even more so-
the beliefs of a segment of viewers. phisticated reading will capture the series finer
We know that to reduce tobacco smoking in details, where a message against smoking will
adolescents, different forms of their advertising emerge, as will a characterization of the indus-
and promotion must be prohibited. I personally try and the visibility of its consequences at the
documented the artful practices of the tobacco series end. It seems that, on the whole, in the
industry in our country, which were totally at odds lives of people who watch Mad Men, the overall
with the self-regulating codes they claimed to impact we hope it may have on our attitude to
adopt. I was also an active agent in the process tobacco will probably be modest. And so, aware
leading to Spanish Law 28/2005 that regulated not only of tobaccos role in the show, but also
this issue in a positive manner. Nevertheless, I of the enjoyment the series has given me, and
believe that the border between freedom of ex- bearing in mind the values in which I believe, I
pression and censorship is sometimes tricky to wholeheartedly recommend it to my friends.

Notebooks of the Esteve Foundation N 42

The Walking Dead

and the Collective Imaginary on Epidemics

Josep M. Comelles and Enrique Perdiguero Gil

If Mad Men and Breaking Bad are the two series that have taken the cable channel AMC to such great
heights as its competitor, Premium HBO, this post-apocalyptic tale based on a Robert Kirkman comic
depicting a world populated by zombies is the show that has brought it audiences in the millions, greater
even than many free-to-air productions. Premiered in 2010 with over five million viewers, it has managed
to multiply this figure threefold in its recent seasons, approaching fifteen million viewers. Such a favorable
reception enabled AMC to try its luck with a sequel set in Los Angeles, Fear the Walking Dead, a strategy
that so far has shown fairly good returns.

Though series such as Mad Men, Breaking Bad, Epiphany of the undead
Fargo and True Detective scooped the major in-
In 1943, Jacques Tourneur directed the film
ternational awards, in the light of data from coun-
IWalked with a Zombie, shortly after publication
tries that publish audience levels, The Walking
of Voodoo Death,1 a foundational article, based
Dead is the most-watched series on cable TV.
on ethnographic sources, regarding the physio
The same occurs in Spain. Is this a further ex-
logical mechanisms related to voodoo death.
ample of viewers preference for action and vio-
lence over complex and convoluted storylines? The living dead and psychosomatic medicine
Perhaps, but the truth is that the series tries to were broached in a centuries-old debate on the
go beyond the horror-series stereotype, and aims capacity of witchcraft and spellcasting to sum-
to analyze how far human beings will go when mon and condemn souls to wander the earth.
struggling to survive. The Walking Dead has not An example is the myth of the Santa Compaa
just earned viewers applause, but also garnered (Holy Company), a procession of the dead that
academic interest. Theses, monographs and winds through the woods of Galicia, prompting
dozens of articles in science journals focus on villagers to lock their doors after sunset and erect
the walking dead and its groups of survivors. Un- cruceiros (calvary crosses) at crossroads to ex-
der the umbrella of such success, zombies and orcise them.
the undead are once again clamoring for atten- Tourneur managed to conjure the mystery of
tion, since The Walking Dead is another link in the the border between life and death, the intimate
chain of audiovisual products focused on such relation between reality and psychotherapy, by
figures. In these pages, we highlight some of the employing visual ellipsis prodigiously and ele
cinematic milestones related to the living dead, gantly regarding a beautiful undead woman. He
their close relationship to the collective imaginary knew how to visually represent the mystery of the
on epidemics and how this tradition crystallizes in Santera religion in a clinic for psycho-neurotic
the series, along with its peculiarities. disorders. Prior to and even more ably than in

Written by Walter B. Cannon in the magazine American Anthropologist, in 1942.

The Walking Dead and the Collective Imaginary on Epidemics

Ingmar Bergmans The Magician (1958), he de- lently invaded the cities, carrying the Black Death.
picted the contrast between the beliefs and cul- The Flying Dutchman, a ghost ship, still haunts a
tural practices of magic, and medical rationalism. collective imaginary that builds on the experience
This is because, in contrast to the Swedish direc- of sailing ships adrift which, an epidemic having
tor, he speaks of the present, not of a figure of killed both crew and passengers, roam the seas
the past. at the mercy of wind and wave endlessly seek-
The undead, lost and wandering souls, form ing peace. A barquentine is likewise the improb-
part of an ancient collective cultural imaginary, able mode of transport in the 1940s by which the
which drew new life from the romanticism of protagonist of I Walked with a Zombie reaches
the Brothers Grimm and folklorists, Washington his destination in the British West Indies (a visual
Irvings Tales of the Alhambra (1832), many of homage to Murnau?). This ship, however, is not
Edgar Allan Poes short stories, Gustavo Adolfo plagued by any rats, undead or epidemic, since
Bcquers Leyendas (18541864) and the recov- the witchcraft is on the island and forms part of
ery of Oriental folklore.2 Bishop (2010) considers, a world that clashes with the rationalism of the
erroneously, that zombies in film correspond to clinics.
highly idiosyncratic aspects of twentieth-century
American culture. He does not take into account
A cinematography of wandering souls
the genealogy of the undead in European litera-
ture and film. Spirits that become flesh populate Murnaus and Tourneurs visual magic has per-
stories retold beside the hearth, while the wind haps faded over time and from the tapestries of
moans outside and rain batters the shutters. At memory. After the Second World War, film recov-
the height of positivism, Allan Kardec (18041869) ered Dracula the vampire, but not zombies. It is
wished to bring them to life. Clustered around tempting to imagine that Tourneur raised the bar
the lamp, believers invoked their presence, drafts so high in terms of sophistication and narrative el-
without a source wafted the curtains, and the liv- egance that later creators dared not follow in his
ing were carried off into trance by spirits. In The tracks. Yet the British film company Hammer gen-
Canterville Ghost (1887), Oscar Wilde wrote ironi- erated extraordinary interest in Draculas, Chris-
cally about Americans who made fun of British topher Lee playing the role, in which he explored
ghosts, and in Dracula (1897), Bram Stoker invit- the vampires sexual and erotic dimensions. Be-
ed the undead into Victorian drawing rooms as if tween Murnaus neo-Romanticism, Nosferatus
they were an epidemic vector. Yet filmic epiphany monstrousness and Christopher Lees Gothic yet
of the undead should be attributed to Nosfera- very British elegance, there was, however, narra-
tu (1922), by F.W. Murnau. It is a palimpsest of tive and visual continuity. And so it was, until in the
Bram Stokers work, and an extraordinary visual year of May 1968, with Vietnam escalating and
recreation blending expressionism and neo-Ro- race riots erupting in Pittsburgh following Martin
manticism. Nosferatu emerges from his coffin in Luther Kings assassination, an unknown film-
the bilges of a barquentine swarming with rats, maker named George R. Romero directed Night
on which no souls remain alive, to alight in a ro- of the Living Dead (1968). In the midst of the Cold
mantic Bremen. Rats, sailing ships, quarantine, War, decaying corpses return to life, stepping, like
epidemics... After the First World War, the deadly Lazarus, from shattered tombs in all their rotting
Spanish flu revived a fear of the plague in the glory. For reasons never fully explained, they make
western cultural imagination, a scenario in which the same gestures as Nosferatu, and feed on the
rats arrived by sea in the holds of ships and si- living until their brains are destroyed.

 afcadio Hearn (1904) saw this in Japanese culture. Some of his stories evolved into a film masterpiece on the un-
dead, the episode The Woman of the Snow in the marvelous Kwaidan (literally strange stories, 1964), by Masaki
Kobayashi (1964).

Notebooks of the Esteve Foundation N 42

Medicine in Television Series

If, in Nosferatu, the narrative makes a link be- curse turned them into waxy damsels or anemic
tween the plague and vampires, playing on the youths, Romeros walking dead are rotting Laza-
cultural imaginary, epidemics were not perceived rus types who take over the world.3
as a threat in 1968, but the apocalyptic context Now enthroned in the pantheon of popular
of radioactivity certainly was. Draculas elegance, culture thanks to Romeros genius and the ev-
midway between bourgeois and aristocratic, from eryday life he portrayed to depict the tragedy,
Bela Lugosi to Christopher Lee, and his capac- the undead have become an icon of postmod-
ity for manipulating social relations to reaffirm his ern society. That society has also digested the
own power and feed on the blood of the living, phenomenon, once more imbuing it with mean-
is absent from these putrefying, twisted, bleed- ing and, to a certain extent, shedding any crit
ing and dirty corpses that move by mere instinct. ical dimension it had of late-twentieth-century
Yet precedents exist, such as representations of north-American society. Yet many studies on the
Mr.Hyde in the successive film versions of Ste- subject reference specific aspects of the political
vensons novel. However, Hyde is our hidden discourse inherent in zombie film and TV. Night
ego, lacking feeling, cold and calculating, and of the Living Dead became a cult film and the
violent to boot, while the walking dead are beasts departure point for a genre that would overflow
in a strict sense. They move due to an electrical the borders of the film medium to invade graphic
instinct and only respond to simple stimuli such novels, including that which inspired the series
as noise, or the expectation of flesh. we are looking at, The Walking Dead, in the early
Night of the Living Dead could be classed twenty-first century.
as a docudrama about the first night of the
apocalypse, perhaps not too far removed from
On plagues, epidemics
the Biblical tale, but with millions of Lazarus fig-
and other calamities
ures wandering the earth. The story, which falls
within the context of fears that were reflected Epidemics, since the metaphoric reference to the
in US cinematography in the 1950s, highlights plague in Nosferatu, have been a subject less
the human species practical capability for sur- visited than others in the entirety of the cinema-
vival and its absolute dependence on technology. tography focused on the field of health, disease
Meanwhile, it claims as its own the phrase homo and healthcare in the twentieth century. Neverthe-
homini lupus (A man is a wolf to another man) less, we can highlight several films for their quality
when trying to survive among supposed equals, or their success. Here are various examples. Elia
in spite of the contention strategies of the states Kazans Panic in the Streets (1950) is nowadays
armed forces, which quickly break down into the an interesting realist tale, likewise packed with
violation of any notion of right and the total domi- metaphors and symbolism, bearing substantial
nance of violence. ethnographic and historical value. It traces an
Night of the Living Dead, filmed in dirty, epidemiological investigation into a classic out-
gloomy and sinister black and white, when color break in the port of New Orleans, originating from
was marching toward absolute hegemony of the a human vector. Almost half a century later, Out-
medium, is a cultural product of the Cold War. break (1995) reflects the technical response and
Here, the plagues etiology is not taken into con- intervention protocols concerning an outbreak of
sideration, though the living, cannibalized by the hemorrhagic fever of a viral origin entering the US,
dead, once dead, join their predators. If Victo- a theme covered with more solvency in Contagion
rian vampires abducted their victims and the (2011). In Panic in the Streets (1950), the refer-

 omeros fable has several sequels, in which the filmmaker used the walking dead to speak of survival in a capitalist
society, such as in Return of the Living Dead (1978), where the living are entrapped in those cathedrals of consum
erism, sprawling north-American shopping malls.

The Walking Dead and the Collective Imaginary on Epidemics

ence point is the plague and prevention; in the via the emergence of the figure of the undead.
other two, the emphasis is on capacity for techno- It is not by chance that Blade and The Walking
logical response to epidemic outbreaks. Conta- Dead have evolved from two graphic novels in
gion also stresses the importance of investigation which viral infection is the major cause of the
in the streets, an aspect that was portrayed in the apocalypse, in a context in which the threat of
TV production And the Band Played On (1993), biological war generated after 9/11 has fed into
centered on investigations leading to the discov- popular fears.
ery of the human immunodeficiency virus (HIV). The three film franchises of Blade (1998) and
Before Outbreak, and in the context of irra- its sequel, Blade: the Series (2006), stay within the
tional fears of the Cold War with its epidemics classic blueprint of the vampire genre, though with
of UFO sightings, to which Spanish weekly El more gore, a lot more sex and a production design
Caso paid riveted attention, Robert Wises The that systematically employs the present world as a
Andromeda Strain (1971), seemingly an exercise referent for the underworld of the vampire minor-
in science fiction so as to remain politically cor- ity. A recent trend, illustrated mainly by various TV
rect, highlighted the problem of biological weap- series, is to treat the living dead and vampires as
ons and their more than probable confinement a minority who manage to coexist with humans.
to installations on the margins of citizens view This is the case of True Blood (20082014), Being
and control. Its most interesting aspect is its re- Human (2008), The Vampire Diaries (2009) and
alistic portrayal of operational protocols in what its spin-off The Originals (2013), among others,
were probably the first laboratories specialized in but especially the caustic British miniseries In the
studying uncontrolled epidemic outbreaks. At the Flesh (2013). This BBC series accepts the hypoth-
time of screening, no collective awareness exist- esis of apocalyptic viral infection, which it defines
ed, much less any moral panic (Garland, 2008), ironically as partially dead syndrome (PDS) en-
regarding any epidemic that was not bacterial in abling, on one hand, an interesting treatment on
nature. That same year saw a minor cholera out- managing a chronic disease, and on the other, a
break in Spain. In the quarter-century between highly critical dissertation on the tolerance of dif-
The Andromeda Strain and Outbreak, epidemic ference in current British society.
risk from a virus became a more patent threat,
albeit in limited circles, such as in the cases of the
Cannibal undead and human assassins
Marburg and Ebola viruses. This is a new model
for limiting and curtailing risks, based on violent When the channel AMC announced the screen-
outbreaks, but modeled by political and rhetori- ing of The Walking Dead, critics were aware that
cal discourses on security. Despite its early con- among the series creators were Frank Darabont,
finement to specific behaviors and risk groups, considered one of Hollywoods best scriptwrit-
HIV/AIDS signified the definitive awareness-rais- ers; Greg Nicotero, the prestigious special effects
ing on the coupling of epidemics and globaliza- creator,4 and Gale Anne Hurd, a successful pro-
tion, stoked even further in recent years by alerts ducer. Another guarantee was that the idea and
regarding bird flu, influenza A virus (N1H1) and scripts originated from the authors of the homon-
the latest Ebola virus outbreak. ymous graphic novel created by Robert Kirkman.
Yet apart from these films in which collective This roll call meant the series would likely have a
terror arises from the outbreak of disease, the certain quality within a television panorama that
idea of the apocalypse associated to an epidemic had changed profoundly in recent years. The se-
is receiving unexpected film and TV development ries has introduced new narrative languages in

 icoteros first large project was, in fact, on a George G. Romero film, Day of the Dead (1985). He is considered one
of the heirs of the tradition of creators of strange creatures, like Ray Harryhausen and especially Tom Savini, who
he trained with.

Notebooks of the Esteve Foundation N 42

Medicine in Television Series

relation to film, and what is more important, ones Although in the classic representation of
accessible to world audiences through the Inter- the zombie in The Walking Dead, the referents
net, allowing broad swathes of viewers access to the Paris-based theater of Grand Guignol
to the production of genre that, in film, would be (18971962) are fairly clear, the series aesthetic,
more on the fringe. in faded, slightly dirty tones, under gloomy skies,
The Walking Deads genealogy no doubt in- tries to reinforce, at least in terms of landscape,
cludes both Night of the Living Dead and 28 Days a certain documentary air. This is probably be-
Later (2002), but with nuances. In Night of the cause it is dealing with landscape. If in Night of
Living Dead, the cause of the deads resurrection the Living Dead the protagonists are the living
is never clarified, but they are dead, while in 28 dead, this is not the case of 28 Days Later or The
Days Later and in The Walking Dead the scripts Walking Dead.
mention an infection of a more viral than bacterial According to Garca Novo (1989; 89) the
nature, which means that the zombies are not re- term epidemiai had been interpreted like visits
suscitated but transformed, as with the idea of overseas, though he emphasizes that the title
Partially Dead Syndrome in In the Flesh. Neverthe- probably refers to being caught unprepared.
less, representation of the undead in The Walking Both definitions correspond very exactly to the
Dead uses referents such as Night of the Living fundamental themes in The Walking Dead. On
Dead rather than the image of a waxy adolescent one hand, the crisis the epidemic brings, in this
as in the British series (closer to the adolescent case in its actual meaning, is skillfully narrated
vampires in The Twilight Saga, 20082012). The in the first episode. The plague surprises the
series dramaturgy is therefore far removed from protagonist, Rick Grimes, while he is convales-
the idea of a chronic illness, whether degenerative cent in hospital, and from this unforeseen situ-
or not, but rather placed in a setting much closer ation the plot arc for the first season develops,
to the original model of the resuscitated corpse, focused on the search for a vaccine and cure,
matching a culture that systematically practices leading them unsuccessfully to the Center for
thanatopraxis and embalming before burial. Disease Control in Atlanta. This first season, in
Even so, by opting for transmission through reality a six-episode miniseries, is the most illu-
biting, it harks back not only to vampires, but also minating of all, because it illustrates the idea of
to the cultural imaginary of rabies contagion, a the crisis, the unimaginable and, meanwhile, the
topic that had significant cultural impact in the hopeful itinerary of the quest for health of the
early twentieth century. It also evokes dementia- founding group.
tion leading to animalization, whose most obvi- From the second season onward, the tone
ous references in history are those associated changes, on the assumption it is an out-of-con-
with late-stage syphilis infection, or with alcohol- trol epidemic and that the forces that might have
ism and epilepsy. However, the series goes be- halted it have failed, leaving no alternative. In view
yond this, since it deals with a type of clinical de- of the infections characteristics, clinical or ther-
cerebration, which governs maintenance of the apeutic solutions are going to involve forceful
most primitive phylogenetic structures in homo responses. For this reason, in the third season,
sapiens and which, curiously, is cured by physi- Carol applies euthanasia and amputates a leg of
cally decerebrating the zombie. one of the members of the group to stop the gan-
The path followed by The Walking Dead grene that has developed from an infected bite.
therefore clashes with the current evolution of At the time of writing in its fourth season, the duo
the vampire genre, centering on post-adolescent made up of soldier Abraham Ford and Dr. Porter
bodies, or on versions that accentuate virility are offered as a hope for a cure, an argument for
to a greater or lesser degree, such as Wesley survival.
Snipes in the saga Blade, or Amazons like Le- It is not the apocalypse caused by the par-
onor Varela in Blade II, far removed from the clas- tially dead and the search for a cure which have
sic manly style of Christopher Lees Dracula. been key to the popular and academic success

The Walking Dead and the Collective Imaginary on Epidemics

of this series, but the manner of portraying the any kind of pathology, but to the deployment of
development of those fighting against the un- skills and the testing of these in order to resist.
dead. In most apocalyptic series (and in films The root difference is in that it is not necessar-
such as The Road, an adaptation of the novel ily the apparently strong who survive, a nuclear
by Cormac McCarthy), as well as in the series argument when designing the protagonists of
we are looking at, the good guys, that is, the some series (in the case concerning us, Rick),
survivors of the human race who are fighting to but those who know how best to adapt to daily
save that heritage, evolve from perspectives we survival without necessarily being leaders or he-
might call democratic American toward radi- roes. The best is not the one who dies, but the
cally totalitarian and neo-fascist attitudes. Their one who reaches the end. Yet this character is
view of the undead is fundamentally racist, with a distrustful, given that he comes to know what he
seemingly unstoppable crescendo of violence. All has done. Allu does not base her arguments
of this leads to a collapse of values, generally jus- mainstay on a moral Christian model, a stance
tified as a form of safeguarding family values, in that would be overwhelmingly present in the
terms that are difficult to comprehend in Europe. heroes ideology and in the idea of redemption
In The Walking Dead, the characters especially through death, another common theme in series
Rick Grimes evolve toward often clinical levels of scripts. To a certain extent, surviving means go-
paranoia. This could also be interpreted as what ing unnoticed, but in The Walking Dead, if you do
is known as a psychic epidemic, taking on ele- so, you do not survive.
ments of classic descriptions of folie deux, or The survival narratives that appear in the se-
shared psychosis, as seems evident in Ricks and ries signify a marked contrast. So, in some char-
Carols attitudes in the fifth season. So not only acters makeup, especially in the development
do we have the cannibal undead but also the of the protagonist Rick Grimes and in the moral
transformation of the good guys into a band of coolness of his adolescent son, Carl Grimes,
serial killers whose paranoia urges them even to both appear as heroes, though often ruthless.
kill each other. So the play between the hellrep- Compared to them, Carols logic and common
resented by the other and ones internal hell is sense are much more closely aligned to the sur-
one of the more fascinating keys to the series. vival model Allu describes. At a certain point,
The storyline resulting from this type of psy- she is forced to execute a girl who has become
chic epidemic highlights the massive use of mili- mad, just because she has gone mad, and un-
tary technology, emphasizing the high degree of der the circumstances, she endangers the other
identification of broad sectors of North American group members. Carols character is perhaps the
culture with the fetishism of firearms, including most interesting. She represents a survival praxis
the crossbow. It appears this scenario is often based on systematic observation of the facts and
presented cynically: surviving at all costs as a on rational decision-making in extreme circum-
payoff for literally becoming killers, or, if you pre- stances. This leads to her being banished for ap-
fer, modern-day gunslingers in a new film genre plying a measure that was inevitable in a situation
that has infused the old forms of the classic west- without alternatives. The contrast between Rick
ern with fresh blood. and Carol, carefully managed by the scriptwrit-
Marta Allu (2008) has written a great deal ers, also links highly idiosyncratic US cultural
about survival in terms that directly contradicts contexts, where the weight of moral and religious
its mode of representation in The Walking Dead. discourse in the media underlines much of the
The plot line of the series, based on concentra- scriptwriters work.
tionary literature and on a careful ethnography, is
that survival is the product of social and cultural
Wild men in the looking glass
learnings, even in situations of maximum vio-
lence, such as surviving in extermination camps. Two decades ago, the anthropologist Roger
Survival, defined as a practice, does not lead to Bartra (1992) published Wild Men in the Look-

Notebooks of the Esteve Foundation N 42

Medicine in Television Series

ing Glass. The Mythic Origins of European Oth- and the doctor (once again, the hope of a cure)
erness, a compelling study on the imaginary of to their destination.
otherness in Medieval Europe, in which the end- We do not know how the series will evolve
less greenwoods hid chimera and mysterious in future. The latest season has focused mainly
beings, wild men and women, and monstrous on the almost impossible rebuilding of civility for
creatures. In the vastness of the Medieval forest, those who have been stripped of their theoreti-
cleared land for farming and cities were spaces cal humanity on their journey toward survival. On
of light. In The Walking Dead in contrast to the their odyssey through nature, their paranoia and
intensely urban 28 Days Later, and with the ex- profound distrust in human beings themselves
ception of the first season woods, fields and have begun to spread like another epidemic.
copses straddling abandoned highways and rail- This situation stems partly from their incapacity
way lines are the setting for the walking dead. to manage resources other than those of tech-
Their transformation turns them into beings who nological society. They are not country people;
live in nature, occasionally shut into houses or they depend on what remains in supermarkets.
warehouses they do not know how to escape Even domestic animals no longer exist. Yet there
from, and they walk day and night in search is always gas for vehicles, and ammo to load the
of what, we suppose, is their food. Instead of magazines of their assault rifles.
deserted cities, fields of undead. Replacing the
idea of quarantine, the exclusion of the savages,
or shutting the pathological into institutions, the
survivors, the sane in The Walking Dead, must It is not a foregone conclusion that The Walking
live enclosed. They live barricaded in refuges, Dead, despite many filmic qualities, will join that
in small redoubts, where they can dig in, con- cult group of series of the last decade. There is
demned to foray out to replenish their water a lot of competition. Academic production on
supply or stock up on food, moving outdoors the series is in itself surprising, given that most
at risk, like the Spanish troops holed up in army of the elements it uses stem from a well-founded
blockhouses in the Battle of Annual, surrounded cultural genealogy, already dealt with in film, the
by the hordes of the Rif. The world is no longer roots of which delve at least as deep as Euro
human: nature, the undead included, have taken pean Medieval cultures. Even the plague, as
over, and as if it were a new Middle Ages, the ref- such, is directly linked to the imaginary of mod-
uges are surrounded by theoretically impregna- ern and Medieval plagues, and the undead, to
ble walls, or, in the greatest of paradoxes, prison the living dead that populate folklore. Neverthe-
and its prisoners become a space of freedom. less, millions of viewers worldwide avidly watch
The play of contrasts between the dangers the episodes as if zombies were a novelty. Such
ofthe epidemic that govern the natural world and articles adventure numerous hypotheses, but
the need to build spaces of exclusion is interest- perhaps it is simply the it works factor of au-
ing from a comparative viewpoint. The typology diovisual products such a hard factor to define.
is suggestive in itself: in the second season, the
farmstead; in the third, the free prison compared
to the Governors enslaved community, the rail-
way station and its warehouses; and in the latest Aguado Pelez D. Imaginario postapocalptico en las
series de televisin norteamericanas tras el 11S: anlisis
season, urban utopia, with links to the France- de The Walking Dead (AMC, 2010-). In: Espacios de co-
Ville in Jules Vernes The Begums Fortune municacin: IV Congreso Internacional de la Asociacin
(1879), is seen as hygienic, as a blueprint for civil Espaola de Investigacin en Comunicacin. Bilbao:
society which the group of barbarous survivors Asociacin Espaola de Investigacin de la Comunica-
cin; 2013. p. 1091.
who accompany Rick and Carol must assimilate. Allu M. La piel curtida. Barcelona, Bellaterra; 2008.
They reach it through a kind of initiatory journey Bartra R. El salvaje en el espejo. UNAM, Ediciones ERA;
that is the result of choosing to take the sergeant 1992.

The Walking Dead and the Collective Imaginary on Epidemics

Berk I. The Walking Dead as a critique of American de- Lavia D. Epidemias y pandemias fantsticas en el cine.
mocracy. CineAction. 2015; 95. Cinefania, March 2009. (Consulted on 13 May 2014.)
Bishop KW. Dead man still walking: a critical investiga- Available at: rroruniversal/
tion into the rise and fall And rise of zombie cinema. index.php?id=188
Arizona: University of Arizona; 2009. Ph. D. Dissertation. Nuckolls C. The Walking Dead as conservative cultu-
Bishop KW. Dead man still walking. Journal of Popular ral critique. Journal for Cultural and Religious Theory.
Film and Television. 2009;37:16-25. 2014;13:102-10.
Bishop KW. American zombie gothic: the rise and fall Pirie D, Ibeas Delgado JM. El vampiro en el cine. Barce-
(and rise) of the walking dead in popular culture. Jeffer- lona: Crculo de Lectores; 1977.
son, NC: McFarland; 2010. Porras-Gallo MI, Davis RA. The Spanish influenza pan-
Carrasco Asenjo M, Jimeno Maestro J. La epidemia de demic of 1918-1919. Rochester: University of Roches-
clera de 1971. Negar la realidad. Revista de Adminis- ter Press; 2014.
tracin Sanitaria Siglo XXI. 2006;4:583-97. Pulliam JM, Fonseca AJ. Encyclopedia of the Zombie.
Cocarla S. Reclaiming public spaces through the perfor- The Walking Dead in popular culture and myth. Santa
mance of the zombie walk. In: Smith R. Braaaiiinnnsss! Brbara, CA: ABC-CLIO; 2014.
From academics to zombies. Ottawa: University of Rawlings R. Survivors and victims: gothic feminism, de-
Ottawa Press; 2011. construction and colonialism in I Walked with a Zom-
Garca Novo E. Introduccin a los libros de epidemias. bie. Meaghan Walsh Issues in Cinema Theory; 2008
In: Tratados Hipocrticos V. Epidemias. Translation, intro- (Spring).
ductions and notes by Alicia Esteban, Elsa Garca Novo Redfern N, Steiger B. The zombie book: the encyclo-
and Beatriz Cabellos. Madrid: Gredos; 1989. p. 7-19. pedia of the living dead. Canton, MI: Ink Visible Press;
Garland D. On the concept of moral panic. Crime, Me- 2015.
dia, Culture. 2008;4:9-30. Roche D. Resisting bodies: power crisis/meaning crisis
Gubern R, Prat Cars J. Las races del miedo: antro- in the zombie film from 1932 to today. Revue Interdis-
pologa del cine de terror. Barcelona: Tusquets; 1979. ciplinaire Textes & contextes, No. 6 (2011). Discours
Hand RJ, Wilson M. Grand-Guignol. The French theatre autoritaires et rsistances aux XXe et XXIe siecles.
of horror. Exeter: University of Exeter Press; 2002. 28 November 2011. (Consulted on 13 May 2015.) Avai-
Hand RJ, Wilson M. Londons Grand Guignol and the lable at:
theatre of horror. Exeter: University of Exeter Press; tes/document.php?id=1355
2007. Tabernero Holgado C, Perdiguero Gil E. El cine y las
Hand RJ, Wilson M. Performing Grand-Guignol. Playing dimensiones colectivas de la enfermedad. Revista Me-
the theatre of horror. Exeter: University of Exeter Press; dicina y Cine. 2011;7:44-53.
2015. Tabernero C, Perdiguero-Gil E. Cine y medicina: im-
Hearn L. Japan. An attempt of interpretation. New York: genes sobre la salud y la enfermedad. In: Brigidi S, edi-
Macmillan; 1904. tor. Cultura, salud y cine. Tarragona: Publicacions URV;
Lavia D. Epidemias y pandemias en el cine. Quintadi- 2015.
mension, March 2009. (Consulted on 13 May 2014.) Tratados Hipocrticos V. Epidemias. Translation, intro-
Available at: http://www.quintadimension. com/televi- ductions and notes by Alicia Esteban, Elsa Garca Novo
cio/index.php?id=243 and Beatriz Cabellos. Madrid: Gredos; 1989.

Notebooks of the Esteve Foundation N 42

Angels in America, The Normal Heart

and Positius: HIV/AIDS in TV Series

Aina Clotet and Marc Clotet, under the supervision of Bonaventura Clotet

Although the human immunodeficiency virus (HIV) and AIDS have been explored in TV series of a gay
bent such as Queer as Folk (Channel 4, Showtime) and Looking (HBO), the fact is that, to date, they have
only been examined more deeply in shorter formats. Such is the case with Angels in America, a miniseries
produced by HBO in 2003, which narrates the spread of the epidemic in the midst of the Reagan era. It
is also true of the more recent The Normal Heart (2014), also by HBO, a movie for TV that travels a little
further back in time to describe the early years of confusion surrounding an unknown virus. Yet rarely has
this infection been dealt with on television away from the gay stigma. One example can be found in the
TV film Positius (2007) by Catalan channel TV3, starring two heterosexual women infected by the disease.

How does a society react to the threat of a new known about what was initially branded the gay
disease? And if that disease apparently only af- cancer, whose cause was a total mystery. The
fects a specific collective? How long would a gov- infection was only recognized when the patient
ernment take to respond? How would it manage developed Kaposis sarcoma, a cancer caused
the fear of the unknown? And once known, how by a virus that produces purplish lesions under
does the stigma develop? How are your world the skin, in the lymph nodes and other parts of
and your surroundings transformed? Do your pri- the body.
orities in life change? To answer these questions Set between 1981 and 1984, the TV movie
that arise with the human immunodeficiency virus relates how society, the government (President
(HIV), we will analyze the North American fictions Reagan having recently entered the White House)
Angels in America and The Normal Heart, and and the US medical sector decided to ignore the
the Catalan production Positius the first, a mini- early spread of the epidemic. The film centers on
series and the other two, TV movies. a group of gay activists who embark on a cam-
In both American productions, the stigma paign to call attention to this infection which ap-
caused by HIV is mainly told through male pro- parently only affects gay men. The scriptwriter
tagonists, men who have sex with men (MSM), Larry Kramer used his own experience in New
who, as well as fighting the disease, must also York in the early 1980s to write this TV film that
confront the social rejection generated by a dis- won several awards in 2014, among them an
ease associated with sexual licentiousness and Emmy for Outstanding Television Movie.
homosexuality. In contrast, Positius portrays two The miniseries Angels in America was devel-
heterosexual women infected by the disease. We oped shortly afterwards, in 1985. Reagan was
will start by examining the American productions, still in the White House, but AIDS was no longer
since they occur chronologically in time, and last- an unknown word, albeit highly stigmatized. The
ly look at how the Catalan fiction has dealt with miniseries focuses on the story of five people (four
this terrible epidemic. men and one woman) affected by the disease in
The Normal Heart portrays the early years one way or another. The four men practice sex
of AIDS, a period in which almost nothing was with other men, though one of them, Republican

Angels in America, The Normal Heart and Positius: HIV/AIDS in TV Series

and Mormon, is married with a wife. The pro- in the hallway, they tell him that hospital staff will
duction earned eleven Emmys and five Golden not deliver the food to the rooms for fear of get-
Globes, in each case including Outstanding Tele- ting infected, the same reason the maintenance
vision Movie and Best Miniseries, respectively. technician refuses to fix one patients TV set.

Diseases from which Discovery of the virus that causes

the protagonists suffer the disease
Neither fiction deeply examines medical treat- In Angels in America, set in 1985, Cohns doc-
ment of the infection, though Angels in America is tor can give his patient a more detailed expla-
somewhat more explicit on symptoms. Two of its nation than Doctor Brookner can. By then, the
lead characters, Prior Walter (Justin Kirk) and Lou virus causing the infection had been identified
(Ben Shenkman), are a couple until the former (in 1983, by scientists at Pariss Institut Pasteur),
confesses he has caught HIV. When Lou ques- and it was known that those infected underwent
tions the accuracy of the diagnosis, Prior Walter a drastic decrease in their white blood cell count.
lists his symptoms: Kaposis sarcoma, the pres- The series, however, does not accurately re-
ence of protein in his urine (from the effect of HIV flectthe information that was known, as reflected
on his kidneys), diarrhea and blood in his feces. in the explanation the doctor gives Cohn after
The other character infected is Roy Cohn
telling him his diagnosis:
(Al Pacino), a highly influential Republican who
Nobody knows what causes it. [This state-
hides his homosexuality to stay in power. Cohn
ment is false because HIV had already been
visits his doctor with a clinical profile of lesions
identified.] And nobody knows how to cure it.
from Kaposis sarcoma, inflammation of glands in
The best theory is that we blame a retrovirus,
his neck, groin and armpits, oral candidiasis and
the human immunodeficiency virus. Its presence
fungus under his nails.
is made known to us by the useless antibodies
which appear in reaction to its entrance into the
Ignorance of the transmission routes bloodstream through a cut, or an orifice. The anti-
bodies are powerless to protect the body against
Meanwhile The Normal Heart bases its medical
it. Why? We dont know. The bodys immune sys-
viewpoint on the relationship that its main char-
tem ceases to function. [It would be more correct
acter, Ned Weeks (Mark Ruffalo), establishes with
Doctor Emma Brookner (Julia Roberts). Brookner to say it gets weaker.] Sometimes the body even
uses a wheelchair, having suffered from polio as attacks itself. [In fact it is the virus that weakens
a girl. For this reason she empathizes with the the immune system.] At any rate, its left open to
impotence her patients feel. However, the doc- a whole horror house of infections from microbes
tor is an exception in the TV movie. At a time it usually defends against. [ ] We think it may
when the immune system was a real unknown also be able to slip past the blood-brain barri-
and the transmission routes of the disease were er into the brain. Which is, of course, very bad
unknown, many doctors refused to see patients news. Its fatal in we dont know what percent of
because of a fear of contagion. They turned us people with suppressed immune responses. [ ... ]
away from four emergency rooms, says a friend The NlH in Bethesda has a new drug called AZT
of Weeks one night when he turns up at his home with a two-year waiting list that not even I can get
with his boyfriend passed out in his arms. you onto.
In another scene, Weeks visits a hospital
where several patients have been hospitalized
Prevention and transmission routes
because of the gay cancer, and where numer-
ous posters warn him that he is entering a conta- Do you think that this cancer is sexually trans-
gious area. When he asks about the lunch trays mitted?. I think it is, yes. Can I prove it yet? No.

Notebooks of the Esteve Foundation N 42

Medicine in Television Series

Through this conversation in The Normal Heart, doctors refuse to examine him for the cause of
Doctor Brookner asks Weeks, a renowned and death. Because there is no death certificate, the
polemic writer, to try to convince the gay commu- undertakers and police will not come, so the de-
nity to stop having unprotected sexual relations. ceaseds boyfriend and mother pay 50 dollars to
His efforts with a generation blinded by the ide- a hospital attendant to remove the corpse from
ology of sexual liberation, one which took them the hospital and they transport it in their own car.
so many years of struggle to attain, are in vain. Once at the funeral home, they are forced to pay
The entire gay political movement is fucking, he 3000 dollars to collect the deceaseds ashes.
says. Guys will become frightened of sex. They In Angels in America, social acceptance of the
will lose our self-respect, that we fought very, very disease has progressed very little. When the doc-
hard for. Brookners discourse, moreover, loses tor tells Cohn his diagnosis, they have the follow-
force from the moment she cannot even assert ing conversation:
that the infection is sexually transmitted.
COHN. This disease
Later it was shown that infection was con-
DOCTOR. Syndrome.
tracted through blood, sexual relations and
COHN. Whatever. It afflicts mostly homosex
mothers milk. Drug addicts, from sharing used
uals and drug addicts.
syringes, hemophiliacs, through contaminated
DOCTOR. Mostly. Hemophiliacs are also at risk.
blood transfusions, and MSM, due to the nature
[ ... ]
of their sexual relations, were the first population
COHN. And what is my diagnosis, Henry?
groups affected. However, the infection was also
DOCTOR. You have AlDS, Roy.
transmitted in heterosexual relations. In fact, at
COHN. No, Henry, no. AlDS is what homo-
one point in The Normal Heart, Brookner states
sexuals have. I have liver cancer.
that Women have been discovered to have it in
Africa, where it is clearly transmitted heterosexu- So Cohn is stating that the version he will
ally. make public regarding his state of health is that
he has liver cancer, since he cannot admit he is
suffering from a disease attributed to homosex
The stigma
uals. If he did, he fears he would lose all his pow-
Social rejection is doubtless the most difficult hur- er and influence.
dle to overcome for characters in both fictions.
Nobody knows where the disease comes from,
A lack of support
not even the homosexual community itself, which
from the public authorities
in The Normal Heart even points to a possible
conspiracy to murder all gay men, or ques- The Normal Heart also shows the fierce struggle
tions monogamy as a possible cause of infec- the activists take on to achieve social and finan-
tion. Outside of their community, things are much cial support from the public authorities. For ex-
worse. They have problems even hiring a venue ample, it took the GMHC 14 months to gain a
for their association, the Gay Mens Health Cri- meeting with the mayor of New York, and in the
sis (GMHC), and one of their members is warned end, he did not show up to the meeting. When,
that, if it came out that he belongs to it, his job at some time later, they receive financing from the
the Department of Health would be at risk. council, they are given strict instructions not to
The toughest situation, however, arises when say where it came from. The justification that
a friend of the protagonists travels to Phoenix Weeks receives from the council is: I dont think
(Arizona) with his boyfriend to visit his mother be- we can afford to make so many enemies.
fore death. The pilot of the plane refuses to take From the White House, the only attention they
off when he discovers there is an AIDS sufferer receive is from one of the presidents advisers
on board. When, thanks to another pilot, they fi- who, once in the meeting, makes it clear that his
nally arrive, the young man dies and the hospital sole interest in the meeting was to find out per-

Angels in America, The Normal Heart and Positius: HIV/AIDS in TV Series

sonally whether the infection can be transmitted on the diseases social aspect. One of its objec-
between men and women. Weeks, beaten, can tives was, precisely, to destigmatize the disease
only answer that, though he cannot guarantee it, and distance it from prejudice.
in theory, the affliction seems only to affect the Its main characters are two women who are
homosexual community. carriers of the virus, but very different to each
For her part, Doctor Brookner also maintains other. Vero (Montse Germn) is a well-to-do
her personal crusade to ensure that study of the graduate of around 38, who seems to have nor-
disease receives government funding. She ac- malized her illness among her friends and inner
cuses the government of spending more mon- circle. She does not tell everyone she meets, but
ey on investigating seven deaths from Tylenol neither is she ashamed of her status, and she
(a drug whose active ingredient is paracetamol) seems to lead a happy life. In contrast, Gloria
than on HIV, and of refusing to cooperate with the (Mercedes Sampietro) is a woman over 60, from
French to steal a Nobel Prize. a low socio-cultural level, who keeps the disease
The allusion to the dispute for the Nobel Prize an absolute secret. She lives with her son Rober
is not anecdotal. The virus was isolated for the (Roger Coma), who is likewise unaware of his
first time in 1983, by investigators at the Insti- mothers status. Both women only meet the odd
tut Pasteur in Pars. Virologist Luc Montagniers time during the film, in hospital, and in the NGO
team identified a new class of human retrovirus, where they both seek shelter.
and indicated it was the cause of AIDS. Mon- The TV movie starts with a birthday celebra-
tagnier sent samples to the American virologist tion, bringing together ex-students from Veros
Robert C. Gallo, who confirmed that HIV was university days after 20 years. This is where Vero
the cause of AIDS, and helped develop the meets Xavier (Pau Dur) again, and everything
blood test to detect it. Nevertheless, the 2008 she thought she had under control comes tum-
Nobel Prize for Medicine was awarded to Mon- bling down. Xavier has just separated from his
tagnier and the French virologist Franoise wife and has a son, but the passion and love
Barr-Sinoussi. Gallo had confirmed the link of between them reignites immediately. In their first
HIV with the disease, but the French were the sexual encounter, Vero does not tell him she is
first to isolate the virus. HIV-positive because she thinks that, since they
The Normal Heart finishes in 1984. The final use protection, it is unnecessary. We then see
credits explain that Reagan did not mention AIDS how, on successive occasions, they always use
in public until 1985, when he promised that re- condoms and she becomes increasingly con-
search against the disease would have maxi- cerned about the situation as her relationship
mum priority and that 126 million dollars would develops and she starts falling in love. Finally,
be earmarked for it in 1986. The film denounces urged on by her best friend, she decides to talk
that this figure was reduced to 85.5 million, an to him. This is a key scene: a conversation lasting
insufficient amount to cover the costs of a pan- over ten minutes that develops into an emotional
demic that, by the end of that year, had caused roller-coaster between the two characters. For
24,559 documented deaths in the US. Vero, it is clear that the fear and anguish hold the
same weight as the need to communicate (it has
taken several weeks for her to feel strong enough
The case of Positius
to take this step). Xavier, for his part, starts by
In Catalonia, the disease has occasionally ap- listening understandingly, but little by little his face
peared in many TV series, though few produc- transforms from apparent understanding to ut-
tions have had HIV as their central theme. In con- ter panic. He does not understand how she
trast, the TV movie Positius, produced by Ovideo could hide something so significant, which dir
for TV3, written by Aina Clotet and lex Maas, ectly affects him. Meanwhile, Vero does not stop
and directed by Judith Colell, did place the dis- repeating that she has always protected him
ease center stage in the script. The story focuses and that she needed to feel safe with [him] in

Notebooks of the Esteve Foundation N 42

Medicine in Television Series

order to share [this knowledge]. The scene lets Conclusions

viewers share and understand the fears that this
Analyzing all three productions, we can see that
disease entails: fear of rejection for the sufferers,
they all practically repeat the same concepts:
and fear of contagion (often the result of massive
disinformation, lack of prevention, stigmatization
disinformation) in the case of the sexual partner.
and scarcity of resources from the authorities to
The scene comes to a tragic end for both, ter-
fight against the disease.
minating with Xaviers exit, leaving Vero broken
In the twenty-first century, AIDS continues to
and alone.
be a reality among us. Nowadays, thanks to the
In contrast, Gloria, the other protagonist,
huge advances made in recent years, we can
gets a job offer to look after the daughter of
chronicle the disease, but at an untenable long-
Beln (Aina Clotet). Glorias lack of education term cost for public health, and with a certain
and knowledge cause her to make excuses and toxicity for the patient.
turn the job down, afraid she will infect the girl Science is progressing in great leaps to cure
just by contact. Worried, Gloria goes to visit an AIDS in infected sufferers. Research seeks to
NGO (pretending she has an HIV-positive friend), eradicate HIV from the organism so that lifelong
where finally they inform her and help her under- treatment becomes unnecessary. Highly prom-
stand that she cannot infect anybody just by ising therapeutic vaccine models exist, which,
touching them. In the end, Gloria is able to ac- combined with other strategies, will lead to a cure
cept the nannying job and the relationship with for the infection. The foremost laboratories world-
the little girl becomes increasingly closer until the wide have set the goal for achieving it in 2020.
girl becomes her reason for living. Unfortunately, But until this occurs, AIDS remains a reality. The
Beln ends up finding out that Gloria is HIV- stigmatization has not disappeared, but young
positive. With no explanation, she immediately people live as if it didnt exist, leading to a fresh
forbids her from seeing her daughter. Gloria falls peak in cases. In these moments of crisis, when
into a deep depression, goes off her medication resources are increasingly limited, we have to ex-
and is admitted to hospital. It is Glorias son, who tend the concept of corporate social responsibil-
until that point had seemed a distant figure and ity not to apply just to companies, but to people
did not know about her illness, who becomes individually. If each of us do our bit, we can help
her greatest support. to end this pandemic.

Notebooks of the Esteve Foundation N 42

Nip/Tuck, Greys Anatomy

and Plastic Surgery

Mara del Mar Vaquero Prez

Both productions could be considered to be the launching pad for two meteoric careers: producers Ryan
Murphy and Shonda Rhimes. Today they are two television industry heavyweights. The former sprang to
fame in 2003 with Nip/Tuck, a polemical vision of plastic surgery, shown through the lives of its two con-
troversial protagonists. Along with The Shield, this program brought the cable channel FX into the orbit
of series addicts. Years later, he would again work for this channel on American Horror Story. Shonda
Rhimess career took off in 2005 with Greys Anatomy, which still keeps audiences in their millions glued
to the screens of free-to-air channel ABC. Its success has enabled the channel to open a production
company for TV series (Scandal, How to Get Away with Murder), now dubbed Shondaland.

It might seem obvious to begin this chapter profession, meaning they share the suffering and
dedicated to plastic surgery in TV series by men- recovery of the sick. There are stories of interpret-
tioning the fascination that doctors private and ing the patients death as a personal failure, or as
professional lives have always held for viewers. proof of the uselessness or insufficiency of their
Every aspect relating to medicine, to the work knowledge. And even why not? stories of the
and coexistence of health professionals in that doctor who acquires more of a human dimen-
independent city that a large hospital constitutes sion when he or she switches roles and becomes
are fertile content. Such aspects include the dra- a patient. This is a fascinating viewpoint, which
matic change of lifestyle a diseases appearance portrays how difficult it is to take (as the saying
brings about, but also the analysis of symptoms, goes) ones own medicine.
like clues in a mystery movie, that lead to uncov- Medicine in film has given us marvelous stor
ering the diagnosis of an illness. Witnessing the ies in every imaginable genre and setting. We
progressive deterioration of a character suffering have seen doctors starring in romantic mov-
from a degenerative disease, or let us say it the ies and who, prompted by love, seek a cure for
moment of death itself, all of these are excellent their loved one. Or else they end up falling in love
storylines for thousands of scripts. They contain with the patient they cure. In war movies of any
enough elements of tragedy, drama, anecdote period, doctors often battle with few resources
and human overcoming of challenges to attract but enormous inventiveness. In natural disasters
viewers. or epidemics, they lead the survivors toward a
The permanent contact of doctors with life, new dawn. In crime films, they reveal the best
suffering and death make them the ideal heroes of a little-known specialization such as forensic
in many stories. These include both their own medicine. There are innumerable stories more. It
and those resulting from their professional voca- is tricky to find a medical specialization that has
tion, which sometimes leads them to sacrifice not been dealt with on the silver screen.
personal or family life. Similar are the stories of As if this were not enough, as series devel-
their involvement with family members and pa- oped, TV let viewers get to know the doctor
tients, stories of the empathy inherent in their starring in a storyline, and to share his or her de-

Nip/Tuck, Greys Anatomy and Plastic Surgery

velopment and dnouement. Furthermore, view- understands what a plastic surgeon may do in
ers could partake of the professionals daily life his practice, he focuses on his facet as a creator
in each episode, experience the adventures that or recoverer of beauty as the sole thing that holds
so attracted them one after another. With every interest in fiction? Or is it that plastic surgeons
weekly broadcast of her or his work, they shared ourselves have not known, been able or wished
his or her achievements, failures and affections, to demystify that image that portrays us as the
against a backdrop of recovery, loss, overcom- most enviable of stars?
ing odds, frustration, life, and even death. Medi- The answer is surely a combination of all of
cal television series have encouraged more than this. Though there are few, if barely any, posi-
a few professional vocations, increasing student tive examples we can point to of this special-
numbers in medical faculties, attracted by the ization on-screen, we will at least aim to reflect
daily adventure of this profession. real knowledge of the specialization and try, by
I think this reminder is apt so as to be aware demystifying the stereotype, to reveal the true
of the scant treatment of equal depth and con- importance of what plastic surgery and its practi-
tent the specialization to which we dedicate this tioners offer patients and the other medical spe-
chapter plastic, reconstructive and aesthetic cializations.
surgery has received in film and TV. I know
some people would say that this is not so. We
A little etymology and history
are used to seeing stars undergo changes in ap-
pearance. It could be so an actor can replace a Plastic, reconstructive and aesthetic surgery. This
colleague in a long-running series without altering is a long name for a broad medical specializa-
the storyline or the central characters in the plot. tion which is nevertheless most often abbrevi-
Or maybe the character has a serious accident, ated to plastic surgery. It is, furthermore, wrongly
or survives an assassination attempt that disfig- associated with just half of its content: aesthetic
ures him or her, and must return with a fresh face surgery. This would be understandable in the
to take revenge. These are recurring themes on- context of the broader public. However, it is un-
screen. This is undeniably true, and is no doubt fortunately also the case among many medical
the first notion that pops into our mind regarding professionals, who remain ignorant of everything
plastic surgery. Yet outside of this easy script re- this specialization encompasses and the services
source a rather surreal concept reflecting none it can offer. Let us look more closely at them.
of the reality of the specialization what does the Plastic, reconstructive and aesthetic surgery
broader public know about what plastic surgery is the medical and surgical specialization con-
consists of when given its full name: plastic, re- cerned with correcting any congenital, acquired,
constructive and aesthetic surgery? How has tumorous, or simply regressive process requiring
TV fiction portrayed this specialization in series repair or repositioning, or which affects bodily
on medical themes? Have the fictional charac- form or function. Its techniques are based on
ters approached the plastic surgeons image as transplanting and mobilizing tissues using grafts
a doctor with the same dimension as a health and flaps, or even implanting inert material. In its
professional as has been fomented for other spe- most recent advances, it also employs complete
cialists? units of donor tissue, such as limbs (arms, hands,
Frequently, plastic surgery and its professional legs) and the covering of the face.
practitioners only inspire frivolous plotlines or em- The full content of plastic surgery encompass-
body characters lacking the basic ethical prin- es two fields of action. The first is reparative or
ciples that govern the doctor-patient relationship. reconstructive plastic surgery. It seeks to restore
Is this the fault of scriptwriters who are ignorant of or improve the function and physical appearance
the specializations content or the fields of inter- of injuries caused by accidents and burns, in skin
est it comprises? Or is it a deviation from reality diseases and tumors, along with the tissues be-
that means that, though the scriptwriter perfectly neath the skin. It may correct congenital anoma-

Notebooks of the Esteve Foundation N 42

Medicine in Television Series

lies, mainly facial, or on the hands or genitals, or scribed to reconstruct the nose, which is known
else anatomical defects caused after an onco- as an Indian flap.
logical surgical resection. Then there is aesthetic Yet no doubt it was World War One (1914
or cosmetic plastic surgery, which treats gener- 1919) which caused plastic surgery to develop
ally healthy and emotionally stable patients. Such as a specialization. A huge number of soldiers
surgery makes alterations that, while not con- were wounded by shelling and burns, as a result
stituting pathological processes in themselves, of which their bodies and faces were disfigured.
cause a deterioration of health to the extent they So professionals had to be trained and medical
interfere with peoples physical and psychological centers specialized in surgical reconstruction
wellbeing. So its aim is to correct differences from created, both in Europe and the US, where this
aesthetic standards or the effects of ageing. specialization was not recognized. It remained
A plastic surgeon, to use his or her shortened more or less associated with maxillofacial surgery
title, may be concerned with repairing congenital for many years. Then in the Second World War
malformations, treating and operating on burn (19391945), plastic surgerys field of activity was
victims, reconstructing any anatomical defect, expanded and it began to appear as an indepen-
carrying out surgery by hand, conducting micro- dent specialization. Dr. Archibald McIndoe devel-
surgery, re-implanting or transplanting limbs or oped (what for the period were seen as strange)
faces, and performing aesthetic surgery. From transfers of healthy tissue to damaged areas,
head to toe. In the words of Dr. Raymond Vilain, using pedicle flaps. These enabled many avia-
the plastic surgeon is, in fact, the last general tors who had been disfigured by fire to abandon
surgeon. the isolation to which they had been condemned
Concerning the names etymology, plastic as monsters. Medicine had certainly saved their
stems from the Greek plastikos, which means lives, but at the cost of depriving them of employ-
to mold or transform. So in its entirety, plastic ment or social life in the community, and leading
surgery is aimed at aesthetically designing bod- in the worst cases to suicide. So McIndoes in-
ies through remodeling to improve them, what- novation thus lessened their suffering, reincorpo-
ever the reason for surgery, or to make them rating them into acceptable social and aesthetic
more beautiful. The plastic surgeon acts thus. norms.
She or he seeks harmony, beauty and adapta- The Spanish TV series Canal Historia and
tion to aesthetic norms and functionality. This is Odisea offer episodes on Dr. McIndoe, using pe-
independent of that separation into two activity riod photos and the real voices of the veteran
fields, which is demarcated, in fact, by society protagonists themselves to tell the stories of the
and health systems (public healthcare and private young pilots in the Allied air forces he treated.
insurance companies), which thereby attempt to When their bombers, loaded with large amounts
limit the coverage of care intervention costs. of highly inflammable fuel crashed, the aircrew
It is not just etymology that unites the func- were consumed in huge blazes, from which they
tions of plastic surgery but also its documented occasionally managed to escape alive, though
history. Both the Edwin Smith Papyrus from with faces and bodies totally charred. Survival
Egypt (30002500 BCE, according to Breasteds was a goal, but afterwards, tortured by their ap-
studies) and the Sushruta Samhita (Surutas pearance, they needed their faces and hands to
Compendium) from India (500 BCE) document appear and function more or less normally again.
nose reconstruction. In that period the nose and They wanted to feel like accepted members of that
ears were considered to be appendages convey- society which, while respecting them as heroes,
ing reputation and respect. So it was common to shied away from their disfiguration. Many were
amputate them as a punishment against crimi- between 17 and 21 years old. Thanks to Dr.
nals and defeated peoples. Rewards were even McIndoes innovative techniques of the time,
paid for every nose and ear delivered. Even now- these men tell how the correction of their dis-
adays we still use the frontal flap Sushruta de- figuring became a virtue. McIndoe founded

Nip/Tuck, Greys Anatomy and Plastic Surgery

his Plastic and Maxillofacial Surgery Service at facets of medical practice. These are developed
Queen Victoria Hospital in the village of East in contrasting environments, for likewise dissimi-
Grinstead, Sussex, England. Here, people got lar purposes. They are even undertaken by sepa-
used to seeing and accepting his patients on the rate medical professionals.
street, in local pubs, and even in London itself.
They would carry their pedicles like small trunks
TV fiction and plastic surgery
that transferred tissue from their abdomen to
the arm, from there to the shoulder and then to To move on from plastic surgerys noble and his-
the face, finally becoming a new nose, cheeks torical facets to analyze its evolution in TV series
or chin. During the time this process lasted, the involves a search. However, we find little mate-
patients and those around them saw how these rial worthy of mention, because as far as I can
disfigured faces were gradually conforming to a recall and trace, few TV series, whether on medi-
normalcy accepted by all. cal themes or not, include a character having
The patients who lived there, sometimes for this specialization. Perhaps the most famous in
three to four years, and underwent 2030 opera- recent years are doctors Sean McNamara and
tions, managed to save not just their lives but also Christian Troy in the series Nip/Tuck, and doc-
their minds thanks to plastic surgery and Dr. Mc- tors Mark Sloan and Jackson Avery in the series
Indoes approach and psychological work. Sev- Greys Anatomy. We would like briefly to pres-
eral ended up marrying the nurses who cared for ent these series to those viewers who have not
them. They even formed a club, The Guinea Pig
watched them, or who have heard of them at
Club, which over its more-than 60 years of his-
some point but do not know them well.
tory brought together over 650 members. Years
Nip/Tuck was a series that aired from July
later, its survivors and their descendants continue
2003 to March 2010 on the American cable TV
to meet to honor their creator and raise a few
network FX Networks. It ran for six seasons and is
pints to him while singing the anthem they com-
considered an innovative TV product for its time,
posed in his name. The light-hearted lyrics go:
because of the subject it tackles and because
We are McIndoes army, it gave the language of TV series a filmic style.
We are his Guinea Pigs. Classified as a drama series, it won the Golden
With dermatomes and pedicles, Globe for best in its category in 2005. Already,
Glass eyes, false teeth and wigs. in 2004 it had won an Emmy from the US Na-
And when we get our discharge, tional Academy of Television Arts and Sciences
Well shout with all our might: (NATAS), for Outstanding Prosthetic Makeup for
Per ardua ad astra [Through adversity to the a Series.
stars] The storyline follows the life and work of two
Wed rather drink than fight plastic surgeons, Dr. Sean McNamara, played
Knowing all this inevitably leads one to reflect. by the actor Dylan Walsh, and Dr. Christian Troy,
It is odd that both the early plastic reconstruc- played by Julian McMahon, who run a private
tions described in written historical documen- clinic first in Miami before moving to Los Angeles
tation, and the main milestones leading to the to set up their practice in Hollywood.
creation and development of plastic surgery as In the series, these professionals qualifica-
a specialization, linked the components of ma- tions and practice is in fact merely an excuse
terial, functional and aesthetic reconstruction so to explore one of the most polemic subjects on
intimately as a basis for a persons social accep- American television through the self-destructive
tance and reincorporation into society. Yet nowa- nature of its characters, true both of the starring
days, it is customary to observe how society has doctors and their patients. Furthermore, it dealt
generally separated the aesthetic and recon- with topics that were not habitual on the medium
structive elements into two clearly differentiated or in the US, such as drugs, abortion, homosex

Notebooks of the Esteve Foundation N 42

Medicine in Television Series

uality, transexuality, sects, personal ambition and were operating, talked about their personal lives,
the constant search for pleasure and money. It relationships, families and hobbies, even their
portrayed a lack of personal or medical ethics, money worries all the while opening up and cut-
and depicted lives dominated by envy, stress, ting into their patients bodies.
lust and even crime. All of this doubtless earned it So these two TV series, with quite different
significant criticisms from more conservative sec- takes on medicine and doctors, were both hugely
tors, both in the US and other countries where it successful and on air for a long time. By focusing
aired. on characters who are plastic surgeons, we will
Greys Anatomy is a medical series from the elucidate how they portray this discipline in TV
US network ABC, which began in March 2005 series. Does the educational tone and appeal for
and is still on air. It takes its name from the re- the wider public, which every TV show strives for,
nowned treatise on human anatomy, Henry manage to convey a faithful or at least realistic im-
Grays Anatomy of the Human Body, better age of plastic, reconstructive and aesthetic sur-
known as Grays Anatomy, a basic textbook for gery? Do they portray the lives and professional
training US medical students published in 1958 dedication of these specialist practitioners?
by Henry Gray. So it plays on his name and
Dr.Meredith Greys, the series central character.
The plastic surgeon: hero or villain?
It won a Golden Globe for Best TV Drama Series
in 2006 and has garnered a total of 38 nomina- In its time, Nip/Tuck was startling for its care-
tions for the Emmy Awards in different catego- ful aesthetic, apparent right from the slickly
ries (script, actors, direction, etc.), of which it has designed opening credits accompanied by its
won four further awards. theme song, Engine Rooms A Perfect Lie. Since
The series is set in Seattle Grace-Mercy West the credits and theme song are brief, we are
Hospital, tracing the professional development of plunged into the atmosphere in which the story
different medical specialists whose lives cross the will develop: aesthetic surgery. The discipline,
protagonists. The series viewpoint is interesting by cuts and stitches, can recreate those perfect
because it focuses on the life and hopes of the bodies represented in the credits as cold, iden-
resident medical interns who join the hospital to tical, beautiful but static mannequins without life
train as future specialists. There is tough compe- or personality, and still semi-packaged while the
tition between them, but also passion not only lyrics croon:
for medicine as a profession but for the value of
Make me beautiful,
patients lives.
A perfect soul,
For the subject concerning us, we look at two
A perfect mind,
characters who, while they began as guest stars
A perfect face,
(conceived as occasional appearances in specific
A perfect lie.
episodes), gradually gained prominence and be-
came part of the core storyline, essential for the At first, it seems viewers are being offered the
series development. They are Dr. Mark Sloan, same view as ever beauty as little more than
played by Eric Dane, and Dr. Jackson Avery, an end. Yet patience will reveal more. Its central
played by Jesse Williams. characters are two plastic surgeons specializing
Series creator Shonda Rhimes seems to have in aesthetic surgery who have been friends since
conceived a fiction that offers a voice to intelligent youth. As we mentioned in the introduction, aes-
women who compete with each other. To do so thetic and reconstructive are two medically in-
she devised a medical setting based on the im- separable facets. Aesthetic, like reconstructive
pression she got when over a period she became surgery, rebuilds bodies and fortifies minds. From
obsessed, along with her sisters, with watching this viewpoint, the series seems to promise to
surgical operations on the Discovery Channel. center on one of the few branches of medicine
She was surprised that the surgeons, while they excluded from any health policy, since it covers

Nip/Tuck, Greys Anatomy and Plastic Surgery

content that is not considered vital. It would even patients want to do with their bodies. Even if
seem a good idea to publicize aesthetic surgery Dr.Frederik McLorg defined the specialization as
as something that is not limited to artists or mil- a surgical discipline that resolves problems, we
lionaires. It would be beneficial for viewers to also said that aesthetic surgery treats healthy and
know what can be done for patients to feel good emotionally stable patients. But the truth is, none
about themselves and in their surroundings, to of those on Nip/Tuck seems to be so. Added to
overturn myths and, somehow democratize ac- this, with every episode, the personal storylines
cess to the specialization. of the main characters get increasingly tangled.
The program starts in the consulting room of When the whirlwind of their lives careers into a
doctors McNamara and Troy while the lights go labyrinth of personal perversions and criminal
on in corridors, waiting and recovery rooms, and underworlds in which no averagely conventional
in the operating theater. They reveal a blend of situation appears ever to have existed, or which
clinical setting with the most spectacular, inno- could not be found in other crime series that do
vative decor imaginable, where elegance and a not need a medical setting, the series starts to
five-star air predominate. It is a vision in which, head rapidly downhill, especially in the final three
furthermore, a fast change in tempo have us seasons, until its demise became inevitable.
abruptly suspecting that the entire medical at- Why did the scriptwriters choose that profes-
mosphere will be nothing but glamor. It seems sion and that surgical setting to present two such
vile and tormented characters? It is difficult to
we will be watching the same sort of program as
know, but I believe it was thoroughly unneces-
always: will it end there, as usual?
sary. Do they contribute anything to our aim to
Dr. Troy is attractive, sexy, single, a woman-
see if aesthetic plastic surgery appeared for the
izer, narcissistic and a less-brilliant surgeon than
first time as a central theme in a television series?
his partner, though he is an excellent public rela-
Personally, I do not think so. On the contrary. Be-
tions man. Dr. McNamara is less attractive, mar-
yond what could be an attempt to shine light on
ried with three kids and the better surgeon of the
certain themes that also fall within the sphere of
two. Following the traditional, good cop/bad
this specialization (surgery on transsexualism, the
cop setup, Troy is the dark side while McNamara
effects of morbid obesity and little else), the rest
represents firm convictions.
is the same as always: scars that appear to van-
Thus, the premise is set up and the story be-
ish as if by magic, body remodeling carried out
gins, with episodes that each bear the name of
using liposuction, and surprisingly fast recoveries
the patient operated upon as a central theme. after surgery. Nevertheless, they try to give a feel-
And at the beginning of each episode, the doc- ing of authenticity by introducing intra-operative
tors always ask the same question: Tell me what shots of cuts, visible wounds, blood, fat that is
you dont like about yourself. It is a good line, but extracted in buckets from patients bodies, and
too simple and even risky for initial intercommu- so on. All of this panders to the morbid fascina-
nication with the patient in a consultancy of this tion of viewers, watching with divided attention
type. The problem gets worse, moreover, when while eating dinner. In the end, nothing different
we observe that none of the patients seems to or of value occurs to reveal the positive side of
present problems or pathologies typical of a plas- aesthetic surgery or to portray it in a realistic way.
tic surgery consultancy that might be called con- Even the patients who seek to recover their faded
ventional. Each patient is increasingly strange or beauty or youth fall into addiction, seeking sur-
unhinged. This confirms our initial fears. In fact, gery as their sole form of survival and showing
the series opts to portray the frivolous side of the the most disastrous image possible to viewers.
specialization. I would say it is quite unreal and The surgeons operate without masks, mak-
even illegal on many occasions. ing surgery seem simple and easy while calcu-
A plastic surgeon who undertakes aesthetic lating their profits. A mini-bar is on display in
surgery is not the achiever of everything his the consulting room, while the doctors coats

Notebooks of the Esteve Foundation N 42

Medicine in Television Series

are not even white but a strange tone of blue to narrator tells us how in 1987, after the infamous
match the decor. The doctors immediately lead Black Monday crash, a new financial golden age
their conversation with patients into personal ter- was born, and along with it, a new industry, the
ritory. They insinuate or leave the field open for luxury industry. Newfound wealth coupled with
their female patients to make sexual insinuations easily available credit opened the door to vani-
in the consulting room. Are these doctors differ- ties and excesses once reserved for the rich and
ent to others, or are they making an effort not to famous, among them, plastic surgery. The new
seem like doctors in front of their patients? This must-have status symbol was a perfect body.
is what happens when one wants to convey the In this narrators words: compliant thighs and ti-
idea that plastic surgery, at the end of the day, tanic tits. At that money-earning peak of offering
is not medicine or even surgery. One should not both the possible and unattainable, McNamara
scare the patients. This goes beyond a doctor- and Troy rub their hands at the profits they earn
patient relationship, into commercial territory, with each patient. They enlarge their consultancy,
trivializing an operations risks, or pretending that furnishing it in luxury, and spend endless amounts
the patients wishes must be served at all costs. on cars, yachts and the high life, thereby marking
We even wonder why plastic surgeons on-screen their professional status in a medical specialization
kiss their patients goodbye instead of offering a very different to others. It seems to allow plastic
friendly but respectful handshake. surgeons to earn huge sums of money very eas-
Leaving aside detective-style plots and situ- ily. No stress can be seen during surgery. They
ations that are far removed from these plastic merely tote up their earnings for each operation.
surgeons professional practice, we might even Yet when this fairytale ends and the international
accept some degree of rivalry between col- credit crunch hits, the operations decrease drasti-
leagues, professional jealousies, or even some cally as do their earnings. It is tough to maintain
small stratagem to become the patients favorite. the world they have created, and even tougher to
These things might be seen to a certain extent appear to be doing so. This is where the financial
typical of medical competition and the quest for stress seems to turn these doctors human, and
professional excellence. Viewers might even for- they start to feel anguish and stress they have
give them such striving after perfection that ev- never shown in the operating theater.
ery plastic surgeon carries inside. Not in vain did Are they a special case? Unfortunately, for the
even Dr. McIndoe, mentioned in the introduction, series creators it seems not, because when an-
say that in his work he felt Gods presence de- other colleague joins the firm for an episode or
scending into his right arm. But doctors McNa- a season, we assume either birds of a feather
mara and Troy take all this to the limits of deceit, stick together, or that the scriptwriters do not
jealousy and destruction. Neither do they seem appear to believe anybody can practice this spe-
to have much empathy with their patients. Some- cialization with a modicum of ethics or medical
times they even clearly make fun of their com- professionalism. For example, in the first sea-
plexes. McNamara, though we noted he is firmer son, Dr. Merril Bobolit, played by Joey Slotnick,
in his personal convictions in early episodes than showed fewer scruples than the central charac-
his partner, allows himself to be swayed in the ters and is able to undertake illegal operations,
quest for the only goal his consultancy pursues: continue operating after losing his license and
money and success at any price. Troy, who use anesthetic gases as a drug. Generally, any
adores female bodies so much for his own plea- other plastic surgeon who enters McNamara and
sure, creates beauty in his patients so as to then Troys consultancy is the same. They all seem to
seek sexual relations with them. He is, moreover, link their profession to a disproportionate quest
profoundly misogynistic, scorning and mistreat- for fame and money, and to a total lack of scru-
ing women. ples to achieve them.
What is interesting at the time of writing is Beauty, success and money seem to be the
the sixth seasons opening episode, in which a ideal in plastic surgery, at the hands of handsome

Nip/Tuck, Greys Anatomy and Plastic Surgery

young doctors like Dr. Troy, who throw out lines hold for the residents in training at Seattle Grace
like Appearance is everything, Beauty is hap- Hospital. They generally refuse to participate in
piness, beauty is power, beauty is confidence, surgery with Sloan while they fight energetical-
or Going against established beauty is to ignore ly to attend, even just to observe, in any other
the world in which we live. When these ideas are specializations operating theater. Is this a subtle
stirred into such a risky fictional cocktail, I firmly way of saying that what plastic surgeons do is
believe this reflects poorly on the reality of plastic not important? Is it a secondary specialization
surgery. According to such tenets, this profession to choose to learn? Dr. Sloan is hard-pressed
does not merely implicitly espouse the cause of to attract any resident who wants to follow his
money and success for surgeons and patients, work, and when he does find someone, he in-
but also flouts it ostentatiously. So these profes- vites them to participate not in his team but in
sionals forget the aims on which the practice was what he calls his Plastics Posse, to the embar-
founded, the work of its pioneers, and everything rassment of the resident selected, who sees no
the practice can achieve, not just in aesthetic sur- special honor in it, rather a means of removing
gery but in collaboration with most other special- them from true surgery. This is a curious view-
izations in a large hospital. point, since in Spain, for example, the special-
Despite Nip/Tucks success more closely ization of plastic, reconstructive and aesthetic
linked to its slick photography, morbid fascination surgery is every year more in demand by re-
with excessive hyper-sexuality and the introduc- cently graduated doctors who have passed the
tion of extreme themes it does not help at all MIR exam (for Resident Intern Doctors). Training
to present the reality of plastic surgery. Rather, places are quickly occupied by students with
it completely distorts its governing foundations the best academic records.
while promoting the most fictitious and unreal It is a shame that in this series too, what is
stereotype of plastic surgery specialists. Medi- sometimes seen as a small glimmer of recogni-
cine and the specialization operate as a mere tion toward the discipline of plastic surgery, or
excuse in which to set the storyline and increase of publicizing the specializations novel and in-
the morbid excitement of their patients increas- teresting aspects, ends up being lost in the ba-
ingly extravagant requests. nality of the character of the plastic surgeon. He
In narrowing the search for more appropriate seems friendly, but is never a leader among his
sensitivities to the plastic surgeons work, there colleagues who have other, better recognized
is more joy in the treatment given to the special- specializations. He ends up once more being
ization in Greys Anatomy. The programs plastic the good-looker, scorned and superficial, who
surgeon is Dr. Mark Sloan. Though we might ex- easily performs less important operations. With-
pect little from a plastic surgeon who, predictably out have taken advantage of the whole range of
following the jaded stereotype of TV fiction, is options the specialization might offer in a series
the most attractive doctor in the hospital, and such as Greys Anatomy about a large hospital,
isdubbed by his female colleagues McSteamy, Dr. Sloan, who first appeared in the third season,
in some episodes he represents plastic surgerys was dropped from the series in the ninth.
contribution much more faithfully. In the series we His place was taken by Dr. Jackson Avery,
see cases of facial reconstruction after traffic ac- the only surgical resident who became Sloans
cidents, micro-surgery, reimplants and children protg, and to date he seems to uphold the
with birth defects. Dr. Mark Sloans work includes moral values and medical practices common to
far more than just aesthetics. It seems the pro- the other specialists. At some point it is revealed
gram wants to introduce us to plastic surgerys that his choice of plastic surgery may have been
more useful side, including collaboration with consistent with his good breeding. Not for noth-
other specializations. ing is he the grandson of one of the countrys
However, it does call attention to the lack of most reputable surgeons. His family owns an im-
attraction that the surgery he conducts seems to mense fortune, thanks to which they are patrons

Notebooks of the Esteve Foundation N 42

Medicine in Television Series

of one of the countrys most significant medi- pursues. The surgeons experience and skill are
cal prizes. Nevertheless, he seems to maintain fundamental, but possibly more than in any other
a straight professional path while, like Sloan, he specialization, a connection with the patient is
tries to attract one of the new residents to the fundamental in order to recognize the latters ex-
Plastics Posse. Such sound professional judg- pectations and offer her or him the most realistic
ment by Dr. Avery seems to have shrunk his solutions, or to know when to refuse if such ex-
participation as a specialist and the presence of pectations are unrealistic or unhealthy. The plas-
pathologies typical of his specialization in the se- tic surgeon must get inside his or her patients
ries. Meanwhile, given the show remains on air, minds, recognize body dysmorphic disorders
we hope for plastic surgery to feature once more and help patients to see that, to paraphrase the
on the small screen at some point. And if not French mountaineer, photographer and filmmak-
portraying it better, at least it may have the same er Louis Audoubert: As far and wide as we travel
degree of reality, professionalism and interest as the world seeking beauty, we will never find it un-
the other specializations. Perhaps Dr. Avery will less we carry it with us.
manage to attract one of the many female doc- It is true that private exercise of the specializa-
tors starring in the series into his specialization. tion enables plastic surgeons to develop a more
This would shatter another myth that only men lucrative professional activity since aesthetics is
work as plastic surgeons, above all in aesthetic one of the few medical activities that falls outside
surgery a specialization belonging to men who of health coverage and health insurance. But
sculpt beauty in women. There is scant need to this does not make plastic surgeons mere skillful
recall the current growing dominance of women businesspeople trading on their patients health
in medicine, in Spain and worldwide. In this sec- at any price. We should not allow the superficial-
tor as in others, reality takes one path while fic- ity of the image that to date has predominated in
tion takes another. A woman surgeon in the con- film and TV fiction of plastic surgery operations.
sulting room would not perhaps offer so much Nor should the model of its professionals obscure
morbid fascination when creating storylines and the reality of a magnificent specialization that ful-
less dramatic play in episodes. So would only fills in its deepest sense the definition of health
the professional viewpoint remain? Would there established in the Preamble of the Constitution of
not be so much room for parallel storylines of sex the World Health Organization: a state of com-
and fast cars? Perhaps the resulting character plete physical, mental and social well-being and
would be too boring. not merely the absence of disease or infirmity.
Yet it is not just film and television that should
convey that image. Plastic surgeons themselves
are responsible for this image we present to so-
As Gaspar Tagliacozzi, one of the pioneers in ciety and to make our practice a reflection of our
plastic surgery in the Medieval period, wrote in professionalism, undergoing constant training
his work De curtorem chirurgia per insitionem, in a state-of-the-art, innovative specialization.
published in 1597: We restore, repair and make Neither do we want to resemble the stereotype
whole those parts of the face which nature has that fiction portrays of us, nor imitate its frivol-
given but which fortune has taken away, not so ity, trivializing the surgery we perform, its visible
much that they may delight the eye but that they ostentation and luxury, or constantly appear on
may buoy up the spirit and help the mind of the programs of frivolous scientific dissemination or
afflicted. in celebrity magazines. If not, we ourselves will
If in any use of medicine one works with and ensure that we continue to be viewed as simple
for the human body, in plastic, reconstructive and dream merchants, creators of beauty to clothe
aesthetic surgery, the raw material is the human humanity. We will lose peoples respect for a
body itself: to reconstruct it and give it beauty great specialization that perhaps we have not
and functionality are the aims this specialization made known in its true dimension. We are still in

Nip/Tuck, Greys Anatomy and Plastic Surgery

time. Otherwise, let us not forget that even after McCarthy JG. Introduction to plastic surgery. In: Plastic
his death, Tagliacozzi was condemned for inter- surgery, vol. 1. Philadelphia: W.B. Saunders; 1990. p.
fering with Gods creation, and his body was ex- Mosley L. Faces from the fire: the biography of Sir Archi-
humed and re-buried in unconsecrated ground. bald McIndoe. London: Weidenfeld and Nicolson; 1962.
Preamble of the Constitution of the World Health Orga-
nization. New York, 22 July 1946. Official Records of the
References World Health Organization, N 2; 100.
Programa de la Especialidad de Ciruga Plstica y Re-
Audoubert L. La gran travesa de los Pirineos. Barcelo- paradora, Secretara de Estado de Universidades e In-
na: Juventud; 1995. vestigacin del Ministerio de Educacin y Ciencia. Re-
Canal Odisea. McIndoe: ciruga reconstructiva en la II solucin 15-7-86. Updated in 1996.
Guerra Mundial. Sociedad Espaola de Ciruga Plstica, Reparadora y
Canal Historia. Archibald McIndoe and the Guinea Pig Esttica (SECPRE). Available at:
Club. Tagliacozzi G. De curtorum chirurgia per insitionem. Ve-
Coiffman F. Ciruga plstica, reconstructiva y esttica. nice: Gaspare Bindoni; 1597.
Bogot: Amolca; 2008. Vilain R. Jeux de mains. Paris: Arthaud; 1992.

Notebooks of the Esteve Foundation N 42

Masters of Sex and Sexology

Helena Boadas

What might seem like an excuse for screening another controversial and polemic series with high-voltage
sex appeal is actually one of the best reflections on scientific method to appear on the small screen.
Based on the biography Thomas Maier wrote on William Masters and Virginia Johnson, the couple who
convulsed the academic sphere in the nineteen-fifties and sixties with their studies on the human sexual
response cycle, this series premiered in 2013 on cable network Showtime (Dexter, Homeland). It is an
accurate and truthful retelling partially thanks to the chemistry between its leading actors, Michael Sheen
and Lizzy Caplan.

In 1956, a national renowned fertility specialist career, commits the indiscretion of becoming
met a former nightclub singer. Ten years later, interested in human sexual response. Studies
they published a scientific study, which revolu- in obstetrics in this period centered on the birth
tionized our understanding of human sexuality. of children, avoiding the process by which they
Opening with these two sentences, this se- were conceived. He had patients who asked him
ries set in the fifties the first scene offers us a what they could do if they felt pain during coitus,
gala dinner with fabulous fifties automobiles, fif- if they did not reach orgasm, or felt no pleasure.
ties dresses and fifties music has us ordering Frustrated because his best answer was to take
in a pizza to remain glued to the sofa for hours a lover, get used to it, or change your hus-
on end. But Masters of Sex, furthermore, has band, Doctor Masters realized there was a need
an added value that makes it even more inter- to shed light on sexuality. The fact he had worked
esting from my viewpoint: it is a real story. And with one of Kinseys disciples at the start of his
one that is quite true to life. Because Masters career no doubt increased his interest in this field.
and Johnsons story was essentially the one the Kinsey had also revolutionized the history of sex-
series tells. uality several years before Masters and Johnson.
Readers may know of Kinseys studies, or have
seen the film based on his life and work, entitled
How did it all start?
Kinsey, containing a lot of similarities to the series
On one hand, we have Virginia Johnson, 32, Masters of Sex. It likewise conveys a clear idea of
thrice-divorced, with two kids from her last mar- the developmental extent of the history of sexual-
riage to a rocker, who had devoted her life to ity at the time. Yet for now let us return to Doctor
singing until the year before. She is now working Masters, who is trying to begin studying human
as a secretary at Washington University School of sexual response.
Medicine, in Saint Louis, Missouri, filling in medi- Throughout medicines history, forbidden terri-
cal insurance. She has studies in music and has tories have existed. It is as if humanity needed to
begun studying sociology at the University. reserve part of the body for the realm of mystery,
Meanwhile, Doctor William H. Masters, nearly the unknown, even the magical. Within this por-
40, an obstetrician at the same hospital, after tion, in this unpredictable space, we store every-
more than ten years of an impeccable medical thing we do not know, or cannot properly explain.

Masters of Sex and Sexology

First it was the brain, then the heart. In the US in has the experience, the broadness of mind and
the nineteen-fifties, it was the turn of sex. (Allow the frankness that Doctor Masters needs. Thus
me a brief parenthesis: in an article on migraines by their collaboration begins though Virginia has
the neurologist Arturo Goicoechea, I recently read practically no university studies nor the slightest
that this magical territory is once again the brain. knowledge of physiology which will continue into
Naturally, sex is not it, but the brain? Is it a magi- the 1990s, almost to the end of both their lives.
cal territory? It seems so. It seems that it is help- What methodologies does the scientific study
ful for us to be able to make statements such as use? In general, case studies, surveys, direct ob-
We only use 10% of our mental capacity, or We servation and the experimental method. So as Al-
know practically nothing of the brain, because we fred Kinsey used surveys, Masters and Johnson
allow space for the unknown, the unexplainable use direct observation. And they do not have it
and the unhoped for in short, for magic. Close easy. Because observing the digestion process
brackets.) We said that in the US of the time, this of somebody who has eaten an apple, for ex-
forbidden territory was sex. It did not exist, and ample, is not the same as observing how this
almost could not be mentioned. Doctor Masters same subject responds to sexual stimulation. In
was obliged to work with prostitutes because he the series, we see how their study causes an up-
had no other option. In the second scene of the roar in the university hospital. We all know that
series, we see him shut in a cupboard spying on something interesting is going on in that office,
a prostitute with a client, measuring the clients but nobody knows exactly what. We even see
sexual response, his timer in his hand. Working an attractive young doctor auscultating the wall
with prostitutes caused many logistical problems, with his stethoscope. Here, in this difficult terri-
aside from the fact that a sexual relationship be- tory, is where Doctor Masters and Virginia John-
tween a prostitute and her client is not represen- son discover that their natures, their skills and
tative of sexual relations in general. Furthermore, working methods complement each other so as
most of them were affected by chronic pelvic to form a formidable team. All the aspects of Vir-
congestion, a factor that also skewed the results. ginias character listed above are added to those
Finally, after much insistence, the doctor manages of Masters: he is obsessive, demanding, rigor-
to convince Willard Allen, his department boss at ous, meticulous, not greatly enamored of social
Washington University, to include his study in the relations, of few words and very serious, though
university. Allen warns him that it could be profes- one should not forget his subtle sense of humor.
sional suicide, but the project goes ahead. These different natures of Masters and Johnson
Doctor Masters needs an assistant and his are very well represented in the series, except,
secretary does not fit the right profile. In the first in my opinion, in one respect. In the character of
episode, we see her dressed in a green suit Doctor Masters that Michael Sheen plays, there
conveying that hard-to-describe air one having is a toughness that I am not sure the real person
nothing to do with beauty which certain women displayed. The strict and serious demeanor of a
give off, as if they have begun to distance them- man of few words does not imply such sometimes
selves from life, from pleasure. Doctor Masters unpleasant toughness, which I have not found in
assistant must be a special woman. He knows any biography on William H. Masters. They rather
that no female doctor would accept the position speak of his great humanity and warm capacity
because it would compromise her reputation and for understanding. However, except for this facet,
career. This is when Virginia appears in his of- both characters are well represented.
fice as if by magic, deploying all her sensuality.
They discuss the job position, their ex-husbands,
Masters and Johnsons importance
and sex. Before you leave, tell me, why would a
in the history of sexology
woman fake an orgasm?. To get a man to cli-
max quickly. Usually so the woman can get back Was their work truly as relevant as the series de-
to whatever it is shed rather be doing. Virginia picts? Yes, it was. Absolutely. Their studies re-

Notebooks of the Esteve Foundation N 42

Medicine in Television Series

vealed a clear before-and-after situation in the Now muscular tension, blood pressure, heart
study of human sexuality. Furthermore, they laid rate and breathing accelerate more and more
the foundations for the sexual revolution of the until orgasm is reached. Tension has reached its
sixties. To start with, they managed to collect peak and is freed with this explosion. Involuntary
highly accurate information on the physiological contractions occur of the mans penis, the wom-
changes in the human sexual response cycle. ans vagina, and the anal sphincter in both. Men
Moreover, they defined these phases: excite- ejaculate although not always! It is not so com-
ment, plateau, orgasm and resolution (Fig. 1). All mon, but orgasm may occur without ejaculation
these data were key in order to profoundly un- in men. In women it is the opposite: normally vis-
derstand the human sexual response cycle, es- ible ejaculation does not occur, though in some
pecially to be able to treat possible dysfunctions. cases it does, composed of a mixture of urine
Let us examine these phases in detail. and vaginal fluids.
In the first, excitement, we observe an in- It seems that female ejaculation is currently
crease in heart rate and temperature. Vasocon- in fashion in pornography, however, be warned:
gestion of the pelvic area means that men ex- most female ejaculation in porn videos is false:
perience an erection and in women, the vagina the actresses use tricks to simulate ejaculation. It
expands and is lubricated. Breasts and nipples is important to know this because such fashions
also become larger. can cause a great deal of sexual frustration in
When the excitement reaches its peak, all the couples who think that certain practices or phe-
changes are maintained at this highest level. This nomena are common, so they feel obligated to
is the phase known as plateau, characterized by try and replicate them. In fact, yes, some women
an intense feeling of pleasure. Though the per- experience ejaculation, but they are definitely not
ception is one of calm, in this phase muscular the majority. Furthermore, these ejaculations are
tension increases and this is when the sex flush substantially more modest than those we see
occurs (some areas of the body, normally the on-screen. Many sexual problems arise from pre-
chest and cheeks, redden). Secretion of vaginal conceptions or false ideas we have in our minds
fluid increases in women and men tend to feel an about sexuality. So in Masters and Johnsons
intense urge to ejaculate. This phases duration is time, such false ideas generally arose from a lack
highly variable. Some couples extend it to enjoy of information. Nowadays, we suffer from the op-
this interval of pleasure for as long as they can posite: we have vast amounts of sexual informa-
(moving very slowly, stopping for a few seconds, tion; the problems come from not understanding
using gentler stimulation, or changing position, or digesting it well. Pornography is a source of
etc.). In general, women have the capability to pleasure if used well: it can liven up our sex life
extend this period for longer than men. with just a click. The danger is forming a mistak-
en idea of sexuality. This occurs often, because
the models in pornography, though exciting to
watch, are generally far from authentic sexuality.
But let us return to the orgasm. As well as
the physical response, an emotional response
Plateau also occurs. The bond between the couple in-
creases through the release of certain hormones
and through their union, which always signifies
shared pleasure. This huge emotional release
may be experienced as sobbing, crying out, or
Resolution even laughter. Each of us expresses it in our own
way. Both men and women can experience more
than one orgasm in every sexual relation. The
Figure 1. Diagram of the human sexual response cycle. male, if he has ejaculated, needs what is called

Masters of Sex and Sexology

a refractory period (a period of rest before get- was, without a doubt, their sex therapy. In fact,
ting excited again). Women are fortunate in never most of todays effective sex therapies were cre-
requiring this; they can have one orgasm after ated through continuing Masters and Johnsons
another. After the orgasm (or orgasms), little by pioneering work. Their fundamental ideas remain
little normal physical and psychological activity is 100% valid and their proposal continues to be ef-
reestablished: this is the resolution phase. Vital fective, while being adapted to todays needs and
signs recover their equilibrium and a sensation of to new contributions and innovations.
relaxation and general wellbeing takes over. It is important to clarify that sexual dysfunc-
Masters and Johnson defined these four tions, the object of the therapy Masters and
phases excitement, plateau, orgasm and res- Johnson proposed, are just a small part of a
olution but, in fact, they omitted one, the first broad spectrum of possible problems related
and essential phase: desire. Without desire, the to sex. The list would be extremely long. We
sexual response cannot begin. Sexologist Hel- could mention: patterns of problematic behav-
len Kaplan added it to the list in 1979, though, ior (exhibitionism, pedophilia, sexual aggression,
in fact, Masters and Johnson had already spo- compulsive sexual behavior, risky behavior, etc.);
ken of it. They specifically defend a concept of sexual identity problems; syndromes related to
sexuality based on a couples relationship, a violence and victimization (due to sexual abuse in
couple who communicate, far removed from the childhood, sexual harassment or sexual violence,
purely mechanical exercise that sexual relations sexual phobias, etc.); syndromes related to repro-
can sometimes become, a concept including de- duction (due to sterility, unwanted pregnancies,
sire. So, despite not including it in their list, it can abortions, etc.); and sexually transmitted in
be inferred between the lines, especially in their fections, among many other problems and con-
later studies. Despite all this, however, the merit ditions. Some of these disorders can be treated
of having correctly included it in the phases of through therapy, though not all. One must always
sexual excitement lies with Kaplan. seek a suitable professional for each case, and
In men, excitement generally occurs faster, but often an interdisciplinary approach is required.
the duration of the plateau is shorter and more- Leaving aside this spectrum of diverse prob-
over drops sharply. In women, excitement occurs lems related to sex, I want to focus on the aim
more gradually and is maintained for longer, but of Masters and Johnsons therapy: sexual dys-
they also have the capacity to extend the plateau functions. We speak of sexual dysfunction when
and their orgasms. Furthermore, their descent is difficulty exists during any phase of an individuals
gradual (Fig. 1). sexual response (desire, excitement, plateau, or-
All these data were significant to fully under- gasm or resolution) and this sexual response sig-
stand the human sexual response cycle and, nificantly deteriorates. This is a weak definition,
above all, to treat possible dysfunctions. I say but to date we do not have a better one.
above all because Masters and Johnsons most Classic sexology distinguishes between male
important contribution to the history of sexology and female sexual dysfunctions (Table 1). Al-

Table 1. Sexual dysfunctions.

Women Men

General sexual dysfunction (frigidity) Erectile dysfunction (impotence)

Vaginismus Premature ejaculation

Orgasmic dysfunction Delayed ejaculation

Ejaculatory incompetence

Ejaculation without orgasm

Notebooks of the Esteve Foundation N 42

Medicine in Television Series

though this classification is already outdated, it to the lack of a bodily response at the moment of
continues to be used, and therefore is useful to excitement (problems of tumescence), with the
know. So traditionally, women experience three orgasm, or else with pain during sexual relations.
sexual dysfunctions: general sexual dysfunction It is useful to note that the incapacity to achieve
refers to a lack of desire or excitement, and to the or maintain an erection and the absence of vagi-
incapability of feeling pleasure; vaginismus is an nal lubrication have exactly the same origin. Each
involuntary contraction of the vagina that makes expression of a dysfunction has its peculiarities in
penetration impossible; orgasmic dysfunction is each sex and each person, of course, but it is im-
the inability to have orgasms. Where men are portant to understand that common origin. Only
concerned, five dysfunctions are described: vaginismus is an exclusively female dysfunction,
erectile dysfunction is an incapability or difficulty in its own category.
of maintaining an erection; premature ejacula- It goes without saying that where sexual
tion is an early ejaculation, shortly after beginning health ends and dysfunctions begin is highly sub-
penetration, while delayed ejaculation is the op- jective. At what point does a man, a woman, or a
posite phenomenon; lastly, there are men who couple decide that his orgasm occurs too soon?
can have an orgasm but cannot ejaculate (ejacu- It may be that a specific time for one couple signi-
latory incompetence) and the opposite, men who fies a problem, but not for another. At what point
can ejaculate but not experience an orgasm. does her orgasm occur too late? The answer is
At first sight, sexual dysfunction in men and in the same. One couple will seek solutions and will
women seem very different, but in fact this is not adapt; while another will experience it as aprob-
so. Modern sexual research proposes a fresh, lem that affects their sex life. Often there is a clear
much more accurate classification of dysfunc- problem, such as vaginismus, or the lack of an
tions. We now understand that, since sexual re- erection stopping penetration, but things are not
sponse in men and women is practically identical, always so obvious. Sex can be enjoyed even
so are their dysfunctions (Table 2). without an erection. In sexology, we understand
Current sexology, then, explains that, though that each couple is a world unto themselves and
expressed differently, sexual dysfunctions in men we are simply here to help people enjoy their sex-
and women are the same. They may be related uality. Above all, nobody should suffer as a result

Table 2.

Disorders of sexual desire: alike in both sexes.

Problems of tumescence:
In women: these occur as a lack of vaginal lubrication.
In men: these occur as a lack of penile erection.
Problems of orgasm:
Depending on the time of appearance:
Shortly after commencing coitus:
In women this is not considered a problem.
In men it is considered a dysfunction if it is too early in his, her or both of their opinions.
A long time after commencing coitus:
In men this is not considered a problem.
In women it is considered a dysfunction if it is too late in his, her or both of their opinions.
Absence of orgasm: alike in both sexes.
Disorders of sexual pain: alike in both sexes.
Vaginismus: a disorder exclusive to women.

Masters of Sex and Sexology

of their sex life. Often consultations are solved by eliminate the habit of masturbation. In the early
an hours conversation in which some false belief twentieth century, Wilhelm Reich defended onan-
is discarded. Sometimes it is that easy. ism to help recover natural sexual function. It also
Until Masters and Johnson, sexual problems seems quite shocking that, following Galenuss
were classified as medicine or psychiatry. In other recommendations, some of his psychoanalytical
words; problems were classed as purely physio colleagues in Vienna masturbated their female
logical or as mental health disorders. Attempts patients in therapy sessions. This type of therapy
were made to resolve the former with medical is currently prohibited by codes of ethics. What
treatments, and the latter basically through psy- all of these examples point to is that often, what
choanalysis, without very effective results. What doctors or therapists call natural is, in fact, a val-
Masters and Johnson did was to give sexual diffi- ue concealed by a supposed scientific truth. It
culties a human and especially a relational dimen- is very difficult perhaps impossible to establish
sion. They understood that a sexual problem was what constitutes natural sexuality according to
a problem of the couple, not just one person. scientific criteria, and almost always ideological,
And that is how they treated it: the therapeutic moral or cultural criteria come into play.
object was the couples relationship. To give an One sensational example of the connections
example: until that time, if a man had problems between science and morality is the following.
achieving an erection, physical causes were It occurred in 1973 and was the greatest suc-
sought within medicine; or else he was treated cess in medicine, almost a miracle: millions of
by psychoanalysis to discover the origin of his people were cured at a stroke, one afternoon.
impotence. After Masters and Johnson, such How? They simply chose to delete homosexual-
erectile dysfunction was considered a problem ity from the Diagnostic and Statistical Manual of
within the couples relationship: perhaps the man Mental Disorders (DSM), which describes mental
felt pressured, was scared of failure, or of losing disorders. Its editions are updated every several
his partner. Or any other reason within the rela- years, and although it has been highly criticized
tionship sphere might be considered (naturally, because it medicalizes behaviors that perhaps
once having eliminated any medical problems). should not be medicalized, such as homosexual-
This change of approach signified a revolution in ity in its time, it is the manual that psychiatrists
treating sexual dysfunction. and psychologists currently use. Nowadays, ho-
The fact that their therapy contained no trace mosexuality is no longer a perversion, but it was.
of dogmatism or arrogance was a key factor in its Who can assure us that what we currently think
effectiveness. Because sex therapy has a pitfall: of as perversions (or paraphilias, as former per-
what is normal, natural or healthy sexuality? Who versions are called) will not be included among
establishes this? Is it possible for scientific criteria natural sexual behaviors in a few years? It will
to be combined with cultural ones? Is it possible depend on a combination of the science, culture
that the therapist unknowingly functions accord- and morality of the period. In fact, this is simply
ing to his or her morality? a conflict between the individual and society. The
Let us take the example of masturbation sex therapist uses training, information and com-
throughout history. In ancient Rome, the re- mon sense to find the exact point, the best equi-
nowned Greek doctor, Aelius Galenus, recom- librium possible.
mended that therapists masturbate their fe- Masters and Johnson developed a sex ther-
male patients to recover their health. Yet in the apy that strives to put aside moral prejudices to
eighteenth century, the Swiss doctor Samuel view the couple exactly as they are and under-
Tissot, though brilliant in other areas, was con- stand each sexual problem within their circum-
vinced that masturbation caused very serious ill- stances, with huge amounts of common sense.
nesses. In the nineteenth century, many women Yet although Masters and Johnson managed
underwent an ablation of the clitoris (as well as to take sexual dysfunctions out of the context
in Europe and in America until very recently) to of medicine and psychiatry, it is clear they did

Notebooks of the Esteve Foundation N 42

Medicine in Television Series

not arrive there by themselves. Several research- able manner of explaining sexuality and counter-
ers prior to them began to lay down the bases ing myths and taboos.
of what would become modern sexology. Pos-
sibly the most important of them was Alfred C.
In order to function sexually, a person
Kinsey, the first researcher to speak of sexual
needs only a reasonable state of general
habits in scientific terms. This was an almost
good health and an interesting and
revolutionary act. He conducted questionnaires
interested partner.
with thousands of men and women, each con-
taining hundreds of questions. The interviewers As mentioned, Masters and Johnsons work be-
were very well selected, even knowing the ques- gan to lay the foundations for the sexual revolu-
tions by heart, and the questionnaires were well tion. It goes without saying that the sexual revo-
designed, so that the research was thoroughly lution meant huge freedom for men and women
valid. His results brought to light habits that (above all the latter). One could speak of equality
supposedly did not exist. For example, sexual of the sexes, the appearance of the contraceptive
encounters outside marriage were found to be pill and, in many countries, free abortion. With the
frequent, masturbation was quite common and sexual revolution, different types of sexuality were
many people had had occasional homosexual normalized, including extramarital relations, chil-
experiences. One of Kinseys successes was to dren born out of wedlock, homosexual or single-
create a scale for classifying ones degree of het- parent families, and even same-sex marriage. All
erosexuality versus homosexuality. This fact was this was extremely necessary and was fabulous.
revolutionary, because until that time the popu- However, there is a large but. The sexual rev-
lation were classed as homosexual or hetero- olution stems from the freedom to have sexual
sexual. However, Kinseys research showed that relationships with whomever we want, and that
this division is not possible: sexual orientation is is good, but we have reached a point that was
a continuum that stretches from pure heterosex unforeseen in the original sexual liberation: the
uality to pure homosexuality. Each and every one
of us is situated at some point on this continu-
um. The Kinsey Scale (Fig. 2) is still used in some
questionnaires on sexuality, and all the informa-
tion in his surveys, published in two volumes, is
very valuable.
After Masters and Johnson, and above all
from the sexual revolution onward, sexuality
became normalized and studies have become Homosexuality
common (Durex Sex Survey, Encuesta de salud
y hbitos sexuales from the Spanish National 0 1 2 3 4 5 6
Institute of Statistics, studies by the Spanish Kinsey Scale
Federation of Sexology Societies, etc.). Perhaps 0: Exclusively heterosexual
the last study that constituted a social change 1: Predominantly heterosexual,
was Shere Hites, published in the sixties, which only incidentally homosexual
2: Predominantly heterosexual,
builds on Masters and Johnsons and Kinseys but more than incidentally homosexual
studies. Hite conducted thousands of question- 3: Equally heterosexual and homosexual
naires on attitudes and sexual behaviors in men 4: Predominantly homosexual,
and women. The Hite Report was criticized for a but more than incidentally heterosexual
5: Predominantly homosexual,
lack of statistical and data processing accuracy. only incidentally heterosexual
In fact, this is true, because more than an analy- 6: Exclusively homosexual
sis it is a compendium of stories. Yet it is likewise
hugely important, because it is an extremely valu- Figure 2. Kinsey Scale.

Masters of Sex and Sexology

trivialization of sexual relations. Sex is an act reasonable state of general good health and an
of deep and intimate communication that has interesting and interested partner.
physical and emotional consequences. Remov-
ing such importance from sex and turning it into
What happened to Masters and Johnson?
a mere act of physical release is causing para-
doxically the same problems that stem from be- At the time of writing this chapter, two seasons
ing forced to have sexual relations in a marriage of Masters of Sex have been screened while a
we do not want to be part of. third is in production. Nevertheless, since we
Masters and Johnson, in their later works, know Masters and Johnsons real lives, I can
spoke of that intimate connection, of the pro- tell you that (spoiler alert!) he finally got divorced
found dialog between two bodies that transcends from Libby, with whom he had three children.
mere physical contact. They themselves experi- Doctor Masters and Virginia Johnson were mar-
enced such a communion with each other. And ried in 1971. The clinic which they had opened
they chose each other, even while Doctor Masters in Saint Louis a year earlier became the Masters
was still married. One reading is that the quest for and Johnson Institute in 1978. They worked to-
a sexuality that goes beyond a physical release gether until 1992. Virginia, at 60 years old, keen
can be interpreted as a conservative, outdated, to enjoy her final years, her family life and to trav-
almost puritanical stance. I believe it is the oppo- el, became weary of a husband who spent al-
site: it now seems to be the more revolutionary most his entire day locked in his office working.
act. Sexual liberation has provided the very free- In 1993, they divorced. A year later, William, ill
dom to do what we want. Now we must choose with Parkinsons, retired and remarried, this time
well. This does not necessarily mean choosing a to an old flame from his childhood. The Masters
partner to get married. We can choose to have and Johnson Institute closed its doors in 1994,
sexual relations with someone of the same sex, though Virginia kept working almost right up to
with two people, or simply not have them with her death.
anybody. Why not? We can do what we wish. But Doctor William H. Masters died in 2001, and
it must have some purpose and, above all, make Virginia Johnson in 2013.
us feel good. Nowadays, we see many women
in the consulting room who believed in this half-
baked sexual revolution along Sex and the City Bibliography published
lines, who do not choose their sexual partners by the researchers cited
well because they never learned to discriminate Human Sexual Response. Masters and Johnson, 1966.
in that sense. The result (naturally, avoiding moral Human Sexual Inadequacy. Masters and Johnson,
judgment of any kind) is that they feel bad. People 1970.
The Pleasure Bond. Masters and Johnson, 1974.
are capable of experiencing vast sexual pleasure if
Sexual Behavior in the Human Male. Alfred Kinsey,
the partner we are with (in whatever form, wheth- 1948.
er a marriage, friendship, de-facto, or casual sex Sexual Behavior in the Human Female. Alfred Kinsey,
partner) acknowledges us. If they recognize us. If 1953.
The Hite Report on Female Sexuality. Shere Hite, 1976.
we like them and they like us.
The Hite Report on Men and Male Sexuality. Shere Hite,
Doctor Masters, at the end of his life, said: In 1981.
order to function sexually, a person needs only a The New Sex Therapy. Helen Kaplan, 1974.

Notebooks of the Esteve Foundation N 42

CSI and Forensic Medicine

Adriana Farr, Marta Torrens, Josep-Eladi Baos and Mag Farr

A successful model for TV franchising, this CBS series about a state-of-the-science forensics team who
can solve even the most complex cases in a matter of minutes has opened franchises in three different
cities, as well as a new division on IT crime called Cyber. The original fiction, which went to air in 2000
starring the now legendary Gil Grissom as Head of the Las Vegas CSI Unit, shut up shop in 2015 after 15
straight seasons and a total of 337 episodes. Its Miami and New York spin-offs, first screened with notable
success in 2002 and 2004 respectively, wound up ten years later. Cyber, which is still on air at the time of
writing, every week attracts an average of ten million viewers.

Crime Scene Investigation (better known as CSI work of a team of forensic scientists and crimi-
or CSI: Las Vegas) is a US TV series created by nologists who belong to the citys police depart-
Anthony E. Zuiker and produced by Jerry Bruck- ment and investigate some of the crimes occur-
heimer, which premiered in October 2000 on ring there. The team is trained to solve each case
the CBS network, winding up after 15 seasons, through the gathering and analysis of evidence
in 2015. The last episode was feature-length, at the scene of the crime, seeking the guilty and
screened in the US on 27 September 2015. interrogating witnesses and suspects. They work
CSI was a television success in the opening de- around the clock until they resolve the situation.
cade of this century, with a worldwide audience Each episode has a main plot related to a violent
of over 73.8 million viewers in 2009. In 2012, it crime and a subplot that affects the investigators.
was recognized as the most-viewed TV series in The crime or felony is almost always solved in a
the world for the fifth year running, since CSI has single episode.
been screened in over 200 countries. Even so, in
the Emmy Awards it only reaped three trophies
The keys to success
in technical categories. It premiered in Spain in
of the forensic scientists
2002 and its early seasons were hugely suc-
cessful, gaining average audience shares above According to the experts, the original series and
25%. It ran free-to-view on Telecinco and Cuatro, its franchises owe their success to blending
among other channels. crime fiction and medical or scientific genres, as
Such success allowed it to become a fran- well as their style of filming. In terms of the for-
chise that spawned three offspring: CSI: Miami mer,the highlight is on the preciseness and de-
(20022012), CSI: NY (20042013) and CSI: Cy- tail in the gathering and analysis of the evidence,
ber (on air since 2014). The structure of all three taking the perspective of a forensic autopsy, the
CSI series set in cities is very much alike: investi- use of fast, sophisticated technology to conduct
gate the scene of the crime live, gather evidence analyses, including genetics and toxicology, and
and solve the mystery, though each uses differ- the investigators scientific knowledge.
ent characters. The original series is set in the US In its day, CSI used an innovative method of
city of Las Vegas (Nevada) and centers on the filming, using many special effects, plus original

CSI and Forensic Medicine

use of color and light. Furthermore, it is filmed on ing, analysis of biological or material remains,
35-mm cameras, typically used in cinema mov- ballistics, insect recognition, DNA analysis and
ies. The storylines tend to happen at night, the detection of poisons and medication. All this de-
cutting is frenetic, the action changes quickly be- velops at a frenetic pace and the results obtained
tween interiors and exteriors while the aesthetic almost immediately. The investigators consult the
in certain scenes resembles a video clip. The forensic pathologist and discuss the autopsy re-
initial hypothesis of the facts and their resolution sults in detail. They scour databases to identify
are presented as a flashback, either in black and the case, the suspects involved or others who
white or sepia. may be related to the case in some way. The
Due to its popularity, it has received several work progresses with further questioning and the
criticisms both for its degree of graphic violence analysis of new evidence, some from subsequent
and sexual content as well as for the rather unre- murders or fresh crimes related to the case. More
alistic image of the procedure for solving a crime. clues are revealed, or where there is a new clue,
It has been accused of being thoroughly exces- a fresh analysis is made. The suspects may be
sive in its violence. It does not shy from clearly questioned again, new evidence is found or the
showing the injuries victims suffer (always with old reviewed, and the final (correct) hypothesis is
plenty of blood), nor does it avoid decomposing formulated. The case is solved by unveiling and
flesh riddled with revealing insects. During the grilling the perpetrator.
necropsy, cadavers are clearly shown with their
entrails on view. They carry out simulations of
CSI in opposition to reality
blows, reconstructions of the identity of the guilty,
and each meticulous detail in the lab analysis of Despite the fact the shows producers consider
the evidence is always shown. One of the most it realistic, CSI is nothing more than fiction. There
original aspects of the series since it began is the are vast differences between the on-screen story
use of enlargements and micro-cameras to show and the reality of police and forensic investigation.
wounds in the greatest detail, reveal a bullets tra- To start with, on CSI it seems like all the team
jectory, or explore injuries or the inside of organs. members are able to take part in all phases of
the investigation. They travel to the crime scene,
process the scene, gather evidence, interrogate
Applying the CSI method
witnesses or suspects, analyze evidence and al-
The scripts of CSI and its franchises are highly most always operate in the streets or in build-
similar. It starts with the presentation of the crime ings to arrest the criminal. It is unusual in that
or felony before the opening credits. Then the CSI they are armed and use their guns if the situation
investigators arrive to make a highly detailed visu- so requires. In the final instance, they solve the
al inspection of the corpse and the crime scene. crime. They all seem to be experts, though it is
They review the victim in detail, photograph the true thatsome of the technicians only work in the
scene and carefully gather the evidence. This lab, some police do not do biological work and
task is shown with great thoroughness. At this the forensic pathologist only conducts autopsies.
point, witnesses and possible perpetrators are The reality of criminal investigation and foren-
also interrogated while the first arrests are made, sic medicine in every country is quite different. In
if deemed necessary. The investigators discuss fact, there is a clear separation between judicial
the murder details and form their early (normally police, who investigate and arrest the accused,
mistaken) hypotheses regarding events, either scientific police, who gather and analyze evi-
at that moment or after the initial analysis of evi- dence, and forensic scientists, who work in insti-
dence. tutes for legal medicine. Each concentrates on
The work continues in the forensics lab, where their own specialization, without trespassing into
they analyze the evidence using technologically any other professional areas. In Spain, the foren-
advanced methods. These include finger-print- sic analyst does not form part of the investigative

Notebooks of the Esteve Foundation N 42

Medicine in Television Series

team. He or she is a technician who only states Naturally this contrasts with reality, with restric-
her or his findings before the judge. The most tions on equipment, staff and techniques, even in
surprising aspect is the role of the CSI characters countries such as the US. Many techniques can-
in questioning and in arrests clearly an exag- not be applied, and in others, the results may be
geration, more in the realm of fiction than truth. delayed for months or even years. Science re-
The characters in the CSI team appear to be quires patience: it is tiresome and takes time. The
scientists, or at any rate, police officers who apply means are all too often insufficient for the need.
scientific methods to solve cases. They use sci- Fiction forces cases to be flashy and complex,
ence, logic and deduction instead of firearms. Evi- to stimulate interest and last the length of each
dence is the most important factor, and it is always episodes storyline. In the early seasons, several
conclusive, in contrast to the interrogations. This cases were often investigated simultaneously in
is obvious in their attitude: the people interrogated a single episode, but recent seasons have about
lie whereas the evidence is absolute. At the crime one case per episode. The crimes are often
scene, they dress characteristically, identified by based on real cases, but they are presented more
their team jackets. At the police station and crime realistically or are clearly exotic. An analysis of the
lab, they wear lab coats and are surrounded by first season revealed a total of 74 cases investi-
analysis apparatuses and computers. The labora- gated in 23 episodes. Most corresponded to vio-
tory is dark and crowded with equipment, flasks, lent crime (72%), especially murders (64%), rob-
precipitate beakers, test tubes containing myste- beries, rapes, suicides, kidnappings, blackmail
rious liquids and high-technology microscopes. and accidents. Most of the detaineeswere male
The actors are seen handling samples, transfer- (77%) and white (87%). The victims were mainly
ring liquids with pipettes and placing vials into an male (66%) and Caucasian (91%). The crime
analyzer. They review the results and reach perti- was committed mainly using firearms (36%) and
nent conclusions. They all seem to have the skills knives or other cutting instruments (17%). In fact,
of lab researchers and use scientific and medical most investigations are routine and it is uncom-
jargon with ease. The reality is quite different, as mon for a police officer to frequently investigate
the arguments given above show. such spectacular or complex cases.
Both the gathering of evidence and samples, The series reinforces the perception that
as well as their processing and laboratory analysis criminals always leave sufficient clues to enable a
are done using very advanced technology. A suit- crime to be solved, which occurs in most cases.
able apparatus for determining a result is never Despite continuous advances in forensic science,
lacking, the equipment is all ultra-modern and situations exist where there is simply insufficient
even more significantly and startlingly the results evidence to solve the case, or the proof available
arrive lightning fast. This situation is valid whether does not help solve it. It seems that officials re-
consulting identity databases, processing and sponsible for ensuring the law is obeyed and fo-
detecting fingerprints, or analyzing toxicology rensic analysts are always one step ahead of the
or genetic DNA evidence. It seems as if the en- criminals, which often is clearly not true.
tire staff and technology are at the service of the
case in hand. There are no delays, breakdowns,
The CSI effect
queues or waiting around. Everything comes out
at the first try with no need for a repeat. The epi- One of the greatest problems the series brought
sodes do not show the time or preparatory proce- to light were the high expectations created
dures that analysis requires, or the time required among people in real life. Watching the series,
to extract samples, which is always much slower. one would believe that crimes can be solved in
Everything is very easy: the sample is placed in two hours, data processed in minutes and that
the suitable apparatus and the required result im- forensic laboratories are crammed with high-tech
mediately obtained. In the series, all the crimes equipment fitted with lasers to do all the work for
are solved within hours or a few days. you. The truth is that processes are long and te-

CSI and Forensic Medicine

dious, though that does not make them any less ing it to exaggerate situations so as to entertain
important. and consolidate its audience. If, furthermore, one
The CSI effect, sometimes called CSI syn- learns something, even better. Reality tends to
drome, refers to the various ways that the ex- be more routine, slower and more boring, though
aggerated representation of forensic science in as the saying goes, sometimes, truth is stranger
CSI and other TV programs influences public per- than fiction.
ception of criminology. The advanced techniques
shown in these series heighten expectations of
judges, juries and criminals on trial, regarding
the evidence found at a crime scene. The term Deustch SK, Cavender G. CSI and forensic real-
is employed in the US for the demand by juries ism. Journal of Criminal Justice and Popular Culture.
for more forensic evidence in criminal trials so as
Durnal EW. Crime scene investigation (as seen on TV).
to make sounder decisions. The same phenom- Forensic Science International. 2010;199:1-5.
enon is applied to defense lawyers, who request Garca Borras F. La serie CSI como metfora de algu-
a greater amount of incriminating evidence. And nas facetas del trabajo cientfico. Revista Eureka sobre
the same happens with the police: demand for Enseanza y Divulgacin de las Ciencias. 2005;2:374-
proof has likewise increased. The truth is that in 87.
Houck MM. CSI: reality. Scientific American. 2006;July:
most cases, this simply overloads crime and fo-
rensic medicine labs with work. Hughes T, Magers M. The perceived impact of Crime
The success of CSI and other similar series Scene Investigation shows on the Administration of
increased viewers interest in forensic medicine Justice. Journal of Criminal Justice and Popular Culture.
and the number of enrollments in courses on 2007;14:259-76.
Kopacki C. Examining the CSI effect and the influence
the subject. In Spain, reliable data does not ex-
of forensic crime television on future jurors. 2013. VCU
ist of its influence on enrollment in the Degree
Theses and Dissertations. Paper 3178.
in Criminology many universities offer. However, Machado H. Prisoners views of CSIs portrayal of foren-
as occurs with all popular series, it is likely that sic identification technologies: a grounded assessment.
it stimulates interest in the subject and so more New Genetics and Society. 2012;31:271-84.
people choose it as a vocation. Nevertheless, the Marrinan C, Parker S. La gua definitiva. CSI: Crime
Scene Investigation. Barcelona: Ediciones B; 2008.
confusion between criminology and forensic sci-
Oros M. La nueva ciencia forense en la novela y en el
ence can lead to the frustration of expectations cine actual. InterseXiones. 2011;2:199-218.
from those starting to study the former without Smith SM, Stinson V, Patry MW. Fact or fiction? The
knowing what, in fact, it is. myth and reality of the CSI effect. Court Review: The
One of the negative effects of CSI and simi- Journal of the American Judges Association. 2011. Pa-
lar series is that criminals can learn from them per 355.
Tous A. Paleotelevisin, neotelevisin y metatelevisin en
and, as a result, better prepare their actions and
las series dramticas estadounidenses. Comunicar, Re-
carry them out in more detail to leave as little in- vista Cientfica de Educomunicacin. 2009;XVII:175-83.
criminating proof as possible at the crime scene. Tous A. El sorgiment dun nou imaginari a la ficci
The result is greater difficulty for investigators at- televisiva de qualitat. Quaderns del CAC. 2008-09;31-
tempting to solve cases. 32:115-23.
In the end, it is more important to be able to Tous A. El text audiovisual: anlisi des duna perspectiva
mediolgica. Doctoral Thesis. Universitat Autnoma de
distinguish between reality and fiction, between
Barcelona; 2008.
what is a police investigation and forensic medi- Wikipedia, the free encyclopedia. Crime scene investi-
cine, compared to what is TV fiction. The latter gation (CSI). Available at:
aims to depict reality in an amusing way, lead- CSI:_Crime_Scene_Investigation

Notebooks of the Esteve Foundation N 42

Homeland and the Emotional Sphere

Liana Vehil and Luis Lalucat

The producers of the action-packed 24, Howard Gordon and Alex Gansa, have at last earned critical
praise on this adaptation of the Israeli series Hatufim, first broadcast on the cable network Showtime in
2011 and still on air. What began as a game of suspense and ambiguity between a CIA agent suffering
from bipolar disorder (Claire Danes) and a US marine recently freed from captivity at Al-Qaedas hands
(Damian Lewis), has developed into a fascinating spy fiction. Year after year it is ranked among the favor-
ites at the Emmy Awards (it harvested six trophies in its premier year), and has even hooked President
Obama himself.

Its different emotional states, as well as its an- sions taken at lightning speed, it represents the
guish, have generated a great deal of interest supremacy of action over introspection. Though
among the different narrative arts. The history of the series main aim does not lie in describing its
literature lets us see into the lives and passions characters mental functioning, the scriptwriters
of fascinating characters. We could mention offer viewers elements to identify with them by
Madame Bovarys day-dreaming and emotional showing how continued exposure to situations of
deception in Gustave Flauberts masterpiece, or risk can affect ones mind and emotional states.
the affective sufferings of the characters in Fy- The storyline focuses particularly on the main
odor Dostoyevskys novels, held captive by their character, Carrie Mathison, a CIA agent who has
emotional development and a heightened intro- been diagnosed with bipolar disorder.
spective view of their life experiences. Film in par- Bipolar disorder is considered one of the
ticular has explored the human personality and most significant psycho-pathological disorders
helped us to experience the reactions of fictional affecting mood. This name is given to disorders
characters as our own. Firstly films, and more that are characterized by mood swings. Ones
recently TV series, have fascinated us with the mood consists of a range of emotions that differ-
lives of their everyday heroes, showing us their ent experiences evoke in one. These emotional
likenesses and revealing our own fears and de- states and resulting behaviors are considered
sires. The treatment given the emotional states healthy and within the norm when they adapt to
constitutes, in fact, the cohesive core of any film the context in which they are expressed. Gener-
genre such as melodrama, which from Douglas ally, at the risk of oversimplifying for clarifications
Sirk to Pedro Almodvar, and including Rainer W. sake, within the range of reactions appropriate to
Fassbinder and recently David O. Russells Silver their setting we would include annoyance at an
Linings Playbook, submerges us in the depths of injustice, sadness when facing loss, or happiness
the most extreme human emotions. at good news. Losing control in expressing ones
Homeland is an action series that centers on feelings would also be considered acceptable as
the coverage of international conflicts and the would exaggerated annoyance at highly stressful
fight against terrorism. Fast-paced, with deci- situations if they occurred momentarily. On the

Homeland and the Emotional Sphere

contrary, in assessing a disorder one should con- lucinations. Sometimes they require psychiatric
sider whether these reactions occur repeatedly hospitalization.
or in an exaggerated way, with no apparent quali- In the above descriptions, it is easy to recog-
tative or quantitative link to outside stimuli, and nize some of the moments and behaviors Carrie
whether they determine the individuals relation- experiences: she seems to fall into a hypomanic
ship with surrounding reality. state when she makes decisions following her im-
Considered to be a serious mental disorder, pulses without considering the risks associated
bipolar disorder, formerly called manic depres- with them, or shows signs of an exaggerated
sion, is characterized by changing moods. These self-esteem that does not seem congruent with
swing between two opposite poles: the mania, or her context. Yet at the same time, she maintains
phase in which the subject appears exalted, eu- a high level of competence. She is capable of
phoric and harbors grandiose delusions on one establishing a significant personal relationship
hand; and on the other, depression, the phase to which she remains emotionally faithful, and
where sadness, inhibition and thoughts of death of modulating her irritability. Nevertheless, she
predominate. Such fluctuations can be observed also displays a more serious clinical presenta-
in Carries character when at times she gets into tion at such times as those behaviors escape
situations of great risk from solely following her her control, she loses her capacity for empathy,
impulses, disregarding her colleagues warnings, becomes submerged in her emotions and even
or else the opposite when, discouraged, she has distorted perceptions and invents delirious
shuts herself away, and is wracked by sobbing, conspiracy ideas. This is when she needs to be
even attempting suicide. hospitalized.
This initial schema of cyclical alternation be- Carrie likewise shows symptoms typical of the
tween mania and depression does not occur depressive phases when overwhelming feelings
evenly in all individuals suffering from this dis- of sadness and despair, tiredness, anxiety and a
order. Cases occur in which the alternation be- marked alteration in her vital rhythms, such as in-
tween euphoric and depressive states are com- somnia and appetite loss, appear.
bined with more or less prolonged phases of full The information provided by the series might
stability and functional restitution, with a good also bring to mind a mixed episode; in other
response to treatment, absence of associated words, one simultaneously combining manic and
problems and a return to a fully independent life. depressive symptoms. So symptoms of hyperac-
Even so, most people tend to face more of a tivity, worry, feeling down, a tendency to cry and
torpid evolution, with frequent relapses and the feelings of guilt can be associated. As the series
manifestation of other associated clinical features reflects, such variability of the mixed episode
like anxiety, substance abuse and some degree hugely complicates diagnosis and treatment, and
of functional deterioration. has the more negative consequence of increas-
During manic phases, patients can also mani- ing the risk of suicide.
fest contrasting states. On one hand is hypo- Given the variability of clinical presentations,
mania, a euphoric state in which individuals ap- bipolar disorder has been subdivided into two
pear to be in a buoyant and expansive mood, conditions: bipolar I disorder (BP-I), is character-
alongside irritability and impulsiveness, disquiet, ized by alternation between depressive and man-
agitation, uninhibitedness and verbosity, which ic episodes; and bipolar II disorder (BP-II), by de-
nevertheless does not significantly interfere with pressive and hypomanic symptoms. In our case,
daily activities. On the other hand is a marked Carries behavior rather resembles BP-II disorder.
state of mania in which manic symptoms of a Investigations developed around the etiologi-
more invalidating nature predominate. The latter cal hypotheses of the disorder show the impor-
seriously interferes with the individuals functional tance of the genetic load, which points to greater
performance, going as far in certain cases as de- personal vulnerability and seems to confirm that
veloping psychotic symptoms like delirium or hal- the presence of a disorder on the bipolar spec-

Notebooks of the Esteve Foundation N 42

Medicine in Television Series

trum in a parent increases the chance that de- may involve an evolution toward chronicity. In
scendants will suffer from it. As occurs with other fact, the frequency of critical episodes gradually
complex mental states, the causes tend to be increases, until two episodes occur in a very brief
due to multiple factors and consequently the in- interval of time.
fluence of other aspects linked to development The quality of therapy plays a large role in the
are highlighted. Altered or unstructured family disorders development. Because it is a highly
relationships in childhood may be another fac- complex disorder, it requires a complete treat-
tor added to the genetic variable, and contrib- ment, both medical and psychological, incor-
ute to forming a fragile psychological apparatus, porating rehabilitative interventions. The series
capable of unleashing the disorder in later life. In fundamentally covers pharmacological treat-
addition to having a father suffering the same ill- ment, the situations requiring psychiatric hospi-
ness, some of Carries family experiences could talization, and certain general recommendations
be related to the tricky regulation of her moods. in relation to healthy living patterns. Given the
Her mothers difficulties in confronting mental suf- importance of the subject, we will briefly outline
fering, plus her own instability in relationships and a description of the recommendations issued in
her fathers manifest psychopathology, bring to clinical practice guides.
mind an atmosphere in which emotional conflicts When designing therapeutic interventions,
generate circular dysfunctional movements that great significance is attached to the extent of ca-
feed into each other, causing huge discomfort pability and commitment the individual must as-
and hindering the resolution of vital problems. Es- sume. Any professional intervention runs the risk
cape from the suffering as a mitigating resource, of not being suitable, or being interrupted, with-
instead of dealing with grief, may have scarred out the involvement and agreement of the suffer-
her familys emotional environment. In the series, er. So it is essential that the individual is aware of
Carrie rarely trusts in introspection to confront the distinctive features of their disorder, that they
and overcome her conflicts and losses, while she know the protective and risk factors associated
opts for life choices that may encourage the de- with it, as well as the importance of maintaining a
stabilizing of her emotions and contribute to her high level of self-care. For the same reason, it is
psychopathological development, such as her advisable that individuals are able to establish alli-
taste for risk and a choice of job that often sub- ances with the professionals responsible for their
jects her to situations of stress and high risk to treatment and with different family members.
her physical and mental health. Despite her scarce awareness of the risk, Car-
We know that bipolar disorder often evolves rie always trusts somebody: when she refuses
toward chronicity. Its most invalidating manifesta- to talk to a psychiatrist who might monitor her
tions tend to appear progressively over a lifetime, medication, she tends to follow the advice of her
and, in general, limit the individuals functional sister, who is both a family member and doctor. In
capacity. However, it is not shown like this in the critical circumstances, she places herself volun-
series, since Carries behavior seems perfectly tarily in the hands of the mental health system to
adapted to her employment context. She of- receive electroshock therapy. Unfortunately, from
fers the image of somebody frequently dealing what we can see, she is not consistent enough in
with emotional crises and physical risk yet she caring for herself, one of the significant aspects of
achieves optimum results in resolving the tasks maintaining clinical stability.
she is set. Only at certain moments does the Currently, pharmacological treatment is con-
tension get too much, affecting her capability to sidered fundamental, above all based on lithium
work and the caliber of her interpersonal rela- salts and other mood stabilizers, but so is partici-
tions. We do not have sufficient data to evaluate pating in a therapy process of psychological and
the foreseeable evolution of the disorder, and one rehabilitative interventions. Carries father, who
must always consider the variability of personal suffers from the same disorder, tells his daughter
characteristics. However, in Carries case, this about his personal experience with the medica-

Homeland and the Emotional Sphere

tion he is on. At other times, he tells us about the an important figure in the US for many years, and
prescription of different drugs, though he men- is acquiring increasingly greater prominence in
tions no medical monitoring system. Spain.
It does not appear he has been recom- Although the capacity for resilience and recov-
mended or tried any structured psychological ery the individual displays should always be taken
or psychosocial intervention beyond certain into account, bipolar disorder poses significant
general recommendations on healthy living pat- problems of a diagnostic and therapeutic nature.
terns. In contrast, currently, a better prognostic In effect, among the various episodes, appar-
is associated to systematic health monitoring ently symptom-free, deceptive intervals tend to
that offers information on the illness and train- appear, which may lead to the sudden abandon-
ing in strategies for combating it. This aims to ment of treatment and the appearance of fresh
optimize handling of the disorder, instructing in relapses. This is what occurs on the occasions
early detection and consequent immediate ac- when Carrie abandons her drug treatment be-
tion when new symptoms appear that forewarn cause she does not feel the need to keep tak-
of a relapse. ing them. This behavior, highly inadvisable in care
Electroshock therapy, which the heroine un- practice, seems to be linked to the most critical
dergoes, is recommended in cases of serious periods of her life and leads to greater psycho-
depressive symptomatology in which any other logical instability.
therapeutic intervention has been shown to be As stated in the Gua de prctica clnica del
unsuccessful, or if the situation is deemed a risk trastorno bipolar (Practical Clinical Guide to Bipo-
to life. Carries desperation and her sense of lar Disorder) published by the Spanish Ministry of
finding herself at a dead-end attract her to this Health, according to several studies conducted in
option, despite being informed of the negative different sociocultural media, patients with bipolar
consequences such treatment can have on her disorder display symptoms during a substantial
cognitive capacities. part of their lives. These phases with clinical mani-
In the course of treatment, great importance festations can cover from a third to half of their
is attached to the presence and participation of lives, with predominance of depressive symp-
family members and other close friends who can toms. It is therefore essential to treat this disorder
contextualize symptoms and grant them a mean- longitudinally, knowing that after the appearance
ing that resonates with individual identity. They and resolution of manic or hypomanic symptoms,
can encourage the maintenance of healthy be- the risk exists of a fresh relapse. Between two
haviors, the reduction of risky behaviors and help thirds and three quarters of patients hospitalized
accommodate phases of greater stability. Such for mania will again be admitted for the same
participation can also be an element of training to cause in the future. The percentage of patients
suitably intervene in crises, after prior agreement with a single episode does not surpass 15%,
with the affected individual. Homeland grants a while the most frequent percentage of relapses
privileged role to family. The sister is idealized over a lifetime falls within the 722% range.
as a mother figure and absent carer, while she The seriousness linked to bipolar disorder is
also acts as guarantor that the pharmacological generally attributed to lifestyle factors associated
treatment is being followed. She is attentive to with it, and to substance abuse, which frequently
the phases of instability that can precede a crisis, occurs during or between episodes.
and offers support during the times Carrie is inca- Based on these data, Carries future does
pable of fulfilling responsibilities taken on impul- not seem very optimistic, though it is true that
sively. The father personifies a figure who speaks in her case some of the more frequent conse-
from a viewpoint of first-hand knowledge and quences of the disorder are not present, such as
experience, aware of the disorders seriousness functional deterioration and difficulty in maintain-
and having overcome his most conflictive peri- ing satisfactory employment activity. Were such
ods. His is the survivors voice, which has been evolution confirmed, it would enable us to trust

Notebooks of the Esteve Foundation N 42

Medicine in Television Series

in a satisfactory evolution. However, as we see in The series chooses to convey a message of

Homeland, Carrie does not maintain her pharma- hope, one that is not always fully justified, but
cological treatment regularly, she consumes al- which hints at the chance to overcome the disor-
cohol often, experiences continual risk situations der. Nowadays we know that certain well-known
and her vital rhythms match the most inadvisable figures who are no longer with us suffered from
behaviors for reaching affective stability. In the se- this disorder in their time. We admire them for
ries she remains constantly active, is efficient at their historical value and courage in a sustained
her job and recovers from her most critical mo- fight to recover their faculties. Currently, moments
ments by adapting to new contexts with resolu- of hope are also experienced every time a well-
tion. In part, this capacity to overcome is related known and respected person makes theirdisor-
to her character, a true fictional heroine who is der known and agrees to share both their suffer-
capable of becoming larger than life itself. Yet it ing and their triumphs with us.
is also true that there are people who can face The scriptwriters display a firm sense of bal-
dramatic situations thanks to their great personal ance and sensitivity by presenting a heroine who
fortitude. We should not forget that studies moni- suffers from a mental disorder that is considered
toring people with this disorder record a (small) serious, without hiding the more disquieting as-
percentage of cases that evolve favorably. pects of her illness. Yet meanwhile they get us to
In Homeland, description of bipolar disorder value and identify with her due to her overall per-
symptoms in their different evolutionary moments, sonality. Carrie is a competent person, who pos-
of the fluctuation between phases, of pharmaco- sesses myriad personal capabilities. She is suc-
logical and medical treatment in general, of the cessful and respected in her professional sphere.
recommendations concerning lifestyle habits and She is surrounded by people who love her and
the importance of family participation in the heal- worry about her, and her identity is linked to her
ing process, respond faithfully to descriptions of overall personality, not to her illness. This is now
international clinical classifications and the rec- the challenge set by the movement fighting to rid
ommendations in the clinical practice guides in those people suffering from a mental disorder and
use. As we saw, it is possible to find examples by extension their family members and the profes-
of many aspects of the disorder presented with sionals attending them of any sort of stigma or
great coherence. The series also conveys to what discrimination. Carrie prompts no rejection from
extent this disorder can affect different aspects viewers. Instead, it is easy to identify with her, feel
of life, guiding us on the combative attitude that jealous of her successes and share her suffering.
suffers must maintain. The series lacks a greater reference to the
It is likewise true that some of the most in- need for integral, structured, integrated and on-
validating and painful consequences of this dis- going therapy, which responds to the extreme
order are omitted or smoothed over, as shown complexity of a disorder that affects different
in clinical practice. Many affected individuals see aspects of life. On one hand, this means mental
their lives completely changed and do not man- health, and with it the capacity to tolerate emo-
age to overcome the progressive worsening of tional pain, create conflicts and be able to build
their personal relationships or their progressive satisfactory personal relationships, and on the
loss of functional autonomy. Behind the appar- other, physical health in its different dimensions.
ent dynamism and speed of response that Carrie Nevertheless, Homelands great truth, from the
displays could nevertheless hover her difficulty in viewpoint of disseminating information on mental
regulating her moods or her incapacity to resolve illness, consists of coherently integrating, with-
her emotional conflicts, incorporating prepara- out interfering in the plot action, a positive and
tion processes and coping with the suffering they seductive character who suffers from a serious
lead to. mental illness without judging her.

Notebooks of the Esteve Foundation N 42

Olive Kitteridge and Depression

Oriol Estrada Rangil

HBO miniseries tend to have few rivals in the award ceremonies. There were good reasons why this
exquisite, four-episode production, aired in 2014, triumphed at the Emmys, winning a total of eight statu-
ettes. Three of them went to the cast, responsible in good measure for its impeccable results. Bill Murray,
Richard Jenkins, and especially Frances McDormand, all help to reflect the personality of a dour woman
with depressive symptoms in an objectively bucolic setting. The script adapts the novel of the same name
written by Elizabeth Strout, the 2009 Pulitzer Prize winner.

It seems as if the entire world knows what depres- discussion on how different North-American gen-
sion is, but very few people truly understand it. erations have confronted this illness.
It is not unusual at all to hear somebody say In the original novel, Olive Kitteridge is basical-
they are depressed. It means no more than ly the common nexus by which the stories of sev-
thatthey are rather sad for some setback or mis- eral families in that small town of Maine are told,
hap. Even if in some cases such sadness may be where neighbors still know each other by first and
more than justified, in others it is no more than last names. She is not necessarily the protago-
the simple expression of a passing sentiment, a nist, which is an aspect the TV series has man-
feeling that will vanish once the worrying problem aged to respect up to a certain point. Olive does
has been solved, or even if the sun comes out the not take absolute prominence until we reach the
next day. Depression has entered our everyday last of the four episodes forming the miniseries.
vocabulary, but that does not mean we are using This leaves the door open for us to get to know
the word correctly. What is more, in the immense the stories of the people surrounding her, and we
majority of cases we are doing a disservice to realize that depression and mental problems in
people truly suffering from clinical depression. general abound in the chilly lands of Maine.
When Olive Kitteridge explains to her son One of the first characters introduced is her
Christopher what depression is, she describes husband, Henry, ironically the village pharmacist.
the sufferer as somebody with bad wiring, His first customer is Rachel, who apparently suf-
someone poorly put together. This is merely a fers from depression, and she tries to convince
figure of speech, far removed from depressions Henry to give her more Valium than he should.
complex reality, but behind it lurks an idea that is The pharmacists reaction is a good example of
actually based on many psychobiological theo- how people who truly do not understand depres-
ries regarding this mental illness. The award- sion react to it. First, he advises her to get out of
winning HBO miniseries, Olive Kitteridge, which the house, since according to him it is good to
adapts Elizabeth Strouts Pulitzer-winning novel, get out when youre feeling blue. Henry uses the
perhaps does not aim to place depression cen- word blue, which can mean both depressed
ter-stage, but thanks to tiny gems such as the and sad. His customer replies: Christ, Henry,
aforesaid scene, it is a good departure point for a blue is what I feel on the good days. The phar-

Olive Kitteridge and Depression

macist continues in the same vein, recommend- interest in certain activities), weight loss or in-
ing insistently that she goes to buy light bulbs of crease, insomnia or hypersomnia, psychomotor
a higher wattage, at least until the end of winter slowdown or agitation, asthenia (the sensation of
when the days get lighter and less gloomy. This physical weakness), recurring feelings of useless-
scene perfectly sums up the way many people ness or guilt, a reduction in intellectual capacity
keep treating and (mis-)understanding this dis- and recurring thoughts of death or suicidal ideas.
order. And this customer expresses what many All of this must affect the individuals social or
people suffering from clinical depression would working life in some way, and must not be related
scream to the four winds every time somebody to organic diseases or drug use, nor with habitual
tried to jog them out of this state with a couple of grieving for somebody who is deceased.
well-meaning platitudes, not understanding that So is Olive Kitteridge suffering from depres-
the problem needs more than brighter light bulbs sion? She is convinced she is. And it is likely that
and a few strolls around town. the DSM mostly agrees with her. Her irritability
Clinical depression is not simply being down- is something that leaps out she has very little
cast or sad. Neither does it refer to feelings that patience and is capable of getting annoyed over
one might experience over a work or relation- any detail. Anhedonia is one of the characteristics
ship crisis, or even at the death of a loved one. that best defines Olives personality, and through-
Problems like these can unleash depression, but out the series she shows a (pathological?) lack
despite most people having phases like these in of interest in any of the things that happen to
their life, not everybody ends up suffering from her. Henry gives her a card for Valentines Day,
this disorder. Clinical depression is a syndrome, a which ends up in the waste. Years later, he gives
set of symptoms related to the individuals affec- her another card, simply to say he loves her, and
tive capacity. One in six people will suffer from it she gives him a hug, displaying possibly the least
at least once in life, most of them from 18 to 44 emotion ever seen on TV. Her sons wedding is a
years old, on average starting at 27. Women are good example. On a day in which her husband
at greater risk of suffering from it, doubling the gets emotional and feels happy because his son
prevalence ratio of men. Its origin is from multiple will be living nearby, Olive is incapable of show-
factors, or rather that different elements intervene ing anybody a smile, even telling her son that she
which cause the illness; one of these tends not hopes the ceremony will be short.
to be enough, but these factors must occur to- Clearly, all of this affects her capacity to re-
gether. late socially, and many guests feel chastised by
It is not easy to diagnose. It cannot be de- her conversations. Yet physically it does not ap-
termined by analyzing blood or any other kind of pear that Olive has many problems, since she is
biological markers to indicate whether somebody always busy, whether cooking, tending the gar-
is suffering from depression. A psychopathologi- den or working at the high school. However, the
cal, clinical diagnosis must be made, normally only scene in which we see her teaching shows
based on the directives set in the Diagnostic and us how strict she is in the detention room with
Statistical Manual of Mental Disorders (DSM), students punishments (to give us yet another
published by the American Psychiatric Associa- example of her impossible nature). Even so, we
tion. This manual describes a number of symp- still do not know whether Olive suffers from other
toms which, according to their presence and symptoms that would be required to diagnose
degree, determine whether a person is suffering her with MDD. The question is, do we not see
from any type of depression. So to diagnose a them because they are not shown, or because
major depressive disorder, the individual must they do not exist?
display a minimum of five of the symptoms de- A better example seems to be the pharmacy
scribed, for at least two weeks. These symptoms customer, Rachel, who is incapable of enjoying
include sadness, dysphoria and irritability, anhe- anything, who spends her day sleeping on the
donia (which is the incapacity to enjoy or display sofa (hypersomnia), forgets to collect her son

Notebooks of the Esteve Foundation N 42

Medicine in Television Series

from school (affecting her family life) and needs mainly due to genetic reasons, or because he
Olive to come and spur her on to get dinner ready has led his entire life watching his mother act like
for her boy. It is that incapacity to see the posi- a depressive person? Living on a daily basis with
tive side of things, and having the certainty that somebody who considers that everything is done
nothing can improve in future, which best de- badly, who barely smiles and makes your life hell,
scribes the typical patient of depression. And it as Christopher recognizes years later, is not the
is not something that will change with a slap on best way of preventing depression from develop-
the back and a 200-watt light bulb. As presented ing. Remember that not everything is based on
at the start, Rachel seems to be the most ste- genes. Many other factors must come into play
reotypical example, though we then see that in to unleash a depression, and the social factor is
reality her problem is even more complex. likewise important.
What probably is not so well known is the ge- Health sciences have other resources for try-
netic factor, which can play a significant role in ing to overcome this obstacle: adoption studies
the development of clinical depression. Doubt- and studies on twins. Adoption studies try to de-
less, ignorance of this factor helps stoke certain termine to what extent genetics have influence
opinions and ideas on how depression functions. in a specific environment. So a comparison is
But Olive, ahead of her time, is clear that a ge- made between children adopted by a healthy
netic relationship exists. Resuming the conversa- family and high-risk children, those who live with
tion on depression with her thirteen-year-old son, their biological parents and suffer from the syn-
she insists that he must know what it is, since his drome. What has been observed is that children
family has always suffered from it. She is con- with the genetic factor who have been adopted
vinced that her son will also suffer from depres- by a healthy family have greater chances of de-
sion throughout his life, and the truth is, as an veloping the illness than the general population.
adult he will end up taking Prozac and attend- But once more, controlling the environmental fac-
ing different types of therapy. During dinner, Olive tor can place this in doubt, so studies of twins
mentions her father, who suffered from depres- seem the best way of determining the respective
sion and ended up committing suicide. Further- weight of genetics and environment. In these, the
more, she claims that her husbands mother went results in different types of twins are compared:
through the same. To this, her husband replies monozygotic (who are identical) and dizygotic
that his mother simply had her moods. Wheth- (who share only half each others genes), and
er Olive is right, or simply analyzing their parents one of the conclusions is that genetic inheritance
and son from her own bias of considering herself plays a considerable role (present in 40% to 60%
depressive, is something that viewers must de- of cases). This tends to occur more frequently
cide by watching the series to the end. But at that with serious depressions and mainly in the case
point, they table the issue of genetics, the heredi- of women, but it also occurs in men, especially in
tary factor of depression, which is something the those cases in which depression starts at under
series should be applauded for. 30 years old.
Science seems to agree with Olive, and Studies on twins also enable environmental
studies of families show that an individual has a factors to be identified that can have some effect
greater risk of suffering from depression if a di- on the development of depression. This is an ill-
rect family member has suffered or is suffering ness triggered by multiple factors, and the genet-
from it. While the prevalence in the general popu- ic or environmental questions alone do not seem
lation is about 5.4%, this increases to 15% for to be enough of a trigger. These studies show
family members with precedents (figures that are, that certain stressful life events have a causal ef-
in fact, a far cry from Olives grim determinism). fect. Some examples are the death of a loved
Nevertheless, this type of study has a risk, which one, separation and even harassment (such as
is that the environmental factor cannot be con- bullying). This means that among identical twins,
trolled. Does Olives son suffer from depression despite them both having the same genetic risk,

Olive Kitteridge and Depression

if one experiences certain stressful episodes dur- question, which could explain why so many peo-
ing their life and the other does not, the former ple with a depressive disorder are concentrated
has a greater probability of suffering from depres- in the same spot. The typical endogamy of more
sion than the latter. Yet we must emphasize the isolated regions may offer an explanation for this
idea of non-determinism: the fact that one has (apart from the authors choice to set the story
a genetic predisposition, and even experiences there, naturally). Yet as noted, this is a continual
several stressful events during their life, does not sum of factors, and one must not only take into
mean they will definitely develop depression. Per- account psychosocial and environmental as-
haps the clearest example (a somewhat simplistic pects, but genetic ones.
view, we admit) is that of a lottery: almost every- Olive seems to display some characteristics
body has tickets, and some people have many typical of a depressed patient, yet throughout
more than others, but that does not guarantee the series, she is able to overturn our assump-
they will win the lottery. So Olive has given her tions with some of her statements and behaviors.
son several tickets, but it is impossible to know Perhaps her posture regarding the illness is what
whether the winning ticket is among them. locates her more in the terrain of fiction than in re-
What the series makes clear is that being born ality. She claims she suffers from depression, but
and living in Maine guarantees you have a good this does not seem to constitute a problem it is
number of tickets in that lottery. Is this because rather a feature of her personality. One could say
of the climate? The idea that a cold, dark location that she even feels happy with it, and has never
such as the state of Maine, with a lot of humidity done absolutely anything to shake off this apathy,
and not much sun, is the perfect place to de- or to improve her social relationships. The irony
velop depression is a widespread literary clich with her husband being the pharmacist is that
and we see little sun in the series. The popular she has never undergone pharmacological treat-
belief that ones surroundings, in the most literal ment. Furthermore, it seems she has no great
sense of the word, have an effect on ones mood love of psychologists and psychiatrists either,
is made patent here. But is this belief true? It since, in her sons words, she thinks headshrink-
seems to be true that winter or fall, the seasons ers are the devil.
with least sunlight, have an effect on our sero- No, Olive does not seem to be upset at having
tonin levels (the so-called mood or pleasure hor- to live with depression. She goes even further:
mone), and so are periods that are more prone when talking about the illness with her son, she
to depression. Seen in this light, it seems that says it goes with being smart, that only normal
Henry was partially right when he recommended people are happy and only intelligent people suf-
Rachel purchase more powerful light bulbs. In fer from depression. Ernest Hemingway thought
this argument, cold places such as Maine have the same, saying it was quite strange to see
a propensity for developing the illness. Therefore, somebody both intelligent and happy. The idea
the number of individuals with depression would that mental illness is associated with intelligence
tend to be greater in comparison with other ar- or creativity has existed for a while. It even seems
eas with a more agreeable climate. However, in to have been demonstrated that certain types of
a study conducted in the US from 2006 to 2008, psychiatric disorders (schizophrenia, bipolar dis-
the prevalence of different forms of depression order) are more prevalent in artistic profiles. But
was greater in states such as California and Flor- the idea that intelligence and depression have
ida, which enjoy a much warmer climate. In fact, a more or less direct relationship is something
it is precisely in the southern states (Louisiana, that has never yet been fully proven. Some stud-
Arkansas, Mississippi, Alabama, etc.) where the ies claim this is so, while others deny it. Some
prevalence of depression is much greater, far sur- claim that intelligent people tend to worry more
passing 10%, while in Maine it remains at 7.9%. as they are more aware of the dangers in their
So if the environment is not always a determi- surroundings, and it is precisely this attitude that
nant, we have to fall back again on the genetic enables greater survival. Nevertheless, if we re-

Notebooks of the Esteve Foundation N 42

Medicine in Television Series

call that US study on depression, we see that Olive avoids, of a character whose mother com-
not having higher studies seems to have a rela- mitted suicide. Likewise, the suspicion hovers
tionship with the prevalence of depression: the that certain accidents, one fatal and the other not
lower the educational level, the more chance of so, were in fact intended. There is even a con-
developing it. So concluding that depression is versation in the third episode where the issue of
exclusive to intelligent people is still too risky and suicide is openly raised as a solution to all ones
simplistic. Firstly, because the concept of intel- problems.
ligence remains, to this day, a highly contro- The reality is that, of all those who at some
versial subject. The idea that there are different point express a wish to kill themselves, only
types of intelligence therefore that we cannot 10% are successful. In the US around 30,000
speak ofintelligent people but of people with cer- people commit suicide every year, but more than
tain intelligences is gaining increasing relevance. 500,000 attempt it. There can be several failed at-
For example, if we speak of emotional intelligence tempts, and a third of them will try again within a
(a relatively novel concept), research shows that, year. It is the fourth cause of death in the US, and
the greater ones emotional intelligence, the lower most victims are from 15 to 24 years old. Speak-
the incidence of depression. Meanwhile, another ing of depression, one in six people who suffer
study demonstrated that people with greater lin- from depression try to commit suicide (implying
guistic intelligence were more prone to suffer from they are unsuccessful). In the light of these data,
anxiety or even depression. the degree of effectiveness of the characters in
The latter quickly prompts us to think of Olive Olive Kitteridge is surprising. As mentioned, in the
Kitteridge again, more specifically her lover, the lit- same series they often talk about suicide. Some
erature professor, who she considers interesting, see it as a solution, even an honorable way of
and truly intelligent, and with whom she seems to ending their misery and problems. Olive seems to
get on much better than with her husband. The play with the idea quite disconcertingly. She will
same occurs between Olive and Rachels son defend at some point that suicide is no solution at
(Rachel, the depressive customer we saw early all to ones problems, or add that it is a dirty way
on) with whom she deals more tactfully than with to go, and always affects somebody negatively,
her own son. Likewise, this young man seems while at other later times in her life, she claims
to understand his literature professor extremely that once her dog is dead, she will have nothing
well, closing this circle of intelligent depressives left to do than shoot herself. She says this in an
with affinities in the town of Crosby. Shortly after- exaggeratedly rational tone, arguing that she no
wards, we discover both he and his mother suffer longer has any more roles and so, therefore, her
from bipolar disorder, not depression, reinforcing existence has no more meaning for anybody.
afresh the relationship between intelligence and Like depression itself, suicide is a complex,
mental illness, and meanwhile the genetic ques- multi-factored phenomenon. Purely psycho
tion of its development. Are we being sold a ro- logical and social factors may intervene, but it
mantic idea of depression? I would not go so far, is also explained by neuro-biological processes.
because Olives story is anything but romantic. Though much remains to be studied on this is-
She will tell her husband he is too good for her, sue, it seems clear that suicide victims have a low
and apologize for being a bad wife, recognizing concentration of serotonin, the substance that,
that she has made his life really tough. And she as mentioned above, modulates our feelings of
herself, when talking about her fathers suicide, pleasure and moods. In the brain, this mainly
says it is neither a pretty end nor a clean one. seems to affect the neurotransmission of sero-
Inevitably, suicide always hovers around de- tonin in the prefrontal cortex, the hippocampus,
pression. In the first scene of the series, we see a the hypothalamus and the septal nuclei. Among
very aged Olive heading out into the woods with its functions, the prefrontal cortex is in charge of
a loaded gun, ready to end her life. The death cognitional control and behavior, which, if dam-
of her father is ever-present, as is another, which aged, can increase impulsiveness and affect our

Olive Kitteridge and Depression

capacity for decision-making. If to this is added even suffer mixed episodes. These episodes
damage in the hippocampus, which controls can last between one and two weeks, and occur
emotions and stress, and the capacity to recall throughout the day. Rachel, who seems to be the
recent facts, then we have an individual who can classic depressive patient, later reveals she has
lose their capacity to make suitable decisions for bipolar disorder. In fact, this is a common diag-
the context in which they find themselves. Lastly, nostic error, since many patients only seek help
damage to the septal nuclei seems to be related during their depressive episodes.
to development of pessimistic feelings. There- Bipolar disorder may sometimes be accom-
fore, committing suicide is not normally a rational panied by certain psychotic symptoms (including
and premeditated decision, but a cumulus of fac- hallucinations), and is often diagnosed wrongly
tors added to each other until they explode. This as schizophrenia. As a matter of fact, one of the
is why Olive Kitteridges calmness when planning most surreal and striking images in the series is
her own suicide is possibly quite divorced from linked to this disorder. At the start of the second
the reality of a depressive person. episode, we meet the adult version of Rachels
It is not just depression that is closely linked son, Kevin Coulson, who has returned to the
to suicide, but also bipolar disorder (likewise town hiding a weapon in his car trunk. Olive, who
seen in the series), schizophrenia, post-traumatic seems to have a sixth sense concerning mat-
stress disorder, borderline personality disorder, ters linked to suicide, ends up getting into the
consumption of alcohol and drugs, and certain car to distract him. This is when we realize Kevin
stressful facts that may be related to financial may have inherited the illness from his mother.
problems or interpersonal relationships. It could Although the only thing we know is that thanks
be one or several of these factors together that to this, he has studied psychiatry, probably to
end up leading a person towards attempting understand what happened with his mother and
to take their life. Yet depression remains one of what is happening to him. We realize our error
the foremost reasons. It is thought that between here, of having thought that she too was another
45% and 70% of those who attempt or commit depressive in Crosbys catalog. Kevins childhood
suicide suffer from depression. Even so, it is still memories help us understand that more was go-
only specific profiles among those suffering from ing on there.
depression who attempt it, profiles with violent Olive Kitteridge is, for many reasons, a great
and impulsive characteristics. It appears con- series, with memorable characters and acting,
clusive that many suicides go through a period especially Frances McDormand as Olive. Though
of great anxiety right at the time of making the she herself, as the series producer, has recog-
attempt. Once more, this does not seem to be nized that at no time did they aim to place depres-
Olives case. In the opening scene, she is head- sion center stage, it is undeniable that the series
ing towards the woods and making all her prepa- invites reflection and even debate on this mental
rations with a certain lack of urgency, as if she illness (along with others), and how it has been
were preparing a picnic rather than a suicide. portrayed over the decades. Within Olives family,
We have mentioned bipolar disorder several starting with her father, continuing with her and
times. Since it appears in the series, and be- ending with her son, viewers are offered three dif-
cause of its relationship to depression, it is worth ferent ways of dealing with depression. We have
examining to some extent. Bipolar disorder is that absent father, who at 45 years old commit-
characterized by a series of extreme changes in ted suicide, but who hailed from a generation in
mood. During certain episodes, some characters which depression was probably not understood.
feel very happy, extremely happy (a phase known It was definitely not considered an illness, and
as a manic episode). However, shortly afterwards theonly way out he found was to shoot himself
they get down and go through a depressive epi- in the kitchen. Then we have Olive, much more
sode, with all the features we have described aware that depression is an illness, and further-
here for depression. In some cases, they can more hereditary. For her, the only thing to do is

Notebooks of the Esteve Foundation N 42

Medicine in Television Series

go forward and endure. We could even say that ing with them has changed a great deal, not
she rebels against the illness and does not allow just based on medical advances but also about
it to take her over, but her means of bearing it what society thinks of these disorders. Perhaps
seems to be cruel and antisocial. Lastly, Chris- medicine nowadays is much more advanced
topher represents the modern way of facing it. concerning knowledge of depression from most
This is the generation of Prozac, psychologists of society, and this series helps us reconsider
and psychiatrists, and even of therapy groups. many aspects regarding it, starting with the ge-
Through these three generations, we have seen netics question.
a social evolution of mental illness, from not even But is Olive Kitteridge somebody who truly
mentioning it to spending the day talking about suffers from depression or not? The definitive
your problems with others, as Olive Kitteridge answer can be found in the final scene of the se-
would surely say her son does. ries, and that scene returns us once more to the
It is important always to bear in mind the start of this chapter, and to rethinking whether
context in which mental illnesses are presented, the use we make of the word depression is
since history has shown that the form of deal- correct or not.

Notebooks of the Esteve Foundation N 42

True Detective and the Attraction of Evil

Luis Lalucat and Liana Vehil

This thriller in the form of an anthology is a clear example of the rise and fall that TV fiction can undergo
from its first to its second season. Created and written by Nic Pizzolatto, the eight episodes in the first sea-
son, which went to air on HBO in summer 2014, submerge viewers in a sordid and disquieting investiga-
tion being carried out by two antagonistic police officers on a serial murder case. Yet the show drew fans
not by the police officers investigations, but because of the deep discussions Matthew McConaugheys
and Woody Harrelsons characters got into. The change of storyline, cast and location it underwent in its
second season did no favors to what had been one of the revelation series of the year.

A pair of detectives in Louisianas Criminal Inves- Robert Mitchum, the serial killer of Seven (David
tigation Division, Marty Hart and Rust Cohle, are Fincher, 1995) or the later Zodiac by the same
assigned a crime in 1995 that bears markedly director (2007), No Country for Old Men (Joel
strange features typical of a ritual murder. In the and Ethan Cohen, 2007) or the perverse criminal
course of the investigation, as events are revealed, dwelling within Hannibal Lecter in The Silence of
we see not only their reactions to the crime, but the Lambs (Jonathan Demme, 1991). Although
also how the powerful emotional shocks accom- all of these offer some common features, they
panying these crimes affect their lives. This emo- also display marked differences in their behavior.
tional buffeting is exchanged in thecontext of the The figure of the monster goes back to investiga-
complex relationship betweenthe pair. tions carried out on serial killers and ritual crimes,
Years later, in 2012, a new case given to two covering both the characteristics of the criminals
other detectives reopens the investigation. Marty and their victims, as well as their modus ope-
and Rust, who have left the Criminal Investigation randi.
Division, are interrogated separately about the In True Detective, the monster is a serial killer
events of 1995. This shows the repercussions who is described to us as having the qualities of
those events had on their lives. The situation a sadistic and perverse psychopath, or as some-
prompts both men to open a new investigation one with an antisocial and sadistic personality
on the fringes of the official one, leading to identi- disorder. In this sense, this person meets most
fication of the perpetrator, confrontation with him of the behavioral characteristics of serial killers.
and to the case being solved. The killers criminal profile includes premeditated
The entire history of film is rich in figures de- behaviors, the use of deceit, a precise choice of
picting horrific behavior, personified by characters victims, a progression in criminal action (kidnap-
who display psychopathic behaviors, project- ping, torture, mutilation, death) and disposal of
ing evil onto their surroundings. Such characters the body with a return to his habitual activities.
populate a gallery of portraits covering extremely The monster of the series is skillful in his crimi-
diverse makeups, from the psychopath of subtle nal actions, at the same time as he appears to
yet malevolent manners in The Night of the Hunter engage in normal behavior in his occupation,
(Charles Laughton, 1955), masterfully acted by which keeps him in touch with the child popu-

True Detective and the Attraction of Evil

lation among whom he selects his victims. His by serial killers, and even go as far as estimating
crimes are planned, always choosing the most there are 150 to 300 serial killers in that coun-
vulnerable victim. And he does so in a broad yet try. So they constitute a significant social and
identifiable radius of action, in which he carries criminological phenomenon, even if their clinical
out his actions of capture, torture and death. In classification remains under debate, despite a
such actions, he furthermore leaves a recogniz- definition of the clinical symptoms having been
able trace through unnecessary elements or fea- arrived at within the sample of criminal psycho-
tures in the carrying out of the crime. However, paths as far back as the 1940s. Obviously, this
these traces accompany the crime, constituting is a controversial question, since inclusion or not
elements that, in one way or another, enable within psychiatric classification of psychopathies
the same perpetrator to be identified: the tying, and personality disorders also concerns the legal
wounds and torture inflicted on his victims, the imputability of the criminal acts and behaviors of
arrangement of the bodies for discovery, and the such subjects.
presence of strange objects around them. Equally controversial is identification of the
In fact, throughout the season, we only know etiopathogenesis of such disorders, in which it
this character through the result of his crimes, is difficult to define to what extent the biological,
the plots unifying thread. The ritual crime that psychological and social components intervene
launches the investigation leads to discovering in the genesis and maintenance of such crimi-
a long chain of murders and disappearances of nal psychopathic behaviors. While participation
children and young people that has been occur- of a psychogenic component based on child-
ring over time, all seeming to point to the same hood experiences of situations of physical and
author. Nevertheless, the storyline also gradually sexual maltreatment and abuse is generally ad-
reveals the direct or indirect participation of other mitted, the absence or distortion of such social
agents. Only at the end of the series is the mon- and affective bonds also appears to be relevant,
ster revealed as a flesh-and-blood person, char- related to acquisition of the necessary emotional
acterized in his living situation by an atmosphere maturity, capacity for relationships and construc-
of degradation and incestuous relationships. The tive exchanges, as well as the incorporation of
sole reference to explanatory or etiological ele- social values. The line the monster uttered above
ments in his behavior is expressed in a line he seems to refer to a vengeful attitude, in response
himself pronounces: You know what they did to to humiliations, maltreatment or harassment suf-
me? Hmm? What I will do to all the sons and fered in his childhood.
daughters of man. The other side of the coin is represented by
Serial killers have long held a morbid fascina- the victims, children and young people who
tion for viewers, and still do. This is partly linked to have been kidnapped, tortured and killed. The
showing the relationship between an external ap- series shows us just one case that did not lead
pearance of normality in everyday behaviors and to the victims death, since they manage to
criminal actions that reveal an absolute disregard rescue the victim at an advanced stage of the
for victims. It is likewise to do with showing highly process. Immediate and long-term serious psy-
elaborate criminal procedures, in which sadism chological consequences are shown as the vic-
and pathological sexuality appear together and tims incapacity to develop psychologically and
are shown openly in public. This is especially so, emotionally. Years later she lives shut away in a
as in the case of True Detective, when the victims psychiatric institution, and displays the mental
are children and young people. functioning of disconnection characteristic ofau-
This type of behavior has been investigated tism. This framing of the character speaks of
for years, both from the police and forensic ex- the serious consequences that may foreseeably
aminers perspective as from the psychiatric stem from an extreme, prolonged traumatic ex-
viewpoint. American studies state that 1% of perience on the still-forming mind of a child or
homicides committed in the US are performed adolescent. For all the above reasons, the figure

Notebooks of the Esteve Foundation N 42

Medicine in Television Series

of the serial killer, such as we have analyzed here, in the information he provides us regarding his
becomes configured in the collective imagining life story and reactions to different significant life
as the representation of evil. events. It is relevant to consider an initial block
Productions that depict the figure of the psy- of events and their evolution since childhood. He
chopath, the serial killer and the monster tend to is the son of an affair of his mothers with a sol-
present viewers with characters or antagonists dier on leave. She abandoned both the father on
who constitute a counterpoint, in the shape of his return and her two-year-old son. Father and
common personalities, who in contact with the son move to Alaska, where they live in an isolated
lead characters reveal new aspects of them- situation, until Cohle decides to return to Texas.
selves. In this interaction between these two There, he marries and has a daughter, experi-
contrasting characterizations, not only the pro- encing family life for the first time. The accidental
tagonists lives but their minds are affected. This death of his daughter ends his marriage in a de-
likewise occurs in True Detective, so we will try to structive emotional context for the couple. Once
include it in the analysis we conduct. more he experiences abandonment through his
It is commonly accepted that exposure to wife leaving. His daughters death, both the fact
traumatic events generates psychological con- itself and its consequences on family and himself,
sequences in the exposed subjects, and clini- seems to become a determining event in his later
cal history offers numerous examples of such evolution. A job transfer from the Larceny division
situations. People who have been exposed to a to Narcotics begins his descent into hell. Living
traumatic event, whether experiencing it them- undercover for four years among drug traffickers,
selves, witnessing it, or recognizing its conse- he begins abusive substance use, takes part in
quences, receive a psychological impact. This violent acts, causes several deaths and reaches
is still greater when deaths or threats to physical a borderline situation, causing him to be admit-
wellbeing have occurred. Each person responds ted to a psychiatric hospital. The diagnosis re-
to the event in a different way, according to their mains unclear, since he says that for a long time
own psychological makeup, but a certain de- after, I... I didnt really sleep. Nightmares, PTSD,
gree of fear will habitually have been generated, exhausted nerves, whatever. The description of
a hopeless response, or they will have experi- his state prior to admission is compatible with
enced intense horror. The psychological conse- the clinical symptoms known as post-traumatic
quences possess a certain specificity, linked to stress disorder (PTSD), understood as a set of
their memory, making themselves felt in dreams, individual reactions to exposure to intense stress
or in maintaining a persistent psychological and factors. This presupposes a one-off or ongo-
sometimes intense unease with everything re- ing, intense, emotional reaction to one or several
lated to the traumatic event. Some symptomatic such factors, for a brief or prolonged period. The
manifestations of such consequences are shown point of departure may be situated in the death
in physiological alterations that can affect not only of his daughter and later family decomposition,
sleep and appetite, but habits and behaviors. when presumably a process of identity was being
True Detective shows how contact with a initiated at the familys core, creating the corre-
crime of special characteristics acts as a trau- sponding affective bonds, a sense of responsibil-
matic event that affects the investigators in ity and participation in a shared project. This loss
charge of investigating it. Below, we will analyze does not lead to full grieving, and the couples
in what way the series presents the psychological consequent rupture prompts him to act in an ever
characteristics and certain psychopathological more precipitate and self-destructive fashion, re-
elements of the main characters, Cohle and Hart. peatedly putting his own life at risk.
Cohle is described in the series through his Once he is released from hospital, he refuses
behavior and comments about himself, and the an offer of retirement on a psych pension and
opinions of others interacting with him. Yet it is asks to be transferred to the homicide division.
necessary to store all these descriptive elements So he chooses to rejoin the police force, to once

True Detective and the Attraction of Evil

more form part of a group, playing on the duality The resolution of the case, in a fresh collab-
of identity and belonging. In his new job, the case oration with Hart, seems to open up a new life
he and Hart are assigned activates the charac- perspective for him, as if he had finally managed,
ters main conflicting cores afresh, centering on for the moment, to break the infernal cycle his life
the loss of his daughter, and giving him a need to had become.
get to the heart of the matter, to solve the case The series presents PTSD in a manner similar
so as to face his own conflicts. The successive to habitual diagnostic descriptions and classifica-
discoveries he will make, the appearance of new tions, but one should not forget that this diagnos-
criminal cases committed against children, once tic has very broad margins of application. It arose
more bring to the fore his inner conflicts, lead- after the Vietnam War to respond to the many
ing him to act increasingly more obsessively, so cases of soldiers who displayed the psychologi-
that he will start to disregard any legal or moral cal and emotional consequences that fighting in
limit that might curb his own behavior. He thus re- the war had caused in them. It was formulated
peats his behavior from the time when he worked as a diagnosis to group reactions that showed
undercover in the narcotics squad, including sub- certain similarities. Even so, the effect of war and
stance abuse and participating in violent actions. the traumatic experiences suffered always has an
His disciplinary suspension from the force leads individual background due to each individuals life
him to follow a path towards increasing isolation baggage, and is expressed in differing intensity,
in which he pursues his own individual investiga- characteristics and recovery capacity. True De-
tion, meanwhile establishing a continued pattern tective seems to place the final accent on capac-
of alcohol consumption that is abusive and self- ity for individual recovery, despite the succession
destructive. of traumatic events, and their intensity and dura-
Throughout the narration, references appear tion. It also focuses on the way they affect the
to the perceptions Cohle has at different times, character. Perhaps too, they put one in mind of
formulated as a perception disorder known as another evolution, more of a definitive collapse, or
synesthesia. He defines it as a misalignment of of prosecuting risk behaviors that lead to him rec-
synaptic receptors and triggers alkalis, colors, ognizing he is incapable of committing suicide.
and certain metallics. Its a type of hypersensi- Meanwhile we would emphasize that these-
tivity. One sense triggers another sense. Some- ries does not provide any information on the
times Ill see a color and it will put a taste in my treatment or treatments Cohle undergoes during
mouth. A touch, a texture, a scent can put a note his hospital admission, though it is plausible to
in my head. Nevertheless, in a certain scene a assume that he was on a detox program linked
perception appears that insinuates hallucinatory to the substance abuse and addictions that re-
content, as when, from the car in which he is sulted from his time in the Narcotics division.
traveling, he sees a girl waving at him, leading Let us now look at the character of Hart, an in-
him to ask Hart if he believes in ghosts. dividual with no special biographical background
Cohle sustains his life continuity in a life philos- worth mentioning. As the series opens, he is mar-
ophy that gives him a certain rationalization, sta- ried with two daughters, and his family situation
bility and strength to face his own self-destructive seems to be following a track displaying no sig-
impulses. He bases it on relevant authors and nificant elements. However, winds of unease ap-
texts, summarizing as: Id consider myself a real- pear to be blowing in the figure of his wife Mag-
ist, alright? But in philosophical terms Im whats gie. This family environment will be progressively
called a pessimist. ... Means Im bad at parties. affected by Harts involvement in the case he has
He believes human consciousness is a tragic been assigned. The characters slow involvement
misstep in evolution. We became too self- in a storyline full of dark aspects, which gradually
aware programmed with total assurance that reveal a chain of ritual crimes whose victims are
we are each somebody, when in fact everybodys the young and the innocent, little by little increase
nobody. And I lack the constitution for suicide. his emotional tension. This experience ends up

Notebooks of the Esteve Foundation N 42

Medicine in Television Series

causing him to indulge in compensatory behav- ing a series of ritual crimes in which children
iors, such as drinking more, and marriage infideli- have been maltreated and murdered, can affect
ties. Both sorts of behavior seem to have the aim the mental and emotional balance of a normal
of an emotional release for him, but also of family subject, unleashing a series of behaviors that end
preservation. However, they end up unleashing up destroying the life project that this person has
the opposite effect: a distancing from his family, been building.
about whom he is less and less concerned, and The series development reveals a well-formed
Maggie leaving, because she does not accept his narrative. Nick Pizzolattos script shows a consis-
affairs. Likewise, his behaviors in and outside the tent narrative thread that gives coherence to the
home become increasingly violent, particularly whole of the production, in particular in relation
when he kills a detainee, as well attacking two to the lead characters psychological character-
young men in the police station who had been istics. They offer us descriptive elements of his
having sex with his adolescent daughter. This sit- personality traits and biographical data on which
uation goes through two different phases. In the his behaviors and reactions may be based. The
first, Maggie throws him out, and only accepts evolution of events and the protagonists involve-
him back after he has undergone a process of ment and behaviors maintain a clear connection
giving up alcohol and attending relationship ther- with the opening scenes and their biographical
apy. However, a new affair leads to their definitive background.
break-up as a consequence of Maggies con- The references to clinical and psychopatho-
scious choice to be unfaithful with Cohle in a situ- logical aspects fall within the acceptable margins
ation she provokes. Later it is revealed that she of professional descriptions. In this way, they
manages to re-orientate her and her daughters help to understand the behaviors and to offer
lives in a new marriage, from then on appearing an understandable view of the responses of the
as Mrs. Sawyer. individuals subjected to especially stressful or
Harts character does not display precise psy- traumatic conditions, both in the personal and
chopathological characteristics, but personality professional sphere. On the whole, the series en-
traits that in habitual contexts rather characterize ables a humanized approach to the characters
him as a person with social skills, who is funny and a certain degree of identification with them,
and quite an extrovert. He has no particular in- attuning to their transformations and suffering.
terests beyond his family life and social relation- This means that even their most unsuitable be-
ships, both in and outside work. Nevertheless, haviors or psychopathological references do not
subjected to a stressful situation, as occurs have a stigmatizing effect.
with the investigation to which he is assigned, The scarce references to therapy procedures
he starts a process whereby his emotional ten- in the series does not enable an evaluation of
sion progressively rises, and increasingly violent their suitable or correct nature, though at certain
behaviors appear that compromise his family moments explicit mentions to couples therapy,
project. The increase in emotional tension due to detox measures or therapy groups appear.
the investigation and the discoveries as they are The series analyzed provides a description of
revealed leads progressively to a situation of a evil through criminal behaviors of diverse natures,
lack of control and non-governing of his own be- the product of a serious personality disorder in
haviors, which are increasingly orientated toward which the notion of rules or limits does not ex-
obtaining immediate compensations through the ist. Only the satisfaction of ones own desires and
consumption of alcohol or extramarital sexual needs prevails, linked to perverse content. Nei-
experiences. These are elements he describes ther does the character have the notion of guilt
as essential, or rather, as the result of a need to as an element in the service of self-control and
awaken his mind and get some relief. reparation. Evil is also depicted as an expression
In any case, the series shows us in what way of revenge and as a path that leads to confronta-
a progressive stress situation, such as confront- tion culminating in self-destruction.

True Detective and the Attraction of Evil

Nevertheless, what is perhaps worth high- via healthy relationships in order to evolve toward
lighting from the series are those figures that, those milestones that carry them toward their life
departing from different personal characteristics, goals. We would also stress the importance that
are attracted to and even fascinated by the evil the series grants the relationship between both
they have come across in their professional lives, characters: highly conflictive at different times,
in its specific manifestations, which the case is but which plays a significant role in their per-
investigating. They are characters both fragile sonal recovery. The friendship that binds these
and also provided with the necessary strength characters exists within a relational and affec-
to equip them to rebuild their lives and create tive framework that endows them with humanity,
fresh personal projects. They are capable of be- enabling them to develop capacities for each of
ing reborn through their confrontation of crime their recoveries, and on which their capacities for
and violence, and of building a contention dike resilience also lie.

Notebooks of the Esteve Foundation N 42

Polseres vermelles and Cancer

Pere Gascn i Vilaplana

This Catalan production, created in 2011 by Albert Espinosa and directed by Pau Freixas for TV3, is one
of the few that has successfully made the leap, first to Spanish national TV (a dubbed version aired on
Antena 3), and later, thanks to Steven Spielberg, onto the complex international circuit. He decided to
adapt it for the US market, but with scant success: Red Band Society foundered in its first season from
poor audiences. Nevertheless, this series about a teenage gang formed in a hospitals corridors is an un-
doubted success; it became a true phenomenon, reaching beyond the limits of the small screen.

Polseres vermelles (Red Wristbands) is a TV3 se- Despite the fact this is a drama and describes
ries created and written by Albert Espinosa, and the day-to-day life of these young hospital in-pa-
directed by Pau Freixas. It first went to air in 2011. tients in detail, the series is infused with humor
The original script is based on the novel El mundo and constitutes a true homage to the values of
amarillo (The Yellow World), of which Albert Es- friendship, companionship, life and the desire to
pinosa is likewise the author. The series, which live it to get cured so as to enjoy it. All these
falls within the medical drama genre, lasted two ingredients are treated with great sensitivity and
seasons with a total of 28 episodes, 13 in the first an exceptional degree of tenderness that means
season and 15 in the second. It tells the story of that practically all the episodes contain scenes,
six adolescents between ten and 17, who are all situations and actions that ensnare viewers in
staying in the pediatrics ward of a hospital where such a way they manage to cause an emotional
they have been admitted for different illnesses: impact.
two have cancer in their leg bone, a type of can- So what is an oncologists impression of the
cer requiring amputation as part of the treatment; series after having watched all 28 episodes? Per-
another is in coma; a fourth has a heart problem; haps the simplest way of approaching the sub-
a fifth has Aspergers syndrome, and the sixth is a ject I have been assigned is to identify the series
girl who suffers from anorexia nervosa. These are different medical aspects and analyze them one
the main characters. Other young patients, suf- by one, from the perspective of cancer. So I will
fering from various illnesses, make appearances analyze the setting where the action takes place,
throughout the series. They include one with leu- the hospital, and its health personnel: doctors,
kemia and a girl with breast cancer, but the latter nurses and orderlies. How do they relate to the
two do not belong to the Red Band Society. One patients? What is their attitude to cancer, espe-
of this series quirks is that children or adoles- cially when faced with a patient, in this case an
cents dominate the entire action. Doctors appear adolescent with the disease? What support do
when necessary, but do not take the initiative they offer the patient to continue his or her daily
and, to a certain extent, always trail behind the life while undergoing treatment? Do staff indulge
young peoples activities. The term red band in dramatics, or present the reality, however
comes from the red wristbands that are attached tough, and help patients to manage it? Since it is
to patients wrists when they enter the operating a fiction, parallel storylines obviously appear that
theater or are given blood transfusions. are not necessarily concerned with cancer.

Polseres vermelles and Cancer

Let us start with the hospital. At first, it seems that although her brother never talks about this
like a childrens hospital, but immediately adult subject it would be good, sometimes, for some-
patients appear who speak to the children and one to stop being so politically correct and to talk
adolescents in the pediatrics wards. To thor- about death, to discuss it openly.
oughly confuse viewers, at one point in the se- Fortunately, nowadays many people win the
ries, a family member of one of the adolescents battle against cancer and can often discuss it
is admitted to ER for birth pains and gives birth normally. This was unthinkable just three decades
in the same hospital. Nowadays this type of hos- ago. There are also patients who want their con-
pital no longer exists, at any rate not in Spain. dition to be explained clearly. This is Lles case.
Since child and adolescent pathology is so differ- He gets irritated because he thinks that life has
ent from adult pathology, and even cancer types not treated him too well and confronts the doc-
do not match adult types, childrens hospitals tor when the latter tells him that his disease has
have been created. Another aspect of the series returned again upon finding a spot on his lung:
that does not follow hospital regulations is mixing
A spot on the lung? You mean its a tumor,
patients of different sexes in the same room. In
the series, this occurs twice. A teenage boy with
bone cancer and a young girl with breast cancer Yes, of course.
are put in the same room.
Well, fuck, call it a tumor! Im sick of doc-
As was mentioned in the introduction, only
tors befuddling me. I dont want to receive
four of the characters appearing in the series
any more treatment. Twenty-three cycles are
have cancer: Lle and Jordi, cancer of the tibia;
enough. That much chemo is going to leave
Rym, breast cancer; and a young boy with Down
me sterile.
syndrome who has leukemia. Only two belong to
the Red Band Society, Lle and Jordi, who re- This is the attitude of an adolescent who is
quire amputation of the leg. The treatment, from battling between life and death, and has lost a
the medical viewpoint, is quite correct. Luckily, leg. Now it appears the tumor has become resis-
nowadays, most adolescents can avoid amputa- tant to chemotherapy. Nevertheless, he is wor-
tion of the leg through a combined treatment of ried about becoming sterile, not about death.
chemotherapy, radiotherapy and surgery. He refuses to think he might die, but obviously
It should be noted that one goes into hospi- thinks about it constantly. One scene in the se-
tal in a mental state that is highly conditioned by ries also exemplifies the stigma that having can-
ones illness. You are living in a strange setting, cer represents for many patients, and for adoles-
with a huge emotional impact, and your emotion- cents in particular. Lle says to Jordi: We have
al state undergoes many fluctuations depending to be brave when we leave the hospital and not
on the results of tests and treatments. A patient be worried they might see us as legless. This
affected with cancer realizes, perhaps for the first shame of how they might be seen occurs more
time in their life, that they are vulnerable. It is a frequently than we might imagine. It should not
state they have entered in a matter of a few days be like that, since the disease is not the patients
or even hours, and because of this they begin to fault. It is partially the sign, the manifestation that
realize they might die. Even so, in the series little I have or have had cancer: the amputation of
is said, or said openly, on the subject. This could a leg, the amputation of a breast. But it is also a
be because it is an adolescent community that problem of image and self-esteem. If this is tough
has difficulty comprehending the true meaning of for an adult, imagine what it must be like for an
that irreversible loss called death. This aspect is adolescent.
exemplified in the words of Lles sister, when she Another aspect the series deals with is denial,
comments that she always thinks and is afraid of represented by Jordi. A lump appeared in his
the fact she might lose her brother. She declares armpit a year ago. He does not tell his mother or

Notebooks of the Esteve Foundation N 42

Medicine in Television Series

visit the doctors in hospital, though they told him at each other and one tells the other, you nev-
that at the slightest sign he should go and see er have a solution for everything, after hearing
them. He thinks or wants to believe that it is noth- Lles answer that he wants to reject any other
ing. This is a very common attitude, denying the treatment. This is an aspect to bear in mind in
symptoms, the signs our body gives us, which oncological treatments. We all want the patient
we often try to justify with many absurd excuses. to keep accepting treatment, but sometimes the
Denial is a very typical reaction in people who doctor must perform an act of humility and ac-
suspect deep inside that those anomalies could cept that they can no longer help the patient ac-
be the appearance of cancer. tively. So perhaps they must accept that thetime
One aspect that in my view is not dealt with remaining to the patient is spent with the opti-
carefully and lapses into stereotypes, is the vom- mum quality of life they can provide. In this sense,
iting and nausea induced by chemotherapy. Lle is brave and decides he wants to be free,
Even if this was true over 20 years ago, we can even if only for a short time. He is absolutely en-
now say that medication exists that has practi- titled to think and act in this way, and the doctors
cally eliminated these secondary effects which accept that decision.
gave chemotherapy such a bad press. While it The case of Rym, suffering from breast can-
is possible for someone to vomit during the first cer, is very well dealt with from the oncological
cycle of chemotherapy, if there is good doctor/ viewpoint. She looks in the mirror before going
patient communication, the treatment pattern into surgery and, in homage, carefully examines
can be modified to avoid vomiting and nausea the breast she will never see again. The doctors
in later cycles. We must overcome this stigma tell her what the operation will be like and what
about the treatment because it does not help pa- will happen afterward. She is a strong girl and
tients. Chemotherapy has other adverse effects, accepts this stoically. Doctor/patient information
but nowadays vomiting is very well controlled. I and communication is fluid, normal, and the as-
would like to stress this because this association pects of the cancer are touched upon with the
of chemotherapy and vomiting means many pa- seriousness the situation demands, but without
tients begin to vomit the moment they see liquid dramatizing at all.
going into their veins, believing it is chemothera- The doctors explanatory dialogs with the
py when in fact it is only the initial saline solution, adolescents parents and with the patients them-
or anti-vomiting medication. selves are also very well scripted. There is time
An important theme in the series concerning for explanation and comment in a relaxed atmo-
cancer is that of respecting the patients decision. sphere.
This is exemplified in the episode where the doc-
tors tell Lle that his illness has spread to several
parts of the body and he only has a 3% chance of Conclusions
living. He decides to throw in the towel, to go off
In conclusion, this series has been produced with
chemo and leave hospital to live the time remain-
exquisite sensitivity, using talented adolescent
ing him freely. The doctors tell him:
actors. The subject of cancer is dealt with natu-
You know that if you go off it, you will defi- rally, without sacrificing the diseases seriousness
nitely die? at any time. Throughout its 28 episodes, it cov-
ers the aspects of the patient/doctor relationship
Yes, I know, but I dont want to die in captiv-
and how the news is given to the patient and his
ity. I want to be free as I am, but free.
or her family environment. All this is dealt with
The two doctors who have told him about the very correctly in medical terms. Cases of denial
relapse and the seriousness of the situation act of symptoms or diagnosis are shown, while the
correctly and humanely, avoiding a situation of patients desires are accepted, and dysthanasia
dysthanasia (artificial extension of life). They look is avoided. The term cancer and its contents

Polseres vermelles and Cancer

are de-stigmatized. The series does fall into the nonetheless draws the short straw. They may
stereotype of associating chemotherapy and have drawn illness or health, enjoyment or suf-
vomiting, a situation that is less common all the fering. The series has an extraordinary educa-
time, dramatization of which does nothing to help tional component in terms of instilling values in
future patients who must undergo anti-cancer children and adolescents. I stress this because,
treatments based on chemotherapy. The series unfortunately, this effect is being lost and becom-
is set in a hospital atmosphere where life or death ing diluted in the great mediocrity of many of the
situations occur in each episode. Therefore, how programs that the communications media of-
characters and dialog are dealt with is significant, fer us. Dont be an egoist. Life is not just yours
in a setting where, though superficially it appears but belongs to everyone who loves you as well,
that everybody is happy, in truth there is a con- says one patient to another. The line reminds us
trolled degree of continual tension, which peaks how far we are from such simple yet undeniably
at a certain point in the series. powerful values. The series offers a little of every-
The series is an ode to the humanity we all thing, despite being a drama in the fullest sense.
carry inside, to friendship, companionship and It emanates both tenderness and harshness, joy
the treasure of being alive. It constantly moves in and suffering, in a similar way to the daily pat-
this biological and mysterious balance between terns of our lives. It is little wonder that the series
life and death that can sometimes be cruel be- has attracted such a powerful following among
cause it functions like Russian roulette a game young people, but we know it has also managed
of chance one has not entered, but in which one to move older people deeply as well.


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Esteve Foundation

Television fiction viewed from the perspective

of medical professionals
Medicine in Television Series
House and Medical Diagnosis. Lisa Sanders
Editor: Toni de la Torre
The Knick and Surgical Techniques. Leire Losa

The Sopranos and Psychoanalysis. Oriol Estrada Rangil

The Big Bang Theory and Aspergers Syndrome. Ramon Cererols

Breaking Bad and Methamphetamine Addiction. Patricia Robledo

Mad Men and Tobacco Addiction. Joan R. Villalb

The Walking Dead and Epidemics in the Collective Imagination. Josep M. Comelles and Enrique Perdiguero Gil

Medicine in Television Series

Angels in America, The Normal Heart and Positius: HIV and AIDS in Television Series.
Aina Clotet and Marc Clotet, under the supervision of Bonaventura Clotet

Nip/Tuck, Greys Anatomy and Plastic Surgery. Mara del Mar Vaquero Prez

Masters of Sex and Sexology. Helena Boadas

CSI and Forensic Medicine. Adriana Farr, Marta Torrens, Josep-Eladi Baos and Mag Farr

Homeland and the Emotional Sphere. Liana Vehil and Luis Lalucat

Olive Kitteridge and Depression. Oriol Estrada Rangil

True Detective and the Attraction of Evil. Luis Lalucat and Liana Vehil

Polseres vermelles and Cancer. Pere Gascn i Vilaplana

ISBN: 978-84-945061-9-2

9 788494 506192