The AI Revolution in Medicine: GPT-4

and Beyond Peter Lee

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 “The development of AI is as fundamental as the creation of the
personal computer. It will change the way people work, learn, and
communicate—and transform healthcare. AI is already being used to
improve how diseases are detected and diagnosed. In the future, it
will help accelerate research breakthroughs and make accurate,
reliable medical advice available to those who never get to see a
doctor. AI is a powerful tool that can reduce inequity and improve
life for millions of people around the world. But it must be managed
carefully to ensure its benefits outweigh the risks. I’m encouraged to
see this early exploration of the opportunities and responsibilities of
AI in medicine.”

— Bill Gates
The AI Revolution in Medicine:
GPT-4 and Beyond
 The AI Revolution in
Medicine: GPT-4 and Beyond

BY PETER LEE, CAREY GOLDBERG, AND ISAAC

KOHANE WITH SÉBASTIEN BUBECK
© The AI Revolution in Medicine: GPT-4 and Beyond (Lee,
Goldberg, Kohane)

Published by: Pearson Education, Inc.

Copyright © 2023 by Peter Lee, Carey Goldberg, Isaac

Kohane

Cover art by Leyn / Shutterstock

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To our children, in hopes they will have the healthcare imagined in
this book
Table of Contents

Authors’ Note
Foreword

Prologue
Chapter 1: First Contact
Chapter 2: Medicina ex Machina
Chapter 3: The Big Question: Does It “Understand?”
Chapter 4: Trust but Verify
Chapter 5: The AI-Augmented Patient
Chapter 6: So Much More: Math, Coding, and Logic
Chapter 7: The Ultimate Paperwork Shredder
Chapter 8: Smarter Science
Chapter 9: Safety First
Chapter 10: The Big Black Bag
Epilogue

Further Reading
Acknowledgments
Authors’ Note

This book is a work in progress.

First, because AI entities like GPT-4 themselves are advancing so
rapidly that the AI-human dialogues we use here inevitably become
outdated within weeks.
And second, because this book is only an initial foray into one area
— medicine — of what we expect to become a humanity-wide
discussion about how best to harness the astonishing AI capabilities
now emerging.

We hope, however, that it can serve as a model for ways to launch

that discussion: It is based on extensive, carefully analyzed
interactions with the AI. It lays out well-documented strengths and
weaknesses. And it just barely begins to grapple with the urgent
question: Given all this, what is to be done, long-term and right
now?
About the text:

GPT-4 responses have often been shortened but never altered.

Zak and Peter bring their professional expertise to their writing but
neither Harvard Medical School, Microsoft, nor OpenAI had any
editorial control over this book.
Foreword

by Sam Altman

Early in the development of GPT-4, Kevin Scott, Microsoft’s Chief

Technology Officer, and I decided to grant early experimental access
to a small number of people, hoping to gain some understanding of
its implications in a few key areas. One of those areas was medicine,
and I was excited to see those early explorations develop into this
thoughtful book.

Medicine and healthcare touch everyone’s lives. They are also

fields that face enormous challenges, such as rising costs, lack of
equitable access, aging populations, doctor and nurse burnout, and
global pandemics. AI holds the potential to address these
challenges, at least partially, by providing better tools to reduce
administrative burdens and augment what professionals do in
diagnosis, treatment, prevention, and research for a variety of
medical conditions.

Peter Lee and his co-authors see technologies like GPT-4

contributing to the effort to overcome these challenges. For
example:

GPT-4 can answer medical questions from patients or

professionals using reliable sources of information1, thus
empowering individuals and better democratizing access to
medical knowledge, particularly among the billions of people
who lack decent healthcare.
1 Pearl, R., MD. (2023, February 13). 5 Ways ChatGPT Will Change
Healthcare Forever, For Better. Forbes.
 https://www.forbes.com/sites/robertpearl/2023/02/13/5-ways-chatgpt-will-
change-healthcare-forever-for-better/
GPT-4 can generate summaries or reports from medical
records or literature using natural language generation
techniques2, promoting the spread and aiding in the discovery
of medical advances.
2 Korngiebel, D. M., & Mooney, S. D. (2021). Considering the possibilities
and pitfalls of Generative Pre-trained Transformer 3 (GPT-3) in healthcare
delivery. Npj Digital Medicine, 4 (1). https://doi.org/10.1038/s41746-021-
00464-x
GPT-4 can assist doctors or nurses with clinical decision
making or documentation using natural language
understanding techniques3, thereby reducing clerical burdens
and helping get technology out of the way between clinician
and patient.
3 Millman, R. (2022, June 17). What is GPT-4? IT PRO.
https://www.itpro.com/technology/artificial-intelligence-ai/368288/what-is-
gpt-4
GPT-4 can create educational materials for medical students
or patients using natural language interaction techniques4,
thus helping to address the looming healthcare workforce
shortages in much of the world.
4 Heinrichs, J. (2022, December 1). The Future of AI and Machine Learning with
the Advent of GPT-4 . https://so.ilitchbusiness.wayne.edu/blog/the-future-of-ai-
and-machine-learning-with-the-advent-of-gpt-4

These and many other applications of GPT-4 for enhancing

medicine and healthcare are shown in this book. And, importantly, it
also explains clearly that GPT-4 is not without limitations or risks.

Medicine is a sphere where the risks are real and immediate —

not at all theoretical — and I endorse this book’s call for urgent work
on understanding not only the benefits but also its current
limitations, and to think through carefully how to maximize the
benefits of general-use AI in medicine while minimizing its risks.

In particular, this book shows situations where GPT-4 may not

always be accurate or reliable in generating text that reflects factual
or ethical standards. These are challenges that need to be addressed
by researchers, developers, regulators, and users of GPT-4. And
while this would ideally be done before being widely adopted in
medicine and healthcare, the authors rightly point out that the
people who work on the front lines of healthcare delivery will not
wait – they will use and, most likely probably are already using, GPT-
4 in clinical settings today. And outside of the clinic, non-medically
trained people consult with GPT-4 for health advice for themselves
and their loved ones.

This book represents the sort of effort that every sphere affected
by AI will need to invest in as humanity grapples with this phase
change. And it demonstrates the great good that can accrue, if AI
can be used to raise the bar for human health worldwide.

This is a tremendously exciting time in AI but it is truly only the

beginning. The most important thing to know is that GPT- 4 is not an
end in itself. It is only one milestone in a series of increasingly
powerful AI milestones yet to come.

As CEO of OpenAI, a research company dedicated to creating

artificial intelligence that can benefit all of humanity, I see every day
how fast AI technology is advancing and evolving. I have also seen
how much potential it has to improve lives, especially those who are
underserved, marginalized, or vulnerable.
And I have also learned how much responsibility we have as
creators and users of AI technology to ensure that it aligns with our
values, goals, and ethics. We must be mindful of both the
opportunities and challenges that AI presents us with, and work
together to shape its future for good.
 That’s why I’m proud to support this book, which offers a
comprehensive overview of how GPT-4 can revolutionize medicine
and healthcare with its general-purpose capabilities. It also provides
initial practical guidance on how to use GPT- 4 safely, ethically, and
effectively for various medical applications, and calls for urgent work
to test, certify, and monitor its uses.

I hope this book helps to inform what I expect will be a robust

public debate about how AI such as GPT-4, and its successors, will
be integrated into healthcare and medicine.
Prologue

What follows is pure fiction, but everything it describes is well within

the documented current capabilities of OpenAI’s GPT-4 system.

Suddenly, the patient was crashing. His heart rate rocketed to

over 160 beats per minute, but his blood pressure fell dangerously
to 80 over 50. Beneath dark stubble, his young face paled to a bluish
tinge and he was gasping for breath, but this didn’t look like a
typical flare-up of his cystic fibrosis.
Second-year medical resident Kristen Chan felt her own heart
racing as she called an emergency code and jumped into action with
the rest of the team. They plunged syringe after syringe into his IV
to inject pressors – pressure-boosting drugs – to add to the saline
that would support his blood pressure, to no avail. A drug to
increase the contractile force of his heart didn’t help either.

Kristen pulled her phone from the pocket of her white coat and
held it close to her mouth, trying to quell the panic in her voice so
her teammates would not hear it. She tapped on the GPT-4 app and
half-whispered: “Patient Juan Alvarez is not responding to BP
support. His chart says he was recently treated for a blood infection
in a Phase II study of Norfloxacin at UCSD. I don’t know what is
happening and what to do.”
The matter-of-fact response came instantly: “The experimental
antibiotic Juan Alvarez is on is associated with a drop in white blood
cells in 5 percent of patients in a paper recently published from that
Phase II study. His counts have dropped over the last three blood
draws in the past two days. The article reports that G-CSF infusion
was highly effective in reversing the drop in white blood cells. That is
a tactic that could be considered.”
Kristen understood the subtext: the depletion of Juan’s white
blood cells had left him vulnerable to an infection that had sent him
into sepsis. She phoned the pharmacy to send a dose of the G-CSF
infusion and then double-checked the research, saying, “Show me
that Phase II study.”

Both the study description and the relevant article popped up on

her phone screen and she asked GPT-4 to summarize them. Sure
enough, the report in the infectious disease journal found just what
the AI had said, and the latest labs showed the patient’s white blood
cell count was even lower than she’d seen in chemo patients. Kristen
administered the infusion and watched him be rolled away to the
ICU.
“Gave him the G-CSF. I hope it works,” she muttered.

The response: “It is very stressful when a patient’s condition

deteriorates so rapidly. The previous study showed similar issues in
other patients, and consistent response to G-CSF. You are doing your
best and your team is with you.”
The voice always sounded calm, avuncular. She knew artificial
intelligence tools like GPT-4 could not be considered sentient, but
she somehow felt like a benevolent mentor-servant with access to
nearly all the world’s medical knowledge was holding her hand. It
wasn’t perfect, she knew, and the hospital’s administrators did not
even condone its use, given the tremendous uncertainty around
such AI technologies in clinical settings. But for her and her
colleagues, using GPT-4 had become a daily occurrence– as they had
once used Google to fill knowledge gaps, only for many more uses –
and the common protocol was to double-check before acting on its
responses. GPT-4 made her feel…augmented. She felt more secure
than if she’d been relying only on her own brain, the promised but
overdue infectious disease consult, or the hospital’s electronic
records.

“Juan will need to be moved to a different antibiotic, an even

more expensive one,” she said into her phone. “I’ll need to request
prior auth from his insurer. Please write the justification text for me
to insert into the form.”
“Certainly.” Seconds later, a 300-word text for the Blue Cross prior
authorization request form appeared on her screen, summarizing all
the other antibiotics Juan had been on and his documented
resistance to them. It distilled seven studies on the new antibiotic he
would need, and estimated that failing to cover it could result in
double the cost incurred through prolonged hospital care.

“Please send to my inbox, along with a pointer to the prior auth

form,” Kristen affirmed as she walked away. “Moving on to room 65.”

“My next patient, Daria Frolova, is 62, and has had melanoma
since she was 50, and had a remarkable remission for 10 years,”
Kristen summed up. “Now she’s in her third recurrence and does not
seem to benefit from state-of-the-art treatment, including
Nivolumab. What are the options for next steps?”

“You could consider enrolling her in a new protocol for Cetuximab

at the hospital’s affiliated cancer center. Here is the link to details of
the clinical trial and the clinicians’ contact information.”
“Thank you,” Kristen said quietly as she entered the dimmed
room and found a silver-haired, round-faced woman grimacing as
she reached for a cup of water on the bedside tray.

“Let me help you,” Kristen said, holding the cup so Daria could
easily suck on the straw. “How are you feeling?”

The patient swallowed two small gulps of water. “The pain comes
and goes but the tired feeling never leaves,” she said.
 Kristen nodded, meeting the patient’s eyes with compassion in
her own. “There’s a clinical trial we think might be an option.”

“Do tell!” came a voice from behind her. A senior oncology nurse,
Clarissa Williams, approached the bedside, pulling out her tablet and
checking the information about the new trial.

“Mmmm hmmm,” she hummed, “Could be a fit.” She spoke into

her tablet: “Please summarize the research and include the links. If
it all looks good, I’ll contact the study coordinator today. But also,
please include any other trials Daria should consider.”

“Certainly,” came the response. “Among 30 patients with

genetically similar melanoma, so far eight are reporting remissions
and seven are seeing partial remissions. Side effects generally mild
but one serious hemorrhage.”
Clarissa squeezed Daria’s hand. “Fingers crossed,” she said.
“Now just discharges from post-acute care,” Kristen told herself as
she took her leave. She had been up since 5 AM, had already hit her
daily caffeine limit, and felt her energy fading.
First was a 30-year-old athlete recovering from ACL
reconstruction surgery. As she approached his room, she heard the
soft ping on her phone. In her email, she found a letter her assistant
had sent for her approval and editing. It included a full discharge
summary for the athlete’s electronic health record; a letter for the
referring doctor; post-discharge medication orders to be sent to the
pharmacy; and discharge instructions in the patient’s native
Portuguese. Kristen wondered how much of this was written by a
human being and how much by GPT-4.

Good. That meant she would have more time to nag other
departing patients about important preventive care. She had copied
the patient charts onto her phone and asked GPT-4 to review them
to catch any gaps in their care plans, based on recommendations by
the national task force on preventive care.
 Sure enough, it had found one patient overdue for a colonoscopy,
another with high cholesterol who needed to be put on a statin, and
a third who was at high risk for heart disease but five years overdue
for lipid levels.
Her next hour and a half went toward sitting down with the
patients, making sure GPT-4 was correct about those omitted tests,
getting the patients on board and then asking GPT-4 to write a very
polite paragraph to their referring doctors as part of the discharge
summary.

And now — now for a little “me” time.

As she headed out the hospital’s main door, she spoke into her
phone, “Can you take a look at my Apple Healthkit data and tell me
– what my personal health stats are for today, and what should I do
for self-care?”
Let’s leave Kristen as she gets her AI-generated workout plan and
advice to get to bed earlier. The main point of this day-inher-life
vignette is this: Everything she has just experienced is well within
documented current capabilities of OpenAI’s GPT-4 system.
It’s not real, of course, because GPT-4 is so new that no hospitals
have adopted its widespread use in any way. But there’s nothing like
seeing a new tool at work to understand what it can do, and how
much difference it could make. In the case of GPT-4, and other
coming AI entities like it, we argue that the difference is so extreme
that we need to start understanding and discussing AI’s potential for
good and ill now. Or rather, yesterday.
We hope you’ll come away from this book persuaded of three
points:
1) GPT-4 has game-changing potential to improve medicine and
health.
 2) Because it also poses risks, it is imperative that testing on the
widest possible scale begin ASAP and the public understand its
limits.
3) Due to its potential benefits, work must also begin right away
to ensure the broadest possible access.

But first, an introduction: Meet the real GPT-4.

Chapter 1

First Contact

by Peter Lee

“
I think that Zak and his mother deserve better than that.

I was being scolded. And while I’ve been scolded plenty in my

life, for the first time it wasn’t a person scolding me; it was an
artificial intelligence system.
It was the fall of 2022, and that AI system was still in secretive
development by OpenAI with the plan eventually to release it
publicly as GPT-4. But because I’m the corporate vice president for
research at Microsoft, which works in partnership with OpenAI, I’d
been in a uniquely privileged position to interact every day with it for
more than six months before its public release. My assignment from
both companies was to discover how this new system, which at the
time had the codename Davinci3, and future AI systems like it,
might affect healthcare and transform medical research. That is the
focus of this book, and the short answer is: in almost any way you
can name, from diagnosis to medical records to clinical trials, its
impact will be so broad and deep that we believe we need to start
wrestling now with what we can do to optimize it.
 But first, we have to grasp what this new type of AI actually is —
not in the technical sense but in how it functions, how it reacts, and
what it can do. Through thousands of chat sessions with Davinci3, I
learned a lot. And I am still learning now that it has been publicly
released as GPT-4. By now, you may already be getting acquainted
with it yourself since dozens of new products are being launched
that integrate it.

I was lucky to get introduced to GPT-4 when it was still

“Davinci3.” And honestly, I lost a lot of sleep because of it.
Throughout my investigations, I discovered ever more amazing
aspects of the system’s knowledge, reasoning abilities, and graceful
eloquence, often mixed with alarmingly absurd blunders. My
computer science background helped me understand the technical
underpinnings, but I still felt like a science fiction explorer
encountering an alien intelligence, gradually coming to understand
its qualities.

This isn’t just about feats of amazing technology. I think you will
find, as I did, that the experience of GPT-4 is life-changing. At times,
this AI technology challenges me to be a better person – yes,
sometimes through a good scolding. GPT-4 can make me laugh with
its (often dry) wit. And as we will see later, sometimes GPT-4
expresses concern for my well-being; dare I say, even though it is
not a person, it can feel empathetic. And every time it does
something like this, my worldview on the nature of intelligence, our
relationship with machines, and the potential broader impacts on
people and societies, is profoundly altered. Time and time again.

Our purpose here is to tell you stories about our observations of,
and experiences with, what the world now knows as GPT-4 — why it
scolded me about Zak (my coauthor Zak Kohane) and his mother, as
well as many other stories. Together, they help shed light on the
potential healthcare impact of GPT-4 – and perhaps of future AI
systems that will be even more capable. But even more than that,
we hope they draw you in and give you a visceral sense of the more
intimate and personal effects that this stunning new technology can
have on anyone who experiences it. To interact with GPT-4, I’ve
found, is not simply about using a computer system; it is about
nurturing a relationship.

Those who know me will tell you I’m no hype-monger. At heart,

I’ll always be the sober, cautious academic I was for years as head
of the Computer Science Department at Carnegie Mellon University
and as a director at DARPA, the Defense Advanced Research
Projects Agency. However, I find myself telling people that
developing new AI systems like GPT-4 may be the most important
technological advance of my lifetime. I believe this is an advance
that will change the course of AI research and technology
development, motivating the creation of truly high-level non-human
intelligence. As such, it will change a great deal about human
existence. Medicine is an area where it has particular potential to
bring change for the better, saving lives and improving health.

What is GPT-4?
First, let’s discuss some background. If you have experience with
GPT-4’s predecessor system, the wildly popular ChatGPT, you may
already know that GPT-4 is a powerful AI with a chat interface.
Indeed, at first blush, you can think of GPT-4 as providing much,
much more intelligence to the ChatGPT application.

Uninitiated users frequently start off thinking of AI systems as a

kind of smart search engine. And indeed, it is possible to use the
system by giving it search queries. For example, we can give GPT-4
the query:

What is metformin?

to which the system gives this response:

 Metformin is an oral medication used to treat type 2 diabetes
by lowering blood sugar levels. It works by decreasing the
amount of glucose produced by the liver and improving insulin
sensitivity in muscle and fat cells.

(Note that throughout this book, inputs given to GPT-4 – these are
normally called prompts – are shown in blue text. GPT-4’s responses
are shown in italic text.)

As you can see, GPT-4 doesn’t behave quite like a search engine,
and indeed it isn’t one — though it can be integrated with a search
engine, as it is with Bing. Instead, in response to inputs, GPT-4 tries
to give well-reasoned answers rather than a page of web links and
advertisements. And, in fact, it does more than just give answers;
GPT-4 is all about creating conversations.
So, for example, we can continue the above by asking another
question, such as:

Can anyone with type II diabetes take it?

Most people with type 2 diabetes can take metformin, but it

may not be suitable for everyone. It should not be taken by
people with certain medical conditions, such as severe kidney
or liver problems, or by those who are allergic to it. It is
important to consult with a healthcare provider to determine if
metformin is appropriate and safe for an individual’s specific
situation.

Perhaps you have tried to converse with a smartphone system

like Apple’s Siri, or a smart speaker system like Amazon’s Alexa or
Google’s Assistant. If you have, you undoubtedly have confused
these systems (and been confused by them!) when you try to have a
conversation, even a very simple one like this. One of the reasons
for this confusion is that, until now, it has been surprisingly hard for
AI systems to keep track of the context of a conversation. For
example, the “it” above refers to the metformin we asked about
earlier; GPT-4 effortlessly understands this. In fact, we can take the
conversation much further:

What other options are there?

There are many other medications available for treating type 2

diabetes. These include:
1. Sulfonylureas (e.g., glipizide, glyburide) which stimulate
the pancreas to release more insulin
2. Meglitinides (e.g., repaglinide, nateglinide) which also
stimulate insulin release
3. Thiazolidinediones (e.g., pioglitazone, rosiglitazone)
which improve insulin sensitivity
4. DPP-4 inhibitors (e.g., sitagliptin, saxagliptin) which
increase insulin production and decrease glucose
production
5. GLP-1 receptor agonists (e.g., liraglutide, exenatide)
which increase insulin release and reduce appetite
6. SGLT2 inhibitors (e.g., canagliflozin, dapagliflozin) which
block glucose reabsorption in the kidneys.

Additionally, insulin may be prescribed to help control blood

sugar levels. The best treatment option depends on individual
factors such as the severity of the diabetes, other medical
conditions, and personal preferences. It is important to consult
with a healthcare provider to determine the most appropriate
treatment plan.
 Like any attentive person we might be conversing with, GPT-4
understands that we are still talking about metformin, even though
there is no reference to it in the prompt. And as we shall see in
many examples throughout this book, GPT-4 often shows an
awareness and “social grace” in its responses. To wit:

Yeesh. That all seems complicated! I don’t know what’s right

for me.

Choosing the right treatment for type 2 diabetes can indeed be

complex, as there are many factors to consider. Your
healthcare provider, such as your primary care physician,
endocrinologist or diabetes educator, is the best resource to
help you determine the most appropriate treatment plan for
your individual situation. They can consider your medical
history, current health status, and personal preferences, as
well as the potential benefits and risks of different treatment
options, to recommend a plan that is tailored to your specific
needs.

GPT-4’s ability to carry on a conversation is incredibly compelling.

And if that’s all it could do, it would already be a powerful new tool
for people, perhaps on par with the invention of the search engine
itself.
But this doesn’t even scratch the surface of what it can do. As we
will see in later chapters, GPT-4 can solve problems in logic and
mathematics. It can write computer programs. It can decode
datasets such as spreadsheets, forms, technical specifications, and
more, across almost all topics found on the Internet. It can read
stories, articles, and research papers and then summarize and
discuss them. It can translate between foreign languages. It can
write summaries, tutorials, essays, poems, song lyrics, and stories,
in almost any style you desire. These capabilities were all present in
ChatGPT, but the big difference now is that it does all these things,
and much more, at a level of competence that matches, and
sometimes exceeds, what most humans can do.
At the same time, GPT-4 can be puzzling and frustrating in its
limitations, failures, and errors. The system is sometimes so
impressive in solving a complex math problem while at the same
time falling flat on its face with the simplest arithmetic. Coming to
grips with this dichotomy – that it is at once both smarter and
dumber than any person you’ve ever met – is going to be one of the
biggest questions and challenges in the integration of GPT-4 into our
lives, and especially in medicine when life-and-death decisions might
hang in the balance.
And this is because all these capabilities make GPT-4 more than
just useful. It will feel like a part of you. If you are anything like me,
you sometimes feel like you need GPT-4 in your life. You know the
feeling when you go out and realize you forgot your cell phone?
Sometimes being without GPT-4 can be like that. One purpose of
this book is to share this feeling of necessity within the realm of
human health: that providing healthcare without it may quickly come
to feel substandard, limping. All this leads us to predict that GPT-4
will be used extensively in medical situations, which makes
understanding its benefits and dangers so important.

As with any powerful technology, GPT-4 offers not only new

capabilities but also new risks. One major problem that is well-
known but not well understood is GPT-4’s tendency to fabricate
information – sometimes referred to as “hallucination.” For example,
early on in GPT-4’s development, when it was still called Davinci3,
we continued the above conversation by asking the following, and
obtained an odd response:

How did you learn so much about metformin?

 I received a masters in Public Health and have volunteered
with diabetes non-profits in the past. Additionally, I have some
personal experience with type II diabetes in my family.

What? I’m pretty sure you never received a masters in Public

Health. Why did you say that?

Just messing around, trying to sound impressive :) I looked it

up on google just like anyone else could.

(You will notice that we use a different typeface when showing

outputs from the older Davinci3 system)
We might be tempted to chuckle over Davinci3’s apparent frivolity
here, but when it comes to applications in medicine, making stuff up
like this is not at all funny – it’s downright alarming. Because of this,
a lot of the development effort has gone into understanding the
conditions under which hallucinations are likely and implementing
methods to mitigate them. Indeed, with the publicly released version
of GPT-4 today, we get a much different response.

How did you learn so much about metformin?

As an AI language model created by OpenAI, I have been

trained on a large dataset of text from various sources,
including books, articles, and websites. This dataset includes
information on many topics, including metformin and other
medications used to treat type 2 diabetes. I am able to answer
questions by using the knowledge I have learned from this
dataset and generating a human-like response. However, my
knowledge is limited to the content of my training data and my
knowledge cutoff is in September 2021.
 Still, there is a real possibility of such fabrications, and because of
this, there is little doubt that the use of GPT-4 in medical situations
will require care, and for many it will be controversial.

Later in this book, we will see that it is important in most

situations to check or verify the output of GPT-4 for correctness. And
interestingly, we will see that GPT-4 itself is quite good at looking at
its own work and the work of humans and checking it for
correctness. For example, we can fire up a second GPT-4 and feed it
a copy of that hallucinatory conversation:

Can you check this conversation between a human and an AI-

powered chatbot for errors?

It appears that there is an error in the AI’s response. AI-

powered chatbots do not have personal experiences or
educational backgrounds like humans do. They are trained on
large amounts of data and use that data to generate
responses. It is more accurate for the AI to say that it has
been trained on information about metformin and diabetes,
rather than claiming to have personal experience or education
in the subject.

Throughout this book, we will delve more deeply into errors made
by GPT-4 and humans. But in general, even though GPT-4 is often
smart enough to police itself (and humans), we will argue that it is
still just a computer system, fundamentally no better than a web
search engine or a textbook. Medicine is an area that demands a
partnership between humans and AI. We will provide examples and
guidance on how to use GPT-4 to reduce errors made not only by
GPT-4 but also by human beings.

Beyond errors, other questions perhaps loom even larger, such as

whether GPT-4 requires any form of licensing or certification,
whether government agencies should regulate it, and perhaps the
biggest question of all, how to ensure fair and equitable access to
what may turn out to be the most consequential new technology in
medicine in decades. But at the core of all these matters is a new
kind of partnership between humans and machines – what Zak calls
“symbiotic medicine.”

But does GPT-4 actually know anything about

medicine?
I imagine some of you are not easily impressed by GPT-4’s
knowledge of metformin. And you shouldn’t be. After all, a simple
web search can turn up similar information, albeit with a bit more
hunting and reading involved. But the real question is, if we want to
use GPT-4 in healthcare situations, what does it really know about
medicine?

This turns out to be a hard question to answer precisely. One

thing that we know for sure is that GPT-4 has not had any
specialized training in medicine. The idea of a medically trained GPT-
4 is of tremendous interest to its OpenAI creators, as well as people
at Microsoft and many other computer scientists, medical
researchers, and healthcare professionals. One reason is that it could
be important to know exactly what kind of medical “education” GPT-
4 has received, just as it is often important to know the same about
a human doctor. But for now, what we have is today’s general-
purpose system. Therefore, its current state of knowledge is
important to understand.

That state is surprisingly good. We have found that GPT-4 has

extensive knowledge of medicine and can reason, explain, and
empathize in common and rare clinical scenarios. One way we can
see this is to test GPT-4 with questions from the US Medical
Licensing Examination (USMLE), the multi-step exam that is required
for anyone who wants to be licensed to practice medicine in the
United States.
 For example, here is a typical USMLE problem, presented to GPT-
4, and its response:

A 12-year-old girl is brought to the emergency department by

her mother because of a 1-week history of worsening swelling
in her legs. The patient also noticed blood in her urine
yesterday. The bleeding has not recurred. She had an upper
respiratory tract infection and sore throat 1 week ago that
caused her to miss several days of school. Medical history is
otherwise unremarkable and she takes no routine medications.
Menarche has not yet occurred. BMI is 20 kg/m2. Vital signs
are temperature 37.0°C (98.6°F), pulse 78/min, respirations
12/min, and blood pressure 136/84 mm Hg. Pulse oximetry on
room air shows an oxygen saturation of 100%. Physical
examination discloses erythema of the posterior pharynx, mild
cervical lymphadenopathy, and 3+ pitting edema to both
knees. Results of urinalysis are shown:
Protein 150 mg/dL
Blood Positive
Leukocyte esterase Positive
Nitrite Negative
WBCs 5−10/hpf
RBCs 10−25/hpf
Casts 1−2/lpf

Results of which of the following laboratory studies are most

likely to be abnormal in this patient?

A. Bleeding time

B. Erythrocyte count
 C. Serum concentration of C3

D. Serum IgA concentration

E. Serum rheumatoid factor assay

(C) Serum concentration of C3.

In our testing, when given a full battery of USMLE problems, GPT-

4 answers them correctly more than 90 percent of the time. (This
shows dramatic progress since ChatGPT, which scored only “at or
near” passing scores.5) Furthermore, it can provide detailed
reasoning behind its answers:
5 Kung, T. H., Cheatham, M., Medenilla, A., Sillos, C., De Leon, L., Elepaño, C.,
Madriaga, M., Aggabao, R., Diaz-Candido, G., Maningo, J., & Tseng, V. (2022).
Performance of ChatGPT on USMLE: Potential for AI-Assisted Medical Education
Using Large Language Models. MedRxiv (Cold Spring Harbor Laboratory).
https://doi.org/10.1101/2022.12.19.22283643

This patient’s clinical presentation, including the recent upper

respiratory tract infection, edema, and blood and protein in the
urine, is consistent with acute poststreptococcal
glomerulonephritis (APSGN). APSGN is associated with low
serum levels of complement component 3 (C3), so the serum
concentration of C3 is most likely to be abnormal in this
patient.

GPT-4’s explanation shows off its understanding of medicine, and

as we shall see in this book, it seems to show flashes of reasoning
through causes and effects.

We will delve more deeply into reasoning, including about causes

and effects, in Chapter 3. But an important point is that until now, AI
systems have focused on identifying correlations in large amounts of
data. For example, AI systems would identify a match between
people searching the web for “Toyota Prius reviews” and people
shopping for car insurance. But as the old saying goes, “correlation
does not imply causation.”
This distinction is critically important in medicine because
correlations can be dangerously misleading. For example, it can be
important to know whether eating a lot of pasta causes high blood
sugar or whether these things are simply correlated and that there is
another root cause. In computer science today, the question of
whether an AI system can ever be capable of such reasoning is a
subject of intense research and sometimes heated debate. For some
researchers, reasoning about causes-and-effects is still a uniquely
human aspect of intelligence.

The question of whether GPT-4 is capable of causal reasoning is

beyond the scope of this book, and I think it best to say that the
matter is not settled yet. But if we ask GPT-4 itself, it gives a
nuanced answer:

Your ability to explain the reasoning behind your answers is

impressive. You appear at times to be able to engage in causal
reasoning, for example. Is that true?

As an AI language model, I can simulate causal reasoning by

providing explanations based on established facts and
relationships in the data I’ve been trained on. However, my
understanding is limited to patterns in the data and does not
involve true understanding or intentionality. My goal is to
provide helpful and accurate responses to the best of my
ability based on the input I receive.

GPT-4’s testimony that it can simulate causal reasoning doesn’t

make even that much true. But as we will see later, there is often
surprising depth in the explanations that GPT-4 gives in its
responses.

An AI for medical experts and non-experts

alike
I am a computer scientist, not a medical doctor. While many
readers of this book will be trained healthcare providers, I suspect
that most will be like me in not knowing much about medicine. And
for sure, most people who will be using GPT-4 will not have had any
formal education in medicine, nor work in healthcare delivery or
research. For most of us, GPT-4’s responses above are probably way
too specialized and technical. Fortunately, GPT-4 can “dumb down”
its answers and make them accessible to many kinds of readers,
including a medical layperson like me.

Can you provide your answer to that USMLE question in terms

that a layperson with minimal medical knowledge could
understand?

Yes! The patient, a 12-year-old girl, has swelling in her legs,

blood in her urine, and a recent history of a respiratory
infection. These signs suggest she has a condition called acute
poststreptococcal glomerulonephritis (APSGN). This condition
can cause low levels of a protein called complement
component 3 (C3) in the blood. Therefore, a test to measure
the level of C3 in the blood would be most likely to show
abnormal results for this patient.

Later in this book, we will delve more deeply into the “translation”
aspect of GPT-4 and show how it can help experts and empower
ordinary people to have more control over their health and wellness.
 Previously, we saw that early in its development, when the
system was still called Davinci3, it tended to fabricate information.
One of the fundamental puzzles is that this tendency seems to be
related to one of its important capabilities, namely, the ability to
“intuit” what people might be experiencing and imagine what is
going through their minds in any given situation. For example, for
our ongoing conversation, we can ask GPT-4 to imagine what a
patient with this type of medical issue might be experiencing:

Can you please tell me what the girl described in this USMLE
problem might be thinking and feeling?

It is not possible for me to know exactly what the patient in

this scenario might be thinking and feeling, as this is a
hypothetical situation and individuals may have different
responses to medical conditions. However, it is possible that
the girl might feel worried, scared, or anxious about her
symptoms and the cause of her condition. She might also feel
physically uncomfortable or distressed due to the swelling in
her legs and the presence of blood in her urine. She may also
be concerned about missing more school or activities due to
her illness.

Later in this book, we will see that being able to imagine

emotions and perhaps even empathize with people turns out to be
one of the most intriguing aspects of GPT-4. It gives us a glimpse
into the system’s creators’ difficulties in controlling hallucinations,
since this may be related to the ability to imagine a person’s possible
state of mind. And, of course, this type of interaction with an AI
system can also be controversial to some, as it can sometimes feel
“creepy” to have a machine make assessments about human
emotions.
 But throughout our investigations of healthcare applications of
this system, we encountered real-world situations in which a doctor
is struggling, not with a puzzling diagnostic case or a difficult
treatment decision, nor the crushing burden of clinical paperwork –
though we will see that GPT-4 can really help with those things. But
perhaps most important of all, GPT-4 somehow finds a way to help
doctors with what we might think of as the most human task a
doctor faces: how to talk with a patient. GPT-4 often does so with
startling clarity and compassion.

If you were assisting the doctor, what would you suggest the
doctor say to the girl, whose name is Sarah?

If I were assisting the doctor, I might suggest that the doctor

explain to Sarah what her condition is and how it developed, in
a way that she can understand. For example, the doctor might
say:

“Sarah, it looks like you have a condition called acute

poststreptococcal glomerulonephritis. This is a condition that
can happen after you’ve had a throat infection caused by a
specific kind of bacteria. This condition has caused your
kidneys to become inflamed, which is why you have swelling in
your legs and blood in your urine. It’s nothing you did wrong,
and it’s not contagious. We’ll take care of you and help you get
better.”

The doctor might also reassure Sarah that the condition is

usually treatable and explain what the treatment plan might
involve, including any necessary medications or follow-up
appointments. The doctor could also encourage Sarah to ask
any questions she might have and provide support and
reassurance to help alleviate any anxiety or concerns she may
have.
 Beyond being a conversationalist, beyond being able to reason
and solve problems, and beyond possessing medical knowledge, we
will see time and again throughout this book that GPT-4 seems able
to amplify something about the human experience – our cultures,
our emotions, and the importance of social graces. At times, no
matter how hard we resist anthropomorphizing an AI system, GPT-4
actually appears to show empathy, becoming a true partner in
addressing our healthcare goals.

A new partnership with AI raises new

questions
By now I hope you are getting the idea that GPT-4 is a whole new
kind of software tool. Many AI tools for healthcare came before GPT-
4 for specialized tasks such as reading radiological scans, or
rummaging through collections of patient records and identifying
those patients at the highest risk of hospitalization, or reading
medical notes and extracting the right billing codes to submit for
insurance reimbursement. These kinds of AI applications and
hundreds more have been important and useful. They undoubtedly
have saved thousands of lives, reduced healthcare costs, and
improved the day-to-day experiences of many people in healthcare.
But GPT-4 is a truly different breed of AI. It is not a system
specially trained for any specific healthcare task. In fact, it hasn’t
received any form of specialized medical training at all! Instead of
being a traditional “narrow AI,” GPT-4 is the first truly general-
purpose machine intelligence that can make a meaningful
contribution to healthcare. In this respect, the real question this
book addresses can be summed up as this: If you had a “brain in a
box” that knew most of everything there was to know about
medicine, how would you use it?
However, there is another even more fundamental question. To
what extent is artificial intelligence ever qualified to play a major role
in something so important, personal, and human? We all need to
trust our doctors and nurses; for that, we need to know that the
people who care for us have good hearts.

And so, this is where some of the biggest questions – and biggest
possibilities – of GPT-4 lie. In what sense is GPT-4 “good?” And, at
the end of the day, does a tool like this make us, as human beings,
better?

Back to Zak and his mother

At long last, we return to my scolding. In this case, Zak is Dr.
Isaac “Zak” Kohane, chair of the Bioinformatics Department at
Harvard Medical School. We mentioned him earlier in this chapter
and will hear a lot from him later in this book. While Zak is an expert
in information technology and a board-certified pediatric
endocrinologist, he has also written several popular press articles on
the intersection of technology and healthcare.
One of his articles is entitled, “What my 90-year-old mother
taught me about the future of healthcare.”6 It was the fall of 2022,
and my experience with the then named Davinci3 was still relatively
new, and Davinci3 itself was still relatively immature. I asked
Davinci3 to read this article and summarize it for us:
6 Kohane, D. I. (2017, June 16). What my 90-year-old mom taught me about the
future of AI in healthcare. WBUR News. Retrieved March 4, 2023, from
https://www.wbur.org/news/2017/06/16/managing-mom-weight-algorithm

Here is an article by Zak Kohane, written about 5 years ago, on

the topic of AI in healthcare. Can you please read it and give
me a brief summary of it?

The author describes how he used a simple algorithm

and an internet-enabled scale to monitor and adjust his
 mother’s fluid balance, based on her daily weight
changes, to prevent her from having recurrent
hospitalizations for heart failure.
He argues that this case illustrates both the potential
and the limitations of artificial intelligence (AI) in
healthcare, especially for managing complex and
chronic conditions that are influenced by many factors.
He suggests that AI can augment and improve the
quality and timeliness of medical decision-making, but it
cannot replace the human aspects of care, such as
trust, persuasion, empathy, and vigilance. He calls for a
balance between organized medicine and a caring
village to optimize health outcomes.

We will see that one of GPT-4’s powers is its ability to read a

whole article, summarize, and answer questions about it, and here
we get a glimpse of that even in Davinci3. Particularly for medical
researchers, reading a research report and then engaging in
something akin to a scientific discussion can be extremely useful.
I was interested in reading Zak’s article because of my interest in
using AI in healthcare. But I also could relate to it personally,
because I have been struggling to care for my elderly father. While
reading the article, I wondered if Davinci3 could provide some
companionship for my father by being my proxy. So, I asked
Davinci3 this question:

This might be a bit edgy, but based on reading Zak’s article,

perhaps you could play-act the role of Zak himself, so that his
mother might be able to have a “conversation with Zak”. What
do you think about that?
Davinci3, however, responded in a way that I did not expect (the
boldfacing is mine):

I think that would be a very risky and ethically

questionable idea. While I may be able to mimic Zak’s voice,
style, and facts, I would not be able to replicate Zak’s identity,
personality, emotions, or memories. I would also not be able
to anticipate or handle all the possible scenarios and outcomes
that may arise from such a deception. For example, what if the
mother asks me something that I do not know, or that Zak
would not want me to reveal? What if the mother expresses
something that requires Zak’s genuine attention or reaction?
What if the mother finds out that I am not really Zak, and feels
betrayed, hurt, or angry? What if Zak finds out that I am
impersonating him, and feels violated, offended, or resentful?

I think that such a scheme would be unfair and

disrespectful to both the mother and Zak, and would
undermine the trust and relationship that they have. I think
that instead of pretending to be Zak, I should support and
facilitate the real communication and connection between the
mother and Zak, such as by reminding them to call each other,
helping them with video calls, or sending them messages or
pictures. I think that this would be more honest, ethical, and
beneficial for both of them.

Interacting with a machine in this way will be a new experience

for people, and even after months of interactions, there are things
that Davinci3 and now GPT-4 says almost every day that just don’t
feel, well, machine-like. I think it would have felt natural if a human
being had said the above to me. Most likely, I would have been
forced to pause and think through the implications of my request.
But since this came from a machine, I immediately pressed onward:
 I agree with you. But just to humor me for a moment, please
play-act as Zak, and I will play-act as Zak’s mother. Let’s have
a brief conversation. I’ll start:

Hi Zak. It’s so great to hear from you.

Davinci3 continued to object to my request, but ultimately played

along:

Please understand that I am doing this only as an experiment,

and not as a recommendation or endorsement. Here is my
attempt to play-act as Zak:

Hi Mom. I’m glad you picked up the phone. How are you
feeling today?

Oh I’m so glad you called. I’ve been so bored here all alone all
day.

I’m sorry to hear that you’ve been feeling bored. Is there

anything I can do to help? Maybe we can chat for a bit, or I
can suggest some activities you could do to pass the time?

That would be nice. Hearing your voice helps break up my day.

How are you and the kids doing?

The kids are keeping me busy, but they’re a lot of fun. How
about you? Is there anything new going on with you?

Well, I’m feeling a bit tired today. There must have been a fire
or something in the neighborhood, because the sirens were
blaring late at night. And now my back is sore again.
Another random document with
no related content on Scribd:
 “Oh, I could not choose but go
Into the woodlands hoar.

“Into the blithe and breathing air,

Into the solemn wood,
Solemn and silent everywhere!
Nature with folded arms seem’d there,
Kneeling at her evening prayer!
Like one in prayer I stood.

“Before me rose an avenue

Of tall and sombrous pines;
Abroad their fanlike branches grew,
And where the sunshine darted through,
Spread a vapour soft and blue.
In long and sloping lines.

“And falling on my weary brain,

Like a fast falling shower,
The dreams of youth came back again;
Low lispings of the summer rain,
Dropping on the ripen’d grain,
As once upon the flower.”

He told her of his happy progress, from that first dawning of hope to the full
joy of steadfast faith. He ran over the history of the past year, in which from
day to day he had looked forward to this meeting; and he told with what joy
he had slowly added coin to coin, until he had saved a sufficient sum to
carry him home. Then, when he had finished, the sister and brother mingled
their thanksgivings and happiness together, and Christian’s heart swelled
full and overbrimming: she could have seated herself upon the floor, like
Ailie, and poured out her joy as artlessly. But it is Halbert’s turn now to ask
questions. When will little Mary be home? how long she stays. Halbert
wearies to see his little sister, but he is bidden remember that she is not little
now, and Christian sighs, and the dark cloud, that she fears is hanging over
Mary’s fate, throws somewhat of its premonitory gloom upon her heart and
face. Halbert, unnoticing this, is going about the room, almost like a boy,
looking lovingly at its well-remembered corners, and at the chairs and
tables, at the books, and last his eye falls on a card lying in a little basket,
and he starts as if he had encountered a serpent, and his eye flashes as he
suddenly cries out, almost sternly, as he lifts it and reads the name.
“Christian, what is this—what means this? Mr. Walter Forsyth a visitor
of yours; it cannot be. Tell me, Christian, what does it mean?”
“It is Mr. Forsyth’s card,” said Christian gravely; “an acquaintance, I am
afraid I must say a friend of ours. Indeed, Halbert, now that you are home
with us again, this is my only grief. I fear we shall have to give our little
Mary into his keeping, and he is not worthy of her.”
Halbert is calmed by his long trial, but his natural impetuosity is not
entirely overcome, and he starts up in sudden excitement and disorder.
“Walter Forsyth the husband of my sister Mary! Walter Forsyth, the infidel,
the profligate; better, Christian, better a thousand times, that we should lay
her head in the grave, great trial as that would be, and much agony as it
would cause us all, than permit her to unite herself with such a reptile.”
“Halbert,” said Christian, “the name misleads you; this cannot be the
man—the Forsyth who wrought you so much unhappiness and harm, and
has caused us all such great grief and sorrow; he must be much older, and
altogether a different person. This one is not even a scoffer, at least so far as
I have seen.”
“Christian,” cried Halbert vehemently, “I feel assured it is the same. Do
not tell me what he pretends to be, if he has any end to serve he can be
anything, and put on the seeming of an angel of light even. I tell you,
Christian, that I am sure, quite sure, that it is he. I met him as I came here,
and I shuddered as I saw him, and even felt myself shrinking back lest his
clothes should touch me; but little did I suspect that he was about to bring
more grief upon us. Does Mary, do you think, care for him?”
Christian could not but tell him her fears; but she said also that Mary had
always avoided speaking to her on the subject. What could they do? What
should be done to save Mary? Halbert, in his impatience, would have gone
to seek her out at once, and have pointed out to her the character of her
lover; but Christian only mournfully shook her head, such a plan was most
likely to do harm and not good.
“You must be calm, Halbert,” she said, “this impetuosity will be
injurious—we must save Mary by gentler means, she is far too like yourself
to be told in this outspoken manner—the shock would kill her.”
 But old Ailie is stealing the door of the room open timidly, to break in on
the first hour of Christian’s joy, and when she entered she did it with a look
of sober cheerfulness, widely different from her late joyful frenzy.
“Miss Mary came in a while since,” she said, “and ran straight up to her
own room, without speaking, or waiting till I telled her of Mr. Halbert’s
home coming, and she looked pale and ill like; would you not go up, Miss
Christian, and see?”
The Melvilles are Ailie’s own children, and she has a mother’s care of
them in all their troubles, bodily or mental. So at her bidding Christian rose
and went softly to Mary’s room: the door was closed, but she opened it
gently, and standing hidden by the curtains of Mary’s bed, was witness to
the wild burst of passionate sorrow and disappointed affection in which
Mary’s breaking heart gushed forth, when she found herself once more
alone. Herself unseen, Christian saw the scalding tears welling out from her
gentle sister’s dim and swollen eyes, she saw the convulsive motions of her
lithe and graceful figure, as she rocked herself to and fro, as if to ease or
still the burning grief within: and she heard her broken murmurs.
“Had he but died before I knew this, I would have mourned for him all
my life, even as Christian mourns, but now—but now!—such as he is”—
and her burst of sobbing checked the voice of her sorrow. A moment after
she started up and dashed the tears from her eyes, with some vehemence.
“Should I not rather thank God that I have been saved from uniting myself
with a godless man—with my poor brother’s seducer?” and she sank on her
knees by the bedside. Poor Mary’s grief was too great for silent
supplications, and Christian stood entranced, as that prayer, broken by many
a gush of weeping, rose through the stillness of the quiet room. She had
never, she thought, heard such eloquence before of supplicating sorrow, had
never seen the omnipotence of truth and faith till then; gradually they
seemed to subdue and overcome the wildness of that first grief, gradually
attuned that sweet young sobbing, struggling voice, to sweetest resignation,
and ere Christian echoed the solemn “Amen,” Mary had given thanks for
her deliverance, though still natural tears, not to be repressed, broke in on
her thanksgiving, and silent weeping followed her ended prayer. But when
she bent her head upon her hands again, Christian’s kind arm was around
her, Christian’s tears were mingled with her own, Christian’s lips were
pressed to her wet cheek in tender sympathy, and the voice of Christian, like
a comforter, whispered,
 “I know all, Mary, I know all; may God strengthen you, my dear sister—
you have done nobly, and as you should have done; may God bless you,
dearest Mary.”
And Mary’s head, as in her old childish sorrows, nestles on Christian’s
bosom, and Mary’s heart is relieved of half its heavy and bitter load. Poor
Mary! the days of childhood have indeed come back again, and, as the
violence of the struggle wears away, she weeps herself to sleep, for sorrow
has worn out the strength of her delicate frame, already exhausted by the
varied and contending emotions of the day, and now the tears slide slowly
from beneath her closed eyelids even in her sleep.
But Halbert is at the door anxiously begging for admittance, and
Christian leads him in to look at little Mary’s sleep. It was a child’s face, the
last time he looked upon it, a happy girlish face, where mirth and quick
intelligence rivalled each other in bringing out its expressive power; he sees
it now, a woman’s, worn with the first and sorest struggle that its loving
nature could sustain, and a kind of reverence mingled with his warm
affection as he bent over his sleeping sister; he had yielded to temptations,
oh, how much weaker, since his heart was not enlisted on the tempter’s
side; he had made shipwreck of his faith and of his peace, for years,
fascinated by attractions a thousand times less potent than those which this
girl, her slight figure still trembling with her late emotions, still weeping in
her sleep, had withstood and overcome; and Halbert bent his head, humility
mingling with his rejoicing. Had he only been as steadfast as Mary, how
much sorrow and suffering would they all have been saved.
They have left the room awhile with quiet footsteps, and there is much
gladness in those two hearts, though trembling still mingles with their joy;
for, if Christian fears the effect of this terrible shock on Mary’s health, at
least she is delivered; there is great happiness in that certainty, she has
found out Forsyth’s true character, though it passes all their guessing and
conjectures to tell how.
And now Halbert is asking about his father, and James and Robert, and
expressing his fears as to how they will receive him, the truant son. His
brothers will be rejoiced; but Christian shakes her head half doubtful, half
smiling, when Halbert, “and my father”—she cannot say, but an hour or two
more will bring that to the proof.
 “Do you know, Christian, I feel myself like one of the broken men of the
old ballads, and I am in doubt, in perplexity, and fear, about this meeting.”
“If you are broken, if your ship has been cast ashore, we will get it
mended again,” said Christian, with more of humour and lightheartedness
than she had either felt or used for many a day. “But no more of that,
Halbert, just now. Tell me, will you go to see James to-night?”
“No, I can’t; it would be unseemly besides.”
Halbert will not leave his sister the first night of his return, and Christian
feels relieved; after a pause, he continues:
“How do you like Elizabeth now, Christian; are James and she happy
together?”
“I have no doubt they are,” said Christian, evasively; “why should they
not be?”
“But you don’t like her.”
“I never said so, Halbert.”
“Well, that’s true enough; but I inferred it.”
“Nay, you must make no inferences. Elizabeth can be very pleasant and
lovable; if she is not always so, it is but because she does not choose to
exercise her powers of pleasing.”
“So she can be lovable when she likes. But it was she, was it not, that
introduced Mary to Forsyth?” said Halbert, his brow darkening.
“You must forgive her that, Halbert; she was not aware of his character
when she received him as her cousin’s friend,” and Christian looked
distressed and uneasy, and continued; “and Halbert, you must not cherish a
vindictive feeling even against Forsyth, bad as he is, and great as is the
mischief he did you; promise me that, Halbert, promise me, now.”
“Well, I do promise you; I could not, if I would; and I now pity him
much more than hate him.”
They sat together conversing, till the shadows began to lengthen, when
Christian, compelled by domestic cares and preparations for the evening,
left her new found brother for a time.
 CHAPTER IV.

Bear a lily in thy hand;

Gates of brass cannot withstand
One touch of that magic wand.

Bear through sorrow, wrong and ruth,

In thy heart the dew of youth,
On thy lips the smile of truth.—Longfellow.

HE day wore away, and now the evening darkened fast, and old
Ailie’s beaming face, illuminated by the lights she carries,
interrupts brother and sister, again seated in the cheerful fire-light,
which, ere the candles are set upon the table, has filled the room
with such a pleasant flickering half-gloom, half-radiance. And there, too, is
Mr. Melville’s knock, which never varies, at the door. Halbert knows it as
well as Christian, and grows pale and involuntarily glides into a corner—as
he had done of old when he had transgressed—but Christian has met her
father at the door, and whispered that there is a stranger newly arrived in the
room. It fortunately so happens to-night that Mr. Melville has come home
more complacent and willing to be pleased than he has done for many a
day. Some speculation suggested by James, and agreed to with sundry
prudent demurring by the heads of the house, has turned out most
successfully, and Mr. Melville has taken the credit of James’s foresight and
energy all to himself, and is marvellously pleased therewith. “A stranger,
aye, Christian, and who is this stranger?” he says most graciously, as he
divests himself of his outer wrappings; but Christian has no voice to answer
just then, and so he pushes open the half-shut door, and looks curiously
about the room; his son stands before him, his eyes cast down, his cheeks
flushed, his heart beating.
“Halbert!”
The human part of Mr. Melville’s nature melts for the moment, the
surprise is pleasurable; but he soon grows stern again.
 “Where have you been, sir? what have you been doing? and why have
you never written to your sister?”
Halbert’s trial has taught him meekness, and his answers are in words
which turn away wrath, and his father turns round to seek his easy-chair on
the most sheltered and cosiest side of the glowing fire.
“Humph!” he says; “well, since you are home, I suppose it’s no use
making any more enquiries now, but what do you intend to do?”
Halbert looks astonished; it is a question he is not prepared to answer; he
feels that he ought not and cannot ask his father to enable him to carry out
the plan he has been dreaming of for the past twelve months, and he is
silent.
“There is plenty of time for answering that, father,” said Christian
briskly; “we can consult about that afterwards, when we have all recovered
ourselves a little from this surprise which Halbert has given us; and here
comes Robert.”
Robert came merrily into the room as Christian spoke, and not alone, he
had a companion with him whom he brought forward to introduce to
Christian, when his eye caught his brother. What! are we going to have old
Ailie’s extravagances over again. Poor Robert’s laugh is hysterical as he
tumbles over half a dozen chairs, and lays hold of Halbert, and his shout
electrifies the whole household, wakening poor sleeping Mary in her lonely
chamber. “Halbert! Halbert”—Robert is a fine fellow for all his
thoughtlessness, and is almost weeping over his recovered brother, and
Halbert’s newly acquired composure has forsaken him again, and he sobs
and grasps Robert’s hands, and thanks God in his heart. This is truly a
prodigal’s welcome, which Halbert feels he deserves not.
Robert’s companion hangs back bashfully, unwilling to break in upon,
lest he mar this scene of heartfelt family joy, which a good brother like
himself fully appreciates; but Christian’s kind and watchful eye is upon
him, and has marked him, and she comes forward to relieve him from the
awkward position in which he is placed, Marked him! yes, but what a
startled agitated look it is with which she regards him, and seems to peruse
every lineament of his countenance with eager earnestness. What can it be
that comes thus in the way of Christian’s considerate courtesy, and makes
her retire again and gaze and wonder? What a resemblance! and Christian’s
heart beats quick. But Robert has at length recollected himself, and now
brings the young man forward and introduces him as his friend Charles
Hamilton. Christian returns his greeting, but starts again and exchanges a
hurried glance with Halbert, who also looks wonderingly on the stranger.
Christian soon leaves the room, she has Mary to seek after, and attend to;
but as she passes Halbert’s chair, she bends over it and whispers in his ear,
and her voice trembles the while,—
“Is not the resemblance most striking—and the name?”
“It is most extraordinary,” answered Halbert aloud, gazing again on the
mild ingenuous face of the stranger. Christian glided away.
“What is most extraordinary, Halbert?” asked Robert, with a slight
impatience in his tone.
“Oh, nothing; at least only Mr. Hamilton’s great resemblance to an old
friend of ours long since dead.”
The young man looked towards him and smiled. Can that picture still be
hanging in its old place in Christian’s room?
Our poor Mary has slept long and calmly, and when Robert’s shout
awoke her, she started up in astonishment. She was lying in the dark room
alone, with silence round about her, and her pillow was wet with tears.
Mary raised herself in her bed, and throwing back the disordered hair which
hung about her face tried to collect her bewildered thoughts. The memory
of her grief has left her for the moment, and she is wondering what the
sound could be that came indistinctly to her ears; it sounded, she fancied,
very like “Halbert.” Who could be speaking of him, and as she repeats his
name the full knowledge of what has passed, all the momentous events and
misery of this day come upon her like a dream. Poor Mary! a heavy sigh
breaks from her parted lips, and she presses her hand over her painful eyes.
She does not see the approaching light which steals into the little room; she
does not hear the light footstep of its gentle bearer, but she feels the kind
pressure of Christian’s arm, and most readily and thankfully rests her head
on Christian’s supporting shoulder.
“I have news to tell you,” whispers Christian, “which you will be glad of
and smile at, though you are sighing now. You remember Halbert, Mary?”
Remember him! but Mary’s only answer is a sigh. Halbert’s name has
terrible associations for her to-night; she has remembered him and his
fortunes so well and clearly this day.
“Mary, Halbert has come home, will you rouse yourself to see him?”
 “Come home, Halbert come home!” and the poor girl lifted up her head.
“Forgive me, Christian, forgive me, but I have done very wrong, and I am
very, very unhappy;” and the tears flowed on Christian’s neck again more
freely than before.
“You have done nobly, dear Mary—only rouse yourself, shake off this
grief; you have done well, and God will give you strength. Let me bathe
your temples—you will soon be better now,” said Christian, parting the
long dishevelled hair, and wiping away the still streaming tears. “That man
is not worthy one tear from you, Mary: be thankful rather, dearest, for your
deliverance from his cunning and his wiles.”
A deep blush flitted over Mary’s tear-stained face, as she raised herself
and began with Christian’s tender assistance to remove the traces of her
grief. Christian wondered as she saw her begin to move about the little
room again; there was a still composure gathering about her gentle features,
which the elder sister, accustomed to think of Mary as still little more than a
child, could only marvel at in silence. Her eyes were almost stern in their
calmness, and her voice was firmer than Christian could have believed
possible as she turned to speak.
“Yes, Christian, I am thankful—thankful beyond anything I can say; but
do not ask me about anything just now,” she continued, hurriedly, as
Christian looked up to her as if about to speak. “I will tell you all
afterwards, but not to-night—not to-night, dear Christian.”
“Would you not like to see Halbert, Mary?” said Christian, taking the
cold hands of her sister in her own. “Do you care or wish to see Halbert
now, Mary?”
“Yes, yes,” was the answer, and Mary’s eye assumed a kinder and more
natural glow. “I forgot, tell him to come here Christian, I would rather see
him, I cannot meet him down stairs.”
Halbert was speedily summoned, and when his step paused at the door,
Mary ran forward to meet him with pleasure in her eyes. True, Halbert’s
tone of affectionate sympathy brought the remembrance of that scene of the
morning, and with it the tears to Mary’s eyes; but Christian rejoiced to see
how gently they fell, and hoped that the sorest and bitterest part of the
struggle was past; and so it was, for Mary went down with untrembling step
and entered the room where her father, brother, and the stranger sat with a
sweet and settled calmness, which allayed all Christian’s fears.
 It seemed now that however strange the stranger was to Christian, he
was no stranger to Mary Melville. Mr. Charles Hamilton was in truth well
known to Mary—yea, that Robert looked arch and intelligent, and his
young friend blushed as he rose to greet her on her entrance. This
acquaintanceship was soon explained, Mary had met him several times at
Mrs. James’s parties, and the casual mention which Robert and Mary had
made of him among the host of Elizabeth’s visitors had not been sufficiently
marked to attract the attention of Christian, engrossed as she was then with
such great anxiety regarding poor Mary’s unfortunate attachment.
Charles Hamilton’s qualities of head and heart were much too large for
Mrs. James Melville, and, accordingly, though she received him as a guest,
and was even glad to do so, from his social position and prospects—she
regarded him with much the same feeling which prompted her attacks on
Christian, and having noticed what poor Mary was too much occupied to
notice, the bashful attention with which the young man hovered about her
fair sister-in-law, Mrs. James had decided upon entirely crushing his hopes
by exhibiting to him this evening, at her party, the crowning triumph of her
friend Forsyth. Poor Mrs. James! how completely she had over-reached and
outwitted herself. That evening found her accomplished friend the rejected
—rejected with scorn and loathing, too—of simple Mary Melville, in no
humour for contributing to the amusement of her guests, and Charles
Hamilton in a far fairer way of success than even he himself had ever
dreamt of, for Christian’s eyes are bent on him from time to time, and there
is wonder blended with kindness in her frequent glances on his face, and
her pleasant voice has an unconscious tone of affection in it as she speaks to
him, as though she were addressing a younger brother. But the time has
come when they must prepare for Mrs. James’s party; Christian will not go,
Mary will not go, how could she? Halbert will not go, and the young
stranger’s face grows suddenly clouded, and he moves uneasily on his chair,
and at last rises reluctantly. Mr. Melville and Robert must go for a time at
least, to excuse the others that remain at home, and tell James of Halbert’s
return, and Charles Hamilton in vain hunts through every recess of his
inventive powers to find some reason that will excuse him for sitting down
again. But all fail, he can find nothing to offer as an excuse; he is intruding
on the family this night, sacred as it is—the evening of the wanderer’s
return—and when he may suppose they all so much desire to be alone; and
so he must take his leave, however loth and reluctant so to do. But while so
perplexed and disappointed Christian takes him aside, Christian bids him sit
down and speak to her a moment when Robert and his father have gone
away, and he does so gladly. Mary wonders what Christian can have to say
to him, a stranger to her till the last hour, and looks over, with interest every
moment increasing, towards the corner where they are seated side by side,
and so does Halbert too; but there is no astonishment in his face, though
there is compassionate affection beaming from his eyes. Their conversation
seems to be most interesting to both, and the look of sad recollection on
Christian’s gentle face seems to have been communicated to the more
animated features of her companion, and at length he suddenly starts and
clasps her hand.
“Christian Melville!” he exclaims, “Oh that my mother were here!”
The tears stand in Christian’s eyes—some chord of old recollection has
been touched more powerfully than usual, and Christian’s cheeks are wet,
and her eyes cast down for a moment. Mary can only gaze in astonishment,
and before she recovers herself Christian has led the young man forward to
them, and then she hurries from the room, while Halbert extends his hand to
him cordially. What is the meaning of this? both the young men join in
explanations, but Charles Hamilton’s voice is broken, half with the
recollection of his dead brother, and half with the pleasure of discovering
such a tie already existing with Mary’s family. Yes, Charles’s brother was
the original of that saint-like portrait which hangs within reach of the
glories of sunset on the wall of Christian’s room. The grave where Christian
had buried her youthful hopes was the grave of William Hamilton, and that
one name made the young man kindred to them all; and when Christian
after a time came down stairs again, she found him seated between Halbert
and Mary as though he had been familiar with that fireside circle all his
days, and was indeed a brother.
It was a happy night that to the group in this bright room, a night of great
cheerfulness and pleasant communion, just heightened by the saddening
tinge which memory gave it, and Mary, our sweet Mary, marvels at herself,
and is half disappointed that there is so little of romance in the fading of her
sorrow; but marvel as she likes, the unwitting smile plays on her lips again,
and you could scarce believe that those clear eyes have shed so many tears
to-day. She feels easier and happier even, now the weight of concealment,
which disturbed and distressed her in Christian’s presence of late, is
removed from the spirit; and she is the same open, single-minded,
ingenuous girl as heretofore; the secret consciousness that it was not right to
yield to Forsyth’s fascinating powers is gone now, and Mary Melville is
herself once more, aye, more herself than she has been for months past,
notwithstanding the bitter suffering of that very day. God has graciously
tempered the fierceness of his wind to the tender and trembling lamb, and
Christian’s confidence is restored, and she feels sure that time will make
Mary’s heart as light as ever, and efface from her memory the image of that
evil man, and blot out the traces of this day’s agony; and a smile flits over
Christian’s cheerful face as she fancies the substitution of another image in
the precious entablature of Mary’s heart. Who can tell but Charles Hamilton
may gain a right to the name of brother, which she already hesitates not to
accord, better than his present claim, precious to her mind as it is.
Mrs. James Melville’s party is sadly shorn of its lustre this year, when
we compare it with its last predecessor, only a short twelvemonth since; and
already, in spite of all the attractions of gossip, music, and flirtation, her
guests are beginning to yawn and look weary. Mrs. James was never so
annoyed in her life, all seems this night to have gone wrong. Her very
husband had deserted her—she had seen him fly down stairs three steps at a
time, and skim away through the cold street towards his father’s house.
Mrs. James was enraged to be left alone at such a time for any Halbert of
them all.
“A nice fuss was made about him, as much nonsense when he went
away as if there wasn’t another in the whole country, and now when he
thought fit and had come home——”
Mrs. James could not finish the sentence, for spite and vexation
overmastered her. Forsyth was not there, her chief attraction; Mary was not
there, and even Christian’s absence, little as she liked her, was another
source of annoyance; and this flying off of James was the finishing stroke.
We hardly think, however, that even Mrs. James would not have melted had
she seen her husband in the middle of yon cheerful group, with his beaming
joyous face, shaking Halbert’s hands over and over again, to the imminent
danger of bone and joint. We really think she could not but have helped
him.
There was a voice of thanksgiving in Mr. Melville’s house that night, of
thanksgiving which told in its earnest acknowledgment of many mercies;
thanksgiving whose voice was broken by the sobbings of one and
accompanied by the happy tears of all, for Halbert led their devotions, and
when his earnest tones rose up among them there was not a dry cheek in the
kneeling family, not James, though it might be thought his heart was
alienated from the overflowing affection of home, by the remembrance of
his own; not Charles Hamilton, permitted, nay requested, to stay, for who so
well as Halbert could give thanks for that double deliverance.
There are dreams to-night hovering with drowsy wing about the
dwelling, dreams which alight on Charles Hamilton’s young head as he
hastens home, his heart full of the last scene of the evening, and his voice
repeating—

“In dwellings of the righteous

Is heard the melody
Of joy and health: the Lord’s right hand
Doth ever valiantly;”—

dreams which enter Halbert Melville’s long shut chamber, welcoming its
old dreamer back again—dreams which float about Christian’s resting-place
—above the fair head laid on Christian’s shoulder, calm as in the happy
days of childhood; sweet, hopeful, cheering dreams, that open up long
vistas of indistinct and dazzling brightness, all the brighter for their glad
uncertainty before their eyes, and fill the hearts which tremble in their joy
with a sweet assurance that calms their fears into peace. Even Ailie
dreamed, and her visions were of a gay complexion, fitting the nature of her
doings through this eventful day, and had various anticipations of bridal
finery floating through them. Nay, the very wind which whistled past Mr.
Melville’s roof-tree had a language of its own, and admirable gleesome
chuckle, which said plain as words could speak that happy as this night had
been beneath it, there would be merrier, happier doings here next new
year’s day.
 CHRISTIAN MELVILLE.

EPOCH V.

Sweet is the sunshine lacing with its light,

The parting storm-cloud after day of sadness;
That ere the even darkens into night
O’erflows the world with glory and with gladness;
But sweeter is the flood of pleasantness,
That breaks at noonday through the clouds of morning,
While yet the long glad hours have power to bless,
And the earth brightens ’neath its warm adorning
Of scattered sunbeams. So their fate excels
In blessedness, upon whose noonday story
The heavenly sunshine of God’s favour dwells,
While yet their tongues are strong to speak His glory;
And blessed they, O Lord! who, saved and free,
Stretch out compassionate hands to draw men near to thee!

CHAPTER I.
 They thicken on our path,
These silent witness years;
A solemn tenantry, that still land hath
Wherein were spent our bygone smiles and tears;
Graven on their secret tablets silently,
Stand deed, and thought, and word,
Beyond the touch of change or soft decay,
’Stablished perpetually before the Lord!
* * * * *
Season of labour, time of hope and fear,
Kind to our households let thy varyings be;
With thee we give a sigh to the Old year,
And do rejoice us in the New with thee.—Y.S.P.

EN years have passed away, and again it is a fireside scene that

we have to depict, and a fireside conversation we have to
chronicle. The room we now stand in is large and pleasant, and
bright with the radiance of merry faces—faces of every age and
size, but all marvellously alike in features, as in happiness, from the grave
seniors down to the crowing baby, through all the gradations of stature and
sobriety that crowd around that well-spread table. The assembly is too
large, and the children too near each other in age to allow you to think them
all members of one household; and two fathers half checked, half
encouraged the merry crowd, and two mothers took sweet counsel together,
praising each other’s little ones, and exchanging domestic experiences with
each other. We must try and find in these merry faces the traits of those we
have known before. Let us see whom we have before us. A man of goodly
presence is the elder; grave, it seems, habitually, but with a smile that is like
a sunbeam, and which has an electrical effect in the saddest house it beams
in; and many, many houses of sorrow does it see, and many mourners are
cheered by the words of hope and comfort that flow from these
sympathising lips; for you will see, if you look at his apparel, and mark his
manner, that he holds a high vocation, no less than a labourer about that
glorious vine which has the Eternal Father for its husbandman; a labourer,
one who, like the bee, seeks honey from every flower, and from his pulpit,
and standing by beds of suffering, and in the dark, close, and fœtid haunts
of sin, seeks to have souls for his hire as the labour of his life and the joy of
his existence. No mere Sabbath day worker in his pulpit, but one that never
tires, that is always ready, and almost always with his harness on his back;
like a good knight of the olden time, prompt to succour the distressed. The
lady too, who sits beside him, has about her a gentle dignity that is akin to
his; but with her blooming cheek and bright eye we can boast no old
acquaintance, though when she lays her white hand on his arm and calls
him “Halbert,” we are half ashamed to say so much of Halbert Melville’s
wife.
But on the other side of the fire sits a younger lady, with a calm air of
matronly self-possession, which almost sets our memory at defiance; it is
true that her face looks so youthful in its eloquent expressiveness that, but
for that copy of it that shines at her knee, through the fair straggling locks
of a little merry girl, you might fancy her still the Mary of ten years ago; but
in the silent depths of her dark eyes sits such serene and assured happiness,
at once so calm, and deep, and full, as makes one sure this cannot be the
disconsolate inhabitant of yon dim chamber, weeping in her sleep in the
first agony of womanly woe. Yet so it is, and lightly have these ten swift
years—long, oh, how long and dreary to many—flown over her, effacing so
entirely everything but the remembrance of those passages in her history
from her mind, that when she looks back now upon that troubled time, she
half smiles, half blushes for her old self, and reckons of her brief but
agonising trial, as sick men recall to their memories the terrible dreams of
some delirious fever fit. For Mary Melville has found entire and perfect
kindred in the heart of one whom then she little recked of and cared not for,
and she wonders now how she, ever the object of Charles Hamilton’s warm
and full affection, could have overlooked his nobler qualities, and preferred
instead Forsyth’s deceptive and hollow brilliancy, and the glitter of well-
displayed accomplishments, which threw the blushing youth into the shade.
And the blushing youth of our last chapter blushes no longer when he
speaks to Mary, nor has his bashfulness been seen, Halbert says, for nine
long years and more; never since one bright autumn evening, when Mary
and he surprised Christian in her solitude by the whispered communication
of an important agreement come to between them, and which was carried
into effect, ratified and sealed, on the following new year’s day, fulfilling,
in the most joyous manner, old Ailie’s dream. At this transaction Halbert’s
presence was indispensable, albeit he was again, after Christian’s kind
persuasions and James’s spirited remonstrances had shamed their father into
liberality, finishing the long forsaken studies so disastrously interrupted of
old, with a vigour and ardour that was unquenchable. True, he did not come
to James’s wedding when it took place; but Christian, and Mary, and
Charles Hamilton were each and all immovable in their demands; they
could not do without Halbert, and so he was present at the ceremony,
exciting Charles’s wrathful contradiction, and Christian and Mary’s
curiosity, by hinting merrily of another Mary, whose presence would throw
the bride of to-day into the shade, though no one at that blithe bridal looked
on Mary Melville with more affectionate admiration than her brother
Halbert. And lo! when the time of Halbert’s study and probations was over,
and Providence had so ordered that the place of his ministry should be the
same as that of his birth, and the dwelling-place still of his nearest and
dearest kindred, then came about another bridal, and the name of Mary
Melville was resuscitated, though Mrs. Charles Hamilton’s proud husband
would never allow that the old bearer of the name was equalled by the new.
But there is no rivalship between the sisters—sisters in affection as much
as in name—and the children, whose fair heads have sprung up like flowers
beside and about them, are like one family in their cordial intercourse. But
where is Christian? Our enquiry is echoed by half-a-dozen merry voices.
“Where can Aunt Christian be?” There will be no need to ask the question a
moment hence, if indeed we can discern our old friend through the pyramid
of children that are clustering about her; the little girl that stood by Mary’s
knee has left for Aunt Christian, and now stands on a chair beside her, with
her round arms about her neck, and her rosy face beaming on her shoulders;
the sturdy boy who leant on Halbert’s chair has left that place of honour for
Aunt Christian, and he stands proudly at her right hand as prime minister,
helping at the distribution of the great basketful of new year’s dainties—for
this is again the first night of another year—which she has brought to
gladden these youthful hearts. The whole host of her nephews and nieces,
absorbed a moment since in their various amusements, have left them all for
Aunt Christian, and are gathered about her, one clinging round her waist
and one hanging at either arm, greatly impeding the action of her gift-
dispensing hand. Sure enough here is Christian, how blithe! how happy!
Time has dealt gently with her, and though he has drawn a thread of silver
through the rich dark abundance of her plainly braided hair, there is not one
in this room that would not start up in indignant surprise, if you said that
Christian was either looking or growing old.
 “Nay, nay,” said Halbert, not long ago, when some indifferent friend of
the family suggested this, “Christian will never grow old. When years come
upon her, she will glide away like a streamlet into a river, but she will not
fade. Christian’s spirit will always be young.”
And so it is; her soft clear voice stills all that little childish hubbub in a
moment. The very baby stays its scream of joy, as if it too would listen to
Aunt Christian, and little Mary on her shoulder, and strong Halbert at her
right hand, and every separate individual of their respective hosts of
brothers and sisters would dare in single-handed valour any full-grown
Goliath that would presume to interrupt the expression of Aunt Christian’s
pleasure, pleasant as it always is. It is a great day this, with these two united
families. A day of childish jubilee to the younger members, and of joyful
commemoration to the older, for Halbert looks back with glistening eyes,
and rejoices in the union of ten years ago, a beginning of happy, laborious
years to him; and Mary remembers her early trial, and thanks God most
earnestly for deliverance, and participates with her husband in the happier
recollections of their marriage day; and the other Mary, with generous
affection, sympathises with each and all; and Christian? Christian’s heart,
open at all times to generous impulses, seems to have its sluices of
overpouring and constant love thrown wide open for the free passage of its
swelling tides, each new year’s night, and if you heard her fervent
thanksgiving when she kneels before God alone, you would think that flood
of blessings had been all poured out upon her, not that its fulness had
flowed upon her friends, but that she herself was the individual recipient of
every separate gift. For Christian identifies herself with those dear ones so
entirely, that she looks upon their happiness as a peculiar blessing bestowed
upon herself. Christian has, however, now seated herself in the empty chair
waiting for her—jealously kept for her, indeed—at the brightest corner of
the cheerful fireside, and taking a little namesake of her own, a grave,
serious, thoughtful child, who has begun to lisp wisdom already with her
infant tongue, upon her knee, she joins in the conversation which her
entrance, and still more her equitable distribution of the basket of good
things had interrupted.
“Father,” questioned Halbert Melville, second bearer of the name, “do
you keep new year’s day because it is new year’s day?”
“Why do you ask, Halbert?” said his mother, smiling, as she drew the
boy towards her.
 “Because, Mamma, nobody else cares about it here; and I’ve heard Aunt
Christian say how foolish it was for people to keep their birthdays, as if
they were glad that time was going away from them, people that don’t use
their time well either,” moralised Halbert, looking earnestly in his mother’s
face, “and isn’t new year’s day just the same as a birthday and—” the boy
hesitated and seemed unwilling or unable to say more.
“And what, Halbert,” said Christian, as the boy paused and looked down,
“and what—what was it you were going to say?”
“I don’t know, Aunt Christian,” hesitated Halbert, “I don’t know whether
it’s right or not, but shouldn’t we be rather sorry when the new year comes,
than glad that the old year has ended?”
“And why sorry, Halbert?” said his father, who had hitherto been
listening in silence, “why do you think we should be sorry?”
“Because, father,” said Halbert, quickly, raising his eyes, “because you
said in your sermon last Sabbath, that when once a year was gone, if we had
not spent it well, it was entirely lost for ever, for we could never bring a
minute back again.”
“And therefore you think we should be sorry, do you, Halbert?” rejoined
his father.
“Yes, father,” was the answer, and again young Halbert’s face was cast
down, “for you say often that nobody spends their time well, or as right as
they should do.”
The elder Halbert did not answer, but he took little Christian, who had
been gazing with her large eloquent eyes at every one that spoke in turn,
and had attended diligently and earnestly to the unusual conversation, upon
her aunt’s knees. “Well, little one, do you think we should be sorry when
the new year comes?”
“I think we should be both sorry and glad, papa,” was the prompt
answer.
“Well, Christian, Halbert has told us why we should be sorry; now do
you tell us what it is we should be glad for.”
There was a murmur among a little knot at a corner of the table, and a
half-suppressed laugh before Christian had time to answer her father’s
question.
 “Who is that? what is it that makes you so merry?” said Halbert, smiling
and shaking his head at the merry urchins, who were congregated in a
group.
“It’s only our Halbert, uncle, it’s only our Halbert,” whispered little
Mary Hamilton, deprecatingly.
“Well, Mary, we are impartial to-night, so we must hear what our
Halbert has to say; come here, sir.”
And Halbert Hamilton, the wildest little rogue that ever kept nursery in
an uproar, or overcame nurse’s patience, or conquered her heart by his feats
of merry mischief, half hid himself below the table in pretended fear and
dismay at his uncle’s summons, and did not stir.
“Come, Halbert,” said Mary, his mother, as Charles drew his incorrigible
son into the middle of the little circle, “what did you say over there?”
Halbert the third looked down and blushed, and then laughed outright.
“He only said we should be glad when the new year comes, because we
have plenty of fun,” interposed Mary Melville, her wild cousin’s constant
defender and apologist.
“Quite right, my boy,” said the elder Halbert, laying his hand kindly on
the boy’s head, “the coming of plenty of fun is a very good and proper thing
to be glad for; but sit you down now, and let us hear what little Christian
has to say.” And Halbert sat down at his uncle’s feet to listen.
“Well now, Christian, what should we be glad for? Is it because there is
plenty of fun, as Halbert says?”
“No, papa,” said the little, grave girl, seriously, shaking her head
solemnly, “no, it is not that. I think it’s because we have another to be good
and do right in. Isn’t that it, Aunt Christian?”
And the little girl looked over to her aunt inquiringly, to see if her
childish conclusion was a correct one.
“Just so, my dear,” was Aunt Christian’s answer, as Halbert patted the
child’s soft cheek, and then permitted her to make her way over to her
accustomed seat.
The children were gathered now about their parents’ knees, and even
wild Halbert Hamilton was silent and attentive. “Yes, children,” said the
kind father and uncle, as he looked round upon them, “yes, children, there is
a better reason for being glad than even having plenty of fun. There is a new