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We Are Not Ourselves

Thomas, Matthew

Last Updated: Jun-20-2016
Annotated by:
Teagarden, J. Russell

Primary Category: Literature / Fiction

Genre: Novel

Summary:

In 1951, Eileen Tumulty, the novel’s main character, was nine years old and living with her Irish immigrant parents in the Woodside section of Queens, New York. The novel follows Eileen straight through the next 60 years, but concentrates on the years covering the time of her husband’s Alzheimer’s disease.    

Eileen was forced to learn how to manage a household at a very young age when first her mother was kept in a hospital for 8 months after a hysterectomy, and then again when her mother became incapacitated by alcoholism. Eileen had reason to think this life was her destiny until she accompanied her father to a better part of Queens. There she saw “places…that contained more happiness than ordinary places did.” She concluded, “unless you knew that such places existed, you might be content to stay where you were.” (pp. 15-16) Eileen’s ambition was ignited. While continuing to manage the household and care for her mother, she does well in school, becomes a nurse, and eventually moves up the nursing management at various hospitals.  

Eileen’s ambitions encompassed ideas on her eventual mate. She chooses Ed Leary despite hoping for someone who was not quite so Irish and not quite so much of the same place. Ed was a promising neuroscience graduate student who she thought could be a high achiever with the right motivation: “If there was anything she could help him with, it was thinking big.” (p. 97) Her motivation was not enough and neither were the many offers he received from life science companies. He became a professor at a local community college. He had a passion for teaching students who attend community colleges and he could never see himself anywhere else—for love or money. Ed’s intransigence frustrated Eileen, but she accepted it and plowed ahead. She studied the possible ways of escaping the old neighborhood and also delivered a son she thought she’d never have after years of futile efforts.  

It doesn’t go smoothly. While she is getting surer of where they would go, Ed begins to exhibit disconcerting behaviors. For them to live in Bronxville, Eileen will have to accept a house that needs a lot of money and attention to rehabilitate. The remainder of the story is about how Eileen simultaneously manages Ed’s rapid deterioration from what eventually is diagnosed as Alzheimer’s disease, her job requirements, and a son progressing from adolescence through college.  

We Are Not Ourselves
touches on many of the aspects involved in prolonged illness including the daily struggles managing the care of someone with progressive dementia, complexities of health care delivery systems, frustrations with byzantine health care coverage, and threats to relationships among the individual family members with one another, and the grace that can manifest during the bleakest moments. The author does not dwell on all these issues, but gives them enough attention so that their effects will be recognizable to many readers who have experienced them. In doing so, he was able to draw from his own experiences with his father who was stricken with early onset Alzheimer’s disease.

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The Lady and Her Monsters

Montillo, Roseanne

Last Updated: Jun-10-2016
Annotated by:
Ratzan, Richard M.

Primary Category: Literature / Nonfiction

Genre: Criticism

Summary:

The Lady and Her Monsters is a companion monograph of literary, cultural and scientific history to Frankenstein , the masterpiece written by a 20 year old Mary Wollstonecraft Shelley (hereafter MWS). Starting, in its prologue, with late 18th Century Italian anatomists, it proceeds chronologically to add layers to the foundation on which MWS built her novel. Although many of these events and stories (grave-robbing, resurrectionists, infamous criminals like Burke and Hare, the setting of the composition of the novel in Switzerland) are well known to students of Frankenstein, the author adds less well known details and narrative flourish, ending with the 1831 edition and the remainder of Mary Shelley’s life following the death of her husband Percy Bysshe Shelley (hereafter PBS).  

The book begins with a prologue describing, narratively, the most proximate scientific influences on Mary Shelley.  The experiments of Aldini and his nephew Galvani form a significant portion of the backdrop for Shelley’s famous literary experiment approximately 30 years later, as famous for its product as it is for its lack of description of materials and methods.

Summary of chapters 1 through 9:

Chapter 1: “The Spark of Life”: biographical information about William Godwin, Mary Wollstonecraft and the early years of MWS

Chapter 2: “Waking the Dead”: a return, with more detail, to late 18th C Italian anatomists and scientists using electricity to stimulate dead animals and their tissues: Vesalius, Galvani, Volta, Aldini

Chapter 3: “Making Monsters”: more on Aldini and the rise of resurrectionists in late 18th C and early 19th C England

Chapter 4: “A Meeting of Two Minds”: Paracelsus and Agrippa as antecedent scientists of interest to PBS and MWS; the couple’s romance

Chapter 5: “Eloping to the Mainland”: the famous story of the trip of the Shelleys, Byron, and Polidori to Castle Frankenstein in Switzerland

Chapter 6: “My Hideous Progeny”: more on the literary history behind the creation of Frankenstein and the continuing soap opera of the lives of the Shelleys, Polidori, Claire Claremont and Lord Byron

Chapter 7: “Frankenstein, or the Modern Prometheus”: suicide of Fanny Imlay (half-sister of MWS), marriage of Shelleys, publication of Frankenstein

Chapter 8: “The Anatomy Act”: more 19th C body snatching; Burke and Hare; and the passage of the Anatomy Act of 1832 in the U. K., controlling the supply of bodies to anatomy labs

Chapter 9: “A Sea Change”: death of PBS and Lord Byron

Epilogue: modern day (2004) grave-robbing; remainder of MWS’s life

Following the epilogue are notes to the chapters, a bibliography and index.

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Annotated by:
Shafer, Audrey

Primary Category: Visual Arts / Painting/Drawing

Genre: Painting

Summary:

Theodor Billroth, one of the most innovative and outstanding surgeons and educators of late 19th century European medicine, is depicted in this painting at the height of fame when he was about 60 years old. Billroth, in full white beard, stands in the center of the canvas, looking away from the patient--an assistant is handing him a surgical instrument. His visage is regal, his bearing composed.Seven white-coated assistants surround the patient, who lays supine with his head elevated. The patient's head is shaved, and according to the artist's notes, the operation is a neurotomy for trigeminal neuralgia--a painful condition of the face. The patient is receiving general anesthesia by open drop method. Billroth favored a mixture of alcohol, chloroform, and ether, anticipating a modern trend to administer multiple agents in anesthesia. Billroth is also using Lister's methods of sterilization and antisepsis. Note that rubber gloves were not yet used in surgery at this time.Light from a large window to the surgeon's right bathes the operating theater with brightness. A full gallery of onlookers includes the artist on the right side of the first row, and the Duke of Bavaria, seated at the opposite end, who came to the operations and lectures for entertainment. Billroth was a celebrated teacher, and thousands came to the Allgemeines Krankenhaus, the General Hospital of the University of Vienna, to observe and study his techniques.

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Annotated by:
Lam, Gretl

Primary Category: Visual Arts / Photography

Genre: Photography

Summary:

In this series of black-and-white photographs, Hannah Wilke poses half-naked for the camera, mimicking the postures of female celebrities and models in magazines and advertisements. She is mockingly flirtatious in some images, playfully wearing a man’s tie, tousling her hair, smiling suggestively with her lips parted. In other images, her expression is cold and distant, as the viewer gazes at the sensuous curves of her neck, back, and breasts.

But there is more. Wilke has also stuck tiny chewing gum sculptures of vulvas to her body. These sculptures simultaneously confront and repel the viewer. The vulvas explicitly confront the viewer about their sexual thoughts and desires as they view photographs of a woman’s body. And the vulvas sprout from her face, back, and chest like warty or diseased growths, and causing the viewer to step back in revulsion, thus breaking their lascivious gaze.

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Annotated by:
Clark, Stephanie Brown

Primary Category: Visual Arts / Painting/Drawing

Genre: Painting

Summary:

In this famous group portrait, seven figures, situated in the anatomical theatre of the Surgeon’s Guild in Amsterdam in 1632, gaze intently in various directions--several look towards the cadaver of Aris Kindt, a criminal recently executed for robbery; others towards the 39-year old surgeon and appointed "city anatomist" (Praelator Anatomie) Nicolaes Tulp; several figures seem to look towards the large text at the bottom right of the painting, possibly the authoritative anatomical atlas by Andreas Vesalius, De Humani Coporius Humani [Fabric of the Human Body] published in 1543; several figures gaze out towards the viewer. Tulp himself appears to look beyond the guild members to an audience elsewhere in the anatomical theatre.Only the left forearm and hand of the cadaver have been dissected. With forceps in his right hand, Tulp holds the muscle which, when contracted, causes the fingers to flex (flexor digitorum superficialis). Tulp’s own left hand position seems to demonstrate this movement. The figure farthest from the cadaver appears to imitate this position. The palour and stiffness of the cadaver contrasts with the intensity and colour on the faces of the onlookers, and with the living hands of Tulp the dissector.

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A Streetcar Named Desire

Williams, Tennessee

Last Updated: May-24-2016
Annotated by:
Glass, Guy

Primary Category: Literature / Plays

Genre: Play

Summary:

The play is set in 1947 (the year it premiered) in New Orleans. Having lost their ancestral Mississippi home to creditors, Blanche Dubois arrives at the shabby French Quarter flat of her sister Stella. When we first meet Blanche she explains she is on a leave of absence from teaching high school English on account of her “nerves.” From her first meeting with Stella’s husband Stanley Kowalski, a World War II vet, we detect class conflict and sexual tension between the two of them. As Blanche’s visit becomes more and more protracted, Stanley becomes increasingly suspicious of her motives and background. Meanwhile, she begins to date Mitch, one of Stanley’s poker buddies. Gradually we learn more about Blanche’s checkered past. She was once married to a young man who committed suicide after she discovered him in a sexual encounter with another man. Stanley uncovers rumors that she was fired from her teaching job for having sex with a student. As the play progresses, fueled by her surreptitious drinking, Blanche’s mental state unravels. When Stanley warns Mitch about Blanche’s notorious reputation, Mitch rejects her.  Adding insult to injury, while Stella is having a baby, Stanley rapes his sister-in-law. Blanche’s emotional deterioration is complete. In the final scene, a doctor and nurse arrive to take Blanche to a mental hospital. She initially resists them, but when the doctor helps her up she willingly surrenders: “Whoever you are - I have always depended on the kindness of strangers"(p. 178).

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Annotated by:
Kohn, Martin

Primary Category: Literature / Nonfiction

Genre: History

Summary:

In this volume, Gonzalez-Crussi trains his sights on medical history, applying his lyrical writing skills to essays that he hopes will help preserve the humanistic core of the medical profession. Because of its brevity (250 pages), he apologizes for its focus on "Western medicine since the inception of the scientific method"(p.xi), but does note that he acknowledges "the continuity between ancient and modern medicine...[and] the contributions of the Orient, and of epochs predating the dominance of the rational spirit" (p.xi).What distinguishes this volume beyond the writing is the thematic organization. It begins with the Rise of Anatomy and Surgery, but then moves to Vitalism and Mechanism, The Mystery of Procreation,  and Pestilence and Mankind, before finishing with a look at Concepts of Disease, The Diagnostic Process and Therapy (including a brief focus on psychiatry). In the last section, Some Concluding Thoughts, Gonzalez-Crussi returns to his motivations for writing this short history, citing the mixed blessings of scientific progress whose gains, for example, are offset by those who "appear to try to 'medicalize' every aspect of human life" (p.210).

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A Little Life

Yanagihara, Hanya

Last Updated: May-17-2016
Annotated by:
Teagarden, J. Russell

Primary Category: Literature / Fiction

Genre: Novel

Summary:

After first meeting as college roommates, Jude, Willem, JB, and Malcolm make their way through college and then onto New York City to pursue career interests. We follow them through the subsequent decades as Jude becomes a highly effective attorney, Willem a famous actor, JB an acclaimed artist, and Malcolm a prize-winning architect.  

What starts as a cluster of four eventually separates into an orbit of Willem, JB, and Malcolm around Jude at the center. The gravitational force pulling the three others towards Jude is the fidelity that can form among college roommates and a love that has bonded them together even more. But, there is also a strong sense among the three that Jude needs them for both physical and emotional support. At first, and for a good long time, it’s just a sense, but they later come to learn that their intuitions are right, that Jude does indeed need them and why. Over the years covered in the novel, a second orbit forms around Jude comprising a surgeon-cum-close friend, adoptive parents, a work colleague, and a neighbor. They, too, know Jude needs them, but only learn why late into their relationships. Until then, they are alternatively and often simultaneously worried, angry, flummoxed, and stymied about what’s at the root of his ambulatory limitations and severe leg pains, and why he cuts himself with terrifying frequency.  

Through a fractured narrative sprinkled with artfully-constructed subliminal hints, Yanagihara reveals Jude’s life before he arrived at college. She tells of Jude’s beginnings as a foundling taken in at a monastery. This hopeful start for Jude, however, becomes a childhood and adolescence of unrelenting, horrific, sexual assault and torture—when at the monastery, when on the road after being kidnapped by a monastery brother, when in protective custody, and even when he is able to escape. He arrives at college bearing the psychological and physical consequences of these experiences, but not openly displayed to a degree that yields more than a few hints of a traumatic past. With the support of the people surrounding him in  his adult life, he is able to become a highly accomplished attorney, and to achieve some measure of ease and happiness from time to time. The support he receives, however, is not enough to protect him from the consequences of further psychological and physical assaults, including his self-mutilation practices, and tragic losses. Ultimately, Jude engineers his own final tragedy.
 

Some of the people left behind suffer from more than Jude’s loss. His friend the surgeon wonders whether he enabled Jude’s self-cutting by always patching him up and never committing him to an inpatient psychiatric unit. Jude’s adoptive father relives the loss of his first son at a very young age to a rare, degenerative, neurological disease. Nearly all the figures in this novel experience suffering in some form or another, but this is more the story of Jude; how the people around him tried to get him past the horrors of his childhood and adolescence, but eventually and sadly to no avail. 

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Summary:

This is the third book in a series on the history of medicine and medical education by Kenneth M. Ludmerer, a practicing physician and historian of medicine at Washington University of St. Louis. The first, Learning to Heal: The Development of American Medical Education, published in 1985, dealt with the history of medical schools and medical education in the US from their origins in the 19th century to the late 20th century. In 1999 he published Time to Heal: Medical Education from 1900 to the Era of Managed Care. This book, Let Me Heal: The Opportunity to Preserve Excellence in American Medicine, published in 2015, is a sweeping history of graduate medical education in the United States from its inception to the current day.

In 13 chapters and 431 pages (334 pages of text, 97 of reference and index), Ludmerer traces the residency from early apprenticeship days to its metamorphosis (at Johns Hopkins, of which he is a justly proud medical school alumnus) into the embryonic form of what we now call an internship and residency. Giants like “The Four Doctors” (to use the title of John Singer Sargent’s famous portrait of William S. Halsted, William Osler, Howard A. Kelly and William H. Welch - but known simply as “The Big Four” at Hopkins) were the godfathers of the American postgraduate medical model which emphasized clinical science, teaching, patient care and research. The rise of acute care teaching hospitals as the venue of postgraduate medical education, and not the medical school or university, is an interesting story and one which Ludmerer tells in great detail over a number of chapters. It is one replete with predictable turf wars, professional turmoil and politics, and societal change in all aspects of the 20th century. This last phenomenon receives its due attention in every chapter but is dissected in meticulous detail in the final chapters dealing with the Libby Zion case, duty hours and the increasing role of the Accreditation Council for Graduate Medical Education (ACGME) in postgraduate medical education.

Beginning in the 1930’s, American medicine grew increasingly specialized and, in the ensuing decades, subspecialized, much to the consternation of pre-WW II general practitioners who, suddenly and for the first time, found themselves in the minority, in numbers and in influence, of their own profession. Concomitant with the phenomenon of specialization was the imprimatur by academic medicine of the structured, sanctioned residency as the sole route to specialty practice with, of course, the birth of associated accrediting agencies. Along with the move, physically, academically and politically, of postgraduate medical education to acute care teaching hospitals, the control of this education moved from medical schools to the profession at large.

Ludmerer deftly describes the “era of abundance”, the salad days of postgraduate medical education in the 1950’s and 1960’s when giants still made rounds on the floors of postgraduate medical venues; funds were plentiful; outside criticism was an as yet unborn bête noir; and social, economic and governmental curbs were only a tiny distant cloud in an otherwise blue sky. Ludmerer is correct in attributing much of medicine’s professional and social hegemony as well as its transient immunity to criticism in this era to the following evident successes of medicine: antibiotics; initial inroads into antineoplastic therapies; startling technological innovations in imaging; a burgeoning spate of life-saving vaccines; and spectacular advances in surgery, especially pediatric, cardiothoracic and transplant. Fatal diseases of the 1930’s and 1940’s were now often cured in days and of historical interest only.

Like all salad days, those of medicine eventually succumbed to new historical forces: foreign medical graduates in the workplace; the ever-growing financial burden of the residency; and economic pressures like Medicare and its associated regulation. There were other factors, too: professional and societal expectations of standardization and quality care; the explosion in subspecialties; the horrid wastefulness of unnecessary diagnostic tests and therapies borne of an earlier undisciplined abundance; the supercession of the intimate primary physician-patient relationship by the fragmented care of specialists and the rising supremacy of technology over personalized histories and careful physical examinations (why percuss the abdomen when you can get a CAT scan?). Dissatisfaction amongst residents is a dominant theme Ludmerer rightly raises early and often: the conflict and tension between education and service, between reasonable work and “scut”, between being a student and a worker (at times, quite a lowly one).

”High throughput” - the much more rapid turnaround time between admission to an hospital and discharge - has radically changed forever the entire nature of postgraduate medical education, and not for the better in the eyes of the author and of this reviewer, who were fellow residents a lifetime ago at Washington University in St. Louis. This decreased length of stay, a result of the remarkable improvements in diagnosis and therapy mentioned above, meant that the working life of providers (attending physicians, residents, physician assistants and nurses) was in high gear from admission to discharge, thereby increasing tension, likelihood for error and, exponentially, the workload for the resident while simultaneously and irrevocably damaging the possibility of a meaningful, careful provider-patient relationship (like a friendship, of which it is a subspecies, such relationships can not be rushed) and decreasing opportunities for learning. Medicare; changing patient populations; societal and professional disgruntlement; the Libby Zion mess and the ensuing cascade of regulations from all sides, but most especially the ACGME - all receive careful and systematic treatment in the final chapters of this monograph.

Ludmerer ends with a chapter listing what he sees as opportunities for achieving (or re-achieving) excellence. Indeed, he has made it the book’s subtitle. They are the following: a plea for the ACGME to revise its 2011 duty-hour regulations; an equally earnest hope that interns and residents will soon realize a more manageable patient load; a related wish for academic medicine to decrease the unfortunate occurrence of economic exploitation of house officers; a suggestion that this annotator shares, i.e., that the process of supervision, improved (but inadequately) with recent ACGME requirements, be further strengthened; and a hope that medical schools will restore teaching to the central place in the institutional value system it used to enjoy. Ludmerer issues a call for the more vigorous promotion of “an agenda of safety and quality in patient care” (page 312) and suggests that the education of residents be expanded to include venues outside in-patient sites. Elsewhere in the book, he also expresses the expectation that the inclusion into clinical teaching of private patients alongside “ward” patients, more feasible with recent improvements in the re-imbursement of medical care, be routine and maximized to the enjoyment and benefit of all concerned.

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Summary:

Samuel Shem's (Stephen Bergman) The House of God, first published in 1978, has sold over two million copies in over 50 countries (see annotation).  Its 30th anniversary was marked by publication of Return to The House of God: Medical Resident Education 1978-2008, a collection of essays offering historical perspectives of residency education, philosophical perspectives, literary criticism, and women's perspectives, among others. Contributors include such well-known scholars as Kenneth Ludmerer, Howard Brody, and Anne Hudson Jones, as well as physician-writers Perri Klass, Abigal Zuger, Susan Onthank Mates, and Jack Coulehan.  The closing section, "Comments from the House of Shem," includes an essay by psychologist and scholar Janet Surrey (Bergman's wife) and one by "both" Samuel Shem and Stephen Bergman. 

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