Summary:

This is a huge and wonderful book about cancer, the collection of diseases that sickens people all over the globe and kills many of them. An epigraph to the book states, “A quarter of all American deaths, and about 15 percent of all deaths worldwide, will be attributed to cancer,” but the book also describes medical advances that now heal, prevent, or palliate most forms of cancer.

Mukherjee, a cancer physician and researcher, has several strong themes. He sees cancer as an affliction with a long history, a story worthy of a biography; indeed recent discoveries show it to be rooted in our genes (although external factors such as viruses, asbestos, and tobacco smoke can cause genetic disruption). The story of cancer implies a surrounding triangle, the stories of sick people, treating physicians, and biological researchers, all of which Mukherjee artfully weaves across 472 pages. Cancer has Rohrschach blot qualities: depending on time, place, and role in life, humans have perceived different attributes of cancer. As the book ends, however, there is a coalescence of scientific understanding that is satisfying—although there is certainly more to be learned and we are all still vulnerable to genetic errors and, of course, we are intractably mortal.

Another strand is the nature of stories themselves, their twists and turns, presumed early solutions, and personal and social values embedded in them. Mukherjee threads throughout the book the case of a contemporary kindergarten teacher, Carla Reed, who has a leukemia. He bookends his text with ancient Persian Queen Atossa with (presumably) breast cancer. Reed, healed by the end of the book, was Mukherjee’s patient; Atossa was described by Herodotus: both suffered emotional turmoil because of their disease.  Mukherjee understands the affective dimensions of disease for patients and caregivers alike; literature represents these in various ways, and he quotes in his chapter epigraphs and in his prose many writers who describe human experience deeply: Aleksandr Solzhenitsyn, Susan Sontag, Charles Dickens, Thomas Mann, William Carlos Williams, Carlo Levi, and Italo Calvino, to name a few.

The primary story, however, is the interplay of cancer and a large cast of observers, investigators, doctors, scientists, activists, and government officials. Sidney Farber and Mary Lasker dominate the first 100 pages with their two-decade war against cancer. While surgery—historically dramatic and disfiguring—had been a mainstay for treatment of cancer, Farber pursued a biochemical route, which elaborated into chemotherapy, the second major approach of the late 20th century.

Mukherjee also explains ancient views, Hippocrates’, Galen’s humors, Vasealius’ anatomy, Hunter’s stages, Lister’s antisepsis, and Röntgen’s X-rays, which became the third major approach. By 1980, however, the American “War on Cancer” had not been won.

Further advances in cellular biology and genetics would be needed to make targeted molecular therapy possible.  Mukherjee tells this complicated story clearly and engagingly, showing the human investigators to be personable and dogged in their pursuits.  

Another important approach is prevention. The biostatistical work of Doll and Hill, for example, showed the links between tobacco and lung cancer. Screening, such as Pap smears and mammograms, also saved lives, but the basic cellular understanding still eluded investigators.

The final 150 pages explain the search for and discovery of genetic factors, specifically oncogenes. Harold Varmus and J. Michael Bishop were the leaders, winning a Nobel Prize in 1989. Bert Vogelstein, Judah Folkman, Robert Weinberg and Douglas Hanahan took the work further, opening the doors for such drugs as Herceptin, Gleevec, and Avastin. 

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The author takes us on a highly colorful autobiographical tour of his medical career - his personal life never enters this account - from a classical medical education in Paris as a young expatriate Swede (he remains expatriate the entire book) to his internal medicine practice in France, including a tour of Naples as a volunteer during the cholera epidemic of 1881 and his finally settling in Italy. There are also anecdotes - many of them side-splitting and told with uncommon skill - about conducting a corpse back to Sweden, a truly thrilling journey to Lapland,  encounters with the legendary Charcot, his return to San Michele whence the book begins with a mythopoetic retelling of his first visit there, and his last years at San Michele as patron of a community (both local and international) and as collector and explorer of the nearby Mediterranean.        

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In the eighteenth century, Europe began to take stock of the horrific infant mortality in foundling homes and hospitals. Infant feeding and care became a major preoccupation for charities and philanthropic doctors. Some organized systems of wet nurses in the communities and institutions to provide for motherless children. 

At the same time, syphilis was becoming a serious problem in newborns. The sexually transmitted disease, which swept the continent following the voyages of Columbus, was known to affect babies born to infected mothers. Since the early sixteenth century, doctors had been convinced that mercury was of benefit.

Founded in 1724, the Vaugirard Hospital of Paris was the city’s home for orphans. By 1780 it had made room for mothers with syphilis and their children.  Sometimes the mothers died, or well-off families would abandon their sick children. Healthy wet nurses were engaged to feed these babies.

Eventually, the wet nurses were viewed as a technology—a vehicle--for administering mercury to the babies through their milk. Many of these healthy women fell ill, either from the mercury or by infection from their charges. Nevertheless, the practice continued into the nineteenth century. The wet nurses did not know (or were not told) that the children were infected. The physicians in charge of this experiment also attempted unsuccessfully to vaccinate the wet nurses against syphilis. That experiment also spread the disease.

Remarkably, some wet nurses brought suits against the doctors or the birth families. Occasionally they won damages, and finally the law was changed to offer greater protection.

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The journalist author investigates the hidden lives of his father and his grandfather, both physicians. He is motivated by the mysterious silence that pervaded the ancestral home in a wealthy Toronto neighborhood, and by the frightening tendency to depression and suicide that stalks his family members like an Irish curse.

He uncovers many details of the early adventures of his parents, the failure of their marriage, and his father’s doomed career. From his beginnings as a debonair socialite, the father, Jack, embarks on a promising medical career as an allergist; however, he virtually sinks into taciturn misery and alcoholic self-destruction, unable to express affection or joy. Jack’s endless travails as a patient through shock therapy, analysis, and heavy psychiatric drugs are presented in merciless detail using hospital records and interviews with caregivers. The author’s self-indulgent anger with his self-absorbed father drives the research deeper into the earlier generation, to learn about the grandfather of whom his parents rarely spoke.

The author's grandfather, Irish-born John Gerald FitzGerald (1882-1940), son of an immigrant pharmacist and an invalid mother, strode through the exciting scientific world of the early twentieth century like a medical Forrest Gump. At first, he is drawn into the new fields of psychoanalysis, psychiatry, and neuropathology; cameo appearances of Freud, Ernest Jones and C.K. Clarke light up the story. But then this elder FitzGerald is swayed by the need to control infections and produce vaccines. He travels Europe and the United States for three years learning bacteriology.

Upon his return to Canada in 1913, he fearlessly launches a Canadian-made solution, outfitting a stable and a horse farm to produce rabies vaccine and diphtheria anti-toxin. The initiative evolves into the famous Connaught Laboratories and the School of Hygiene, its academic arm. Other luminaries enter the story– such as Banting and Best of insulin fame and C.B. Farrar of psychiatry. FitzGerald served as Scientific Director of the International Health Division of the Rockefeller Foundation and as Dean of the University of Toronto medical school.

Nevertheless in his late fifties, having accomplished so much, the grandfather crashes into doubt, depression and self-destruction, believing himself a failure and consumed with guilt for some never-disclosed transgression. Did his stellar achievements, his high expectations, and his baffling demise dictate the collapse of his son Jack?

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In 1951 when Henrietta Lacks was dying of cancer in the colored ward of Johns Hopkins, cancer cells taken from her without her knowledge "became the first immortal human cells grown in a laboratory"(4).  Known as HeLa cells, they are still reproducing today and are used world wide in research for cancer, cloning, genetics, Parkinsons, and many technologies. Henrietta's family did not know she was the source of these immortal cells until scientists began testing the family members too.  Poor and black, they were very angry to find the white establishment had made fortunes using HeLa cells while the family got nothing for it and couldn't even get good health care. In her thorough and careful investigation, Rebecca Skloot interviewed the Lacks family; scientists, doctors, and others who worked with HeLa cells; historians; journalists; ethicists. This book traces the complex stages of her search for the truth about what happened to Henrietta Lacks, her HeLa cells, and her family.

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As explained in the succinct yet thorough introduction by co-editor Kimberly Myers, an international conference on the topic of "The Patient" was convened at Bucknell University in Pennsylvania in 2006. This collection of essays, which range from personal experience to scholarly literary critique, results from the conference presentations.
 
Of the ten essays, four concern personal or familial experience of illness. These four cover a vast range: literature and disability specialist Kristin Lindgren describes her story of the elusive diagnosis of chronic fatigue syndrome and her coping skills; medical humanities and medical ethics expert Carol Schilling offers a poignant narrative of her experience as a mother of a previously healthy, athletic son who suffers a cervical spine injury from a skiing accident; Gayle Whittier places the story of her daughter's disability amongst a trio of nonfictional and fictional narratives of disability and illness; and renowned poet Tess Gallagher explores her relationship with and caring of her mother who has Alzheimer's disease. These essays, written as they are by women steeped in literature and writing, are not merely chronicles; rather they are infused with commentary on story and the meaning of life as story, journey and relationship.
 
The other six essays are likewise diverse and range from cultural/political studies from the Navajo to the Irish (which includes literary analysis of works by poets Eavan Boland and Nuala Ní Dhomhnaill), to insightful critiques of literary works such as  Hjalmar Soderberg 's Doctor Glas, Lauren Slater's Lying: A Metaphorical Memoir, Brian Clark's Whose Life Is It Anyway?, Alejandros Amenabar's film The Sea Inside (Mar Adentro), and George (Marian Evans) Eliot's Janet's Repentance.

Consistent with the nature of medical humanities, the essays cross boundaries. For example, Whittier weaves her experiences as a mother of a disabled child with reflections on embodiment and literary critique. Gallagher compares the notions of time in poem-making with the necessity to live in the moment when caring for a loved one with Alzheimer's. She notes: "Of the written arts, poetry is most responsive to the moment and so coincides with the condensed time frame of those with Alzheimer's - which oscillates between the distant past and the present moment." (p. 71) Schilling tenderly writes of her family (for an illness strikes not just the patient): "We live the best lives we can, folding each of our stories into one another's." (p. 40) Diedrich explores not just the (at times infuriating) play with deceit in Lying, but also examines the ways in which patients lie and medical language obfuscates illness. She further explores, with great insight, expectations: of literary reviewers, patients and physicians.

 

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Zol Szabo, is public health doctor for the Hamilton Ontario region. He is also a single parent to a seven-year-old, Max, because his wife could not deal with Max’s physical disability. But Sol thinks there is hope for Max in an injection of a miraculous new substance called “Endotox” that may loosen the contractures of his arm. Soon he his investigating a cluster of variant CJD (mad cow) cases that may be related to Endotox. But they also seem to be connected to the grocery store where Sol does his shopping. The products that all victims had in common were an imported candy and a sausage, both Max’s favorites.

Conspiracy theories about corrupt pharmaceutical companies and the antics of a pair of unethical mink farmers lead the investigation in many different directions, all personally threatening to Sol because of the health of his son or the ire of his boss. Pressure from his superiors to avoid publicity cramps Sol’s freedom. He seeks help from an attractive woman detective who, of course, sticks with him to the terrifying (and satisfying) conclusion.

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As Audrey Young describes her process of becoming a compassionate internist in a besieged public hospital, she simultaneously argues for turning the hospital's patient care and financial practices into a model for improving health care in America.  Young, a compelling storyteller, first entered Seattle's Harborview Medical Center in 1996 as a third-year medical student on trauma surgery service.  She completed a residency there in general internal medicine and stayed on as an attending for six more years.  She stayed, she tells us, because she met physicians "committed to a vision of equality" who were "the sort of people I hoped to become" (xiii).   She also "fell in love" with "the story of a unique place" (xiii).  Young's stories of that often chaotic place, where ambulances regularly transport homeless, indigent, addicted, and mentally ill refugees from neighboring private hospitals, emphasizes the ways the Harborview staff manages to treat patients with dignity and to choose an ethic of hope in the face of dire circumstances.           

We quickly learn that at Harborview compassion is expressed concretely as actions toward patients.  Michael Copass, known as "the mostly benign dictator of emergency operations," pronounced the core of these actions in what came to be known as his commandments:  "1. Work hard.  2. Be polite.  3. Treat the patient graciously, even if he is not the president of the United States" (9).  Politeness always meant asking "'How may I help you, sir?'" regardless of the patient's social status or addiction history.  Politeness sometimes meant finding a way to reach the patient who regularly threatened the staff.  Young finds ways and creates a therapeutic bond.  But working hard and treating patients considerately also took measurable forms, such as not allowing emergency patients to wait.  Facing a flurry of admissions, the Emergency Department (ED) staff interpreted a young Ethiopian's complaints about pain as a drug addict's ploy.  Because Young glanced at the admissions board and noticed that he remained unattended for three hours--far longer than Copass could tolerate--she jumped into action.  He suffered, she discovered, from a collapsed lung. 

However, Young moves her narrative beyond individual doctor and patient encounters and into the larger, interrelated social and financial structures in which medicine is practiced.  For instance, she links meager funding for drug and alcohol rehabilitation programs with expensive ED admissions and rising healthcare costs.  In the chapter "Bunks for Drunks," Young visits an experimental residence that houses homeless addicts in furnished studios with private baths and cooking appliances.  Although residents can keep alcohol in their rooms and elect not to participate in the home's social services, including counseling, alcohol consumption and ED admissions decrease.  While the chapter points out the cost savings of such arrangements, Young further urges readers to value the dignity residents experience there.

In "Black Friday," Young details the hospital's tense, but ingenious responses to a Mass Casualty Incident, the result of carbon monoxide poisoning, which almost depleted the resources of all of Seattle's medical centers.  The final chapter, "A Vision," outlines how Harborview has tried to succeed as both a charitable institution and a business, as a provider of both indigent and luxury care, with the hope that others will follow the medical center's example.  However, in presenting her recommendations for "health justice," Audrey Young also makes the case that "seemingly ordinary citizens" are implicated in healthcare reform (231).  To enable their informed participation in making changes, Young includes an appendix with further readings and another that lists strategies for effecting reform.  

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This annotation is based upon the version presented at The Mint Theatre in New York City in 2010, translated and directed by Gus Kaikkonnen.  It featured Thomas M. Hammond as Dr Knock and Patrick Husted as Dr Parpalaid, with Chris Mixon, Scott Barrow, and Patti Perkins in supporting roles.

A middle-aged but recently licensed physician, one Dr Knock, has arrived in rural France to take over a practice purchased from the genial old country doctor, Dr Paraplaid.  Much to Dr Knock's surprise, he discovers that Dr Paraplaid has done very little over the past three decades, seeing only a few patients a week and enjoying much of the time playing pool, riding around in his jalopy, and admiring the countryside.  Feeling slightly cheated, Dr Knock realizes that the practice he has purchased at some expense amounts to very little at all. He is, however, an ambitious man.  He did not become a licensed physician in the eager flush of late adolescence but as a man of the world, or rather, a man of the entreprenurial modern world where opportunities are seized and technology is transformative.  

Once Dr Paraplaid has gone, Dr Knock promptly sets about employing the town crier to advertise his practice so that the entire valley knows he is there.  He meets up with the local school teacher and the pharmacist, enlisting them as allies.  With everybody he encounters, he smilingly and then sharply insists that unlike Dr Paraplaid, he will not go by "Monsieur" but by "Doctor".  And when he actually opens the office, he begins by offering free consultations.  Of course, he always seems to find something wrong, elaborately explaining the aches, pains, and illnesses he discovers (or induces), but the free consultations, like free "samples" are designed to create grateful customers.  Invariably, they learn that the cost of the treatment is commensurate with the exact maximum amount they could pay.  And thus, Dr Knock takes a placid, lazy practice and builds up an expanding medical business. 

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In 2008, editor and physician Paul Gross launched a new online publication, "Pulse--voices from the heart of medicine" (published by the Department of Family and Social Medicine, Albert Einstein College of Medicine and Montefiore Medical Center). This anthology contains every poem and first-person narrative published during Pulse's first year, arranged in five sections corresponding to publication date and not to theme: Spring, Summer, Autumn, Winter, and Spring.  Paul Gross, in his introduction, states "After more than a decade of practice as a family doctor, I came to appreciate that the science I'd learned in medical school, though powerful and useful, was also incomplete . . . . it contained much truth about illness and healing, but not the whole truth" (xvii).  Like many other caregivers, Gross discovered "that writing and sharing my healthcare stories with others was therapeutic" (xviii).  He looked to "Sun Magazine" as an example of how first person narratives, both prose and poems, could turn "hurts and triumphs into something potentially beautiful, funny or moving" (xviii). 

The poems and prose that arrive every Friday online to Pulse's thousands of subscribers (and the selections in this anthology) are carefully screened by the editors according to these guidelines: the stories have to be first-person, and they have to be true, recounting the writer's own experience.  Submissions are accepted from any person involved in healthcare.  The language used must be "clear, simple language.  No medical jargon. No arcane literary devices" (xx).  Gross and his editors decided that Pulse would not be a medical journal nor a literary magazine--its purpose fell outside the perimeters of both genres--and so Pulse, and this anthology, offers work that is, in a refreshing and honest way, different from the slick or more polished poetry and prose that might be found elsewhere.

In reading this anthology from cover to cover, and so from season to season, I found that the poems and prose seemed to fall into several categories: Personal musings, in which authors relate healthcare experiences that engender intimate and revealing narratives about their own lives--among the best of these are "Well Baby Check," p.3; "Finding Innisfree," p. 31; "First Patient," p. 39; "Losing Tyrek," p. 45; "Carmen's Story," p. 62; and "Chemo? No Thanks," p. 106.  Other pieces are commentaries on the other side of healthcare, the one that cries out for reform and affects both patients and caregivers.  Among the best of these are "Redesigning the Practice of Medicine," p. 9; "A Brush with the Beast," p. 22; "Rx," p. 60; "Halloween Horrors," p. 69; and "Brain Cutting," p. 136.

Other pieces are humorous ("Aunt Helen Sees a Ghost," p. 6) or political ("My War Story," p. 11), and many poems and prose pieces speak of patient encounters or about being a patient, some more anecdotal, relating a specific incident that affected the author ("Once," p. 41) and others multi-layered, some relating medical student or intern experiences ("Jeannie," p. 48; "A View from Nepal," p. 87; "Ripped from the Headlights," p. 90; "Snowscape," p. 97; "First Night Call," p. 100; and "Wounded Messenger," p. 114.)  The "category" I found most interesting and most unique are the selections I will call "confessions."  These writings--demonstrating openess and bravery on the part of the authors--tell of regrets, mistakes, sorrows, wrong calls and other mishaps that occur, daily, in the practice of healthcare.  In these, the most human face of caregiving is revealed.  Although most of the pieces in this anthology contain elements of "confession," the most specifically revealing include "Mothers and Meaning," p. 14; "Physician's Exasperation," p. 44; "Confidential," p. 53; "My Patient, My Friend," p. 73; and "Apologies," p. 104.

Editor's note: Coincidentally, a recent relevant paper on confessional writing by physicians expounds further on this topic:"Bless Me Reader for I Have Sinned: physicians and confessional writing" by Delese Wear and Therese Jones (Perspectives in Biology and Medicine, Vo. 53, No.2, Spring 2010, pp. 215-30).

 

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