Summary:

The subtitle is accurate enough: “A Memoir of a Family and Culture in Crisis,” although the author J.D. Vance is, in fact, the focal point of view throughout, from his childhood to his success as an adult. Few young people made it out of the hills to enjoy stable and successful lives, but J.D. was one of them, earning a degree at Ohio State University, then a law degree at Yale. While recounting his life, he also describes his relatives and neighbors, and he interprets the many dilemmas of his hillbilly culture. 
 
Vance was born in 1984 and grew up in Jackson, Kentucky, a poor town following the collapse of coal mining. His family was beset with poverty, alcoholism, mental instability, and more. His mother had nine miscarriages and suffered from addictions; she had multiple husbands. The culture around him suffered from domestic violence, drug abuse, hoarding, unemployment, honor defended by fists, knives, or guns, as well as bad financial habits, bad diets, obesity, lack of exercise, sugary drinks, dental problems, and what he calls “emotional poverty.”  There was welfare abuse and, in general “a chaotic life.”  He credits his grandparents, other relatives, various teachers and professors for supporting him, guiding him, and comforting him when he was hurt, angry, and/or confused.  

Like many other hillbillies, J.D. moved some hundred miles north into southern Ohio, where steel companies provided jobs—that is, until they closed, like many other employers in the Rust Belt. There also, hillbillies were left without income and social problems increased. Stores and restaurants closed. Payday lenders and cash-for-gold shops took their place. Drug dealers and users took over empty houses.  

After high school, Vance joined the Marines. He credits the military for teaching him discipline, persistence, and for developing his self-respect. For his success at Yale, he thanks his professors, his girlfriend (later wife), and classmates for helping him understand customs of New England society. One example: he leaves a banquet to call his girlfriend; she instructs him on how to handle the nine pieces of unfamiliar silverware surrounding his plate.  

The last three chapters (11, 12, 13) and the conclusion analyze his experience on more conceptual terms, including the “social capital” prized by the the New England world, social instability of the culture he was raised in, and “adverse childhood experiences” (or ACEs), the psychologists’ phrase for the damaging events children experience in a culture of poverty, violence, and limited futures. He writes that governmental child services have policies that don’t understand the important roles of aunts, uncles, and grandparents in subcultures that rely on extended families.  Indeed, faithful to his mother, he, as an adult, provides specific help to her. 

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The novel takes the form of a memoir written from prison. The fictional author is Dr. Norton Perina who was awarded the Nobel Prize in Medicine for discovering what caused some people on a remote Micronesian island to live for up to 250 years or longer. Dr. Ronald Kubodera, Perina’s long-time colleague, convinced him to write the memoir while he was in prison. Perina sent Kubodera a chapter at a time, which he would then “lightly edit” and add occasional footnotes to elaborate on a given section. 

Perina is in prison for being convicted on “two counts of sexual assault,” (p. 349) though we can believe he is guilty of many more counts. All of these transgressions involved children, many of whom were under his care as their adopted father. However, the bulk of the memoir is not about the behavior that lands him in prison. Instead, it tells of Perina’s successful scientific investigations of a hidden people in a secluded partition of an unknown island in Micronesia. He came to this place while stumbling around for a career direction after medical school, and then came to discover the hidden people when stumbling upon one lying on the forest floor.

Perina eventually linked the consumption of the meat of a particular turtle on this island to a prolongation of life measured in hundreds of years. Only the inhabitants who reached around 60 years were given the turtle meat and only during a ceremony to mark the milestone. While the bodies of these people remained as they were physically when they consumed the turtle meat, their minds did not. As they aged they became non compos mentis—“all they could do was jitter and babble and laugh at nothing, the neighing laughter of the brainless.” (p. 95) Perina’s published papers called attention to a possible fountain of youth and produced the expected rush among pharmaceutical companies to distill the turtle’s magic into a pill. All they managed to do instead was to destroy the island’s habitats, corrupt its people, and hunt the turtles into extinction.  

Very little is said in Perina’s memoir about any activities leading to his pedophilia conviction until the very end; however, occasional hints that Perina could be a pedophile appear before then. At one point in particular he describes an encounter with a 10-year old boy from the village that might have awakened any such tendencies that had been dormant. Another time he admits “some of the only comfort (and certainly the only amusement) I’d found had been with the village’s children.” (p. 267). During subsequent trips to the island over the next few decades, Perina adopted 43 island children and brought them home to raise as his own. He was drawn to children, but in not so innocent a manner. Only at the very end of book, and only in the postscript, do we get any details about how he preyed upon these children.

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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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Best Boy is a novel about Todd Aaron, a 54-year-old autistic man who has lived for 40 years in a Payton LivingCenter (sic); he was involuntarily committed to this facility. Todd has been in five previous places for congregate living, but Payton seems to be the best for him, thanks in part to a loving caregiver, Raykene. Todd has accepted the institutional “Law” of Payton and takes his drugs right on schedule, including Risperdal, an antipsychotic that slows him down, making a “roof” over him and muffling, he says, “the voice in my brain.”  The story is told from Todd’s point of view, often with startling imagery:  he pictures his dead parents turning into giant cigars, a raindrop “explodes,” and, when upset, he rocks back and forth and feels “volts.”  Now and then he recalls that his mother called him her “best boy.”
   
Into this stable setting come three personified disruptions. The first two are fellow patients, Terry Doon (a pun on “doom”?), a brain-injured roommate who teases, torments, and bullies Todd, and Martine Calhoun. While Terry disrupts Todd’s living space, Martine is a siren who lures him to different parts of Payton’s campus; she is also a rebel who urges him to stop taking Risperdal and shows him how to hide the drug in his hand and get rid of it later.   

The third is Mike Hinton, a day staffer who lies, manipulates, and in general mistreats Todd. Todd understands Hinton as evil and entertains violence against him—but does not act. Hinton has sex with a female patient who dies, apparently a suicide, although the language of Payton’s staff, as reported by Todd, euphemistically hides the truth.

Todd has the “Idea” of escape and sets out, on foot, to go 744 miles to “home.” A state policeman soon returns him to Payton.

Now and then Todd’s younger brother Nate calls, often while drinking. Near the end of the book, Nate and his wife Beth take Todd to his childhood home, where he had been abused physically and mentally. In a moving scene, Todd enters the only unchanged area, a crawl space and feels the return he yearned for.            

All three tormentors leave Payton, and there is a surprising resolution for Todd.  The balance and harmony of Payton’s LivingCenter are restored, and Todd, reminded by Raykene, affirms that “Somebody always loved me.” 

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Blow’s account of growing up in rural Louisiana, exposed to negligence, sexual molestation, violence, and loss focuses on a child’s strategies of survival first, and then on sexual confusion, social ambition, and discovery of the gifts that led him to his life as a writer for the New York Times.  A major theme in the memoir is his learning to claim his bisexuality after years of secrecy and shame.  That emergent fact about his identity, along with moving to New York after a life in the rural South required an unusual level of self-reflection and hard, costly choices that challenged norms at every level.  His account of learning to assume a leadership role in a college fraternity and deciding to finally leave it behind offers a particularly vivid example of what it takes to resist perpetuating rites of humiliation and conformity designed to curb individuation.     

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In 1894 France, Madeleine Karno hopes to follow in her father’s footsteps as a pathologist. She is passionate about medicine and especially about science and how it can help the dead 'speak.' When a young girl is found lifeless outside her own home, the autopsy can find no evidence of murder; however, the discovery of tiny mites in her nostrils leads Madeleine and her father on a lengthy investigation involving the girl’s family, a priest, abused children, and a convent school that has a three-hundred year tradition of keeping wolves.

By the end, the story is littered with corpses, each needing careful pathological inspection. Madeleine is chillingly threatened, but she lives and justice prevails.  

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This anthology is a sequel to Pulse: The First Year (2010). Both anthologies are comprised of postings to the website “Pulse: voices from the heart of medicine,” an online publication that sends out short poems and prose pieces every Friday. As the website subtitle suggests, the topics are from the medical world, the writing is personal (not scientific), and the writers give voice to feelings and perceptions from their direct experience as care-givers, patients, or family members of patients. All the pieces are short (typically one to five pages), usually with a tight subject focus. For example, in "Touched," Karen Myers reports how massage has helped her muscular dystrophy. 

The postings in the second anthology originally appeared from April 2009 through December of 2010. Because the 87 pieces appear in the order they were published, they don’t have linear coherence. Therefore the editors of have thoughtfully provided four indices in the back of the book: by author, by title with summaries, by healthcare role, and by subject/theme.

Prose pieces vary widely in style and technique. The poems are almost all free verse, although some poets have used regular stanzas. “Depression Session,” (p. 157) is an 18-line poem by a physician about a difficult mental patient. Many of the pieces explore the intensity of medical subjects with impacts on doctor, patient, and/or family. Some of them show limits of medicine. “Pearls before swine” (p. 191) relates the experience of a third-year medical student in a rotation at the office of a racist and sexist physician. “Babel: the Voice of Medical Trauma” (p. 158) dramatically tells the story of a poorly handled birth at a hospital.  

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While the author's surgery for throat cancer when he was 14 years old, and its aftermath are the central events in this graphic memoir, Stitches is more essentially the story of a dysfunctional family. The memoir begins when David Small is six, growing up in Detroit, drawing, and observing the body language of his often silent parents and brother. Tension fills the house. David's mother's face is in an almost permanent scowl and the "mere moving of her fork a half inch to the right spelled dread at the dinner table" (16).  She slams pots and kitchen cabinet doors while David's radiologist father lets loose on a punching bag in the basement and his brother beats drums. David is in a constant struggle to avoid his mother's fury, which author/artist David depicts as a tidal wave. His father is remote, puffing silently on his pipe.
 
When David is 11 a female friend of the family, the wife of a surgeon, draws attention to a growth on David's neck, which his parents have either failed to notice or knowingly ignored. In due time the neck is x-rayed. The surgeon-friend diagnoses a sebaceous cyst and recommends an operation. With the mother's frequent protests about lack of money--in spite of an extended shopping spree the parents undertake-- it is three and a half more years before the surgery takes place. David undergoes the procedure with relative equanimity, the hospital and medical staff being familiar -- people he "thought of as my extended family, my protectors" (160). When he wakes up from the surgery, his father assures him that nothing is wrong but that he will need a second operation by a specialist. Uncharacteristically, his mother asks if there is anything she can get for him.

Waking up from the second surgery, David has no voice -- one vocal cord and his thyroid gland have been removed. "The fact that you now have no voice will define you from here on in" (186). Later, when changing his bandage by himself, he discovers a long, ugly array of stitches on the side of his neck. He has nightmares, and on one sleepless night as he wanders the house, discovers a letter written by one of his parents to "mama" which says, "of course the boy does not know it was cancer" (204). The accumulated silences and parental betrayal trigger David's delinquent behavior and  time in a boarding school, from which he runs away three times; ultimately he is expelled with a recommendation to get psychiatric help. Reluctantly, his mother drives him to a psychoanalyst -- "it's like throwing money down a hole, if you ask me" (247) -- but this intervention turns David's life around. The analyst, depicted by the author as a tall, fully clothed white rabbit, explains to David, "your mother doesn't love you" (255).  "It was such a relief to hear" said Small in an interview. Another truth is eventually revealed by David's father, who takes David out to dinner to tell him, after a lengthy silence, that the numerous x-ray treatments for sinus infections he had given the young David must have caused the throat cancer: "two-to-four hundred rads. I GAVE YOU CANCER" (286-287).

 

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Tish brings a knife to the breakfast table and threatens to use it on her stepfather if he tries to come into her room again.  Her mother, working at the sink, does her best to ignore the conversation, in which the stepfather moves from mockery to threats.  Tish carries the knife in her boots to school.  When her gym teacher insists on her removing her boots she begins to scream uncontrollably, is sent to the principal, and, unable to tell her secret, runs away.  She finally makes her way to a friend's father, a lawyer, who listens to her story and assures her of legal protection, though as the story ends, Tish has a lot of decisions left to make, and a long way to go before she feels safe and healed.

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A movie buff in northern France goes blind after watching a short anonymous horror film. He calls on Lucie his ex-girlfriend and a cop in Lille, to take the film to an expert film analyst. The expert demonstrates that the film, made in Canada in 1955, contains subliminal images and a whole other hidden movie of little girls torturing rabbits. He is soon found brutally murdered and the film stolen.

Four bodies missing part of their skulls, their eyes, and hands are found buried by a crew laying a pipeline and the profiler Sharko is brought in to explore the crime. They make a connection to a triple murder of girls in Egypt in 1994—the three girls who did not know each other were found in different places with their brains and eyes missing.

Sharko and Lucie begin to unravel the mystery by tracking the people in the film and those who made it. Sharko goes to Egypt; she goes to Canada –both nearly lose their lives as a result. Their research brings them closer to linking the seemingly disparate murders to occult military operations, involving the French Foreign Legion and the CIA.

They solve the crime, but the ending is disturbing.

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