Summary:

In this account of early practitioners and advocates of 'inoculation,' or the use of tiny amounts of smallpox contagion to induce a mild case of smallpox and immunity, author Carrell weaves prodigious historical research with fictionalized dialogue to create a tale of two prominent figures: Lady Mary Wortley Montagu of London and Dr. Zabdiel Boylston of Boston. Both Lady Mary and Boylston suffered scarring from smallpox, and, by living in the early 18th century, both witnessed the devastation of epidemics in terms of public health and private loss.

Both were also aware of the use of inoculation to prevent severe disease in Turkey (Lady Mary visited with her ambassador husband) and in Africa (on the advice of Cotton Mather, Boylston interviewed Africans, slave and freemen, living in Boston). Both faced formidable challenges and risked personal security to promote the use of this technique. Both proved their belief in the technique by the inoculation of their own children. And both, perhaps, met. At the behest of the Royal Society, Boylston traveled to London, witnessed numerous inoculations, and presented his Boston experience to the Society.

The book also chronicles the natural course of the disease, its various symptoms, forms and popular treatments, and the political impact of smallpox on the royal families of Europe and business interests in Boston. The medical research of various doctors is detailed. In particular, selected Newgate prisoners were offered pardon in return for participation in an experiment conducted by Mr. Maitland, who also inoculated Lady Mary's children. These experiments were used to test the safety and efficacy of inoculation prior to royal inoculation.

Ultimately, detractors of inoculation ceased their vitriolic attacks, as the risks of inoculation were proven to be far lower than exposure without such protection. The success of inoculation paved the way for Edward Jenner, often called 'the father of immunology,' to successfully use cowpox to induce smallpox immunity later in the 18th century.

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The Agnew Clinic by Eakins was commissioned by Dr. D. Hayes Agnew's students at the University of Pennsylvania to celebrate the seventy-year-old physician's retirement as Professor of Surgery in 1889. It was unveiled at commencement 1 May 1889. The size of the painting, the largest Eakins ever created, is 84 3/8 x 118 1/8 inches. The artist painted the work in ninety days and received a fee of $750. Its frame carries this inscription in Latin: The most experienced surgeon, the clearest writer and teacher, the most venerated and beloved man.

Dr. Agnew (1818-1892), a Pennsylvania native, was a well-respected surgeon and educator who had served in two army hospitals during the Civil War. He was best known for his competence in removing bullets, but Eakins has chosen to show him performing a lumpectomy or partial mastectomy.

The surgeon is shown standing in an enclosure, having stepped back from the operation. He is lecturing to students, faculty, and spectators seated in the operating theatre. Dr. Agnew holds a scalpel in his left hand. He is wearing a white surgical gown.

Eakins has placed the operating table with the female patient in front of Dr. Agnew. Her hair and face are visible, the ether cone just above her chin. Her right breast and arm are shown; the left breast is being operated on. A sheet covers her lower body. The sheet beneath the patient carries the inscription: University of Pennsylvania. Between Dr. Agnew and the bed we see a closed case holding the sterilized instruments. The anesthesiologist and the surgeons all wear white. Dr. Agnew's nurse, Mary Clymer, stands by the patient's waist. She is dressed in a high white cap, white apron and black dress.

Eakins illuminates Dr. Agnew, the patient and her doctors, and the nurse. The spectators sit in semi-darkness, but they are individualized by face and posture. The painting contains about thirty small portraits of doctors. Most of the doctors and spectators have been identified by name (see site at University of Pennsylvania: http://www.archives.upenn.edu/histy/features/1800s/1889med/agnewclinic.html). Eakins is standing to the extreme right, listening to a doctor who whispers to him. Because of time constraints, Eakins's mini portrait was painted by his wife, the artist Susan Macdowell Eakins.

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Aaron Raz Link was born a girl, named Sarah, and loved as a daughter. Twenty-nine years later, after inner turmoil, deep thought and relentless examination of how society views gender, Sarah became Aaron, a gay man. This starkly open and moving book describes, in Aaron's words and then in his mother's words, both the costs and the rewards of this journey.

The book is divided into two sections: the longer, beginning section is Aaron's, an intense rendering of what might be called an inner dialogue: Aaron talking to himself about his place in a gendered world; Aaron talking to society about the role of men and women; and Aaron talking to us, the readers, as if we were his close friends, gathered around him as he revealed his life.

The second section belongs to his mother, Hilda Raz. In musing, episodic scenes, she writes about herself as Sarah and then Aaron's mother, about her own work as a poet and editor, and most poignantly about losing her breast to cancer.

On page 86 Aaron says, "A stereotype is a kind of camouflage; the eye finds what it expects to find, and passes over details." Throughout this book we are asked to look at, directly but never sensationally, our bodies' organs, our gender "details," not only as functional anatomy but as symbols of identification.

In both sections, I felt pulled along on this journey, both as someone invited and as someone looking on, an emotional voyeur, and in both sections I observed the unflinching honesty of the authors' revelations. But it in was this final section, the mother's story, that I felt most keenly the love between the two authors. It is this love that becomes the strength of the narrative, the ground on which this incredible story unfolds.

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David Lynch’s The Elephant Man is based on the life of Joseph Merrick (1862-1890), a man who we first encounter in the film as “The Elephant Man” of a freak show, whose physical differences are so frightening to the authorities that the exhibit is closed. An ambitious young surgeon, Frederick Treves (Anthony Hopkins), seeks out Merrick (John Hurt) as a subject for a presentation to the Pathological Society and, taken by Merrick’s intelligence and amiability, arranges for Merrick to have a permanent home on the premises of London Hospital. The film portrays Treves as rescuing Merrick from a wretched existence in the squalid wharf district, where he is beaten savagely and otherwise abused by his sideshow manager, Bytes.

Treves provides Merrick with modest bourgeois comfort in the form of private rooms on the hospital premises. When the London Times publishes a letter from the hospital director describing Merrick’s disfigurement as terrifying and requiring isolation, first a famous actress, then most of London high society seek out Merrick, some to befriend him, others to indulge in spectatorship or the fashion of the day. A hospital porter who has access to Merrick’s room brings drunken revelers to view Merrick for a fee, giving the villainous Bytes the opportunity to kidnap Merrick and spirit him off to Belgium and a desperate existence as an abused and degraded sideshow freak.

Eventually, the other members of the freak show free Merrick and send him back to London, where, in a dramatic chase scene, he is pursued by an angry mob until the police arrive. Treves is summoned and reinstalls Merrick in his rooms at the hospital. Merrick is then celebrated by society when he attends his first theater performance. That night, he arranges himself to be able to sleep lying down, like a “normal person,” a position he knows will lead to his asphyxiation due to the size of his head, and he dies.

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This is a collection of 91 poems on medical topics by medical students, physicians in training, and attending physicians; two are Canadian and the rest American. The poems are organized by six traditional groups of medical training and advancement in the profession: Medical Student, First Year; Medical Student, Second Year, Medical Student, Clinical Years; Intern; Resident; and Attending. There are no sections for pre-meds, retired doctors, or other programs (naturopath, chiropractor).

The editors have done a good job of picking well crafted and evocative poems. A dozen have been previously published. For the most part, the poems are short, easily fitting on one page. Almost all are in free verse, although there is one group of haiku, one prose poem, and an impressive sequence of ten Shakespearean sonnets “Breughel at Bellevue” by Anna Reisman.

Many poems treat dramatic moments in training: the anatomy lab, first gynecological exams, physician-patient relationships, especially when a patient is gravely ill or dying. Several poems in the first three sections comment on the differences between the normal social world and the intense medical world of the hospital. Throughout there are references to the pressures of high-tech, unfeeling medicine. Indeed Jack Coulehan sounds this theme in his introduction; he writes that "steadiness and tenderness" are both needed in medical practice.

 

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Dr. Pauline Chen is a transplant surgeon and hence highly trained in the surgical care of desperately ill patients. She found, however, that although she had intensive and first rate training, time and again the message she received from her mentors and peers encouraged a distance from frank discussions about dying with patients who were clearly dying. Dr. Chen successfully suppressed her urges to reflect on the meaning of illness and death. Years into her training, she finally witnessed an attending surgeon stay with a patient and the patient's wife until the patient passed away. The widow sent a thank you note to Dr. Chen for allowing a "dignified and peaceful death." (p. 101) Chen notes that observing her attending stand with the patient during death changed her profoundly: "...from that moment on, I would believe that I could do something more than cure. This narrative, then, is my acknowledgment to him." (p. 101)

Final Exam chronicles Chen's journey from medical student to attending surgeon and examines her experiences with death and serious illness - of patients, family members, friends. The memoir contains three parts: Principles, Practice, and Reappraisal - each with three chapters. The book is chronologically arranged, beginning with anatomy dissection at the start of medical school and ending with Chen as an attending arranging for hospice, thus honoring a patient's desire to die at home rather than in hospital. Chen skillfully weaves her stories around commentary on the social, cultural and philosophical issues surrounding death and the medical response to death. An introduction and epilogue bookend the text and 46 pages of extensive notes and bibliography complete the book.

Although Chen claims to have slowly and painfully awakened to the fact that patient needs extend well beyond good technical care, in fact one sees Chen emerge as a caring physician even from her initial patient contacts in medical school. Chen speaks more to her role as an Asian-American than to being a woman in a male-dominated field, but she clearly has what it takes to succeed in this extremely competitive field, including a good dose of compulsiveness and an incredible work ethic.

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The Cuban-American physician-poet Rafael Campo tells a story in this poem. His speaker is both a curandero, or folk healer, and a modern-day American physician. Returning home after a trauma-filled day at the Emergency Ward, the speaker immerses himself in a soothing bath with "Twenty different herbs at first (dill, spices / From the Caribbean, aloe vera)." He weeps and prays to his patron saint and curandero St. Rafael, who has the same name as the poet himself. Rafael announces his arrival: "Rafael, / He says, I am your saint." The speaker tells his healer about two female patients he has seen that day, one, an abused wife, and the second a little girl killed on her tricycle. St. Rafael listens, touches the speaker, and carries him to bed. Sleep "takes the world away."

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The authors analyze developments in the scientific article in Europe from the seventeenth century to the present. They devote a chapter to "style and presentation" in each century, and a separate chapter to "argument" more specifically in each century, in French, German, and English examples. They find a remarkable similarity of style already evident in seventeenth-century examples, demonstrating that scientific authors were already addressing an international audience. Seventeenth-century articles show an "impression of objectivity" and "a movement toward a more impersonal style" (47), although the English examples were somewhat more personal, less quantitative, and less interested in explanation than were the French examples, and the prose overall is hardly what we would currently expect from a scientific article.

Although the eighteenth-century examples should, perhaps, be considered part of a larger period that included the seventeenth century, Gross et al do track a movement from impersonal to personal style, nominal to verbal style, and minimal presentation to more elaborate presentation during this period. Also, the French examples continue to approximate more closely to twentieth-century norms of scientific style, reflecting their more professionalized community. Overall, the authors characterize much of the eighteenth century as a period of "consolidation and altered emphasis," with "relative stability" of style (116), although the last quarter of the eighteenth century showed a sharp rise in standardization and standards for accuracy and precision.

Gross et al note that nineteenth-century prose still addresses amateurs as well as professionals, and they comment on its persistent difference from "the highly compressed, neutral, monotonal prose" of late-twentieth-century science(137). However, the English and German examples do become more professional in their use of impersonal style, and examples demonstrate a consolidation toward a more "homogeneous communicative style" (138). They also note that the nineteenth century exhibits a "master presentation system approaching maturity," with "title and author credits, headings, equations segregated from text, visuals provided with legends, and citations standardized as to format and position," as well as standardized introductions and conclusions (138).

They find that the combination of an increasing "passion for factual precision" and systematization produces more careful theorizing generally in science during this period, even as individual sciences specialize and diverge (158). Increased attention is given to the process by which facts are linked to theory, and to the role of evidence, governed by an "overriding need for explicitness" (160).

Twentieth-century examples include shorter sentences with more information packed into each by way of "complex noun phrases with multiple modifications in the subject position, noun strings, abbreviations, mathematical expressions, and citations" (186). The scientific article is now generally marked by high incidence of passive voice and low incidence of personal reference, along with a "master finding system" made up of "headings, graphic legends, numbered citations, numbered equations, and so on" (186). They argue that the current state of the scientific article reflects an evolutionary process whereby "current practices are a consequence of the selective survival of practices that were, persistently, better adapted to the changing environments of the various scientific disciplines over time" (212).

 

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In 1921, the twenty-four year-old Scottish medical graduate, Andrew Manson, takes up an assistant’s position in a small Welsh mining town. He is idealistic, but he quickly learns that his training is inadequate and that his hemiplegic employer will never return to practice. Manson must do all the work for a pittance and bad food. He befriends another assistant, the surgeon Phillip Denny, whose fatal flaw is devotion to drink. Together they solve the town’s problem with typhoid by blowing up the sewer.

Manson’s escape comes in a new job in a larger town and marriage to the equally idealistic Christine. She encourages him to continue his studies and to conduct research on the relationship between dust inhalation and tuberculosis. The results include higher degrees and international recognition, but they also bring about the wrath of the town’s antivivisectionists. To add to the gloom, Christine looses a much wanted pregnancy and the ability to have children.

The Mansons leave Wales for London, where Manson hopes to extend his research within a government agency. Quickly disillusioned by bureaucracy, he is lured into society practice and slowly abandons his ideals in exchange for prestige and wealth. Christine is increasingly unhappy, but his response is annoyance with her and an affair with a married woman. When one of his new associates botches an elective operation on a trusting patient, he realizes the colleague is nothing more than a society abortionist and that he and his new friends are little better.

He decides to sell his practice and renews contact with Denny to establish a group consulting practice "on scientific principles" in a carefully chosen Midland town. He also helps the tubercular daughter of an old friend to an unorthodox (but effective) pneumothorax in a clinic run by Stillman, an American who does not have an MD. Just as he and Christine have rediscovered joy in each other and their future together, she is killed in a freak accident. Only days later in the depths of grief, he is brought before the General Medical Council on charges of unprofessional conduct laid by his former associates. He acquits himself brilliantly and leaves with his old friend Denny for work in the Midlands.

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Sultana, a doctor who escaped her illiterate nomadic background to study and work in France, returns to her native Algeria when she hears of the death of her former lover and fellow physician, Yacine. She is treated with hostility, but defiantly stays in Yacine’s place at the clinic. Vincent, a Frenchman who is the baffled recipient of a perfectly matched kidney from a young Algerian woman, travels to the desert to explore the culture of this unknown person whose death has brought him back to life.

Sultana and Vincent meet through their common friendship with the furtive, questioning children, Dalila and Alilou. Vincent and Salah, Yasmine’s best friend, both fall in love with Sultana, but she seems indifferent to them. The violence and suspicion of the town leaders causes her to regress into anorexia and mutism, during which she is tormented by the horrible memory of the loss of her parents. Her three male friends and the village women help her to recover a sense of self worth, but she must flee when the leaders set fire to their dwellings. A glimmer of optimism can be found in the aspirations of the children and the solidarity of the women.

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