Back when I was doing my internship at Pennsylvania Hospital, I was so surrounded by history I felt like I was working in a museum. Even the china we dined on in the hospital cafeteria sported the original historic pattern. And when we finished our training, a brass plaque with our names went up on the same wall as the plaques of our predecessors going back to the 18th century.

At the time, none of this was widely known. But fortunately, Pennsylvania Hospital now has an actual museum, open to the public just in time for the nation’s 250th anniversary. The Pennsylvania Hospital Museum is compact yet chock-full of art, architecture, artifacts, and documents, and has at once become a must-see destination in Philadelphia.

Although Bellevue Hospital has roots that go back to 1736, it started out as an almshouse. Pennsylvania Hospital was the first institution in the colonies founded specifically as a hospital, established in 1751 by Benjamin Franklin and Thomas Bond. The 1756 building housing the museum is a National Historic Landmark. Not only is it considered an important example of Georgian architecture, but its cornerstone even bears an inscription by Franklin referring to King George II.

The landscaped grounds are a serene oasis in the middle of Philadelphia’s Society Hill neighborhood and include a Physic Garden containing herbs and plants used for medicines in the 18th century.

As one enters the building, the first room encountered is the pharmacy, which remained in use until 1927 and now contains interactive displays. A fire engine purchased in 1803 sits in the foyer at the base of a grand staircase. After ascending to the second floor, visitors enter America’s first medical library, a handsome wood-paneled room containing more than 13,000 volumes from floor to ceiling, including one of the nation’s most complete collections of medical books published between 1750 and 1850.

The third floor houses the nation’s oldest surgical amphitheater. In the era before electricity, it was illuminated by skylight, so surgeries could only be performed on sunny days. (I must confess that we interns used to sneak into this room when on call. It was spooky in the middle of the night!)

For me, as a psychiatrist, the highlights of the museum were the exhibits on mental health. I have previously written in MedHum about Benjamin Rush, often called the father of American psychiatry, whose portrait is on view here. Rush served on the staff at Pennsylvania Hospital from 1783 until 1813 and was known for his groundbreaking and humane treatment of the mentally ill. Metal shackles once used as restraints are also on display, although hopefully they predated Rush’s tenure.

Another psychiatric pioneer whose portrait hangs in the museum is Thomas Story Kirkbride, who came to Pennsylvania Hospital for residency training in 1834. When the psychiatric wards exceeded capacity and a satellite facility was built on 101 acres in West Philadelphia, Kirkbride was named superintendent. His ideas about the layout and design of mental institutions became highly influential, leaving an imprint on hospitals throughout the country.

Initially called the Pennsylvania Asylum for the Insane, the new campus eventually became known as the Institute of Pennsylvania Hospital. I completed my residency training there, but over time it was no longer financially viable, and it closed in 1997.

How fascinating to learn that Francis Scott Key, of “The Star-Spangled Banner” fame, wrote a poem titled On Visiting the Pennsylvania Hospital. And to see 18th-century anatomical casts used for teaching at a time when formal dissection was illegal.

There is so much history in this museum that I could not absorb it all in one visit. With its addition, Philadelphia further demonstrates its role as the cradle of American medicine. Indeed, one would have to travel to London to find a larger assemblage of medical historical sites.

In one very busy day—or a more leisurely two-day trip—a visitor can now experience this museum, plus the College of Physicians of Philadelphia and its famous Mütter Museum, while also stopping to see The Gross Clinic by Thomas Eakins. (The painting alternates between the Philadelphia Museum of Art and the Pennsylvania Academy of the Fine Arts, but will spend 2026 at the latter.)

Bravo, Philadelphia!

Benjamin Rush:  Reflections from a Psychiatrist 

Guy Glass 09.02.24 0

A founding figure in American psychiatry, known for pioneering reforms, but also controversial for his treatments and complex contradictions in beliefs and practices.

For more information about the museum, visit Pennsylvania Hospital Museum.
Web image from Wiki Commons

Out of the gay rights activism in the 1970s came AIDS activism in the early 1980s. By then, the incidence and severity of AIDS had become evident and caused enough fear to generate social backlash against those with the disease. This, along with federal government insouciance at the time, made it necessary for gay rights activists to extend their remit into advocacy for health care specialization and research advancements for AIDS. The expanded activism was visible on the streets and at governmental research institutions (e.g., National Institutes of Health). Where it was also taking place, and not in such an obvious way, was within certain hospitals.  

San Francisco General Hospital answered the call first in 1983 when it created a special unit for the care of people with AIDS in “Ward 5B.” The unit was in operation through its move in 1986 into Ward 5A to accommodate more patients, and until 2003 when advances in antiretroviral treatment of AIDS made the unit no longer necessary. But throughout, the struggle to maintain and advance the unit medically, socially, and politically persisted. The documentary film, aptly named “5B,” covers the struggles, successes, and failures of the unit, and the activism required of the staff and advocates for its creation and ongoing viability.  

From the Inside 

The story is told from various perspectives through interviews with key figures in the unit’s development and operation, and with archival footage of the unit and AIDS activism in the community. The most prominent among the key figures is Cliff Morrison, a clinical nurse specialist who spearheaded the idea for the unit and then managed it. Several other nurses who served in staff and supervisory positions are also featured. Participating physicians include Paul Volberding, an oncologist at the time who became pivotal in the development of effective HIV treatments, and Julie Gerberding, a physician treating patients on the unit who later became the Director of the Centers for Disease Control (CDC). Lorraine Day, the chief of orthopedic surgery at the hospital when the unit opened, is heard often as an opposing voice. Hank Plante, a local television news reporter, also appears frequently to offer his perspectives on many of the social and political issues swirling around the unit. Among other participants are AIDS activists, volunteers, and family members of unit patients. 

Several storylines frame the documentary including how nurses drove the unit’s inception and then were instrumental in running it. “Nurses were in charge,” said Volberding, admiringly. Interwoven throughout the film are the experiences of the patients and individual nurses, including one nurse who was infected with HIV from a needle stick. “Those nurses were the real heroes,” said one activist.    

Rare is the story, though, about heroes who aren’t confronted with daunting challenges, and thus this documentary includes a storyline involving attacks the unit nurses encountered from inside the hospital. The nurses of this unit practiced in ways they considered safe but not in such a manner that would preclude them from touching patients or require them to don so much protective gear they become unseeable. Nurses and clinicians from other units objected and did not want to be compelled to adopt practices they thought endangered them on the occasions they took care of AIDS patients. The film follows this story through union grievances and public debates to their conclusion, which sided with the unit nurses and their advocates. The spirit of activism among the unit staff was pivotal in fending off the many challenges they faced. 

Keeping in Touch 

The documentary reveals stark juxtapositions that can manifest in the midst of an infectious epidemic, and in particular when an epidemic selects an identifiable group that is unwelcome in mainstream society. Two juxtapositions that stand out are the emotion of love with that of fear, and those who are deemed worthy with those who are considered disreputable. 

No treatments for the HIV infection or for the many horrid and lethal diseases resulting from AIDS were available when the unit opened—it was “a very, very unpleasant death” as one nurse put it. The nurses saw a big part of their role as offering love: “Here you were allowed to love your patients.” They offered it through human touch. Morrison’s view was, “If we can’t save these folks, we’re going to touch them.” To touch the patients in this way required that they balance it with the risk of exposure to infection and still comply with universal precautions. Nevertheless, fear was prevalent—some people were “truly hysterical” according to Gerberding—and it touched off conflict among the health care staff. “People were afraid…we found ourselves attacking each other…everyone was so stressed,” is how Volberding described the situation. This balance is one that is continuously negotiated in health care settings, but it was more pronounced during the early years of the AIDS epidemic, and at San Francisco General, it had to be mediated by hospital and union officials. 

At the time unit opened, and for a long while after, people with AIDS were scorned. The gay lifestyle was linked to the disease and so a view held by many was that the gay community deserved to be struck down by this plague. They were not worthy of all the human resources, technology, and money the disease required. The documentary brings this sentiment to life by showing the actions some people took to prevent getting these patients help, and the actions governments didn’t take to help them. Also shown, however, was how the activism of health care professionals and others in Ward 5B helped to overcome these obstacles. Without it in the case of the unit in Ward 5B, the activism in the streets outside the hospital alone may not have been enough.  

But Then 

These fevers abated some when medical advances produced treatments that obviated the need for AIDS units, and changes in societal attitudes led to more acceptance of gay lifestyles. The next epidemic that targeted marginalized and susceptible groups would determine whether lessons learned from the time of this unit had been incorporated in response protocols. That opportunity came the year this documentary was released in 2019 when Covid struck elderly people first and hardest, and especially those in communal living arrangements.  

Note: 

The documentary was featured on the podcast episode, How Terrible It Was: Three Takes on the AIDS Crisis with Dr. Ross Slotten, which can be accessed here on medhum. In addition to the documentary, the podcast episode included the novel, The Great Believers, and the memoir, The Plague Years: A Doctor’s Journey through the AIDS Crisis were discussed. The author of the memoir, Dr. Ross Slotten, joined the podcast as a guest. 

Title image credit: 
James Steakley, CC BY-SA 4.0 <https://creativecommons.org/licenses/by-sa/4.0>, via Wikimedia Commons 

Documentary information: 
Film title: 5B
Directors: Paul Haggis, Dan Krauss 
Studio: Vertical Entertainment 
Viewing source: Amazon Prime 
U.S. release date: June, 2019 
Run time: 134 minutes  

Trailers from 5B Film

Five years into writing about her mother’s slow decline from a respiratory illness, Joanne Jacobson was diagnosed with a rare, life-threatening blood disease. That discovery dissolved the illusion that she and her mother had separate fates. “How could I continue writing about my mother as though I were observing her from outside the circle of Illness?” Jacobson asks (27). She can’t. And Every Last Breath becomes, as its subtitle discloses, “A Memoir of Two Illnesses.” Doubling its concern, Jacobson’s memoir in essays becomes a richer, more urgent, and ironic revision of her original project.  

With writerly attentiveness, perceptive intelligence, and some impatience, the four opening essays witness the negotiations that Florence Jacobson makes with her body, her environment, and her psyche. From a distanced perspective, Jacobson wonders at her mother’s courage and stubborn animal will to go on. Her mother’s slow pace and reluctance to let go—of her possessions, her habits, her life—initially frustrate and puzzle Jacobson. She even expresses impatience with the constant sound of her mother’s oxygen pump filling the apartment, the inconvenient bulk of the oxygen canister, the tangles of tubing connecting the machine with her mother’s nostrils.  

As Jacobson’s diagnosis closes the distance she perceived between herself and her mother, it ignites the memoir’s transformative insight. It’s first articulated at the end of the essay titled “Mirror Writing” and it sustains the rest of the memoir. Realizing that her mother might outlive her, Jacobson writes: “. . . I can no longer pretend that the ragged approach of death is likely to be smoothed by nature’s grace, or by the natural order. So long as I believed I was writing about my mother, I was able to hold mortality at a distance . . . Now in the mirror of my mother’s aging face I see myself” (29). In “Dead Reckoning,” when Jacobson learns that her blood is starved for oxygen, she hears her “own lungs fall into the thrumming motor’s pulse” of her mother’s respirator. Revising her response to the technology, she writes that it is “the sound of death being pushed mechanically away that is audible to me now—steadily asserting its nearness . . .” (63-4). Jacobson’s descriptions of her hospitalizations and treatments (“Written in Blood,” “If My Disease Were an Animal”) sharply observe her new understanding of herself and the “call to the imagination” that her experience issues (59). Jacobson’s elegant and vulnerable rendering of her efforts to survive pain, uncertainty, and terrifying treatments register her courage and will to go on.  

The final essays bring together the shared destinies of mother and daughter. Jacobson thinks of their relationship as “invisibly entwined, cellular,” as she recalls that mothers’ bodies can absorb the fetuses’ cells (88). In “Book of Names,” Jacobson’s closing essay, she and her mother recite the names in Florence’s heavily edited address book, tracking the alterations in the lives she’s shared. The recitation invokes the lists in Genesis. Begotten. Gone.  

Every Last Breath should be read. Its profound and startling reflections on mortality are lyrical, fierce, and deeply felt. At times readers take extravagantly metaphorical flights of the imagination. At times we’re immersed in revelatory scientific facts about the natural world and our human biology. This slender book melts other boundaries as well: between caregiver and patient, mother and daughter, self and other, personal and universal. It simultaneously challenges literary classifications, blending poetry, essay, and memoir. Read separately or together—either way can be satisfying—Jacobson’s brilliant essays refuse to let us ignore our shared vulnerability or the unpredictability of living in a body, as Jacobson once naively thought she could. 

Every Last Breath–A Memoir of Two Illnesses
Joanne Jacobson 
The University of Utah Press, 2020; 114 pages 
https://uofupress.com/books/every-last-breath/

A previous version of this review was published in the NYU Literature, Arts, and Medicine Database. 
Web image created by Medhum.org

At one point Ragin accidentally visits Ward #6, the mental ward, where he encounters Ivan Gromov, a brilliant patient, and strikes up a conversation with him.  Gromov, who carries a diagnosis of paranoia, loves life passionately.  His passion attracts Ragin, whose sensibilities are blunted by the emotional numbness from which many physicians suffer.  Ragin is attracted to Gromov like a moth to a candle. He begins to visit Ward 6 daily to debate with Gromov. Since the other doctors never visit Ward 6, this behavior is considered very peculiar. 

Ragin yearns to feel something, anything, even to experience suffering, rather than to remain suspended in his emotionless cocoon.  He develops an obsession that only suffering can redeem him.  This obsession makes him even more dysfunctional, a situation which allows a junior doctor to have him fired as hospital director and, ultimately, admitted to Ward #6 as mentally ill.  Once Ragin has become a patient, a “nobody,” the ward orderly hits him, thereby giving him the opportunity to suffer.  Shortly thereafter, he has a stroke and dies.

Enormous demands and poor working conditions contribute to Ragin’s predicament, but Chekhov suggests that Ragin’s character is also deficient.  Something is missing.  He experiences a sense of futility and numbness.  Is this an inevitable consequence of medical practice?  Or is he particularly vulnerable to burnout?  The deeper theme in “Ward No. 6” is Ragin’s failure to live an authentic life, to discover a sense of wholeness and meaning in his existence.  It is possible that Ragin’s early enthusiasm for hospital practice disguised the fact that he never came to terms with his own needs and values.  

Lady With Lapdog and Other Stories
Anton Chekhov
David Magarshack (Ed.)
London, Penguin Books, 1964.

A previous version of this review was published in the NYU Literature, Arts, and Medicine Database (Litmed).

Reviews of Chekhov’s Stories

Cold Eye, Warm Heart: Medicine and Anton Chekhov  

Jack CoulehanAug 6, 2025

An Awkward Business by Anton Chekhov 

Jack CoulehanJun 11, 2025

The Grasshopper by Anton Chekhov

Jack CoulehanMay 11, 2025

Ionych by Anton Chekhov 

Jack CoulehanMar 11, 2025

A Doctor’s Visit  by Anton Chekhov 

Jack CoulehanMar 11, 2025

Ward No. 6 by Anton Chekhov

Jack CoulehanMar 11, 2025

A Nervous Breakdown by Anton Chekhov 

Jack CoulehanFeb 11, 2025

Enemies by Anton Chekhov

Jack CoulehanJan 11, 2025

The narrator has enjoyed a mostly healthy life. He has traveled to Europe and once was treated for syphilis while there. He has been together with L for seven years. Both men are writers who teach at the university. Now, the pain that grips him defies exact description (even for a professional writer). The closest comparison that he can conjure is having someone’s hand plunge into his body and twist his guts along with the sensation of being kneed in the groin. He’s reluctant to seek medical attention since medical facilities are especially risky during the pandemic. So he waits and hurts. The pain is soon accompanied by fever, chills, and aching of the limbs. 

He decides to go to urgent care. After a brief evaluation, he’s referred to the university medical center ER. Covid testing is negative. A CT scan reveals an aortic dissection (tear in the aorta) associated with aortitis (an inflammation of this large blood vessel). He is told that such a tear is frequently fatal. He’s lucky to be alive. The narrator is placed in the ICU and treated with IV antibiotics, fluids, and antihypertensive medications. The vascular surgeon recommends holding off on any operation (either a stent or a graft), hoping the tear and inflammation will stabilize and heal. 

Hospitalized for a week and a half, the narrator confesses his feelings of helplessness, shame, bewilderment, and fear. He is intrigued by the bustle of the hospital – almost electric with human energy – but despondent over the seemingly omnipresent suffering there – his own, that of fellow patients, and even the distress of healthcare workers. He is most impressed by and appreciative of his ICU nurse, Alivia. As for the physicians involved in his care, the narrator notes the stark clinical detachment of many doctors. Reflecting on a visit from a rheumatologist, he concludes, “I was nothing to her, really, I was her job, she would clock out and enter her real life” (p124). He craves to sense some vulnerability and genuine concern emanating from his physicians. As for empathy, the narrator reveals some of his own when he decides, “it must be hell to be a resident” (p129) in training. 

The search for possible rare etiologies of his condition comes up empty. As his condition slowly improves, the narrator still worries about his current predicament and the future: “I was an enigma, they said, a conundrum, they were running out of ideas” (p121). The waiting for and indecision about any kind of surgical intervention wears on him. He wonders if it might be best to have an operation. 

But the narrator never has surgery. A repeat CT scan confirms stability of the aorta and resolution of all inflammation. He is discharged home on oral medicines and continued IV antibiotics. Frequent follow-up appointments with his doctors and imaging studies of his aorta are scheduled. His partner L lovingly tends to his needs. His sister G arrives to help too. The narrator’s prognosis is murky. Did he dodge a bullet? Or are further problems with his aorta inevitable? How does a person cope with such chronic uncertainty. Although the narrator is weak and emotionally rattled, he is happy to be alive, pain-free, ambulatory, and home with his lover. Shouldn’t that be enough? 

The novel reads more like a memoir than a work of fiction. It is impressively authentic and accurate about medical matters – the lingo and professional behavior of physicians, nursing care, clinical procedures, what it feels like to be a patient. Readers will rightfully consider whether the book’s author is perhaps recounting his own experience with a serious health problem.  

In this novel, the human body is depicted in many ways: sensuous, serviceable, surrendered to others, surreal when sick. The narrator’s experience of illness includes a warping of time, the pull of memory, the weight of regret, the need for truth, and the magic of love.  

The poet-protagonist is occasionally irritated by the language and metaphors spewed by doctors and nurses. The use of broad-spectrum antibiotics is explained to him as a “carpet bomb approach.” He is warned about the caustic effect of IV drugs and that his veins might “burn out.” This medical lexicon prompts the narrator to ponder “who taught these people, who gave them their vocabulary, their stock of images” (p86).  

We don’t need a novel (even an exceptional one like Small Rain) to remind us about the randomness and chaos of ordinary life, the uncertainty of health in the future. But we can look to great literature for inspiration, to help us understand and cope with those looming, difficult experiences. The word rain is both a noun (drops of moisture or a spiritual blessing) and a verb (something sent down in abundance). Whether it is tears (of pain and emotion), love, or gratitude, the rain in this story is hardly small.  

Small Rain: A Novel 
by Garth Greenwell 
New York: Farrar, Straus and Giroux, 2024, 320 pages 
ISBN 9780374279547 
Web photo by Pawel Nolbert 

Junger’s memoir, In My Time of Dying, begins with a vivid account of that potentially fatal event. An aneurysm of a mid-sized artery in his pancreas had burst, causing unchecked internal bleeding. At the hospital, Junger slipped into hypotension, hypothermia, and semi-consciousness before surgical repair, which gave him a last minute surgical “save.”  

However, the main focus of Junger’s memoir is his experience of coming “face-to-face with an afterlife.” In the hospital, his dead father appeared to him. His father “exuded reassurance and seemed to be inviting me to go with him.” (p. 37) While this was happening, Junger recalls being awake and speaking to a doctor. Much that follows is a sustained reflection on the meaning of near-death experiences, drawing on the published literature, anecdotal accounts, as well as his own encounter with dying. 

He recounts the story of Tyler Carroll, a combat medic in Afghanistan, who was critically wounded and, as he was near death, “his whole life presented itself to him simultaneously and in great detail, as if twenty-one years of experience could exist outside linear time.” (p. 80) This so-called “life review,” is a common feature of such experiences, as well as encountering deceased loved ones, hovering outside the body, moving through a tunnel of light, and “being filled with love and bliss.” (p. 82) Junger is particularly impressed with the feelings of universal unity, often followed by a profound change in patients’ perspectives on the meaning of life. In the bibliography, he cites dozens of studies documenting the prevalence and characteristics of such phenomena.  

The author was initially skeptical, “Was I blessed by special knowledge or cursed by it?” (p. 93) He first considers the view of most neuroscientists that near-death experiences are hallucinations created by the dying brain, “The overwhelming likelihood is that our sense of another reality is just a comforting illusion that helps us live our lives.” (p. 118) He then considers the minority report, i.e. well-structured visions and thought processes, along with specific memories of external events (e.g. happenings in the room) raise a number of perplexing questions about the functioning of an oxygen-starved brain.  

We have absolutely no idea how the interior world of subjectivity arises from electrical impulses in the brain. Subjectivity exists, although nothing we know about the most basic components of the universe as we know it—quarks, electrons, waves, fields—permits it. Consequently, the belief that further research on the brain itself will yield a key to consciousness must be mistaken. Junger sums up the situation, “Our understanding of reality might be as limited as a dog’s understanding of television.” (p. 118)  

Junger points out that reality at the deepest level (i.e. the quantum world) is full of paradoxes and seeming impossibilities. It fails to answer many questions about the universe, in addition to the origin of mental phenomena. Consequently, he provisionally accepts the philosophical theory of panpsychism, i.e. “consciousness is woven into the very structure of matter” (p. 136) In other words, every component (e.g. quarks, fields) of the universe has a mental aspect, as well as a physical one. (I might interject here that panpsychism is not a prevalent theory among philosophers of mind, because they believe it raises more problems than it solves.) Given this framework, Sebastian Junger concludes that human consciousness might continue after death as part of a universal consciousness. From the text, I don’t think he believes this afterlife would necessarily retain a sense of individual identity.  

My Time of Dying is a thoughtful reflection on the meaning of life from a man who has experienced a close encounter with death. Junger has created a compelling narrative, making his memoir worth reading whether you believe near-death psychic phenomena point the way toward an afterlife, or think they are hallucinations generated by the dying brain.  

1. Van Lommel P, R. van Wees, V. Meyers, and I Elfferich. Near Death Survivors of Cardiac Arrest: A Prospective Study in the Netherlands. Lancet 358 (2001): 2039=2045 

2. Parnia S. and P. Fenwick. Near Death Experiences in Cardiac Arrest: Visions of a Dying Brain or Visions of a New Science. Resuscitation 52, no. 1 (2002): 5-11 

In My Time of Dying
Sebastian Junger
New York, Simon & Shuster, 2024, 162 pp.
http://www.sebastianjunger.com/in-my-time-of-dying 
Web photo byu Sebastien Gabriel

This is my third trip to Naggalama.

In the summer of 2016, I flew to Entebbe with the doctors to direct a documentary about the US-Ugandan palliative care team. I wanted to explore how the Americans fared in a place lacking the diagnostic tools and tests they depend on in the US, and whether people in the villages, many of whom rely on traditional healers, were receptive to their care. 

Access to healthcare remains a major problem in these areas. The people visited by the team are often in the advanced stages of their disease and need the liquid morphine provided by the government to ease their pain and suffering. Many of the villagers we visited had no idea of their diagnosis and what they could expect as their condition progressed.  

With the footage from earlier trips, we created a video about cancer and what to expect when diagnosed. The video will be shown on mobile phones by Village Health workers to the people they visit in their districts. The purpose of this trip was to produce translated versions of the program.    

There are more than 40 languages spoken in Uganda. English, an official language of the country, and Luganda are the most widely spoken, but to reach a broader audience, including the rural population, we to produce other versions. On this trip, we spent a week in Kampala at Stone Age Pictures filming in Kiswahili, French, sign language and Luo, a language mostly spoken in northern Uganda. The plan is to record more versions once these are successfully piloted.

Ali Musoke is the head of Stone Age Pictures in Kampala and was the Director of Photography on my documentary film, Oli Otya? Life & Lost in Rural Uganda, in 2017. Travel to and from Stone Age from our guest house averaged 20 minutes door to door. We drove alongside women and men carrying all sorts of items balanced on their heads even an open suitcase displaying pieces of jewelry.   We passed roadside markets and goats nibbling grass on the side of the road. Traffic was heavier than I remember with government and army vehicles speeding down the middle of the road. Public transportation is either by boda boda motorcycles or buses, really no bigger than vans, that stop along the roads to pick up and drop off passengers. There were so many boda bodas to dodge,  at times I felt I was an avatar in a video game, dodging incoming traffic.   

Ali, his crew and I worked in the studio for six days. Together we directed and edited the new versions. To avoid having to re-edit the video for each language, on-camera actors- two nurses and three professional actors- had to read to time while watching the finely cut scenes in the video. For example, in the section about how cancer is diagnosed, we show techs examining scans then processing a blood sample, The translations of the scripts were handled by a professional translation service in Kampala. Because the translated versions were uniformly longer than the English one, we had the translators on the set to make any last-minute adjustments to the text and to ensure that the reading was accurate. Cultural differences quickly surfaced. For example, biopsy is not a commonly used word, and it was necessary to use a description of the procedure. Similarly, the phrase “palliative care” is not widely known, and not simple to translate. We used the English phrase but showed the team in the field talking to a patient and delivering medicine. Images played a key role throughout the video. For the sign language version, we split the screen evenly between the program and the accompanying signing so that people viewing the video on their mobile phones would be able to see the woman signing. 

Once we finished the studio work, we set out for Naggalama to meet up with the team at St. Francis hospital and head out to the villages to visit women who have breast cancer. The next project is a video to help destigmatize a breast cancer diagnosis.

As I drove with my crew along the red dirt, rough, and deeply rutted roads to the women’s homes, I couldn’t imagine how women in this area could cope with breast cancer, that is if they were able to be evaluated once they suspected they had an abnormality. Village Health Workers play a key role in connecting women to health centers. But evaluation and treatment is costly and require many trips to the Uganda Cancer Center in Kampala, a trip that can take two hours or more.   

In this area, many people rely on traditional healers. Szozzi, our soundperson, grew up in one of the villages we drove through, and we stopped to say a quick hello to his family. He told me that the healers have a placebo effect, using talk to soothe their patients even when the herbs they offer have little effect on their physical illness. Sometimes, Szozzi said, people lack the language to express how they feel at vulnerable points in their lives. How a question is asked can make all the difference. And sometimes, they believe that by giving voice to what they feel can make the illness worse.

On this morning in Naggalama, we pack our bags and prepare for the trip in the hospital van to the Entebbe airport. The doctors and I take a final walk around the hospital grounds. Much is unchanged since my last visit. The hospital now offers CAT scans, and there is a new building with private rooms.  We drop in on the maternity ward to say goodbye to Immy, a nurse and the spiritual leader of the palliative care team, who is caring for her new granddaughter born at the hospital the day we arrived.  

I leave with mixed feelings, overwhelmed by the needs of the population and grateful for the dedication of the health care workers. I will miss you, Naggalama.

For readers interested in the art of translation, I recommend Is That a Fish in Your Ear, Translation and the Meaning of Everything by David Bellos 

Kline opens with the shocking practice of team doctor Larry Nassar (1963-), pedophile and serial abuser of the gymnasts under his care who successfully took him down in 2017. He is serving decades in prison, where he was stabbed multiple times in 2023. She continues with the story of the Johns Hopkins University gynecologist Nikita Levy (1959-2013) who secretly photographed (or filmed) his patients’ genitalia with cameras concealed in pens that he wore on a lanyard around his neck. Abruptly fired when the story came to light, Levy died by suicide in 2013. Two years later 9000 victims were awarded a class-action settlement of $190M.

 It is not surprising, albeit horrifying, that such abuse could emerge in a medical specialty that centers on the most intimate aspects of women’s healthcare.  In a sequence of readable chapters, each of which could stand alone, Kline examines medical achievements in women’s health that could be (and have been) told in triumphalist tones: the speculum, gynecological surgery, the Pap smear, and oral contraceptives. All were invented by men. She also includes marriage counseling and patients as lay instructors in pelvic exams, both initiatives also promoted by men.

Without denying the potential value of these innovations, Kline brings every chapter into the present with the voices and actions of women who object because of painful incursions upon their bodies, denial of their humanity, and distortions of power. Her sources include archives, journals, histories (many written by women scholars), interviews, patient stories, and artistic creations—objects, music, films, poetry. Issues of gender, race, and class pervade the analysis.

The nineteenth-century inventions of the much-maligned J. Marion Sims (1813-1883) end with the 2018 dismantling of his Manhattan statue and the 2022 unveiling, in Montgomery, Alabama, of Michelle Bowder’s Mothers of Gynecology in honor of the three slaves who had been his research subjects. The chapter on Robert Battey (1828-1895) cites the critical secondary literature on how his procedure to remove ovaries by the vaginal route became vastly overused for all female complaints, even mental illness; however, it also draws upon his papers, kept in Atlanta, allowing the reader to comprehend how his initial motivation was to end the menstrual cycle for patients.

Similarly, Kline explores the previously unexamined papers including numerous drawings and photographs of R.L. Dickenson who strove to comprehend female sexual response while purporting to avoid prurience. As much as we are put off by the excruciating details of his oeuvre, letters from grateful patients demand reconsideration of his efforts to understand female sexuality.

The Pap test, which detects early cervical cancer, and the birth-control pill both advanced women’s healthcare. Yet they each prompted reactions from lay women: the failures and inaccessibility of Pap testing and consequent delays in diagnosis, resulted in cervical-cancer survivors‘ organizations; the impersonal implementation and insistence upon regular pelvic examinations spurred the vaginal self-examination movement. Kline lays out the medical achievements and plunges into the social reactions through interviews with the founders and leaders of these activist groups, tracking them down internationally. They express the militant goal to avoid the gynecologist (as if they are all brutal), and the unalloyed joy of seeing one’s own cervix (without the benefit of cytology). Some activists called for men to be banned from the specialty. One wonders if the strident anger and hostility directed at male professionals, many of whom try to practice with compassion and care, may well have incited previously unfelt, reactionary attitudes in the practitioners.

The use of surrogate patients for teaching history-taking and physical examination was proposed and advocated by Harold Barrows in the mid-1960s. A decade later, once academic and professional gynecology accepted the complaints of activists, it followed the trend and began to engage lay women as teaching assistants on how to perform pelvic examinations. Kline outlines Robert Kretschmar’s extension of the trend to pelvic examination at the University of Iowa. She also describes the Pelvic Teaching Program of Harvard and its involvement of the Women’s Community Health Center (WCHC). Even there, we read of pushback and disillusionment as relationships soured. What kind of a woman would do that? – and why? The originally enthusiastic female participants were underpaid and treated as passive objects rather than instructors. Prostitutes had been engaged, as well as gender activists who “started feeling like [they] were in the same positions as are prostitutes….and then started saying ‘Yeah, we are. We are.’” (p. 206) The professors eventually learned to quietly observe, but the students themselves tainted the experience with sexual inuendo and disrespect. Kline provides statistics on how widely lay instructors are used today.

Also using statistics, she exposes today’s teaching of the pelvic examination on anesthetized women who have not given consent. Although the American Association of Medical Colleges deemed the practice unethical in 2003, it is still widely used, most often on racialized, “public” patients.

Kline also highlights the medical, social and financial obstacles to care for transgender people.  Citing surveys from 2015, she reminds readers that most medical students receive no training on care of trans people and that trans men should receive Pap tests but most do not, because of their own discomfort and the ignorance of health care professionals.

Under Kline’s gaze, the benefits of each medical achievement tend to unravel in clinical practice. She rarely outright condemns or criticizes the physician actors; however, she uses irony, targets hypocrisy, and never fails to highlight the opportunities for self-promotion within the benefits that they provided to their patients. Just as she observes gynecologists second-guessing or failing to believe their patients, she views their own stated motives and goals with skepticism. Instead, she allows the male physicians to skewer themselves in their own words with choice quotes. Believing his patients’ pains were psychological, James C. Wood described how he cleared a clogged ward: “’I wanted their beds above all things for real surgical cases, and I knew not one of them wanted to be cut’ So he started scheduling them for various surgeries and, within a week, all ten beds were ‘well emptied for legitimate hospital use’” (p. 102).

Issues of power, trust and consent underpin the fallout of these stories and explain why many women avoid pelvic examination despite its undeniable advantages. In a counterpoint to the miserable tales of criminals at her opening, Kline closes with a patient’s tribute to a sensitive gynecologist on Martha’s Vineyard. The patient has long suffered from an iatrogenic injury owing to the diethylstilbestrol (DES) treatment given to her mother during pregnancy. Her doctor, Dan Pesch, listens well, comprehends her justified fear, grants her control over decisions, and yet manages to wield all the advances of last two centuries to catch her cancer early. Compassion, Kline observes, “can literally save lives.”

Now—will she next expose the hidden history of the prostate exam?

Exposed: The Hidden History of the Pelvic Exam
Wendy Kline
Cambridge and Hoboken: Polity Press, 2024.