In her second collection, “I Watched You Disappear” Silver’s poems invited us to accompany her on her journey through treatment, anger, despair, determination, and faith. This third collection (her penultimate) continues the author’s beautifully written illness narrative, again presenting moments of joy and of despair, and always of hope. 

Silver places her title poem, “From Nothing” (pg. 1), before Section I as an epigraph to the entire collection. “Each death I witness makes me more my own,” she writes, and although the poem sees “muscle shredded” and “bone sheared,” the poem’s last lines lift, as do many of Silver’s poems, into hope and faith: “and my molecules will vault, emerging. / From darkening days, the light will surge and flee.” Section I begins with poems of memory–“Summers in Vermont” with her family (pg. 5)–and “Coincidence,” when her sister’s child is born on the same day that Silver holds her breath and presses her “shorn chest” to an X-ray machine (pg. 7). The memories here are of family moments, both the joyful and those tinged with such “darkening days.” In “Luzerne,” she recalls when time was “consigning” her to such darkness, but two things saved her: her son, the poet’s hand touching his “damp blond hair,” and poetry, “offering itself like a pair of velvet shoes” (pg.13). Silver develops the idea of poetry as a special entity, a gift that enables her to walk forward in her journey, in “Raven” (pg. 15). She imagines a raven lifting her, holding her, and then setting her down in her home, where, she says, “dawn drove a pen into my hand.” This sense of urgency and necessity pervades all of Silver’s poems, as if she has been commanded to write her story.  

Section II begins in “Anguish” (pg. 19) a stunning poem about the loss of her first child, a daughter, but the section ends in joy with “After a Favorable PET Scan” (pg. 38). It might be difficult to find another poem by any author that offers such resounding relief and happiness. This poem, especially, speaks to how terrible every test is for those who are suffering, for those whose test results might mean more medication, more surgery, or less time to live. The celebratory release felt by patients when results bring good news must be a special kind of joy: “Oh world, I will give you all my love. / I will race like a child through the fields, / I will chase off the unkindness of ravens. / My words will grow thick as marshes, / sheltering nests in salty steams.” The poems in Section II are some of the most beautiful and moving poems in this collection. See especially “Tenebrae” (pg. 21), a plea for life; “Poise” (pg. 26), a rant against giving in to cancer; “Snow White” (pg. 30), a poem of mourning for self and others; and “Four Prayers for Forgiveness” (pg. 34-35), a poem that turns illness into beauty: “–the scattered lumps in my lungs / become church domes roofed in green mosaics, / my bones’ fissures fill in with grass-green yarn. / . . . I open my eyes and all is golden.” 

Section III seems to present a corrective reaction to the joy expressed in the final poem in Section II. The poems in this last section are short, mostly one stanza, a catalog of things that are broken, cracked, ripped, or chipped. The warning that nothing lasts forever is implied in poems such as “Partings” (pg. 44) and “Woman with a Hole in Her Stocking” (pg. 45), in “Red Never Lasts” (pg. 47) and “Autumn” (pg. 57). Yet, as always in Silver’s poems, the warning is tempered by the beauty of her words and the depth of her insight into what it is to suffer over the course of an illness that has remissions and recurrences, that sees the body changed and relationships altered. In “Ideal Speech” (pg. 58), she writes “Listen to the Holy Ghost. She blows through you, / she blows her poems right through you.” Even when days seem darkest, the ideal speech for Silver is poetry, and she is the “you” through which the Holy Ghost speaks these auricles. In the book’s final poem, “Three Roses” (pg. 59), the author once again works her spell, turning illness into beauty and despair into hope. “Where only my scar line remains, a red rose blooms. / Luscious, full, so open that if it dropped a single petal, / it would not be as lovely as it is this very moment.” And in the poem’s final lines, “Lay her hands on my chest–here, I give it to you. / Feel your palm on my skin heat and spark,” What is the “it” she gives us? I believe that Silver invites us, as Whitman did, to merge with her and to live within her words, which are her flesh, the poems she writes and then gives us to read and ponder.  

Miscellaneous 

In my annotation of Silver’s second collection, “I Watched You Disappear,” I wrote that her poems might be difficult for some to read: “These poems are beautifully crafted, often primal, and they touch the deepest reaches of personal illness and the shadow of mortality. Readers who have breast cancer or who have family or friends living with breast cancer, might find these poems difficult to read–others under the same circumstances might find them difficult and yet, at the same time, essential.” The poems in this collection can be as raw as they are hauntingly beautiful. But, as do her other books, this one again opens to us a world apart, one we cannot enter unless we share this author’s diagnosis and illness trajectory. If we are caregivers or care receivers, if we suffer or we watch loved ones suffer, these poems plunge us into emotions that we ignore at our peril.  

Publisher Louisiana State University Press 
Place Published Baton Rouge 
Edition 2016 
Page Count 65 

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

On the one hand, if the doctor is physically unable to treat, then he is not responsible for withholding treatment. On the other hand, by being rendered professionally helpless, perhaps he is being punished for not taking a moral stance against his patient. This interpretation seems to have validity because the last line recalls Psalm 137, which warns, “If I forget thee O Jerusalem, let my right hand forget her cunning.” 

For drawing attention to the biblical reference, I am grateful to Dr. Danielle Ofri (clinical professor) and Lara DeLong (Class of 2001), both at NYU School of Medicine. Dannie Abse (1923-2014) was a practicing physician and poet. 

Reading by Dannie Abse

Case History
‘Most Welshmen are worthless,
an inferior breed, doctor.’
He did not know I was Welsh.
Then he praised the architects
of the German death-camps–
did not know I was a Jew.
He called liberals, ‘White blacks’,
and continued to invent curses.

When I palpated his liver
I felt the soft liver of Goering;
when I lifted my stethoscope
I heard the heartbeats of Himmler;
when I read his encephalograph
I thought, ‘Sieg heil, mein Fuhrer.’

In the clinic’s dispensary
red berry of black bryony,
cowbane, deadly nightshade, deathcap.
Yet I prescribed for him
as if he were my brother.

Later that night I must have slept
on my arm: momentarily
my right hand lost its cunning.

Commentary

“Sometimes it’s very difficult to like some patients. Patients imagine that they’re always likable, but in fact there are some one has great difficulty with, I think. And indeed there was one patient that bugged me so sufficiently that I wrote two poems about him.”

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

As The Ghost Road begins, Prior has been cured of shell shock and is preparing to return to the front in France. Rivers takes care of his patients and his invalid sister, amid memories of his experience ten years earlier on an anthropological expedition to Melanesia (Eddystone Island). He befriended Nijiru, the local priest-healer who took Rivers on his rounds to see sick villagers and also to the island’s sacred Place of the Skulls.

Rivers entertains very un-British thoughts about the morality of these headhunting people, and about the power of symbolic healing. As these thoughts intrude upon his consciousness, Rivers is himself in the process of curing by suggestion a soldier with hysterical paralysis. Meanwhile, Billy Prior returns to the front. It is the autumn of 1918 and the last inhuman spasms of the war are in progress. In a futile battle that takes place a few days before the Armistice, Billy and his friend Wilfred Owen are killed.

To me The Ghost Road, which won the Booker Prize in 1995, is the most gripping and fastest paced of Pat Barker’s trilogy. The first two novels are Regeneration (1991) and The Eye in the Door (1993). As W. H. R. Rivers reflects on the culture of death on Eddystone Island, World War I, a culmination of the culture of death in Europe, grinds to a close, taking with it the poet Wilfred Owen. Of course, the characters in The Ghost Road are unaware of the new heights (or depths) that the culture of death will attain later in the 20th Century.

The Ghost Road
Pat Barker
Dutton, 1995
New York, 256 pages

Web image by  Claudio Carrozzo 

Mental Cases by Wilfred Owen

Carol Donley Aug 11, 2025

Owen’s stark poem portrays shell-shocked soldiers haunted by war, exposing both their torment and society’s complicity in their suffering.

Kaplan shares nostalgic memories about a time when she still had the luxury of not having to worry about a patient’s insurance coverage. In an essay about anatomy lab in medical school she conjures up the surrealistic experience of being forced into intimacy with three strangers around a cadaver: “The four of us don’t know each other well. By the end of the semester, we will…We won’t ask the ordinary questions of each other that people do on the way to friendship, like where we grew up and what we like to eat” (p. 9) Since Dr. Kaplan and I were in the same medical school class this proved especially poignant for this reviewer to read.  

Kaplan’s recollection of being proposed to by her husband while working a shift in the hospital is charming and hilarious:” ‘Look, you better talk fast,’ I told him. ‘One patient is bleeding out, and another might need a balloon pump.’ I thought for a split second about how absurd my situation was. I was standing in a closet with my boyfriend while people were dying just outside the door…Ask me to marry you.’ ‘Larry, this isn’t funny. I have to go. Mr. B is exsanguinating.’” (p.37). 

Even in the halcyon days of her training Kaplan encounters obstacles. At an interview for one of her top medical school choices, she is criticized about her views on abortion. She leaves discouraged and ends up going to another program.  

Later, during Kaplan’s residency, she is traumatized when a male resident makes lewd, vicious comments to her. Her humiliation is compounded by being dismissed by her male supervisors: “What did you do to get him so angry?” (p.58), and “it’s your word against his” (p. 60). It is clear “the Old Boys Network still has its hold over medicine” (p. 68).  

Yet there are also women doctors who might have been role models for Kaplan and were not. In an essay entitled “Detach,” she asks if one has “to detach in order to care for sick patients? …What doesn’t make sense to me is to push feelings aside permanently, to sweep them away as though they don’t exist” (p. 191). She tells of an oncologist, “a middle-aged woman with long, frizzy hair dyed pitch-black and frighteningly pale skin, [who] reminded me of Morticia Addams” (p.188). She calls “Morticia” for guidance but never hears back, and the patient rapidly goes downhill. When she cannot hide how she feels, she is given negative feedback: “you have to detach” (p.190).  

After residency, Kaplan contentedly treats patients in an old-fashioned, low-tech private practice for years, but eventually that becomes impossible: “We tried, but ultimately closed our doors…when we became aware we would soon have to choose between paying our staff, paying ourselves, and maintaining our computer hardware and software” (p. 141). She goes to work for a health system where the time she used to spend caring for patients is now taken up by writing electronic notes and getting authorizations. After years of selfless sacrifices for patients, she is shamed at being informed she must take “remedial compliance training” (p. 148). If this doesn’t work, she will be considered an “error prone provider.”  

Demoralized, Kaplan resigns from her position. Once she is no longer under the yoke of her job, Kaplan gains perspective and undergoes her personal healing process. She enters a program to get a Master of Fine Arts in writing, which she uses to teach in the humanities program at a medical school to help students “process the joys, sorrows, fears, and frustrations of medical training and practice” (p. 162), noting that “I still have something to give, and now I am getting nourished in return. Writing, my patients, and my students are healing me” (P. 164). She goes on to volunteer at a free clinic, a kind of utopia where she can give patients her undivided attention without limits on resources. Finally, in an act of poetic justice, she trains as a physician coach to become the kind of “confidante for other doctors” (p. 241) who have gone through burnout.  

In brief, this is a lovely book filled with insights gained from a long career.  

Still Healing  
Rosalind Kaplan, MD 
Minerva Rising Press, 2025, 253 pages 
https://minervarising.com/product/still-healing-by-rosalind-kaplan

Web photo by Cezar Sampaio

The place: a nondescript, ramshackle medical clinic located on the second floor of a large Chinese mall, located in the suburbs of Toronto, just north of the city, circa 2008. 

Our narrator, the protagonist, is a newly minted family physician, a Chinese Canadian who grew up not far from this neighbourhood. 

On this otherwise nondescript morning, I get into the office and find that the first patient of the day is already waiting for me. 

On my way into exam room eight, I grab the large patient file that sits in the file holder just outside the door. Many of these files are for longstanding patients of the clinic, and even though I’ve only been working at the clinic for just over a year now, I’ve basically inherited them and their problems from the doctors who worked shifts here before me. 

Inside the room are two middle aged Chinese men. One is a stocky, heavy built man in work clothes. Next to him is a clean-shaven man wearing a dress shirt and slacks. I vaguely recognize the larger man. I’ve definitely seen him before. I’m not sure who his friend is. 

The two men greet me enthusiastically. 

“Good morning doctor,” says the man I recognize. 

“Here, we bought you a cup of coffee,” says the other man. He points at a styrofoam cup of Chinese mall coffee that is sitting on my desk. 

I nod and smile. It occurs to me that it is odd that they are so friendly. But it won’t be the last odd thing to happen to me on this day. 

“What brings you in today?” I ask in Mandarin. I’ve gotten used to speaking Mandarin during the majority of my patient encounters at this clinic. In fact, I’ve spoken more Mandarin since I started this job than I have in the preceding ten years, maybe since childhood when I spent a year living in Taiwan. 

The man in the dress shirt speaks. “Do you remember filling out a life insurance application for him recently?” 

As he speaks, I open the manila folder and start flipping through the chart to orient myself. I do remember this chart. The patient, the blue-collar worker, is not a regular patient of mine. I’ve only seen him once or twice in the past over the last few months, for prescription refills, and a discussion about his hypertension. Most of the chart, years and years of doctor visits, predates me. 

A month or two earlier, a request came in from an insurance company, asking me to provide a letter documenting the patient’s medical record. Insurance companies use these records to determine if a patient should qualify for life insurance, or how much of a premium they should pay based on their pre-existing medical conditions. 

“Yes. I do remember filling this out for you.” It is starting to dawn on me what the purpose of this visit is. The problem here is that the patient has a long history of high blood pressure, and he’s been consistently noncompliant with his treatment. I flip further back through the chart. There are multiple records of high blood pressure readings over the years, and lists of medications that were prescribed that he never ended up taking. 

All of this was documented in the note that I sent back to the insurance company last month when they asked me for a record of the patient’s medical history. 

Now it’s the patient’s turn to speak. “I don’t understand why I didn’t qualify for insurance. I have no health problems. What did you write on the insurance application?” 

I brace myself. I know he won’t like the answer. “I didn’t write anything special. I just told them what happened at your doctor visits based on what is written in the chart.” 

“You told them that I have high blood pressure?” 

“You did have high blood pressure at the last visit.” I turn the notes to the page from the last visit. “Your blood pressure was 154/96 at the last visit.” 

“I don’t have high blood pressure. I feel fine.” 

Of course, the patient feels fine. Hypertension is a silent disease. Patients usually don’t feel anything. 

“Why don’t you check my blood pressure now? I’ll prove to you that I’m fine.” 

I can feel myself start to tense up. I’m not really sure how to extricate myself from this situation. I agree to check his blood pressure as a way to buy myself some time. 

I put his arm inside the blood pressure cuff and pump the cuff. I use the silence to think about what I should do next but there isn’t enough time. Nothing comes to me. 

Not surprisingly, the reading is elevated.  

“160/100” I report. I try not to sound too triumphant. “It’s still high.” 

The patient ponders this for a moment. 

The friend decides to try a different tack. “Doctor, my friend here is trying to apply for health insurance. Can you please help us out? “ 

“I’m not sure how I can help.” As I say this, I look up and notice once again, the styrofoam cup of coffee. Now I see the gift for what it is. A payout or a bribe. Either way, something dirty. 

“If you can just write a letter explaining that he is healthy and he doesn’t have these issues, we can take it to the insurance company. Please help us out.” 

I have to choose my words carefully here. It’s harder for me to do this in Mandarin and I wish I could speak English here. “I can’t do that. It’s in the file. I can’t change the record.” I open the file and show the two men. The patient has a long history of high blood pressure. It isn’t one reading, or one visit, but a pattern of high readings over many years. I try to explain this in as simple Mandarin as I can. 

“Really? All we need is just a letter, explaining that he is healthy.” 

For a moment, I’m tempted to write them a letter, just to get them out the door. But what purpose would it serve? There’s no way around the fact that the insurance company has already received my prior correspondence clearly documenting the high blood pressure readings. I can’t lie to them. I think about my medical license, my career, and the prospect of losing it all over a two-dollar styrofoam cup of coffee. 

I shake my head. “I can’t do it.” 

In medical school, we attend classes on how to conduct patient interviews. We’re taught ways to de-escalate angry patients who are upset about things like having waited too long in the waiting room. For patient visits that are spiraling out of control, we’re taught the importance of body language. If a visit is going nowhere, we’re taught to stand up and move towards the door. This will suggest to the patient that this discussion is coming to an end. So this is what I do. I get up and move towards the door. 

The patient and his friend look offended. “Why are you getting up? We’re not done talking.” 

I’m now feeling very edgy. Medical school didn’t teach me what to do in this situation. A pit is forming in the bottom of my stomach. My sympathetic nervous system has kicked into overdrive. 

“I don’t have anything more to say.” I manage to force out this sentence in slow, stilted Mandarin, but my stomach is churning. 

“Why can’t you help us?” 

“I didn’t say I can’t help you. But you’re asking me to do something I can’t do.” 

“You’re a doctor. A doctor is supposed to help people.” 

I’m lost for words now. I stare back at the patient, the gears in my brain spinning frantically but to no avail. 

“You call yourself a doctor? What kind of doctor are you?” 

In our training, we’re taught a formula of what to say to patients in this type of situation. If a total breakdown in communication with a patient occurs (I’m pretty sure when a patient is pressuring the doctor to do something illegal and unethical, this would be grounds for a total breakdown), we’re taught to say something along the lines of “I feel like we’re having a breakdown in the patient-physician relationship, and we cannot continue this way. It might be best if you find another doctor to try to help you.” Right. You try translating that sentence into Mandarin. You try translating that sentence when a large, Mandarin-speaking man is breathing down your neck and asking you what kind of doctor are you? 

I try to come up with that sentence, but all my years of spoken Mandarin at the dinner table with my parents, and two years of university level Chinese fail me in that moment. 

I’m trying to say that our relationship is breaking down, but what actually comes out of my mouth is this sentence: 

我不喜欢你的态度  

This translates roughly into “I do not like your attitude.” In hindsight, maybe the sentence sounds too much like how a parent might lecture their teenage son when said son refuses to take off his headphones to hear whatever lecture the parent is offering. Or maybe it’s simpler than that, that maybe nobody likes being told that they have an attitude problem. Or maybe it was just the moment. I’ll never know for sure. 

In the next instant, the patient leaps up and charges at me. 

Terrified, I bolt out of the room. Luckily, I am already at the door of the exam room and in an instant, I am down the corridor, with the patient hot on my heels. Near the end of the hall, a friend of mine, another doctor in the clinic, comes out of his room to see what the commotion is about, and manages to get between the patient and myself, giving me a moment to flee to the relative safety of the computer room in the back of the clinic. I shut the door behind me. 

Outside, I hear the ruckus continue. My friend and one of the receptionists are trying to talk the patient off the ledge while the patient is hurling epithets at me in Mandarin. As I stand there, my entire future career flashes before my eyes. I tell myself this: if he makes it into the room, do not throw the first punch under any circumstances. But if he throws the first punch, then what? 

Over the years, I’ve been asked many times what it’s like working almost entirely with Chinese patients in a language that isn’t my native tongue. I’ve even given talks to the Medical Mandarin club at the University of Toronto about how to conduct medical interviews in Mandarin, and I have a few prepared answers for the students. But the full truth is too hard to explain. Only this incident can explain it. 

The truth is that I speak Mandarin well for a Chinese-born Canadian but compared to a native speaker, I am only just getting by. I can order food at a restaurant. I can understand television dramas from China and Taiwan. I can even haggle with a salesperson over the price of a speaker system if need be. 

In time, my medical Mandarin has improved too. When I started, I only knew a few medical catchphrases that my parents spoke at home. I knew how to say, “Hepatitis B” and “cholesterol” and “blood sugar.” The rest of the terms, I gradually learned from my patients over the years, as we talked about erectile dysfunction, menopause, thyroids, and everything else under the sun. 

All of this is great for my vocabulary, but the truth is that anyone can order dishes off a menu if they practice enough times, and the rote conversations that fill Mandarin textbooks and audio Mandarin lessons can be memorized and rehearsed until one can fool most people into thinking one is proficient. What I’ve learned about languages from medicine, and most specifically, through this incident, is that true mastery of a language should also include being able to nimbly think up an intelligent, appropriate response when one is under emotional pressure. 

Thankfully, this scenario doesn’t occur that often. In the years since, I’ve had to teach myself to be very, very careful when having emotionally charged conversations. And over time, I learned a technique that I could deploy now if necessary. If a situation like this encounter were to recur in the future, I would stick to English to avoid miscommunication and to retain control of the conversation.  

Fortunately, the office manager managed to talk the patient into calming down and the door to the computer room was not barged through, and there were no fisticuffs. It was, to date, the closest I’ve ever come to physical blows in my adult life. The patient had initially demanded that I come out and apologize, and insisted they would wait outside the office until I reappeared. But eventually, the manager explained to the patient that if he kept on threatening the office, we might just have to call the police. 

As for me, for a few weeks thereafter, I thought twice about walking down the long corridor to the underground parking lot alone, but time passed and eventually this incident moved out of the forefront of my mind and life went on. I never saw the patient or his friend again. 

Web Image by Brando Makes Branding

Additional Chapters from A Chinese City Doctor’s Notebook

When Your Body Isn’t Yours 

01.12.26 783

From Tigers to Otaku

09.16.25 1655

The Happiest Couple

07.28.25 1398

The Things We Don’t Talk About When We Talk About Dying 

05.13.25 1975

One Patient, Two Systems 

02.24.25 2658

One of the most successful patient-artists was Auguste Forestier, hospitalized at Saint-Alban at the age of 27 after placing pebbles on a train track and causing a train to derail.  After his discharge from treatment, Forestier remained at Saint-Alban for the rest of his life, where he worked in the kitchen. He began to create toys for the children of hospital employees using discarded materials, even butcher’s bones.  In this exhibition we see not only a boat created by Forestier from scraps of wood but also a print of Tosquelles proudly holding up one of Forestier’s boats.  

The work of Saint-Alban artists came to the attention of French artist Jean Dubuffet, who, after reading the 1922 book Art of the Insane, had founded the Art Brut (also known as Outsider Art) movement.  Dubuffet’s attempts to collect it were at first greeted with skepticism by Tosquelles.  However, the success of Forestier (eventually he even came to the attention of Picasso) was such that the profits from his work were used to help fund the hospital.   

At its previous venues in Europe (the show originated in Barcelona) a larger number of pieces from Saint-Alban were displayed.  At its US venue, the show has been augmented with work from American asylums, which prove to be a highlight of the exhibition.  Even without a Tosquelles to inspire them, these patients created beautiful and fascinating art.  

We see, for example, a coat made by Myrllen, a schizophrenic patient from Tennessee.  The patient had reportedly worsened in response to such few treatments as were available at the time.  In desperation, she was given discarded rags and threads.  What she produced gives us a window into her condition, with strange words and figures whose meaning was known only to her.  Ironically, after making several such pieces the patient lost her creative impulse and stopped sewing once put on Thorazine, the first antipsychotic medication.   

Another piece, a watercolor entitled “An Antarctic Scenery,” is one of the earliest known American asylum paintings (c. 1816).  The patient-artist, Richard Nisbett, in his paranoid imagination has chosen to depict “a fleet of murtherous Pirates” invading Antarctica. Nisbett was a patient at Pennsylvania Hospital in Philadelphia under the treatment of none other than Benjamin Rush, often considered to be the father of American psychiatry.  

Although the exhibition closes in August, a book (which will be for sale at the Museum and online) is expected to be released in November 2024.  The link to a virtual conversation with the show’s curators is given here:  https://www.youtube.com/watch?v=s9j3fMn0xJA (1 hour 19 minutes).

Francesc Tosquelles is frequently mentioned in The Rebel’s Clinic, by Adam Shatz,  a recent biography of the psychiatrist, Frantz Fanon.

A Tosquelles Glossary from the Barcelona exhibition is also a helpful tool: https://www.cccb.org/en/exhibitions/guide/francesc-tosquelles/237849 

Illustrations: 

Auguste Forestier (1887–1958, France) Untitled (Boat), 1935–1949, Wood, fabric, metal, leather, nail, 29 1/2 x 45 1/4 x 9 1/2 in. Centre Pompidou, Paris, Musée national d’art moderne/Centre de création industrielle, ART BRUT/Gift of Bruno Decharme in 2021, AM 2022-43. 

Romain Vigouroux (active mid-20th century, France), Francesc Tosquelles on the Roof of a Building at the Saint-Alban Psychiatric Hospital, Holding a Sculpture by Auguste Forestier, 1947, Gelatin silver print, 7 x 4 7/8 in Collection Family Ou-Rabah Tosquelles. 

Richard Nisbett (1753 England-1823, United States) An Antarctic Scenery, 1816, watercolor.  Collection of The Library Company of Philadelphia.  

American Folk Art Museum  
Lincoln Square, New York, NY 10023
Folkartmuseum.org

“Should we worry about the reliability of medical knowledge?” asks philosopher John Huss (University of Akron). We consider this question from the perspective of Thomas Kuhn’s classic, 1962 book, The Structure of Scientific Revolutions. Kuhn explains how science does not evolve incrementally, one step following another, but rather undergoes wholesale revolutions disconnected from all that came before. He called these revolutions, “paradigm shifts” (to his everlasting regret). While Kuhn draws mostly from astronomy to make his case, we draw from recent and past medical examples to show how his concept applies to medicine as well. We talk about how various groups dependent on reliable medical knowledge (e.g., patients, health care professionals, educators) can be affected by the possibility of major shifts in established approaches to health care at any time. There’s no escape from reality, as the song goes.

Primary Source Citation
Kuhn T. The Structure of Scientific Revolutions, 3rd ed, Chicago: The University of Chicago Press; 1996.

Links
Russell Teagarden’s related blog posts on According to the Arts:
-Kuhn’s book, The Structure of Scientific Revolution
-Michel Foucault’s book, The Birth of the Clinic

Dr. Barry Marshall’s story of how he and Dr. Robin Warren engineered the change in peptic ulcer disease from acid based to infection based.
The Clinic & The Person Episode 12 (September, 2023), featuring the paradigm shift from lobotomies and other forms of psychosurgery to psychopharmacology.
Sir Brian May’s bio (guitarist for Queen and PhD-level astrophysicist).

The Clinic & The Person is a podcast developed by our editor Russell Teagarden to summon or quicken the attention of health care professionals, their educators, researchers and others to the interests and plights of people with specific health problems aided through knowledge and perspectives the humanities provide.

Feature photo by National Cancer Institute

Born in Berlin to a Jewish father and a Christian mother, Harry Benjamin (1885-1986) became a physician in 1912 at a time when German physiology and medicine had much to celebrate. He ended his days in New York City more than a century later, a much lauded, if controversial founder of the entirely new field of transgender medicine. The path was not easy as his own transitions were often painfully turbulent: bullied as a schoolboy for being neither Jew nor Christian, shunned in wartime America for being German, accused of quackery for being an advocate of glandular therapy. And he transited the Atlantic many times always both at home and alien on two continents. Nevertheless, he kept his faith in the miraculous effects of hormones and held fast to an undiminished will to help people live happier lives. 

Using intimate diaries, letters, and interviews in both German and English, Alison Li has written a sensitive, insightful biography that not only traces this remarkable life, but also tracks the birth of endocrinology and the advent of an unprecedented discursive consciousness that challenged social norms. Her earlier biography of J.B. Collip, biochemist of insulin fame, provided her with extensive knowledge of emerging hormones; she handles the technicalities with deft, accessible prose.  

From witnessing the “resurrection” of a moribund patient with dried thyroid medication, Benjamin was captivated by the potential of hormones to bring even the sickest of people to perfect health. Initially intent on the rejuvenating possibilities, he thought of his work as “gerontotherapy” –treatment of the elderly – not so much to live longer but to live better. He became a devoté of Eugen Steinach and his procedure – which aimed to enhance hormone production of the gonads by suppression (through X-irradiation) of their competing elaboration of eggs or sperm. As the female and male hormones became commercially available as pills, they were added to the protocol. Inevitable slippage led to equating (or reducing) these goals to enhancing sexual prowess and attractiveness. 

Along the way, Benjamin encountered many prominent figures, and we read their impressions of each other. Havelock Ellis, Alfred Kinsey, Robert Masters, and Robert A. Wilson make appearances. The semi-autobiographical novel Black Oxen (1923) of his ever-loyal Californian patient, Gertrude Atherton, proclaimed the power of glandular therapy to a wide public and cemented Benjamin’s reputation for dealing with problems of sexuality. From listening carefully to each patient, he realized that the socially pervasive male/female binary failed to reflect individual identifications and orientations; gender was not a duality but a spectrum. Language had to evolve too and that is another theme of the book.  

Married to a much younger woman, Benjamin consulted Sigmund Freud when his desire for her waned; however, thinking of himself as a courtly ladies’ man, he was offended by Freud’s suggestion that he could be a latent homosexual. The experience conditioned his mistrust of psychoanalysis. Choosing physiology over psychology, both men, we learn, underwent Steinach’s treatment.  

With an office in New York City and later a satellite in San Francisco, Benjamin moved in a heady circle of artists, writers, politicians, and intellectuals—striving to find comfort in their own identities. He viewed the source of what became gender dysphoria as something biological.  Instead of fixing the mind, he sought to repair bodies to match minds. For some, peace came from simply living as one of the opposite sex, for others it was hormones, and eventually, for some, it was surgery. Benjamin befriended Christine Jorgensen and collaborated with a few surgeons willing –even eager–to develop operative interventions that resulted in physical sex change. After their transition, he continued to follow his patients to understand if and how the procedures had helped their quality of life. 

Always in private practice, never associated with academe except through research organizations of his own creation, Benjamin was dismayed by how his work was shunned by the medical establishment. From 1929 to 1935, he waged a lengthy lawsuit against Morris Fishbein the crusty leader of the American Medical Association for having disparaged him and his work. Benjamin wanted a retraction and an opportunity to explain in the pages of JAMA how his treatments were based in scientific research. He never got it. 

Nevertheless, at the end of his long career Benjamin witnessed the establishment of gender identity clinics at universities beginning with John Hopkins University and extending to some twenty sites by the late 1970s. He also witnessed their numerous closures in the 1980s as a struggle was waged between those who saw gender dysphoria as a mental illness– not deserving of physical intervention, and those who followed Benjamin’s pragmatic, biological approach.   

With curiosity and tolerance, Li probes the convoluted path of Benjamin’s career. She recreates the atmospheric ambience of exotic pre-war Berlin and the heady optimism of post-war America. She privileges the stories and perspectives of well-known trans people –Renée Richards, Reid Erickson, Jan Morris and many others. Without defensiveness, she presents the current criticisms of Benjamin and his so-called “standards” that had been generated to guide the medical approach to people with gender dysphoria. She treats the critics with the same attentive balance and consideration that Benjamin gave to his patients.  

As a physician, Benjamin could scarcely formulate solutions to the distress of those who sought his help in any way other than through a disease model. His efforts brought their plight out of the shadows of deviance and crime to the attention of well-intentioned minds who applied pills and procedures to serve their complex needs, empowering them to live openly, and enabling them to eventually reject the disease model entirely. Trans is diversity—one of many to populate the postmodern world. This is a very good book. 

Wondrous Transformations: A Maverick Physician, the Science of Hormones and the Birth of the Transgender Revolution   
Alison Li
Chapel Hill NC: University of North Carolina Press, 2023 

https://uncpress.org/book/9781469674858/wondrous-transformations
https://alisonli.com

Rearranged by Kathleen Watt is subtitled “An Opera Singer’s Facial Cancer and Life Tranposed.”  At the outset of the book, the author feels on top of the world.  She can hardly believe she has the opportunity, as a member of the Metropolitan Opera Extra Chorus, to share the stage with some of her biggest idols.  She has a wonderful partner and a warm and close family. 

Then, one day, Watt discovers a bump in her mouth.  She is found to have a rare and aggressive oral cancer that is “breathtakingly tailored to obliterate my profession and my raison d’être, never mind my face” (p. 51).  She undergoes multiple reconstructive surgeries, some of which are unsuccessful or become infected.   While she is initially reassured she will be able to sing again in a few months, that goal proves unrealistic.  Watt’s partner is emotionally supportive for years, but even for her there is a limit.  When the author is unable to pull her own weight financially and develops an addiction to alcohol, the relationship unravels. 

The greater part of Rearranged chronicles Watt’s medical ordeals. Previously an active and productive person, she is now at the whim of her doctors’ schedules.  She gives up all hope of performing again. As anyone who has experienced an illness or the illness of a loved one knows, navigating the health care system can easily become a full-time job.   

The book ends optimistically as Watt’s condition stabilizes. She realizes she is lucky to be alive and accepts her “rearranged” looks.  She reconciles herself to a future where she will “henceforth sing mostly for myself “(p. 304), and redefines herself as a writer specializing in the performing arts. 

Rearranged is a book which teaches valuable lessons.  Watt endures extreme hardship, has her dreams shattered, and acquires wisdom that will benefit providers and patients.    

One lesson learned is that unempathic caregivers may compound a patient’s suffering.  “A multi-gigging freelancer with catastrophic coverage at best” (p. 31), the author has a miscommunication with an endodontist and is threatened with a lawsuit for presumed nonpayment.   And when she dares to question another doctor, he snaps at her: “Ha, ha!  I’m not going to teach you surgery” (p. 57).  Fortunately, other providers have a manner that is more conducive to healing: “Because he [the doctor] conveyed neither arrogance nor impatience, his confident command allowed me to trust him easily.  And at that moment, nothing mattered more to my successful outcome” (p. 55), and “Alone among my doctors, he had thought to lament my loss.  A helium cloud filled me at this simple expression of kindness.  Nothing at that moment could have been more restorative” (p.108).    

One can understand how traumatic it must be to have one’s facial features distorted as the result of illness.  For a singer it can be career-ending, not only because she needs to show her face to the public but because the vocal cavity may be damaged.  But, beyond this, because “the face is the single most important organ of human communication” (p.105), the author feels she has lost her identity: “I felt as bereft of myself as I was of my voice…I missed seeing my reflection in the faces of others.  I began to lose track of my own subtexts, and myself” (p.237)    

The author relates a vivid and frightening memory of experiencing post-operative delirium (sometimes called ICU psychosis). When she comes out of surgery and suddenly realizes she cannot talk because she has had a tracheotomy, she pounds on the wall.  She wishes she had had “healthy people to paste accurate information alongside my cockeyed perception, so I could avoid drawing mistaken conclusions from my misperceptions” (p.146).  Instead, she overhears attendants saying “Boy, she’s really out of it” (p. 149) and referring to her as “a royal bitch” (p.140).  At no time does anyone think to help “confirm her sanity, quell her fears” (p. 150).  Hopefully, health care professionals will read this and think about it the next time they see a patient right out of the OR.    

In closing, it bears mentioning that at one point Kathleen Watt consults with surgeon Iain Hutchison in London.  Hutchison is the initiator and sponsor of the Saving Faces Art Project, a series of paintings by artist Mark Gilbert which “portray the faces of patients before, after and in some cases actually during their surgery for injury, deformity or cancer” and whose purpose is to “communicate the strength of spirit which can enable people with facial disfigurements and trauma to lead full and happy lives.” (from https://savingfaces.co.uk/our-mission/art-project/ )  Likewise, the author of Rearranged inspires the reader by her strength of spirit in the face of inconceivable adversity. 

REARRANGED
An Opera Singer’s Facial Cancer And Life Transposed
Heliotrope Books, New York, 2023   
384 pages 

Kathleen Watt’s website: kathleenwatt.com

We draw from two short stories published long ago, but recently discovered, that help us discern whether current problems associated with professionalism in health care and access to health care are unique to our time, or whether they have always been with us in one form or another. One of the stories is Anton Chekhov’s At the Pharmacy, written in 1885 and found in the late 1990s, and the other story is Raymond Chandler’s It’s All Right – He Only Died, written in the late 1950s and found in 2017. A throughline from these stories led us to the classic, 1978 satirical novel, The House of God, by Samuel Shem. We consider its importance to health care professionalism at the time—including our own professional behavior—and whether its influence persists. We conclude musing about how the perspectives these sources offer can be used in modern-day health care.

After the podcast was released, the New York Times published an investigative report  concerning the operation of the New York University emergency department on December 22, 2022 indicating that what Chandler described in his short story is still in practice. And a Kaiser Family Foundation report published on December 21, 2022 concerning the policies and practices many individual hospitals apply in collecting money their patients owe them shows how the issues raised in Chekhov’s story still exist.

Links:
See Russell Teagarden’s blog postings at According to the Arts for further analysis of the short stories featured in this podcast, At the Pharmacy (Chekhov) and It’s All Right – He Only Died (Chandler).
At the Pharmacy is included in the anthology, The Undiscovered Chekhov: Thirty-Eight New Stories, as is the story of how the translator, Peter Constantine, found these unpublished works more than a century after they were written. An online version of At the Pharmacy is published in the weekly newsletter, Falltide.
It’s All Right – He Only Died, was published in The Strand Magazine, along with the story of its discovery sixty years after it was first written.
The version of The House of God we referenced in the podcast is the Berkley trade paperback edition, 2010.

The Clinic & The Person is a podcast developed by our editor Russell Teagarden to summon or quicken the attention of health care professionals, their educators, researchers and others to the interests and plights of people with specific health problems aided through knowledge and perspectives the humanities provide.

Feature image by Hush Naidoo