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The Left Atrium
Difficult journeys
Cancer stories: on life and suffering
This is a disturbing book that took courage to write. The first chapters present an overview of cancer and the difference between the science and the humanity of cancer care. Do we really understand what people with cancer are living through, or do we let them suffer in silence? The authors challenge us as health care professionals to examine whether we attend to the suffering of our patients or hide behind science instead.
The body of the book narrates the stories of five people who were interviewed by David Gregory at weekly intervals for up to six months. All five "wanted their stories shared with others"; they "wanted their encounters with cancer to matter." Following each narrative is a section presenting the "practical knowledge embedded in experience." To health care professionals, these sections demonstrate that "not all suffering can be treated with a pill, a tonic, or a counselling session." And, more universally, "the experiential knowledge uncovered in each of the narratives can prepare us to live more fully with advanced cancer, should cancer enter our lives or the lives of those we love."
Courage is central to these testimonies. It took courage for these people to allow themselves to be accompanied on their journey, to allow themselves to be vulnerable and reveal their innermost hopes and fears. Their suffering is not glossed over, but is conveyed in such a way that the reader cannot be unmoved. I read the entire five stories in one day. As I read each one, I needed to go on. The reflection I was seeing of the health care system was a hard one to accept. I realized that I needed to find some redemption for the health care providers depicted in these accounts. With each new story my hopes would rise, only to be disappointed. John's story, the last of the five, left me angry and numb. John was a difficult man whose challenging personality made it especially difficult for him to live with a disease that was destroying him physically, emotionally and spiritually. Admittedly, some of the things that happened to him were the consequence of his manner of interacting with others. We all know that such a devastating journey can bring out the worst in people as they resort to whatever coping strategies they have. Instead of finding an empathetic system, one that attempted to understand him and to draw alongside him, we hear how the system abandoned him at the very time he needed help most.
In contrast to the depth of emotion and the reality of lived experience expressed in the narratives, the sections on lessons learned are very practical. They contain a combination of science and experience that attempts to set out some guideposts, suggestions that may help to make the cancer journey easier. Tellingly, many of the suggestions are about how to navigate through the health care system, so that one is heard and one's needs are met. As soon as the science is put back in, the tone of the book shifts. No longer close and personal, it takes a step back and becomes more objective. This made me realize why most of us would rather stay in the domain of science and leave it for others to attend to the suffering.
The authors challenge us to look at the language and images that surround cancer. Patients are given messages of coping, hope and survival, as in the slogan, "Cancer can be beaten." They are told that it is important to take control, to look and feel good. But for those whose experience does not fit into this framework, suffering can be compounded by a sense of failure. The reality is that suffering occurs regardless of the outcome.
For the five people whose stories are told in this book, suffering occurred because of the nature of cancer itself, difficulties with intimate relationships and encounters within the health care system. Their experiences challenge us to examine how we do our work. Do we add to the suffering of those we are attempting to care for? Are we "interested in [our] patient's spiritual and emotional lives as well as their medical histories"? Are we "able to hear a patient's fears about dying?" Are we willing to listen, knowing we have no answers? These things require "a high degree of spiritual maturity."
This book achieves its goal of "giving voice" to those who have died with cancer. As a palliative care physician, I became much more aware of the extent of the suffering experienced by people living with cancer. This is a book that should be read by everyone who encounters cancer in his or her life. It is a book that takes courage to read, but it is well worth the effort.
Janice Mulder
Exploratory surgery
The mysteries within: a surgeon reflects
Sherwin B. Nuland's latest nonfiction work, The Mysteries Within: A Surgeon Reflects on Medical Myths is an informative and entertaining chronicle of Western medicine as reflected in the science and mythology of five internal organs: the stomach, liver, spleen, heart and uterus. From the "mystical musings" of Babylonian times to the "ultramicroscopic manifestations" of today, Nuland offers a thoughtful guide to "the journey that superstition, religion, and medicine have taken in one another's company." In so doing he traverses two geographies: the landscape of the body and the landscape of scientific thought.
Nuland's impulse to frame the book with his own experiences in the operating room heightens the reader's interest in the legend and lore surrounding each of the organs that he confronts as a surgeon. Sometimes, however, his anecdotes are almost too good. Although the historical chapters are filled with drama, interesting personalities and lively analyses, they are not as gripping as the introductory tales. One has to resist the urge to flip to the next dramatic scene from the operating room.
The historical sections require some concentration, but Nuland rewards the reader with his gentle wit and conversational tone. One of the strengths of the book is the author's ability to present historical events and scientific facts in an accessible manner. From Galen, to Aristotle, to Harvey, he relates in the context of particular organs the contributions, errors and beliefs of some of the greatest movers and shakers in the history of medicine. Throughout, he reiterates his thesis that, although humankind has often resorted to mystical and supernatural explanations of biologic phenomena, the foundation of Western medicine is critical thought, skepticism and reason.
Historically, medicine's journey has been coloured by "mysticism, magical thinking, superstition, philosophy, religion, authority, rationalistic patterns of thought, preconception, misapprehension of the criteria for evidence, ambition, and ... deceit." Early conceptions of the structure and function of organs, he explains, was based on the theory of humours, and explanations of biologic processes relied on notions of "spiritual and other non-verifiable energies." It wasn't until the 16th and 17th centuries that the scientific method of experiment and observation finally began to be practised and, in some manner, instituted. Nuland traces the shift within science from attempting to explain the functioning of all living things with a unified theory (with divinity at its core) toward making small observations and small claims without necessarily putting divinity at the centre. This shift, Nuland argues, is the basis for the progress of Western medicine.
Nuland has spent a lifetime occupied with both the immediate, visceral reality of the internal organs and the more distant, theoretical contemplation of their history. One senses that he is engaged with his subject with both his head and his heart. Indeed, it is his descriptions of the heart that best convey the spirit of the book: I have never lost that awe. It remains with me in spite of all I have since learned of the heart's nuts and bolts and valves and cords — not to mention its flows and its fluid forces, its electricity and its chemical influences. I know them and know also the heart's weaknesses just as well as I do any other part of this human body of ours that I have never stopped studying since those youthful days. And yet, the thorough familiarity with cardiac anatomy and physiology — and romance and breakability — has not lessened by an iota the spell cast on me when I first gazed at it that day in the laboratory.
One appreciates the range of Nuland's intellectual curiosity as he roams through literature, religion, metaphysics, science and history to assemble a story for each organ. To take again the example of the heart, he moves from discussing this organ in the context of the Talmudic Midrash Rabbah, to Homer's Iliad, Shakespeare's The Merchant of Venice and an account by a 16th-century French battlefield surgeon.
Nuland is skeptical and critical, but he retains a sufficient sense of wonder for his subject matter to create a book that synthesizes his experience with the human body. Anyone interested in the history of medicine and organ folklore will enjoy this work. In the future, however, one hopes Nuland will venture farther into the area that is the true foundation of this book: the operating-room stories of his encounters with patients, colleagues and, most important, organs.
Punam Mony Singh
Room for a view Parallax
When my father was in his 30s, he left his homeland and immigrated to America; when I was 30 I immigrated to Canada. He and my mother had three children together; my wife and I have three also. He was a physician; I am a physician. He died of cancer at age 64; I was diagnosed with lymphoma at age 54.
After my father died the New York Times published his obituary. The hospital where he had directed a tumour clinic for 25 years put up a plaque in his memory. Such was his fame as a radiation therapist that for about a year after his death we received condolences from around the world.
When I was still in medical school my father developed bowel cancer, and I wondered whether his occupational exposure to radiation was a factor. He came from the school where cancer patients were not told about their diagnosis. Issues of grieving and the work of Elizabeth Kubler-Ross were not current at the time. He knew, of course, exactly what was happening to him, but his denial was so strong that neither I nor the rest of the family could talk to him about his impending demise. Instead, he would talk about getting better, tell old stories about his struggles and accomplishments and do crossword puzzles. I found it hard to play along, but I felt I had no choice.
My father and I would often talk about my medical studies. I would try to describe some exciting concept or experience, but he rarely listened. Rather, I would end up hearing for the umteenth time about his experiences at his German medical school. Evidently, these experiences were more interesting or important than mine.
I began to resent his need to impress me with his achievements and his need to undervalue my own.
His death came during my last year in medical school. I felt cheated and angry that he would not be there to celebrate my graduation. I almost convinced myself that he had died rather than acknowledge my accomplishment. But these thoughts were soon pushed aside. I was newly married. I had a gruelling internship to complete, and then a two-year military obligation. I had no time to grieve or to examine my feelings. And so life continued. The next 10 years, as I recall them, were stressful, but happy and fulfilling.
Then I decided to enter psychiatry. One requirement of my training was to be involved in personal therapy; this included a 2-week course in psychodrama. Although I wanted to learn the techniques, I was expected to be a participant and learn from my own life experience. After a week of observing and assisting with other peoples' "dramas," I was finally triggered to work on my own "unfinished business." In an arduous five-hour session the therapist–trainers helped me to deal with my unresolved grief for my father.
I had always looked at my relationship with my father from my own perspective, a vantage-point from which I felt anger and self-pity. I was asked at the workshop to play the role of my father, to better understand his perspective. In one scene I acted the part of my father lying in a hospital bed, talking to the son who would soon graduate from medical school. I knew I was dying and would never have the pleasure of attending his graduation. I talked about my feelings, and cried with my son about our mutual frustration and grief. I was able to listen to him tell me how the graduation went and how his life evolved in the ensuing years. He told me about his psychiatry training, his marriage and the two children I would never meet. In this way, father and son came to an understanding, and the scene resolved in a long, wonderful hug. I was finally able to be the father my son needed.
It was an experience that profoundly influenced my future life. I could finally forgive my father and remember him with love. I could finally forgive myself. My own experience with cancer has been so different. I have been able to grieve more openly with my own children, and I have attempted to remain in the present. I appreciate more deeply what my father must have gone through and, even at this distance of time, feel closer to him. The world may have forgotten him, but I have not.
Peter Uhlmann
Lifeworks Caught looking Recently the Beaverbrook Art Gallery in Fredericton acquired a major work by one of Canada's most important artistic exports of the 1990s, Geneviève Cadieux. Rubis (1993), a photographic diptych, juxtaposes the bare back of the artist's mother on one panel against an enlargement of cancer cells on the other. At over 2.5 × 3.5 metres, Rubis is gigantic, which is a signature technique of Cadieux's: the monstrous scale "makes strange" its subject. This cinematic mode of exhibition, though, is very much of its time, and many of the most successful artists of the 90s tended to work large.
A decade or two ago, when "sculpture" was usurped by "installation" and "aesthetics" was hung up in the old boy's club to make way for psychoanalysis and semiology, Canadian artists were especially well placed to make their mark in the international art scene. Canada had a sophisticated (if modest) structure of arts funding and a network of noncommercial artist-run centres unrivalled anywhere else in the world. Also, the proliferation of postgraduate degrees in fine arts across the country produced and supported an intensely intellectualized artistic atmosphere that exactly matched the mood on the international circuit.
In 1987 Cadieux exhibited a large diptych entitled La blessure d'une cicatrice ou Les Anges by setting it on the gallery floor, leaning against a wall. La blessure pressed a lot of buttons by refusing its pedigree as either painting or sculpture. Its provisional installation provoked viewers to imagine for themselves how they might have displayed it. But, quite apart from playing games with the institutional boundaries of objects and spaces, it was the juxtaposition of subjects, and their literal effacement, that so enticed critics. An image of Saint-Exupéry's Little Prince (the face erased, but still striking a pose of masterful self-confidence) was set beside a 19th-century photograph of an anonymous female prostitute (back toward the camera, and drawing a butterfly on the wall). What was brilliant about this piece was how it evoked so many contemporary analyses pertaining to power and patriarchy and at the same time generated its meanings ambiguously, poetically. More to the point: it was big, smart and sexy.
As feminism gained entrance into the mainstream, intellectual debate shifted from the nature of political constructions to the construction of the subject. ("Boys read Marx and girls read Freud," I learned in graduate school, but these two heroes of the artistic academy really signalled the old and the new guard.) Artists abandoned the old ideological critiques of the museum and set out to explore the social and cultural production of subjecthoods. At the same time, the rapid escalation of technological consumption, the spectre of cybernetic utopias and AIDS ushered in wide-ranging discussions and representations of "the body." The late 20th-century obsession with rippling muscles and fat reduction notwithstanding, artists tended to focus on the body-in-pain and to brood about its demise, not sing its glories. For a time, it seemed as if art-supply stores would have to burn their stocks of oil paint and plaster to make way for blood, excrement, semen and toenails.
These discourses start to sketch a historical backdrop for Rubis, a beautiful piece that revels in its own perversity. The title refers to the colour of the cells, and ultimately to the abstract beauty of the microscopic image. This seems innocent enough, and the syntax of the two panels isn't difficult to grasp. It's like a photograph with a caption: "This back is diseased." The rub comes when your gaze veers away from the all-too-human, monochromatic back and indulges in the exquisite abstraction of the cancer. In the end, it catches you looking, and there's nothing innocent about that.
Marcus Miller
Copyright 2000 Canadian Medical Association or its licensors |
My father wanted one of his sons to follow in his footsteps, much as he had emulated his Uncle Gustav in Germany. My two older brothers, following their own lights, failed to pick up this torch. It was left to me to fulfil my father's dream. Actually, at the time I graduated from high school there seemed to be few career options: I could study medicine, law or engineering — unless I wanted to join the military or pump gas. I must admit that I enjoyed medical school and the practice of medicine, but my choice was strongly influenced by my father.
