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Book Review: The Way We Die Now

28 Jun, 16 | by cquigley




Seamus O’Mahony, The Way We Die Now. Head of Zeus, 2016.


Reviewed by Richard Smith


Perhaps the first and most important thing to say about this book is that it’s a joy to read. I started it on a flight from Dhaka to Mexico City when I was exhausted, but quickly I was deeply engaged and read it for the last two hours of the flight. When I was eating alone I chose it rather than my E M Forster novel. “But isn’t it depressing?” asked a friend. “Not at all,” I answered, “it’s a joy.” Most books a medical journal sends you to review may be packed with wisdom, but they are a labour not a joy to read. (I might add, as a committed Kindle reader, that the book is also physically beautiful, even including a ribbon as a bookmark, a splendidly old fashioned delight.)

Seamus O’Mahony has written the book using his own extensive experience of people dying in acute hospitals and the experiences of friends and family, but the best parts of the book may be his critical accounts of thinkers—like Phillipe Ariès and Ivan Illich—who have gone before and his witty analysis of the deaths of various celebrities, including Susan Sontag and Christopher Hitchens, both sceptics who fought death beyond what was sensible.

I hope that when I die that I have a doctor like O’Mahony to look after me, a doctor who is deeply conscious of the many failings of medicine and his own fragility. He tries all he can to avoid The Lie, giving the false impression that a dying person is not dying, and he calls together patient, relatives, and nurses to have the Difficult Conversation, the discussion when he tells patients that they are going to die. “It is much easier,” he writes, “in the middle of a busy clinic, to order another scan than to have the Difficult Conversation.” And “The entire modern hospital system conspires against those doctors willing to have this dialogue: the relatives, the chaos and noise of the environment, the techno-juggernaut of modern hospital care, the customer-friendly doctors who are happy and willing to dole out false delusional hope, and sometimes the patients themselves, who may not want to hear what the doctor has to say.”

The last clinical medicine I did was in an oncology ward in New Zealand, and I was left feeling that I’d completely misunderstood my medical education. I thought (and this was 1978) that patients with metastatic cancer, most of those in the ward, were close to death. But nobody mentioned death. The patients were all making plans for the future, the doctors were irrepressibly optimistic. O’Mahony “confesses” that he is an oncology, “schmoncology” “apostate” and quotes the Lancet Commission that “cancer treatment is becoming a culture of excess.” (The use of religious words is important because O’Mahony, brought up as a Catholic, agrees with Illich that modern medicine is becoming a global religion.)

The core of O’Mahony’s argument is that death is a bloody business and always will be. It is, as Henry James calls it, “the distinguished thing” that cannot be tamed or controlled, and the concept of a “good death” is a fantasy dreamt up by palliative care physicians, who offer deluxe dying to the few. Most people die in acute hospitals, which have become “a dustbin for all sorts of societal problems, not just dying” and are places of “filth, torture and death, a sort of antechamber to the tomb.” Dying well in such places is virtually impossible, and anyway “The needs of patients seem to come a poor second to those of the staff and the institution….much of modern medicine is characterized by a culture of excess and dishonesty, and this culture ill serves the dying.” People are poorly prepared for dying, and even the fashionable idea (of which I’m a victim) that “To philosophise is to learn how to die” is so much nonsense. None of us know how we will react when we learn we are close to death, rendering advanced directives absurd. And the move to assisted dying is a vain attempt to strip death of its “awesome grandeur.” Doctors, he complains, are “the whipping boys for our inadequate understanding of how we die.”

E M Forster would seem largely to agree with O’Mahony: on the day that I read The Way We Die Now I also read this in Howard’s End: “Sane sound Englishmen building up empires, levelling all the world into what they call common sense. But mention Death to them and they’re offended, because Death’s really Imperial, and He cries out against them for ever. Death destroys a man: the idea of Death saves him. Behind the coffins and the skeletons that stay on the vulgar mind lies something so immense that all that is great in us responds to it. Men of the world may recoil from the charnel house that they will one day enter, but Love knows better. Death is his foe, but his peer, and in their age-long struggle the thews of Love have been strengthened, and his vision cleared, until there is no one who can stand against him.” [If like me you didn’t know the meaning of “thews” it’s “the muscles and tendons perceived as generating strength.”

Wisely, O’Mahony doesn’t venture into love, but I think he’d be sceptical of the poetic notion that love can conquer death.

O’Mahony is a “doctor’s doctor” insofar as he resent the intrusion into the doctors’ space of lawyers, politicians, managers, evidence based medicine, guidelines, personalised medicine, narrative medicine (“which provokes mockery and contempt for its smugness”), shared decision making, informed consent (“a legalistic fantasy”) and worthy but empty platitudes from royal colleges, medical schools, medical journals, and the like. He believes, for example, that there is no good way to break bad news, although he concedes that there are bad ways, which does mean that there are better, if not good, ways. Medicine has, he believes, become a service industry rather than a profession. He seems as well to be in constant battle with patients’ relatives insisting that every last thing be done for their dying relatives—but he recognises that this folly comes not simply from families but from medicine and doctors having helped create unrealistic aspirations. He quotes Kieran Sweeney, a doctor who wrote about being diagnosed with mesothelioma: “When is enough enough? This will be the defining question for the next generation of practitioners.”

He raises but does not explore what medicine is for, writing “I obstinately cling to the notion that a doctor’s role is limited: our job should be the treatment of illness.” Are doctors not to be about promoting health and preventing disease? And what about relieving suffering? Some argue that that is the true role of the doctor, recognising that suffering and illness are not the same thing. Taking O’Mahony’s notion literally would imply, which he surely didn’t intend, that once the doctor could no longer treat the illness (not the patient, note) he would hand over the dying person to somebody else. In fact, he believes, as I do, that caring for the dying patient is the job of all doctors not just palliative care physicians. Perhaps he can explore what medicine is for in his next book.

“The default setting of modern medicine is full intervention,” writes O’Mahony, “unless you are instructed otherwise.” This might be the starting sentence for a chapter arguing in favour of advanced directives and assisted dying, but in fact he’s strongly against both. His argument against advanced directives is simply that we cannot know how we will feel about dying until we arrive at the day when we know it’s close, so an advanced directive is meaningless. I have an advanced directive which I’ve emailed to my wife and children, and like most doctors I think at this stage that I don’t want anything heroic. I doubt that I’ll have the courage to forego all treatment like Ivan Illich, but I find the prospect of morphine and whiskey much more attractive than chemotherapy. I accept that I may think differently when the day comes, and if I’m conscious and in my right mind then the advanced directive won’t be needed. If, however, I have, say, a stroke, then I may well not be conscious. In those circumstances it is what I think now that is relevant—even if I would have thought differently if conscious.

His argument against assisted dying seems to be an objection to control. He does not rehearse the arguments for and against assisted dying but rather objects on almost poetic or religious grounds. It is an affront to “the distinguished thing” to try and control it, and people are behaving like God in trying to control death. He writes almost cruelly about Marie Fleming, an Irish “right to die” campaigner who took her case to the Supreme Court and became “something of a national heroine.” She had, he writes “an obsession with control” and her time in court “gave her ‘the voice she always craved.’” Had she succeeded in her case then “she would have altered forever the way in which I practice my profession.” O’Mahony may retire before it happens, but it seems to me that assisted dying is going to become routine eventually just as abortion has. We can trace its steady appearance around the world, including most recently in Canada.

I’m not sure why O’Mahony should object so strongly to control. I imagine that he is in control of most of his life–and very glad that he is. He was presumably in control of getting married, choosing his profession, and determining how he would spend his spare time and energy. The problem seems to be with trying to control death—partly because it never can be controlled. We will all die—and thank goodness that we will—and we can’t control that, although many are trying. But we can potentially control how we die. O’Mahony does not write about suicide, but presumably he accepts its legality. He’s no doubt read Hume’s famous essay making the case for suicide. There are several arguments against assisted dying, but I don’t accept O’Mahony’s argument that trying to control death is unacceptable.

O’Mahony writes approvingly of “tame death,” a termed coined by the French historian Phillippe Ariès. In pre-industrial Europe tame death was characterised by “indifference, resignation, familiarity, and lack of privacy.” None of those—except perhaps resignation—are likely to return, and O’Mahony thinks that we are unlikely to be able to fashion a secular version of tame death—because “death is tamed by ritual.”

But is he right to be so sceptical? He’s surely right that death in an acute hospital is unlikely ever to be anything but mostly bad. But does death have to happen in hospital? And does death have to belong to doctors caught up in what he calls “the madness…[of] much of modern medicine”? O’Mahony advises that “A wise person needs to acquire and treasure an amicus mortis, one who tells you the bitter truth and stays with you to the bitter end.” That amicus mortis could be a doctor, but it need not be—and even if is the doctor does not have to be in the hospital. We are seeing the emergence of doulas for the dying, lay people and a modern version of amicus mortis.

It’s a pity that O’Mahony does not write about the social movements—like Dying Matters in England and Good Life, Good Death, Good Grief in Scotland or the community programme in Kerala, India—that are trying to bring death back into life and demedicalise it. Perhaps he would be scornful, but, as his book convincingly shows, doctors have made a mess of death—perhaps lay people, assisted by doctors, can do better.


Related articles and posts:

Neil Vickers. Book review: At the end of life: true stories about how we die. Med Humanities 2012;38:2 122123

F Brennan. ‘As vast as the world”–reflections on A Very Easy Death by Simone de Beauvoir. Med Humanities 2004;30:85-90

Robert C Abrams. Book review: The Violet Hour: Great Writers at the End.

Wellcome Book Prize Winner 2016 – ‘It’s All In Your Head’ reviewed

23 Jun, 16 | by cquigley

It's All in Your Head


Suzanne O’Sullivan, It’s All In Your Head: True Stories of Imaginary Illness. London: Vintage, 2016; first publ in hardback 2015 by Chatto & Windus

Reviewed by Professor Edward Shorter

The very subtitle of the book makes one nervous: “stories of imaginary illness.” If there is one phrase that psychosomatic patients – who have symptoms without lesions ­– do not want to hear it is that their problems are “all in their heads.” Even though O’Sullivan may use the phrase ironically, it does take us back to the days when discovering organic causation was the Mecca of medical practice and psychiatry was left to “the shrinks.” Of course things are more complicated, and O’Sullivan, a neurology consultant at the National Hospital for Neurology and Neurosurgery knows this well. The book does make some finer distinctions so that “all in your head” doesn’t come out and hit us in the face. But still, O’Sullivan says that “psychosomatic refers to physical symptoms that occur for psychological reasons . . . How many are aware of the frequency with which our emotions can produce serious disability where no physical disease of any sort exists to explain it?” So in other words the origin of such symptoms is clearly psychological. These patients amount, she says, to fully a third of the cases seen in general practice and in neurology.

The book is a kind of odyssey of patients O’Sullivan has seen whose problems seem to have been caused by mental distress – a tour interleaved with explanations of historical figures such as the Parisian neurologist Jean-Martin Charcot, who once peopled this scene.

O’Sullivan has gone to such lengths to obscure the patients’ actual identities that one is never entirely sure whether the “Paulines” and “Matthews” that parade through these pages are more fictional than real – though their complaints are real. And O’Sullivan, it must be said, writes beautifully, a low-key golden flow of prose that makes the book simply a good read. There are no references. No authorities are invoked. This is the author, a veteran neurologist, speaking to us from the heart.

But is what the heart says true? How reliable is her analysis that psychosomatic symptoms are “physical symptoms that mask emotional distress”?

Right off the bat, there are problems with this stress-causes-functional-illness model. There are several major causes of psychosomatic symptoms, some of which get short shrift.

One, O’Sullivan tells us about classical psychosomatic symptoms that are caused by “stress” or by the emotional overlay of underlying organic disease. Her patients’ emotional woes are apparent to her in the course of many clinical interviews, and she ends up referring many of them to a “psychiatrist.” This is the most useless referral imaginable, as psychiatrists shun and fear psychosomatic patients and can usually do little for them because the patients themselves reject the whole notion of “psychogenesis”; patients usually accept such referrals only with the greatest reservation, convinced – not entirely incorrectly – that they are being turfed.

Two, O’Sullivan is silent about a huge source of psychosomatic illness, namely the phenomenon of suggestion. Patients who can be suggested into illness require no deep psychological problems, no intractable “stress,” to become symptomatic. They simply are suggestible.

A perfect illustration of suggestibility is epidemic hysteria: Sally begins vomiting and suddenly all the ten-year-olds in the schoolyard start vomiting as well. The public health authorities rush in. There is alarm in the press. An organic cause is never found but everybody is better the next day. It is an epidemic of suggestion that has invested the schoolyard.

The culture can be a source of suggestion as well, a subject on which O’Sullivan is silent. The culture can tell us that “fatigue” or “pain” are acceptable models of presenting illness, and these patients turn up in physicians’ surgeries with “myalgic encephalomyelitis” (ME), known as “chronic fatigue syndrome” (CFS) on the other side of the Pond. They do not in fact have an occult organic illness called “ME” but have suggested themselves into their chronic pain, fatigue and dizziness because the culture says those are appropriate symptoms. (And the culture has largely ceased to sanction “paralysis” as a convincing symptom – too easy to disprove with a negative Babinski.)

Three, frank psychiatric illnesses may spin off somatic symptoms. Patients with melancholic depression will light up the medical charts like a Christmas tree. Their aches and pains are legion, and disappear once the melancholia – one of the most treatment-responsive illnesses in psychiatry – is successfully treated. Catatonia shoots off somatic symptomatology, the stupors, tics and stereotypies often misdiagnosed as organic disease and the catatonia not recognized. Why does this matter?Catatonia is another highly treatment-responsive disorder, but there’s nothing “psychosomatic” about it. In medicine, therefore, the concept of psychosomatic can get one into rough psychiatric water.

It is striking that O’Sullivan sees deep sadness as a source of psychosomaticity rather than as a symptom of glaring psychiatric psychopathology. “I have met many people whose sadness is so overwhelming that they cannot bear to feel it,” she writes. Yoo hoo!  Such melancholic patients are indeed candidates for psychiatric treatment, not for repeated neurological assessments.

There is, finally, a fourth variety of apparent “psychosomatic” illness. But it is quite foreign to the other three and is usually not included in reviews of the topic. It is malingering. One rather has the feeling that some of O’Sullivan’s patients –  their gaze strictly averted from hers, their long silences – were malingerers. (She presents one.) You can’t prove that someone is not fatigued, or not in pain. But you can prove that they don’t have multiple sclerosis or another upper motor neuron lesion. So malingerers choose symptoms that can’t be disproven. And many physicians who work, for example, in insurance medicine, cast a cynical eye upon many of the complaints that O’Sullivan takes for true-bill.

How best to treat these patients? O’Sullivan has good words for a procedure that has largely passed from medicine, namely the amobarbital (amytal) interview. But it is increasingly seen as outmoded and dangerous (the barbiturates have undeservedly acquired a bad reputation, and most physicians are simply not in the habit of prescribing them).

O’Sullivan believes in letting the patients have it full blast: Your “disability has a psychological cause.” Sorry. The patients are left open-mouthed, since virtually every psychosomatic patient in the history of the world has had a profound belief in the organicity of his or her woes. And even though we have exalted “never lying to patients” to a beacon of medical ethics, in fact there are moments when a bit of evasion may prove therapeutic.

“Shahina” comes in with a contracture of the fingers of one hand. Another consultant recommends a botulinum injection. Bingo! The contracture releases instantly. Shahina is cured! Now, usually you take your therapeutic victories where you can get them. But O’Sullivan presses on. She tells Shahina that normally the botulinum works only after a day or two. “The speed at which your hand responded to the toxin makes me wonder if there is a chance that the spasm in your hand might have had a psychological rather than a physical cause.”

Shahina responds, “You think I’m mad?” No, of course not but…

This is actually a model of what not to do: throw patients into confusion with the relentless urge to enlighten them about their supposed psychological problems.

For other patients, as I have argued above, the psychiatrist is held out as the solution of choice. This is a problematic idea, and it is dismaying to see it propagated so vehemently in these pages. Psychiatrists tend to be baffled by such referrals. “This is a patient whose chief complaint is chest pain? C’mon!”

The general internist, the rheumatologist, or another neurologist should be the physicians of reference, because only they are able to build the necessary therapeutic alliance, to keep the myth of organicity semi-intact. It is this myth that patients require to retain their self-respect, while the real therapy takes places in the context of the doctor-patient relationship. What actually works is spending a lot of time with these patients and letting them tell and, if necessary, retell their stories. This is cathartic. But it is advice that is most unwelcome to many clinicians because it takes so much time.

It is not really fair for me to second-guess Dr O’Sullivan from the comfort of my armchair thousands of miles away. Physicians on the front line of medicine, at Queen’s Square and elsewhere, have to cope as best they can – and with relatives that make Himmler seem like Santa Claus. (O’Sullivan’s patience in dealing with these furies is remarkable.) The take-home message is that the book is a great immersion in psychosomatic problems. One may quibble about some of the author’s therapeutic choices but this is for the Thursday afternoon seminar room. If you want to get a head-on feeling for the clinical experience of psychosomatic patients, read this book.


Edward Shorter is Jason A Hannah Professor of the History of Medicine in the Faculty of Medicine of the University of Toronto, where he also has the academic rank of Professor of Psychiatry. Among his books is From Paralysis to Fatigue: A History of Psychosomatic Illness in the Modern Era (New York: Basic Books, 1992)



Poetry and Medicine: Prize Winners

20 Jun, 16 | by cquigley



In April I attended the 7th International Symposium on Poetry and Medicine where the 2016 Hippocrates Awards were announced. A fascinating day, the programme included critiques on Philip Larkin’s The Building, Celia de Freine Blood Debts, Mary Kennan Herbert’s Skin Man series, as well as a presentation on Poetry, Psychoanalysis and Ageing, and a discussion around the evidence for the benefits of poetry for patients. Poetry readings of course dominated the proceedings, not just from winning and commended poets, but also sessions from Rafael Campo and Wendy French. A day truly rich in poetry, it left much to reflect on in terms of the potential for the genre to impact on the illness experience.

Winners for the three categories within the Hippocrates Awards are featured below. These and many other poems selected by the judges are available in the 2016 anthology.

Poems very gratefully reproduced by permission of the poets and the Hippocrates Prize.


2016 Hippocrates Prize for Poetry and Medicine


NHS First Prize

Denise Bundred (Kitchiner)


A Cardiologist Seeks Certainty

I spread cold gel on a newborn chest

rest the probe on creamy skin, angle

between ribs, rotate to find a heart

no larger than the tiny fist

pushing me away.


Two dimensions defy translation into three

as I locate chambers

amid the maze of vessels.

A millimeter of movement and the image melts

to snowstorm on my screen.

I re-trace arcs of ultrasound to relieve

the twist of doubt.

Adrenalin dries saliva as I strive to decide

whether the aorta arches

to the left or right.


The nurse checks the prescription

against an ampoule, initials in black ink

secure in her certainty of drug and dose.


The surgeon weighs my words

to determine his incision

shape his operation

as the incubator trundles towards theatre

escorting mother and the nurse.


I resolve inconsistencies

into diagnosis, wipe the sweat

from my hands, write my notes;

make my decision.



Open First Prize

Owen Lewis


At Tribeca’s Edge

This evening, I walk to the water where the Hudson opens

itself to the sea, and the sea with its rough cross-currents

is in the air and in the light—the light spectacular, clear,

illuminates the buildings of Newark across the water-way

with gold. The shimmering gold at their backs, they gather

to watch the harbor—the skiffs, prow-high, skip like kids

on a great lawn, a run-away pair braid ribbons of bridal white.

What will I tell my colleagues, gathering in a nearby auditorium?


I am thinking of my students, this first evening of Autumn,

young doctors eager with learning, still saddened by the sick.

The best are afraid. They’ve heard their voices tired, darkened

and hoarse. A ferry glides by, its wake spilling the embankment,

so close it seems we must hitch a ride, step in—and the light

between the distant buildings prying free, the sails opening with light.



Young Poets Prize

Catherine Wang


Six pills

Spread out in line like a
formal salute, phrased carefully on
the glass dining table.
Prednisolone coated in
white powder
bitter as a serrated edge. Mycophenolate
always stuck to my tongue,
a thick bullet. Then,
Esomeprazole and Hydroxychloroquine
coated my
with chalk. I swallowed Calcium,
Vitamin D, just to ensure
that my thinning bones
would not crumble
like wet
There is nothing greater than the
drama of the human body,
its desires, indulgences.


Fevers and rashes. There was so
much that sixth grade
science could not
account for.
was not a model disease, not a
display easily shown on brown
and pink plastic organs.
I embraced the
liberties of
deciphering my disease through its nocturnal
whispers. Pushed by the wind’s
warm muscles, I probed
the orange membranes
of streetlamps.
traced the moon’s breath, lingering on
the black glass of the sky.
Six pills spread out in line.
Head tilted back, I was grateful
for the silence,
for the empty taste of air.


Copyright  © 2016 the individual poets.

More information, including readings and excerpts from winning and commended poets, can be found here.


Check out the poetry and prose pages in the current issue of Medical Humanities



Film Review: stories from Arab women during the Spring Revolutions

17 Jun, 16 | by cquigley


‘Our oath’ short film, 2015, directed by Laura Finney

I was intrigued and moved by ‘The trials of Spring’, a documentary film depicting the fight of Arab women during the Spring Revolutions in 2010 ( The film portrays heart-felt human stories of women from Syria, Yemen, Libya, Bahrain, Tunisia, and Egypt.  Filming took place over three years focusing on the stories of nine women from these six countries fighting for peace in a time of war.

One of the most thought-provoking shorts in the film was ‘Our oath’. Through recorded interviews with Dr Nada Dhaif, a practicing dentist, we follow her fight with the ruling regime in Bahrain in 2011. When the demonstrations broke from the Diamond ‘Lolouah’ Square in central Bahrain, the government launched a brutal military response, resulting in several dead and injured casualties. Dr Nada along with doctor colleagues set up field-hospitals to provide essential basic life-aid support to the casualties. Dr Dhaif states ‘I could not believe what was happening, it was so unexpected. I could not process it mentally. What happened was against our religious, social, and cultural traditions. The sole motivation behind our action was our professional medical duty in practicing the Hippocratic Oath that urges doctors to uphold certain ethical standards:

‘I will apply, for the benefit of the sick, all measures which are required, avoiding those twin traps of overtreatment and therapeutic nihilism’ and

‘I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm’
Dr Nada was soon confronted by accusations of ‘plotting to overthrow the ruling regime’ and duly arrested.

Dr Nada: how did you react to this unexpected turn of events?

‘During my detention, it all felt unreal, a nightmare that I will wake up from. I did not stop to think or question my course of action. I was isolated and did not know what was happening outside. There were other women there too from various professional backgrounds’
After two months in jail, Dr Nada was sentenced to 15 years in prison in a military trial.

Following her sentence, international Human Rights and professional medical organizations from Ireland and elsewhere lobbied for her release. There was significant pressure from the British and American embassies in Bahrain. The news reached international press, after which Dr Dhaif and other doctors were released from prison.

The harsh jail experience proved to be a wake-up call for the doctor, wife and mother. Dr Dhaif continues: ‘By that time, I realized that my professional and humanitarian duties should extend to provide aid to political prisoners and their families as many of them suffer from mental illness and in dire need for care and mental rehabilitation. I set up an organization- BRAVO– Bahrain Rehabilitation and Anti Violence Organization- for treating citizens who were subject to torture and violence’.

In addition, she founded her own You-tube channel aimed at increasing awareness amongst the Bahraini and Arab communities about mental illness resulting from oppression in various forms and shapes.

Dr Nada: can you tell us more about the current state of your BRAVO organization, and you-tube channel?

‘BRAVO was founded in January 2012, and our work focused on providing physical, mental, and psychological care for victims. In the first few years we were able to provide various types of rehabilitation programs for up to 400 victims per year. But since the end of 2015 up till now, due to escalating risks, we shifted our efforts in providing rehabilitation care programs to the on-line channel. The idea of my YouTube channel “Nada Time” helped us reach out to over 20,000 people viewing the channel, with remarkable feedback’.

Dr Nada’s convictions are apparent in her opinion that change takes a long time, and that she herself might not live to see its impact in the near future.

Credit goes to the film director, Laura Finney in exploring the ideology of ‘peaceful resistance’ in a focused narrative from an Arab doctor’s perspective in as little time as 5 minutes. The film explores candidly the doctor’s role in their community particularly in relation to ‘Human rights’. The doctor is no longer a passive professional caring for a few patients, but indeed a formidable ‘power for change’.
To view the film, you can access the following link
Dr Khalid Ali, Screening room editor

Address for correspondence:

THIS IS A VOICE at Wellcome Collection reviewed

16 Jun, 16 | by cquigley

L0081645 'His Masters Voice'. Painting by Franci

‘His Masters Voice’. Painting by Francis Barraud, 1919. Credit:Courtesy of the EMI Group Archive Trust



Wellcome Collection, 14 April – 31 July 2016

Reviewed by Steven Kenny


Approaching the exhibition entrance of THIS IS A VOICE at the Wellcome Collection, it is easy to think the voice is treated as criminal, being contained, controlled and its behaviour segregated from the world outside. Initial thoughts would suggest that it is being acoustically surveyed; with the steady opening and closing of the exhibition door, sound rushes to the exit. Yet its attempts are ultimately futile, the room has been sound proofed, noise restricted from accessing the outside world. On entering the space, grey triangular padded shapes line the walls, detail reminiscent of a kitsch science fiction film from the 1980s. The exposed patterned structures, evocative of the décor of Ridley Scott’s periled spaceship in Alien, enclose you in a warm, familiar hug of nostalgia. Sensing that this space is one visually tread before, it is easy to forget the prestigious institutional context of the exhibition. THIS IS A VOICE, a show investigating the potential of the voice in all its forms, techniques, objects and cultural baggage, is particularly engaging for it knowingly understands such a topic cannot be wholly represented (due to various cultural and language complexities). Yet it does a heartfelt job in attempting to at least understand how the voice as a product, both commercially and non-commercially viable, can be exhibited. Curatorial flourishes can be found everywhere, from the nooks and crannies of seated listening stations to the maze-like paths that allow a gentle flow of avid listeners from one space to the next. From attending numerous shows at the Wellcome Collection I must comment that THIS IS A VOICE is one of the most stimulating and generally refreshing exhibitions to be held in its space.

It would seem that an inner versus outer exploration of the body and the voice is focused on throughout. One telling example of this is immediately apparent in the work Circular Song, 1974 by Joan La Barbara. A half dome like structure hangs from the ceiling, the speaker’s hollow interior pervading the space below with sound. The experience of entering this wall of sound is generally unnerving, a constant and increasingly uncomfortable echo of inhaling and exhaling performed by the artist, breathes all over you. It is nightmarish, a deathly noise that would seem totally apt in the exhaling howls of a victim being chased by a stalker in a nerve inducing slasher film. Sound in this manner is represented as an abject substance, an uncanny emotional pulling of the visitors’ own sentiments to the body and the amplified vocalisation of a body process that now seems one of disgust. Yet this is in direct contrast to Marcus Coates multi-screen film installation Dawn Chorus, 2007, which is silly, funny and surprisingly touching. This room is filled with the fluttering sounds of birdsong, a number of monitors positioned at varying heights depicting subjects in everyday locations comically singing along to each sound created. Experiencing this work initially seemed deceptive­­–I could not understand how both image and sound aligned so perfectly, as though the birdsong was actually being produced by a human lip whistle. Subjects pursed their lips and jotted their heads up and down in perfect alignment. The façade is lifted on reading the work’s description: ‘After recording the dawn chorus with multiple microphones, the individual birdsongs were slowed down to last approximately 16 times as long, which enabled the participants to imitate them, while being filmed’. Yet not knowing these details did not matter as my imagination roamed freely around the space. I observed each subject as one would watch a bird in the wild, mesmerised by its harmonic whistle and merry bouncing of its head.


THIS IS A VOICE at Wellcome Collection, 2016. Credit:Photography by Michael Bowles

Dotted around the exhibition are various textual works, the written word laid bare. Erik Bunger’s wall text I Hearby Command You to Give Voice to These Letters Silently or Out Loud, 2011 was surprising in that it forced an involuntary restriction of my own voice from permeating the gallery. I so badly wanted to shout out loud the words I was reading yet thought better than to add to the already noisy space. Yet on second thoughts maybe that would have made for some interesting spectator reactions. Bunger’s playful register, was paralleled by Mikhail Karikis’s digital prints (photographs by Thierry Bal) Sculpting Voice, 2010, where the artist was photographically recorded pulling various facial gestures. Three prints line the wall in sequence, each exhibiting Karikis’s comically retuned face, made even more comical by the muting of what would probably have been quite a painful or otherwise loud projection of sound.

L0081817 THIS IS A VOICE at Wellcome Collection, p

THIS IS A VOICE at Wellcome Collection. Credit:Photography by Michael Bowles


The exhibition saved its loudest and most intriguing work for last. Entering the final room of the show, you would think that you might have woken in a Lynchian nightmare. Best described as an interactive, participatory constructed, sound installation, a lone and somewhat foredooming sound booth, tempts the spectator.

L0081800 Matthew Herbert, Chorus, 2016

Matthew Herbert, Chorus, 2016. Credit:Photography by Michael Bowles

The aptly titled Chorus, 2016 is by the British electronic musician Matthew Herbert, whose work ‘asks visitors to sing a single note within a professional recording booth following a set of instructions. The visitor’s voices are then automatically added to a chorus of voices, including performers and staff from the Royal Opera House, forming an ever-expanding sound installation that plays in the exhibition space and at the Royal Opera House’s Stage Door in Covent Garden’. I entered the space to sing the requested solitary note. Escaping my throat, my voice joined the squeaks, squeals, and sometimes correctly pitched notes above. Noise reverberated violently throughout the room, puncturing the space like a diminished fifth encroaching a melodic passage. The voice in this exhibition is presented as an ever-changing entity, one that is able to attack, calm and arrest.


Articles from Medical Humanities on the human voice:

Kelly BD. Searching for the patient’s voice in the Irish asylums. Med Humanit 2016;42:87-91.

Demjén Z and Semino E. Henry’s voices: the representation of auditory verbal hallucinations in an autobiographical narrative. Med Humanities 2015;41:1 5762.

Puustinen R. Voices to be heard—the many positions of a physician in Anton Chekhov’s short story, A Case History. Med Humanities 2000;26:1 3742.


Book review: Social Class in the 21st Century

15 Jun, 16 | by cquigley



Mike Savage, Social Class in the 21st Century, Pelican, 2015


Reviewed by Jacob King, Medical Student.


You may have heard about the Great British Class Survey, you may have even completed the Great British Class survey (GBCS) or tried their online Class Calculator. In 2015 Mike Savage and colleagues summarised the findings of this great exploration into British society in their book Social Class in the 21st Century. Launched by the BBC in 2011, over 161,000 people (p.409) replied to a survey assessing an extensive range of factors regarding the lives of anyone living in Britain who volunteered to be heard: your income, your savings, the value of a home you may own, whether you went to university/which university? Who do you socialise with? Do you know a cleaner, a doctor, a student, travel agent, what about an aristocrat or noble? What did your parents do for work? Where are you from? What class do you think you belong to?

It’s almost hard to believe that anyone would divulge all this information, and yet a second wave of data collection has since yielded an additional 164,000 respondents, and millions more have tried the abridged Class Calculator online. Social Class in the 21st Century is an Aladdin’s cave of data for the socially curious, for those interested in what makes British society tick, for the man who wants to know what others presuppose of him, not just the class conscious Hyacinth Buckets of the world (though I am certain she would eagerly paw through its pages of charts too). Through the wealth of collected data, and extensive interviewing, the results of the GBCS made revolutionary revisions to the historic models of class, and what, if anything, could justify these. The book in its whole therefore relates to the analysis of their investigations, the establishing of new class identities and explanations of what qualifies membership to these groups, but importantly, it examines the relationship between each of these factors, and the political ramifications the results may hold for society.

While the authors ultimately conclude that the concept of social class has significant flaws, unfairly stereotyping the bottom of society and justifying the position of those at the top, their work identifies three key qualities which influence social standing. They term these economic capital, cultural capital and social capital. (p.46)

Economic capital: The value of your home, whether you rent, your household income, what savings do you have.

Cultural capital: The type and range of interests you pursue: from visiting stately homes to attending rave parties.

Social capital: The kinds of people, and the range of the kinds of people you know: have you an aristocrat friend, has one of your friends never worked?

On the back of this, the authors develop a new model for class structure based on typical and common groupings of traits expressed through these forms of capital. (p.169) With the greatest showing of each of these traits, the ‘Elite’ class characterises those financially well off with high scores for social capital, consumption of ‘highbrow’ cultures (opera and classical music, for example) and relatively high consumption of emerging culture (social media use, listening to hip hop/rap music). At the other end of the grouping the authors describe the precariously placed ‘Precariat’, who often demonstrate very low household income, low social contact scores, very low levels of the consumption of highbrow culture and low levels of emerging culture. The model is completed with five intermediate groupings: established middle class, technical middle class, new affluent workers, traditional working class, and emerging service workers, each with a different pattern of capital forms.

Throughout the book, the authors consider whether class is useful as a stratification tool. In practice, only one-third of people in the UK believe themselves to belong to a class. (p.367) Interestingly, those with higher economic, cultural and social capital reservoirs are more likely to believe that they belong to a class, and are more accurately able to identify which grouping they may fall into. (p.369) On the other hand, 75% of those with lower levels of capital do not believe that they are part of a social class. But despite popular rejection of class titles, the authors describe evidence of lines being drawn between groups, and argue that the labels are perpetuated “even if only to prompt negative reactions to them”. Key examples include the relationships between the traditional working classes and the ‘benefit scroungers’ below, or the technical middle classes and the ‘posh snobs’ above. Commonly, a person’s job, the way they speak, and even, as evidenced by inflammatory comments made by journalist Katie Hopkins on ITV’s This Morning in 2015, what you name your children indicates social class, and where these lines are drawn. (p. 363)

But, what do these models of class, concepts of capital forms, rejections of a class hierarchy but lines being drawn all the same, mean for our lives? While this book is certainly not a medical text, the conclusions may have significant impact on the state of medicine. In one aspect, doctors as a profession have been widely drawn upon for examples of why capital reserves matter.

We are all aware of the gender pay gap, the concept that women are paid less than men for equivalent work. The GBCS highlights the importance of the ‘social background pay gap’, especially among professionals. The results demonstrate that while many other professional groups experience wild differences in their future income depending on their background, doctors are more or less immune to this phenomenon. Doctors beginning their lives in the most elite upbringings only earn around £5,000 more per year than a doctor from a background where their parents did manual work or did not work (£80,226 versus £74,915). (p. 202) Compare this to lawyers (£86,363 versus £65,583) or company CEOs (101,052 versus £83,467). There is not enough room in the book to speculate on why this is the case, but perhaps an industry monopoly, and concrete training programs could offer explanation for why strong social networks, varied interests and comfortable finances do not impact on doctor’s career progression notably. The implications of this exploration of social class have significant (at least proven financial) impacts on the future lives of individuals.

We are treated to a handy metaphor for social mobility. When climbing the mountain that is the social/economic ladder, those who start off near the top of the mountain do not have to climb as far. They have the resources, experience and ability of those around them to support the short climb to the top. Those who start off at the bottom have significantly further to climb, and lack the experience or resources with which to climb. To emphasise the point, Social Class in the 21st Century also takes us through how whether we go to independent or comprehensive school, which university we go to, which course we do, and where we live significantly predicts future social standing.

Reading this book – especially the targeted interviews which provide delightful insight into the very real lives of the anonymous subjects – one leaps to think of people in our own lives, maybe a patient, or family member or friend. You think about their start in life, what jobs they have taken, how much their house may be worth, what are their interests, how does all this link? Aside from the direct implications that this work reveals for the medical community, doctors and patients, and broad examples of health experiences, this work is not a traditional medical piece. Yet, the profound impact that sociological relations have, not just on the day-to-day observable doctor-patient relationship or even medico-sociological phenomenon: access to health, quality of life, health behaviours, attitudes to health and others, but also in shaping everything else in between. The structure of society is linked so fantastically to health, wellbeing and illness, through education, employment, family ties, that the direct health implications that result from disruption in any one of these, could be considered a precursor for the occurrence of poor health and the ultimate success of outcomes.

I relay the conclusions of Prof. Mike Savage and others; despite the quirks and quandaries a sociology study’s methodology faces, the importance of this understanding and how it shapes every aspect of a life is important to appreciate. From our medically tainted view of this book, we can only conclude that our status as doctors fundamentally and inescapably plies us with a high degree of social, cultural and economic capital. Our patients more often than not will not be similar. It is our job then to ensure that social status, presuppositions of ‘our kind’ is in no way a detriment to the clinical relationship. Perhaps more importantly, on a political note, appreciating capital in our patients and the overwhelming effect our early years circumstances has on our social networks, on our interests, our finances, and how this frames all of our interactions is vital to understanding the context of a patient’s life.

Social Class in the 21st Century is a book with beautifully broad scoping commentary, revealing a glimpse into the nature of society, and opening significantly more questions than attempts were ever made to provide answers.


Other articles that may be of interest:

Daniel Holman and Erica Borgstrom. Applying social theory to understand health-related behaviours. Med Humanities 2016;42:2 143145 

John Harley Warner. The humanising power of medical history: responses to biomedicine in the 20th century United States. Med Humanities 2011;37:2 9196 

Claire Hooker and Estelle Noonan. Medical humanities as expressive of Western culture. Med Humanities 2011;37:2 7984 

Kenneth M Boyd. Disease, illness, sickness, health, healing and wholeness: exploring some elusive concept. Med Humanities 2000;26:1 917 


The Reading Room: The Violet Hour – Great Writers at the End

10 Jun, 16 | by cquigley


the violet hour

Katie Roiphe. The Violet Hour: Great Writers at the End. Virago, 2016


Reviewed by Professor Robert C Abrams, Professor of Psychiatry, Weill Cornell Medical College, New York


A central premise of Katie Roiphe’s The Violet Hour is that the awareness of approaching death is a milestone we all will face at some time and in some form. From there, Roiphe explores how the moment of awareness, the awful prognosis, was confronted by each member of an august selection of writers and thinkers. But it is not only that first acute glimmer of understanding that Roiphe examines, since dealing with death more often than not involves a lengthy, even a lifelong, prodrome, an unwelcome perception that appears slowly and gathers to invade consciousness.

Roiphe’s subjects are persons of uniquely substantial depth, creative visionaries in their own fields—Susan Sontag, Sigmund Freud, John Updike, Dylan Thomas, Maurice Sendak. An interesting aspect of the book is that, when the subject is death, these luminaries are just as avoidant and vexing as the rest of us. One is at first tempted, naively, to believe that what these individuals have accomplished in their lives ought to ease the pain of anticipated death, or enable them to articulate the experience in a way that leads us to greater insight. However, intellectual or artistic stature does little to soften the impact or illuminate the journey—at least for this select group. Instead, Roiphe shows how the nearness of death strikes with terror at one’s narcissistic heart and can derail the psychological homeostasis of almost everyone.

What can be derived from the accounts of these great thinkers is therefore not clarity, but an analysis of how they actually felt as death loomed. In a way, Roiphe’s writers coped with death much as they had lived, in all their contradictory ways. Like strands of spaghetti Bolognese, each story line branches out and swirls around in so many messy directions that the themes can be difficult to untangle and trace. (In fact, compared with their highly variable, tortured pre-death processes, the actual moment of death for these writers seems to have been uniformly anticlimactic; all the complicated action has taken place earlier). So it is that we are shown how Dylan Thomas dreaded death but died in a self-destructive orgy of alcohol and Benzedrine, the culmination of years of punishing abuse of his health. John Updike, on hearing his dire prognosis, turned immediately to poetry, for him a reliable source of consolation, and he kept at it, creating what some have considered his finest work, for as long as his strength allowed.  Susan Sontag did something similar, finding solace under the cover of the intellectual constructs that were her hallmark, except that she fiercely refused to give in or let go; she marshalled all the intellectual force at her command to master her illness and survive it­­, until she simply fell away. Freud was magnificently inconsistent: Freud, the ultra-rational doctor who once famously insisted that “a cigar is just a cigar” could never give up what he knew was rooted in primitive oral gratification and thus knowingly died of smoking-related cancer. Maurice Sendak, who seemed to have imbibed angst prenatally, was completely preoccupied with death and had been preparing for it nearly all of his life.

But thinking about death when it is not proximal is very different from grappling with it in the moment. Death is something for other people, never for oneself, until it isn’t. But up to that moment, it is safe enough to wish for death, romanticize it, flirt with it. When death actually does arrive, it is presented as a full-stop but not necessarily a resolution; one dies, not after living but during it, leaving everything that is unsolved, unsolved. Again, these observations would be unremarkable were it not for Roiphe’s notion that the deaths of such hyper-articulate individuals should be exceptionally revelatory. That in the end her characters are merely ordinary humans contending with the direst possible threat to their existence may be in fact the point.

If The Violet Hour can be a dark, depressing read, it is also a brilliant one, framed in stunning, exquisite prose by an artist-of-a-writer.  Roiphe’s introductory synthesis of thoughts about death could easily stand alone as a splendid thought-piece, and there is a touching personal epilogue at the end. But for most of the book the author is rather coy about her own views of death. For that one must look to her casting choices. Starting with a set of 20th century cultural icons who wrestled with the concept of death and left written records and accounts of witnesses to prove it, her chosen characters add up to a grim group of players, John Updike being the sole possible exception. The others are grim, not only because they are dying, but because of the bleakness they have created for themselves.

It is probably a consequence of Roiphe’s selection of characters that there is missing in this book any serious discussion of hope—Emily Dickinson’s resilient little creature with “feathers.” Hope is too effeminate for the likes of Susan Sontag, who preferred to submit to a brutal stem-cell transplant in lieu of gentle palliation because the transplant offered a slim hope of survival. Hope is too shallow and totemic for Freud, who prided himself on tolerating pain with what Roiphe aptly calls “heroic clarity” instead of mind-numbing analgesics. Hope was off the radar entirely for that 20th-century poet-maudit, the personification of romantic self-loathing, Dylan Thomas. But for us ordinary folk, readers who are death-fearing, moderately self-defeating but not quite blatantly self-destructive, some consideration of hope just might be welcome.

In an influential article in the geriatric psychiatry literature, Sullivan succinctly formulated how “hopelessness at the end of life is not simply the absence of hope but attachment to a form of hope that is lost.” [1] Consistent with the writings of Erik Erikson, [2] this view holds that a dying person must deflect mental energy away from the goal of survival, the currency of which has been divested of all value, to some alternative ethos consistent with his life and personality; this should ideally be something larger in scope than one person’s life, some experience or value that will outlast and transcend the individual, such as intimacy, democracy, art, or salvation. In the absence of any realistic point of future reference, redirection of hope becomes the urgent task to be confronted when one is handed a final sentence of death.

Considering Roiphe’s cases from this perspective, she shows how Sontag haughtily spurned everything but survival, and by embracing a losing cause, died sadly, though she left a spectacular record of written reflections. She documents how Freud, who worked until the end, died with little psychological adjustment to make, well aware that he had created an incomparably rich legacy; he also had an heir to his intellectual estate, his daughter, Anna, who was eager to perpetuate it. Only Updike seemed to achieve a meaningful transition; his hopeless prognosis spurred him on to new creative heights and enabled him to return, albeit briefly, to the top of his form as a writer, a peak from which prior to his cancer diagnosis he’d felt he had been slipping. Previously it had been sexual affairs that had seemed to energize his writing; now it was the awareness of death. When he could no longer write, he died.  Neither Dylan Thomas nor Maurice Sendak ever entertained any sustained vision of themselves as surviving, so no such transition applied to them.

Reflecting on the absence of hope in the main body of The Violet Hour should not be taken as a criticism, for Roiphe, by clinging to neutrality and avoiding any position other than that of reporter until the book’s final pages, invites readers to abstract their own lessons from these stories and integrate them in a personal way. And it is fortunate indeed that she does not entirely neglect the critical human need for love, solace and inspiration at the end of life. It had to have been for such a purpose that she cited these beautiful lines written by the terminally ill John Updike:

“To live is good / but not to live—to be pulled down  / with scarce a ripping sound,  / still flourishing, still / stretching toward the sun– / is good also.”



  1. Sullivan MD. Hope and hopelessness at the end of life. Am J Ger Psychiatry. 2003; 11(4):393-405.
  2. Erikson EH, Erikson J, Kivnick HQ. Vital involvement in old age. New York: W.W. Norton & Company; 1994.

CHCI Health Humanities Summer Institute 2016

8 Jun, 16 | by cquigley



Sunday 26 – Monday 27 June 2016, 10.00

CHCI Health Humanities Summer Institute 2016

Health Humanities Now

Anatomy Lecture Theatre & Museum, King’s Building, Strand Campus

2 day Conference which aims to gather scholars and practitioners from all over the world in the burgeoning field of the health humanities. By showcasing some of the most innovative and pioneering work taking place in the health humanities today.

This event is open to all, the Standard Delegate rate is £90 with the option to book the conference dinner for £10.

Student Rate is £40 with the option to book the conference dinner for £10.

Registration is required via King’s e-store, you can book your place here

We do hope you will be able to join us.

Centre for the Humanities and Health

Arts & Humanities Research Institute

Faculty of Arts & Humanities

King’s College London

Tel: +44 (0)20 7848 7963



First impressions only happen once

7 Jun, 16 | by cquigley


Fergus Shanahan


Eyes smiling, face beaming, the porter rose from his stool to greet arrivals at the cancer centre, each nervously hesitant, staying close to a supporting loved one. With the confidence of a man who enjoyed being good at his job, he paused for those needing directions, reassured us that we were in the right place for our appointment, and then boomed: “Welcome everyone, and good luck to you all today.”

Good start. After that, we didn’t mind inconveniences like waiting for the single working elevator and felt better about whatever unknowns were ahead. The moment was still fresh when we got to the sixth floor. There, we faced a receptionist unable to switch her gaze from a computer to address us. Detached with jaded eyes fixed elsewhere, her outstretched arm dispatched us to an adjacent touch screen to register. We obeyed but the system insisted on a five-digit address code. Bad enough to be labelled ‘international’ as code for not having acceptable insurance, but not having a zip code was a new stigma. Before we could explain, Miss No-Eye-Contact was on the phone staring at some distant point behind us, then back to her screen with a facial expression that said: “Can’t you see! I’m busy.” Bristling a little, I blurted out my son’s details to demand attention. Without the slightest shift in posture, she confirmed our existence in the system with a few flicks of her keyboard. Progress. Then she left us with the unsettling comment: “Hmm, that’s interesting…take a seat and wait while I check with Accounts.” This is not what patients want to hear as they contemplate the prospect of major surgery. No one wants to be that kind of interesting.

Joe shot a warning glance at me “Dad…don’t be rude with this lady. Don’t lose it!”

Lose it! After 8 months of continual worry and stress trying to steer my son through the complexities and decision-making of a young man’s cancer treatment, I was determined not to ‘lose it’. We were overseas in a different healthcare system for a high stakes operation. They were now in charge and I would just have to play it their way. After all, I wasn’t the patient. I was supposed to be the support. So I stayed quiet. Then, the silence was broken, delightfully so, it seemed to me, when an old woman behind us flatly refused to have anything to do with self-registration. Dismissing the technology with an impatient wave of her hand, she snapped at no one in particular in a brash accent: “I’m not gonna do it, I can’t be bothered with that.”

Miss No-Eye-Contact receptionist had met her match.

While waiting, I imagined myself telling anyone seeking my opinion that professional staff within medical offices and hospitals should heed the little things that comfort patients. I would tell them that little things are important. Staff should know that routine for them is crisis for the patient. I would remind them that there is only one opportunity to make a first impression. First impressions are made up of little things. Little things can make a big impression. If the front office experience is poor, anxiety increases and confidence in the rest of the enterprise becomes more doubtful. In other words, if the dentist’s receptionist is a barracuda, don’t expect much pain relief when you get to the back office.

Then, we heard our name called out and we were on our way into the back office.

The interview with the surgeon was probably over within minutes but it seemed much longer. He began with a firm handshake. Then, sitting beside us not across a table, he spoke confidently in clear, crisp, explanatory sentences. These, he must have repeated on hundreds of previous occasions but it didn’t seem that way. He anticipated our questions and acknowledged our sense of urgency.

In the end, the professionalism of the porter that morning and his memorable welcome was the bellwether for what followed. The surgeon’s skill and experienced team determined what was to be a favourable outcome. But something else made a difference and a lasting impression. To borrow from the poet Maya Angelou:  “…people will forget what you said, people will forget what you did, but people will never forget how you made them feel.”


Fergus Shanahan, MD, DSc

Professor and Chair,

Department of Medicine,

Director, APC Microbiome Institute

University College Cork,

National University of Ireland

Tel +353-(0)21-4901226  also cell phone 086 280 4881

FAX +353-(0)21-4345300



The Reading Room: Reading for Health

3 Jun, 16 | by cquigley



Erika Wright. Reading for Health: Medical Narratives and the Nineteenth-Century Novel (Athens, Ohio: Ohio University Press, 2016)


Reviewed by Dr Jane Darcy, Department of English, University College London


Erika Wright begins Reading for Health with a timely reminder for Victorianists, quoting Ruskin’s argument about the dangerous temptation of the ‘phenomenon of the sick-room’ for weak novelists. Its lure, he writes, is that illness and dying have probably been for these writers ‘the most impressive part of their own personal experience.’ Ruskin prefers older novelists such as Scott, whose works exemplify ‘healthy and helpful literature’.

Wright seeks to address this nineteenth-century preoccupation with disease, together with the broader epistemological question of what constitutes health. She sets herself an ambitious argument: to re-examine a wide range of texts by canonical writers (Austen, Charlotte Brontë, Dickens, Martineau, Gaskell) using a new theoretical framework, ‘reading for health.’ She argues that the language we use to theorise disease narratives in the traditional novel assumes a ‘therapeutic’ model, relying exclusively on ‘a reading of crisis and recovery that imagines health as the end of beginning, as the absence of action.’ We should rather, she suggests, consider such writings in terms of a ‘hygienic’ model of ‘maintenance and prevention’. This new way of reading, she argues, will  ‘challeng[e] our sense of order and temporality, setting and metaphor, point of view and voice.’

It is a large and controversial claim, not least because it depends on examining, in Wright’s words, ‘narrative strategies used by novelists and medical writers when trying to preserve, promote, and define health’ [my italics]. This forces her to suggest that the nineteenth-century writers of her study are consciously subscribing to a new and, to my mind, not entirely lucid theoretical framework within which they should be read. A further problem is that in seeking to cover so broad a range of literature, the working-out of her suggested framework in practice can read at times as over-simplified and over-determined.

Her first chapter, for example, is entitled ‘Jane Austen’s Plots of Prevention’. Using and Thomas Beddoes’ Hygeia (1802-3) against William Buchan’s popular Domestic Medicine (1769), she argues that the former ‘enacts a subtle but important shift from cure to prevention.’ The implication that Beddoes was the first to write on the importance of diet and exercise in health maintenance, however, ignores centuries of medical writing about the significance of non-naturals (air, sleep, food and drink etc). From here her focus on Sense and Sensibility (1811) is inevitably narrow. ‘Austen targets negligent parents’, she writes. Well, yes and no. Negligent parents are a useful jumping off point for stories, just as much as they are in fairy tales. She is right, however, to draw attention to Marianne Dashwood’s dangerous cultivation of grief. But while Wright offers sensitive reading of some of the novel’s language, there is no discussion of that key eighteenth-century notion, sensibility. The ‘sense’ and ‘sensibility’ of Austen’s title may suggest a simple binary, but the words are of course cognates, and the novel offers a subtle exploration of the need for both sense and sensibility (the characters who lack sensibility’s gift for compassion are revealed as unpleasant materialists). Most worrying, Wright argues that ‘All of Austen’s novels have, to varying degrees, embedded narratives that function as warnings.’ Mansfield Park she later writes, is ‘teaching us something else. She is instructing us not to improve but sustain … not to cure but prevent.’ She is on thin ice here with literary scholars who will surely bridle at the suggestion that Austen is fundamentally a didactic writer.

Again one of the difficulties of Wright’s range is that she focuses exclusively on physical health, avoiding the vexed issue of the mind-body-spirit relationship. ‘We are encouraged,’ she writes, to see Mansfield’s Fanny Price ‘as a struggling preventionist.’ Apart from making Fanny sound like an unsuccessful apprehender of smugglers, this misses Austen’s skill here in the extraordinarily acute psychological portrait she gives of sustained unhappiness rooted in childhood. There is a careless misreading too. Henry Crawford doesn’t invite Maria Bertram to ‘slip dangerously over the ha-ha’. It is not the ha-ha – that feature of fashionable landscaping – but the symbolically loaded locked gate into the ‘wilderness’ that Crawford encourages the unhappily engaged Maria to slip round.

Dickens offers plentiful examples of diseased individuals, of course. Wright in the next chapter focuses on Little Dorrit and metaphors of quarantine. She also considers less familiar material: her subsequent exploration of Harriet Martineau’s novel Deerbrook (1839) and memoir Life in the Sick-Room (1844) is a welcome one. Her argument, however, for ‘the omniscience of invalidism’ is flawed by an imperfect understanding of narrative theory. The invalid can indeed occupy an important place as a story’s observant outsider figure, but this is far from making her an omniscient narrator. Wright is on safer ground with her discussion of the figure of the newly professionalised doctor in Gaskell’s writing and references to Victorian fiction’s most famous doctor – George Elliot’s Lydgate in Middlemarch.

Wright teaches family health at the University of Southern California. Her medical expertise perhaps allows her to assume in her readers a full grasp of the history of medicine in the period Reading for Health covers. It would have been helpful for non-specialists, however, had she set her discussion of preventive medicine in the wider context of evolving medical understanding across this period. There is one reference, for instance, to humoral medicine, but no mention of how that ancient model of human physiology had been comprehensively replaced by Enlightenment understanding of the nervous system. Above all, Reading for Health, however, is about story-telling. Wright follows Rita Charon in holding great store by its therapeutic powers; indeed her afterword comes to rest almost exclusively on Charon’s work. It is without doubt an appealing position, but a detailed critique of the claims for narrative medicine would have added sharpness Wright’s argument.



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