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medical humanities

Reclaiming Reflection: Creative Writing and the Medical Humanities (3)

16 Sep, 16 | by cquigley

 

 

Reminiscence Bumps: self-mythology and the landscapes of the mind

by Eleanor Holmes

 

When I think about the landscapes of the mind, I recall the undulations of the brain’s surface. The ridges and valleys of cortex, the gyri and sulci I had learnt about in my neuroanatomy classes aged nineteen. Those white plastic tubs we eased open to reveal two, pale grey hemispheres floating in straw-coloured formaldehyde. That clinical but distinctly organic smell of burnt rubber, astringency and wax. How we sliced sections of brain with something that resembled the knife my father used on home-cured ham. How surprisingly soft it was to cut.

Prior to starting my Spring School creative writing week at Newcastle University in 2014, I had read Pieces of Light: The New Science of Memory by Charles Fernyhough. It has been an invaluable source of information on the latest scientific research on memory, particularly autobiographical memory, but it has also been hugely inspirational as a piece of science writing (or creative non-fiction). Two things particularly stood out to me when reading the book and in researching this subject. Firstly, the notion that memory is random and secondly, that it is ultimately self-serving. As Charles Fernyhough states and the American writer and physicist Austin O’Malley wrote:

“Memory is a crazy woman that hoards coloured rags and throws away food.”

The randomness of memory is something that has often struck me. Why do we remember odd, apparently insignificant facts and not the things that would seem more important when looking back on our lives? Why can I recall the sandwich filling (garlic sausage) my brother threw out of the window that blocked the guttering, aged thirteen, but cannot remember the name of the actor who lodged with us? How can I remember the cigarette brand and packaging my grandmother smoked (Benson and Hedges, Silver) and a conversation we had about a TV programme aged fourteen but cannot remember any of the details of her funeral?

 Yet it is the small details, those seemingly random colourful rags that stick and then float to the surface when we recall the past, especially it seems when writing about it. It is particularly that rich period for memory from our teens to our twenties, the reminiscence bump that Charles Fernyhough writes about in Pieces of Light, that keeps emerging in my writing, whether I want it to or not.

“A British study showed that when autobiographical memories were cued verbally, there was a predictable peak between the ages of eleven and twenty-five: the well replicated phenomenon known as the reminiscence bump.”

The majority of the poems I wrote in 2014 for the Spring School fell into this verbally cued reminiscence bump. On the first day of our course, the poet Bill Herbert asked us to think about “where am I from?”, followed by “where do I identify as home?” This led to an exploration of self and belonging that I initially found hard to write about. I was born in Bristol, we moved to the Midlands when I was seven and there I stayed until I left for Nottingham University.

I disliked living in land-locked Warwickshire and didn’t manage to change this land-bound situation when I moved to Nottingham for university, but at least I had moved north. I have always been moving north, by increments, as well as edging closer to the sea. I had wanted to go to medical school in Newcastle but didn’t get an interview. I wonder whether it is really a coincidence of fate that led me to the North East (Durham initially and then Newcastle) or something that needed to happen; a kind of embodied genetic pull to this landscape next to the sea. Tynemouth is where I live now, positioned on the mouth of the Tyne and next to the North Sea with its wild surf and beaches, stretching up the Northumberland coast to Scotland like a golden thread. This is the place I am now most likely to call home.

What emerged from Bill Herbert’s class was a need to write about my birth, my mother and our at times difficult relationship. It was a theme that was to flow through all my submitted poems, along with water as the element that I most identify with. Bill also encouraged us to think of body as place, by reading an extract from Paterson by William Carlos Williams, a theme that resonated with me and the obsession I have with writing about the human body and my memories of anatomy and dissection from medical school.

It is now clear to me (after six years of pursuing a writing life alongside medicine) that when I write I don’t always decide in advance on form, I just like to write. It is later that I make a decision as to whether I am writing poetry, prose or script, when looking back over the words. Fiona Evans took our scriptwriting class mid-week and I was encouraged when she advised us not to be tied to form or structure. Her session also introduced me to Marina Carr as a playwright, specifically her play By The Bog Of Cats. As we read sections of this script it felt to me to be very poetic and suddenly the idea of scriptwriting seemed less daunting.

Learning about performance and the concept of the clown with ‘Miscreations Theatre’, and the history behind the art form with Helen Limon as facilitator, also influenced my poems, particularly the idea of embracing the ridiculous. The importance of being able to laugh at yourself I hope comes through in my writing. Black humour, said to be a medical trait but more often than not a coping strategy for the difficulties encounters of healthcare work, is something I often explore when writing about medicine and health. Too easily my writing can stray towards the subject of death; my father jokes that it is my favourite topic. It is perhaps an occupational hazard but I hope to strike a balance between being respectful of serious subjects whilst seeking out the humour inherent in most human interactions.

In William Fiennes’s class we were asked to draw a map from memory. I ended up drawing a detailed plan of my childhood home where we lived from the age of seven to sixteen, and wrote about the memories attached to this house. Here it seemed was an endlessly rich seam of childhood and teenage memories in terms of a reminiscence bump that still feels very vivid to me. I liked the idea of writing about my territory being invaded and many stories bubbled up from this exercise. I hoped it would link several themes together by highlighting an aspect of my growing up and the emergence of identity. This aspect of identity as an internalised life-story is another recurring theme in my writing, one that is so clearly linked to reminiscence bumps and the reason psychologists believe this age looms so large in people’s memories.

I am aware that much of what I’ve learned in creative writing workshops is that these small details – proper nouns, the use of all five of the senses when we write – that help to bring our writing alive. This must be linked to the way we remember. When we write we are creating a world (the world) for the reader, just as we do for ourselves when we remember the past. Memories are not stored like files in a cabinet, they are created anew each time we recall the past. We narrate our lives as serves us best at the time of recollection.

Childhood memories particularly are often recalled through collaborative acts of remembering, like a collage. I know that in a number of the poems I have written some details I’ve had to ask my mother about, as I couldn’t recall something exactly, or the name of a place or person. My mother, father and brother have helped me fill in the gaps where needed, but it is also noticeable that they do not remember everything as I do. Charles Fernyhough writes:

“The idea that the past is a story that we tell ourselves, whose vividness can be no guarantee of its authenticity, highlights our reliance on language for social acts of remembering. If our autobiographical memory system serves to create a coherent narrative of our own past, it is a system that can frequently fool us into believing stories that are not true, as evidenced by the fact that many of us ‘remember’ events that we no longer believe actually happened.”

This was the concept that I was fascinated to read about in Judith Schalansky’s beautifully realised Atlas of Remote Islands: Fifty Islands I have not visited and never will. Christy Ducker recommended this book (it’s really very beautiful, brilliant and unique) and the preface particularly intrigued me:

“The absurdity of reality is lost on the large land masses, but here on the islands, it is writ large. An island offers a stage: everything that happens on it is practically forced to turn into a story, into a chamber piece in the middle of nowhere, into the stuff of literature. What is unique about these tales is that fact and fiction can no longer be separated: fact is fictionalised and fiction is turned into fact.”

I think everything I write tends to start out as an exploration of autobiographical memory that I then run with, to a greater or lesser degree. Christy Ducker invited us to think of a place that we were experts on, then asked us to put someone into that environment who had no knowledge of it. This was the inspiration for My Mother Visits the Dissection Room, a blend of factual information in terms of place (the dissection room I remember from medical school and that I have lately re-visited) and my knowledge of my maternal relationship that ended up as a poem about an imagined scenario that incorporated all of these elements.

 

My Mother Visits the Dissection Room

by Eliot North

 

She said she wanted to go there.

So I pulled some strings,

read her the rules.

“Sensible shoes?” she said.

“Yes Mother. Plus clothes

you don’t mind ruined.

Fixers, they don’t wash out.

The smell will get you,

but not of death. More chemicals

like wax and rubber.”

But my mother, being my mother

didn’t seem to mind.

Walked right up to the

plastic head,

stuck her hand inside.

“You won’t even know

I’m here,” she said.

Pulled on a dark-blue lab coat.

Watched closely

as I unzipped the body bag,

revealed cavities and cages.

Stood on tiptoes to peer inside,

scribbled in her notebook.

So I placed a stool

three feet away;

her territory and mine.

When the students filed in

they looked at her,

the older woman with colourful shoes.

Whilst I quizzed the students,

she daubed her paints.

At the end they crowded round her.

Admired her line and

brave use of colour

whilst I put the organs back.

As the students left

she called out to them.

“Call me Poppy!” she cried.

They waved from the door.

“Weren’t they interesting?

What a wonderful body,

all those nooks and crannies.”

I slung the heart in a plastic bag.

Looked at my watch

before herding her out.

Then as we went to the door

she turned round and said,

“Shall we say the same time next week?”

 

Published by Ink, Sweat and Tears on 30/08/2016 http://www.inksweatandtears.co.uk/pages/?p=11697

 

These two concepts, the unreliability of memory and the way in which we narrate our lives using a blend of fact and fiction to best suit ourselves at the time of telling, is endlessly fascinating to me. I’ve struggled at times to differentiate between what I think actually happened and what I have imagined when recalling the past. The poems I write are often a conscious blending of fact and fiction, something termed in memory research as imagination inflation (what a great term!) I don’t like to pin down my writing necessarily as creative non-fiction. I would prefer to think of my poems as fictionalised truths. In this my drive towards a cohesive narrative wins each time; I will bend the facts to meet the needs of the story I am writing. Who hasn’t done that after all?

 

Acknowledgments

This essay draws on the poetry, prose and script suggested by tutors Bill Herbert, Christy Ducker, Fiona Evans, Helen Limon and William Fiennes, as well as the following books, performances and readings:

Fernyhough, Charles, 2013, Pieces of Light: The New Science of Memory, London: Profile Books Ltd. (quoted passages p 3, p 20, p 54.)

Ishiguro, Kazuo, 1995, The Unconsoled, London: Faber and Faber Ltd.

Lively, Penelope, 2013, Ammonites and Leaping Fish: A Life in Time, London: Penguin Books Ltd. Extract read by the author at NCLA Reading: ‘Penelope Lively in conversation with William Fiennes,’ on 1/5/14.

Payne, Nick, 2014, Incognito, London: Faber and Faber Ltd. (Script) and Performance at Live Theatre, Newcastle, 30/4/1/4 followed by post-show discussion with the author, neuroscientists and clinicians working with memory disorders.

Schalansky, Judith, 2010, Atlas of Remote Islands: Fifty Islands I have not visited and never will, London: Penguin Books Ltd. (quoted passage pp. 19 – 20)

Henig, Robin Marantz, The Reminiscence Bump: People looking back on life remember their twenties best. Psychology Today, Posted October 24, 2012. Cited https://www.psychologytoday.com/blog/cusp/201210/the-reminiscence-bump 2/8/16

Reclaiming Reflection: Creative Writing and the Medical Humanities (2)

15 Sep, 16 | by cquigley

 

Creative Non-Fiction: imagination and the nature of truth

by Eleanor Holmes

 

A copy of Primo Levi’s The Periodic Table lay on my bookshelf for years, a gift from my father, one of his favourite texts. The fact that I’d not actually read it until my creative writing tutor at Newcastle University, the author William Fiennes, re-introduced me to the collection, specifically the final story Carbon, reveals how I had for most of my life considered non-fiction to be less worthy of my time than fiction.

Why had I drawn such a distinction?

I had read numerous books at medical school by Oliver Sacks, such as The Man Who Mistook His Wife for a Hat and more recently Hallucinations. These books, it turned out, definitely fell under the banner of creative non-fiction. On the one hand they could be considered factual science writing, but Oliver Sacks as an author seemed to be doing so much more than that. This realisation made me re-think what this genre was or indeed could be. Since taking William Fiennes’ module in 2013, my consumption of creative non-fiction has dramatically increased and shows no signs of abating.

Creative non-fiction, as I now understand it, is writing based in truth that uses literary techniques more commonly associated with poetry, prose and script. The attention to character, voice, style, shape, structure and form mark out this genre from journalism and reporting; the facts of a piece not necessarily being as important as the way in which it is written. For me, the words ‘not necessarily’ are crucial here.

The suggested reading list provided by William Fiennes surprised me in its breadth and scope: memoir, reportage, nature writing, science writing, portraits, travel writing, case studies and essays. Unwittingly, I had read more than I had expected but it had never occurred to me to ask, “What kind of book is this?”

In favouring fiction, particularly the novel, I’d often sought to escape reality and move away from my own experiences as a child, growing up, going to medical school and latterly working as a doctor. I soon noticed that in writing creative non-fiction, whether telling your own story or that of another person, the writer can leave themselves very exposed. There is something that appeals to readers when an author states ‘this happened’ – to them or to someone else. It creates a stamp of authenticity that can be quite interesting to unpick.

The criticism Jon Krakauer received after publishing Into Thin Air is a reminder of this. In telling his own story, he was also telling the story of those who had died on Everest. His book reads like a thriller, the tension created by the narrative pace is palpable, but the story was never going to be easy to write or to be without its controversies. The moral and ethical debate surrounding consent and sensitivity when writing creative non-fiction is very interesting to me, particularly as this is something I have wrestled with when I have wanted to write about my own work as a doctor, the truth of my own experiences.

Having researched the science behind memory, I now know that when we recall something, memories are created from scratch using different areas of our brain. In remembering, we create our own unique version of the truth, every single time, which begs the question “what is truth anyway?” The latest scientific research on memory, gleaned from my reading of Charles Fernyhough’s fascinating book Pieces of Light, sits quite neatly alongside the fact that creative non-fiction can often blur what has happened (fact) with things that have been imagined (fiction). This creative license and economy with the truth when telling our own stories is something we are all likely to be familiar with, writers or not. I cannot remember with perfect accuracy conversations I had at the age of ten, but I can use my imagination to fill in the gaps, thereby telling the story I want to tell.

This seemed a minefield to me when I started to write, so much so that I wrote under a pen name and still do. This name is no longer a secret, I have become more comfortable writing about my experiences as time has passed. It now acts as more of a separation of my writer and doctor roles. The professional duties I am bound by I take very seriously; those of anonymity, confidentiality and consent. But these same concerns paralysed me for many years in terms of writing about my life as a doctor and all that medicine has done to shape who I am. The subject of family I find far easier to explore than strangers, colleagues or indeed patient encounters; not that I do not also consider and respect those professional parameters when writing about my family, particularly consent, as my mother will attest to in my latest series of creative non-fiction blog posts entitled Consultations with my mother.

The two poems I’ve written and published about clinical encounters (He Blew Me A Kiss in the previous post and The Milkweed Monarchs here) are two examples of how you can blend medical science and clinical detail within a human narrative, writing from different points of view, using characterisation and voice alongside a narrative arc. Interestingly, I can’t seem to write poetry without some kind of narrative inherent in them, perhaps because I was a prose writer before I started to write poetry. It wasn’t possible to gain consent to write these poems from the persons that inspired them, so providing anonymity was very important when I considered publication; a very deliberate blurring of fact and fiction.

One writer from William Fiennes’ reading list particularly stood out for me, and that was Jo Ann Beard. We read her story Werner, and the dramatic tension she created and her poetic prose style mesmerised me. This was a piece of writing based in truth, but it was someone else’s story, that of a man called Werner who the author had read about and contacted. The way she got inside his head, however, and the use of flash backs was so effective at creating this man’s inner world as well as re-enacting the outer facts of his extraordinary escape from a burning building, that you felt you were experiencing what happened as if you were Werner himself.

What particularly struck me after reading this was “how did she achieve this?” I have since researched Jo Ann Beard and found her writing described as ‘dramatic re-enactments.’ I went on to source another essay called Undertaker, Please Drive Slow which was published in Tin House after The New Yorker declined to run it as creative non-fiction. She wrote this forward to the piece:

In December 1997, Cheri Tremble committed suicide with the assistance of Dr. Jack Kevorkian. What follows is a merging of fact with fiction: the external details of Cheri’s life and illness are as accurate as possible, gleaned from interviews with her friends and family, while the internal details – her thoughts, her memories, and what occurred after her loved ones saw her for the last time – are imagined.”

In Undertaker, Please Drive Slow she utilises flash backs to Cheri Tremble’s past and childhood, flickering memories that mark her decline from a healthy, working woman and mother through her diagnosis of breast cancer, the treatment she endures, then her terminal decline. The images she uses to convey the final circumstances of her death are free of cloying sentiment and all the more powerful for it.

This writing is however right on the edge, clearly controversial because of the subject matter and the question of ownership as well as truth, whatever we mean by this. It does however shed light on a subject that is so rarely spoken about, that of death and dying. Clearly we cannot ask the person who has died to tell us about their experience of dying, but in this extraordinary essay I feel Jo Ann Beard comes as close as possible to doing that. There is a kind of alchemy at work here, the way she pushes creative non-fiction as a genre to its very limits to explore an emotional truth that I believe would not have been possible if this had been written as fiction.

Primo Levi notes in Carbon his final essay of The Periodic Table:

The reader, at this point, will have realised for some time now that this is not a chemical treatise: my presumption does not reach so far… Nor is it an autobiography, save in the partial and symbolic limits in which every piece of writing is autobiographical, indeed every human work; but it is in some fashion a history.”

I have now finished reading The Periodic Table, a book that defies easy classification, something I now realise is a positive draw for me and that I seek to explore in my own writing. The blend of short stories, memoir and science writing, woven together by Primo Levi’s love of chemistry, his training and work in this field, his survival of Auschwitz and the horrors of the Holocaust, and his undoubted genius with words is such a moving and life-affirming whole.

BBC Radio 4 have just dramatised The Periodic Table for radio, the different chapters named after single elements from the periodic table broadcast in episodes, ranging from fifteen minutes to an hour. This provides a perfect entry point to Primo Levi’s work as well as a way in to explore this rich and endlessly rewarding genre of creative non-fiction. If you read or listen to no other essay of Primo Levi’s make it Carbon, the story of a single atom of carbon as it journeys from limestone crag to the author’s brain cell as he writes. As William Fiennes said to me it is perfection in writing, the perfect full stop.

BBC Radio 4 iPlayer: Primo Levi’s The Periodic Table, available now: www.bbc.co.uk/programmes/p040d1vz/members

 

The Milkweed Monarchs

by Eliot North

 

I was riding my favourite bike. The Chopper

with the red flag and the silver streamers on the handlebars.

Minding my own business, cruising down Beach Road

to school at Kaikoura Flat. Happened right outside the

Whale Watch Office. “Idiot tourists,” Dad said,

“never bloody look where they’re going.”

 

Don’t remember much after that. Just the pain

in my belly, the voming and that funny shaped

bruise that crept like a shadow across my skin.

“Handlebars mashed his Pancreas,” the guy said to Mum

after they airlifted me to Christchurch. Wish I could

remember the ride. They’d given me the needle by then.

 

Couldn’t understand a word when I came to; most of

the docs were from England. Got my own room

on the kids ward though, was pretty stoked at first.

Turns out nine weeks in one room can really turn you off

a place. Kept telling me I couldn’t eat and put a stupid tube

in my chest, for that pseudo-food to drip in overnight.

 

Would’ve gone mad if it weren’t for the Monarchs.

Mum and Dad bought them in from the farm,

loads of tiny ones on bunches of Milkweed. Boy were

they hungry, just ate and ate whilst I couldn’t. Got fatter

and fatter, the black and yellow stripes growing further

and further apart. They were more interested in them than me.

 

Didn’t mind though, those ugly critters. Gave most of them

names. Watched how they crawled around my room before

they tucked their tails under like upside-down question marks.

Mum said I was daft, but I knew the Monarchs would save me.

As soon as they slipped into those bright green overcoats

and changed for good, with their precious crowns of gold.

 

“Coincidence,” the docs said. I don’t reckon. My pancreas

would’ve been stuffed if it weren’t for them. When the cocoons

turned black and then transparent, I could see the orange

wings inside.  First one came out all small and wet with

a loud POP!  Like the noise my brother makes when

people kiss on TV. I knew it was my time too.

 

Just pressed the buzzer and the nurses came flying.

Pulled out the drips, blood spurting over the sheets

but I was free. Stretched my arms wide and stuffed a

Chocolate Fish in my mouth before they got near my room.

You should’ve heard the shouting but I didn’t care;

there weren’t no Pseudocyst in me no more.

 

Commended in the Hippocrates Poetry Prize NHS category 2014

http://hippocrates-poetry.org/hippocrates-prize/2014-hippocrates-prize-open/2014-hippocrates-commended.html

Published in the accompanying anthology

 

Acknowledgements

This essay draws on the suggested reading list provided by William Fiennes for his Creative Non-Fiction course at Newcastle University and the following books, periodicals and podcasts:

Beard, Jo Ann, 2002, Undertaker, Please Drive Slow, Tin House Magazine, Portland: McCormack Communications. Vol. 3, No. 4, pp 27 – 59.

Levi, Primo, 2000, The Periodic Table, Penguin Books, London. Translated from the Italian by Raymond Rosenthal.

Fernyhough, Charles, 2012, Pieces of Light: The New Science of Memory, London: Profile Books Ltd.

Cusk, Rachel, 2013, New Writing: Memoir, Newcastle: Mslexia Publications Ltd. pp 30 – 42.

Radiolab podcast: Season 3, Episode 4, 2007, Memory and Forgetting, New York: accessed 1/3/13 at www.radiolab.org.

N+1 podcast: Episode 3, 31st August 2011, Both Fish and Fowl – Jo Ann Beard, New York: accessed 16/3/13 at www.nplusonemag.com.

Reclaiming Reflection: Creative Writing and the Medical Humanities (1)

14 Sep, 16 | by cquigley

 

Poetry and Reflection: a powerful tool for learning

This post is part of a series over the next three days on the theme of Creative Writing and Medical Humanities by Dr Eleanor Holmes (pen name Eliot North).

 

 As a GP Tutor I’ve delivered seminars on the patient centred medicine (PCM) component of Newcastle University’s Medical Undergraduate (MBBS) course to 1st and 2nd year students, for the past three years. Professional reflective practice is taught and assessed across all five years of the curriculum.

The ability to reflect and learn from clinical encounters is central to medical education and continuing professional development. Delivered within a creative context, I believe written reflection can also be an important tool to foster wellbeing and resilience in healthcare students and professionals.

Working in an increasingly overstretched and under resourced system such as the NHS, in which clinician burnout and mental health problems are on the rise, the question of how we reflect on the difficult and complex nature of care is becoming ever more important to address.

Stating that the answer might be found outwith Medicine may seem heretical, but it is my belief that we need to look outwards to move forwards. The Arts and Humanities, like Health and Medicine, explore and reflect upon the human condition. What therefore can we learn from each other?

My last seminar with my first year group was entitled ‘Professional Reflective Practice 2.’ After a year of working together trust, an essential element of clinical reflection, had been built within the group. I used my own writing, a poem called He Blew Me a Kiss, as a launch point for discussion, which was published under my pen name Eliot North.

 

            He Blew Me a Kiss

 

She liked Frank, they connected

despite his expressionless face. Behind the wound-up limbs and tremor

a gentle man shone out from the mask.

 

When she visited they would share a cuppa,

chat about this and that. Do the ‘medication shuffle’;

a two-step dance they both knew well.

 

She’d heard about stem cell research.

How they’d taken swabs from patients’ skin. Growing stem cells

from skin cells in dishes, right there in the lab up the road.

 

These stem cells would then become brain cells.

Models of Parkinson’s just like Frank’s. For testing newer and better

medications and perhaps one day even a cure.

 

The last time she saw Frank it was snowing

but he insisted on accompanying her out. Standing by the gate like a sentinel

he’d wave her off that one last time.

 

Later she’d think of stem cells like kisses

blown on the winter air. The moment captured in her rear-view mirror;

A hand lifted slowly, toward a frozen face.

 

Published by EuroStemCell ‘Tales from Within: Imaginative Non-Fiction on Stem Cells,’ 2013. (Frank is a pseudonym)

http://www.eurostemcell.org/he-blew-me-kiss-eliot-north

 

I have found that reading a poem aloud, that I’ve written myself, is an extremely powerful learning tool. There are obvious medical elements I can draw out regarding Parkinson’s Disease and stem cell research, but more than that the poem makes an important statement about connectedness, communication, the complex and varied role of a doctor as well as the limitations of medical science. It speaks to students about the importance of getting to know patients and continuity of care; how embracing the humanity in an encounter can be both powerful and revelatory.

The moment captured in the poem will live with me until the day I die, reading it always chokes me up; I choose to show this emotion to my students. We as clinicians who teach, whether in seminars or on the wards and in clinics, are hugely powerful role models. By stating and showing that this encounter moved me I am by example saying, “It’s OK to show emotion.” This leads to discussions about professionalism, boundaries and clinician wellbeing linked to the evidence base that demonstrates better patient outcomes when doctors show that they are emotionally affected when breaking bad news.

I wrote this poem many years after the event, it was something that sat in my brain waiting to come out. I wish that I’d been able to share it with the man who inspired the poem but he died some years before I got it down on paper. It was a EuroStemCell competition, partnered with the Centre for Regenerative Medicine in Edinburgh that spurred me to write it.

The challenge to submit an ‘imaginative non-fiction’ poem that incorporated stem cell research brought this encounter immediately to mind, the link between stem cells and Parkinson’s a way to explore how I felt about this patient. Discussing the creative process and the fact that I write under a pen name and changed the patient’s name forms a nice link to the importance of anonymity, confidentiality and consent, as well as patient and doctor voice.

With my students I then facilitated a creative guided writing exercise on a memorable clinical encounter followed by small group work, drawing and writing Haiku. The seminar culminated in poster presentations delivered by the students to the group. The results were insightful, empathetic and moving; their use of metaphor and close observation giving authenticity to the explorations they had made of encounters with patients and carers struggling to cope with dementia, a potential diagnosis of cancer and the communication difficulties witnessed for a patient with learning disabilities, linking this to issues of capacity and consent.

As someone who uses creative outlets as a way of coping with the stresses of practicing medicine, it amazes me that the word ‘creative’ can strike fear in to the hearts of medical students and healthcare professionals alike. I believe that by embracing creativity and essentially our inner child, written reflection can be much more than a required component of assessment and appraisal. All humans have the capacity to be creative, no matter how much they protest to the contrary. The skill lies in being able to coax it out of them.

 

Acknowledgements

All of the work I’m currently doing in this area is in collaboration with Sue Spencer with whom I wrote the guided writing framework I used above with my students, influenced by reading the books and on-line resources below. We are delivering a ‘Reflection of Clinical Encounters’ workshop using creative writing methodologies in November 2016 for the Staff Development Programme, School of Medical Education, Newcastle University.

Writing Poems by Peter Sansom, Bloodaxe 1994

The Poetry Toolkit – The Poetry Trust 2010, available as a free PDF download http://www.thepoetrytrust.org/images/uploads/pdfs/Toolkit%20for%20Teachers.pdf

 

Related reading

S E Gull, R O’Flynn, J Y L Hunter. Creative writing workshops for medical education: learning from a pilot study with hospital staff. Med Humanities 2002;28:2 102104

Khaled KarkabiOrit Cohen Castel. Teaching reflective competence in medical education using paintings. Med Humanities 2011;37:1 5859

T J Collett, J C McLachlan. Evaluating a poetry workshop in medical education. Med Humanities 2006;32:1 5964

Book review: The Heart

21 Jul, 16 | by cquigley

heart

Maylis de Kerangal, The Heart. Translated by Sam Taylor. Farrar, Strauss and Giroux, US.

In the UK it is titled Mend the Living, translated by Jessica French, and published by MacLehose Press.

 

Reviewed by Elizabeth Glass, PhD student in Comparative Humanities, University of Louisville.

 

The Heart by Maylis de Kerangal tells the story of 24 hours in the life, and death, of twenty-year-old Simon Limbeau. The narrative includes snippets from the brief hours before a car wreck that ultimately takes Simon’s life, moving through to the aftermath of his death when his heart is transplanted into the recipient Claire Méjan.

At the beginning of The Heart, Simon goes on a surfing trip with friends. On the way home, they are involved in a car accident. The other two young men escape with minor injuries, but Simon is critically injured. Once it has been determined that Simon’s injuries are fatal, and that his brain has ceased functioning, the doctor, Pierre Révol, approaches Simon’s parents to discuss organ donation. Initially reluctant, particularly about donating Simon’s heart which they believe holds his dreams, love and life, they eventually agree. Thereafter we follow the journey of Simon’s heart.

The Heart spends more time with Révol than any other character as we observe him negotiating with different aspects of the organ donation process. We also see Simon’s mom, Marianne, arrive at the hospital, her trauma heightened by being unable initially to get hold of her estranged husband, Sean, Simon’s dad. We then follow the interaction between the parents throughout the horrendous process of losing their adult son. We watch the hospital staff work with and around Simon. We are there when Révol asks Marianne and Sean to donate Simon’s organs. The most painful part of the novel involves witnessing Marianne’s reactions to learning new information about Simon as he is dying. Though we spend more time with Révol, we know Marianne better–we can feel her emotions. We meet Claire, who receives Simon’s heart. We also meet the transplant team and witness both operations: the organ removal surgery and the heart transplantation.

The novel is not about Simon’s life, and it is also not entirely about his death. Instead, it focuses on the donation and transplantation of Simon’s organs, and his heart in particular which we follow to Claire. We care about Simon’s organs as he is being kept alive awaiting surgery, and then it our own hearts that quicken as his is removed. The surgical scenes are the most tense in the novel overall. They allow the reader to alternate between a distance of watching from afar and that of being almost so near to hand that we could imagine ourselves passing the sponge to the surgeon. This is when we are closest to feeling and understanding what the characters experiencing. While the surgery and the donation process are both simplified, for someone who is only peripherally acquainted with such processes, the medical procedures were described in a detailed and interesting manner without becoming overly technical.

The Heart is told from an omniscient narrator’s point of view with a distance that gave me the feeling of being outside a glass door, or looking down from above in an operating theatre, an onlooker on unfolding scenarios. The narrator is not only all-knowing but is also an I who addresses the reader as you on occasion. This had the effect of taking me out of the moment of the action and of detaching me from the story. It caused me to wonder who I actually was, but the answer to this is never revealed and the identity of I remained hidden throughout. At one point the narrator writes, “You undoubtedly remember the description of the books on Révol’s metal shelf, mentioning a copy of an issue of that magazine from 1959, so you will have already guessed that the article appeared in that very issue” (p. 32). Instead of drawing me into the story, this aside had the opposite effect. Such asides were infrequent, but when they did occur I found them distracting. The narrator was not a presence that I was aware of all the time; the opposite in fact, as most of the time the narrator was in the background. Thus, when he or she appeared, it felt strange and distanced me from the ongoing story.

This distancing, which creates the illusion of watching what is happening, of being an onlooker instead of being directly involved, means that as readers we can only access the characters’ thoughts tangentially. The things we know are told to us, but with the impassivity of overhearing a stranger’s order at a restaurant. As a result, it is hard to care about the characters to the extent that the subject matter deserves. However, if one did become very involved with the serious content, The Heart would surely become a challenging and potentially harrowing read. Thus, the sense of clinical detachment evoked probably serves a useful purpose, and will, I suspect, ensure a wider readership.

Each sentence in The Heart tends to be a paragraph in length, containing many phrases separated by commas. This makes the novel a difficult read at times and is potentially distracting; yet it also encourages a sense of urgency. The reading experience felt halting initially, but this sensation ceased as I progressed through the book. At the outset I found myself stumbling and searching for parts of speech to make sense of some of the sentences, but there came a point later in the book when I found myself unable to put it down.

There are two versions of the novel translated into English from the original French: for the United States it is titled The Heart, and for the United Kingdom Mend the Living, which is a more direct translation of Maylis de Kerangal’s original French title Réparer les vivants. Mend the Living was nominated for the Man Booker Prize. The US reader will have difficulty with Mend the Living, however. For example, in Mend the Living, as Simon and his friends are getting ready to surf, they are said to have “liquid rhinitis, sleep with your clothes on.” In The Heart, it says they have, “runny noses, slept-in clothes.” This type of difference exists between the two translations throughout. The end of Mend the Living is as exciting as The Heart, but elements of the writing will limit its appeal to the American reader. Thus, for this reader, Sam Taylor’s translation was a more satisfactory read.

In terms of the Medical Humanities, The Heart is an illustrative example of the arts interacting with medicine. The reader witnesses doctors wrestling with complex ethical issues such as how far to push the parents to donate Simon’s organs, decisions around to whom his organs will be donated, as well as the reality of the organ removal surgery that ends his life. The reader also observes Claire’s Méjan’s difficulty coping with the fact of receiving the heart of someone who has died, as well as her transplant surgery. All these issues render The Heart a compelling read.

Overall, The Heart is a gripping novel. Although we know at the outset that Simon will die, this fact does not detract from the extent to wish it engages the reader. The book is not without its faults. The reading experience may indeed have benefitted from a shorter sentence structure, and from a more in depth delving into the characters’ minds and thoughts. Notwithstanding, the narrative that underpins the novel remains intriguing and engaging. The Heart is particularly recommended to readers of Medical Humanities.

 

 

 

Related reading

M Shildrick, P McKeever, S Abbey, J Poole and H Ross. Troubling dimensions of heart transplantation. Med Humanities 2009;35:1 3538

TA Faunce. Book review: Cutting for Stone. Med Humanities 2009;35:2 123124

‘I am Book’ – Clare Best

1 Jul, 16 | by cquigley

Illustrated talk for University of Kent symposium

on Artists’ Books and the Medical Humanities, on 21 April 2016

http://www.kent.ac.uk/english/research/conferences/artistsbooks.html

I had been so looking forward to this wonderful symposium devised, designed and immaculately planned by Stella Bolaki, and to seeing the exhibition of Martha Hall’s and other book artists’ work  – which is still on until 14 August  (Prescriptions Beaney House of Art & Knowledge, 21 April-14 August 2016). Then I went down with a virus the day before the symposium and lost my voice overnight. Stella very kindly delivered my talk for me and showed the images that went with the words. Here is a potted version of my talk. See some of the images at https://selfportraitwithoutbreasts.wordpress.com/2016/05/26/illustrated-talk-for-university-of-kent-symposium-on-artists-books-and-the-medical-humanities-on-21st-april-2016/

As well as being a writer, I have worked as a fine bookbinder, a bookseller, an editor and a Creative Writing teacher. Throughout my life, making books has provided me with metaphorical and physical structures within which to reconstruct versions of my self, and body.

I am Book. A bold statement, but a pragmatic one. To a great extent we are all Book. We have our narratives, we talk of turning the page, or of starting a new chapter in our lives. We shelter, disguise or hide ourselves between covers. But I think I’ve always been particularly absorbed in the idea of books, of Bookness, and today I’m going to talk about why that is so, and perhaps my sense of Bookness might suggest things about artistic identity in general.

My father was a papermaker for his entire working life. As children, my brothers and I spent our Saturday afternoons at Dartford Paper Mill, where my father was then Manager. Our lives were full of paper samples and offcuts. I wrote on them, folded them into pamphlets and made childish books out of them from my earliest years. And I was an obsessive reader. It all began with the illustrated Golden Treasury of Poetry I was given for my 6th birthday. It’s still one of my most precious belongings. I feel a primal thrill when I open it. Most of the time, growing up, I had my nose in a book.

I went on to read English Literature at Cambridge, gathering along the way a passion for print and fine books, and after university I decided to become a book maker and book doctor – I trained as a Fine Bookbinder and loved working with fine papers, cloths, marbled papers, leather, vellum, gold leaf. But after nearly wrecking my eyesight with close work (gold tooling) I was obliged to change professional direction. I went to work for Tim Waterstone in the early 1980s when his bookshops were taking London by storm. In time I moved across from the art book department at the High Street Kensington store to working with Waterstones Publishing Division, first as a researcher, then as an editor. Later I was an editor for ten years with the French publisher Gallimard Jeunesse and their English language partner Moonlight Publishing.

I can see now that up to this point I was wanting more and more to inhabit Bookness – to read, to make and bind, to edit and publish and sell – but had not yet dared to jump into the very stuff of my identity, or identities – the writing itself. And, through the writing, to uncover the reasons for my Bookness in the first place.

So I see these stages of my life, up to my early 40s, as serial constructions, deconstructions and reconstructions of different versions of myself in the world, in efforts to find out what I was and where I belonged. I was creating and exploring a kind of library showing different aspects of my identity, or indeed different identities.

Since then, the past twenty years have represented a deeper and infinitely more satisfying deconstruction and reconstruction of my self, my selves, through writing and making Books that I inhabit from the inside, outwards.

I had always written, but the pressure to ‘come out’ as a writer built up through the 1990s and beyond. The latter part of this period then coincided with another pressure in my life, that of facing head-on my high risk of contracting the genetic breast cancer in my mother’s family. The result of this confluence was my first full collection of poetry, Excisions, which has at its core the autobiographical cycle Self-portrait without Breasts.

(Here I would have read a few of these poems, alongside showing some of Laura Stevens’ photographs which were taken in two shoots, the first a few weeks before, and the second some 18 months after, my risk-reducing double mastectomy.)

 

Self-portrait without Breasts

 

Tangled hair, charcoal-socket eyes,

mouth slack after one more long night

restless on my back. This body’s fenscape,

manscaped, hills removed – the meaty joins

still livid, tight shut mouths

where distant territories were stitched

 

in touch. Blood seeps in deltas over ribs,

yellow and purple track to the waist.

You’re even more beautiful now, you say

and I believe, for though I never was, I am

explorer, seeker – I’ve travelled

and I have an ear for truth.

 

Memento

 

When you cast me, I held my breath

as the plaster set. You kept your focus,

capturing the contours of my breasts.

 

Remember that awkward fold by the clavicle,

air trapped between layers, remember

my fear – that flesh could not be cast

 

to look like flesh. But now, when I touch

the rough white woven skin, I want to quit

my body, let the twin chalk rind

 

contain my breath, while I recall a lover’s kiss,

the heat of milk-tight flesh, my newborn

trying to focus as I held him.

 

How will I remember this?

Numb flesh stapled over ribs,

my breath snagged within.

 

Making the Self-portrait poems provided me not only with a way of working through and revisioning my experience of this trauma and its many repercussions, but also with a way of reconstructing my changed body into a body of work – and, metaphorically and literally, into a Book. Excisions has proved to be a key book in my development as a writer and in my personal growth – a milestone on my artistic journey. At the level of line and stanza, as well as at the level of physical object, I used poetic form to bring new order to my altered identity and to my sense of belonging both in terms of family history and artistic inheritance.

I later put together that very solo experience of writing the Self-portrait without Breasts poems with Laura Stevens’ before and after photos (in book/pamphlet form, as Breastless).

Since then I have returned several times to the Bookish concept of collaboration – through a site-specific theatre piece called Vacant Possession co-written with Sara Clifford in summer 2015, through a multimedia project Take Me With You: the museum of friendship, remembrance and loss, with the film-maker Tim Andrews, which was launched at BSMS in February 2016, through Springlines, a project with the painter Mary Anne Aytoun-Ellis in which we are exploring hidden and mysterious bodies of water across the South of England – and through a three-way collaboration to make CELL, involving my own long poem in twelve parts, Michaela Ridgway’s drawings and Katy Mawhood’s design.

This last project, CELL, had been many years in gestation before being published in its unusual ‘almost-pamphlet’ state in 2015, and in some respects it is – of all the books I have made – the one that most closely represents, in its themes and emotional content and in its form, my own earliest sense of identity.

The poem is a retelling of the story of Christine Carpenter, a girl of fourteen who was enclosed in an anchorite cell in 1329. She requested release after more than a thousand days of living in the cell, and did come out, only to be forcibly re-enclosed when the Bishop heard of her release.

I myself was sexually abused, and emotionally ‘locked away’ as a young child. I underwent many years of isolation, silence, shame and suffering before finding my way out of the cell and into healing.

(I would then have read out parts of an interview about CELL with Kay Syrad for the most recent edition of The Frogmore Papers.)

 

Kay Syrad in dialogue with Clare Best about CELL (Frogmore Press, 2015)

 

‘KS: Getting ready to read CELL, I found myself acting rather ritualistically: I cleared the table, placed the pamphlet parallel to the edge of it, carefully removed the wrapper, studied the cover and the printed burgundy paper sleeve, eased off the sleeve and finally held the pamphlet in my two hands. Standing up throughout, I read the poem until I came to the point where, following the diagram, I was to unfold the pages in a way that creates a paper ‘cell’. There could be no rush.

 

I think this is the closest I have come to genuinely embodied poetry: knowing there is a potential space within the form, waiting for it, creating it, reading the poetry within that confined space, unfolding the structure to a flat sheet and then refolding it into its pamphlet form – these experiences seem to me quite as emotionally significant as reading the poem. Would you agree?

 

CB: With CELL, I wanted the reader’s experience of content and physical form to be especially closely bound.

 

To write the poem, I’d researched what happens to the body and mind in situations of extreme privation such as enclosure in a basic cell over this kind of period. I wanted to emphasise the changes Christine would have lived through by achieving a physical form for the work which is several different things at once (pamphlet, paper sculpture, flat printed sheet) and which suggests alternations between different states.

 

The object’s form is designed to mirror the unfolding drama described in the poetry and the drawings. Early sections of the poem can be read by turning the pages, so far so relatively normal. Then the reader discovers the ‘cell’. Next they must open the entire sheet – making the ‘cell’ vanish and freeing its imagined prisoner – in order to find and read the last section of the poem. Finally, refolding the sheet into a pamphlet is like re-enclosing Christine or even burying her. Throughout, the reader is in some way complicit in the events of the poem simply by carrying out the act of reading.

 

KS: Your crystal clear, unflinching poem lives and breathes not only the pain of its subject, Christine Carpenter, but her heart-breaking effort to justify her pain – and in this way the poem speaks to every woman who knows the cultural and mortal price of imagined or projected ‘sin’. Clare, what precipitated the writing of CELL?

 

CB: I’d started thinking about the themes in CELL when I spent some intense weeks working with male life prisoners, witnessing the damage that separation and isolation can do to a person. And I know a lot, personally, about the damage inflicted on the self by shame. Finding and retelling Christine’s story presented an opportunity to write in a focused way about the double prison of isolation and shame.

 

CELL evolved slowly over a number of years when I was working on other poems and sequences and also on a prose memoir which explores relationships between daughter and father, daughter and mother. Christine’s mother plays an important role in CELL, although we never hear her voice. There are also male figures in the poem – the priest/father figure whom Christine watches through her cell window, the real or remembered or imagined Lucifer/rapist, and the Bishop. The mother’s absence, together with the ambiguous overlapping presences of these males, points to some essential but unspoken truth about Christine’s vulnerability. Today we would probably say that she was acting out a traumatic past. I am interested in how the ‘choice’ of extreme deprivation (still) can be framed as religious cleansing.

 

But in some ways I wrote CELL blind and it wasn’t until the poem was almost complete that I realised fully what it was about.

 

KS: The pen and charcoal drawings by Michaela Ridgway (who is herself a poet) also embody a claustrophobic intensity in the way they refuse to stay within their borders, at once hiding and exposing a female body that is tender and fierce, layered, smudged (almost erased), dark or clear. Can you tell us how this extremely effective collaboration began and how it developed into what we see here?

 

CB: I was finishing the umpteenth draft of CELL and beginning to think about how to send it out into the world, when I saw Michaela’s powerful and enigmatic drawings of female nudes which she was posting on Facebook. We met and talked at length. Michaela completely ‘got’ the poem and the layers of it, plus she agreed with my aim of wanting poem and art to work independently and together – this was no illustration task.

 

We talked about how we wanted words and images to complement each other, moods and feelings to bounce around between them. From this point, our work was to whittle down the choice of drawings, discover how to sit the images within or across the confines of rectangular spaces, and figure out where to place them in relation to the poetry in order to imply both incarceration and breakout, confinement and rebellion. We also wanted some significant blank space – with only a single folding sheet this was challenging, but we managed it!

At the same time that Michaela and I were thinking about all this, we were consulting the designer Katy Mawhood, whom I had commissioned. Katy had excellent ideas for placing Michaela’s art and my words in the context of the particular pamphlet form we had decided on. For instance, Katy’s suggestion for the lettering on the cover, where the C of CELL appears like a cap over the neck of a headless female figure, was daring. Michaela loved it and so did I. In fact, that C and the entire cover design encapsulate the power of word and image working in close harness.’

To finish, I’d say that for me and for my evolving identities, the idea of Bookness carries sacramental meaning.

Books, in all their forms and in all their manifestations in my life, have been my saving and my making, my containment and my freedom, my focus, my work and my relaxation.

I made my first books with my father’s discarded paper. Later – in training to be a bookbinder – I was preparing to rescue, restore and protect my own damaged and vulnerable yet resilient substance, my own Bookness. I was drawn to bookselling and publishing because they kept me in close contact with my life blood. But writing and imagining my own Books into being has been and is for me the most faithful and true expression of my identity/ies.

I like to think of my bookbinding skills, tools and materials as interchangeable with elements of my life and creativity. I start with flat sheets, I fold and sew and cut them into books, press them in presses, cover them, decorate them, leave them under weights. Like the surgeon or the tailor – as a writer, artist and maker of books, I keep my knives sharp, my eyes clear, my needles and tape measure close to me.

As a child I reached for what was closest and I made of the materials what I could, what I had to. I have continued to do this and I will do it all my life.

 

The bookbinder

 

Pare the leather, thin the skin

where it must stretch and crease.

Then paste: the tanned flesh darkens,

 

wet and chill, fingers working

over spine and cords, into joints,

mitreing corners neat and flat.

 

Bandage the book in paper, let it

settle under weights, day after day

until the leather’s dry and tight.

 

When the time is right for finishing,

black the room, clamp the book

spine up in the beech-wood press,

 

the lamp pointing where to begin.

Hot brass letters and a vigilant hand –

an accurate blind impression.

 

Paint in glair with a fine brush,

lay on gold leaf, with level breath.

Tilt the light, shadows will reveal

 

the place to press the tool again.

Now, strike the gold – feel the title

word by word, bright in the grain.

 

Clare Best is a poet and writer with particular interests in writing body and landscape. Her poems are widely published in magazines including The Rialto, The London Magazine, Magma, Resurgence, Agenda and The Warwick Review. A chapbook, Treasure Ground (HappenStance 2009), resulted from her residency at Woodlands Organic Farm on the Lincolnshire fens. Breastless – poems from the sequence Self-portrait without Breasts with photographs by Laura Stevens – came out with Pighog in 2011, and Clare’s first full collection, Excisions (Waterloo Press 2011) was shortlisted for the Seamus Heaney Centre Award. She teaches Creative Writing for Brighton University and the Open University, and lives in Lewes, Sussex.

www.clarebest.co.uk

http://selfportraitwithoutbreasts.wordpress.com

Kay Syrad’s website: www.kaysyrad.co.uk

 

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.”

 

References

  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.

The Reading Room: Salka Valka

27 May, 16 | by cquigley

 

Salka Valka by Halldór Laxness: she needs to be alone

 

Reviewed by David S. Baldwin, Professor of Psychiatry

Clinical and Experimental Sciences Academic Unit

Faculty of Medicine, University of Southampton, United Kingdom

Email:  dsb1@soton.ac.uk

 

Born in Reykjavík in April 1902, Halldór Guðjónsson (he changed his name to Halldór Kiljan Laxness in 1923) lived through almost the entire twentieth century. Raised in an isolated and traditional society, he travelled widely and embraced cosmopolitan modernity, though retained an essentially Icelandic identity. In early life Laxness adhered to staunch revivalist Catholicism, then embraced socialism for thirty years. He subsequently espoused ecological and pacifist causes and addressed philosophical questions reflecting an interest in humanism and Taoism. But the principal achievement of Laxness was the authentic portrayal of sympathetic but struggling characters that symbolised the determined aspirations of the Icelandic nation and marked its long path towards eventual independence from colonialist Denmark (1).

 

Laxness travelled to America in the 1927 summer intending to become a Hollywood screenwriter. Writing to his then wife Inga at the end of that year, he described work on a film script provisionally titled Salka Valka (or, A Woman in Pants): the eponymous protagonist is described as ‘tall and strongly built’ with an expression encompassing ‘rustic virginity, dare-devilry, primitive charm’, and ‘dressed like a fisherman: wide pants, the boot-legs reaching up over her knees, a pipe in her mouth’. The script reflects contemporaneous Freudian concepts of human sexuality and is redolent with surrealist images, such as the final scene in a lover’s cottage where Salka lingeringly unfolds and kisses the leather straps of an Icelandic whip (often made from skin of bull penis) and Laxness imagined the cross-dressing Swedish actress Greta Garbo in the title role (1). Not surprisingly, negotiations with MGM floundered so the script was transformed into a two-part novel: the first manuscript was written whilst visiting isolated Icelandic fishing villages, the second was completed in cosmopolitan Weimar-era Leipzig. These were published a year apart with the support from the national Cultural Fund: the first (O Thou Pure Vine) was well received, but the second (The Bird on the Beach) was chastised by conservatives for its perceived lampoon of boorish ‘upper class’ motivations and criticised by progressives for its caricature of labour movement infighting – the Communist Party leader suggesting Laxness approached socialism as an idealist, with only a bourgeois understanding of the workers’ struggle (1).

 

An English translation of the combined parts of Salka Valka was published in 1936. The English language version has been out of print for many years, but Guðny Halldórsdóttir kindly lent me her copy, which was published in 1973 following revision by her father (2). A previous review commended its saga-like objectivity and clarity, and the masterful portrayal of down-trodden characters whose local quotidian travails seem emblematic of wider persistent human suffering (3): another account praised its Christian symbolism and careful balance of honourable parishioners and devious villains on both sides of the class struggle (4). The themes reflect the author’s perennial concerns with the nature of love, position of women, role of the intellectual, and the lot of common people: many chapters are full of visceral emotions and disturbing sexual acts perpetrated against young women. In a notebook Laxness described his wish to provide ‘tragic perspectives on the incomprehensibility of human feelings’, perhaps drawing on his desolation, anguish and guilt at the end of an affair with an Icelandic woman whilst living in America. But neither review has considered how the progressive emancipation of Salvör Valgerður (‘Salka Valka’) – as she first becomes a prominent local activist, then distances herself from the competing attentions of aggressively preying or dependently needy men – may reflect a growing awareness of her own sexuality.

 

The novel starts with the mid-winter night-time arrival by boat of eleven-year old Salvör and her unmarried mother Sigurlína at the run-down fishing village of Óseyri. The daughter disembarks first and reassures her mother, ‘in a low deep voice’ which suggests that of a man. They are grudgingly offered a room for the night at the Salvation Army hostel, but the next day their destitute status is acknowledged but not addressed by the local storekeeper, rector or doctor. They return to the hostel and fall prey to the impulsive but persuasive drunkard Steinþor Steinsson, who leads them towards ‘Marbud’, the home of his elderly aunt Steinunn and almost-blind uncle Eyjolfur, where they are offered lodgings. That evening Salvör tells her mother that whilst she was outside Steinþor had ‘grabbed hold of me here and here, and here’, and ‘whispered some stuff in my ear’ but Sigurlína responds inadequately, by asking for mutual understanding between ‘two women’, a response which has a fatal consequence. During the night Salvör is woken by the sound of tussling in the bed, as Steinþor forces himself on Sigurlína: he is repulsed, but only after he whispers a proposition which makes her recoil ‘Almighty Jesus, no! You know you can’t ask me to do a thing like that’. Later, whilst lying awake, Salvör realises she had often lain alone at night whilst her mother was absent, and for the first time appreciates she will have to rely on herself for her future safety: the narrator commenting ‘perhaps one really had nobody but oneself’.

 

The first part ends at dawn on Easter Day, when Sigurlína is found drowned, ‘a little grey oblong piece of flotsam which had been washed up on the sand’. This suicide is the result of a long process which includes remorse for the relationship with a married man which led to pregnancy with Salvör, regret for a subsequent series of damaging sexual liaisons with exploitative men, persistent grief following the death of her two-year old son Sigurlinni from scrofula (tuberculous cervical lymphadenitis: it is later revealed that Steinunn lost many children at Marbud to the same illness), a demoralizing awareness that Steinþor had once again attempted to force Salka into a sexual relationship, and acute anguish following a second desertion by Steinþor, just a few days before their hastily-arranged ‘Hallelujah Wedding’ scheduled for Holy Saturday. Her fragile personality could not withstand such prolonged adversity, without unconditional support from her daughter for whom ‘her mother’s weeping no longer went so deep to the heart as it had done’. During her testimony on entry into the Salvation Army two years before, Sigurlína had told the Congregation of her intention to commit suicide whilst pregnant with Salvör, but attempts at spiritual consolation by vigilant fellow Congregationalists following this nuptial desertion had made no impact: and the position of the often-derided Sigurlína within the wider community had always been marginal. Salvör, just fourteen years old, guarantees the costs of the funeral and walks back to Marbud, alone.

The second part of the novel charts the rise to prominence of Salvör within Óseyri. She establishes a local branch of the seamen’s union to defend workers against managerial exploitation; educates herself through reading political, evolutionist and philosophical texts; and assumes maternal responsibilities for four children once their mother dies. She is praised for being ‘a match for any man alive’. She is tall, erect and high-shouldered, her thick hair cut short with a side-parting; has courageous clear eyes, strong jaw and full lips, firm hands and a deep voice; and wears Alpine hiking-boots, woollen trousers and a roll-neck Jersey sweater which does not conceal the full curve of her firm breasts. She is commended by her childhood crush Arnaldur (by then a Communist agitator) for being a ‘tovarisch’ (Bolshevik comrade worker) icon, but current observers might recognise her portrait as iconographic of something else. She withstands the pleading entreaties and forcible sexual attentions of now-wealthy but still unscrupulous Steinþor, and leaves Marbud after she discovers it was Steinþor who had provided anonymous funds which enabled her to remain there after the death of Steinunn and Eyjolfur. Once aware of the feckless serial infidelity of the impractically idealistic Arnaldur (and despite some lingering affection for him), she reluctantly but determinedly ends their relationship by encouraging him to pursue his dreams in America. At the end of the novel, when the twenty-two year-old Salvör is finally free of unwanted male attention, the narrator compares her solitary precarious existence to the eggs of winter birds resting on narrow ledges on a high cliff-face: but contemporary readers might contend that having rid herself of both barbarous Steinþor and immature Arnaldur, Salvör may not want but certainly needs to be alone. Though with a typical twist, Laxness suggests she may be pregnant: for as Salvör walks past her most long-standing friend, he comments enigmatically, ‘cold weather to be born in’.

The novel therefore carefully illustrates the potentially damaging consequences of parentlessness, childhood abuse, unexpected bereavement and marital desertion; the corrosive effects of social and economic inequality; and the undermining of the aspirations of women by patriarchal institutions. Sigurlína succumbs after accumulated experiences of deprivation and loss, mediated through demoralisation and despair. It is argued that ‘resilience’ represents a process which allows the resumption of development following trauma or other adversity, and contends that ‘bonding’ and ‘meaning’ are important dynamic features which support this process (5). Those with only fragile affiliation or for whom life has lost its meaning (as depicted by Sigurlína) are less buffered against undermining challenges: but the active community engagement of Salvör provides a supportive network facilitating her eventual passage towards probable independence and emancipation.

 

References 

  1. Guðmundsson H. The Islander. A Biography of Halldór Laxness, trans. by Philip Roughton. MacLehose Press 2008.
  2. Laxness H. Salka Valka, trans. by F.H. Lyon. London: Allen & Unwin, 1973. Originally published in two parts as Þú Vínidur Hreini (1931) and Fuglinn Í Fjörunni (1932).
  3. Magnússon S. The World of Halldór Laxness. World Literature Today 1992; 66: 457-63.
  4. Hallmundsson H. Halldór Laxness and the Sagas of Modern Iceland. The Georgia Review 1995; 49: 39-45.
  5. Cyrulnik B. The Whispering of Ghosts. Trauma and Resilience, trans. by Susan Fairfield. New York: Other Press 2005.

The Reading Room: ‘Making Medical Knowledge’

25 Apr, 16 | by cquigley

 

Making Medical Knowledge

By Miriam Solomon

Oxford University Press, 2015

 

Reviewed by Dr Jonathan Fuller, University of Toronto

 

We should forgive anyone unfamiliar with recent trends in ‘scientific medicine’ for thinking that within scientific medicine there are now multiple medicines to choose from: evidence-based medicine (EBM), translational medicine, narrative medicine, personalized medicine, and so forth. These approaches are not distinct professions in the same sense as allopathic medicine and naturopathy. But just what are the relationships among modern medicines many ‘medicines’?

In Making Medical Knowledge [1], philosopher Miriam Solomon sets out to assess four of these movements introduced over the last forty years: medical consensus conferences, EBM, translational medicine, and narrative medicine. She calls them ‘methods’ to be concise, but notes that they are distinct epistemological approaches, or approaches to (medical) knowledge. Solomon writes that she selected these four methods because of their “dual and paradoxical epistemic character” (p. 14): there is something obvious about each of them (of course medicine should be ‘based on evidence’), as well as something odd (‘evidence-based medicine’ deemphasizes many kinds of evidence, including expert consensus). Given how much time, effort and money is being spent in the name of these movements, a close inspection is certainly warranted.

Solomon’s approach in her book is to examine these methods using an interdisciplinary lens. She situates her study in the realms of social epistemology, philosophy of medicine, integrated history and philosophy of science, science and technology studies (STS), and critical medical studies. She describes her approach as “Naturalistic, Normative, Applied, Pluralist, Social Epistemology” (p. 11); in other words, she aims to describe and evaluate actual medical knowledge and practice using a diverse set of tools, and with a focus on the social. She writes for a broad academic audience, including the medical community.

In the introductory chapter, Solomon argues that “[t]he science/art dichotomy is no longer a fruitful disciplinary divide” or a meaningful way of describing medicine (p. 11). She instead argues that a ‘methodological pluralism’ describes contemporary medicine and its many methods for negotiating knowledge. Solomon then spends three chapters examining medical consensus conferences and group process, two chapters on EBM, one chapter on translational medicine, and one chapter on narrative medicine. The penultimate chapter advances Solomon’s ‘developing, untidy, methodological pluralism’. According to this view, medicine’s epistemological approaches do not have exclusive domains of application; all of the methods she describes are in active use, their domains overlap, they sometimes come into conflict with one another, and there is no “hierarchy of methods” (p. 229) to rescue us when they clash. The final chapter summarizes Solomon’s main conclusions.

Making Medical Knowledge is an excellent and pioneering study of some of the dominant movements in early Twenty-First Century medicine, which – with the exception of EBM – are relatively unexplored by scholars. It provides a good entry point, offering detailed and insightful reconstructions of each method within its historical context, thus satisfying Solomon’s descriptive aim. The historical detail is rich, especially for medical consensus conferences. Solomon is charitable towards each method, and manages to find substance amidst the rhetoric, even for translational medicine, which is especially difficult to pin down and appears at first glance to offer no more than metaphor. She also provides thoughtful criticisms of each method, thus satisfying her normative aim.

Overall, I think Solomon pitches the discussion well for the broad audience she has in mind. The philosopher, historian, sociologist and anthropologist should all find something of interest in her book. I expect that clinicians, especially within academic medicine, will find it fairly accessible. Satisfying the needs of her diverse audience perhaps prohibits Solomon from going into as much depth as some philosophers, historians or social scientists might like. Such is the cost of interdisciplinarity, but it pays off in the form of a study that benefits from its use of multiple disciplinary lenses.

While I generally agree with Solomon’s analysis of each method, I was not fully convinced that an ‘untidy, methodological pluralism’ is the best way to understand the relationships among the methods. Solomon accepts that the methods are often active at different stages of research, but nonetheless argues that they do not fall on a “tidy linear spectrum” from research to practice (p. 206). Yet as her own analysis reveals, translational medicine (research from ‘bench to market’, or ‘T1’) refers to basic medical science research as well as Phase I and II clinical trials, EBM appraises and aggregates the results of Phase III trials, medical consensus conferences make therapeutic recommendations based on the results of Phase III trials or systematic reviews of trials, and narrative medicine (in its integrated form) interprets guidelines and the research literature in the context of the patient’s story. In other words, translational medicine applies to medical research, consensus conferences apply to knowledge dissemination, and EBM and narrative medicine apply to clinical practice. The main purpose towards which each method is put is unique: translational medicine develops new medical technologies, consensus conferences develop consensus statements or clinical guidelines (often pertaining to those technologies), EBM appraises evidence and applies it in clinical practice, and narrative medicine uses narrative techniques at the bedside. Thus, their domains are less overlapping and arranged more linearly than Solomon’s untidy pluralism might suggest.

Of course, the practice of EBM might sometimes conflict with the practice of narrative medicine (more on this point in a moment). Moreover, the practice of narrative medicine or of EBM might sometimes conflict with the products of consensus conferences: clinical guidelines. Narrative medicine locates individuality in the patient’s narrative, and EBM is often defined as the use of evidence in the care of individual patients [2]. On the other hand, guidelines make recommendations for broad groups of patients, not for individuals.

Solomon presents the example of breast cancer screening for women in their forties to illustrate the various ways that the methods can clash with one another. However, most of the conflict that Solomon describes occurs within each method: among pathophysiologic theories of breast tumour development, among primary studies and systematic reviews with respect to the magnitude of benefit from screening, and among guidelines making recommendations about mammography. While some of the products of EBM (systematic reviews) might appear to conflict with some of the products of consensus conferences (guideline recommendations), the former recommending against mammography and the latter often recommending in favour of mammography, this appearance is illusory. The evidence, on its own, does not have the power to recommend. Conflicts arise among individuals and groups due to their differing interpretations of the evidence and divergent recommendations for which they use the evidence to argue.

Similarly, it might appear that generalized breast cancer screening guidelines conflict with the individualized practice of narrative medicine or EBM. However, even though guidelines make general recommendations on mammography for women in their forties, Solomon notes that the guidelines explicitly state that patients and their physicians should make an individualized decision. There is thus less conflict among the different methods than first meets the eye.

Rather than an untidy methodological pluralism, another way to describe the situation is as follows. Medical research has a dominant aim (‘translation’), and medical practice has a dominant epistemology (EBM). The aim of translation regulates the funding of research, and motivates the use of consensus conferences to disseminate knowledge. Meanwhile, EBM has been embraced by leading medical journals and medical training programs around the world. While medical consensus conferences and clinical guidelines predate EBM, they are now based on the principles of EBM and can be considered EBM tools (the use of evidence-based practice guidelines has been called the ‘using mode’ of EBM [3]). The practice of narrative medicine might sometimes conflict with the practice of EBM. But narrative medicine is a developing movement and approach to clinical medicine, not a dominant one. It does not yet have the political power of EBM. Thus, within research and medical practice, there is more hegemony and less egalitarianism than Solomon’s untidy pluralism perhaps suggests.

Making Medical Knowledge raises interesting questions about the function, theory and practice of medicine’s most influential movements. Modern medicine is a mess of many ‘medicines’, and while it is not the intention of this book to make this mess look tidy, Solomon does succeed in making it intelligible.

 

Acknowledgments

I gratefully acknowledge funding support from the Canadian Institutes of Health Research.

 

Funding

Canadian Institutes of Health Research.

References

  1. Solomon M. Making Medical Knowledge. Oxford: Oxford University Press, 2015.
  2. Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS. Evidence Based Medicine: What It Is and What It Isn’t. British Medical Journal 1996;312:71 – 72.
  3. Straus S, Glasziou P, Richardson WS, Haynes B. Evidence-Based Medicine: How to Practice and Teach It. Edinburgh: Elsevier Churchill Livingstone, 2011.

PCMD Medical Humanities Conference 2016

18 Apr, 16 | by cquigley

 

Ian Fussell

Community Sub Dean UEMS

 

In 2002, The Peninsula Medical School (now Peninsular College of Medicine and Dentistry (PCMD)) became the first UK medical school to integrate the medical humanities as core curriculum.

Every year since, year four students engage in a six-month project alongside and mentored by an artist. The culmination of the project is a conference organised by the students displaying and presenting their work.

The work thus created has become increasingly sophisticated over the years, as evidenced by the 2016 conference that just took place in Truro (April 2016). In fact, it was probably the highest quality of work seen to date and would not be out of place at any international medical humanities conference.

The morning session was opened by Professor Alan Bleakly, the current President of the Association for Medical Humanities and a leading world expert in the field. This was a particularly poignant conference as 2016 is the final year that it will be run under the auspices of PCMD following the disaggregation of Exeter and Plymouth Medical Schools. It may have been this, or the unsettled future that the current students are facing, that gave this year’s presentations an extra edge.

Following a superb talk by Alan that encouraged a political voice, we were treated to three songs written and performed by “Dull to Percussion”, a band formed in the “Medical School of Rock” module. The songs were indeed political, satirising the split between the universities and included a protest song aimed squarely at our Health Secretary. Search iTunes or Spotify to listen for yourself, and watch “A Song for a Hunt” go viral.

The day was then jam-packed and it was impossible to experience all that was on offer. The range of skill and talent was breathtaking. We were lectured on the human cost of the western desire for sweetness by students from the anthropology module, and invited to debate “Do Christians make better doctors” by the Christian ethics students. This year a number of new Special Study Units (SSUs) were run. They were also extremely good and included a collaboration with Truro’s Hall for Cornwall team.

The students worked at the theatre, but more impressively wrote a play on mental health in medical students. We were treated to a premiere performance – “Permission to be Human” should be performed at every medical school in the country. There was also a monologue by a shy mature student who helped us understand alcoholism and PTSD in war veterans. The mood was lifted by a hilarious stand up routine; how can dislocating your shoulder be so funny?!

There were a number of writing modules, including poetry. The audience was encouraged to write poems in a short workshop. Another new module was “Writing the Knife”, which generated superb short reflections on memorable clinical incidents. One piece called “Quayside” was outstanding and deservedly won a prize. Read it here https://memorablemedicmoments.wordpress.com/author/memorablemedicmoments/ and add your comments.

There was so much more to the students’ work, and this short piece cannot cover everything. However, I do want to mention a some other excellent pieces: working with clay exploring the professional masks doctors wear; pottery boxes representing the mess that doctors get into as they progress through their careers; moving and uncomfortable films that depicted a child’s journey through a hospital; the doctors strike shown as a frightening political movement; dopamine photography; a project on how we smell; and life drawing in conjunction with Falmouth Art School. At the end of the day we were “kettled” into a small room, and forced to party…

The aim of this SSU is to develop student’s tolerance to ambiguity. But the SSU achieves much more than this: it helps students develop a community of practice; it also fosters development of resilience and peer support; and importantly, the students have fun while exploring other perspectives on life and illness. I am extremely proud of our medical students and feel very privileged to work with them in this way. I hope that both Exeter and Plymouth continue with medical humanities in their developing curricula.

 

 

 

Ayesha Ahmad: ‘Lahore is an Illusion, Lahore is Everywhere’

27 Mar, 16 | by Ayesha Ahmad

The mango tree faded many shadows ago, its fruit became stones and the branches became a skeleton. Yet, the roots remained, and they embrace the soil in the womb of the earth.

images-1

This was the cradle of my family’s birth.

Now, blood is watering Lahore’s gardens.

In sorrow, I remembered these words given to me a few days ago by my father.

 ‘Lahore is an illusion, Lahore is everywhere’

I wondered about them for sometime afterwards and I did not realise the gift that these words were to become.

more…

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