Essay Sampler

• Writing the Doctor Stories by Richard Selzer
• Deep Blue, Deep Structure and the Mental Health Professional as Writer by Ronald Pies
• Anatomy Lessons by Jerald Winakur
• Off Call/White Light by Jerald Winakur
• Old Friends by Jerald Winakur
• J.C. Boileau Grant: Anatomist Extraordinary by George Burnstein
• Journal Writing for the Physician - A Course In Survival Training by George Burnstein
• Bacteria Wars by Vincent Black

I'm as far from being a Great Writer as you can get. To be a Great Writer it's at least as important as genius to lead a colorful life, one that will provide material for a vivid biography when the time comes. (As for genius, I long ago gave that up, and just do the best I can.) Read ing the letters of Lord Byron and the life of Hemingway has made me acutely aware of my defects in this regard. I refer to the constant percolation of the lives of Great Writers - plots, counterplots, grievances real and imagined, enemies, scandals, matters of pride and humiliation without which no one can rightly call himself a Great Writer. But I have swum no Hellespont, discovered no new element, hunted no big game. Aside from a few acts of faithlessness on the part of publishers, which I refuse to elevate to the satanic, mine has been a glacial, moribund, and nerveless sojourn in the world of letters. Now that is not good. Where are the duels to be fought? The cruel mistresses? The rivalries, the cheating, the plagiarism? The imitators, the hatred? How can one be expected to write paragraphs seething with passion and vitality when one is forever lying in a meadow of bluets and buttercups in a state of imbecilic contentment? While the rest of the literary world has whipped itself into a sultry chafe, I am the very incarnation of Ferdinand the Bull. Try as I may to work up an outrage, I remain stupidly grateful that I have any readers at all. You're not going to get anywhere that way. Besides, the only "great" writing I've done has been in the hospital charts of my patients. Only there were the words a matter of life and death, and devoid of the vanity of the author or the pomp of language.

Who was it wrote about the terrible freedom one has when one's father dies? By age 15 my formation as a doctor was well under way. That summer I rode night ambulance for St. Mary's hospital. No doctor, nurse, or emergency medical technician. Just Tim, the driver, and myself. Tim was a toothless skinny Irishman with a Lucky Strike forever clamped between his gums, and a nose that almost touched his chin. He was in his 40s but looked 20 years older. His breath came in wheezes and was punctuated by a wet, productive cough. The driver's window had to be kept open even in winter, to enable spitting. For Tim, driving ambulance was the best of all possible jobs, and I was inclined to agree. It was thrilling to go careering through the streets of Troy at all hours of the night, siren blaring, even if we were only going downtown to buy a pack of Luckies. On more legitimate rides we'd screech up to a stop where already a silent crowd was standing, the way cows will gather in that corner of a pasture where one of them has stumbled, fallen, and is unable to get up. As though they would summon help by the mere presence of their massive bodies. Riding ambulance was an adventure movie in which Tim and I were the stars.

There came the night when we pulled up to a tenement, were pointed silently upstairs - four flights. I opened the door to a garret room to see a man standing with a rope around his neck. Not standing, I saw next, the way his shoes swung gently in the breeze from the window. On that dark landing, the needle of my heart pointed due north.

"Have to cut him down," said Tim. "You grab him around the middle so he don't fall on the floor with a thud." I wrapped my arms around the suicide and braced myself for the weight. Tim stood on a chair, sawing away. All at once the dead man came crashing so that we both fell to the floor, arms and legs entangled, the body of the man covering mine in the most ghastly embrace of my life. This isn't death, I thought. Not my old familiar death, the one I'd seen on house calls, nor the death that had cruelly snagged Father three years before. Here was Death as pursuer, pinning me in His arms. Death as rapist!

Tim took hold of an arm and a leg and dragged the corpse off me, snickering as he did so. Back in the ambulance we lit up and inhaled deeply. I had already become expert in the management of horror by fumigation, a reliance I wasn't to break for half a century. That snicker! I shall never be rid of that soft dry inhuman sound.

On another run it was an old woman lying in bed. A sort of whitish quilt covered her midsection. Otherwise, she was naked. White, yes, but not the terrible white of a blank page or the equally threatening white of a bride's linen. No, it was the old white of a tusk, parchment, a drumhead, the moon. As I gazed, it dawned on me that while the woman lay still, the quilt was moving! A moment later I saw that it was no quilt but a mass of maggots going about their slow business at her genitalia. "Horror," wrote Emily Dickinson. "'Tis so Appalling, it Exhilarates." I know what she meant, for I was strangely exhilarated by everything I saw that summer. I like to think that part of the feeling of pleasure lay in the fact that I had at last set out upon the odyssey at the end of which stood Father, waiting for me. If the way were strewn with hanged men and maggoty women, well, so be it. I knew that he had encountered the same. We were in it together.

My own children are parents themselves and more than three times the age at which I first witnessed death. About death they are still virginal. Perhaps I have erred in protecting those maidenly three. It isn't wise to distance yourself from death. Doing so increases its power over you. Familiarity is better, to confront the old adversary rather than the unknown knight. Only with familiarity comes the humor and fatalism to deflate the terror and to incorporate death into life. Now I can only hope that the first corpse my children see is not mine. That would be too cruel.

It is 12 years since I walked away from my beloved workbench in the operating room. It was not done with a cheery wave of the hand. For a long time, there was a sense of dislocation as if I were standing on the bank of a stream, and it was the bank that was flowing while the stream stood still. Surgery was my native land. The writer who cuts himself off from his native land does so at great risk. The subject of so much of my writing had been my work as a doctor. Would I be punished for sending myself into exile? Have nothing left to say? I needn't have worried. There is always the sharp and aching tooth of memory. Then too, my dreams are filled with surgery. Every night I am once again at the operating table striving to control bleeding or to repair what had gone wrong. Still, whenever that former self, the surgeon, insists upon being remembered, I'm astonished, as though a prehistoric creature had somehow managed not to die and was now reclaiming its place in my life.

Most days I go to the Yale Library where I read and write. Toward evening I take the Yale shuttle bus home. Not long ago, while waiting for the bus, two blond ladies came up, each as homely as virtue. One tall and fat, the other short and fat.

"Hello, Doctor."

"Whom do we have here?"

"You operated on us both." Were they mad? I wouldn't do a thing like that to anyone!

"I was a gallbladder," said Tall and Fat.

"I was hemorrhoids," said Short and Fat. I said how happy and relieved I was to see they'd made it. Curious how pretty they both became at that moment. Along came the bus and I shuttled off.

It is one of the risks of retiring and staying in the town where you have laid open the bodies of half the population. Shortly after I retired, I was asked to give a benefit reading for the local library. Upon entering the auditorium I was astonished to find that the audience consisted of 200 of my former patients. And it seemed to me that they had grouped themselves anatomically with the gallbladders up front, the hernias in the middle and the hemorrhoids at the rear. I had a moment of panic in which I imagined that at a given signal, they would rise to show what I had done to them. At least the two blond ladies would have known where to sit.

On another day I got on the shuttle bus and took a seat across the aisle and one row behind the driver, a man I hadn't seen before. A new bus driver, I decided.

"Where do you want to get off?" he asked.

"The Divinity School. I live nearby." When he turned to listen, I saw that his chin, lower lip and the entire front of his neck had been grafted with skin, doubtless to release the contracture of a burn scar. He appeared to be in his late 30s. From where I sat, I could see how easily he turned his head from side to side, raised, then lowered his chin. An excellent functional result, I thought. Not perfect cosmetically - a ridge here and there, a spot of pallor - but of this the man seemed unaware. He made no effort at concealment, wore no scarf or collar. All at once it dawned upon me that I was the one who had performed that skin graft, that this bus driver as a child had been my patient. A moment later I remembered a small boy naked, lying on an operating table, his chin attached to his chest by a great purple fan of scar tissue. So dense was this scar that the boy could not extend his head to see but must wrinkle his forehead and peer from the very top of his vision. The mouth was pulled open and twisted, the lower lip entirely lost in the wild mass of flesh. I remembered leaning over him, holding his hand, his struggle not to cry. Moments later he was asleep with a breathing tube in one nostril.

Now, so many years later, I had an impulse to go up behind the bus driver to examine, to feel, to ask him to show me the donor site. Per haps I would recognize it the way one knows his own handwriting. Perhaps he would remember my name? But I stayed in my seat.

"Divinity!" he called out. I rose to leave the bus. It is best not to trespass upon a previous incarnation. In Book VI of the Aeneid, Aeneas has met up with his father Anchises in the Elysian Fields. They come upon a crowd of souls waiting by a river. Anchises explains that they are awaiting the summons to new bodies and must now drink of the waters of the river Lethe to learn forgetfulness of their past lives. Sometimes, mostly at noon or midnight - those twin hinges of the day when both hands of the clock are upthrust in supplication - I have a fleeting memory, it is no more than an inkling, that my own father had once conducted me just as Anchises had done Aeneas, that he had bade me join those who were destined to come back. For some reason - disobedience, I suppose - I didn't drink of the waters of forgetfulness and so it is that I know full well what I had been in my former life: a surgeon. I used to think that the past was safer than the future. It had already happened and could do no more damage. Now I know it is the past to which we are vulnerable, the past that is far more apt to slay us.

I began this essay the day after Gary Kasparov lost his chess tournament to the IBM supercomputer known as Deep Blue. To judge from Kasparov's astonishment at this machine's prowess, you'd think that some kind of cosmic threshold had been crossed - at one point the world champion described Deep Blue as "playing like God." I wondered whether the computer had truly fathomed the "deep structure" of chess, much as great psychotherapists see beneath the surface of a patient's words. The term "deep structure" was coined by linguist, Noam Chomsky, in order to describe the difference between two superficially related sentences, such as "John appealed to Bill to like himself" and "John appeared to Bill to like himself." As Chomsky noted in his 1971 Russell Lectures, "The two sentences are virtually identical in surface form, but obviously require different interpretation...." In short, they have radically different deep structures.

Many years ago computer programs were devised to simulate the process of psychotherapy. I recall my first interaction with one of these programs as I played the role of the patient. OK - the role of a wiseacre patient, intent on defeating the damn computer. When asked about my chief complaint, I replied, "Suicide." The computer responded, "It must be difficult for you to cope with your suicide." The computer had failed to grasp the deep structure of my communication and was responding merely to a programmed set of linguistic rules. I understand that recent software has become much more sophisticated and has even been used clinically with some success - but I remain a skeptic. Human therapists - the good ones - attend not only to the deep semantic structure of their patients' language, but to its emotive and metaphoric structure as well. They hear what nurse-turned-novelist Elizabeth Berg calls, "the real language of body and soul that you hear when people are being serious - and they are being real serious when they are sick." I recall an example of this from the psychiatry literature in which a very confused schizophrenic patient asks her doctor - let's call him Dr. Rosen - "Dr. Rosen, will you water the roses in your garden?" At first the doctor dismissed the question as typical schizophrenic thought process disorder in which "Rosen" was conflated with "roses." When he saw the patient softly crying a few minutes later, he understood that the question was a plea for compassion and reassurance - asking, on the level of deep structure, "Dr. Rosen, will you take care of me if I need help?"

But there is a flip-side to this matter of construing our patients' language. It's easy for those of us with a literary bent to find metaphors under every linguistic bush. This can sometimes lead to a radical misunderstanding of very disturbed patients, as I've suggested elsewhere.(1) The French surrealist actor and producer, Antonin Artaud (1896-1948), provides us with an illustration. Artaud writes, "My mind is open through the belly, and from below, it piles up dark, inexpressible knowledge full of subterranean tides, concave blocks, and frozen turbulence."(2) The poetically-minded might think, "What powerful images!" upon hearing or reading this expression. But suppose you knew that Artaud was periodically psychotic and that he himself admonished, after writing the above-quoted lines, "Do not mistake this for imagery." This, in fact, was the case. I believe that the apparent images in Artaud's lines are direct presentations of his psychotic experience - not representations of the sort we find in poetry. We would be misunderstanding Artaud if we "appreciated" his words as colorful metaphors. So when a patient with schizophrenia says to me, "Doc, my brain is a nest of vipers!" I never assume that he or she is using colorful imagery. A few minutes later that same patient may be telling me how these vipers are crawling through his skull, biting his brain, and so on. In listening to such disturbed patients, I often find myself teetering on that fine line between metaphoric interpretation and the horrible literalness of mental illness.

The very best therapists can negotiate this balancing act. But even if great therapists are great listeners and interpreters - utilizing what Theodor Reik called, "the third ear" - does that make them great writers? I know from the many manuscripts I read for Mediphors that mental health practitioners are often passionate and prolific writers. I'm also mindful of physician-writer W. Somerset Maugham's acerbic observation - this is a paraphrase - that some people's most sincere emotions are simply ridiculous. As a therapist I find this judgment a bit harsh. But as a writer I extract from Maugham's words this caveat: The good therapist cannot be assumed to be a good writer simply because he or she is in touch with intense feelings and capable of putting them down on paper. In fact the contents of a wonderful therapy session can make for excruciatingly bad literature, without the transforming hand of art. Curiously, in another passage, Maugham provides us with a very different point of view. He states, "If you can tell stories, create characters, devise incidents, and have sincerity and passion, it doesn't matter a damn how you write."(3) This was probably intended as advice to young writers and has a comforting grain of truth in it. But when I review a manuscript - even one written with "sincerity and passion" - it does matter a damn how the author writes!

Fortunately we have many examples of mental health professionals who are also fine writers - I think particularly of Keith Ablow, Elissa Ely, Sue Chance, and one of my teachers in psychiatry residency, Richard Hart Phillips. (All of these writer-clinicians are psychiatrists, but there are psychologists, social workers, and nurses who also write well - pick up nearly any copy of this journal or the Journal of Poetry Therapy, to satisfy yourself on this point). Keith Ablow - who has had a distinguished career as both journalist and psychiatrist - has written eloquently of the need for psychiatry to preserve its interest in the mind and not merely in the brain. In his book Anatomy of a Psychiatric Illness (4), Ablow reminds us that psychiatrists must attend not only to the chemicals of the brain but also to "the poetry of the mind." In this image, Ablow calls up something akin to the "deep structure" I described earlier.

Elissa Ely - who writes for the Boston Globe and reads her work on National Public Radio - transforms mundane events on the psychiatric ward into epiphanies. In a recent piece (5), she describes her encounter with a hospitalized man suffering from recurrent, violent thoughts - impulses "to bludgeon people with lead pipes and guns." In Dr. Ely's office the patient happens to notice a picture of the family golden retriever, which catches this hardened man "in a moment of special and infectious delight." After the man's discharge, Dr. Ely runs into him on the street, where she sees, in the man's pick-up truck, a sleek Labrador retriever sleeping against the steering wheel. She reflects that "though he was a man filled with violent thoughts - even on the busy street I felt a bit of trepidation for myself - I did not fear for [the dog]. She was all he had... and he was her life. It could have been worse."

Sue Chance, in her book, A Voice of My Own, confronts us with the pain of Alzheimer's Disease, observing that, "for the Alzheimer's patient, the mind is a retreating army, and no matter the successful skirmishes, the war is always lost in the end."(6) She describes a friend of hers whose mother has Alzheimer's and no longer recognizes her own daughter. Reaching up to touch a locket the daughter is wearing - a birthday gift from the mother - the old woman says, "My little girl used to have a locket just like that."

Finally, in his poem "Separation," Richard Hart Phillips gives us this gorgeously understated vision of human loss: "As I sit fanning leaves/ Of this small paperback,/ A book of poems/ Laid on love,/ The one you left behind-/ As substitute/ For your own words-/ I find against page forty-eight,/ A single hair;/ Not quite so dark/ As moonless nights,/ Nor long enough/ To touch your hips/ But yours/ I sense/ With certainty...."(7).

So - are mental health professionals, by nature, likely to be good writers? I'm not sure. But I have no doubt about this: Those in the mental health profession, perhaps even more than other caregivers, are in an excellent position to probe the deep structure of their patients' language and to resonate empathically with its richness. A shrinky version of Deep Blue may come along some day, but for my money, it is unlikely to replace these human listeners and healers. And to transform one's experience as a therapist into good writing - ah, now there's a job IBM won't be taking on very soon.

1. Pies, R: "Distinguishing Schizophrenic from Poetic Language: Implications for Therapy." The American Journal of Social Psychiatry VII, 2, Spring 1987, 122-124.

2. Artaud A: "Further Letter about Myself." In Antonin Artaud: Collected Works. Vol. 1, V. Corti, translator. London, Calder & Boyars, 1968, p. 187.

3. Maugham WS: In Writers on Writing, edited by J. Winokur, Running Press, Philadelphia, 1986, p. 65.

4. Ablow, KR: Anatomy of a Psychiatric Illness. American Psychiatric Press, Washington, DC, 1993, p. 189.

5. Ely E: "Tamed By a Dog." The Boston Globe, May 30, 1997, p. A23.

6. Chance S: A Voice of My Own. Bonne Chance Press, 1991, p. 55.

7. Phillips RH: Bind Weed, Marcellus NY, Gander's Knob Press, 1988.

I was dreading my first year of medical school. I had nightmares about walking into the human anatomy lab for the first time. Shrouded corpses on stainless steel tables, row after row. Pulling off the sheet, looking into that death mask, those opaque eyes. My hands holding and dissecting another's. The acrid smell of formaldehyde, day after day.

I was a Biology major in college. Bios. Life. But to get into medical school 25 years ago, I had to excel in the sciences of deconstruction: quantitative chemistry, organic chemistry, physics. In those labs, one could only infer what was happening. The atoms, the molecules, the forces were invisible.

Back then I liked to see the thing for itself. Euglena whipping around the slide. Amoebas rolling along. Certainly I took things apart: I slit a pot-bellied frog open from chin to genitals. The same with hamsters and cats. These animals were served up to me on paraffin filled trays, cold and dead. Still, I could see that a frog was a frog, run my fingers over its green, leathery skin. The hamster's thick coat. The cat's long tail. I was such a boy back then.

Some people couldn't bring themselves to do it. Usually I did the dissections while the others in my group looked over my shoulder, their lab books resting on my back. "That must be the cecum," they would say as I shifted the intestines around with my gloved fingers. Yet, thinking about doing this to another human made me ill.

A couple of months before medical school was to begin I received a letter from the dean asking me to volunteer for an experimental program. If I wanted, I could be assigned to rotating hospital services and spend my first year seeing real, live patients. I jumped at the chance, thinking I could postpone gross anatomy until my second year. Or so I figured.

The skull is hard.

"Put your finger here. Feel that. Is that a fracture?" The trauma resident pushed my finger back and forth into a scalp laceration over a ridge of bone on the side of a teenage boy's head. The boy groaned in semi-consciousness.

"I guess it is," I said.

"Wrong," the resident said to me. "It's a normal temporoparietal suture. Remember from anatomy? Where those two bones of the skull come together and fuse. This is not a fracture."

It was two in the morning, Saturday, and I was in the ER. The trauma resident had no idea I had never taken anatomy (I soon gave up trying to explain to people about the experimental program: They would look at me as if I were some sort of incompetent freak which, of course, I was.)

"Am I hurting him?" I asked.

"Look at him! He's so bombed out of his mind, I doubt he even felt the injury, let alone you probing the wound."

"But are you sure it isn't fractured?" I asked.

"Get an X-ray. Always get an X-ray," he said.

The skull is pretty hard. I saw it withstand blows from pipes and bottles and rocks. I also saw it reduced to bloody bags of shifting pieces, like something a witch doctor might carry around, after heads went through windshields, crashed unhelmeted into utility poles, after the "Jaws of Life" brought in the chewed remains.

Once I was staring at a glistening wrapper protruding just above a little girl's ear. I thought maybe it was a special dressing the EMTs had applied.

"Dura mater," the resident said to me.

I know I had a blank look.

"You know, it covers the brain not the skull. Normally."

The ophthalmology resident was explaining to a small woman with a shock of white-hair, who must have been at least 90 years old, how he was going to fix her cataracts. She had been blind for many years but someone had finally brought her into the clinic.

"We're going to make an incision through your cornea and remove the lens," he said. I was standing behind him, alternately watching the patient's face and following along on a small, colored drawing of a cross-section of the eye, the parts all labeled. She tried to touch his face, but he kept fending off her hands.

"Certainly, we can't make you any worse off than you are now. Vision-wise, that is. Of course, if you get a post-op infection, you may lose the eye." Then he turned and walked out.

She reminded me of my grandmother. I stayed behind and sat down on the bed next to her. "Do you understand what they're planning to do?" I asked.

She put her hands up to my face. I closed my eyes as her rough, bony fingers explored me.

"I trust you, doctor," she said.

"I'm not the doctor," I said. "I'm just a medical student."

"It's going to be all right, doctor," she said.

The old man was stone deaf and the intern and resident and ENT fellow were screaming in his ear.

"YOU'VE GOT OLD AGE DAMAGE TO THE BONES OF YOUR MIDDLE EAR. WE CAN TRY TO OPERATE ON ONE OF THEM TO SEE IF YOU CAN GET SOME HEARING BACK. BUT THE SURGERY MAY NOT WORK."

He sat impassively on the side of his bed.

"DO YOU WANT THE OPERATION, OR NOT?" they yelled again.

He didn't answer.

"Discharge him today," the fellow said to the resident. "No sense keeping him in a bed if we don't operate on him."

"Send him home," the resident said to the intern.

Behind my little cross-sectional drawing of the bones of the middle ear, I saw the one on the eye.

I wrote in block letters on a notepad, "Can you read?"

He said, "Yes."

I wrote, "Do you want an operation to try to fix your hearing?"

He said, "No."

"Send him home," the intern said to me.

"I don't know how to do that," I said.

"You seem to be a bright boy. Figure it out," he said, walking out.

She was "just in for a sore throat." That's what she told me several times at the walk-in medicine clinic where I had been assigned. I was supposed to take a complete medical history and do a full physical examination on her and then "present" her case to the harried resident who was overseeing a bunch of us students in the clinic that day.

She refused to get undressed and put on a gown. "I just have a runny nose and a bad sore throat," she said.

"Look, I'm a medical student and I'm supposed to do a complete physical examination," I said. "It can't hurt to have a full examination... maybe we'll uncover something." I suspected this was a lie. She was young and pretty and perfectly healthy.

"Just check my throat or I'm leaving," she said.

I took a deep breath. "OK," I said. I wondered how I would satisfy the resident.

I knew a little something about eyes and ears by then. Her eyes were fine. Hypnotic, in fact. That deep, dark chocolate brown that can draw you in, make you a co-conspirator. I had been drawn in once in my life, though, only three months into medical school; I could barely remember that life.

Anyway, her eyes were fine, maybe a little redness of the conjunctivae. She had a cold, after all. Her left tympanic membrane was pink, and I asked if her ear hurt. "A little," she said.

Her throat was very red and there was some yellow stuff towards the back, on the left side sitting on top of a raw-looking lump of tissue. Her tonsil, I figured. There was a symmetrical lump on the other side of her throat and I knew everyone has two tonsils. That thing that hangs down in the middle was red and glistening and looked a lot fatter than mine.

I checked her neck for swollen lymph nodes and there were a few tender ones on both sides, under her jaw, and one pretty good sized one almost at the bottom of her neck, just below her voice-box. That's as far as she would let me go.

"You have tonsillitis," I told her. "And a left inner ear infection. Let me present your case to the resident and I'm sure he'll just put you on antibiotics and you'll be fine in a few days."

"Thanks, doctor," she said.

"I'm a medical student," I said.

I presented her case to the resident. "What about the rest of her physical exam?" he asked me.

"That's all she would let me do."

"You know, doctors get sued every day because they're not thorough," he told me. He slammed his pen down in her chart. "Let's look at her." My face burned.

"I'm the resident on-call here in the clinic," he said to her. "Open your mouth," he said. "Ugly."

"OK, we'll give you a script for penicillin." He was running his fingers up and down her neck, checking for nodes. "You have to take all of them - whoa, what's this?" he asked. "Didn't you feel this?" he said to me, his hands at the base of her neck, fingers lying just above the notch there.

"Yes. I told you about the lymph nodes in her neck," I said.

"This isn't a lymph node. This is the thyroid gland, and this," he grabbed my hand and ran my fingers over the lump I had felt earlier, "is a tumor of the thyroid gland. Probably a cancer. You forget your anatomy already?" he asked.

She and I were shocked. We looked at each other; her eyes filled with tears. She couldn't talk.

"Couldn't it be something other than a cancer?" I asked. "A cyst, maybe?"

"Maybe. We'll know after surgery," he said.

"Miss," he turned to her. "You have to go into the hospital so we can remove this tumor. You are very lucky we found it when we did."

And then to me. "Now you can complete your examination. You never know what else you might find - metastases to the liver, other areas of lymph node involvement. You never know. Do everything to everybody. That way you won't miss anything." Then he left.

We looked at each other. I wanted to put my arm around her, tell her it would be all right. But I didn't know any more than she did. I reached over to the shelf and pulled out a couple of tissues and handed them to her.

"I have to do the rest of the exam," I said.

"It's OK," she said.

The house staff was in awe of Dr. Raj Mishra, a renowned cardiologist. The intern whom I was trailing a step or so behind on the way to rounds with Dr. Mishra said, "The guy's amazing. He trained in India - you know, they got all this clinical material over there - he's a regular Houdini of diagnosis."

The patient was someone Dr. Mishra had never met. Someone whose chart he had never seen. I expected the resident to present the patient's case history in typical fashion but instead, he said only, "Dr. Mishra, this is Mr. Post."

Dr. Mishra extended his hand, and Mr. Post, a little reluctantly, took it as he studied Dr. Mishra in his tan turban and long billowing white coat.

Dr. Mishra did not let go of his hand.

"You smoke cigarettes, don't you, Mr. Post?" Dr. Mishra asked in his lilting, sing-song Indian accent, looking out at us.

Mr. Post coughed a few times. "I'm trying to quit," he said.

"Notice the permanent yellow nicotine stains on Mr. Post's fingers. I suspect you have smoked two packs of cigarettes per day for more than 50 years. Isn't that correct, Mr. Post?"

"Pretty near," he answered.

Dr. Mishra still held his hand. Mr. Post was getting restless.

"Notice also the shape of Mr. Post's fingernails. How rounded they are. Notice that the angle the nail makes with the nailbed is obliterated, is now concave. An obtuse angle."

I looked at my nails. Then at Mr. Post's. His looked like the backside of teaspoons.

"This is called 'clubbing,'" Dr. Mishra said. "Nicotine-stained, clubbed fingers are pathognomonic for carcinoma of the lung."

Mr. Post pulled his hand back. He stared at his fingers. "They've been this way forever," he said to Dr. Mishra. "Anyway, I'm here because of my heart." He fidgeted uneasily on the bed.

"Not forever," Dr. Mishra said. "Where is this man's chest X-ray?" he asked the resident.

"It was read as normal, sir," the resident said. "Except for his enlarged heart."

"Get me the films," Dr. Mishra said.

The resident looked at the intern who looked at me. I turned and ran out of the room and down to X-ray. The girl in the file room actually found the films, a miracle in itself, and I ran back. Dr. Mishra hadn't moved. No one had.

Dr. Mishra took the film from its jacket and held it up to the light coming in from the window. "There is a 1.5 centimeter nodule behind the heart. The radiologist missed it. All of you missed it. It will be malignant." He began walking out.

The resident, flustered and red-faced, asked, "Dr. Mishra, what about his heart? Mr. Post has severe aortic valvular disease as well. Wouldn't you like to listen to his murmur?"

"We do not replace aortic valves in patients who will be dead in six months," Dr. Mishra said.

We all trailed out of Mr. Post's room. I glanced back at him. He was still staring at his fingers.

As the chief resident explained to me, the purpose of General Surgery Clinic was to find cases on which the surgical house staff could operate. "It's like panning for gold," he told me.

I walked into an exam room and introduced myself. She was already sitting up on the table. She had a tired, resigned look about her.

"What brings you into the clinic today?" I asked.

"My breast is bad," she said.

"What do you mean, 'bad'?"

"You'll see."

I went through the litany of medical history questions that have by now been etched into my brain by adrenaline and caffeine over years of sleepless nights. Back then I carried a form with me on which they were all written.

I examined her as she lay supine on the table, saving her breasts for last. They were pendulous and I could feel nothing abnormal. I asked, "Where is this 'bad' part?"

She got a slightly heartened look on her face. "You don't feel nothin' then?"

"Well... sit up for me and raise your arms above your head," I said.

"That's how I always feel it," she said.

I stared at her breasts. Her nipples were dark and erect. She was a handsome woman. There was a small dimpled area just lateral to her left areola. I rolled this area between the fingertips of both my hands. My mouth filled with saliva. I felt a hard irregular lump.

"That's it. I told you it was bad, doctor."

"I don't know yet. I'll get the resident to take a look. I'm just a student."

"I brought a suitcase," she said.

I went out of the room and presented her case to the Chief Resident. "Terrific!" he said.

"I'm not sure that this is a cancer," I said. I knew it was.

"Sure it is. Let's look at her," he said.

He asked her no questions; examined only her breasts. "I think you have cancer," he said to her.

"I knew it was bad," she said. "I've got my suitcase with me."

"Good. This young doctor here will arrange your admission to the surgical floor. We'll take care of this for you."

"Thank you, Doctor."

"Nice pick-up," he said to me.

"She found it," I said.

"Good case," he said, as he left.

I swallowed hard.

Phil and I had been friends since college. He was a fraternity boy, something I teased him about unmercifully and which he chalked up to adolescent folly. Now we were roommates. He was in business school, planned to make a million - or more - in the stock market before he was 40. I tolerated his Wall Street Journals which reproduced in our apartment, it seemed, like rabbits; he tolerated my medical books and journals which cluttered our only desk (he read sitting up in the easy chair) and my plastic model of the human brainstem which sat on the kitchen table.

One Saturday night he was, once again, trying to drag me out to a party. "I can't," I told him. "I'm in the middle of my internal medicine rotation. The textbook - not that I have time to read it - weighs more than you do." I looked at him and something made me ask, "Are you OK?"

He was always thin, but he looked even skinnier than usual.

"Finally you're good for something, Jerry," he told me. "Free medical advice."

"Hey, here's my standard, up-front disclaimer: 'I'm just a student,'" I said. "Really, are you OK?"

"Sure. A little tired is all. Go ahead. Check me over, doc. You know, lay me on some hands."

"I don't know. How about I get you in to see one of the med school professors...."

"Come on, come on. I can always do that," he said. "Anyway, I'm fine, and you need the practice." He took off his shirt and lay down on my bed. I went to get my black bag and dropped it. The damn thing was getting heavier and heavier.

"Pants, too," I said. "If I'm going to do this, I'm going to do it right. Well, the best I can do at this stage of the game, anyway."

Phil grinned. "Way to inspire confidence in your patients, doc," he said.

Everything was fine until I put my hand on his abdomen. His liver and spleen both bulged under my fingers when I asked him to take a deep breath. I had already spent time on the oncology ward. That's where I learned to feel livers and spleens. Even a first-year student who had never taken anatomy couldn't miss the monstrous, cancer-choked organs in those patients.

"What is it?" He was staring at my face.

"I think your liver and spleen are a little big," I said.

"What does that mean?" he said. "Am I OK?"

"Sure, it's probably nothing. A virus. Mononucleosis, maybe. I'll get you in to see someone at the school, run a couple blood tests... it'll be fine," I said. I couldn't look into his eyes.

"Are you sure it's nothing worse?"

I had never lied to a friend or to a patient before. It was time I learned. "It'll be fine, Phil. Just go see a real doctor, will you?"

"Sure," he said. "If this party doesn't last all week!"

After the party - after the consultation, the blood work, the scans and the biopsy - after the chemotherapy, after my roomie puked a thousand times and lost his hair, after his short remission and his second go-round of chemo, he died. I never saw him being laid to rest because he willed himself to Science. I wanted to tell him not to do it, but I never said anything. He believed he was doing something good.

She knew it was my first time. After I fumbled as she attempted to gown me, after I plunged my hands into all the wrong finger spaces of both latex gloves she had held wide open for me, she said, "Keep your hands clasped to your chest at all times. Don't even think about touching anything on the table." All I could see of her was her no-nonsense eyes, and I said, "Yes, ma'am," though somehow I knew this OR nurse was younger than I.

It was an orthopedic case, the replacement of an old arthritic hip with a new stainless steel ball on the end of a metal stem. A large man, white-haired at the temples, with a booming voice was working over a long incision in what I guessed was the patient's outer thigh. There really was no way to tell there was a patient under there. The rest of the body was either covered over with heavy blue sterile sheets, or curtained off completely from the operative field. There could have been a cow under there.

The nurse guided me up next to the surgeon. There was another surgeon working across the table from him.

"Remember," she said to me, "hands clasped against your chest."

"Ah, we have a medical student scrubbed in with us this morning." His voice filled the OR. "I'm Dr. Grayson. That's Dr. Leone." Neither of them looked up from what they were doing, which was using stainless steel chisels and hammers to knock away excess bone.

"Yes," I said. They kept working, the scrub nurse handing them various stainless steel implements as they called for them: saws and screwdrivers and pins and screws and planes and drills. The surgeons had fancy names for these things, but to me they were just tools.

There was a smell like my old wood burning kit used to give off when I would emblazon my initials into a piece of scrap. They had cut off the top part of the hip bone and had fitted the new stainless steel stem and ball into place. Dr. Grayson seemed very happy with his work. He spoke to me as he continued to chisel here, drill there.

"What is the name of the cavity, the socket, if you will, that this new hip will fit into?" Then as an aside to Dr. Leone: "The patient should only last as long as her new prosthesis, right Dr. Leone?"

"We won't hold our breaths, will we Chief," Dr. Leone said. Then they both laughed.

"Well, what's it called?" Dr. Grayson asked me again. I knew this. I had been looking at a schematic drawing of a hip that was tacked to the wall over the sink where I had spent 10 minutes scrubbing my hands before coming into the operating suite.

"Acetabulum... I think," I answered.

"What do you mean you think?" he asked. "Don't you remember your anatomy?" He was intent on planing off a section of bone.

"I haven't had anatomy yet, sir," I said. "I'm in a special program."

"Craziness," he said. "I read something about that... this medical school is going to the dogs," he said. "Hand me the rongeur again, will you nurse," he said.

"Well," he said, "have you ever seen any orthopedic surgery before, son?" he asked me. More burning smell wafted up from the table as the drill bit into the bone.

"Well, no, but I helped my father finish our club basement," I answered. I don't know what made me say this.

Dr. Grayson and Dr. Leone both stopped what they were doing and looked at me.

"Out of my OR, now!" Dr. Grayson said to me.

"But...."

"Now!" he said.

Out in the hall I leaned against the wall, awaiting the fall of a stainless steel ax. The nurse who helped me gown and glove came up and winked at me. She still had on her surgical mask. "Don't worry," she said, "They have no idea who you are. And I won't tell them."

"Thanks," I said.

"You're gonna be OK," she said. "One of these days."

I had been up with Angie all night. She was laboring alone and for the first time. She had a pretty face. Sweet. Only 18, she looked younger. She didn't know who the father was, or wouldn't say. Her mother wasn't around either: "She works nights," Angie told me.

The OB resident had assigned me to her. "Watch her closely. These Prima Gravidas can be real problems," he told me.

I was taking her pulse and blood pressure every 15 minutes, listening to the fetal heart tones with one of those old-fashioned fetoscopes, a stethoscope that you wear around your head, as well as in your ears. Pressing it to the mother's belly, you can feel that baby's heart racing through your bones.

Every so often I had to check the state of her cervical dilatation and position of the baby's head. I would try to get a nurse in the room, just to stand there, but sometimes they were all tied up and I'd call and call, wait and wait.

"It's OK," she told me. "I know you have to check. Go ahead."

And I'd slip on a pair of gloves and slide two fingers of my right hand inside of her and try, unpracticed as I was, to gauge the diameter of her cervix and how the baby lay in her uterus by feeling its soft fontanel. I would close my eyes, conjuring diagrams I had been studying of babies in wombs, turned this way and that, of babies sliding down the birth canal, the relationship of the head to the pelvic bones. The babies in those renderings were always smiling.

"I don't think you're any further along than the last time I checked," I told her.

"Is that OK?" Beads of sweat had popped out again on her now that another contraction had begun. I wrung out a cool washcloth and placed it on her forehead, then moved to make notes in her chart.

"It's fine, Angie, don't worry. Remember how we talked about it taking a long time with the first baby?" I said.

"Yes, OK," she said. Then, "What's your name, doctor?"

"Remember, I told you I'm only a medical student."

"I know that. I mean what's your first name?"

"Jerry," I said.

"If the baby's a boy, I'm going to name him for you."

I stopped writing in the chart and turned to look at her. She reminded me of the first date I ever had back in high school, a cherubic red-haired girl who asked me to a dance. All I could remember at that moment is how it felt to have her chest pressed up against mine.

"Well... that's a wonderful thing to offer. And I'd be honored, but what about another man... a father or grandfather...."

"No one has ever been as nice to me as you," she said, her face suddenly twisting in pain again.

"Well... thanks," I said. "OK, Angie, OK... now just breathe through this contraction like we were doing before." She squeezed my hand.

I was taking her blood pressure after the contraction when she said, "Something came out of me."

"What!"

"I feel something down there," she said.

I threw back the drape sheet. A blue loop of umbilical cord pulsed between her thighs. I had read about this.

"What is it?" Her voice trembled as she looked at my face.

"Angie, it's time for you to have your baby." Then I reached inside of her and pushed the head of that child as far up into the birth canal as I could, yelling for the nurse, all the time pushing the stretcher toward the delivery room.

Suddenly there were people everywhere.

"What are you doing?" the resident said to me. He had just finished another delivery. His surgical gown was drenched in amniotic fluid and blood.

"Prolapsed cord," I said. He lifted the drape sheet and peered over my shoulder as I pushed the gurney down the hall.

"Get anesthesia down here STAT," he barked at one of the nurses. He guided me into one of the delivery rooms.

"Jerry, I'm scared!" Angie said. She was crying now.

"You need a Cesarean right away if you want to save your baby," the resident said to her.

"Jerry?" she called.

"I'm here, Angie; I'm going to be with you the whole time... it's going to be all right, it's going to all be fine." But what did I know then? I looked at the resident, wanting him to take over.

"Keep the head up," he said to me. "Someone get me a fetal pulse, now!"

Nurses were scampering everywhere. One was prepping her abdomen with iodine. Another was draping her, curtaining her upper body off from the surgical field. Another was enclosing me off, leaving me between Angie's open thighs, my fingers in her vagina holding up her baby, my eyes riveted on the still-pulsing cord.

I could feel Angie beginning another contraction. She screamed in pain and fear. Anesthesia had not yet arrived.

"She's contracting again. Can't you give her something for pain?" I asked from inside the tent they had made around me.

"I need another fetal pulse," I heard the resident say. Then to me, "Keep the cord moist with saline." A nurse passed me a stainless steel bowl and a stack of gauze pads. I soaked some and placed them on the cord.

Angie's thighs were wet with perspiration. I could feel her breathing hard and sobbing. "God, what about her pain?" I yelled again.

"This baby's gonna have enough problems without narcotics depressing its respirations," the resident said from somewhere in the room. "Massage her clitoris."

"What?" I asked. I felt the blood rushing into my face even though no one could see me.

"Her clitoris," he said. "Massage her clitoris... you know where that is, don't you? If you can't remember your anatomy, think about your last date."

"But...." I started to say.

"It's OK," he said. "It helps the pain some."

Someone burst into the room. "It's about time," the resident said. "We're five minutes into this. We're losing brain cells here."

I was alone in the semi-darkness; Angie's smooth, white thighs tensed and untensed around me as she struggled with the contraction. I stared at where my fingers went into her. Somewhere just above them, enfolded in and protected by her engorged labia was her clitoris. I was immersed in her woman's smells. I let my thumb touch her there, and I began a gentle, rhythmic massage. She began to relax; her cries softened to moans. It may have been the anesthesia, but I felt the tension leave her and then me, and I felt as if I were balancing Angie and her baby on my fingertips. And that somehow I could manage all this. Would manage all this.

I don't know how much time passed. But suddenly the cord slithered away from me. I heard a baby's healthy cry, and the resident told me that I could come out now and that I had done a good job. I wanted to stay with Angie until she woke up, but there was another patient in labor to whom I had already been assigned. But I went back to see her every day until she went home.

It was a boy.

The first morning of my second year of medical school, I walked into the anatomy lab. An entire year would pass before I saw another living, breathing patient. I took my place among the nervous, wise cracking first-year students fresh from college. I could hardly remember being that young.

I removed the plastic sheet, then the formaldehyde-soaked linen one. My eyes burned a little, but it was not as bad as I had feared. She was a woman, emaciated and bent. Just looking at her, I knew she had died of cancer. But someone else had made that diagnosis. Someone else had treated her and failed. Someone who had first steeped himself among the dead before he had confronted the living. Someone I would never be.

I touched her hand, and then I began.

(From MEDIPHORS Spring/Summer 1993, Issue No. 1)

White light. Cursor pulsing, expectant, your heartbeat on the screen. Waiting, waiting for the spark of a beginning, the hint of a middle, bare glimpse of the end.

Finally, it is your weekend off-call. Beeper off, phone silenced. Saturday and Sunday stretch like two blank sheets of paper before Monday comes again and you resume probing inside others. You have ached to see the white light, to explore within yourself if only for the two days out of 14 your schedule will allow.

Once again you have made excuses to friends: Unexpected out-of-towners, a planned "getaway" (to your study), illness feigned (and you are ill without the light). You have used them all; the weekend invitations only trickle in now. Even your family has learned to settle for their meager share of the other 12 days.

You are up at the usual time, before the sun, microwave your water hot, and flip on the computer. As it's coming up, you work to suppress the concerns about those whom you will not see on rounds today. You reach for the phone just to check in with the nurses... but you resist. For yourself, you must resist. It is not easy, will never be easy; the compulsion to call must be quelled.

The white light is there, but you are distracted now before you can even begin. A check of your journal, a leaf through the random jottings about patients you have dropped on the desk over the last two weeks, provide nowhere to start. You always write about them; they are always there, in your conscious mind, lingering into your subconscious as you sleep.

But what of your own rhythms? Middle-aged, you realize how finite is the heartbeat which blinks at you from the tiny corner of the light. How many pulses have you seen extinguished no matter your effort, your compassion, these last 20 years? How many phosphorescent images at how many bedsides have you seen shiver, shudder, and disappear, save for the straight line that you hope guides your patient towards his own white light. Of course you know it is but a matter of time for yourself, and it is this realization which drives you these fleeting weekends more than any other.

Asystole. Where to begin... you must begin! There is so little time for this in your life.

Heal Thyself! Every letter on the screen a molecule of oxygen-rich heme, every word a red corpuscle, every sentence a life-sustaining capillary coursing across this white light of your living life. Every paragraph a transfusion. Metaphors, a breath of air; similes to unify the whole.

And as your fingers fly across the keyboard, you watch the white light diminish as your thoughts fill the screen, and you know you will survive, know you are alive.

(From MEDIPHORS Fall/Winter 1994, Issue No. 4)

When we were born, after America was safe again, our mothers pushed strollers along the smooth, freshly poured sidewalk of our suburban street, both of us, side by side, dressed in blue, cooing at each other as sapling shadows fell across our faces.

When we were three, we played in the sandbox in his backyard. I liked to make neat piles, and he would stomp on them. I was bigger, pushed him, and he cried. When we were five he had a swing set, and we launched each other; he would scream, "Higher, higher!" while it was I who always said, "Not too high!" He laughed that high-pitched, cackling, semi-maniacal laugh of his which always stayed the same.

When we were in grade school, he was never in my reading group, though he read much more than I.

When we were 10, the fourth of July, we climbed one of the trees lining our street and watched faraway fireworks light up the night. Afterwards, summer sky twinkling above, he asked me to believe that there were more stars than grains of sand. I told him he was crazy.

When we tossed a baseball, he was the pitcher, I the catcher. When we threw a football, he was the quarterback, I the tight end. We always played on his lawn; mine had flower beds.

When we were in junior high, I was the tallest boy in the class and he was the shortest, but I picked him first every time there was a game, and we always won.

When we were 14 he insisted we take the bus to the shore; I told him he had to talk my mother into letting me go, which to my amazement he did. We strolled the Boardwalk singing Doo-Wop songs. I sang bass to any girls who would listen, and we got our first French kisses in the shadows of those wooden planks, the ocean roaring in our ears.

When the President was shot, we played poker and pitch and war in his club basement for hours and hours until I said he cheated and he said I cheated, and we fought and I bloodied his nose. By the time they laid the President at Arlington we were best buddies again.

When we were in high school he always knew what to do on Friday nights, on Saturday nights. No matter how many of us were in his car, I always rode shotgun. I got involved with a girl after Junior Prom; he spent four years trying to shake me loose, and when she finally did, and I was a wreck, he got me drunk, read to me from Manon Lescaut and laughed and laughed that laugh of his out of happiness for me, years before I could for myself.

When we were 17 his father died, and I remember how grown up he looked at the funeral: the dark blue suit, arm around his mother. I finally asked if there was something I could do, and he said no.

When he decided where we should go to college, I applied. I got in and he didn't, but he made me go anyway. He went somewhere else, but we stayed friends. I took biology, calculus, organic chemistry, and physics while he immersed himself in art, literature, music, and philosophy. When I finally tore away from my books to visit him, he was taller for the first time.

When he got his low draft number, I got a high one. He taught grade school, I went to medical school. When I was sick and tired of it, he showed up at winter break and dragged me and Gray's Anatomy to Florida, and restored my spirits with fresh orange juice and ripe women. I graduated; he moved to California, invested in real estate and made a million dollars.

When I told him I was getting married, he flew back the next week just to make sure I wasn't screwing up again. At our wedding, he danced with the bride more than I, who never really learned how. When our son was born, he came with a stuffed bear, bigger than life, and we smoked cigars, and talked until all hours. I played a song for him about two old men, old friends, who sat like bookends together on a park bench. He said thinking about getting old depressed him, and he made me turn it off.

When he called and said he was getting married, I forced myself away from my fledgling practice, and went to the wedding. His bride was a china doll: a shy, mysterious beauty dressed in white satin. He tried to teach me Tai Chi, but, unlike him, I couldn't move like a river. I watched them drive off in his Silver Shadow, heading for a trek in the Himalayas.

When he called me a few months later and told me that he had lost the sight of one eye, I demanded that he get on a plane and fly back. He laughed in that way he had, and asked if I thought I was the only doctor in the world. He had a good one, he said, a specialist. I told him to call in a couple of days. In a week he called and said his vision was restored, and I should quit worrying about him. I didn't.

When we were both 33, just a few months later, his business associate was on the phone saying my old friend had had a massive brain hemorrhage, and his mother asked that I please come help make the decision about letting him go.

When I stood at his bedside, the machine hissing and clicking, my years as a doctor slipped away, and I was just a little boy again.

When they asked for his corneas, his mother looked at me and I nodded.

When they asked for his kidneys, I nodded.

When they asked for his heart, I was still. But that went in the end.

When I was a pallbearer, the hole in my life opened.

When I was 10 years older, I visited his grave; our old neighborhood. The ground over him was covered with ivy. The houses of our boyhood were dark, small. The trees along our street were massive: the pavement cracked and lifted from strong, deep-running roots. Mothers still wheeled strollers.

I hope to hear him laugh again when it is my time.

My brother Merton and I began medical school at the University of Toronto in 1944. Fresh from demobilization at Wolsey Barracks in London, we rattled down the No. 2 King's Highway in my ancient pre-war Chevy and just made it to the big city before the gas and our money ran out.

As the Oxonian campus loomed up in the fog, I had a premonition akin to facing a Panzer group and being flattened in its wake.

We knew that survival in medical school depended less on our I.Q. and more on our cunning and guile. Our first priority required solving that Delphean dilemma of negotiating the narrow and tortuous passages between the Scylla and Charybdis of Dr. Grant's anatomy labs; and at all cost foundering not on the jagged poetic rocks such as, "The Lingual nerve did take a swerve around the hyo-glossus; said Wharton's duct, 'Well I'll be....'" etc. I felt that medical school survival would be a more Herculean task than surviving the army mess hall; that is to say, more anatomical than gastronomical.

As we carried those heavy, ominous texts and atlases, the upper classmen would terrorize us by chanting, outside the door of the university bookstore, pages of Grant from memory, we not knowing that each had spent half the night memorizing the pages.

Who was Dr. J.C. Boileau Grant and what was the immense legacy he left to thousands of students and surgeons whom he helped train in Canada and to the thousands more in the Western world who used his texts, translated into many languages?

J. Charles Boileau Grant was born a son of the manse, in Loanhead, near Edinburgh, Scotland, on February 6, 1889, and died in Toronto on August 14, 1973. Between these events his life, like the course of the seventh cranial nerve, was complicated but purposeful. After graduating from the University of Edinburgh medical school in 1908, Grant spent two years as an anatomy demonstrator and then became a resident at the Bristol Infirmary. When World War I broke out, Grant volunteered, receiving a commission in the Royal Army Medical Corps. He won a Military Cross (MC) in 1917, and a bar to the MC in 1918. Shortly after demobilization, he became a professor of anatomy at the University of Manitoba at the invitation of Dr. Alexander Gibson, then professor of orthopedic surgery at the University. In 1930 Grant accepted the Chair of Anatomy at the University of Toronto, a position he held until his retirement in 1956. He then became curator of the University of Toronto's Anatomy Museum. This museum of anatomical specimens, which he and his students had created, remains to this day a superb resource for the teaching and the study of anatomy. In 1961 he was invited to the University of California at Los Angeles as a visiting professor for another 10 years, where the students year after year voted him "The Most Valuable Teacher."

Grant's greatest achievements, in addition to his exemplary career as a teacher, were his textbooks, Method of Anatomy, Atlas of Anatomy and Dissector, which sold more than 500,000 copies, making them the most popular anatomy texts in the English-speaking world.

Grant was once asked what qualities he considered to be most valuable as a physician. Without hesitation he gave, "sympathy and understanding for his patient, a high degree of moral integrity and in the case of difficulty or doubt, a readiness to consult with a colleague." Of course, this says it all; what could any compassionate physician add to this magnificent medical credo?

I fondly remember Grant's lectures in the old University of Toronto medical building in the mid-1940's: his high-pitched, squeaky voice and the beautifully colored blackboard diagrams created with chalk. Grant would gesticulate like a great conjurer, as a whole region of anatomy appeared just as the surgeon would see it. None of us would ever forget these diagrams, even at examination time. The students loved his sense of the theatrical, patience, dry wit and adorable idiosyncrasies; he was truly the last of the gentlemen professors. Those who studied under J.C.B. never forgot him, while those who never met him desired to know him.

Thinking back over the years, I returned to those heady, halcyon days at the University of Toronto and I found myself smiling, with the occasional dab of the handkerchief to the eye.

All students who worked in Grant's anatomy laboratories have at least one humorous anecdote, and this is mine. One of our first dissecting assignments involved the axilla. Nose buried in my Dissector, I did the unspeakable, wantonly slicing through the brachial plexus. Our anatomy "demonstrator" twitched with an impending generalized seizure and in a strangled gurgle screamed for Grant, who was two tables away, propelling the Great One to our table. I knew that the game was up and I would soon be back at the Ford Motor Company in Windsor, Ontario, wiring tank engines for $0.90 an hour. Grant pranced to my side (he never really walked), gazed at the armpit calamity, made a few judgmental "clucking" sounds, cocked his head to one side like a robin and, in his squeaky voice, said, "Mr. Bernstein, this is indeed a most vital structure that you, ah, desecrated." His voice almost reaching high-C, he continued, "You will, after laboratory hours, repair the damage, tie the repaired nerve ends with catgut sutures and neatly label each area of repair." More was to come. "T-h-e-n" - he drew out this word to excruciating length - "you will dissect out each branch of the plexus to its muscle supply and label these as well, neatly." He finished with a devastating cut, much to the delight of my lab partners. "Mr. Bernstein, may I make a suggestion?" I was in no bargaining position at this point and said, "Yes, sir!" The Great Man continued, "You should consider very carefully the, uh, hazards of seeking a career in surgery - if you graduate." I genuflected back to my chair and mentally cancelled all my study hours and football practices for the next week, maybe the next month.

Eight years later in the emergency room of a U. S. inner-city hospital, I was confronted with a patient up to her armpit in trouble; a lacerated brachial plexus - what else! The neurosurgical residents were all on vacation in MASH units in Korea and the one remaining was on an urgently enforced honeymoon.

I called the staff surgeon at 3 a.m. and wailed out my dilemma. He countered, in a voice often associated with a major hangover, "Son, you don't need me. You need Grant's Atlas of Anatomy! Good Luck, old chap." After several attempts with the receiver, he hung up.

So I said to my interns, "Let's get this gal to the OR. No sweat, I've repaired this type of problem before." To myself I added, "in a cadaver, after a whole week's work." So with Grant at my side, at least with his magnificent atlas, Mike Duggan, Angela Fuentes and I worked through the night, effecting a reasonable repair - minus the labels.

Grant has been at my side during my 40 years of surgical practice. If I were about to make an uncertain move, I would hear his squeaky voice cry out, "No! No! Not again, Mr. Bernstein."

John Charles Boileau Grant died of cancer on Tuesday, August 14, 1973 at the Toronto General Hospital, his beloved wife Catriona at his bedside. They had had no children. His students though, were his children, often invited to the Grant home for a Sunday brunch. Once in a while he would ask one of them, "Lad, where does the head of the femur reside?" Timidly, the response would be, "In the acetabulum, the hip socket, Sir." With a twinkle in his eye he would answer, "Laddie, you know your anatomy, but not your geography. The answer, of course, is in thighland."

Impeccable scholarship, quirky humor, and behind the mask of old-fashioned politeness and reserve, a warm friendliness, ensure Grant's immortality in the annals of Canadian medicine.

Grant's biographer, Clayton Robinson M.D. and a former Hunterian Professor of the Royal College of Surgeons in England wrote in Dr. Grant's obituary in The New York Times, "Dr. Grant faced death with composure, and his faith carried him gently out of his life as harmoniously as it supported him in his illustrious career."

Although the dictionary meaning of a journal and a diary are exactly the same, a book of days, I shall use the term, journal writing, as a way to understand the past, discover the joy in the present and create the future. The journal is a sanctuary where all disparate elements of life-feelings, thought, dreams, hopes, fears, fantasies, practicalities, worries, facts and intuitions can merge and give a sense of wholeness and coherence. A journal can be a safe place to re-create the sense of child-wonder and experience the full range of imagination. It is a practical tool that enables us to express feelings without inhibitions, recognize and alter self-defeating habits and come to know who we are. The journal allows us to travel in time, not to seek a destination, but to go on a journey. We must understand that the path of the journal is created and not defined. There are no rules to adhere to, no goals to achieve and no plans to follow. The journal exists solely to help fulfill a private need. The journal may be brilliant and boring; superficial and meticulous; humorous and even hazardous; but the voyage is a venture we can trust.

Who can benefit most from a journal? Though the circumstances of our lives may differ greatly, all of us are involved in similar life struggles and seeking similar relationships.

Individuals who keep a journal speak of its magical qualities. They marvel at this method as a means to experience the essential humaneness that links all people... a path to spiritual peace... a workbook of creative writing and other art forms... a safe place to take intellectual and creative risks... a source book for future projects.

The journal is a way to nourish friendship and self-acceptance... to develop a capacity for intimacy... a way to enjoy and profit from solitude... a guide to finding clarity and courage in the midst of crisis and change... a place to record meaningful insights... a quiet place to relax and refresh yourself... a way to resolve the past... a way to re-create yourself.

I encouraged my children, when they were young, to keep a book of questions. My son Danny, about eight at the time, thrilled by his first trans-Atlantic flight, looked down in awe at the white fleecy cotton clouds bathed in the blue sea far below. He wrote a line in his notebook which he later shared with me. "Why is the sky upside-down?" Today as a professional, he still keeps his notebook and pen at the ready, never having lost his sense of wonder.

The following is an excerpt from my journal of September 5, 1975, my 20th year in surgical practice. The page was written shortly after re-reading Camus' "The Myth of Sisyphus."

With each task I successfully complete I sense a fleeting premonition about tomorrow's effort. Can I do better - as well - will I fail? Unlike Sisyphus we are not doomed to repeat each futile task, but as humans, are doomed to be uncertain of our success. For if certain, why care about attempting the task? Doesn't the seed of genius grow from the loam of uncertainty? We are more than just the sum of our parts. To discover how much more - well, that's the mystery of it all.

Several years ago during a not uncommon 3 a.m. awakening with insomnia, I leafed through an old album containing pictures of my father and some of his letters sent to my brother and me when we were away at school. My scribbled notes and questions on his letters were questions meant for him that would never be answered. A story rushed from those unanswered questions and wrote itself in my mind, the nucleus of which became my first published tale called "Father and Sons." That's when I decided journal writing was going to be my way of beginning a second career, a way of restructuring my priorities, my way of becoming a better physician - a way of survival. My journal became "a river, a mirror, both anchor and wings, a process of renewal... myself."

How can journal writing help the physician? We can become better communicators with our families and patients, friends and colleagues and with ourselves. It can help emphasize the present human condition in which normal relations among people are becoming an irrelevance.

The tail of technology now wags the body of medicine. The physician journal-writer can develop a technological perspective allowing a return to the Art, to relate one-on-one with the patient, offering all of the advantages of technology in the diagnosis and treatment of disease but not allowing technology to become a dehumanizing intrusion.

Several years ago the late Norman Cousins, author of Anatomy of An Illness, helped initiate courses in the humanities for medical students at a California university as an assist in tempering medical science with the art of medicine, a leavening of objectivity with compassion. Given Goethe and Thomas Mann, Beethoven and Hegel, the humanities had little effect on the Nazi doctors; as little effect as Tolstoy and Dostoevsky, Tchaikovsky and Chekov had on Stalin's and Brezhnev's psychiatrists. Those steeped in the humanities were involved in a catastrophic corruption of the medical profession never before seen in modern Western history. Although we cannot totally comprehend the reasons for this professional descent into the inferno, one thing, however, is certain: The obsession of German medical science with cold utilitarian objectivity to such a degree that a moral framework for the profession crumbled when overwhelmed by the crushing burden of totalitarianism.

As medicine along with the other sciences navigates into the dangerous uncharted waters of the 21st century and as increasing pseudo-humanist pragmatism seeps into theology, philosophy, government, academia and the media, these forces of historic leadership and guidance may fail.

The 20th century, one of the most violent in our history, is such that a vital and uncompromising vigilance must arise from groups of informed citizens with educated insight to guarantee a free and responsible society. I believe that the physician journal-writer can be such a citizen and captain such a vigilance.

The summer of 1995 was my first hospital admission for an arrhythmia and I required a pacemaker placement. The device worked normally, operation uncomplicated, all went well until three weeks later when an infection developed at the implantation site. The time-course was unusual, well out of the post-operative period. There was a surrounding cellulitis and continuous purulent drainage, although the pacer continued to function well. The laboratory culture of the site grew an unusual bacteria, rarely reported for this type of infection.

It was a surprise to my physicians that I recognized the name, in fact I knew the bacteria far better than they did: Serratia marcesens. The name ripples off the tongue like a vibrating knife-edge and it had come back to haunt me over the decades. Serratia was one of the presumed-harmless bacteria that we tested on unknowing human populations.

Bacteria warfare research, the U.S. Army, circa 1950s. I worked for one of the major U.S. pharmaceutical companies under government contract and although technically not in the army, we were all under their security umbrella. The place was an army base I'll call Camp Harvey. It still exists; I'm not sure what they do there now. I knew healthy men that went in and, after a couple years of various maladies, died there. Numerous hot levels of security ranged up through Anthrax and worse.

Serratia were the safest of our bacterial assortment. They were gram negative rods under the microscope. Harmless to humans. No known disease. We were assigned to manufacture them, tons of them, to test the delivery ordinance, dispersal and such. Vats of 20,000 gallons bubbled with cultures. We tended to the whole manufacturing process, mothering along the microbes. Other types of bacteria formed spores. We manufactured them as well, vast quantities in granular form. Scooping up a handful of powder, one could feel it run through the fingers like sand. I wore a respirator almost always. Some personnel didn't bother with the recommended safety precautions. Men with too high a spore load in their stomachs or lungs would run from the building, vomiting outside on the ground. Later the diarrhea developed.

Over the months our job proceeded as planned. Cultures were incubated and processed. The army worked on the logistics, weaponry, meteorology. Finally testing began. It was a slow time, boring, remote from normal civilization. In our isolation we went about the daily routines. Large culture plates were laid out on grids to catch dispersal of the spores and aerosols. Dropping bacteria directly from a bomb-bay door was useless against the wind. As expected, airburst explosion proved optimum and was refined by altitude, size, and mechanism of the warhead.

In all fairness I have to say that at the time we thought the work was important and in the best interest of the country. Our data could be used for establishing defense as well as offense. Other countries had active biological warfare programs, as they do today - now with even more virulent organisms. Our work investigated patterns of delivery and dispersal, not to inflict injury and assess damage. If we had thought that Serratia would injure humans, the organism could easily have been changed to a different "harmless" and ubiquitous bacteria.

Serratia grew nice red colonies on the agar plates. Their blood-red appearances on food have been signs of miracles and omens for 2,000 years. Eucharistic bread in damp medieval churches dripped the blood of Christ - an example of Serratia alarming the populace. For the biologists these colonies were easy to spot and quantify in the laboratory. Other bacteria grew white and blue. For a diversion from the hum-drum routine, someone streaked a giant plate in the shape of an American flag with red-and-white stripes, blue-and-white stars. It was quite nice. The bacteria were interesting to work with in those days. Standard microbiology techniques were the basic rule.

Inevitably the testing moved on to the population phase. The army pretty much took over. Logistics were the key - and secrecy. A small town was selected, monitored, positioned. Mounted on the back of a train car was the special warhead - maximum spread with minimum noise. It slipped through town and was detonated. Dispersal was proven to be erratic by collection plates. Airburst detonation was the better way.

Small town No. 2: level terrain with a natural border of hills. Typical sunrise: clear, quiet air. No one stirring. The bomb was released from an aircraft for low altitude detonation. At the time most people heard very little bang. Few of the townsfolk were awake for work yet. Nice dispersal, good data. The community carried on its business. Our job was successful.

Now I'm haunted again by the bacteria. Antibiotics for months will not eradicate it. Cephalosporins, aminoglycosides - a list of old and new names. Intravenous Vancomycin can't stop it. My doctors know about my past - I've told them. Am I colonized with the Serratia from decades ago, just now finding clinical expression? Doubtful, they murmur, and culture everything, drop sensitivity discs over and over. Then it must be coincidence. Serratia. Coincidence. Like a small town feeling aerosols randomly carried on the wind?

One of my doctors sat in front of me, an internist talking to me, then pausing to think hard: something about a town once? Graduate school? Yes, he had heard the rumors. A professor of epidemiology told the story of flying there as a public health consultant years ago. An outbreak in a single town: diarrhea and various illnesses. Water reservoir contaminated. Here was a kicker the professor presented to his class, a test problem to solve: The contaminant in the town was a pure culture of bacteria. Where does one find a pure culture? The class was stumped. Answer: only in a laboratory. The investigating team's official report was inconclusive at the time. The members' personal opinions focused on deliberate sabotage - or an experiment gone awry. There was no proof, so it was another unsubstantiated claim of just another biological oddity. Of course their opinions were not released; no need to alarm the public with confusing information. The report's data made its way to the hushed army department responsible and was a further aid for military analysis, an unintended consequence of the civilian biologists' work.

Now what of the present? What about my Serratia? The red skin around the pacer? The throb in my chest? The doctors have mulled it over - cardiologists, internists, surgeons, dermatologists, infectious disease specialists. There are risks, but the pacer will be removed. Hardware out. Antibiotics once more. Culture it all again: my skin, blood, excretions. I'd offer to streak the plates myself. Culture the damn pacemaker, too, even its electrodes. Then we'll see. If the coast is clear, another pacer will be placed in the opposite side of my chest. If not, it's the war all over again.

click to home page * click to page top