Thomas Merton, a/k/a Fr. Mary Louis Merton, O.C.S.O, a member of the monastic community of the Abbey of Our Lady of Gethsemani, in Trappist, Kentucky. The initials O.C.S.O stand for "Order of Cistercians of the Strict Observance," a monastic order of Roman Catholic men and women commonly known as "Trappists." Merton died in Bangkok, December 10, 1968, while attending an international conference on East-West MonasticDialogue.


Albrecht van Haller, Swiss physiologist, 1708-1777. Credited with writing the first standard physiology textbook.


Epeira, [Greek: epi, "upon," and eiros, "wool"] a genus of spiders typical of the family Epiridæ. Epeira diadema is the typical garden spider.


Vale, fratre. Atque ave. [Latin: "Farewell brother, hail and farewell."] Catullus, Carmina, Song 101.


Akili Tyson was a producer on the staff of NPR's All Things Considered. He died in 1996. This poem was among many writings found in his journal.


Essays and Clinical Matters


A Do Not Resuscitate order written into a patient's chart by the physician indicating the patients preference that no attempt be made to revive the individual in the event or cardiac or respiratory failure, a/k/a No Code. A patient's wishes concerning code status can be made clear by using an advance directive. Some research indicates that physicians often ignore these preferences, even when they are known.


Earlier in this chapter, Cassell writes about the paradox of the suffering that results, not only during the course of a disease, but as a result of its treatment.

"Consider this case (occurring a number of years ago): A thirty-five-year-old sculptor with cancer of the breast that had spread widely was treated by competent physicians employing advanced knowledge and technology and acting out of kindness and true concern. At every stage, the treatment as well as the disease was a source of suffering to her. She was frightened and uncertain about her future but could get little information from her physicians, and what she was told was not always the truth. She was unaware, for example, that the radiation therapy to the breast (in lieu of mastectomy) would be so disfiguring. After her ovaries were removed and a regimen of medications that were masculinizing, she became obese, grew facial and body hair of a male type, and her libido disappeared. When tumor invaded the nerves near her shoulder, she lost strength in the hand she used in sculpting and became profoundly depressed. At one time she had watery diarrhea that would occur unexpectedly and often cause incontinence, sometimes when visitors were present. She could not get her physicians to give her medication to stop the diarrhea because they were afraid of possible disease-related side effects (although she was not told the reason). She had a pathologic fracture of her thigh resulting from an area of cancer in the bone. Treatment was delayed while her physicians openly disagreed about pinning her hip. The view that it was wrong to operate on someone with such a poor prognosis prevailed. She remained in traction but her severe pain could not be relieved. She changed hospitals and physicians and the fracture was repaired. Because of the extent of metastatic disease in the unrepaired leg, she was advised not to bear weight on it for fear that it might also break, a possibility that haunted her."



Cancer cells spread locally, by invasion, and systemically, through a process known as metastasis [Greek: meta, "to change," and histanai, "place."] Metastatic disease, as used here, means breast cancer cells have migrated to the patients leg.



The Dubner Maggid, Jacob ben Wolf Kranz of Dubno, Ukraine, was an 18th century itinerant Jewish preacher celebrated for his parables and his homiletics.


François Mitterand was the President of the France from 1981-1995. He died January 8, 1996.



Earlier in the work, Nuland describes the death of James McCarty, a 52 year old man whom Nuland encountered during his medical training. McCarty is admitted to the medical floor to which Nuland is assigned after presenting at the Emergency Room, complaining of a constricting pressure behind his breastbone, looking ashen and sweaty. Nuland, then a third year medical student, is sent to McCarty's room at eleven o'clock at night to do an admissions workup.

"McCarty greeted me with a thin, forced smile, but he couldn't have found my presence reassuring. I have often wondered over the years what must have gone through the mind of that high-pressure boss of large, tough men when he saw my boyish (I was then twenty-two) face and heard me say that I had come to take his history and examine him. Whatever it was, he didn't get much chance to mull it over. As I sat down at his bedside, he suddenly threw his head back and bellowed out a wordless roar that seemed to rise up out of his throat from somewhere deep within his stricken heart. He hit his balled fists with startling force up against the front of his chest in a single synchronous thump, just as his face and neck, in a flash of an instant, turned swollen and purple. His eyes seemed to have pushed themselves forward in one bulging thrust, as though they were going to leap out of his head. He took one immensely long, gurgling breath, and died.

"In those days, every room housing a coronary patient was supplied with a large muslin-wrapped package that contained a thoracotomy kit-a set of instruments with which the chest could be opened in the event of cardiac arrest. Closed-chest cardiopulmonary resuscitation, or CPR, had not yet been invented, and the standard technique in this situation was to attempt to massage the heart directly, by holding it in the hand and applying a long series of rhythmic squeezes.

"I had read that the sensation imparted by a fibrillating heart is like holding in ones' palm a wet, jellylike bagful of hyperactive worms, and that is exactly the way it was. I could tell by its rapidly decreasing resistance to the pressure of my squeezes that the heart was not filling with blood, and so my efforts to force something out of it were useless, especially since the lungs were not being oxygenated. But still I kept at it. And suddenly, something stupefying in its horror took place: the dead McCarty, whose soul was by that time totally departed,threw back his head once more and, staring upward at the ceiling with the glassy, unseeing gaze of open dead eyes, roared out to the distant heavens a dreadful rasping whoop that sounded like the hounds of hell were barking. Only later did I realize that what I had heard was McCarty's version of the death rattle, a sound made by spasm in the muscles of the voice box, caused by the increased acidity in the blood of the newly dead man. It was his way, it seemed, of telling me to desist my efforts to bring him back to life could only be in vain."


This material about Dr. Gary Leinbach appears in "A Fatally Ill Doctor's Reaction to Dying," by Lawrence Altman. The New York Times, July 22, 1974.

Excerpts from Novels and Short Stories



Minnie is the name of her car.



Libera Me Domine [Latin: "Deliver me, O Lord"] The responsory in the absolution at the end of the of the pre-Vatican II Requiem Mass. The text in its entirety is: "Deliver me, O Lord from eternal death on that extraordinary day when the heavens and the earth are moved, when you will come to judge the world by fire."


Spirtual and Religious Texts


Compline [Latin: complere, "to complete"] is the last prayer of the day in the Liturgy of the Hours, the daily cycle of common prayer in Christian communities, especially monastic ones. The prayer is said just before retiring.



The Talmud [Hebrew: lamad, "to learn"] is a collection of ancient Rabbinic writings consisting of the Mishna and the Gemora. The Talmud is the basic and central document of post-biblical Jewish law. The Mishna [Hebrew: anâ, "to repeat"], the first part of the Talmud, consists of early oral interpretations of the scripture and teachings of rabbis and other authorities on Jewish law.


The Jívaro live in the rain forest of Ecuador and Peru.


Bede Jarrett, O.P. was a Dominican priest living in England at the beginning of the 20th century. The initials O.P stand for "Ordo Prædicatorum" [Latin: "Order of Preachers"] the mendicant religious order founded by St. Dominic as part of a monastic reform movement of the Roman Catholic Church.


Exsultet [Latin: "Rejoice!"] The title comes from the first word of the Latin proclamation. This text is sung during the vigil on Holy Saturday (the eve of Easter.)


In Paradisum [Latin: "Into Paradise"] The title comes from the first words of the Latin text. This hymn is sung during the funeral liturgy of the Roman Catholic Church, usually as the body is taken from the Church for burial. The reference to Lazarus calls to mind the story in the Gospel of Jesus raising his friend from the dead after being moved to tears by the grief of Mary and Martha, the sisters of Lazarus.

Visual Images


∆sculapius. Medicine has two competing, but amazingly similar, traditional symbols. The Caduceus of Hermes (two intertwined snakes around a winged-wand) and the staff of ∆sculapius (the knotty tree limb with a single serpent). ∆sculapius was the earliest doctor trained by a centaur Chiron and the ships' surgeon of the Argo. He was so skilled in his profession he could bring the dead back to life. After many successful operations and numerous remarkable cures, Pluto fearful that his dominion would vanish, convinced Zeus to strike ∆sculapius with a thunderbolt and transfer him to the stars. Many medical historians and vociferous literary critics insist that the only true symbol of medicine is the limb branch of life with a single entwined serpent. In the eyes of many, caduceus of Hermes is more distinguished looking and elegant than the "knotty walking stick." The radiant silver wings and the two snakes in concert coiled around the firmly established magic wand make an outstanding emblem in comparison to the fatigued-appearing serpent hanging at best to the slippery bark of a tree limb. Each emblem respectively has its supporters. Legend presents a parable between the two fighting snakes of Hermes, which were attacking one another, but judiciously separated by Hermes' wand, and then were converted from hostility to love; in contradistinction to the sincere serpent of ∆sculapius whose divine powers included the soothing of souls and the healing of wounds. The caduceus probably should be the medical emblem for the military because of the fighting snakes who finally reach a neutrality and peace. The staff of ∆sculapius may satisfactorily represent the ideals of the medical fraternity as mythology describes ∆sculapius defying death in treating his patients with relaxation, diet, hydrotherapy, herbs, massage, advice, and tender loving care.