Irritating fictional doctors: Dr Gregory in F Scott Fitzgerald’s “Gretchen’s Forty Winks” and the balanced life

A while back I posted about the less-than-busy doctors of Victorian detective fiction. Another medical archetype of fiction is the irritatingly bluff doctor. While Dr Gregory in F Scott Fitzgerald’s short story “Gretchen’s Forty Winks” is a minor character, he encapsulates a certain cheery complacency.

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This story is not among Fitzgerald’s best. An awful lot of Fitzgerald’s writing was for money, in the midst of a chaotic life. There’s nothing wrong with this – remember Dr Johnson’s dictum that no man but a blockhead writes except for money. However, “Gretchen’s Forty Winks” is no Great Gatsby. There is also much that would now be deemed sexist, not to mention casual gaslighting and slipping of Mickey Finns within the marital relationship . Of course, no doubt there is much we find unexceptional or even virtuous in our own culture which will in nearly a century seem laughably unethical.and the story has some by-the-way flashes of Fitzgerald’s acuity and brilliance. It also has some historical interest as an portrayal of what might have been seen as a “balanced life” in 1924.

The story was published in the Saturday Evening Post of March 15, 1924.

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It is a rather heavy handed spoof of the cult of the “balanced life” (nowadays we would say work-life balance). The protagonist, Roger Halsey, is an advertising man, who has struck out for himself having left “the New York Lithographic Company.” We meet him coming home to his wife Gretchen. Fitzgerald writes thus of their marriage: “it was seldom that they hated each other with that violent hate of which only young couples are capable, for Roger was still acutely sensitive to her beauty.” Halsey has to work for forty solid days to obtain “some of the largest accounts in the country”, to the disappointment of his wife – “she was a Southern girl, and any question that had to do with getting ahead in the world always gave her a headache.”

His wife introduces Halsey to George Tompkins, an interior designer and devotee of the “the balanced life.” An irritated Halsey asks for a definition:

“Well’ – he hesitated – probably the best way to tell you would be to describe my own day. Would that seem horribly egotistic?”

“Oh  no!” Gretchen looked at him with interest. ‘I’d love to hear about it’

‘Well, in the morning I get up and go through a series of exercises. I’ve got one room fitted up as a little gymnasium, and I punching the bag and do shadow-boxing and weight-pulling for an hour. Then after a cold bath – There’s a thing now? Do you take a daily cold bath?’

‘No,’ admitted Roger. ‘I take a hot bath in the evening three or four times a week.’

A horrified silence fell. Tompkins and Gretchen exchanged a glance as if something obscene had been said.

‘What’s the matter?’ broke out Roger, glancing from one to the other in some irritation. ‘You know I don’t take a bath every day – I haven’t got the time.’

Tompkins gave  a prolonged sigh.

‘After my bath,’ he continued, drawing a merciful veil of silence over the matter, ‘I have breakfast and drive to my office in New York, where I work until four. Then I lay off, and if it’s summer I hurry out here for nine holes of golf, or if it’s winter I play squash for an hour at my club. Then a good snappy game of bridge until dinner. Dinner is liable to have something to do with business, but in a pleasant way. Perhaps I’ve just finished a house for some customer, and he wants me to be on hand for his first party to see that the lighting is soft enough and all that sort of thing. Or maybe I sit down with a good book of poetry and spend the evening alone. At any rate, I do something every night to get me out of myself.’

Roger is unimpressed. As the story progresses, he keeps to his exacting work schedule, until he nearly has secured a major account. Gretchen has chafed all along at the economising, and the night before a crucial submission forces another dinner with Tompkins. At this, Roger and Tompkins end up having a blazing row, simmering with the fury of the man who suspects he be becoming a cuckold:

“‘Are you implying my work is useless?’ demanded Tompkins incredulously.

‘No: not if it brings happiness to some poor sucker of a pants manufacturer who doesn’t known how to spend his money'”

SPOILER ALERT!

 

 

 

 

After ejecting Tompkins from his house, Roger resorts to obtaining something unmentioned from the local drugstore, and putting “into the coffee half a teaspoonful of a white substance that was not powdered sugar” before giving it to his wife. He also hides all her shoes in a  bag.

This allows him to spend all night working on the account (not before giving his grumpy landlord the bag of shoes as a guarantee, having missed that month’s rent) with ultimate success. A contrite Gretchen awakes after a full day going missing from her life, thanks to her husband’s deployment of white powder, and so distressed is she at finding her shoes missing that Roger agrees to take her to the doctor.  Enter Doctor Gregory, a man for whom the word ‘confidentiality’ has no meaning:

The doctor arrived in ten minutes.

‘I think I’m on the verge of a collapse,’ Gretchen told him in a strained voice.

Doctor Gregory sat does on the edge of the bed and took her wrist in his hand.

‘It seems to be in the air this morning.’

‘I got up,’ said Gretchen in an awed voice, ‘and I found that I’d lost a hole day. I had an engagement to go riding with George Tompkins -‘

‘What?’ exclaimed the doctor in surprise. Then he laughed.

‘George Tompkins won’t go riding with anyone for many days to come.’

‘Has he gone away?’ asked Gretchen curiously.

‘He’s going West.’

‘Why?’ demanded Roger. ‘Is he running away with somebody’s wife?’

‘No,’ said Doctor Gregory. ‘He’s had a nervous breakdown.’

‘What?’ they exclaimed in unison.

‘He just collapsed like an opera-hat in his cold shower.’

‘But he was always talking about his – his balanced life,’ gasped Gretchen. ‘He had it on his mind.’

‘I know,’ said the doctor. ‘He’s been babbling about it all morning. I think it’s driven him a little mad. He worked pretty hard at it, you know.’

‘At what?’ demanded Roger in bewilderment.

‘At keeping his life balanced.’ He turned to Gretchen. ‘Now all I’ll prescribe for this lady here is a good rest. If she’ll just stay around the house for a few days and take forty winks of sleep she’ll be as fit as ever. She’s been under some strain.’

Dr Gregory’s utter disregard for confidentiality is impressive in its brazenness (and if he could make a house call in ten minutes he is himself presumably impressively non-busy) but, for me, the height of his irritatingness is still to come:

‘Doctor,’ exclaimed Roger hoarsely, ‘don’t you think I’d better have a rest or something. I’ve been working pretty hard lately.’

‘You!’ Doctor Gregory laughed, slapped him violently on the back. ‘My boy, I never saw you looking better in your life.’

 

“slapped him violently on the back” – truly Dr Gregory is a prince among doctors… (the phrase also pops up in James Herriot)

As for the more general spoof of “the balanced life”, it is surely wise to reflect moderation in all things is wise, especially moderation. A suspicion of overly-programmed approaches to nature and leisure underlies my mild suspicion of “forest bathing” One of the founders of The Idler once wrote about having a breakdown due to his frenetic life of writing and talking about the wonders of idleness.

But it might also be wise to recall that Fitzgerald’s book of autobiographical writings was called The Crack-Up.

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“Wise pearls of refractive and cataract surgery revealed in charming style” review of 101 Pearls In Refractive, Cataract and Corneal Surgery. Eurotimes, Jan 2007

PDF of the original is here. I was always billed as “MD” by Eurotimes, despite repeated requests to change it on my part. This review is again fairly typical. My musings on evidence based practice and the possible return of clinical wisdom seem germane to the considerations I wrote about here . Credit to the subeditor for the haiku-like title (too many syllables though)

“Wise pearls of refractive and cataract surgery revealed in charming style”

There is something of a tradition in medical publishing of books claiming to provide “pearls” or “clinical gems” or “clinical secrets”.

These are never primary textbooks that could be used for study, but supplement basic knowledge, and mirror a learning technique of definite effectiveness.

We like to think the practice of medicine is a rational exercise, the application of knowledge gleaned from evidence-based sources and from a rigorous training in the basic sciences that underpin medicine.

The fact is, however, that our practice is very often based on the cases that stick in the mind, those that illustrate some point or other much more effectively than, let us be honest, any amount of high-minded praise of evidence-based practice.

After all, a little introspection will reveal that we remember the unusual, the striking, the individual, far more than the great mass of material we are instructed to recall. Of course, properly applied, evidence  basedpractice flows from the individual case to the peer-reviewed paper, and not the other way round.

Melki and Azar have assembled an international cast of contributors to produce this concise, clear, practical volume, which is aimed at practitioners and assumes a certain degree of familiarity with surgical technique, indication and practice. So this is a typical “pearls” book – not one for the student or the beginner but one for the active practitioner, guiding and advising the actual process of clinical medicine. In this case, the surgeon of the anterior chamber.

There is something charming and collegial about this approach, an approach that conjures up old-fashioned images of medical training and education as a body of knowledge handed down, apprenticeship style, from older practitioners to younger ones.The “pearls” book concept presumably began life as a compilation of the sayings of certain eminent clinicians.

Again, the current of medical education and training now – as well as reforms and/or tinkerings (delete according to taste) with medical training  – is towards self-directed,“problem-based” learning. Fashions change in medical training as much as any other field, and there is something to be said for the older approach. No doubt it will return to some degree.The notion of “expertise” of senior clinicians – or even not so senior ones – counting for much is old-fashioned in medicine.Yet have we lost something in the rush to elevate the meta-analysis of a series of double-blind randomised controlled trials as the measure of all things?

Claes H Dohlman, professor of ophthalmology at Harvard Medical School, contributes a foreword to this second edition as he did to the first edition. Dohlman writes of the apparent presumption of the editors in taking on three enormous areas in a single, relatively compact text.“However, instead of trying to grind through the topics in the traditional way, resulting in superficiality, the authors have cleverly singled out a series of discrete key issues along the cutting edge of this surgery.” Thus the “pearls” of the title.

So what are the pearls? Given that there are 101, the reader will forgive the absence of a list of each and every one.There are 25 subsections, aggregations of pearls so to speak, which begin with surgical planning with wavefront tomography and end with posterior keratoplasty. Each “pearl” is essentially a little section of text, with the accent on practical advice and issues, and at the end an “Always Remember” box succinctly summarises the crucial point. In between, every technical area is covered – as explained above and reiterated by Dohlman in his Foreword, this is not and does not claim to be a comprehensive textbook or, indeed, a manual of every single step of surgery, but a supplement to these sources. The pearls very often relate to the use of specific technologies in surgery, and practitioners may need familiarity with and indeed availability of these technologies to fully benefit from the book.

There is no doubt, however, that what is described is cutting edge, if the pun can be excused, and consistently reflects a high standard of practice which all practitioners should aim to emulate.The pearls also cover anaesthetic issues as well as those relating to particular points of surgical technique and preoperative work-up.

Thus, the relatively slim size and portability of the book. It is attractively presented, with good clear fonts on highquality paper, and a range of full-colour photographs and diagrams.The book I reviewed was a soft-cover edition with an attractively colourful cover. It is a snappy cover that reflects the snappy concept contained therein.

Overall, I was impressed with this book, which will complement comprehensive textbooks for the trainee ophthalmologist of the anterior section, with access to the technical innovations mentioned.

Review submitted in Feb 2007 of “Mastering the Techniques of Glaucoma Diagnosis and Management.” for Eurotimes

OK, undoubtedly the writing I have been paid the most for over the years – the writing that has been the closest I have been to earning some kind of living via the pen – were the book reviews I wrote for Eurotimes, the publication of the European Society of Cataract and Refractive Surgeons, from 2004 until 2010. With a payment by the word, and a brief essentially to write a piece about a book that would include a physical description of the size, cover design and proportions of the book, this was an assignment that ultimately became too much “for the  money” rather than any great emotional investment on my part. Perhaps that was all to the good. Generally I would hold forth for some paragraphs about some wider issue inspired by the book, and this is fairly typical of my efforts.

I was upfront with the magazine about my lack of specialist knowledge of ophthalmology (although it has always been an interest and even quite far into psychiatric training I thought of changing specialties…. occasionally I think of it still) but that didn’t matter – the ability to write serviceable prose on a reliable schedule was the important thing. I tried to make these pieces interesting. I am not sure I always succeeded. Payment by the word may have engendered a certain long windedness.

Mastering the Techniques of Glaucoma Diagnosis and Management. Editors: Ashok

Garg et al. Jaypee Brothers, New Delhi, 2006. richly illustrated with colour

photographs, diagrams and tables. 556 pp.

Over the last number of months, this column has increasingly been dominated by the

publications of Jaypee Brothers of New Delhi. This production, from the cover in, is

their most lavish production yet. “Mastering the Techniques of Glaucoma Diagnosis

& Management” – which boasts a tiny picture of an eye in the “o” of “Glaucoma” on

the cover – is a production resulting from the efforts of 97 international contributors

from 15 countries. It required ten editors, with as nearly a spread of nationalities

involved. Perhaps unsurprisingly, the text on the back cover about this platoon of

editors requires quite a small typeface cover to accommodate all their life stories and

achievements.

India is often used a case study in the effects of globalisation, and while from a

European point of view stories about outsourcing are often used as a stick to beat

globalisation, this books global range and scope illustrate the positive side of the

process. The internet has made the idea of a book published in India with contributors

from 15 different countries and editors from 7 countries all collaborating not merely

feasible, but a commonplace, and the globalisation of computer technology has made

the technical quality of the book achievable in a wide range of settings.

As glaucoma is now catching up with cataract as a worldwide cause of blindness, this

book is timely. Our awareness of the pathophysiology and natural history of glaucoma

has greatly increased. With an ageing population worldwide, chronic progressive

conditions like glaucoma will affect both patients themselves and practitioners more

and more as time goes by. New therapies offer the promise of a more efficient, more

cost-effective and therefore more available approach to glaucoma therapy.

The book is divided into four sections. First one on preliminary considerations and

diagnostic procedures in glaucoma. Secondly the management of glaucoma itself –

medical, surgical and laser – is discussed. This section, unsurprisingly, takes up the

largest section of the book, at over three hundred pages. There follows a short section

on complications of therapy, and finally a section on minimally invasive glaucoma

surgery, which focuses on recent technological and technical advances and possible

future developments.

The book is extremely practical. The final section in particular on innovative

techniques is, by its very nature perhaps, quite didactic and instructive. Experienced

surgeons will find this section of particular interest and will be able to compare their

technique with that of the authors due to the high quality of the instructions given.

In the early section on diagnostic and pre-operative assessment too, we see this

eminently practical approach. Checklists and instructions for very practical tasks are

given, while the more discursive text describes the evidence base and technical and

theoretical reasons for the actions recommended. We find the same approach

throughout the longest section on the technical issues around management of

glaucoma itself.

I have commented before on the high quality of books coming out of India in general,

and in particular on the high quality of books being published by Jaypee Brothers.

This book is not only of as high quality, it is aesthetically more pleasing. The typeface

and general design seem cleaner and more pleasing to the eye – and the various

sections are colour-coded for ease of access. The book is pleasant to handle. It is a

large, reference book, rather than one one could easily carry around the wards or into

theatre. It has a very attractive, soothing even, blue colour scheme on the cover.

The quality of the illustrations – and in particular the reproductions of colour

photographs – is also much to be commended. It is pleasant to come across a book

about ophthalmology so, in its way, attractive to look at. And again, this enhances the

practicality of the book.

As is the fashion nowadays, and as is the tradition with these large Jaypee Brothers

books, there is a DVD provided with the book. It is important to actually see

procedures being performed rather than just written about, and the selection of video

clips from the practices of some of the contributors is a valuable addition to the book.

Sometimes DVDs and CD-ROMs that come packaged with textbooks have a rather

gimmicky feel to them, replicating elements of the book rather than being used for

their own unique qualities, but this DVD is focused on providing visual backup for

the text rather than this pointless duplication.

This book is boggingly comprehensive and will satisfy both the trainee and the

specialist. There is perhaps overmuch detail for all but the most enthusiastic medical

student or non ophthalmologic doctor. With the rise of glaucoma noted above, it is

important that books for these groups are also produced, to raise awareness of the

condition and to give a simpler overview of treatment modalities. However, this

certainly is a useful overview of the state of the art with glaucoma management, with

a strong practical bent.