Course 1; 2009; Fall; Book 2; Lost in America;

Author; Sherwin Nuland

There is a real sense of knowing this man through this book. He does not pull punches, fully exposes himself warts and all, and thus reveals his full humanity. The book also contains one of the best descriptions of depression in literature, and raises many questions about life events that may have contributed to that depression. It is an incredibly moving story.

Winner of the 2003 Kenneth Johnson Memorial Award for the best book on mental illness from the National Alliance for the Mentally Ill

Ethical Issues

1. Aging – Social Issues
2. Doctor Patient Relations; How is Meyer N treated in Clinic?
3. Rationing of Care; Limited for Elderly &/or Infirm?
4. Autonomy; Truth Telling; Telling diagnosis to patient
5. Managing Depression; major procedure (eg lobotomy) in someone with diminished competence.
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General Issues

1. What did you like or not like about the book?

2. What issues did it raise for you personally?

3. Is this book Nulands way of fighting his way out of despair? Coming to terms with some of the causes of his depression?

4. Or did he write book to assuage his guilt regarding his wishes that his father would die and save him embarrassment?

5. Major issue is family dynamics and dysfunction. What do you think?

6. Other issues are raised; ethnicity, immigrants difficulties, guilt, personal failure, poverty, despair, hatred, rage, control.

7. What do you think it was like for Nuland to discover that his father had tertiarly syphilis?


8. What does this book tell us about memory? What does it mean that so many complex full lives are not only gone, but not even remembered? Standing in cemetery in forward; lives long-mourned or forgotten

9. Understanding life; Can we ever really understand ourselves? Is this really a journey that can’t be completed?

10. Making peace with our parents. This book is about Nulands attempt to make such a peace. Can we ever do this?

Close Reading
6. Read Depression; wonderful description here. Examine the words used on P 3-5.

7. “Return to memory”. P 4. Have any of you ever tried to do this? Difficult?

8. Re the psychiatric resident who refused to give in to the others. What do you think about him? Guardian angel? Fortunate interlocutor? Quirk of luck? What happens when we dont have such luck? How are lives changed? Path in the road. If Nuland had had lobotomy, might never have become great writer.

9. Role of hope. P 8. Nuland always knew he would get better. What is the impact of this optimism? How are love and connection eg with his children, related to this.

10. Meyer Nudelman; sui generis, in class by himself. Isnt that true for everyone?

11. Statement p 11. “A proud man reduced to deblitiy is hypersensitive to any perceived slight.” Agree?

12. Fathers anger (rage). Where does this fit in the spectrum of mental illness. It is a paramount feature of depression, more in men than women often coming as attacks.

13. P12 “His weakness was his strength” This statement seems to be a paradox. What does it mean?

14. P12; “Not freedom I should have been seeking but understanding”. (And what else? Perhaps acceptatnce that his father did the best he was capable of doing. The father was also depressed, and lacked the sophistication of the son not to take it out on his children.

15. P14-15 How are these feelings connected to Nulands depression?

16. P 18. What was the immigrant experience like? Tuberculosis was common disease of immigrants. No real treatement at that time. Disease, poverty, bigotry, harsh work conditions all part of immigrant experience, but still better than where they came from.

17. P 20. Why might father not speak of family back home? Desertion? Left agisnt their will? Did not want to feel responsible for them? Too responsible with too much sorrow?

18. P21. In telling story of his forbears changing their surname with no guilt, is Nuland trying to justify his doing this? Does he protest too much?

19. P22. Most families have secrets. What might have been going on here?

20. P23. What is reason for nostalgia of immigrant experience? Is it because it reminds us of our lost youth? The possibilities, most of which were never realized? A way to connect with forebears that we ignored when we were younger?

24. P37. Do we in fact repress hurtful memories? Nuland did not repress these; they are there. Is this why he got depressed?


25. What it the importance of children to an immigrant family? Triumph over adversity and hardships. Gives some sense of purpose to work and struggle. Children are the proof of value of perseverance. A form of redemption.

26. p 38. Why does Sherwin’s father get angry when his son pulls back from his clumsy gesture of affection?
Anger is not a primary emotion. Is always secondary to something else,
usually fear or hurt. In this case, primary emotion is hurt. Father is
frequently hurt. He is probably chronically depressed and thus easily hurt
and on edge or rage.

27. Read P 64-65; Yom Kippur prayer; a central feature of the day. Nuland attributes a major cause of his depression to be this prayer. (What do you think?) Prayer contains religious/supernatural forces. The imagery consumed him; he blelieved in this literally. Lingering fear, re the risk of luring him back to the depression, the obsessive thinking.

Could this really be the basis of depression?
Depression is result of complex interaction between genetics and environment. (nature vs nurture). This is the environment/nurture part.

28. Read P69. What was impact on Sherwin of hearing his family described as crazy?

29. Read P71 Discuss the differences between his father and his uncle Manny

30. Read P72-73; This says much about the nature of connection in many first generation immigrant families

31. Read P77 Shows the complexity of relationships; multiple facets.

32. P 79; Discuss influence of Esther; calm and cheerful; she changed the mood of the entire house.

33. Read P82-83 This is one of the best descriptions of grief in an 11 year old boy who has just lost his mother.

34. Read P 85-86 Discussion of mourning and grief. Each one alone; Private thoughts. Is this peculiar to this author, or is it universal? Intimacy and closeness are often cut off at times of intense grief

35. P 88-89 Two brothers showed a ‘remarkable sense of obligation. Why do some act this way, most do not?

36. P 90 It is Tante Aya who prevailed over his father in decision for him to spend time with Joe’s family. Women often strong figures in immigrant families. It was their role to hold family together, ensure enough financial stablitiy, etc.

37. P 92. Good description of poor boy being rescued by wealthy, and how that can be transforming. What are the pros and cons, if any, of him having that escape?

38. P 92 Joe sits in his fathers place. Place has great significance. I remember a very dominant man who always took a seat at the head of the table whenever he went anywhere.

39. P 92-99; Joe’s offer; A wonderful description of ambivalence when faced with a critical choice. Much anguish all around. Everyone has their own ambivalence to deal with. Discuss from point of view of Sherwin, his father, his Bubbe.

40. Read P 96-97 A description of the love that occurs in some close knit families that transcends the poverty, the superstition, the craziness. Children as consolation for all the trials of life.

41. P 98. Meyer explodes. How do you suppose he felt? Was he justified in wanting Sherwin to stay with him? In seeing it as an affront? What about Joe? What was he thinking? There is an expression “No good deed goes unpunished”. This was certainly true of Joe’s offer. Except that one could make the case that the offer was insensitive.

42. Read P 102 Good description of Rheumatic Fever; common in those days. Complication of Strep Throat. Wiped out since advent of penicillin. When I was a med student, no RF but much RHD. Now most cases have died. Then disease could cause heart valve closure or leakage, usually in 30s and 40s, followed by heart failure. One of commonest causes of heart failure in 1940s and 1950s. as legacy for earlier Strep throat.

43. P102 Words in medicine have powerful connotations to lay persons, especially to the unsophisticated. Words like murmur, cancer. Discuss.

44. P 104-105; Nuland compares RF treatment in early 1940s to modern concepts of treatment of RF caution against “unwarranted invalidism” Much of medicine has changed, relying on “evidence based” medicine, rather that what appeared to make sense but was nothing more than folklore. Harvey that Sherwin had known was “gone forever”

45. P 105. Meyer Nudelman speaks of thoughts of suicide if he got more bad news about Harvey. Do you think he might have killed himself? Was he being dramatic? Was Meyer that depressed? What was evidence, if any of depression ? Yes, his lack of sense of self-esteem, purposelessness, irritability, fits of rage, trouble connecting, all point to depression.

46. P107 Sherwin speaks of redemption for his father. This is a common theme in books, film, etc. It cuts across myths from many cultures. For all of Meyer’s troubles, he still saw Sherwin as the carrier of that redemption. Now much do we count on children to do this? Is there a flip side to this? Eg putting pressure on kids to fulfill our needs?

47. P 108; Sherwin speaks of self-incrimination later in life for not taking his father more seriously. Was this justified?

48. P109 Description of estrangement by means of how the sons refer to the father. How common is this for kids?

49. Read P 111 Very accurate description of clinic. A marked disparity between medical care for poor vs affluent. Discuss. What were differences? Affluent got appointments, seen on time, treated with dignity. Back then, Sherwin knew this was no way to treat patients. As he states, this is his model for how not to treat patients.

50. P 111. What is dignity? How important is it? What effect does it have on persons, like Meyer, who aren’t treated with dignity?

51. Episode in subway car when he explodes at three girls. What led up to this outburst? Underlying depression, loss of dignity with searing of soul, frustration, insensivity of strangers lead to rage which leads to public humiliation.

52. P 116 Description of a federal bureaucracy. This is why so many persons don’t want government running anything.

53. P 118-120. Sherwin continually refers to himself as being a 14 year old self-absorbed boy. Is he being too hard on himself? Is this normall? What about children who are self-sacrificing? Again, when they get to the movie and Sherwin refuses to go and his father pleads with him, the scene is heart-breaking. Sherwin states that “anyone with an iota of compassion would have responded”

54. P 120 Was Sherwins reaction justified? Point of view of 14 year old vs more experienced adult recpgnizing cruelty of his own behavior. Do we all do this?

55. P 120 Father asks Sherwin to show Rachmones; this is a major concept in Yiddish, for which there is no exact translation. He translates it as mercy, but its closest meaning is “compassion.” It is a concept that is central to Judaism. I have heard one scholar translate it as referring to the love that a mother has for her newborn baby.

56. P 121 Are painful memories likely to be repressed? I am not sure, perhaps we don’t allow ourselves to dwell on them because of the pain, and because this saves us from depression. Avoiding them allows apparent forgetting. The fact that so many of his memories are accessible likely has contributed to his depression.

57. Read P 123 Wonderful description of the retention of a powerful response to fathers displeasure. Father may have been weak and inadequate, but in this way he was exceedingly powerful. Sherwin cowered. “flaying the skin from my soul” Again, probably contributing factor is his depression.

58. P 125. Grandmother and aunt are described as holding onto grudges. Why do people hold onto grudges?

59. P 131-133; Issue of homosexuality vs feminine traits. High school boys tend to equate the two. Sherwin engages in self-deprecation. MMPI, the most widely used psychological inventory, historically made the assumption that the two were equal They tried to diagnose homosexuality by asking questions like “I would like a job as a flower arranger”, or “I like going to the ballet” T or F.

60. P133 Talks of his “constant introverted sadness”. This is the first evidence of his depression.

61. P 133-134 Aunt thought Sherwins depression was secondary to fathers tirade three weeks earlier. Was it? Yes and no. No because he has the genetic predisposition. Yes, because the tirade may have been a trigger.

62. Psychiatrist. Why is he so effective? Most important features are that he is gentle and “understanding” Without these, competence doesn’t mean much.

63. P 134. Why did the taking of a shower, and toweling vigorously work to get him out of depression? Placebo effect. Sherwin believed in the recommendations of the psych because he liked and trusted him. And it worked.

64. P 137-138. Immigrant Jewish families; most came from Pale of Russia. Thin sliver of Western Russia, that permitted (required) Jews to live there. Mainly Ukraine, Belarus, Lithuania, Eastern Poland. Romania. These were areas completely occupied by Nazi Germany, and it was a major trauma for families who had emigrated to hear about the murder of the families that they had left behind. The reaction of Meyer was repeated thousands of times for other immigrants from Eastern Europe.

65. Bubbeh and Rose came from same town. Why didn’t they react?

66. P 139 Meyer gets letter from his brother who left Russia 20-30 years after Meyer left. He did not know he was alive. This means that one member of his family survived Holocaust. Why didn’t Meyer write back to his brother?.

67. P 140 Why did Sherwin want name change? Embarrasment, ridicule, bigotry, medical school quotas, unpleasant associations

68. p 144. Sherwin and Harvey are changing name to Nuland. Father wants to change his name also. Why? He fears that he will be labeled as alien, different, left behind by his sons . “We should be all the same” His fears are accurate.

69. P 144-145 Why don’t the sons want their father to change his name? Their name change is as much an escape from father as it is the other reasons. Their major motivation for their own name change is shame

70. P 145 Sherwin makes the point that he is still Nudelman. He points out the fact that name change was illegal. This is a metaphor for the fact that he is still Nudleman in his heart and soul.

71. P 149 Public wards. Why are they no longer there? There was no privacy and they represented the absence of dignity. It was assembly line medicine. We would make rounds, going from bed to bed, intern, resident, attending staff, every morning. Meanwhile, paying patients had semi-private rooms (two per room), and really affluent had private (one person in room). The contrast based on ability to pay ended with the advent of universal health care and everyone being treated the same.

72. P 150 Father particularly proud that his son would be a doctor. Why was he proud? This was culmination of his life. It had all been worthwhile. All the suffering, death of son and wife, poverty, illness; finally his life could be said to have purpose.

73. P 151 Sherwin says that he did not want to work in laboratories, even thlough he liked science. “Biology with people” He was Bubbes son; life meant people. How do doctors choose their specialties? By their underlying personalities.

74. P 151. Sherwin has an idealized picture of what a doctor should be. Is this realistic? Yes, he has seen it. Important feature is to maintain hope. What are the two factors Sherwin thinks are most important? Two persons; Leo; imperturbability --> loss of panic and pessimism . Willie; energetic competence. These are his role models.

75. P 152. Sherwin thinks it naïve to link science with literature. Is this correct? I don’t think so. Many doctors are also great writers. Checkov, Michael Crichton, Somerset Maugham. In my opinion, appreciation of literature makes one a beltter doctor

76. P 153. Sherwin would leave whatever he was doing if he thought his father needed him. Is this self-sacrifice a good thing?. Open to many answers.

77. P 154. Father is chronically ill, but can go for years like this. Sherwin admits he wishes father would die. Is this wish bad? Irresponsible? Common under the circumstances?

78. Many become alienated from a sick parent, and do anything to escape, including changing name, religion, occupation, etc. Associate parent with oppression, superstition, bad upbringing, etc.

79. P 158. Camp Boiberik exemplities values of many immigrants, (not like Meyer). These were peope who had rejected religion and Zionism. Their faith was secular and political. Socialism or Communism, usuall with their own separate camps and instituions, One common denomator was commitment to Yiddish language.

80. P 159-161. At camp, 19 years old, entering senior year of college, he undergoes an “exploratory hedonism” What was that about? Major change from his previous life. “time of your life”

81. P 161-163 Sherwin is furious that his father wants him to come visit him in the hospital, even though he is getting better. Is fathers demand reasonable and responsible? Is Sherwins fury reasonable and responsible?

82. P 163 Sherwin has a recurrence of depression. Discuss. How is it manifest? loss of enthusiasm, loss of sense of pleasure, and irritability. Triggered by visit to father. Powerful trigger. His whole personality changes. This is a good description of what depression feels like “I lost the happy wonder”

83. P 164. Application to Med School I also came from a predom Jewish school; about 20 applied to Med School; 8 were accepted.

84. P 166 Why is he so eager to go to Yale? Fantasy, affluent America, free of Bronx, Yiddish accents, his father. Unattainable, therefore even more desirable.

85. P 167 Re Meyer and Rose’s reaction to him possibley going to Yale, he feels smothered by their love. How does that work?

86. P 169-171 Why did Meyer want to marry Rose?

87. P 173. Why is Sherwin depressed again? He is not only going to College, but leaving his father and aunt for the first time. Guilt, dramatic change in life circumstances, likely act as triggers.

88. P 176-178. What do you think about Sherwins reaction to learning that his father had tabes dorsalis, one of the forms of neurosyphilis? Does it change his attitude toward his father? He refers to “strong man robbed of his manhood” And in very dramatic fashion, he becomes aware of his own longing, of the mutual love that he and his father have for each other. And this knowledge (P 183) allows Sherwin to appreciate the “magnitude of his burden”.

89. P 182-183 Re father not knowing his diagnosis. One of the principles of bioethics is autonomy. This includes the right of everyone to make their own decisions, and that requires full disclosure by any physician of whatever is wrong with the patient. This runs counter to the principle of beneficence in which you do whatever is right for the patient. In the case of Meyer, he was not told his diagnosis. Most bioethicists would disagree with this. What do you think?

90. Treatment of syphilis. Prior to penicillin (about 1945), treatment was of little value. Used fever therapy in attempt to kill spirochetes (organisms that cause the disease). However, penicillin is very effective for primary syphilis, but has little or no effect on later tabes.

91. P 184. Talks about his father having lost. What is he referring to? He had given up fighting against his disease, finally accepting that his life was over, and he had two sons to show for it.

92. P 188-192. Sherwin’s first girl friend. Contrast her family with his family and effect that had on him, seeing a family where they all liked each other. Was this because the families were really different or because the individuals had no history of tragedy, depression, etc.

93. P 193-194 Sherwin realizes he will never totally separate from his father and home. Why Is this? Drenched in memories, Old emotional burden both a burden and a support.

94. P 197 Why did Sherwin pick surgery as a specialty? Influence of charismatic teacher, for him a combination of aesthetics and intellectual factors,

95. P 206-209 Sherwins final visit with his father. Finally they were at peace with each other. Why couldn’t Sherwin tell his father that he loved him?

96. Afterward; In what ways will Sherwin never be free of his father?