Those Who Will Not be Healed
The Antioch Review
Volume 64, No. 4, P. 799
Vivian Kleinfelter was a thirty-nine-year-old patient with nineteen chief complaints. Her feet tingled. Her ears rang. She saw spots in front of her eyes. Gas pains kept her awake all night. Daily attacks of nausea were accompanied by cramps and rainbow-colored vomitus. All this had started with shortness of breath in her youth, suffocating attacks so severe she sometimes fainted dead away, but a wise old family doctor had taught her to manage these by breathing into a paper bag, while the remaining symptoms had resisted the ministrations of a dozen specialists for more than a decade. It took me an hour and a half, rushing a bit at the end, but I finally got every last complaint scribbled down in her chart, together with her past medical history, family history, social history, and review of systems. Physical examination took ten minutes – normal head to toe except for the well-healed scar of a biopsy on her left breast (done three years before, a benign cyst) and a varicose vein on her left calf.
To the semi-skilled eyes and hands of a third-year medical student, Vivian seemed the picture of health. Tall and solid, ramrod straight, with curly auburn hair, she had the body and skin tone of a woman ten years younger. She talked on and on with the momentum of eager, well-rehearsed speech, her hand flitting about like a hummingbird as she touched the body part that harbored each complaint: eyes, ears, nose, throat, bosom, stomach . . . But alas, her visit to the Stanford Medical Clinic came to naught. Less than naught.
Alan Barbour, the clinic director, gave Vivian his best. He examined her body and reviewed every detail in her chart, which included voluminous records from the Cedars-Sinai in Los Angeles and the Pacific Medical Center in San Francisco, then delivered his diagnosis. He spoke with the deepest compassion, but the noble fellow insisted on telling the truth – it was all in Vivian’s head, every symptom a hypochondriacal paradigm – and his efforts only enraged her. A disastrous consultation. In the end she stormed out of the clinic. I called her at home three months later to find out how she was doing.
“I’m better,” she said. “A little better, since I saw an iridologist, and this aroma therapist in San Mateo gave me some essential oils – juniper and lavender, I sniff with my right nostril every morning, then patchouli up my left nostril at night. They’ve helped a little. My ears don’t ring as much so I can sleep at night, at least when the gas pains let up, and my feet don’t bother me like they used to. But that Doctor Barbour” – her voice rose to a shout, quavering with rage – “you can tell that son of a bitch to go straight to hell! All in my head! Why, I’d like to take his head and smash it with a hammer . . . ”
Indeed, of all the hypochondriacs I presented to Alan in the Stanford Medical Clinic, the poor man – a self-proclaimed specialist in hypochondria – never cured a single one. His intentions were good, his integrity unimpeachable, but the truths he told, however kindly imparted, left dozens of patients grinding their teeth.
* * *
I know a lot about hypochondria, having suffered from it most of my adult life – such a severe case that my search for a cure drove me to become a physician. The sense of my own mortality first came upon me during my senior year in high school, when Ed Miller, the brother of a close friend, died of Hodgkin’s disease. I had seen Ed fading, growing thinner and weaker each month, choked with phlegm and tormented by painful lumps in his groin and armpits, but it was not until the end that his fate took on a personal meaning. I had seen death before: Mamaw, my beloved maternal grandmother, together with my father’s parents and two great uncles. But they were old. Though I missed them terribly, especially Mamaw, their deaths had nothing to do with my own vulnerability. Ed Miller was young, just three years older than I. His face haunted me – chalky white, the cheeks sunken, the eyes wide with confusion and terror.
My first year of college brought night sweats (an early sign of lymphatic cancer, or so I had heard) and an endless tossing about in my bed as every lymph node in my body throbbed like a boil. The doctor at the student infirmary was unimpressed; my temperature measured sub-normal, his probing fingers found nothing amiss in my groin or armpits. An agonizing three-day wait yielded a lab report that removed all doubt – no sign of disease.
I groaned with relief, slept soundly for a month or two, but then discovered a tingling sensation in my throat, just a scratch, perhaps, but more noticeable day by day, gagging me with pain by the end of a week. A sore, perhaps a festering ulcer, or perhaps . . . Every swallow brought agony and waves of fear. A finger thrust down my throat discovered lumps at the base of my tongue. Again I fled in panic to the student infirmary. They referred me to an ENT specialist, a short, bald, light-footed man with a mirror on his head who peered down my throat and laughed. I had discovered my posterior lingual papillae, normal structures located at the base of every human tongue, as non-malignant as my nose and ears. My throat pain vanished, only to be replaced a few weeks later by a stabbing sensation beneath my breastbone that portended certain disaster.
For years my hypochondria ran a broken course. Some attacks came in the form of what one might call angst – an abstract fear, nameless and terrible, worse (how could that be?) than death itself. I fell into a frenzy when Comet Kohoutek was discovered in 1973. Despite astronomical assurances of a miss half the width of the solar system, I convinced myself this icy terror would smash the earth to bits. But more often my fear focused on an organ or two, a tumor that might spread to my lungs from a malignant mole, or a lump in my bowels that might soon invade my liver. Anxious fingers discovered a pulsating mass in the center of my abdomen. It was my aorta. One channel of my brain knew that each attack was nonsense, a false alarm no less absurd than all the others, but this was the weaker channel, too feeble to oppose the panic that tormented me when I woke during the night with my heart racing and my sheets damp with sweat. More knowledge was wanted. More knowledge and – here for once my instincts served me well – a confrontation. I had to face down my fears.
* * *
The Stanford Medical Clinic was a hypochondriacal quagmire, a magnet for psychosomatic whiners from all over the San Francisco Peninsula. Alan Barbour, the director, was a wonderful man, a philosopher, a devoted teacher. I loved him dearly. He was sixty when we met, semi-retired after three decades of practicing internal medicine. During that era every physician in America – except for Alan, or so it seemed – dismissed hypochondriacs from their practice as quickly as possible, but he was a pioneer, the noblest and most dangerous role a physician can play. Alan would be the first to heal those patients who did not want to be healed, a Don Quixote despised by his testy and vituperative Dulcineas. Short but striking in appearance, he had a large head, a long torso, stubby legs, iron-gray disheveled hair that had to be constantly swept from his eyes. The veins of age formed a delicate lacework on his lower eyelids. His voice was gravelly, his speech measured in long, rhythmic phrases.
“No one wants to be sick,” he’d say, “These patients just need to be shown that health will cure their loneliness, bring the affection they crave, and do it better than any imagined disease. Truth is their only hope.”
I was young, inexperienced as they come, but even so the pragmatist in me rebelled at this philosophy. Alan reminded me of the parent who snatches a toy from a child because the toy is ugly. Who’s to say a toy is ugly? This paternalism proved a disaster for the patients in the Stanford Medical Clinic. One couple in particular comes to mind, émigrés whom Alan nicknamed the Nabokovs; the husband, like the author, was both Russian and an avid lepidopterist. His wife suffered from a pain in her arm that had eluded diagnosis for more than a decade. They were an aristocratic pair, married for twenty-five years, trim and vigorous in their late forties, with beguiling Russian accents and the poise of landed gentry.
They entered the exam room hand-in-hand and gazed fondly at each other every few moments throughout the interview. The husband couldn’t sit still. He patted his wife’s knee, fidgeted in his chair, clasped and unclasped his hands, staring at Alan or his wife with watery, red-rimmed eyes. Alan set upon them with the skill of a master and soon rooted out the truth, not in the wife’s physical exam or medical record, which revealed no sign of organic disease, but in the husband’s tale of their nightly intimacies. A pathetic tale indeed. Though they slept in separate bedrooms, every evening brought an elaborate ritual: he wrapped his wife’s ailing arm in a hot towel for ten minutes, then removed the towel, dried the arm, propped it carefully on three satin pillows, covered it with an eiderdown comforter. He described with a gesture how he pulled the comforter up to her chin, leaning close to his wife and exchanging a smile of tender endearment.
“My darling,” she said, laying a hand against his cheek, “you do take such good care of me.” At her touch, the husband fell silent and stared at the floor.
“Do you kiss you wife?” Alan said.
“Well . . . yes, well, of course,” the husband stammered. A blush reddened his cheeks. “A kiss, a gentle kiss, of course, on the forehead.” He spoke rapidly, as though hoping to outrun the embarrassment of further questions. “I come back several times in the night. The pillows shift, the comforter slides about, I must adjust them to assure that her sleep is not disturbed. I . . . ”
“Do you make love to your wife?” Alan interrupted, leaning forward with elbows on knees to stare the poor man in the eye. The husband’s mouth gaped. The blush on his cheeks grew darker. He blinked his red-rimmed eyes.
“I . . . we . . . of course, at our age . . . our children grown . . . ”
“Has it been long? How long?” Alan’s gaze was steady, his jaw set.
“Well . . . ” The husband’s face was purple, like a man holding his breath. He wrung his hands. At last, with a sob of humiliation: “A few years, perhaps . . . perhaps ten. But at our age . . . ”
“Let me tell you something,” Alan said. “For her age, your wife is as healthy as any woman I’ve ever seen. Ten minutes ago, in my exam room, I watched her lean over and press her palms on the floor. And you – you seem to be in good shape.”
“Yes yes yes,” the husband gasped, relieved at the change of subject. “I play tennis almost every day, maybe two or three sets. Young men, college boys, sometimes they cannot beat me. I . . . ”
“Can you achieve an erection?”
“I . . . well . . . yes, but . . .” The husband opened and closed his mouth. Silence. He and Alan stared at one another. At last the husband leaned forward, clutching the arms of his chair. “Why do you speak of such silly things? My wife is in pain, and you are meant to help her.”
Alan gave his finest performance. He explained how their conjugal bliss had strayed from the path assigned by nature, fallen from the health and vigor of flesh-on-flesh embraces into the black hole of a cultivated illness. Would it not be better, more joyful and precious and satisfying, to lift off his wife’s nightgown rather than fiddle around half the night with a pile of pillows? Why not throw away that ugly toy, his wife’s spurious pain, so the two of them could savor the ecstasy of marital coitus? The Nabokovs received this wisdom in stony-faced silence. They missed their follow-up appointment and never returned.
Perhaps Mr. Nabokov needed his ugly toy. Perhaps the toy Alan wanted him to play with scared the poor man to death. Since Alan’s pioneering disasters, hypochondria has worked its way into the mainstream. There is even a title – psychosomatic medicine – given to the treatment of those who will not be healed. Research on this subject has disclosed a tedious but reassuring consistency: though the occasional hypochondriac may fall down dead, he is no more likely to do so than a man of the same age who considers himself the picture of health. Which is to say, fear of disease and death, however troublesome for the patient and his or her doctors, has no effect on lifespan. As for treatment, direct confrontation seldom works, and most specialists now recommend a regimen of long-term compromise and accommodation, avoiding any statement that resembles “It’s all in your head,” substituting instead variations on “Let’s try this – many of my patients have found it helpful.” Naturopaths, chiropractors, aroma therapists – an all but countless host of “alternative” practitioners – remain famously popular with hypochondriacs, while the purists who follow in Alan’s footsteps by telling the raw truth have enjoyed little success. Truth is not beautiful when it steals a man or woman’s raison d’etre.
* * *
Marguerite Sellers was a clever, silken-haired woman in her mid-thirties who came to the ER of the Santa Clara Valley Medical Center on a quiet Sunday afternoon. Half the gurneys stood empty. The two ward clerks sat dozing behind their desks, and one of the orderlies lay sound asleep in the cast room. My fellow intern thought himself a lucky fellow when he opened the curtains around a gurney to find a woman who looked like Elizabeth Taylor. Her dark hair hung down to her shoulders. She had pale skin and desperate, convincing eyes. Even more convincing was her abdomen, a crisscross of angry red scars fringed by the tic marks of surgical closure, what doctors call a road-map belly. Worse yet, her belly grew tense at the lightest touch – the sign of a life-threatening abdominal catastrophe such as hemorrhage or peritonitis.
Marguerite told a compelling story, a tale for every scar: excision of a ruptured appendix, followed by a laparotomy for abdominal adhesions, followed by an ectopic pregnancy in the right fallopian tube. Not such a run of random bad luck as one might think, since each of these disasters predisposes to the next. Her belly impressed Sam Elmore, the surgical resident who examined Marguerite. To a group of interns and nurses gathered in a corridor outside the ER, he announced, “That’s it – the classic board-like abdomen. She’s been trying to get pregnant, missed her period last month, now her belly’s tender over the left fallopian tube. That’s the best story you’ll ever get for a second ectopic.”
A second ectopic! We all sucked in our breath. Ectopic pregnancy – an ovum, fertilized but misdirected, takes root in a fallopian tube and sprouts a false placenta shot through with fragile vessels. Rupture could come at any moment, causing internal bleeding, shock, death. To our surprise, Sam didn’t whisk Marguerite up to the OR. Instead he inserted a catheter just beneath her umbilicus, then sucked back on the syringe, looking for any trace of blood in the peritoneal cavity. The tap was negative, but that gave no real assurance. The false placenta could be the size of a lemon, growing larger by the hour, waiting to rupture and spill pints of blood into her abdomen. Sam admitted Marguerite to the ICU and ordered her vital signs checked every fifteen minutes.
A sad case, since her husband was in Singapore, with no hope of phone contact, while all of her other relatives were dead, and none of her friends lived close enough to come keep her company. Marguerite would have to suffer alone. Alone indeed – flat on her back in the ICU, surrounded by comatose patients, listening to the ceaseless hiss and clunk of their respirators. The two windows by her bed looked out over a macadam parking lot. The ICU had no TV sets.
The morning after her admission, I stopped by the ICU to check on a patient I had admitted from the ER the night before. In contrast to the semi-corpses who lay in the surrounding beds, Marguerite’s face looked like the cover of a fashion magazine, an effect that enhanced her resemblance to Elizabeth Taylor. We said nothing to each other, but her eyes followed my every move, as though anxious to share their desperation with everyone who entered the room. Her loneliness lasted two more days, until Richard Burton arrived. That was the nickname the ICU staff gave Marguerite’s husband. The charge nurse swore he was the handsomest man she had ever seen. In retrospect, it seems uncanny that Marguerite’s illness should coexist with such abundant physical beauty.
Elizabeth and Richard reunited, with all the fiery rage one might expect; much shouting and waving of arms, though Richard spewed venom not at Elizabeth but at the charge nurse and every doctor in sight. When informed that no one had laid a scalpel on his wife, he lapsed into a plaintive stupor for several minutes, then wandered about the ICU mumbling apologies. His curse in life was to chase after Marguerite as she drove all over Northern California seeking a bizarre visceral redemption. Working her way from San Raphael to San Jose, she had sold her story to three surgeons. Only Sam Elmore’s restraint had denied her a fourth ecstatic incision.
I don’t know what has happened since to Marguerite, but the prognosis is poor. In terms of curability, Munchausen Syndrome – the compulsion to feign, create, or exaggerate illness in one’s self – ranks right down there with bulimia, pedophilia, and morbid obesity. Marguerite probably escaped her husband’s vigilance again, and in all likelihood other surgeons fell victim to her desperate eyes, her rigid, road-map belly. She had a PhD in nursing, had once supervised a pediatric oncology ward at the University of Oregon. Few doctors can resist a patient who knows the right story to tell.
* * *
Marguerite gave me wisdom – the wisdom to look into dark corners, root out terrible truths. The lesson she taught was to serve me well when I met a patient named Mack Rae during the third year of my ophthalmology residency. A Major General with the Strategic Air Command, Mack had piloted a B-52 Stratofortress on “hot” flights over the arctic circle. While his plane soared at forty thousand feet – carrying four hydrogen bombs, each addressed to a city inhabited by millions of people – Mack listened to his radio for a coded go/no-go command, thus assuring the most rapid possible massacre should war break out with Russia before his plane reached the point of no return. A cruel job, a thrilling job, but old men are not allowed to do such things, so at age sixty Mack had to retire and resign himself to an ordinary life. His life did not remain ordinary for long.
Mack was always cheerful, especially when a new resident took over his case, since this allowed him to tell his story from start to finish. His face glowed with pride as I thumbed through his massive chart. His beet-red eyes were blind, the corneas clouded by a greenish-yellow cast. The lashes were sticky with mucous.
“Can you imagine it, Doc?” he said, smiling broadly. “A man gets the tops of his eyeballs cut off. Then they have to go in there and take out his cataracts. His retinas fall off, they’ve got to be hooked back up – first one eye, then the other, then the first one again. Then they’ve got to cut off the tops of his eyeballs again and damned if they don’t get all scarred up just like the first time.”
Those who had cared for him before me made several diagnoses: herpetic keratitis, secondary bacterial infection, perforated corneal ulcer, failed graft, secondary cataract, aphakic retinal detachment. Indeed, Mack’s corneas had rotted away twice, but all attempts to culture herpes virus had failed, as had every treatment in Duane’s Textbook of Ophthalmology. Drops and pills and injections gave no more benefit than so much tap water. Each complication had come in tandem, with simultaneous onset and simultaneous progression in both eyes – evidence, or so it seemed to me, of a compulsive force.
Everyone rejected my theory. Even the attending on the cornea service balked, insisting that no one could do such things to himself, but he had not seen Marguerite’s performance. Mack boasted of his suffering, his exciting new life. I asked him one day if he ever touched his eyes.
“Well, Doc,” he said, “sometimes a man can’t help himself. Just a little, every now and then. They sort of itch.”
As he spoke, he held apart the lids of his right eye and rubbed the glaucous cornea with his index finger. The tip of the finger moved in vigorous circles, spiraling outward onto the velvety surface of his beet-red conjunctiva. The sight shocked me: a normal eye, especially the cornea, sends out waves of searing pain at any but the lightest touch. Then Mack closed the eye and rubbed it with his knuckle until the violence of his gouging sent chills down my spine. The swollen lids made a wet, sucking sound. A strand of mucous oozed from the tear duct. “Ah, that feels better,” he said, and began rubbing the other eye. This time the mucous squirted onto his cheek.
Of course I couldn’t be sure. Perhaps Mack didn’t know what he was doing. Perhaps all that scarring had left his corneas no more sensitive to pain than the soles of his feet. But the smile on his face, even as his knuckle squeezed mucous from his tormented eyes, suggested a man in the throes of ecstasy. Perhaps this was the ecstasy denied when – day after day, year after year – fate kept him from unleashing the thermonuclear treasures nestled in the belly of his B-52.
* * *
No one rescued me from my hypochondria, a dark, suffocating cloud that cast its pall on the brightest skies of summer and threatened to hound me to my grave. Without radical therapy, my desolate life would dribble away in a procession of fearful days and sleepless nights. The first glimmer of hope came from a related neurosis – my flying phobia. After one hand-wringing, knee-knocking flight, I noticed that my return flight a few days later aroused only a few sweaty tremors, while a third flight soon thereafter left my armpits dry and gave me only a twinge of acrophobic nausea as the misty landscape unfolded six miles below. Repetition seemed to calm my fear of airplanes. Hmmm, I thought – perhaps my hypochondria might also give way to a frontal assault. Rather than whimper like a coward, squirming in darkness and misery, perhaps I should look my dragon full in the face.
I launched the first attack against my fear of needles. Needles terrified me, and a whiff of the isopropyl alcohol used to clean the skin sent me reeling. During my sophomore year of college, with trembling courage I offered myself up to the Red Cross blood bank. The first few visits left me sweaty, light-headed, tingling in my toes and fingers, but eventually I mastered my fears, chatted with the phlebotomist, even watched the needle as it popped through my bluish flesh into the swollen vein.
This therapy seemed to work, but my darkest fear had yet to be faced: hospitals, where patients, some even younger than I, lay dying from unspeakable diseases. I volunteered as an EKG technician at Boston City, the oldest and most infamous charity hospital in all of New England. The ancient brick buildings were connected by tunnels that smelled of urine and garbage. The wards stretched on forever, gray walls and high ceilings, twenty beds on each side of scuffed linoleum aisles. Worse yet were the private rooms, sanctuaries reserved for the dying. The doors were kept discreetly closed. After a week on the job, I opened one of these doors to perform an EKG and found an enormous dead woman, but she was old. Later I caught a glimpse inside another private room as a nurse departed carrying a soiled emesis basin. The patient was a teenager with damp blonde hair, his face contorted in pain, a dark lump bulging at the angle of his jaw. The image burned itself into my mind. That night I tossed and turned for hours, my jaw throbbing with such terrible pain it seemed about to explode.
But I persisted, seeking ever more gruesome sights. Surgeons allowed me to peek over their shoulders at bellies filled with churning intestines. Orderlies allowed me to wheel dead patients, old and young alike, down to the morgue. At last, after college, I began the final attack on my hypochondria: eleven years of medical training. This strategy worked, though there were many bad moments. I almost fainted when an anatomy instructor unveiled the liverwurst-colored cadaver my three partners and I were meant to dissect down to the last tendon. I lost countless nights of sleep writhing in fear of whatever cancer had caught my fancy. One evening, suspecting the onset of schizophrenia, I wandered about my neighborhood in a panicked search for the source of faint, possibly psychotic voices, only to find that they came from the PA system of a high school football stadium a few blocks away.
Yet slowly, year by year, my attacks became less frequent and less severe. Now, as I enter my fifth decade in medicine, an abdominal spasm or a sore on my skin brings only a twinge of the old fear. Perhaps my hypochondria faded over time thanks to aging, the same villain that stole my hair and my libido and my skin turgor. But no, I reject this theory. Nor do I accept such unheroic, mealy-mouthed terms as “desensitization” or “self-actualization.” I like to think that raw courage effected my cure, that my suffocating phobias gave way to a bold headlong assault. It makes a better story.