Travels (10 page)

And pretty soon their hearts were
literally
attacked. And they experienced physical pain. And that pain, that attack, was going to force a change in their lives, and the lives of those around them. These were men in late middle life, all undergoing a transformation that was signaled by this illness event.

It made almost too much sense.

Finally I brought it up with Herman Gardner. Dr. Gardner was then chief of medicine at the hospital, and a remarkable, extremely thoughtful man. As it happened, he was the attending physician who made rounds with us each day. I said to him that I had been talking with the patients, and I told him their stories.

He listened carefully.

“Yes,” he said. “You know, once I was admitted to the hospital for a slipped disc, and sitting in bed I began to wonder why this had happened to me. And I realized that I had a paper from a colleague that I had to reject, and I didn’t want to face up to it. To postpone it, I got a slipped disc. At the time, I thought it was as good an explanation as any for what had happened to me.”

Here was the chief of medicine himself reporting the same kind of experience. And it opened up all sorts of possibilities. Were psychological factors more important than we were acknowledging? Was it even possible that psychological factors were the most important causes of disease? If so, how far could you push that idea? Could you consider myocardial infarctions to be a brain disease? How would medicine be different if we considered all these people, in all these beds, to be manifesting mental processes through their physical bodies?

Because at the moment we were treating their physical bodies. We acted as if the heart was sick and the brain had nothing to do with it. We treated the heart. Were all these people being treated for the wrong organs?

Such errors were known. For example, some patients with severe abdominal pain actually had glaucoma, a disease of the eye. If you operated on their abdomens, you didn’t cure the disease. But if you treated their eyes, the abdominal pains disappeared.

But to extend that idea more broadly to the brain suggested something quite alarming. It suggested a new conception of medicine, a whole new view of patients and disease.

To take the simplest example, we all believed implicitly the germ theory of disease. Pasteur proposed it one hundred years before, and it had stood the test of time. There were germs—micro-organisms, viruses, parasites—that got into the body and caused infectious disease. That was how it worked.

We all knew that you were more likely to get infected at some times than others, but the basic cause and effect—germs caused disease—was not questioned. To suggest that germs were always out there, a constant factor in the environment, and that the disease process therefore reflected our mental state, was to say something else.

It was to say mental states caused disease.

And if you accepted that concept for infectious disease, where did you draw the line? Did mental states also cause cancer? Did mental states cause heart attacks? Did mental states cause arthritis? What about diseases of old age? Did mental states cause Alzheimer’s? What about children? Did mental states cause leukemia in young children? What about birth defects? Did mental states cause mongolism at birth? If so, whose mental state—the mother’s or the child’s? Or both?

It became clear that at the farther reaches of this idea, you came uncomfortably close to medieval notions that a pregnant woman who suffered a fright would later produce a deformed child. And any consideration of mental states automatically raised the idea of blame. If you caused your illness, weren’t you also to blame? Much medical attention had been devoted to removing ideas of blame from disease. Only a few illnesses, such as alcoholism and other addictions, still had notions of blame attached.

So this idea that mental processes caused disease seemed to have retrogressive aspects. No wonder doctors hesitated to pursue it. I myself backed away from it for many years.

It was Dr. Gardner’s view that both the physical and the mental aspects were important. Even if you imagined the heart attack had a psychological origin, once the cardiac muscle was damaged it needed to be treated as a physical injury. Thus the medical care we were giving was appropriate.

I wasn’t so sure about this. Because, if you imagined that the mental process had injured the heart, then couldn’t the mental process also heal the heart? Shouldn’t we be encouraging people to invoke their inner resources to deal with the injury? We certainly weren’t doing that. We were doing the opposite: we were constantly telling people to lie down, to take it easy, to give over their treatment to us. We were reinforcing the idea that they were helpless and weak, that there was nothing they
could do, and they’d better be careful even going to the bathroom because the least strain and—poof!—you were dead. That was how weak you were.

This didn’t seem like a good instruction from an authority figure to a patient’s unconscious mental process. It seemed as if we might actually be delaying the cure by our behavior. But, on the other hand, some patients who refused to listen to their doctors, who jumped out of bed, would die suddenly while having a bowel movement. And who wanted to take responsibility for that?

Many years passed, and I had long since left medicine, before I arrived at a view of disease that seemed to make sense to me. The view is this:

We cause our diseases. We are directly responsible for any illness that happens to us.

In some cases, we understand this perfectly well. We knew we should have not gotten run-down and caught a cold. In the case of more catastrophic illnesses, the mechanism is not so clear to us. But whether we can see a mechanism or not—whether there is a mechanism or not—it is healthier to assume responsibility for our lives, and for everything that happens to us.

Of course it isn’t helpful to blame ourselves for an illness. That much is clear. (It’s rarely helpful to blame anybody for anything.) But that doesn’t mean we should abdicate all responsibility as well. To give up responsibility for our lives is not healthy.

In other words, given the choice of saying to ourselves, “I am sick but it has nothing to do with me,” or saying, “I am sick because I caused the sickness,” we are better off thinking and behaving as if we did it to ourselves. I believe we are more likely to recover if we take that responsibility.

For one thing, when we take responsibility for a situation, we also take control of it. We are less frightened and more practical. We are better able to focus on what we can do now to ameliorate the illness, and to assist healing.

We also keep the true role of the doctor in better perspective. The doctor is not a miracle worker who can magically save us but, rather, an expert adviser who can assist us in our own recovery. We are better off when we keep that distinction clear.

When I get sick, I go to my doctor like everyone else. A doctor has powerful tools that may help me. Or those tools may hurt me, make me worse. I have to decide. It’s my life. It’s my responsibility.

Drs. W, X, Y, and Z
 

Mr. Erwin, a fifty-two-year-old man, was admitted to the hospital because of a spot found on a routine chest X-ray taken by his private physician. Once he was in the hospital, the X-rays were repeated. The spot was there, no doubt about it, in the upper left lobe of his lung.

Mr. Erwin was told that he should have surgery, and he agreed. But when it came to signing the forms, he asked for time to think it over. The next day, he was again advised to have surgery, and again he agreed, only to back out at the last moment. A week passed in this way.

Mr. Erwin never asked what was in his lung that required surgery. He never asked anything at all. And nobody volunteered to tell him. For one thing, the X-ray image was anomalous; it appeared to be some sort of tumor, but it didn’t present a classical picture. Mr. Erwin was extremely nervous, and the house staff chose to wait.

On the other hand, a week was a week. It became difficult to justify keeping someone in an expensive bed, but the house staff didn’t want to discharge Mr. Erwin because they felt he’d never confront his illness once he left the hospital. So there was an impasse. Mr. Erwin still didn’t ask about the operation. And still no one told him.

Finally, at the end of the week, Dr. W, a surgeon from a nearby hospital, came to conduct visiting rounds. Dr. W, a former athlete, was a big blustery man who performed surgery with drama and verve. The house staff presented him with the case of the reluctant Mr. Erwin. Dr.
W was outraged at the way the staff had coddled this man, and insisted on seeing him at once.

Dr. W walked into the man’s room and said, “Mr. Erwin, I’m Dr. W; you have cancer and I’m going to take it out!”

Mr. Erwin burst into tears, and agreed to surgery.

The following day, the operation was performed. A granulomatous lesion was removed. In the center of the lesion was found some stringy material identified by the pathologists as beef. Apparently Mr. Erwin had, at some earlier time, inhaled a bit of meat while eating. The beef had lodged in his lung, and had been overgrown with a protective coating of tissue.

When Mr. Erwin awoke, he was told the good news by the delighted house staff. Mr. Erwin remained glum. He still cried frequently. As the days went on, he said he knew the house staff was lying to him, that he had cancer; Dr. W had told him so. The residents assured him that Dr. W was wrong, that there was no cancer. They showed him the pathology reports. They offered to let him see his chart. Mr. Erwin believed none of it.

Two days later, Mr. Erwin crawled out the narrow window of his room, and jumped to his death.

Dr. X performed surgery on the leg of a thirty-five-year-old woman. His intention was to tie off the femoral vein. Immediately after surgery, the woman complained of severe pain in the leg, which was noted to be blue and cold, with little pulse. Twenty-four hours after surgery, when there was no improvement in her condition, it was realized that Dr. X had mistakenly tied off the femoral artery, not the vein. The woman’s leg would now have to be amputated at the hip.

Dr. X was an elderly Jewish refugee from Nazi Germany. He was known to have made such errors before, and his surgical privileges had been revoked at a suburban hospital. The question was whether Dr. X would now lose his privileges at this hospital as well.

Two things interested me. The first was that nobody told the woman anything was amiss. In those days, before the flood of malpractice litigation, a woman who had been grossly mistreated by a physician known to be negligent was not being told anything by the other doctors around her. The woman was relatively young, and the mother of two; with one leg amputated, she was now going to have a very different life.

The second thing was that there was discussion about whether Dr. X would lose his surgical privileges, as if the question were in doubt. (In fact,
the hospital did not revoke his privileges entirely. He was merely forbidden to operate alone any longer.)

Dr. Y was discussing the case of a traveling salesman who had been admitted for gall-bladder surgery. The salesman was a chronic alcoholic, and the staff was afraid that he would go into the DTs while in the hospital, which would complicate his treatment and might even kill him. It was decided that he should be allowed beer while in the hospital; every day the salesman got a case of beer delivered to his bedside.

I asked whether Dr. Y was troubled by the fact that this alcoholic patient was also a traveling salesman. Presumably, once his medical condition was resolved, he would be back on the road, drinking and driving. Did the hospital, knowing the man was an alcoholic, have any greater responsibility to the man, his employers, or the wider society of drivers?

“Well, this is a very difficult problem,” Dr. Y said. “For instance, I recently performed an insurance exam on an airline pilot who was a chronic alcoholic.”

What did you do in that case? I asked.

Dr. Y shrugged. “I certified him,” he said. “What else could I do? I couldn’t take away his livelihood.”

Dr. Z was a seventy-eight-year-old physician who entered the hospital in a near coma, in end-stage cardiac and renal failure. His son was also a physician, but not on the staff of the hospital, so he could only visit like any other relative, and he had nothing to say about his father’s care. He did, however, state that he wanted his father to die peacefully.

The old man was on the critical list for nearly a week. He had a cardiac arrest one night, but he was resuscitated. His son came in the next day and asked, with a certain delicacy, why the staff had resuscitated the old man. Nobody answered him.

Later that day, old Dr. Z suffered sudden massive congestive heart failure. The hospital staff was making rounds; they all rushed to his bedside. In a moment he was entirely surrounded by white-jacketed interns and residents, working on the old man, sticking needles and tubes into his body.

In the midst of all this, he somehow emerged from his coma, sat bolt upright in bed, and shouted clearly and distinctly, “I refuse this therapy! I refuse this therapy!”