A History of the Present Illness

by Louise Aronson

  4. She started telling patients about similarities between her life and theirs, as if what was going on between them was a friendship.

  Years earlier, already a surgeon but not yet a mother, she’d gone to art openings, guerrilla theater, readings of playful postmodern novels, the sorts of events where technique and interpretation mattered as much as outcome. “The thing about him,” a critic once said of a writer who had lived a long, full life but wrote again and again about a certain personal trauma, “is that he doesn’t shrink from the travail of understanding, even when no true understanding can be found. With each effort, he tries to come at the same material in a crazy new way, as if by doing so, he’ll eventually make sense of the inevitably tragic ending.”

  But another night, there had been a tribute to an artist who’d spent her career exploring her life and fantasies using soft woods and pliable metals, found objects and slivers of colored glass; she had created and re-created, until she could no longer distinguish the autobiographical facts of her real life from the fiction of her sculptures, until she believed she’d tasted failures she’d deftly eluded and she’d heard the rapturous wails and touched the tiny tufts of darkly bristled finger hair of men she’d never actually slept with.

  She’d crossed countries off the list: “Iraq, Afghanistan, Lebanon, Sudan, Israel, Congo, Nepal, Iran—”

  “Dude!” her son interrupted. “Is there anywhere I can go this summer?”

  “If you would just please make an effort,” the psychiatrist said at the end of their first full day in paradise.

  They were in the bar then: indoor-outdoor, thatch roofed, wall-free, calypso music coming through invisible speakers. They were watching the sun drop through a mango-berry sky onto a slick, flat edge of ocean that made the world seem at once finite and limitless.

  His colleagues scanned the crowd as they transitioned from the afternoon’s passive learning to poolside evening cocktails or, somewhat less steadily, from the tall wicker barstools up the two steps to the open-air ocean-view dining room. The glances of more than a few lingered on the psychiatrist and his wife while they pretended to look for an errant child or a waiter.

  “Perhaps if you tried to articulate,” he said, speaking in the same wounded tone he used to say You’re drinking again or He’s my son too.

  She snorted. The way he spoke. The affectation, the absurdity. He’d spent one year at Oxford. One year, thirty years ago. And he hadn’t even been a Rhodes scholar—it was just an ordinary year abroad.

  That made her smile.

  “What’s funny?” he asked.

  She looked at him. She knew she was behaving badly. “Nothing,” she said. “Not one little thing.”

  * * *

  After her second switcher, the psychiatrist’s wife signals for the ebony man. When he reaches for her glass, she holds it up, then doesn’t let go.

  “How many of these do you think one person can drink?” she asks.

  He squints, as if she’s suddenly out of focus, but he neither releases the glass nor pulls it from between her fingers. And so, their hands nearly touching, she tells him that she’s drinking because her father recently died, writhing and grimacing in intractable pain. Gunshot wounds, she says. And: the wrong place at the wrong time. The ebony man lowers his eyes and shakes his head. He mumbles something she can’t understand, then slides the glass from her grasp and vanishes with it, only to reappear seconds later with a new one.

  After her third switcher, she tells him that she got it wrong, that in fact her father died by drowning, pink-tinged fluid filling his lungs, thrashing and gasping in a way she can’t forget, the walls of his damaged heart flaccid and unable to pump.

  The ebony man puts a hand on her shoulder so quickly, so briefly—like a fly on a too-hot light, the flick of a lizard across a wall—that she isn’t sure it happened. And so she tells him that she got it wrong again and that what really happened was this: her father died well, calm and comfortable, and that she, his daughter, was present both in the traditional physical sense and in the more modern and spiritual version of the word.

  But none of that is true. Though she attended each one of those deaths and too many more, her father is not merely alive, but well, a nimble, athletic eighty-two, still managing his small-appliance-repair shop in the Outer Sunset, still turning heads, and it’s the psychiatrist’s wife who is uncomfortable, writhing, and drowning in some modern and spiritual way.

  She and the psychiatrist dated in medical school. He was handsome and smart and, unlike her other boyfriends, listened to what she said, thought about it, and, sometimes days or weeks later, commented in an understatedly supportive way. But that wasn’t what she wanted back then. She wanted someone who took charge, someone driven and decisive. They split up during residency, married other people—she an entrepreneur, he a psychologist—divorced, and then, united by surprise at the smallness of their lives and achievements, married each other just in time to convert one of her last viable ova into a son. That was when he took the job at the university hospital. “For him,” he said, lifting their wailing infant up over his head, “so he’ll be proud of us and ambitious for himself.”

  In those early years of their marriage, busy with diapers and playdates, she hardly noticed as her husband began amassing awards and publications, responsibilities and prestige. What she did notice was the disappearance of his abdominal muscles below a generous layer of excess flesh; the phone call from the day care center when their son waited, forgotten, long after the drop-dead hour on her husband’s day for pickup; his impatience with her new, young, and not terribly accomplished but unfailingly supportive friends from the Noe Valley No Nanny parents group.

  “Oh, please,” her son said when they discussed where he’d stay during his parents’ Caribbean absence. And then, pulling his jeans well below his slim hips and running one hand over his buzz cut, he added, “Like my plan for the three weeks you’re gone, yo, is to throw a bitchin’ party and let the other kids trash the place while I hook up with some totally fly chick, knock boots, and let the baby gravy swim. You feel me?”

  People made assumptions. They assigned values. She knew people who said Holocaust as if, in recent human history, there had been only one. Newscasters and journalists said “the tragedy of September 11, 2001” and meant New York City, as if those who that day succumbed to malaria or malnutrition, to ruptured abdominal aneurysms or perforated intestines deserved less sympathy because of the quiet and unoriginal way they chose to die. In the cruise ship ballroom, she winced as her husband said his study of a promising new drug showed negligible mortality, as if one death in four hundred was the same as none.

  Signs:

  1. Dreams in which her pager flashed a phone number and then the three digits 9 and 1 and 1, and she raced from elevator to elevator, then down one empty corridor and along another, into and out of every hospital and clinic she’d ever worked in, unable to find the right operating room.

  2. The way a hand on her forearm here in the Caribbean for whatever benign reason provoked for her both an unwarranted startle and memories of a different hand, warm but insistent, and with it her colleague’s voice saying stop, saying that’s enough, saying you cant win ’em all . . .

  3. The ebb of her sanity and the flow of her self-absorption; the certain knowledge that she was theoretically right but pragmatically going about everything in just the wrong way.

  “For me,” her husband proclaimed one late afternoon as she cut up fruits and vegetables and laid out expensive cheeses and pêtés for his biannual departmental open house, “medicine is to life as mold is to Stilton. For you, it’s more like the rind of overripe brie.”

  “Excuse me?” says the psychiatrist’s wife.

  The ebony man’s nostrils flare. “Madame is American,” he asks a second time, though his tone is not that of a question.

  “Yes,” she says, and he nods, as if that explains everything he knows about her.

  * * *

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sp; A perfect sky. A landscape of red rooftops and white sand beaches, of blues and greens and azures. Even the plants standing tall, slick and robust, dripping with sweat.

  The heat and alcohol pin the psychiatrist’s wife to her chair. Low to the earth, she droops. She doesn’t need an infinity pool to float, to drown.

  “Do something,” her husband had said, donning his swim trunks. “Do anything.”

  And, standing at the door with his snorkel and fins: “This morning, a propos of coping skills in combat veterans, Dick Tan quoted Confucius, who said, ‘Learning is like paddling a boat upstream; stop paddling and you go backwards.’”

  In the beginning she had noticed nothing but the saves. Right away after such triumphs, families brought presents—candy and flowers and fortune cookies, curries and tamales, kimchi and lumpia, cheap, tarnished jewelry, hand-knitted scarves, paintings and Bibles and poetry. And for a while, once they were whole and healthy again, patients sent cards or stopped by her office just to visit. Years later, some still called, sent her e-mail, invited her to family reunions—lavish affairs where she was hugged, kissed, cried over, and fed to the point of physiologic jeopardy, where she received the welcome of a sibling lost in a long-ago, faraway civil war, a folk hero, the risen dead.

  She’d needed to be a doctor for so many reasons—for security and self-esteem and social approbation, or, as the psychiatrist put it, for id and ego and superego—and so she was. She’d been a great resident, efficient and technically skilled, had easily secured a job at the hospital of her choice after she finished her training, and for more than two decades had excelled at her work, earning more referrals than she could keep up with, a good salary, and, way back when, the hospital’s award for outstanding devotion and compassion.

  The night their son came to the dinner table with a metal rod punched through his nasal septum, her husband said, “Identity isn’t an abstraction. It’s more like a ceramic pot, carefully molded over time, then decorated, and finally glazed and baked to maintain a certain look and feel. Break it, and no matter how well you remember the original look and feel, you have to start again from scratch.”

  She hadn’t gone to medical school hoping, like the Cowardly Lion in Oz, to become someone she wasn’t. But she’d be the first to admit she’d imagined that knowing how to save a life would make it easy to do so. Or straightforward. Or, at the very least, more possible than not.

  “It is,” her husband argued. “Crunch the numbers.”

  In medicine, numbers conferred prestige and legitimacy. Sometimes she thought of Albert Einstein, who said, Not everything that matters can be measured, and not everything that gets measured matters.

  She didn’t mean that she couldn’t save a life by removing a tumor from a lung or a bullet from a liver, but that doing so didn’t stop people from smoking cigarettes, or from shooting each other, or from doing any one of thousands of other dangerous and deadly things she couldn’t control or fix or even imagine, until they appeared on her operating table—like the man whose third-degree burns were the result of a house fire intentionally set by his young son after weeks of practicing on bugs and bicycles and just six days after the boy’s mother’s death from cancer.

  Her mother-in-law was very ill. The psychiatrist was very busy. The psychiatrist’s wife took family medical leave and stayed with her mother-in-law night and day for a week, then just days, then night and day again, then days again, then hours. Hospital, rehab, hospital, rehab. Finally, after nearly two months, her mother-in-law got better. Knowing the worst was over, she felt as if she had money in the bank, food in the larder, a stockpile of marital credit. She felt entitled to her own life again. Desperate for it, in fact, like a refugee willing to trample others to catch a bag of rice thrown from a relief truck.

  “It’s not about trying to feel something,” their son said casually, as if reporting what he’d eaten for lunch. “I feel plenty. I feel too much. It’s about saying, Look at me! and also FUCK YOU, FUCK YOU, FUCK YOU, FUCK YOU, FUCK YOU, FUCK YOU FUCK YOU, FUCK YOU, FUCK YOU FUCK YOU, FUCK YOU, FUCK YOU . . .”

  So much of life was contextual, but she wanted to believe there were absolutes as well, that some choices, viewpoints, and activities could be considered more moral than others, better by some universal standard of human decency and societal need, however unrecognized, however hopeless, and that the flip side held other choices, viewpoints, and activities that could be written off as unwise or simply wrong.

  Theirs wasn’t one of those families afraid to call a thing by its name. The psychiatrist had no patience for false solace, half-truths, or religion. Their son never heard the expressions “passed away,” “with the Lord,” or “moved to the great beyond” except from his friends and in books and movies. When their cat died, they said, “Sorry, honey, but Hippocrates is dead.”

  Relief hit like an endorphin rush. A switch thrown by a single unplanned thought: she could quit. She tried to be rational, but it was over. She was done. She could think of nothing but getting out. She smiled at patients and nurses, ignored pages, and canceled cases. She wrote orders for follow-up in hours, days, a week—anytime when the problem wouldn’t be hers. Load lifted, the heels of her shoes touched down without sound on the speckled linoleum. As she made her way to the elevators, explosions of light and color lit the periphery of her visual fields where once there had been only cliched art in mass-market frames, red crash carts, black-faced monitors, and sliding glass doors to dimly lit rooms of mechanized furniture and malfunctioning humans. “I quit,” she incanted, her lips clenched, her tongue trembling to resist the devastating allure of emotional incontinence.

  The ebony man asks the psychiatrist’s wife if she wants another switcher.

  “Oh, yes,” she says. “Please.”

  He puts her empty glass on his tray.

  “Madame’s vacation,” he says, “is for how long?”

  “I don’t know.”

  For a fraction of a second, his smile wavers—there’s the slightest narrowing of his eyes, a flicker along his jaw.

  “Madame works?” he asks.

  She looks at the pool, the palm trees, the tanned feet and pink, pedicured toenails of a passing stranger, and she shakes her head, wishing she had a scar like his, for all the world to see.

  * * *

  It’s lonely at the top, or so the saying went, and the psychiatrist’s wife used to wonder if it had to be that way, whether nice guys really always finished last while those better able to maintain the demarcation between Self and Other would—like scum—more surely rise to the top of the sweet organic mélange that sustained them.

  Her husband told her it wasn’t so. But that was decades earlier, when they were peers in both stature and passion, when her mind still resembled a well-organized catalog of scientific information rather than an endlessly unfurling commemorative scroll, when she too believed that a person’s profession could and should define her life.

  Morbid preoccupation, the psychiatrist said, not unkindly, in the days before she stopped telling him her dreams.

  Histrionic personality disorder, he whispered on one of his rare visits with his hospitalized mother.

  Adolescence, he recently said of their son. No longer a child but not yet an adult.

  “Please,” he says not infrequently, even now. His hands touching, reaching.

  She had a colleague who said that sometimes, when nothing else he’d tried worked, he figured the last thing he could do was to give good death. He told families that he was sorry he couldn’t move things along, but if anything happened, any little thing, he’d treat it with morphine only. No more machines, no electricity, no antibiotics. Some families fired him; others clasped his hands in theirs as if he were an angel.

  “I just want to make a difference in the world,” her son said. “Why can’t you understand that?”

  In medical school they’d been taught the words of the great physician Francis Weld Peabody, who said, “The secret to caring for the pati
ent is to care for the patient.” Too late, she knew that Dr. Peabody was wrong. Too late, she understood that the secret was caring for the patient—for anyone—just a little. Enough, but not too much.

  The ebony man asks if the psychiatrist’s wife has come for the conference. She shakes her head. “No,” she says. Then, “Yes.

  My husband is there now.” The ebony man smiles. “So your husband is a doctor?”

  She nods.

  “That is good,” he says. “That is very, very good.”

  “Why?” she had asked her son when the piercings began.

  For the longest time, until after the fourth switcher, until the ebony man with his scar and his questions, she hadn’t understood her son’s answer, the Look at me followed by the stream of FUCK YOUs.

  When her husband returns from his scuba cruise, the psychiatrist’s wife sits waiting on a bed stripped of everything but a single white sheet. Her hair is stylishly short and newly bleached, a blond so pale it trifles with light and time. She’s wearing an ocean-blue spaghetti-strap dress that tapers at her waist and thighs and stops above her knees. Her makeup is perfect and her suitcase is packed.

  Blurred Boundary Disorder

  Dear Drs. Saperstein and DiBenedetto: It has come to my attention1 that you are, respectively, the director and associate director of the working group charged with revising the Diagnostic and Statistical Manual of Mental Disorders for its much-anticipated (and long-awaited) fifth edition.

  Below please find (again)2 my3 suggestion for an addition to the second section of the “Personality Disorders” chapter, which I heretofore will refer to as Cluster4 B.

  301.85 BLURRED BOUNDARY DISORDER

  The essential feature of this disorder is a pervasive pattern of personal boundary instability exhibited by a caregiving professional, affecting mood, self-image, and not just intimate relationships (e.g., lovers, friends, and—where applicable6—spouse and children) but also professional ones.7