God’s Hotel: A Doctor, a Hospital, and a Pilgrimage to the Heart of Medicine

by Victoria Sweet

  With Dr. Jeffers at the counter desk full-time, I began to job-share with Dr. Fintner.

  I knew Dr. Fintner pretty well by this time, but it still took some adjustment. There was her corner of our common desk, piled high with everything she saved to look at later: drug companies’ invitations for free dinners, administrative memos on asbestos, patients’ X-ray reports and laboratory tests. Each morning when I came in, I went through the pile, tossing out and tidying up; and every few weeks Dr. Fintner arrived with a new system of organization—colored folders, numbered binders, labeled pads of paper.

  Slowly the two of us came to understand that Dr. Fintner had the temperament of the physician and I, although I was an internist, the temperament of the surgeon. I was interested in action, or not; she was interested in the most precise action and would spend quite a bit of time to get it right. It took us a while to work it out, to use our differences as double strengths and not as double weaknesses. Truth to tell, both strategies worked well. Especially when applied to the right patient at the right time.

  One day of the week we overlapped; that is, we were both in the doctors’ office at the same time. On those days we would see patients together, walking around the ward at the end of the day, discussing cases. One late afternoon we came to the bed of Mrs. Georges, who’d been admitted by Dr. Fintner with the diagnosis of, well, old age. She didn’t have Alzheimer’s disease or another dementia or any fatal disease. She was a widow, with no children, no family, no friends. Her life, as far as Dr. Fintner could tell, was the dash between the date of her birth and the not-yet-established date of her death.

  It was late-afternoon quiet, and when we got to her bed, Mrs. Georges was sleeping, or so I thought. Nevertheless, Dr. Fintner went over and stood at the left of her bed, and I went to the right, and for a while we both stood there in silence. After a time, I realized that Mrs. Georges wasn’t sleeping. Although her eyes were closed, they fluttered a bit, and her breathing was not the even breathing of the sleeper, but the active breathing of the dreamer or the thinker.

  Dr. Fintner was looking down at her, not saying anything. Then softly, she asked, “Mrs. Georges, what are you doing?”

  Mrs. Georges’s eyes opened, and she looked up at us.

  “I was at my high school prom, and I was waiting to be asked to dance …. The boys were so handsome! And the girls were so pretty!”

  “Is there anything you need? Can we get you something?”

  “No, no … I’m fine, thank you.”

  We left her bed then and continued on our rounds, but I never forgot that moment. I was surprised when Dr. Fintner bothered to stop at Mrs. Georges, who seemed to be sleeping. But as we stood there, waiting or maybe just watching, I gradually became aware of a quality I’d felt before with patients, though never consciously—the quality of shared, peaceful silence. It was a healing space, I realized at that moment, and not only for the patient. For the doctor, too, a quiet space of non-asking and non-answering, of non-doing.

  Then there was Dr. Fintner’s voice, tentative but persistent, which pierced that quiet space and crossed the distance between herself and Mrs. Georges. And there was Mrs. Georges’s answer to the questions that hang in the air of the dementia ward, of the coma ward: What are you doing? Are you still here? Are you someplace else?

  “I was at my high school prom, and I was waiting to be asked to dance …. The boys were so handsome! And the girls were so pretty!”

  It was a hint from behind the curtain, about where those patients might be in their muteness. Perhaps not all of them, and not all the time, but some of them, much of the time. They were not dead, Mrs. Georges showed me, but lived in that other world we all know so well: the inner world that has everything this world has—anxiety and anticipation and appreciation; dances and dresses and decorated gyms—that kingdom within.

  Dr. Fintner and I worked out our job-sharing, both for ourselves and our patients, as we learned what each was best at. The aged and the feeble, those who had retired after a lifetime of work, of duty; these were the patients that Dr. Fintner appreciated and understood. The Bad Boys and Bad Girls were mine. Dr. Fintner just couldn’t quite understand or appreciate them. Their choices, their actions, made no sense to her.

  Early in this process, she admitted Jim Jay, and he was a problem. Hair long and uncombed, unwashed and unshaven, with decayed teeth, he had come to the hospital in order to recover from still another bout with alcohol that had ended in a draw. His liver was regenerating; and his mind was clearing; his balance was steadying. In fact, he’d improved enough to walk himself out to the large hall, where he sat at the little round tables with other patients, sipping coffee from a paper cup and sometimes staring into space, but still—recovering.

  He came back to the ward after one such outing, however, smelling a little—not much, but a little—like alcohol. We had a long meeting to discuss the matter, with nurses, social worker, doctors, and Jim Jay himself. He hadn’t had anything to drink, he assured us. Absolutely not. He knew that drink would kill him; he could not understand why we thought he smelled like alcohol. Perhaps it was his aftershave lotion.

  Since she’d admitted him, Dr. Fintner was his main doctor, and she ran the meeting.

  “But Mr. Jay,” she said, in her soft voice, “you understand how bad alcohol is for you, don’t you? It damages your liver cells, and you don’t have many left. You remember how you were when you first got here? You don’t want that to happen again, do you?”

  “No, ma’am, I do remember, and I don’t want that to happen again. But ma’am, I’ve made a vow not to touch the stuff ever again, not ever; and I’m hoping once I get well I can go and live with my sister in Akron.”

  Dr. Fintner looked satisfied.

  “Well, I’m relieved to hear that, Mr. Jay. We’re all here to help you do just that, and we will help you, won’t we?” she said, looking around.

  Everyone nodded cheerily.

  But a few days later, when I telephoned in to see how our patients were faring, Dr. Fintner had some bad news.

  “Mr. Jay has disappeared.”

  Humph, I let out, under my breath.

  “What did you say, Victoria?”

  “Nothing. What happened?”

  “Well, you’re going to laugh at me. Don’t be mad, but yesterday Mr. Jay stopped me in the hall, and he looked so nice, Victoria, all cleaned up. His hair was slicked back, he’d shaved really well, and the nurses had found him a nice sports coat in the clothing department. And, well, he told me that he needed fifteen dollars to mail a package to his sister. He’d lost the money the social worker had given him. Someone had stolen it from him, Victoria, while he was sleeping!”

  “You didn’t give it to him?”

  “I did.”

  “Oh, Julie!”

  “He went to Reno, Victoria; that’s what we found out; and he hasn’t come back.”

  And he never did come back. But after that, Dr. Fintner and I took pains to sort our patients or, perhaps more accurately, to choose the proper instrument for the case. When gentleness, forgiveness, and patience were needed—long meetings with angry family members, demented patients, and officious bureaucrats, for instance—Dr. Fintner was on. But when a firm disciplinary hand and an ironic frame of mind were needed, well, we sent me out. It was better for both of us and undoubtedly better for our patients.

  By this time, I was well into my first year in Dr. Weitz’s History of Medicine program.

  It met in a small seminar room on the fourth floor of the University Hospital’s oldest wing. I’d walk into the new hospital building and then through the lobby, splashed with news of the hospital’s latest nanotechnological discoveries. I’d go through research departments and past well-appointed clinics, and then up three flights of concrete stairs with their old-fashioned iron banisters. The history department was hidden away upstairs, as if modern medicine, like a second wife, did not want to know about or even have a past.

  There were six of us
graduate students, three physicians and three nonphysicians, and in a few months Dr. Weitz marched us through the medicine of Ancient Greece, Rome, the Middle Ages, the Renaissance, and the Enlightenment, on our way to Modernity, where we would dwell for many weeks. During those 2,400 years, we learned, premodern medicine had been the only medical system in the West. It was how everyone understood health and disease; the way all physicians practiced; and how all patients expected to be treated. Then suddenly, in only a few decades toward the end of the nineteenth century, premodern medicine was abruptly replaced by modern medicine and forgotten.

  Dr. Weitz explained its theory to us. For premodern medicine, he said, the cosmos was made up of four abstract elements—Earth, Water, Air, and Fire. Each of the four elements, in turn, was made up of four qualities—hot and cold, and wet and dry. Thus Earth was cold and dry; Water, cold and wet; Air was hot and wet; Fire, hot and dry. Everything in the universe was made up of a mixture of these four elements and four qualities, but in various proportions, and this included the building blocks of the body, which were the four humors—blood, bile (or choler), phlegm, and melancholia. Blood was hot and wet; and bile, hot and dry; phlegm was cold and wet; and melancholia, cold and dry. Health was thought to be the proper balance of these four bodily humors, and disease was an imbalance. The job of the physician was to diagnose his patient’s humoral imbalance and correct it by prescribing a “regime.” For diagnosis, the physician took the pulse of the patient and examined the urine. The prescribed regime was made up of diet, herbal medicines, bleeding, moxibustion, and bathing. It also included prescriptions for changes of climate, sexual activity, rest, sleep, and exercise.

  This system, Dr. Weitz told us, was usually known as the “humoral system,” but, because there were four elements, four qualities, and four humors, it was also called the “System of the Fours.” Sometimes other “fours” were included in it: the four seasons—spring, summer, fall, winter; the four directions—east, west, north, south; even the four evangelists—Matthew, Mark, Luke, and John. Then he showed us a medieval drawing in which the entire theory was portrayed. The human body was in the center; arrayed around it, top and bottom, left and right, were the four seasons, directions, elements, humors, and qualities.

  Humoral medicine was a beautiful and long-lived medical system, Dr. Weitz ended, but how it actually worked to explain the body was pretty much a mystery.

  Naturally the physician graduate students among us had many questions. Why did premodern medicine last so long, and why did it end so abruptly? Why was it so similar to the Chinese and Indian systems, which were also based on elements, qualities, and humors, and yet so different?

  Dr. Weitz didn’t know. He couldn’t say. He looked over at me. That would be Dr. S.’s project, he said.

  The second year of the program prepared us for writing our master’s theses, teaching us the many ways to write history. Toward the end of that year, I started my thesis. I would use the medical text of Hildegard of Bingen, the twelfth-century Benedictine nun, to explore how humoral medicine worked. I would approach it, I decided, as if I were her student—and as if I had her text, and only her text, to guide me.

  I can’t say that I learned how to practice humoral medicine from Hildegard, but I did learn quite a lot. I learned that it was not just an elegant philosophical system, but a real medicine for real patients with real diseases, although the diseases were understood differently from how modern medicine understood them.

  I learned that the System of the Fours was useful as a heuristic device—that is, as a way of imagining how the environment outside the body could affect the inside of the body. And there was a trick to it. The trick was that the four elements were not imagined as abstractions but as real material substances. Earth meant land or dirt; Water, rain; Air was wind; and Fire was the sun. The “elements” of the humoral system were not the elements of the philosopher, but the natural elements of the farmer and the gardener.

  I began to understand that the premodern system was based on the gardener’s understanding of the world, and that Hildegard took a gardener’s approach to the body, not a mechanic’s or a computer programmer’s. She did not focus down to the cellular level of the body; instead, she stood back from her patient and looked around. She calculated in her mind not just the internal balance of the four humors, but the whole balance of her patient within and as a part of his environment. With that numberless measure, she manipulated and rebalanced the environment inside of and outside her patient. She did so slowly, like a gardener, by fussing and fiddling, doing a little of this and a little of that. Then she waited to see what would happen. Which is to say that she followed the patient’s body; she did not lead.

  There seemed to be something in it, to me. And while I did not start giving my patients complex medieval concoctions, I did bake some of Hildegard’s antidepressant cookies; I did brew some of her medicinal beers; and now and then, with a difficult, puzzling patient, I asked myself: Now, how would humoral medicine understand this? What would Hildegard do?

  The first patient I tried this with was Mrs. Maria McCoy.

  She was sent to us to die, but I didn’t know that at first because, ever since Lev Grenz and his tongue, I’d changed the order of my workup. I’d try to see the patient right away, before I looked at the records, and I didn’t spend much time on asking the patient for his history, either. The histories of the patients who came to us were just too complicated for anyone to remember. Instead, I’d follow the ambulance drivers into the ward and watch as they moved my new patient into bed. Then I’d take the vital signs myself and begin my examination. I’d see how much I could deduce about the patient and his life from my examination alone—which medications he was taking, which diseases he had, his line of work, and something of the course of his life. It was amazing how much I could learn.

  For instance, some blood-pressure medications cause distinctive physical signs, as do certain neurological medications, and I could often figure out which medications the patients were on and why by noticing those signs. Then there are the physical signs of diabetes, and those of high blood pressure, and both can reveal how long-standing those diagnoses are. There are the patient’s scars—from surgeries forgotten or remembered, from stab wounds, war wounds, childhood accidents. And there are the tattoos. Many of the patients who came to us had tattoos, and they are informative. For instance, there are specific tattoos acquired in prison; others obtained when someone is high on hallucinogens; there are schizophrenic tattoos; tattoos from a drunken high school night on the town; and tattoos of the merchant seaman. Sometimes a patient had all kinds of tattoos, and his history was really written on his body: first the drunken night on the town, then the LSD, then the time in prison, the schizophrenic break, and the flight to sea.

  So I followed as the ambulance drivers wheeled Maria McCoy into one of the semiprivate rooms at the front of the ward. This in itself was a bad sign, because the nurses reserved those rooms for the sickest patients. I watched as the drivers transferred her from the gurney into the bed in the corner, next to the window. She was bundled up in a coat as if she were a package being delivered, and they grabbed the sheet on which she was lying by its top and bottom, and heaved her onto the bed. She didn’t move. Then they handed me her records, maneuvered the gurney around me, and left.

  I began to look over my new patient.

  Her eyes were half closed, glazed, and almost empty, and she did not seem to realize I was there. Her face was yellow, and her hands, which the drivers had placed outside the bedclothes, were puffy. Then I went over to her right side and looked down. It was not a pretty sight, or, to be precise, it was not a pretty feeling. Mrs. McCoy had almost no life force left.

  “Life force” is not a medical term. In the more than one hundred thousand words of Stedman’s Medical Dictionary, there is no word that names what I didn’t feel from Mrs. McCoy that day—there was almost nothing coming from her to meet my presence. She was alive, to be sure; s
he was breathing, and I could sense the faint warmth that emanates from the living body. But there sure wasn’t much to work with.

  I introduced myself, and her yellowed eyes turned toward my voice. Her hair was thin and unwashed; her face swollen; her lips cracked; and her mouth dry. The rest of her body was swollen, too, especially her belly. It was as big as a beach ball, and when I lifted up the sheets, I saw that her skin was covered with the death marks called “spiders”—red spots that signified, as did her yellow skin and eyes, and the swelling of her face, arms, legs, and belly, that her liver was no longer working.

  Her records made it clear that Mrs. McCoy was not expected to live. She was expected to die of liver failure, and soon. Her crime was alcohol. Now, the liver can tolerate many years of drinking; unlike the brain, heart, or limbs, under the right conditions the liver can regenerate and reconstruct itself. And that’s a good thing, because, as Mrs. McCoy’s body demonstrated, without a functioning liver, the body fails. The liver makes protein—the protein that clots our blood; without that protein we bleed to death from nose, mouth, lungs. It makes the protein that holds serum—the yellow fluid of our blood—inside our blood vessels; without that protein, the serum moves out of the blood vessels and swells the face, arms, legs, and belly. The liver also removes toxins from the blood; without it, they poison the brain, putting it into the state of Mrs. McCoy’s brain—first dull, then confused, sleepy, and, ultimately, dead. We don’t need that much liver, though, only 5 percent of what we’re born with. With 5 percent, our liver can clot our blood, make proteins, filter toxins, and even regenerate itself. Without that 5 percent, we die. And Mrs. McCoy was going to die.

  She would bleed to death, suddenly and without warning. She would sit up in her bed and vomit blood—all her blood—and then fall back in a minute or two with a puzzled look on her gray, dead face. Or she would get agitated and combative, with a fever and infection that confused her further, and she would die in twenty-four hours. Or, lacking fluid in her veins, and, therefore, lacking enough blood pressure to adequately irrigate her kidneys and brain, her belly would get bigger and bigger; her face, yellower and yellower; and her spirit, quieter and quieter, until her lungs stopped breathing and her heart stopped beating.