But then the first of the month rolled around, and Mike showed up.
He was still pretty cute, still wearing his tight Levi’s, still walking with a flirtatious, though constrained, strut. The nurses made him wait in the smoking room, and Terry wheeled herself on her gurney, facedown, back covered, the whole length of the ward. Then she rolled into the smoking room. They were there a long time. Then the door opened, and Mike came out and left.
Terry had thrown him out. She told him never to come back.
Then she stopped smoking. So her appetite improved, and she gained weight. Without nicotine constricting her blood vessels, the tiny new arteries and veins at the base of her bedsore could absorb the vitamins and protein she was eating, and the hole in her backside began to fill in.
Since I did not check the bedsore daily but only once a week, its progress seemed as magical to me as one of those time-lapse movies they showed us in school, where a plant grows from a seed in a matter of minutes. Dirt falls on either side of the sprout as it pushes its way up through the earth; then a minute later tiny leaves unfurl; buds appear and then expand until their sides split open and the first petals uncurl.
Just so, Terry’s bedsore seemed to heal. There was her back filleted open, with a huge, deep wound over half of it. Then the base of it began to shine as endothelial cells spun blood vessels and connective tissue. The bones began to glisten, and then muscle, fat, and subcutaneous tissue appeared. This week, a few new blood vessels over the spine; at the edges of the wound, a few millimeters of new skin. Next week, nothing in particular, except that the bedsore was a little shallower.
Terry’s wound began to look like a huge scab. The scab thickened until it was even with the rest of the skin, and then, just as petals push against the constriction of the bud and open it, so the scab flaked off, and there was pink skin underneath. That awful crater filled in from bottom to top and from side to side.
It took a long time. It took two and a half years. But we were in no hurry, and neither was she.
After two and a half years the bedsore had healed. Also Terry’s teeth had been repaired by our dentist, and eyeglasses prescribed by our optometrist. She’d gained a considerable amount of weight. The crevices in her face had filled in; her hair grew in thick and dark; and behind her new eyeglasses, makeup appeared.
One day toward the end of the two and a half years, the social worker found her brother, who still lived back in Arkansas with his wife and two children. He asked whether his sister could come and live with him. He was not rich; he didn’t have the money to send for her; but if the hospital would send her out to Arkansas, he would do the rest. Since we did have the Patient Gift Fund, donated by families for just this kind of situation, the social worker bought an airplane ticket and made arrangements for Terry to be cared for in a hospital in Arkansas.
With Terry Becker I got a glimmer of what Dr. Curtis meant when he told me that Laguna Honda was a gift. Laguna Honda was a once-in-a-lifetime opportunity not only to see cases that no one any longer got to see, but to observe processes that no one any longer got to observe. With Terry, I witnessed healing from the inside out.
It was a long, ironic, and miraculous process.
I was impressed by how long it took. Two and a half years. And it did take two and a half years; I can’t imagine her healing in any less time. The general rule of thumb in premodern medicine was that it took as long to heal an illness as it took for the illness to develop. Depending on how we label Terry’s illness, as transverse myelitis, as a bedsore, as drug abuse, as a poor self-image, or—what I really believe it was—as some deep spiritual wound, two and a half years was just about right.
Not only did her healing take a long time and need a long time, but time was the most important ingredient in her treatment. Premodern medicine knew about that special ingredient; it was called “tincture of time.” Almost everything, it had observed, healed in time under the right conditions. And the most valuable thing that Terry received at the hospital was just that: enough—that is, the right amount of—time, the right amount of time being time without pressure and without end.
What was ironic was how difficult it was for her to get it. Our much-criticized health-care system provided every medication, no matter how expensive, and every necessary procedure; and yet, after each of her fifty-thousand-dollar hospitalizations, she was discharged in a wheelchair to the streets or the Baxter Hotel. The value of Laguna Honda, where time was not at a premium, struck me. Patients like Terry should, I decided, be tucked away at our hotel, out of sight of the administrators and out of the mind of budgeters, so the tincture of time could do its work.
But it was watching her healing that was miraculous, that transformed my practice of medicine. In this day of efficient health care, no one ever gets to see such a process. It seemed to me more than mechanical; it seemed magical, a sleight of hand.
Of course, modern medicine can readily explain the mechanism of Terry’s healing. Once the breeding tissue for microbes had been removed by our plastic surgeon and nutrients provided, healthy cells at the base of the wound dedifferentiated—that is, they lost various inhibitive structures on their DNA. They turned into pluripotential stem cells, and then, by means of a complex but explainable process of membrane receptors, enzymes, and transcriptases, they began to produce first the RNA and then the proteins necessary for reconstituting the muscle cell, the endothelial cell, the cartilage cell, the collagen. There was nothing magical about it. Once this process was set in motion, it happened mechanically.
And yet it felt like something different, as if I were watching an invisible artist fill in his vision of Terry Becker’s perfect body. I wouldn’t say that modern medicine was wrong in its explanation, but the process seemed more than mechanical; it seemed deliberate, as if there were a perfecting force, clear about its purpose and its final form. But, just like the absence of the little black box at Mr. Baker’s autopsy, I had no word for it.
Although, as I researched Hildegard’s concept of viriditas for my PhD and tried to understand what she meant by it, I discovered that premodern medicine did have a name for this magical act that the body performs. It was called the vis medicatrix naturae, usually translated as “the healing power of nature.” But this is not a great translation. Vis is related to vim and vigor and means the force of life, of youth, of newness. Medicatrix is related to remedy and medication. And naturae does not mean nature as in “Mother Nature,” but rather your nature, my nature, Terry Becker’s nature. It means the nature of us to be ourselves. So the vis medicatrix naturae is really “the remedying force of your own nature to be itself,” to turn back into itself when it has been wounded.
The idea goes all the way back to Hippocrates, who wrote that “what heals disease is nature [physis].” And what did he mean by physis? Physis comes from phuo, which means to grow, and signifies the observation that a seed grows into the only plant it can: a mustard seed into a mustard plant, a seed of wheat into a sheaf of wheat. By physis Hippocrates meant the “nature” of a being to grow into itself; and it was, in part, what Hildegard meant by viriditas.
Physis—the individual nature of each person—also gives us the word physician. The physician is the person who studies physis, the individual nature of his patient, who understands it and follows its lead.
But like anima and spiritus, physis and the healing power of nature were exiled from medicine more than one hundred years ago. They were victims in the battle between two completely different conceptions of health, disease, and healing—mechanism and vitalism.
The mechanists believed that life was mechanical, simply a series of processes that science could eventually understand and duplicate; the body was a machine that could be fixed. For the vitalists, the body was not a machine. They believed that life had something special about it that science could never duplicate. The vitalists were the romantics of medicine, and in the last decades of the nineteenth century they lost their battle with the mechanists. By
the early twentieth century, any reference to vitalism or the healing power of nature was considered heretical. Yet vitalism did not disappear. Instead, it dived down into the subterranean rivers of Western medicine and reappeared in the many side streams of alternative medicine.
Whether there is such a thing as the healing power of nature is, perhaps, beside the point. What I do know for sure is that it is a useful way of looking at my patients’ bodies; it gives me a way of imagining that the body’s natural state is to be whole, perfect, and without blemish. And it is what differentiates the living body from a machine: because if nothing interferes, the body, unlike a machine, will heal itself.
Watching Terry heal from Hildegard’s perspective of viriditas changed my point of view from figure to ground. Forever after, instead of focusing on my patient vaguely surrounded by his environment, I also did the opposite—I stepped back and focused on the environment surrounding my patient. And asked myself: Is anything interfering with viriditas? What can I do to remove it?
There was still one more insight that I got from Terry Becker.
And that was the other—and just as impressive—healing process that went on, beginning with her throwing out her boyfriend, then giving up smoking, alcohol, and drugs; and then moving on to a remarkable change in temperament, from irritable and angry to pleasant, grateful, and even, I think, happy. Some fundamental change gelled and became irreversible just when she wheeled herself into the smoking room to meet Mike that last time.
I don’t know when it started or how. It wasn’t when he abandoned her, quadriplegic and wheelchair-bound on the streets of our city, because she let him check her out of the hospital two or three more times after that. I don’t think it had started even when she was admitted with that huge and terrible bedsore. I think it happened after she got to us, before Mike turned up at the first of the month, while she was lying there at the far end of the ward with the window open above her, facedown, for weeks.
After two and a half years, Terry was discharged.
Her social worker drove her to the airport, and her brother, whom she hadn’t seen in years, was waiting at the airport in Arkansas to pick her up. After that, I don’t know what happened to her or how she lived. I only know what I read in her obituary, eleven years later, which mentions children and grandchildren but nothing about her long stay in our city; nothing about Mike or living on the streets or the big bedsore. Or the effort of will that saved her life, that reaching down for a sense of self she’d forgotten or didn’t know she had, or didn’t have until that moment on the gurney in the smoking room.
Perhaps she never spoke to her family of those lost years; perhaps they never asked. Perhaps she spoke of them often, and her children and grandchildren knew all those stories. From the narrowed eyes and high cheekbones in the obituary photo, the proud lift to her head with its traditional beads and the firmly closed mouth, I think not. Although—who knows?—in the photo she is still wearing our glasses.
Five
SLOW MEDICINE
NOT LONG AFTER Terry Becker went back to Arkansas, Laguna Honda was notified that it was under investigation by the Department of Justice. Someone at the hospital had contacted the DOJ with a tip, although what the tip was and who contacted them were never divulged—to the satisfaction of Larissa, I might add.
But everyone had his favorite suspect. Some thought it was Dr. Kay, our hospice director; others that it was Sister Miriam, our resident nun. Larissa guessed Miss Lester, the director of nursing, who’d protested the halving of her head nurses all the way up to the director of public health. Larissa thought Miss Lester might have done it as a last resort, a way of stopping the destruction of the nursing system she’d spent her life creating. That seemed unlikely to me, at first. From what I knew of Miss Lester, she was not the kind to turn in her own people, though from what I later learned, she was a possible, even probable, informant.
By the time I arrived at Laguna Honda, Miss Lester had been director of nursing for thirty-six years and would be director of nursing for another eight. She’d been at the hospital longer than almost anyone else—longer than the chief of our institutional police, longer than the baker in the kitchen, longer even than Mrs. Lantos with her lobotomy, although just barely. Miss Lester had accepted the position right after she got out of the army, and so far she’d survived five executive administrators, six medical directors, and eight directors of public health.
As soon as she arrived, she took over the two-room office between the entrance door for ambulances and the large hall where patients smoked and played cards. In the first room she stationed her second in command, Donnie McFarland, and for the next forty-four years Donnie stood sentinel at the open Dutch door of that first room, where nurses hovered to ask about sick leave and problem patients. Anything that went wrong in the hospital during the day was taken to that Dutch door and vetted by Donnie.
Miss Lester herself moved into the second room, which could be reached only through an inside door in the first office, so she was mostly undisturbed in her work. Larissa told me that she’d been in Miss Lester’s office only once. Donnie being gone for a minute, she’d stepped inside and found Miss Lester’s door open.
“I looked inside,” she told me in her Russian accent. “The room was dark, and Miss Lester was sitting at her desk, smoking. There were two piles of white papers on each side of the desk, and two cats sitting on them, one on each pile. She asked me what I wanted; and I was scared; but I was asking for vacation so I told her. She said just make sure that my request was written on yellow paper because she only looked at the yellow paper. If I wrote it on white paper, it would get thrown out.”
Larissa was quiet for a moment. “She was tough, that one, but fair.”
Miss Lester was short, stocky, and squarely built, and though she no longer wore a white uniform or a nursing cap, she might as well have. She ran the hospital with a firm hand, which, I gradually realized, was what gave the hospital its stability. Also, perhaps, its hidden softness. Miss Lester’s nursing structure was simple: She was at the top; underneath her was the assistant director of nursing, then the nursing supervisors and the head nurses for each ward. From her little office she ran the hospital or, at least, the nursing part of it. She did so without a computer, a secretary, or an answering machine. If something needed to be typed, she typed it; if a call needed to be made, she made it; and she answered the telephone herself. Unhappy family members got the director of nursing right away; so did patients and so did staff—which minimized the number of sick days requested.
Miss Lester stayed in that office for decades. She stayed in it through the hospital’s transition from premodern nursing to modern medicine; and during its transition from modern medicine to health care. Through all the changes Miss Lester kept her staff—many hundreds of nurses and orderlies—as organized and disciplined as an army, or at least a battalion. More disciplined, really.
Each morning at six-thirty AM, she was met at her office by the nursing supervisor of the night and the nursing supervisor of the morn, and the three of them went to see every patient in the hospital, all 1,178 of them.
I knew this because every day at eight AM they came through the double doors of the admitting ward and sailed past the open door of the doctors’ office. They would stop at the nursing station, and the head nurse would join them. Then, with Miss Lester, top lip clamped firmly on the lower, at their head, the group would walk the ward. Miss Lester would stop at each bed. Her eyes would latch for a moment on the patient and then scan the area. Any evidence of commotion, anything out of place, but also any sign of unmet suffering—of moaning, dirty bedclothes, twisted limbs—would be noted and questioned. And then the procession would sail on to the next patient.
Before leaving the ward, Miss Lester would give her orders to the head nurse and then walk to the next of the thirty-eight wards. It took her the good part of the first three hours of her day, but by the end, Miss Lester knew just about everything about her
army and had a plan. She would return to her dark, cool office, light up a cigarette, and set to work.
Her plan, however, did not include the doctors. Rather, it precisely excluded them. In fact, for all my years on the admitting ward, Miss Lester marched past the open door of our office, surrounded by her officers, and never once looked in. Once and once only did we meet face-to-face, and she didn’t have time to glance away. But she did have time to glaze her eyes and stare just past me, not acknowledging my presence or position in any way.
I didn’t mind, though. For one thing, even with the disadvantages of her system—with doctors and nurses meeting in stairwells and linen closets—it worked pretty well. With so little in the way of modernity, Miss Lester nonetheless provided what is necessary for the best care of the patient—a gentle and reliable staff. The peculiar softness underneath her system—the kindness woven like an invisible thread through the decrepit fabric of the place—may or may not have been due to her, but it was not hindered by her. It wasn’t dismantled, removed, or teased out.
For another thing, I didn’t take it personally. Miss Lester was right to be suspicious of the medical profession; I knew this from Dr. Weitz’s class on the history of the hospital. Ever since the duties of the monk infirmarian had been split between doctor and nurse, and the Latin curare split into cure and care, there’d been a battle going on for control. Who would be in command of the hospital? Doctor or nurse? Whose model of curare would triumph? Cure or care? And this battle was joined at the French Revolution, when the doctors tried to wrest control of the Hôtel-Dieu in Paris from its nursing nuns.
For more than a thousand years the nuns ran the Hôtel-Dieu: Caring for the sick poor defined their monastic vocation. They provided food, shelter, and spiritual care; they nursed the sick; and only when necessary did they call in a physician. Until the end of the eighteenth century that was just fine with the doctors, because the sick poor at the Hôtel-Dieu did not offer them a pecuniary or any other reward.
God’s Hotel: A Doctor, a Hospital, and a Pilgrimage to the Heart of Medicine Page 11