Long ago Saint Isidore wrote that dementia showed that life could go on even without the spirit. I knew what he meant. Those were the patients on the feeding-tube ward, mute and still. But, he continued, sometimes in dementia, the soul—the anima—remains in spite of the loss of mind. I learned that from Mr. Bramwell. No matter how demented a patient seemed, it just might be that deep within he still had his anima, his soul. If we could just get to it!
That wasn’t all I learned from Mr. Bramwell. There was his sister-in-law, Lorna Mae.
Lorna Mae was Mrs. Bramwell’s sister. While not as beautiful or as statuesque as her sister, she was just as tall and just as dark and rich a color, and a year into my rather ineffectual treatment of Mr. Bramwell, she turned up one day at his bedside. At once, as soon as she saw me, she burst out, with a big, embracing smile and a lit-up face, “Is that you … Miz Altman’s great-niece?”
I looked at her. It took me a while to remember.
“How is your dear mother? And your sisters? And how are you?” she went on.
Suddenly it all came back. Lorna Mae had taken care of my great-aunt Bess years before. I remembered her walking out of the kitchen, as I was sitting with my aged, feeble great-aunt, to bring her soup; and I remembered her at my great-aunt’s funeral, too.
She’d come to the funeral with two other friends, and they sat in the back. It was a formal funeral, attended mostly by white-haired little white people in black suits and ties, black dresses and pearls. Since my great-aunt was not religious, in lieu of a service there were a violinist and a cellist, playing Bach. I sat on the side of the chapel, and the mood was somber, staid, and philosophic. The little white-haired white people sat in front, listening in silence to the cello and violin, and dealing as best they could with the meaning of life in the face of death.
But I could see Lorna Mae in the back row. I didn’t know why she came, whether to mourn my great-aunt, to honor her, or, perhaps, from a sense of accomplishment—a job done well, now over. She was not dressed in black, but wore a heavy dark purple silk dress and a huge purple felt hat with a swooping green feather. She did not seem sad or dismayed; she sat confidently, with satisfaction, I thought, in the sure and certain hope of resurrection and faith in a life to come. Her confidence and her purple hat with its green feather became the focal points in the first piece of writing I’d ever published.
And here she was, fifteen years later.
Sitting by the side of her brother-in-law’s bed, she looked at me expectantly. What would I do for him? And what hit me at that moment was the reversal of our positions. Once I’d been sitting by my relative’s bed, and she’d been the giver; now she was sitting by her relative’s bed, and I was the giver. It was the reversal of our positions that struck me. It illuminated something I’d been puzzling over, which was that the root of hospital is hospitality, and the root of hospitality is hospes, which can mean either “guest” or “host.”
In Rome hospitalitas—hospitality—meant caring for the traveler, the stranger, and the pilgrim, but only when he was of the same class as oneself, because then one could expect an equivalent return. So Roman hospitality was a kind of fair exchange. It was based on the idea that every host (hospes) was also a guest (hospes) somewhere else; that one’s identity as either host or guest was interchangeable.
After Rome collapsed, the monasteries grew out of their old villas, and took over many of the social contracts left in Rome’s dust, especially that of hospitality. But the hospitality of the monasteries was radically different from Rome’s, because the monks and nuns opened the door of their hospices to everyone, regardless of their social standing. To rich and to poor, to travelers, pilgrims, and the sick, to Muslim and to Jew. The reason for that was Matthew in the New Testament, who had quoted Jesus as saying: Whatever you do for the least of these, you do for me. Which was interpreted by the monks to mean that any guest was welcome in the monastery because any guest could be—and therefore was—Christ. That was how the Roman hospitalitas turned into the medieval hospitality of the monastery’s hospice.
What I’d been puzzling over when Lorna Mae and I recognized each other was why, in Latin, French, and even, originally, in English, the concepts of guest and host were not differentiated; there was no word for telling them apart. They were the same. And at the moment when I recognized Lorna Mae, I suddenly understood why: It was because our parts are, in fact, interchangeable. The essence of hospitality—hospes—is that guest and host are identical, if not in the moment, then at some moment. Whatever our current role, it was temporary. With time and the seasons, a host goes traveling and becomes a guest; a guest returns home and becomes a host. That is what the word hospitality encodes. And in a hospital, the meaning of that interchangeability is even more profound, because in the hospital, every host will for sure become a guest; every doctor, a patient.
That is what I realized in that moment with Lorna Mae. I, too, would go from being a host in the hospital to being its guest; I, too, would become a patient. Although sobering, that was the essence of the matter.
Mrs. Bramwell’s sister takes care of my great-aunt; I take care of her brother-in-law. I teach my medical students to be good doctors, and it is not entirely unselfish, because sooner or later, they will be taking care of me. It was the measure of the Golden Rule and a good, selfish Golden Rule: Do unto others as you want them to do to you because pretty soon they will be doing unto you, directly or indirectly.
It was in this sense—hospes, the non-distinction between guest and host—that hospitality was, and should be, the essence of the hospital. That is what I learned from Lorna Mae.
And although I never heard it talked about, the longer I was at Laguna Honda, the more sure I was that its first principle was not medicine, nursing, or a balanced budget, but hospitality in the sense of taking care of anyone who knocked at the door because—it could be me. It was me.
As I was getting to know the Bramwells, the politics of the hospital were complexifying. The Department of Justice was adamant: If the city did not correct Laguna Honda’s violation of the patient’s right to privacy, it would be closed.
Dr. Stein spent almost a year working up every one of his options. He looked at shutting us down and using the money saved to take care of our former patients at home. He looked at building several minihospitals scattered around the city. He looked at renovating the old buildings. Last he looked at the most expensive option: tearing down the old Laguna Honda and rebuilding a new Laguna Honda as a modern, state-of-the-art health-care facility with two thousand beds.
Each option was costly—many hundreds of millions of dollars costly. There seemed to be no way around it. And I sometimes wondered whether Dr. Stein ever thought, as I sometimes did: Why not just let the place close down? Almost every other county had closed its almshouse, and their citizens seemed to manage. True, their private hospitals were even more jammed up than our city’s, and their streets were filled with even more of the sick poor. Or perhaps not. Our city was a magnet for every loose iron filing in the country, and no matter how large Dr. Stein made the new Laguna Honda, it would never be big enough to take care of them all.
If he did think it, Dr. Stein never said so. His final recommendation was to rebuild a huge new health-care facility, one big enough to accommodate the wave of frail elderly, destitute disabled, and mentally ill expected to deluge the city as the Boomers aged.
He presented his recommendation to the board of supervisors. The supervisors were aghast. Five hundred million dollars. Not all of the money would have to come from the citizens, fortunately; half would come from what the tobacco companies were going to pay the city for tobacco’s role in lung disease. But the other half would have to come from a bond, and the bond would have to be approved by a two-thirds vote of the citizens. Times were not good, and the mayor did not want to put the bond on the ballot. He did not want to support something he knew would fail. But he succumbed to pressure, and the bond for a new Laguna Honda did go on
the ballot.
The bond had many enemies but, since no one imagined it would pass, the forces against it were lackadaisical. The Republican Party was against it, arguing that the rebuild was unnecessary because Laguna Honda’s patients could be cared for more cheaply elsewhere. The mayor’s opponents were against it: the rebuild was simply a boondoggle for the unions that supported the mayor. Disability activists were against it: The disabled had a right to live at home, and the city should spend its money providing homes or homelike places so every patient could live in the community.
Still, all considering, there was only lukewarm opposition.
By contrast, the pro–Laguna Honda forces were passionate, organized, and active; and the arguments in favor of the rebuild ran to thirty-five pages. The Society of Architects argued that no matter how expensive a new hospital would be, it would still be less expensive than any alternative. The unions argued that a new hospital would provide jobs and maintain a safety net for disabled workers. Nurses, doctors, and patients argued that a new hospital was simply the right thing to do, no matter how much it cost. AIDS groups, Hispanic groups, African- American, Asian, and Catholic groups all spoke up for a new Laguna Honda, too.
And there was Miss Lester, who though retired was still active in the hospital’s politics. Of course, except for Miss Lester, it could be said that everyone in favor of the bond was arguing from self-interest. Miss Lester did not even argue. She wrote: “After forty-four years of caring for thousands of our brothers and sisters who were restored and returned to their homes, and for thousands who were cared for in love and respect until their final hour, I am convinced that Laguna Honda must forever be part of our city. Vote Yes on Proposition A.”
And the citizens obeyed her. They did vote Yes. It was stunning. It was unexpected. In the middle of a recession, with job losses, deflation, and a frightening future, the bond passed by nearly three to one. Although given the times—times when anybody might need the almshouse—it was less surprising than it might have seemed. Still, Dr. Stein, the mayor, and the board of supervisors were astonished. They scratched their heads, smiled and frowned, and began to put the structures in place to collect the five hundred million dollars they would need.
Believing for quite a while that our hospital would close, and then finding out instead that there would be a new, enormous, and expensive health-care facility built next door was stressful to us all, and I cherished even more those Tuesdays, Thursdays, and Saturdays, when I could hide out in the library with Hildegard and premodern medicine. Having studied her context and her medical practice in Switzerland, I now turned to understanding her medical theory: that is, how she conceptualized what she did with her patients—her framework.
For us, for modern medicine, our basic framework is the cell. We begin life as a single cell, the fertilized egg, which then multiplies and divides and differentiates into all the different cells of our body. Inside each cell, we believe, is a kind of chemical factory, with production machinery, communication devices, and energy machines; and their programs are contained in the code called DNA. Each cell follows its DNA instructions and so produces the chemicals necessary for its life. To communicate with other cells, each cell secretes certain of these chemicals into the blood. There they circulate and interact with other cells, modifying these other cells’ DNA orders, and so unite the individuality of each cell into a corporate whole.
Modern medicine’s framework for the body, then, is industrial, mechanical, and democratic: The body is a factory with workers; a machine with parts; a democratic republic of cells, each obedient, hardworking, and united for the common good. Though complex, our cell model of the body obeys clear laws; it is orderly, rational, and predictable, up to a point. Once the cell is understood, it is easy to understand how each organ functions, how diseases injure, and how medications work.
And so I asked myself: What was Hildegard’s framework for understanding the body? What was her intuitive, internal model of the body, which worked for her the way the cellular model worked for me?
It took me a long time to grasp Hildegard’s framework. Even now I’m not sure I understand it fully, but I do understand it enough to put myself inside it and even use it sometimes, as a way of thinking about a patient, a disease, or a medication, as a way of thinking outside my box. Because, although Hildegard’s framework could not be more different from cell theory, it is not unfamiliar. It is our oldest way of thinking about the body, preserved in the etymology of our words and in our proverbs. Alternative medicine, homeopathy, naturopathy, and even astrology use this premodern model, which is, doubtless, one of their attractions for the modern temperament.
Hildegard’s framework was based on the classic system of premodern medicine—humoral medicine—which was also known as the System of the Fours. What were the fours of the System of the Fours? They were many, and they were all related: four elements, four qualities, four humors, four directions, four colors, four temperaments, four ages, four times of day, four seasons.
It is best understood with a diagram (see page 181).
The way the diagram works is this. The world is made out of four basic elements—Earth, Air, Water, Fire, each of which occupies one of the four corners of the diagram. Each element is made up of two of the four qualities—hot and cold, and wet and dry. Earth is cold and dry; Water is cold and wet; Air is hot and wet; and Fire is hot and dry.
Like the world, the body is also made up of a “four”: the four humors—blood, phlegm, bile, and melancholia. And just like the elements, so, too, are these humors made up of two qualities, each humor corresponding to an element. The humor blood is hot and wet, and corresponds to Air; phlegm is cold and wet, and corresponds to Water; bile is hot and dry, and corresponds to Fire; and melancholia is cold and dry, and corresponds to Earth. In the diagram, they are placed with their respective element at each of the four corners.
Since the qualities of hot and cold and wet and dry are also the qualities of weather and climate—that is, of temperature and humidity—each of the four elements and each of the four humors is related to one of the four seasons and increases during that season. For instance, in spring, which is hot and wet, the element of Air increases outside the body, and inside the body, the humor of blood increases. In summer, which is hot and dry, outside the body the element of Fire increases, and inside the body, the humor of bile increases. In autumn, the dry, cold element of Earth and the dry, cold humor of melancholia increase; and in winter, the moist, cold element Water and the moist, cold humor phlegm increase. This is true not only for human bodies, but also for animals and plants.
As the year passes, and the Sun moves around the Earth—clockwise during the day; counterclockwise during the year, and from south to north and back again—what is wet, dries; what is hot becomes cold. The seasons give way to one another, and the four elements rise and fall. For instance a spring turns into summer; Air decreases, and Fire increases. There is a corresponding change in one’s lifetime: The hot, wet youth becomes the cold, dry elderly. Since health results from the right balance of the four humors inside the body, the way to ensure it is to compensate for the seasonal changes outside the body by modifying the humors inside the body.
This was where Hildegard’s prescription for “regime” came in. Regime was made up of all those things that could be changed as the seasons changed—the kinds of food we eat, the kinds of drink; the amount of rest and exercise, sex and emotion. For example, since summer was by its nature hot and dry, Hildegard typically prescribed a regime that was cold and wet: so beer instead of wine; tepid bathing instead of hot baths; less sex, less stress, and more relaxation.
It wasn’t just the human body that had a temperament affected by the seasons. So did animals and plants. In fact, every plant had its own balance of the four qualities, being more or less hot or cold and wet or dry; its qualities being determined by its taste. (We still do this today, but only for wine.) It was by their qualities that plants could counteract th
e effects of the seasons, and many of Hildegard’s prescriptions rely on those qualities for their medicinal effect. For instance, for Mrs. McCoy’s cold, wet edema, Hildegard would have chosen hot and drying plants; for Mr. Bramwell’s cold and dry brain, hot and moistening plants. Hildegard’s was a gardener’s point of view, taking account of each patient’s individual nature and compensating for its excesses or deficiencies—drying what was too wet, wetting what was too dry, and paying attention to the seasons.
It had taken me a long time, but I finally understood why the premodern medical system had worked so satisfactorily for so long and then fallen out of favor so quickly. Hildegard’s System of the Fours was based on the simplest of observations—the effects of the four seasons on plants, animals, and human bodies. It was a holistic system whose underlying metaphor was horticultural, and it had corresponded perfectly to the rural and agricultural life of the premodern world. With the rise of industrial modernity, it disappeared quite naturally, if abruptly.
It took Dr. Stein almost as long to begin the rebuild as it had for me to understand Hildegard’s Way.
It took him four years. It took that long to sell the bonds for the new hospital, to accumulate the first of the tobacco money, to obtain building permits, and to choose a site, which would be the valley between the main building and the even older building of Clarendon Hall. From the point of view of Hildegard’s System of the Fours, this valley was insalubrious, being deprived of the drying sun and cleansing winds, but from the point of view of Dr. Stein, it was perfect—vacant and hidden from the neighbors.
The plan was that once the new Laguna Honda was built, the old Laguna Honda would be partially demolished and a multilevel parking lot constructed in its place. It could not be completely demolished, though, because the front part of the main building was on the Register of Historic Places and would, therefore, be saved from the Grim Reaper—saved and renovated and turned into offices for the city’s administrators. It was, after all, a beautiful if decrepit building, with spectacular views of the city and the ocean.
God’s Hotel: A Doctor, a Hospital, and a Pilgrimage to the Heart of Medicine Page 19