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In a Medical Sanctuary

groopman_2-092712.jpg
Biblioteca Statale di Lucca
‘Universal Man’; from Hildegard von Bingen’s Liber Divinorum Operum (Book of Divine Works), circa 1173

Several years ago, I cared for a woman with breast cancer. Her treatment began with surgery and radiation for the initial tumor, and then a series of chemotherapeutic drugs, each inducing only a temporary remission. Ultimately, the cancer grew in her liver and bones. I knew of no drugs, either standard or experimental, that offered a real chance of ameliorating her condition. Early in the evening when the hospital grows quiet, I went to her bedside to tell her.

I sat and grasped her hand and described how the cancer had regrown. “Barbara,” I said, “we’ve been honest with each other every step of the way. I know of no medicines that I can give at this point to help you.” For a long while we sat together in heavy silence, and then she turned to me and shook her head, “No, Jerry. You do have something to give. You have the medicine of friendship.”2

Victoria Sweet describes how one patient early in her career taught her about this other dimension of a doctor’s care:

Miss Tod capped my experience of those first years at Laguna Honda. She summarized it and hinted at what I would be learning later. Even when there is nothing to do for a patient—no cancer to discover, no paradoxical pulse to take—there is still something to do. It doesn’t have to be lifesaving, grandiose, and heroic. It can be as simple as a pair of glasses or a different diet. In fact, it usually is.

Sweet later decided to work part-time at Laguna Honda, so as to pursue graduate study in the history of Western medicine. She chose as a thesis topic the work of Hildegard of Bingen, a nun who lived in the twelfth century, a mystic, composer, and theologian, as well as a medical practitioner. She wrote a book about diagnosis and treatment. Sweet writes, “Although [it] was not a great book, it was thrilling.” The thrill was that it emphasized the observation of the ill, and the importance of focusing on their environment. Hildegard’s medicine did not imagine the body as a machine or disease as mechanical breakdown. Rather, as Sweet elaborates, Hildegard had a

remarkable concept of viriditas. Viriditas comes from the Latin word for green, viridis—which also gives the French vert, and the Italian and Spanish verde. Viriditas meant greenness. So usually it referred to the color of plants or of gems like emerald, although it was also used metaphorically to mean vigor or youthfulness.
But Hildegard used viriditas—greening or greenness—in a broader sense…. She used it to mean the power of plants to put forth leaves, flowers, and fruits; and she also used it for the analogous power of human beings to grow, to give birth, and to heal.

Hildegard’s metaphor informs Sweet’s therapeutic approach to Terry, a patient at Laguna Honda with an open bedsore, festering with microbes that were mercilessly feasting on the decaying flesh. This was not a small, simple bedsore, but a cavernous wound that extended to the surface of bone and had dramatically worsened at other hospitals:

To see what else was needed, I had to start with a vision of Terry whole, complete, and healthy, in a future when all that was missing from her complete health was a pair of glasses. And walk my way back from that. Which I did. I walked past the repair of her teeth, the strengthening of her body, the strengthening of her will, the resolution of her depression, and the healing of her bedsore. I walked all the way back from the perfect future to the imperfect now, and then I organized my strategy forward.
What my strategy would be, I understood from Hildegard, was that in addition to removing obstructions to viriditas, I would fortify Terry’s viriditas with Earth, Water, Air, and Fire. That is, with good nutrition—tasty food, vitamins, liquids—deep sleep, fresh air, and sunlight.
After that? Peace. Rest. Safety.
Not much else. It might be just that simple. Oh, and time. As much time as Terry needed.

This approach succeeds, and affords a lesson not only for this one patient but for our health care policymakers:

With Terry, I witnessed healing from the inside out…. 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.

Sweet is not a Luddite; her metaphors are poetic and hint at the mystical, but she then pulls back with the educated eye of a scientist:

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….
Watching Terry heal from Hildegard’s perspective of viriditas changed my point of view…. 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?

Sweet’s study of medieval medicine, its concepts expressed in Latin and Greek terms, informs not only her unique view of clinical care, but her evolving sense of self:

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.

She also draws on her experience making a Catholic pilgrimage in southern France and Spain, offered hospitality in convents and monasteries, to illuminate a contranym:

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.

Ultimately, Sweet and her fellow physicians and nurses at Laguna Honda are buffeted by the powerful forces reconfiguring American health care in the form of efficiency experts, politicians, budget directors, and government lawyers. The culture of an institution where time is not limited cannot persist. Indeed, its space also is changed, as a new building is erected. But even as the environment changes, Sweet still experiences instructive moments, like the “return” of Meng Tam, a patient who had been designated “DNR,” for “do not resuscitate.” Tam’s heart was diseased and entered into ventricular fibrillation, a lethal arrhythmia in which blood cannot be effectively pumped to the tissues:

We looked at each other, and Hildegard’s lines about dying came into my mind: “It is as if the soul, the anima, stands with one foot in this world and one in the next, uncertain whether to stay or go.” That was just it. Meng Tam was undecided. He was halfway between life and death. And as I looked into his eyes, which were soft, shining, almost a greenish color, I saw them become clear and still, like a shallow mountain pool after a rain, and I knew that he had decided to stay. I can’t tell you that I nodded, but I knew, and Meng Tam knew that I knew, that he was coming back.

But the DNR order does not allow Tam to be electro shocked into a normal cardiac rhythm, or intubated. Sweet and her colleague Dr. Mark revert to ancient measures:

I called Meng Tam’s name, and I shook him, and Dr. Mack started to move his legs. I even slapped his face a few times. And sure enough, Meng Tam’s pulse returned; it became quite steady; and then his eyes opened and stayed open, staring at me….
In my first autopsy I’d been surprised by the difference between the dead body and the live Mr. Baker I’d known. There was something missing—that I missed, and that I’d missed. And now with Mr. Tam I’d caught it; seen it go toward death, stop, change its mind, and come back. I’d seen the anima—that which animates the body and the mind.

A reader, medical professional or not, may not embrace all of Sweet’s visions, expressed in the metaphors of Hildegard. Nor must one have a religious sensibility, specifically a Catholic one, to appreciate her insights. For both agnostic and believer, Sweet pinpoints the element of medicine that makes it a calling rather than a job: the unique and sustaining love that is sparked between doctor and patient or nurse and patient. This love opens up an avenue for understanding the patient as a person rather than as a body with disease. Love does not occur with every person you care for, nor is it felt at every moment for those who are special to you. But it may be felt acutely at those moments of mystery, at birth and at death, and during a patient’s struggle to find meaning in her condition. Indeed, it is the ultimate antidote to suffering, given without prescription. And as with all forms of love, it enriches the life of not only the recipient but the giver.

  1. 2

    Jerome Groopman, The Anatomy of Hope (Random House, 2004), p. 135. 

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