SUNY Upstate Medical University, Syracuse, New York and Tufts University School of Medicine, Boston, Massachusetts, United States
This piece originally appeared in the August, 2010 issue of Healing Muse, a publication of the Center for Bioethics & Humanities at SUNY Upstate Medical University, Syracuse, New York
Suddenly and inexplicably I discovered that I was anemic. My hemoglobin had run reliably in the 14-15 range for nearly the whole of my adult life. My hematocrit had been almost as steady, usually running between 43 and 44. Now, for the first time, both values had dipped below the norm for men. My primary care physician was mystified, and so was I. But given my age, we both knew the list of bleak possibilities.
Common sense tells us that the ultimate and universal boundary is that between the living and the dead. But the dead are silent on this issue. For all we know, there is more traffic across that border than our science or senses reveal. In contrast, the boundary between the well and the sick is a high and fortified wall. I do not have in mind those brief incursions into the territory of illness we all make now and then: the occasional broken limb, the bout of seasonal flu, or the odd run-in with a nasty bacillus. I am thinking of the border between the robustly healthy and the chronically ill. What different lands these peoples inhabit—and how alien their two cultures are to one another. These realms are as distinct as the fragrance of the rose and the scent of wormwood; they are as far from each other as the dance hall and the cancer ward.
Of course, any second-year medical student knows that the differential diagnosis of anemia is long and broad: anything from acute bleeding to a vitamin deficiency can cause it. But the elaborate list converges on two main pathways: either your body is not producing enough red blood cells or hemoglobin; or there is loss or destruction of red blood cells. The volume of the individual red cells can tell you a great deal: too large (macrocytic), and you may have a deficiency of vitamin B12; too small (microcytic), and you might have iron-deficiency anemia. When the red cell volume is normal, as in my case, the list of suspects is long and frightening, including everything from bone marrow failure to some insidious, chronic disease.
When I was 17, my father died of renal carcinoma. This was before the era of the CT scan, and his cancer was first discovered when the tumor was palpated by my uncle, a renowned surgeon in Buffalo, New York. I cannot imagine the kind of deep and deft palpation it would take literally to feel somebody’s renal tumor—the textbooks say that the examiner’s hand must be pushed firmly and deeply beneath the costal margin—but my uncle knew immediately what he had found. Surgery was quickly arranged, and the malignant growth was skillfully excised. But six months later my father was dead, the microscopic tumor remnants having metastasized to his brain. His cancer, I now recalled, had shown itself as anemia—detected as part of a routine physical examination. Most renal cancers are not thought to run in families—but I am my father’s son in so many ways, from his curly hair to his baritone voice. So I wondered if I would also share his fate.
I quickly learned that you do not need to be seriously ill in order to surmount that forbidding wall between the well and the sick. It is enough to imagine your way over. In the 16th century, a condition called “chlorosis” was recognized as an anemia often found in adolescent females and was widely considered a form of hysteria. Later, in the 18th and 19th centuries, chlorosis was attributed to a “nervous disorder” affecting the blood-forming organs. All this quack psychology eventually gave way to medical understanding. But merely having received the diagnosis of “anemia,” I soon found my mental state tugged drastically downward, along with my hemoglobin.
I began to feel a sense of estrangement from those around me—wondering at times how these frivolous people could possibly remain so happy when I was so sick! Intellectually, of course, I knew I was still in the realm of the healthy. After all, my appetite was good, I had a reasonable amount of energy, and I was in no physical pain. But something inside me had made that leap—some primitive part of my limbic brain had already crossed into the land of the sick. For over a week, my sleep was ridden with dreams of wandering through shabby neighborhoods in some strange city, its inhabitants apparently oblivious to my presence. I awakened each morning feeling slightly unreal, as if I were observing my body from somewhere above my bed.
My doctor remained calm throughout the period of my deepening dread. Quite sensibly, he told me to repeat the blood count in another couple of weeks. We held out the hope that the anomalous finding might be explained by something benign and simple, like the wisdom tooth extraction I had undergone a few weeks earlier, which had resulted in considerable oozing of blood for several days. The hypothesis was borne out by the second blood drawing: my hemoglobin and hematocrit had bounced back sharply—right into the range they had occupied for the past twenty years.
As a psychiatrist, I have seen many patients emerge from the dense fog of depression, but I had never experienced anything quite like that myself. Throughout my life, I have been blessed with a resilience and buoyancy of mood that rarely lets me dip beneath a day or two of gloomy thoughts. But this time, I felt I understood a bit of what my patients described, as they escaped the shadow-world of depression and returned to the land of the living. Almost immediately after getting the good news, I actually felt my breathing change—as if a constricting steel band around my chest had just been cut. And I felt lighter: able to float and bounce, in a kind of zany, zero-gravity moon-walk. Suddenly, the universe seemed a sunny and generous place.
Writing on the subject of gratitude in a recent piece for the Boston Globe (Nov. 23, 2009), James Carroll well expresses what I have been feeling since my seemingly miraculous “recovery”: “Gratitude … [needs] no specified object, much less a named benefactor. Gratitude extends simply to all that went before and all that sustains; [we are] grateful to parents, and all ancestors; grateful to the fragile web of nature; grateful to the very air.”
I came away from my strange border-crossing with a great gift—one that seems to have altered my entire visual processing system. Each day is magnified. Each moment is held before the lens of my gratitude, and grows in its colors, sounds, aromas, and tastes. Crossing briefly into the land of the sick has induced in me a beneficent mutation: suddenly and inexplicably, I am fully human.
RONALD PIES, MD is Professor of Psychiatry and Lecturer on Bioethics & Humanities at SUNY Upstate Medical University. He is also Clinical Professor of Psychiatry at Tufts University School of Medicine, and Editor-in-Chief Emeritus of Psychiatric Times. Dr. Pies is the author of a book of poetry (Creeping thyme, Brandylane Publishing) and Everything has two handles: the stoic’s guide to the art of living (Hamilton Books). His upcoming book, Becoming a mensch, is forthcoming from Hamilton Books.