And the prisoner released from the cave, will he not fancy that the shadows which
he formerly saw are truer than the objects which are now shown to him?
—Plato, The Republic (4th century B.C.)
The black-and-white image on the little TV screen was at first formless and incomprehensible, but, explained by the ultrasound technician, it resolved itself—with some imagination on my part—into a stylized heart. First a spasm in the top third of the screen, a blossom of light spreading and dissipating, then a spasm at the bottom, larger, stronger. I saw it as an abstract pattern and then suddenly I saw it as a heart. And then, as suddenly, I saw it as my heart, at the same moment I felt the tiny thump in my chest seem to grow louder and more palpable; I could feel and see my heart beat. My heart. It beat slowly, suppressed by the digitalis my doctor had prescribed after my episode of dizziness, an effect of disturbance in my heart’s rhythm. Now the rhythm was very regular, though as if in slow motion: lub, DUB . . . lub, DUB. This “lub, DUB” is the conventional transcription of the heart’s sound heard through a stethoscope. To me, the sound was more personal: “heart BEAT . . . heart BEAT” or “my HEART . . . my HEART.” I was hypnotized, unable to look away. This trance did not seem to surprise the technician, who had probably seen it before.
The inside of the body is another country. Invaded by major surgery or injury and forced to show its secret organs, the body’s interior shocks us and makes us wince. We don’t ignore the fact we have bodies or think of ourselves as wholly mind; rather, we think of our bodies as those parts we can keep an eye on—the exterior. The outer body is easier to take: we worry about its bulges, sags and wrinkles, but at least we can keep an eye on them, and we have the illusion of controlling the body’s appearance through exercise, diet, shaving or refraining from it, hair dyes and -dos, makeup, jewelry stuck in the skin or tattoos inked into it. We avoid the knowledge that we might be those slippery, bright, impolitely-colored, soft and moving shapes, those stark white bones.
The ultrasound machine shows the inside of the body without invading it with flak or scalpel. The machine shows a black-and-white picture on a TV monitor, a picture formed something like a radar image, by reflected radiation just beyond the frequency of waves we can hear as sound. The blood-red field of the operating theater or the trauma room is absent in ultrasound. Its stylized and abstract image speaks to the observer, saying “I am my organs,” but saying it in the metallic accents of a machine. Ultrasound images can be cause for joy and wonder when the device helps expectant parents view their unborn, growing children. Much used in obstetrics, ultrasound is the safest way to get a good look at what’s going on inside the body. Heart specialists like ultrasound also. With it they can watch the heart at work.
I watched my own at work for perhaps twenty or thirty beats, thinking about this amazing little pump that had always worked so regularly, so constantly and unfailingly without my thinking about it—a little pump upon which the whole of my consciousness and my life depended. Then the conviction began to grow in me that this constancy and this perseverance was more than amazing; it was magic. And I don’t believe in magic. I saw the little pump as just another piece of connective tissue, like the ones that had been failing me over the last year. “It cannot continue to do that,” I thought, “minute after minute, hour after hour, a hundred thousand times a day. It will stop. Maybe in five more beats.” I watched and counted five more beats. It didn’t stop. “Maybe in a thousand, but it will stop. And when it stops I will die.” The fear in this thought was so palpable I expected it to be somehow visible in the image on the screen: the beating would suddenly speed up or pause. But its chemically-slowed regularity persisted. lub . . . DUB, lub . . . DUB. “Not while they’re watching,” it seemed to say. “Tonight, in your bed. On the road in the country. Somewhere far from help.”
The melodrama of these thoughts galled me, chagrined me, but knowing the thoughts were overdramatic did not stop them. I had always been either offhand at the prospect of death or unconscious of it. I knew I would die someday, of course. I had come close to death a few times in cars and once or twice in planes, close enough to be aware that my surviving in those instances was a chance that could easily have gone the other way. I knew intellectually that I would not live forever and that I could die at any moment. But the thought was not often present, and when it was it did not oppress me or obsess me.
Staring at the monitor now, though, watching my beating heart, I found the thought of my imminent death both oppressive and obsessive. It was also unwarranted. My heartbeat was now normal after an episode of atrial fibrillation caused by exertion and overindulgence in alcohol on a hot day, dehydration, and a consequent imbalance in electrolytic fluids—solutions of sodium and potassium in the blood that facilitate the electric impulses of nerves to heart muscles. This imbalance, once corrected, was not likely to return. After a week or so of precautionary medication, the doctor would take me off the digitalis. “You’re fine,” he would say, “and your heart is sound.” But, starting on that day in the ultrasound room and for two years afterward I was convinced, if my heart fluttered or I had a momentary chest pain, that I was going to die.
What was even worse, I began to extend this fear beyond worries about my heart. If I wheezed a little, I was sure that a lung had collapsed or I had lung cancer. If my urine came slowly I knew it was prostate cancer. None of my organs was safe. I had become a hypochondriac. Whenever I felt a twinge, a momentary shortness of breath, or an accelerated heartbeat, I was convinced it was the onset, not just of sickness, but of mortal disease.
The modern definition of hypochondria is an abnormal anxiety about health: the sufferers fear or actually believe that they have a life-threatening disease: a cough means lung cancer, a stitch in the side means a heart attack, a headache means a brain tumor. The doctor’s reassurances to the contrary are either not believed or else are effective only until the next ache, pain, or minor symptom convinces the sufferers anew of the onset of the mortal threat they fear. The word hypochondria has not always been so specific in its denotation; at the time Shakespeare was writing, the word was another name for what the English variously called the spleen or melancholy. This was a much more general ailment, corresponding to a series of neurotic disorders we would now call by the blanket term depression.
In 1621 Robert Burton wrote a long treatise, The Anatomy of Melancholy, about this general malady. In Burton’s scheme, hypochondria is merely one of the three bodily areas of origin for melancholy, which he says can originate in the mind, in the body as a whole, or just in the organs of the abdomen—the hypochondries, which literally means below the cartilage of the ribs. For Burton, melancholy is a disease, and he gives us the theory of disease most popular during his time, which said that it results from a lack of balance among the body’s constituent fluids or humours: blood, phlegm, yellow bile or choler, and black bile or melancholy.
Burton describes the symptoms in great detail, and I was not far into his description before I began to recognize the very complaints my friends and my family members had told me about when their doctors had diagnosed them with “clinical depression.” Burton’s melancholics are sleepless, anxious—sometimes with rapidly pounding hearts and hot or cold sweats. Their main symptoms are fear and sorrow. The fear is without cause, and may be a conviction that something disastrous is about to happen or that they will suddenly die or will suffer some disease or injury. Their fear may be only of disgrace or embarrassment, but in any case it is a disabling fear, paralyzing. Sorrow or sadness is also a constant symptom. Also without cause, it makes the sufferers restless and guilty and troubled, irresolute, indecisive, and robbed of the will to act. Suspicion, the readiness to take offense and to misconstrue what others say or do, is also a symptom, as is what Burton calls humorousness; we would call it quick mood changes. Burton’s vocabulary does not include phrases like mood swings or terms such as paranoia, but he effectively anatomizes the whole spectrum of ills we call depression, anxiety disorders including hypochondria, and panic attacks.
The causes of melancholy, both supernatural and natural, get a lot of space in Burton’s Anatomy. Supernatural causes include not only evil spirits, but God himself, imposing the disease for his own inscrutable reasons. As cures, Burton recommends prayer, the care of an honest physician, moderation in diet, good air, exercise, “mirth and merry company.” His concluding advice is “Be not solitary, be not idle.”
The identification of hypochondria with depression continued into the eighteenth century. James Boswell, the biographer of Dr. Samuel Johnson, wrote about his own low moods and periods of helpless inactivity—in other words his depression—in a series of columns for the London Magazine where he signed himself as The Hypochondriack. Boswell wrote one of these essays every month for almost six years, from November 1777 to August 1783. He thought of the writing as therapy, combining the discipline of the deadline with the knowledge that self-examination might bring.
Boswell understands the sufferers’ belief that they are very ill as only one of many manifestations of the complaint called hypochondria, which he equates with melancholy, “the spleen, or vapours.” For Boswell, the main quality of hypochondria is irresolution, sometimes extreme languor, together with agitation about what one should be accomplishing while idle.
Before the eighteenth century was over, doctors had begun to separate from general “melancholy” those neurotic symptoms that relate to the sufferers’ beliefs about their health, and a new name for the complaint, hypochondriasis, began to be used among some physicians. This term did not replace the words hypochondria and hypochondriac among lay persons, but all these words came to denote the condition and the person who suffers from ungrounded fears about health, rather than the whole complex of symptoms described by Burton and Boswell as part of the melancholic’s complaint.
Of course, even before he was called by that name, the hypochondriac was among us. Jane Austen depicted such a character in Mr. Woodhouse, the title character’s father in Emma (1815). Mr. Woodhouse worries and guards not only his own health, but is solicitous about that of everyone about him. He warns the neighborhood children, in vain, not to eat the cake at a wedding celebration, and, even when he is host of an entertainment, would much prefer that his guests eat a bowl of warm gruel rather than the more enticing foods he and his daughter have laid out for them. Mr. Woodhouse has a mild form of hypochondria, redeemed from the neurotic extreme by his optimism: he knows that danger and disease lurk everywhere, but he believes that they can be defeated by constant vigilance. Austen did not call Mr. Woodhouse a hypochondriac; the term she used was valetudinarian—one concerned for his health. But the latter word could be confusing, since it was sometimes used of a person whose concern was real rather than imaginary—one in weak health. In any case, hypochondriac has superseded valetudinarian, a word hardly ever seen these days.
Hypochondria has recently begun to be treated as a variety of depression, with some of the same tools used for the more general illness. According to Dr. Ingvald Wilhelmsen, a Norwegian physician and psychiatrist who specializes in hypochondria (“Norwegians are melancholy,” he says, “it’s very dark here most of the year”), it is “excessive health anxiety,” as common in men as in women, and found in people of all ages. Dr. Wilhelmsen recommends a talking cure, with behavioral modification and building up of the patients’ awareness of their tendency to move from a minor symptom to suspecting the worst possibility for its origin. He has also tried his patients on a drug, one of the classes of medications known as selective serotonin reuptake inhibitors that are marketed in this country under such names as Paxil and Lexapro. Wilhelmsen was featured in a Wall Street Journal article in 1996. The article’s fairly jocular tone probably reflects a general attitude among the public about hypochondria. It’s a difficult malady to take seriously, unless of course one has it.
The good news, had I consulted Dr. Wilhelmsen when I had my problem, would have been this: the easiest case of hypochondria to treat is one that comes on later in life rather than being a part of one’s psyche from childhood. These later onset cases often result from major life changes or critical events; the death of a close friend is one triggering factor. Wilhelmsen’s characterization, which I read some years after the events I am describing, seemed to fit my experience.
As I turned forty-four, my back began to give me trouble. At first it was a pain in my left hip, then pain down the back of my leg and numbness in my foot, then spasms in the muscles of my lower back. What had been annoying became incapacitating. I could get relief in the beginning by walking or by lying down; only sitting or standing still were painful. Then the pain would only relent when I was flat on my back. Finally it was constant.
I had the ruptured disk in my spine repaired later that year in an operation called a laminectomy. The surgeon cleaned up the disk and enlarged the hole in the backbone segment through which the sciatic nerve exits; the ruptured disk’s pressure on the nerve at this point had caused the pain. The procedure sounds simple, but since it involves the spinal column and therefore all the nerves that serve the lower part of the body, it has risks. Late in the evening before my surgery, my back surgeon showed up in my room flanked by two nurses, to explain the risks and get my signature on a release form. The nurses were there as witnesses. My doctor, a small neat man (“Do you have back trouble?” I had asked him. “Oh no,” he said, “I’m a little guy”) went through the list of possible bad outcomes, a litany that included loss of feeling in one or both feet or legs, paralysis, loss of control of bladder or bowels, and loss of erectile function. The litany ended not, as might have been appropriate, with ora pro nobis, but with death. I signed the form, they instructed me to “get a good night’s sleep,” and they turned out the light as they left. To my surprise, I did sleep. The surgery went well and my recovery proceeded without any setbacks. At the end of the year I was playing golf with no thought about the pain of a few months before.
Then in the spring of the next year I woke up wheezing one morning. A little walk winded me, so I went to my doctor. He was about to send me home with some asthma medicine when I mentioned that my chest also hurt a little. He listened again with his stethoscope before sending me for a chest x-ray that revealed my right lung had collapsed.
If air gets into the chest cavity outside the lung, either through a wound or, as in this case, through a small hole in the lung itself, the air pressure outside the lung prevents it from inflating. No disease or injury had happened to make my lung deflate; my doctor called it a “spontaneous” collapse, a word that evoked for me all the wrong associations of Whitman’s “spontaneous me”: insouciance and unrehearsed charm. Charming it wasn’t. A collapsed lung is treated by first cutting a hole in the side of the chest between two ribs. Through this hole the surgeon pushes a tube, which is then hooked to a suction pump. The pump evacuates the air inside the chest cavity around the lung, allowing the lung to inflate. The tube remains connected to the pump until the hole in the lung seals itself; in my case this took three days. Then the surgeon pulls out the tube, puts a purse-string suture around the wound, tightens it up, and covers the whole thing with a dressing, all the while trying to keep more air from leaking back through the wound into the space around the lung.
I recovered quickly from the collapse and the repair (the chest-tube procedure leaves a scar like a stab wound—is in fact a stab wound), immediately resuming my usual activities with no ill effects and no further lung problems. To this day no one knows why my lung collapsed.
In the fall of that year my oldest friend called to say he had colon cancer that had spread to his liver. He talked lightly about an experimental drug program he was entering, but he had no illusions—and would not suffer his friends to entertain any—about the fact that he was going to die. And until his death a year later he maintained an attitude that, while not always cheerful, was curious, open, and calmly accepting of the stages of his disease and his death. “Get a colonoscopy,” he said, and I did, but the clean bill of health the doctor gave me was not a surprise to me; at that time I did not have the hypochondriac’s conviction that the news would always be bad. The onset of my hypochondria came suddenly with my heart problem the summer following my back operation.
June that year was even hotter than usual, and I liked to have a cold beer or two—occasionally three—as I played golf. One day I felt particularly exhausted after a round, and I lay down to take a rest. My heart started to flutter. It felt as if it were trying to get out of my chest. For seconds at a time it beat very fast, and I grew dizzy. No pain accompanied the fluttering and the dizziness, but these symptoms were alarming enough for me to call my doctor, who said, “go to the emergency room.” There the attending doctor told me I had atrial fibrillation, a misfiring of the electrical impulse that begins the heartbeat in the atria, the two chambers at the top of the heart. In fibrillation the heartbeat begins but is never completed, so little or no blood is pumped. The faulty heartbeat speeds up to try to compensate, and may reach 150 beats per minute, more than twice the normal rate. After a test revealed low potassium levels in my blood, the doctor ordered an intravenous solution to increase the potassium, which is one of the substances—sodium is another—that makes blood an electrolyte, able to transmit electric current and thus nerve impulses. I remained in the hospital overnight, hooked to a heart monitor with an alarm in case the heart rhythm worsened. During the night, as I slept, the rhythm “converted” or changed back to its normal, efficient pumping action that starts in the top of the heart and is completed by the stronger muscles of the ventricles at the bottom. The doctor let me go home the next day, but I had to return later in the week for a stress test, which is an electrocardiogram or graph of the heartbeat taken while one is exercising on a treadmill. The doctor also ordered an ultrasound test of my heart, and it was while I watched the ultrasound waves imaging my beating heart, as I have written above, that my hypochondria started.
I had gone through a year-long demonstration of what can go wrong with heart, lungs, spinal cord, and bowels. A healthy response would have been gratitude for my escape, when my friend with colon cancer was not so lucky. Instead I became fixated on the body underneath the surface. I felt I was these organs and bones. I began to study medical encyclopedias and books, which had the predictable effect of increasing my fears. Hypochondriacs seek relief through knowledge about disease, but instead of relief they find symptoms to worry about (“Is this red spot the beginning of a rash?”) or alarming facts (“Every 44 seconds, someone dies of heart disease”).
For two years I stayed tensely alert to the inevitable failing of my body. A dozen times a day I checked my breathing to see if it was shallow or wheezing; were my lungs okay? If my stomach griped I could envision the cancer growing there. Every time I went to a doctor I would be reassured for a few days or weeks; then with the next heart flutter or tiny stitch in the side the conviction would return that something was fatally wrong. And then, even more suddenly than it had come, this neurotic delusion went away.
I flew in to Salem by way of Seattle to do a lecture and workshop at Willamette University with Bill Braden’s students. Bill had liked my book on Hamlet and had invited me for the Willamette University Senior Seminars in the Humanities. Willamette is a small liberal arts college and these Senior Humanities Seminars focus on a single text. The instructors invite a scholar/teacher who has done work on the text to come for a few days to meet with the seminar, confer individually with the students on their paper topics, and give a public lecture on some topic related to the seminar.
On the last day of my stay, Braden took me to lunch just before he drove me to the airport. Midway through our sandwiches and microbrewery beer, he told me a shocking story. The year before, during a routine physical, the doctor had taken him into his office and announced that Braden had a fatal stomach cancer that would kill him within months. Braden lived with this judgment for several weeks before telling his parents, who then told him he had a congenital thickening of the stomach wall that showed up on x-rays as disease. “When the doctors realized their mistake and corrected their diagnosis,” Braden said, “they didn’t even apologize.”
My reaction to Braden’s story, a mixture of horror that it was possible, compassion for his ordeal, and effusive congratulations on his escape, was followed by more self-centered musings: “What does this mean for me?” I thought. What does the possibility of a mistake in an unanticipated sentence of death (for Braden had no hint or fear of what the doctors would tell him) mean to a hypochondriac, who is always anticipating such a sentence? My happiness for his reversal of fortune, Braden may have thought oddly overdone from an acquaintance of a few days. And the extent of my joy was hard for me to explain, even to myself.
On the way back, flying from Salem to Seattle on the first leg of my return home, I was sitting next to the window as we flew through a thunderstorm. I thought about Braden’s story. At the moment he told me that the stomach cancer diagnosis had been revealed as false, I felt in my own stomach a realization that will sound like a commonplace to anyone who has not felt depression or hypochondria: there is good as well as bad fortune. The hypochondriac thinks of contingency and chance as all going one way. One’s health can only get worse; news about it will always be bad. But Braden’s story showed that even the diagnosis one fears isn’t always right.
There was little lightning but a lot of rain, and as I stared idly out the window at the rain streaming straight back along the Plexiglas, I became aware of a flashing white light coming from below me. Apparently a powerful strobe light was mounted on the bottom of the fuselage where I could not see it, but as I pressed against the window looking down toward the source of the light, I saw below me fat raindrops hanging in space, motionless, each time the strobe flashed. I blinked and drew back from the window. Rain rushed across the outside surface, and just inches away it whipped past the window at several hundred miles per hour. I put my face to the window and looked down again. Globules of water were suspended in the gray night. Unmoving. None of the drops was a perfect sphere, and as I looked closer they seemed to quiver slightly in the image that persisted after each flash. For minutes I stared at these unnervingly arrested raindrops below my window, until the shower stopped and we began to descend into Seattle.
I continued idly staring out into the night until the flashing strobe began to light the ground rushing up at us from the obscurity below. I thought about the unnaturally still raindrops, and the strobe’s strangely revealing light. I thought back to that other strange illumination of the ultrasound, revealing my heart in hiding. These machines show us entrancing pictures, but they do not tell the truth. Rain falls; it doesn’t hang suspended in space. The heart beats, as it should, in secret. There are reasons why our skin is not transparent like some jellyfish’s. The skin is the rightful limit of our concern: we can attend to it, clean it, clear it of nits and mosquitoes, but we gain no advantage from being able to see our secret hearts. We cannot see time arrested any more than we can see the future and be certain that it holds ill fortune. I thought these thoughts and knew that, for now at least, my hypochondria was gone.