In the Country of Illness: Comfort and Advice for the Journey

From the New York Times

A Traveler in a Land Called Malady
Writes a Guide
By SHERWIN B. NULAND


Robert Lipsyte has several times traveled to a land that visitors enter only reluctantly. It is a place where people are detained against their will and from which some do not return. No one leaves it without being changed, nor is it possible ever after to be free of the apprehension that there may one day come a summons for yet another tour.

Mr. Lipsyte, a columnist for The New York Times, is hardly original in drawing an analogy between major sickness and a voyage to a dangerous place. Moreover, in using his experience to produce a guidebook for others, he is standing on ground already well trod by previous writers. But his book is distinguished from the vast majority of its predecessors by qualities well beyond merely his intent and the title he has chosen: its pages speak about the forbidding territories of illness with a voice more perceptive and practical -- and yet remarkably affecting -- than we have been accustomed to hearing.

Take, for example, the separate roles he plays in what are essentially two different, albeit interwoven, travel stories, his own with testicular malignancy and his former wife's with widespread breast cancer. In the first, he is Odysseus; this is the tale of his fearsome combat with the disease itself, the enraging complexities of the medical-industrial establishment, the slings and arrows (almost literally sometimes, in the form of blood-drawing needles) suffered at the hands of its most uncaring personnel, and his encounters with the various levels of professional staff who are the dominion's major and minor nobility.

In the second tale, he is Virgil. Doing his best to be friend, guide and source of spiritual support, he accompanies Margie, the still-beloved woman with whom he has shared so much of his life, on the tortuous and tortured journey through the thickets of the land he calls Malady. But unlike the classical poet's literary companion, Margie will die.

Though any narrative of illness must by its very nature be impressionistic, what we are given here are observations so acute and discerning that the truth of their details will be recognized not only by other visitors but also by every reader whose official domain lies within Malady's borders, such as doctors and nurses. Few aspects of one of our renowned hospitals escape the scrutiny of Mr. Lipsyte's keen eye, nor is sickness itself permitted to make any of its marauding inroads on patient or family without his trenchant commentary.

Readers familiar with the literary genre of disease-memoir know that the mix of motivations stimulating its authorship is almost invariably weighted heavily with the need to be relieved of one or another burden, be it anger, guilt, vengefulness or simply the frustration brought on by the combination of ill health and the perceived inadequacies of the medical system. Mr. Lipsyte has managed to keep his book remarkably free of these distorting factors, although there is plenty of reason to suppose that any or all of them are close to the forefront of his mind. But his editorial approach is one of measured commentary, and his counsel a commitment to the possible.

Doctors are forever being enjoined to see themselves through the eyes of their patients. It is unusual to hear a medical school commencement speaker who does not in one or another form present that message, because it is so basic to good care. And yet such advice is without one potential source of ammunition, since most people who might help us physicians by commenting on our performance are either upset with us or so awed by our wondrous stature that their words do nothing but force-feed our arrogance.

Somehow, we have not awed, angered or cowed Mr. Lipsyte. He sees through the surgeon's encouraging pat or pinch when it is really only a "signal of patronizing affection"; he is aware of the "tendency for young doctors to think out loud, to dump out memorized blocks of medical-school text along with their anxieties"; he has cottoned to the "fact of life that doctors speak differently to people they consider on their socioeconomic and educational level"; it has not escaped him that too many of us "who originally signed on to save people, are caught between doing good and doing well," and when he points out that uncomfortable truth he does so not in self-righteous indignation but with full understanding of the factors that have given rise to a situation of such immense dissatisfaction that it is decried not only by patients but by the vast majority of our profession as well.

Finally, it is important to point out that this book is not a narrative of astute observations alone, nor does it consist only of the compiled experiences of a man who has endured the anguish that sickness and the search for cure inflict on people. There is much in it that touches the deepest sensibilities of love, loss and even transcendence. Its final 60 pages are in essence a tribute to the courageous struggle of Margie Lipsyte and the devotion most particularly of her children but also of friends and the other members of her family, not excluding the author himself.

Most memorable to readers, it seems to me, will be the description of the vigil of those very last days when, in the words of Margie's son Sam, "There was a great energy and love in that room, and it was emanating from her, and flowing through us, and gave us the strength to overcome our own fears, our own weaknesses, and stay, and be with her." Sam's father had by then learned what can be shared during such final days, provided that the battle is acknowledged to be over and strivings have been reconciled with reality: "It was the richest of times," Mr. Lipsyte writes. In that brief sentence, he reveals the most important goal to be sought at the end of the eventual last journey through the land of Malady, and bestows on us his wisest comfort and advice.

Sherwin B. Nuland is Clinical Professor of Surgery at Yale University. He is the author of "How We Die" and "The Wisdom of the Body."

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