On my reading list

I've been reading The Magic Mountain, written in 1924 by Thomas Mann. In brief, it is the story of a privileged young man who goes to a tuberculosis sanitarium to visit his stricken cousin, and ends up spending years there--finding it impossible to leave a world where illness is center stage. He shuns the banal world of family and work and instead spends his time having lofty thoughts and conversations about the meaning of .... everything. I've wanted to read it for some years, but I finally bought it after I came across the just published first volume of Susan Sontag's journals, Reborn: Journals and Notebooks, 1927-1963 issued by her son, David Rieff.

Sontag wrote about many things--essays, stories, novels, extended conversations--but so often the tie-in was the body and medicine. She wrote Regarding the Pain of Others; Illness as Metaphor; AIDS and its Metaphors; Death Kit, a Novel. Apparently she was very affected by The Magic Mountain, reading it and arranging for herself a private meeting with Thomas Mann when she was quite young. I read Illness as Metaphor and AIDS and its Metaphors during the years I was immersed in AIDS, but I'm not sure that I understood her ideas until some years later. Reading her son's memoir of his mother's last illness and death--and now reading The Magic Mountain--deepens my understanding. Or gives me more to think about, another layer. For starters, the issues I think about every day, issues dealt with in medicine--and particularly in palliative care--are nothing new. The arguments, the conundrums, the hard choices and painful decisions--all of these just come with the territory of the body.

Here, Mann has his protagonist share thoughts about the origins of disease and its inevitable association with the body:

So much for pathology, the study of disease, with an emphasis on bodily pain, which at the same time was an emphasis on the body, an emphasis on its pleasures—disease was life’s lascivious form. And for its part, what was life? Was it perhaps only an infectious disease of matter—just as the so-called spontaneous generation of matter was perhaps only an illness, a cancerous stimulation of the immaterial? … The second spontaneous generation, the birth of the organic from the inorganic, was only the sad progression of corporeality into consciousness, just as disease in an organism was the intoxicating enhancement and crude accentuation of its own corporeality. Life was only the next step along the reckless path of spirit turned disreputable, matter blushing in reflex, both sensitive and receptive to whatever had awakened it.

This is a brilliant meditation on the origin of life itself. But it also suggests that the illness dilemma derives from the problem of having physical bodies; the flaw of not being simply spirits.

Mann goes on to have his protagonist (Hans) and his cousin (Joachim) consider the costs of medicine, and the use of medical resources. Hans has taken to visiting the shut-ins at the sanitarium, those who stay closed off in their rooms at the end to die. Hans hates that death is so shrouded in this place where people go to die.

Hans Castorp made a personal inspection of the deceased. He did so in open defiance of the institutional practice of concealment; he despised the egotism of all the others, who did not want to know, hear, or see anything, and hoped to reproach them with this act. . . . . [I]n fact, there were complicated motives behind this wish. His protest against the egotism prevalent here was only one of them. Likewise playing a role was his own spiritual need to take suffering and death seriously, to pay attention to them, a need he hoped would be nourished and satisfied by his getting closer to the seriously ill and dying.

A wonderful meditation for those of us who choose to work with the dying.

Here, "the horseman" has just died after a long stay. His caregiver offers her thoughts, to which Joachim expresses the idea that resources were wasted keeping this man alive for so long.

It was a miracle, she said, that the horseman had lived to see the holiday. He had long since proved what a tough cavalier he was—it was hard to know what he had used to breathe with toward the end. True, for days he had kept himself going only with the help of massive amounts of oxygen; had used forty demijohns yesterday alone, at six francs a bottle. That must have run into some money, as the gentlemen could well imagine, especially since his wife, in whose arms he had passed away, had been left quite penniless. Joachim expressed disapproval of such expense. What was the point of these tortures, of clinging to life in such an expensive, artificial way, when the case was hopeless? One could not blame the man for blindly consuming expensive gas keeping him alive, when they had forced it on him. But those treating him ought to have acted more reasonably and have let him walk the inevitable path, for God’s sake—regardless of the question of resources, or better, with considerable regard to them.

Point for point, this is exactly what we face in the ICU. How often do we feel this way? How often do we keep such thoughts to ourselves?