A History of the Present Illness

TO MY PATIENTS
FOR JANE

If you don't care for obscenity,
you don't care for the truth.

—TIM O'BRIEN,
HOW TO TELL A TRUE WAR STORY

Snapshots from an Institution

An American Problem

Giving Good Death

Heart Failure

Becoming a Doctor

After

Twenty-five Things I Know About My Husband's Mother

Soup or Sex?

Fires and Flat Lines

The Psychiatrist's Wife

Blurred Boundary Disorder

Vital Signs Stable

Days of Awe

Lucky You

The Promise

A Medical Story

Acknowledgments

Footnotes

A Note on the Author

She lies in bed the way a letter lies in its envelope. Her eyes are blank and her mouth is open. The image appears to be black and white.

He waits in an armchair by the main entrance dressed in a thick brown suit, a blue plaid cap in his left hand and a battered silver-tipped cane between his legs. The chair—beige vinyl, a two-inch slash in the upper-left corner—is meant to frame him, but he's too tall, too robust; his shoulders exceed the backrest; his legs stretch out on the mosaic floor across an ocher diamond and well into the adjacent roseate square. Each time the scarred double doors of the main entrance open, he smiles. He's waited one hour and forty-five minutes so far. He's missed
lunch. His thighs tingle and his stomach growls, but there's no sign of his son.

It's a collection of sandstone buildings in California Mission style, with red-tiled roofs and a hilltop location coveted with equal fervor by real estate developers and urban preservationists. If you bisected the city of San Francisco on both horizontal and vertical axes and went to that location, you would find yourself gazing at the view shown by this wide-angle shot: greenery stretches top to bottom on the left, and a parking lot for two hundred cars does the same on the right. In life, as in this photograph, a vast and gently sloped front lawn popular with local dog walkers fills much of the foreground. Behind the lawn is a traffic circle and behind that a wide staircase and a wheelchair ramp that bring visitors to a terrace where giant pots of native plants surround the main entrance. A newly paved drive lined by twin rows of sentinel palms connects the eleven buildings above with the security gate and busy street below. But the eco-friendly landscaping and handsome square bell tower notwithstanding, only the most inattentive passerby would mistake this place for a college campus or corporate headquarters. The walls and windows are streaked with grime, and too many of the people, coming and going, wear uniforms.

This photo was taken a few hours ago, though it might just as easily have been taken yesterday or last week or last month
or last year. In it, Jiao and Quingshan sit in the fenced garden adjacent to Building 7. Although it's a warm, sunny morning, Quingshan is perched at the far end of a black metal bench wearing his suit coat and cap and Jiao is beside him in her wheelchair, bundled in blankets and scarves. He visits her seven days a week and stays six hours each day, taking three buses from, and then back to, his studio apartment downtown. Every other Sunday, when his daughter calls by long-distance telephone from her home in another state, he tells her it's no problem.
What else would I do
, he asks, a question for which his daughter has no satisfying answer. And so, each morning at more or less ten o'clock, he arrives, rolls his wife outside, wipes her drool, makes sure she's warm, then watches the bees on the bougainvillea or the liquid food dropping through plastic tubing into a body he once lay awake admiring, timing himself to see how long he could hold back before reaching out with a foot, a fingertip, his tongue. It's much like caring for a baby, he explains to his daughter, except without the sweet smells, without the hope.

In the late nineteenth century, when the institution opened, its residents were called inmates. The able-bodied majority worked in the kitchens and laundry (women) or—as shown in this recently colorized archival photograph—on maintenance and road-repair crews (men). They also operated a large working farm and provided mending and tailoring services to other inmates, to the paid staff, and, for a small fee, to people in the surrounding neighborhoods of St. Francis
Wood, Twin Peaks, and the Inner Sunset. Now there are no able-bodied residents. These days, the average age is seventy-six, and even the crazies don't want to live here. Even the homeless, though they do live here, unofficially and undeniably, inside and out. Look back at snapshot 3. Use a magnifying glass. See the colorful mounds beneath the drooping fronds of the sentinel palms and on the margins of the litter-strewn lawn? If this were videography, you'd notice that the mounds move from time to time—a bottle raised to eager lips, an ill-defined shape morphing into something vertical and recognizable, standing and stretching before ambling off. But even with a still image you can appreciate how very many mounds there are, curled under bushes and burrowed in heaps of trash on the extensive grounds the city doesn't have money to maintain.

Quingshan and Jiao's oldest son arrives two hours late and doesn't apologize. The camera captures the exact moment when his left hand, with its manicured fingernails and thick gold wedding band, touches down on the sleeve of his father's coat. The only moment it touches down.

He's the piece that doesn't belong, standing in the institution's ancient foyer in his silk suit with his sixty-dollar haircut and limited-edition platinum watch.
Sesame Street!
his made-in-America daughter would shout, delighted, but he doesn't bring her here.

From the street outside, there's a loud pop. The telephoto lens zooms in on a boy facedown on the sidewalk. This image actually is black and white: white cement, black boy.

A group of professionals, all women, three brown and two white, gather in Jiao's room. Quingshan stands by the door, his head pressed against the sun-warmed wall, his discount-store loafers firmly planted on the speckled linoleum. From beneath half-lowered lids, he watches Charles with the doctor and nurses and social worker, watches as his son charms and instructs them. He himself does not speak. There's so much he might say in his language or under different circumstances, but nothing that can be said here.

She steals a glance at her watch while explaining to Charles how sometimes families choose to forgo treatments such as resuscitation and hospitalization, and sometimes even X-rays and blood draws and antibiotics, everything but that which increases the patient's comfort. And then, fingering the name badge that hangs from her neck like a long, gaudy necklace, a faded photograph on the flip side of the plastic sleeve, she explains how such decisions are not only perfectly legal but ethical and moral as well, based as they are on respect and compassion for the afflicted loved one. The doctor's slim, stylish
watch is secured with a tiny piece of duct tape and her shoes need reheeling, but if she saw this photograph, she wouldn't focus the way most women her age would on the physical indignities of her middle decades: the lips in need of lipstick, the crimped skin forming vertical lines between her brows and furrows around her lips, a body now more attractive clothed than naked. No. This doctor would see only the photograph within the photograph, the years-ago Hawaiian holiday shot of her children from the days when there were three of them, not only her now-teenage baby girl and collegiate boy, but also an oldest child, her firstborn, the lost child who taught her everything she knows about respect and compassion.

All eyes turn toward Quingshan as the social worker in her smartly tapered skirt, faux-cashmere sweater, and three-inch heels asks in his language—which is also her language, or at any rate, the language of her childhood—
Did you ever talk to your wife about what she would and would not want as she got older?
But before Quingshan can answer, Charles steps into the center of the room and poses his own questions, first in English, then in that other language, flipping easily back and forth and smiling at the staff while keeping his eyes on the older, more foreign version of himself. He asks his father whether he still loves his mother, and whether Quingshan still enjoys spending time with Jiao and wants to do everything possible to help her and keep her alive, or whether he agrees with the staff that his wife would be better off dead. Immediately and simultaneously, the social worker and doctor protest, but the son silences them without even a glance, his
hands raised like international stop signs as he completes the translation into his father's language.

Quingshan coughs and smiles at the floor. From beyond the open door comes the click-hum of an electric wheelchair in the hallway. Then Quingshan answers
Yes
,
Yes
,
Yes
, and
No
. What else can he say? He doesn't know what Jiao would tell him if she could speak. He imagines, but he does not know.

With her healthy young son beside her, Jiao looks as if she's already dead. In the distant, impoverished province they come from, she would be. So would Quingshan. Their children might even be dead, at least some of them. But this is America, and in America any person, rich or poor, can be kept alive even when they can't walk or talk, eat or think, even when they can't say,
No
,
Please
,
Stop
, and especially when the doctor is told
Do everything
by a man with a good job, good English, and real leather shoes.

On his way out the door, Charles nearly trips over a young man in a wheelchair rolling down the corridor in a hospital gown and backwards baseball cap. White cords dangle from the young man's ears, and a McDonald's milk shake rests in his wheelchair cup holder. It's hard to tell from this one shot—and Charles doesn't notice—but this young man is working, and though the work he's doing is very different from the work of his nineteenth-century predecessors, it's the sort of work he's
done since he arrived in America at age eleven, a kind of work that on this particular day looks like this: a kid from outside hoping to make good with the crew slipped him a knife in a thirty-two-ounce milk shake cup, and while the Building 7 social worker was at the Jiao Liang family meeting, the young man, quadriplegic from a gunshot wound, used the knife and his more functional hand to break into her office and steal her laptop computer, an act he considers totally legitimate, since, as he told the kid,
that bitch don't do jack for me, dawg
. Next, with the tidy chrome machine hidden beneath his lap blanket, he wheeled himself down to the Total Care Unit kitchen, where he sold it at one third its retail value to a woman who smelled of garlic and dirty dishwater and barely spoke English but knew her kids needed computers if they were going to avoid ending up like the young man from whom she bought the computer. Now, unaware that he's being photographed, the young man pushes past Charles and heads to the Ambulatory Dementia Unit, where he scores an A-bomb and some baby T off one of the aides. Then he follows the painted green line along the cement walls of the underground tunnel system to the main building, takes the service elevator up to the lobby, and, just beyond a tan vinyl chair with a rip in the upper-left corner, enters a handicapped restroom with a functioning door lock and enough floor space for him to do a back-to-back and have a happy nod undisturbed by staff or security.

At the nurses' station on the Total Care Unit in Building 7, the doctor's left hand rests on a thick binder bearing the name Jiao Liang, and her right hand reaches out toward a dispenser of
round red stickers. An assortment of stickers in other colors already decorates the chart's spine: blue (incommunicado), purple (skin breakdown), and yellow (nothing by mouth), the latter two not quite obscuring the stickers they replaced eighteen months earlier: green (fall risk) and orange (danger to staff).