A History of Present Illness
by anna deforest
little, brown and company, 176 pages, $25
Martin Luther had a sort of terror (anfechtung) engendered by the perfect holiness of a God who would not suffer sin. Acutely aware of his own failings, Luther tried every curative on offer: He joined the Augustinian order, practiced rigorous self-denial, sought comfort in the sacraments. He even made pilgrimage to Rome to pray away the sickness unto death before relics and icons. But the holy city was gangrenous and reeked of sin. When at last the young Luther’s spiritual mentor, Johann von Staupitz, prescribed a doctor’s degree en route to a teaching post at Wittenberg, Luther was shocked. “Staupitz was,” in Roland Bainton’s telling, “practically saying, ‘Physician, cure thyself by curing others.’”
The language may strike us as odd, but Luther was a medieval. Doctors were originally teachers. Those who dealt with blood were called, somewhat less nobly, “leeches.” To be a doctor was to have a licentia docendi, a license to teach from a university. Education was more than learning sums or memorizing the names of things: It was a remedy for the effects of sin. Hugh of St. Victor makes this explicit in his Didascalicon, noting that despite Adam’s curse, “we are restored through instruction.” The liberal arts enable you to inhabit your humanity, effecting “the restoration of our nature and the removal of our deficiency.” Luther was to become a physician of souls.
Today, medicine denies both the proper end of education and the existence of the soul it shapes. A History of Present Illness is the debut novel of Anna DeForest, a neurologist who works in palliative care at Memorial Sloan Kettering in New York City. The book offers an etiology of the malady afflicting modern medicine.
In eighteen lyrical chapters, her unnamed narrator recounts stories from medical school interwoven with memories from childhood and poignant vignettes about patients. Though her rotations move her throughout the hospital, she often returns to two patients: Ada, who deteriorates throughout the novel due to slow encephalitis, and a beautiful young girl on suicide watch. The novel is unified, then, by the narrator’s attempt to come to terms with her own suffering, which is clarified by carefully observing and participating in the suffering of others.
It is in the hospital, the St. Peter’s of her day, that she finds corruption. The physicians who fill it may be worse off than the patients. Like Luther, she is disillusioned. As she lifts the veil, she beholds the worst sins of modern society. They are, of course, au courant: entitled and wealthy students from elite private schools, chauvinistic surgeons, doctors that deride students and patients, incurable racists who joke about the pregnant “poor and Black and brown” girls who ought to have been “sterilized by age 13.”
These revelations titillated the reviewer at the New York Times, who “wished [DeForest] had written something as straight and clear as an indictment.” But the Times misses the point. DeForest is up to something far more substantial than writing a whistle-blowing op-ed. She is an artist at work, and her eschewal of preachment enhances the novel’s aesthetic merit.
DeForest follows Flannery O’Connor’s method of depicting large and startling figures to shock the reader. Ultimately, it is the illness that permeates contemporary medicine that shocks. The pathological behavior of the physicians is merely one part of this. The novel also reveals the brutal and visceral reality of suffering, the cruel way in which the body betrays itself in a world seemingly bereft of grace.
So too DeForest presents the stark reality of medical procedures, whether a clinical description of a horrific autopsy of a fetus with Zika or a coolly indifferent account of abortion:
I held the woman’s hand while she screamed and screamed. Here is what I didn’t know: We count the pieces after. A bin off the machine holds all the fetal tissue—we say products of conception for a neutral moral tone. And we take the bin into a back room and empty it into a square glass casserole dish over a lighted panel and use streams of saline and tweezers to pull the clumps apart until the pieces are recognizable as hips and legs and arms.
Far from being gratuitous, moments like these reveal that medicine is so awash with death it has become anesthetized to suffering. A History of Present Illness shocks, but it attends to the physical to probe the metaphysical, where the true sickness lies. Observed closely enough, medicine raises theological questions.
DeForest advertises herself as agnostic, a “recovered fundamentalist,” and her narrator rejects Christianity, in large part due to the sexual abuse and rejection of science rampant in the Southern fundamentalism she was raised in. And yet she is haunted by God’s absence. She thinks through theodicies while wandering the hospital, and though she does not quite have a Staupitz, she does have a seminarian. She calls him “Esteban” (the Spanish equivalent of “Stephen”), a reference to a short story by Gabriel García Márquez. Like Stephen the first martyr, Esteban attempts to make sense of life and death and suffering alongside the narrator. Drawn to him and his God, she spends the summer sleeping next to but not with him, and when he invites her to church, she goes and sits in the back.
She finds it easier to consummate her relationship with poetry than with faith, or perhaps she just has faith in poetry. The text is full of echoes of the modernists who maintained tenuous relationships with faith themselves. The certainty of Eliot’s “all shall be well” is ironically tempered into “All manner of things, I thought, can be well” as she watches Ada’s husband slowly lose his beloved. And Elizabeth Bishop’s “One Art” animates the narrator’s claim that “I love a lot of things I have lost. It barely bothers me now.” The literary and philosophical references are manifold, but the novel does more than just catalogue the narrator’s—and DeForest’s—reading.
The many allusions are not mere flourishes but the means by which she searches for meaning. Her reading is part of her search for God, and poetry becomes her prayer. The narrator, who like Hemingway’s Jake Barnes desperately wants to pray but cannot, utters the poetry of Anna Kamienska instead: “There is one prayer I know will be answered: Lord, let me suffer a lot and then let me die.” Like Barnes, she also prefers empty churches. While the novel begins in the cadaver lab, it ends in “the little church that is hidden in the hospital, where the services are rare enough to easily avoid.”
A mournful timbre permeates the prose, but it is not a heavy or weary sadness for something that has been lost so much as the pained song that might arise in the search for grace. The lament is interspersed with moments of sudden and unexpected humor—“I still have saved no lives myself, though I did check the pulse once of a woman who fainted on the subway. Let go of me is what she said.”
The narrator’s confession brings us into contact with the braindead and the dying, the pitiable and the pathetic, the histories of present illness of patients and modern medicine. The figures are startling and heartrending, but they also reveal something of the metaphysical angst at the heart of medicine. More importantly, they reveal a violent grace: Surgery wounds in order to heal, and poetry sears our suffering. Esteban helps the narrator navigate despair as she embodies what Eliot called “the sharp compassion of the healer’s art.” She offers something of Christ’s grace, the grace she’s not even sure exists, to those who need it most. DeForest’s novel is an aesthetic achievement, and it suggests how medicine might be humanized or “restored through instruction” once more.
Nathan M. Antiel is an editor, author, and classical educator based in Raleigh, North Carolina.
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Image by Nenad Stojkovic licensed via Creative Commons. Image cropped.
