by M. J. Cates
And facts, Imogen was learning, were everything to Jonas Ganz. Diagnosis was as nothing compared with facts.
One day, when Imogen asked why she had to interview the paternal aunt of a patient who had had no contact with the aunt for ten years, Ganz invited her to take a stroll with him around the cloistered courtyard. The days were getting colder, and the air had a bite to it.
“I’ve made two appointments for her to come in,” Imogen said, “and both times she has not shown up.”
“Some cases require more persistence than others—or more flexibility. You may need to see her after normal hours. From what you’ve said, you’re far from understanding what underlies your patient’s apparent break with reality.”
“Perhaps it’s just lack of insight on my part.”
Ganz smiled at her. “Doubtful. More likely it’s a shortage of information. When I was a pathologist at Indiana State, I was giving a lecture to the ward physicians and one of them asked me, ‘Dr. Ganz,’ he said, ‘you have outlined numerous possibilities and similarities and conjectures, but can you tell us where in the brain the cause of the disease is located?’ And do you know, I believe it was at that moment that I realized I no longer wanted to be a pathologist working in a laboratory, I wanted to be a psychiatrist working in a clinic. I answered him instantly, without thinking. I simply pointed at my briefcase and said, ‘Gentlemen, the cause of the disease will be found in there, in the files, in his life history.’ Mental disease is above all a reaction. Each patient faces unique pressures—pressures to which you and I would react differently. Now, what is it about him, about her, about her life, that causes her to react the way she does? To discover this you must observe, you must ask, you must record.”
“But this aunt is not in his life.”
“Really? And who is on your mind when you go to sleep at night? When you feel weak or afraid?”
“Well, a lot of people—my family. Perhaps an old friend.”
“People who are not here.”
“Yes, but—”
“Collect your facts, Dr. Lang. Collect your facts and then decide what’s relevant.”
Imogen was not alone in her frustration. The other interns also tired of writing patient histories, interviewing not just the patients but their parents, their siblings, their employers, their friends. Patients, overcome with shame, never wanted to grant permission at first, but Imogen found that when they perceived her genuine desire to understand, most of them relented.
Another sore point was that Ganz often made them go out into the field to perform such interviews. “I’m sorry,” Jasper Bylsma, newly arrived from the Netherlands, cried, “but I do not want to inquire of a butcher whether his apprentice is masturbating at work or not.”
“Why would that be?” Donna Artemis said in a sly voice. “Sharp objects make you nervous, Jasper?”
In his passion for observation Ganz reminded Imogen of Sherlock Holmes, though without the fictional character’s theatricality. When he summoned her to his office, and those .45 calibre irises were aimed in her direction, she could not help but feel that he was mentally photographing her for later summing up on an index card. Miss Lang is a tall, ungainly female with marked insecurities that she attempts to disguise with excessively correct manners and locution, or witty remarks. Perhaps ashamed of her rough Chicago provenance, she adopts the manner of the cool clinician, but her hands are restless and her eye contact sometimes fleeting.
One evening after work she changed out of her white smock and stepped into the vestibule to knock on Donna’s door.
Donna opened it and greeted her with “Guten Abend, Doktor.”
“Does Dr. Ganz make you nervous?”
“Hah! Come and sit awhile.” Donna opened the door wider, and indicated the desk chair. “You can have the uncomfortable one.” She herself plopped down in the Morris chair and adjusted the back into a more upright position. A volume of Janet lay open on the bed.
“Every time he speaks to me,” Imogen said, “I’m convinced he’s about to tell me I should find a nice respectable man to marry and forget I ever heard about psychiatry.”
“Has he ever said any such thing to you?”
“Not in so many words, but…”
“And he never will. It’s just his face, Imogen. I’ve never met anyone whose looks are in such contradiction to their personality.”
“He looks like he suspects me of something terrible.”
“I know. It throws everybody, at first. But have you noticed that the patients love him?”
“Love may be a bit strong.”
“But they’re not afraid of him, right? Don’t you find that remarkable, when he has us all cowering?”
“Yes, I suppose it is.”
“It’s as if they have some sixth sense that he can really help them—even if he can’t. They seem to see right past his facial expression.”
“Either that, or their world is already so frightening that a demonic stare is not so bad.”
“I’ll tell you what I do like about him.” Donna adjusted the chair again so that the footrest came down with a clack. “You can spend an hour with him discussing the most taboo subjects and there is absolutely no sexual frisson whatsoever. You know how with most men—and I don’t mean lechers, I mean any man—with most men, there’s an unacknowledged spark between you. The male-female charge. There’s none at all with him. And I for one am really, really grateful.”
“That’s probably different for you.” Imogen envied Donna’s gamine looks, her doll-like size and perfect proportions. You wanted to pick her up and admire her like some fascinating objet. “Not everyone is so attractive, you know.”
“Yes, I know. Isn’t it just terrible?” Donna grabbed a pillow from the bed and threw it at Imogen. “Blockhead. ‘Not everyone is so attractive.’ Listen to her.”
Imogen hugged the pillow, a strangely intimate thing, and didn’t know what to say.
* * *
—
Ganz was behind his desk, surrounded by his jars of brains, his displays of spines, and the aroma of his omnipresent cigars, about to give Imogen her first quarterly review. Although he never failed to address her with respect and even kindness, she still sometimes thought he must be putting it on, or that he must behave in the same manner to all his residents. Yet Donna assured her this was not the case, that he had given her several dressings-down. Still, Imogen had been anticipating this meeting with dread.
A helix of cigar smoke curled from the ashtray and wound its way upward with the precision of a spiral staircase through a shaft of sunlight. Dr. Ganz balanced a clipboard on his knee, from which he read aloud the comments he would be placing in Imogen’s file. “You have adapted yourself marvellously well to clinic routine, your patient histories are excellent examples of thoroughness combined with clarity and concision—a trick many never master. The patients, even the most difficult, respond to you with warmth and trust, which does not surprise me. I note a special rapport with those who suffer from depression. Two of these—Miss Garner and Mrs. Krumholtz—were released far earlier than initial assessment indicated was likely.” He looked up from the clipboard. “I hope you’re pleased.”
“Oh, yes, sir—very. I’m sure I don’t deserve such…”
“Yes, you most certainly do,” Ganz said with a smile. “In fact…” Here he read from the clipboard. “ ‘The only liability I see in the future for Dr. Lang is an innate lack of confidence—surprising in one whose young life is so rich with achievement.’ ”
He put the clipboard on the desk and took up his cigar. “Would you agree with that?”
“Lack of confidence? Well, yes—but it’s well placed.”
He puffed on his cigar, making the tip fiery, and squinted through the smoke. “I disagree. And in this you must bow to my greater experience. I know a good physician when I see one. I know an excellent psychiatrist in the making.”
“Then why do I feel at sea so much of the time?”
“Because you should. So should we all, now and then.” He tapped his clipboard with a well-manicured finger. “I’m interested in this rapport you have with our depressives. Several of the ward psychiatrists have noted it.”
“Really?”
“Dr. Mackenzie and Dr. Quinn have both commented on it.”
“Dr. Quinn?”
“High praise indeed. I’m wondering where this comes from. Something you mentioned to me before, concerning your mother…I’m wondering if we might not venture in that direction.”
Imogen hadn’t exactly mentioned her mother’s moods. She had noted them in response to that intrusive questionnaire—a confessional lapse she was now regretting.
“Well, um, yes—she certainly suffers from what I should call depressive attacks. Stays in her room for days, won’t see anyone, loses interest in all her usual activities.”
“And the apparent cause, in your view—if there is one?”
“Well, the proximate cause would be my father’s behaviour toward her.”
“And not the death of her daughter at the age of five?”
“That was a matter of fate. It was not done to her by anyone. My father is cruel.” Imogen squeezed her intertwined fingers until they whitened. “Very cruel.”
“And yet in your psychological profile you wrote of your happiness as a child.”
“As a young child. Before I knew what he was really like, especially to my mother.”
“He is disloyal to her?”
“Yes.”
“With another woman.”
“I don’t like to say, really.”
“Of course not. It’s painful to think of one’s mother being hurt. But you realize I do not ask out of idle curiosity.”
“Yes, I know.”
“One of the sidelights of our profession is we get to analyze each other. Sometimes it can be painful. But if we don’t do it to ourselves we can hardly expect the patients to put up with it.”
“No.”
“Also, it’s essential to be aware of one’s blind spots and sensitivities. All of us wear tinted glasses, and it’s important to know what shade.”
Imogen felt a wall of resistance building up inside her. But Jonas Ganz clearly saw the analysis of the human mind as a rarefied skill that required constant development, constant practice. “To be a psychiatrist,” he had said in the morning staff meeting, “is not just a profession, it is a way of life, a mode of thought, and a practitioner cannot consider himself an adept until it becomes second nature.”
“My mother knows…the situation,” Imogen forced herself to say, “but she never speaks of it. No one in the family does.”
“But why does she retire to her room? Is she punishing herself, do you think? Or is she punishing your father, withholding her affection?”
“Herself. She’s punishing herself.”
“But she has done nothing wrong.”
“No, but she blames herself. It’s obvious what she must be thinking: Am I not enough for him? Am I so repellent that he must seek physical affection elsewhere?”
“Why does she not get angry at him? Yell at him. Throw things, perhaps.”
“One obvious reason is because she cannot afford to suffer the consequences of his anger in return. Were he to withdraw his support she would be impoverished overnight.”
“And a less obvious reason?”
“She doesn’t express anger because she doesn’t feel anger. She feels hurt, dismay, disappointment, abandonment, unworthiness, loneliness, loss, worry, heartbreak.”
“Indeed, it would be difficult to function under such a burden of negative emotions. How is it you have the list on the tip of your tongue?”
“Because I feel them myself.”
There it was. It had just slipped out. Those eyes of his, which at first had seemed so threatening, now just expressed curiosity, a willingness to accept without judging. Imogen had never made such a revelation to anyone. It felt illicit, as if she had got away with something but might yet be caught.
“You feel them yourself—the loneliness, loss, and heartbreak. How could you not? Because it’s not just your mother who gets left behind when your father goes wandering, is it?”
Imogen shook her head. Pressure was rapidly building in her chest, gathering in her throat. She pressed her lips together to hold it back, but something inside her gave way; the cry escaped her lips and the tears poured forth. It should have been humiliating, but the relief was too profound.
With just a handful of words, deftly applied, he took her deeper.
“As if it were not enough that he withdraws his love and attention from you, he drives your mother into a state so unresponsive that in effect he has orphaned you. At a stroke you are rendered not just fatherless but motherless.”
The truth of this was so piercing she could do nothing but cry harder.
Ganz waited for the tears to subside a little, before encircling her with the warmth of a revelation of his own.
“I too feel a particular affinity with patients who suffer from depression,” he said, “and I think I know why this is so.” He set the clipboard down on the desk, and fingered his stack of index cards, puffing on his cigar for a moment and contemplating the smoke. “By the time I had won my MD and had finished my apprenticeships with Kraepelin and Alzheimer, there were no positions available in Zurich, or none that I wanted. At best I would have remained a lecturer in pathology, earning little, with little prestige and no hope of advancement.
“I decided to move to America. My father had died eight months earlier, and my mother was understandably still grieving, but I did not let that stop me. My older brother had moved away to Paris, but my younger brother, Michael, would still be in Zurich to provide her with company and support. My mother begged me not to go, ostensibly for my sake—I would be lonely, America was so big, I knew no one, et cetera—but of course she was concerned, too, for herself.
“I was ambitious. I had a small offer from the University of Chicago and I wanted to take it. So, despite my mother’s protests, I got on the boat. Shortly after my arrival in the United States, she suffered a severe case of influenza. She recovered from the fever, but it left her in a condition, as she wrote to me, of ‘unbearable sadness.’ And then Michael, my younger brother, died.”
“How awful,” Imogen said. “Your poor mother.”
“Indeed. She sank into a depression so disabling she had to be hospitalized at the Bergholzi, where I had previously worked. Her psychiatrist was Dr. Forel, who had trained me. I maintained a close correspondence with him, and he informed me that he did not think she would ever recover. I’ll never forget his exact words: ‘recovery, in her case, is extremely unlikely.’ ”
“You must have been devastated.”
“I was deeply worried, of course. But I did not concur with Dr. Forel’s prognosis. You see, I had one telling advantage over him: I knew my mother. Knew her strength, her resilience. I always believed she would recover, and luckily, after a period of some eighteen months, she did.”
“Which is why you are telling me about her?” It came as a shock that her august director would open up to a mere intern this way.
“Partly, yes. But also as a way of explaining that you and I have this in common. In part because my own mother so suffered, and in part because I know she recovered and this gives me reason for more optimism than another physician might feel. I believe patients sense this optimism, which is entirely unfeigned, and take heart. I hope the same for you.”
Imogen felt her cheeks redden. “I’m not depressed.”
“But you didn’t finish your thought about your mother. You have a way with depressed people because you love someone who is subject to such sadness. But there is another reason.”
“Because I’m prone to it myself, you mean.”
“Well?”
She had been feeling so light after her tears, but now shame and embarrassment crept in. He could see it on her face; she could feel him reac
ting before he even spoke. He leaned toward her now, his posture, his gaze, saying nothing in the world was more important to him at this moment than how his intern Imogen Lang felt about her tendency to depression.
“Yes, I suppose I am prone to it,” she said, trying to keep her voice neutral. “I try to be aware when it is coming on and take appropriate steps—try to ensure I eat well, and get enough sleep.”
“And do such measures help?”
“Do we have to talk about this?”
“No. But you need to know that we can talk about it. I want you to know in advance that, should you feel so afflicted, there is no need to hide away.”
“I feel as if we’re discussing a limp, or a facial deformity.”
“The analogy is not exact. Talk is of little help in such matters.”
5
I mogen was just beginning to feel she had got her bearings at the Phipps when she was sent off to the Byberry State Asylum for a three-month rotation. Located in the countryside northeast of Philadelphia, Byberry was not one of the grander institutions. The main building was a long bungalow, and the nurses’ residence, where Imogen was housed, was an ugly block of yellow brick. The surrounding cottages were not cottages at all but brick, multistorey buildings labelled A, B, C, and D. Still, being tucked amid low hills and rich farmland, the grounds did offer a certain tranquility.
The director was Dr. Ben Zachary, a friendly, shambling man of sixty with hair like straw, who reminded Imogen of the Scarecrow in The Wonderful Wizard of Oz.
