In The Lives of a Cell, Lewis Thomas reveals what he calls the "great secret" of medicine -- known to internists, he says, but unknown to the general public: "Most things get better by themselves. Most things, in fact, are better by morning." Of course one segment of the general public knows this secret intimately: the uninsured. Up until a couple of years ago, I had passed my entire adult life without health insurance, and I'd grown so conversant with the secret that if I found myself with a sucking chest wound, my first impulse would still be to wait and see if it was better by morning.
On the Tuesday before Labor Day I noticed that something was wrong with my eyesight. I'd been working on the computer into the evening, and by the time I was ready to quit, I was beginning to feel as though I were in a science fiction movie: every time I looked into the screen, a laser beam of agonizing intensity arrowed into my right eye. I didn't know what the problem was, but what was the big deal? I wasn't about to go to the emergency room for it. I figured I had some fashionable new syndrome that hadn't been named yet: VDT red-eye, maybe they'd call it. I went to sleep that night certain that Thomas's secret would work for me as it always had.
It didn't; in the morning, my eye was drastically worse. Any change in the light, even so much as a glance from a white wall to the wood floor, sent a skyrocket of pain exploding behind the eye into my sinus cavity. The view in the mirror was genuinely frightening: the eye was swollen and intricately bloodshot -- the white was like a fireworks show of spiderwebbing blood vessels. My wife said it looked like the eyeball was about to pop out of my head.
I installed myself in a dark room and tried to decide what to do.
I have in my wallet a wad of ID cards that would prove to any passing doctor that I am no longer a wanderer in the medical netherworld, but a real person with a real HMO who may be treated without fear of liability. (Doctors must long for the old days, when they were afraid to treat patients only because they didn't want to catch bubonic plague.) But that morning I discovered that I didn't still believe in any of it, not really. I couldn't convince myself that a doctor would be able to do me any good -- or in fact that there was anything that needed to be done anyway. The only reason to try was a creeping, directionless panic I couldn't figure out how to get rid of, and the growing certainty that the panic was going to get worse if I didn't do something soon.
So -- for the first time in my life -- I called up a doctor because there was something wrong with me.
Inevitably, my primary-care physician was just about to leave on two weeks' vacation and his office was a madhouse. But he couldn't give me a referral to an ophthalmologist without first examining my eye himself. So I described my symptoms in detail to his nurse -- who tried to think of some way to avoid having me come in. I'm not instinctively good at melodrama, but I did hear myself getting more and more impassioned; by the time I was done, it must have sounded like my eye was inflating by the second and was about to burst like a soap bubble. At last she said that it didn't sound serious, but the doctor would have a few minutes free at the end of the day tomorrow, so I might as well stop by then.
I find this hard to believe now, but I was actually reassured. I spent the rest of the day telling myself that it didn't sound serious because it wasn't serious, and I kept checking my symptoms for proof that the eye was starting to get better on its own. When I woke up on Thursday morning and discovered that the pain was lessening, I was tempted to call the doctor back and cancel the appointment -- tempted, but not quite carefree enough to do it.
The appointment itself proved to be another test of my resolve -- maybe doctors arrange things that way so they can weed out the malingerers. In the whirl of phone buzzings and beeper chimes and loudspeaker pages that surrounded my doctor everywhere he went, I felt like I was trying to tell my life story to somebody on a subway platform while his train was pulling in. But he did finally put in some quality time with my eye. He couldn't tell what was wrong, but he too thought it probably wasn't serious. He gave me a prescription for antibiotic eyedrops and told me to call him in the morning if there was no improvement.
"What do you mean, improvement?" I asked.
He made a vague gesture and said, "Improvement."
"Okay," I said, and started to stand up.
"No," he said. "You don't get it. If the eyedrops don't clear it up, we're going to have to get you to an ophthalmologist right away. So if there isn't improvement, call me first thing in the morning, and I'll give you a referral."
"What have I got?" I asked.
"Well, probably it's a bacterial infection. But I can't rule out a disease called iritis. It's pretty unusual, so the odds are you don't have it, but if you do, you'll need to get it treated immediately. And the same thing goes if you get a recurrence while I'm on vacation -- you have to promise me you'll call my office and get that referral."
"I promise," I said. "Where are you going?"
"The Grand Canyon," he said, and seemed about to add, "Thank God."
I picked up the prescription on the way home and obediently passed the night drowning my eyeball in antibiotics. In the morning there was indeed improvement: the pain had faded into a dull ache. The eye was still swollen (though less so, it seemed to me) and my sight was fuzzy -- but these symptoms seemed trivial. I decided not to call for the referral.
That was a mistake.
At the end of the day I went out to meet my wife for dinner. My eye felt tired and a little raw, but I had been working on the computer again, and I wasn't expecting my condition to be cured. As I walked to the restaurant, though, I began to notice that I was developing some kind of new symptom. The problem was, it was one I wouldn't know how to describe to a doctor -- even to a psychiatrist.
There was something wrong with my vision. Not with my eye: but with something more intangible -- with whatever it is that the eye is for. My sight seemed to be working properly, but the world around me was coming apart. Whatever I looked at would suddenly loom and teeter at a nightmarish angle, as though it were about to fall away into a new and horrible dimension of space: then it would flick back to where it belonged and leave me groping after what I'd just seen. It was as though I was losing some crucial, intuitive hold on how the world was supposed to be looked at. But what was I supposed to do about it? Tell my doctor that my eye infection was causing metaphysical side effects?
After dinner, as my wife and I were walking home, I noticed yet another new symptom. But this one would have made the call to the doctor a lot simpler. Around every streetlight I now saw a thick, milky gray halo, fading off into a fringe of brown.
That night I had a hard time getting to sleep; the pain was coming back. I got up more than once to give my eye another dose of the antibiotics. Toward morning I fell into a dream of soothing dimness: I was riding on a dark train through a country landscape at night. I was met at an unlit little station by a group of shadowy friends in black, shapeless cloaks -- one of them carried a lantern that he kept covered. They took me up a hill to look out over the countryside. I could see in the starlit distance a scattering of silhouettes like Indian mounds. But they were buildings -- titanic barns or barracks. As I watched, huge windows in their sloping roofs began to glow with pale gold light, a scattering of luminous flowers blossoming everywhere in the night land. I understood why I'd been brought here; and I thought that if this were the last thing I would ever see, it was worth it.
Then I woke. I already knew what I would find: the sight in my right eye was gone.
When I was young and limber I once went hiking by myself in the hilly country of northern California; and I almost killed myself trying to get across a gap in the trail that had been taken out by a slide. I was clinging to the slope, trying to feel my way past the emptiness below me, when I felt a kind of generalized slippage, as though every pebble and clod of dirt around me was shifting about six inches downward. I had no experience as a hiker and ought to have died right then; but without a moment's thought I made some kind of move -- to this day I don't know what it was, a jump or a twist or a lunge, something no doubt thoroughly ungraceful -- and found myself safely on the far side of the gap, as though I'd teleported.
That was one of the defining events of my life: The Most Frightened I Have Ever Been. But now I lay in bed so frightened I was about to jump out of my skin. All I could think was that this time I had no idea which way to jump.
And yet -- and I don't want to sound any more mystical about this than I have to -- I also felt curiously comforted. All I can say without sounding foolish even to myself is that I felt my dream was a consoling message. After all, I wasn't entirely blind. I still had perfect sight in my left eye. And as the light brightened around me, I could tell that something in my right eye was still functioning: the world appeared to be a uniform milky gray, but there were a few vague movements detectable in the depths, like whales in a cloudy sea. So I went on quite placidly staring at the vague dawn in the window and waited for my wife to wake up on her own.
My doctor's office turned out to be closed, of course. His answering service paged the doctor on call -- and I'll give him full marks for this one: he did pick up the phone instantly. He told me he'd give me a referral for an ophthalmologist and had me call the hospital's eye center. But it was closed too. Their answering service found me the ophthalmologist on call -- and pretty high marks for him too: he phoned me back in ten minutes. By then my calm had grown positively glacial. I actually thought he was going to cut me off with a curt instruction to buy some Visine and call him back after Labor Day.
He did cut me off -- but instead he said something else. And if I had been looking to shake conclusively free of all my private musings and spike my adrenalin way up into the red zone, hearing a doctor say this to me compared favorably with that morning in the California hills. "I'm going to open up the office," he told me. "How quickly can you get down here?"
One glance at my eye was enough for him. "You have severe and galloping iritis," he said. It's a rare disease: an inflammation of the iris. He turned away from me and pulled out from a desk drawer an enormous plastic cutaway model of an eye -- which, with its bulging veins and disassembled cornea, still looked better than my eye felt. Nobody knows what causes iritis, he explained -- but one effect of it is that white corpuscles and excess protein leak out from the inflamed area and fill up the aqueous humor of the eye. "So it's a good thing you came in," he said.
"What would have happened if I didn't?"
"If you'd waited till after the holiday, you would have been risking acute glaucoma." He showed me how the inflammation could block the internal movement of the aqueous humor; if left untreated the increased pressure would cause permanent damage to the optic nerve.
He then settled in for a detailed examination: which meant that I had to rest my head in a fantastic cage of metal bars and hanging lenses while he shone brilliantly colored lights into my eyes and prodded them with sinister pressure monitors. The milk in my right eye was soon charred into inky black; and when yet another circle of searing blue fire advanced out of the darkness to fill up my field of vision, I felt as though I were in a railway tunnel watching an express train bear down on me.
Afterward, as I sat blinking and wincing, he wrote out a sheaf of prescriptions for me. Iritis is treated with steroids, so I first got a prescription for steroid pills; then one for steroid drops; then a second eyedrop that would keep my pupil dilated; and a third to reduce the pressure in my eyeball. "The pressure is troubling," he said. "With the medicine, you're probably OK until Tuesday, but I'd feel better if you came in again tomorrow and got another reading."
"Anything else?" I asked.
"Yeah, stay out of direct sunlight. And don't expect your eyesight to get any better, at least not right away."
The sunlight thing turned out to be a challenge. It was a brilliant Saturday afternoon, swarming with people and traffic; and I had several blocks to cross to the pharmacy, with my eyes in severe meltdown. Through my right eye the world appeared as a black ocean, swarming with vast and shapeless shadows of faint copper and metallic red. My left eye was now no better; the ophthalmologist had had to dilate it to check to see if the iritis had spread, so now its visual field was a riot of overabundant intensity. Everything I saw through it was too dazzling to look at: a scrap of chewing-gum wrapper, the reflection of a cloud in a store window, the buckle on somebody's sandal. My brain didn't even bother to try to reconcile the two opposing visions: inside of a block, the world disintegrated.
It was what I'd been afraid of -- in some ways even more than going blind: a return of that vertigo-inducing sense of wrongness. I could live without my sight, probably; but I couldn't bear the thought of spending the rest of my life in a carnival fun house. I felt as though I had fallen through a trapdoor into a kind of visual hurricane that to everybody else was nothing more than a peaceful sunlit street. When I reached an intersection I had to sift among the avalanches of shattered, dazzling imagery and try to add them up into something recognizable: people waiting for the light to change, cars making turns, walk signs blinking. Idly, as though I were considering my condition from the audience, I found myself wondering if a time-traveling caveman would be as bewildered as I was by all the subliminal cues that everybody else took for granted. Even eyesight, evidently, was a social construction -- a middle ground between formlessness and blinding clarity; maybe my disease was only that I'd lost my balance in this endless torrent of information.
Things were more tepid by the time I reached the pharmacy. All those recreational drugs I'd taken in high school had finally come in handy -- I'd been able to walk down the street quietly and unobtrusively, while my vision erupted with glittering phantoms. The medication in my left eye finally began to wear off; and the darkness in my right eye was slowly suffusing again with featureless gray. I bought myself a pair of sunglasses that reduced the world to a manageable chaos. I knew I could get home all right.
After I had my prescriptions filled I decided to indulge myself with a side trip to a stereo store. It had been my wife's idea. "If you really are going blind," she'd told me, "you might as well replace those crappy headphones you're always bitching about." My wife's first instinct in any disaster is to check the supplies.
The next day was Sunday, and the hospital was as desolate as a bus station on Christmas. In the lobby a few families sat here and there in huddles, murmuring to each other and looking about blankly: waiting around, it appeared, to send somebody off. At the information desk a scruffy, wild-eyed man in a T-shirt and tattered jeans was arguing with a security guard who didn't want to let him in. "My wife's been in labor for 36 hours," he kept saying. "I just went home long enough to take a shower. Come on, man, I have to get back up there!" The guard barely gave me a glance as I sauntered past. I was wearing sandals, shorts, a loud Hawaiian shirt, a battered straw hat, and my new shades -- evidently only a middle-aged white guy of the better sort would dress like that for a medical emergency.
The corridors and elevator bays were empty; the doors were all closed and the windows were dark. In the distance I sometimes heard the faint, glassy rattle of a cart in a hidden reach of hallway. I kept thinking about all the silent machines hidden in the rooms I was passing. It was as though I were in some kind of deserted museum left by an alien civilization. The hospital was a warehouse filled with intricate, eerie, well-intentioned but bizarrely impractical devices -- imperfectly designed to cope with the infinite subtleties of human damage.
The eye center was locked; the ophthalmologist's technician showed up just as I did. She didn't bother to turn on more than a couple of lights, and she left all the machines in their protective shrouding. Instead she used a handheld monitor to check the pressure -- still dangerously high but beginning to respond to the medication. To anyone who could bear to watch, it would have looked as though she were repeatedly sticking a pencil in my eye. I marveled at how casual I'd become about that; by then I probably wouldn't have flinched if she'd come at me with a scalpel.
On the Tuesday after Labor Day those silent corridors were as jammed as an office building at lunch hour. Crowds of people in suits and ties were hurrying everywhere, carrying stylish briefcases and thick three-ring binders filled with promotions and order forms. They brushed up now and again against frail patients in wheelchairs, but were studiously tuning them out. Here and there in the swarm technicians slowly pushed enormous pieces of equipment that looked like leftovers from the set of Blade Runner. The lobbies and waiting rooms were spilling over with families joking with each other and sharing stories; there were TVs turned on everywhere, bright with Oprah or dark with the soaps. I spent hours sitting around in the mob, waiting for my name to be called.
Everywhere I looked were people wearing eye patches and bandages, dark glasses and glasses thicker than Coke bottles: the ordinary, nonemergency crowd of the wounded and blind, who'd taken the holiday weekend off with the rest of the world. I think that was the first time I began to realize that I was joining in for the long haul. My weekend of panic was over, and now I had before me a routine as dull and gray as my sight.
The ranks of secretaries and administrators were back from the holiday weekend too. They were skeptical about my emergency; there was a suspicious shortage of paperwork; they didn't believe any doctor had ever promised a referral. I felt like a member of the underground trying to stay calm while the SS officers checked over my forged papers.
Gradually my vision began to clear, as though somebody were very slowly diluting the milk with water. But my afflicted eye couldn't focus; after a week it was still impossible for me to read anything with my left eye closed. At my next appointment the ophthalmologist told me that my blurred vision was now largely an effect of the medication. They would be able to reduce the dosage when my iritis was a little better, and my eyesight would then begin to return to normal. But that was still a couple of weeks down the road. I had to be patient.
So I was patient.
Then I began to see a mysterious, elusive sparkling in the extreme periphery of my right eye. It happened every few minutes: just outside my field of vision, there would be a quick bright movement, like a dribble of molten silver. I didn't know what it was; I actually wondered if it was runoff from the draining milk. And of course -- that old reflex of denial coming back again -- I hesitated to mention it to the ophthalmologist at my next visit. But I was finally smart enough now to overcome my hesitation.
He immediately broke off the exam and rummaged around in his desk for another piece of equipment: a brighter floodlight, it proved. For a couple of minutes he shone it into the murky depths of my eye. Then he turned away and began writing something in my file. "Your iritis continues to improve," he said. Then he thought for a long moment.
That was when I learned that despite everything that had happened to me over the past couple of weeks, I still had within me somewhere an untouched reserve of alarm.
At last he said, "There's an abnormality in your retina. I don't know what it is. Maybe it's nothing. Retinas aren't my specialty. So I'll have to have you checked out by our guy who does retinas."
"When?" I asked.
"Right now," he said.
My new ophthalmologist squeezed and pummeled my eyeball as though he were kneading bread. Then he too thought for a moment. Or maybe he didn't think about it at all: maybe this is another secret all doctors learn, to pause just long enough before delivering bad news so that your subliminal warning system lights up.
"I see the abnormality," he told me. "I'm not absolutely sure what it is, either, but it's suspicious. I think it's a tiny tear in the retina. So you're going to need laser surgery." He didn't pull out another plastic eyeball, but his explanation was lucid enough: the laser would burn a little circle around the tear, fusing that part of the retina to the choroid layer underneath.
"What if it isn't a tear?" I asked.
"If it isn't a tear, and we do the surgery, there's no harm done. But if it is a tear and we don't do the surgery, your retina could peel away from the eye wall like the skin of an orange. Then neither one of us would be very happy."
I made a gesture. Not rude, not really angry, not exactly cheerful. A vague arm wave of acquiescence and exhaustion.
"If it's okay with you," he said, "I'd like to do the surgery right now."
"It's okay with me," I said.
So this was how I found myself coming full circle: I'd begun with the feeling that my computer was firing laser beams at me, and now a doctor was about to do it for real. I had my head in yet another preposterous birdcage of metal struts and mysterious bulging cylinders; the doctor was pressing very firmly into my eye a big plastic disk like a monocle or the pointer in a Ouija board. "Hold still," he said. "You'll hear a click, and you'll see a very bright flash. Some people say they feel a pinch. And then it'll be repeated several times."
I wanted to say something about how that sounded like a civil-defense film about what would happen during a nuclear attack. But there wasn't time before the warheads started going off.
In the blackness where my sight had been, a green starburst flowered and died: the most brilliant and glassy green I had ever seen. Then there was another, and another. Soon they were red. My left eye, either in sympathy or because it was suffering collateral damage, closed tight against the intolerable, agonizing light. Tears started flowing down my cheeks. Each new flash seemed to be pinpointing and annihilating the straggling remnants of my old assurance that I would ever be better by morning. The final blast lit up my whole field of vision like lightning in a night sky: and I saw, as a red flame emblazoned across the clouds, the intricate network of my blood vessels. At last I understood what was happening to me. I had spent my life looking through my eye; I was now going to spend the rest of my life looking at it.
The prognosis for iritis, as long as it is treated quickly, is good. But it can become a recurrent affliction. My eye is responding well to the steroids. But if I begin having more severe flare-ups my friends the ophthalmologists will have to begin injecting the steroids directly into the inflammation. I can't say I was cheered to hear that. In the last few weeks my eye has been poked, battered, prodded, and fried by all the different kinds of light in the electromagnetic spectrum; but I'm still not ready yet to have it stuck with needles.
On the other hand the world does now look something like it did before that remote Tuesday. My sight is still blurry, but at least familiar objects now sit squarely where they ought to. They have an insubstantial quality, though -- a ghost shadow from my veiled eye. Sometimes it seems as if another and more enigmatic light were shining behind them. But I suppose on balance I can live with that, if I have to.
The feeling of wrongness is gone, and something duller has replaced it: the knowledge that I have a prognosis. It's like having a job description. A while ago I had as little contact with modern medicine as a street person does with the Internet. Now, out of nowhere, I've been shanghaied into a lifetime career in the health-care industry. From here on out, I'm beginning to realize, I will have to think of myself as a part-time temp worker. That's my real prognosis: to be permanently on call, ready at a moment's notice to head off to the next in an interminable series of strange offices.