Paula's House of Toast

Small shocks of color amidst the general gray and brown of the midwinter woods: red berries, the hard, iridescent green-blue of a mallard's head, the softer green of the pine boughs. Underfoot: mud and decaying leaves, plates of glaucous ice, burly, exposed roots. At the riverbank, shorn knotweed, hollow as bamboo. The eye seeks out the beautiful minutiae. The single ghostly leaf, the thin coils, the weed stalks, still sparsely knobbed with seeds. Their names don't matter anymore. Taxonomies fall away. There is just eye and weed, eye and branch, eye and stone, eye and leaf. Eye and color, movement, shape.The winter days lengthen, illuminate the dead woods. Merciless floodlight.

I am in the riverbank thicket peering at a slip of vine through my camera lens. On the bike path, a young woman passes, singing, walking a groomed white poodle on a leash. The dog's wearing a red bandana. The woman turns, looks at then through me, and keeps on singing: no shyness. A beautiful bird on display.

Later, unlocking my car, I am startled by my reflection in the dark glass of the window: hat pulled low, glasses, face. Low afternoon sunlight harsh in every furrow. Skin taut over cheekbones, loose and concave beneath, quivering slightly with breath. When did I become so old, so thin, so frail ?

Just ask Baudelaire.

I ventured into the local pharmacy to buy a Valentine's card for DK last night after work. I was overcome by spleen: ill temper, pique, low spirits, melancholia. It was fueled by the unnatural and fluorescent-bright onslaught of the color red, and a father yammering in an over-loud, impatient voice to a gaggle of unpleasant children. Who in turn were clamoring for stuff. My eyes and ears were bleeding.

All the way home, our local NPR station had been interrupting the news with its yearly loathsome Valentine's Day fund raiser. That's when they lard their usual chipper "give us cash" tirades with pitches for roses and chocolates, snippets of bad rock and roll tunes about love, and excerpts of dialogue culled from romantic comedies. It's like being force fed upscale treacle.

I would like to replace the Valentine heart with the Valentine spleen.

I confess that I find the word "spleen," (and, by extension, the organ) amusing in a Monty Pythonesque sort of way. This is probably an attitude unbecoming an internist. Nonetheless, here are my translations of and variations on Baudelaire's "Spleen" poems. (They appeared in JAMA a few years ago.)



Splenic Translations And Variations
(after Baudelaire)



LXXV. SPLEEN

January, pissed off at the whole city,
dumps an urn full of icy shadows
onto the pale residents of the local graveyard.
Death splatters far into the foggy outskirts.

My cat scours the cold tiles for a bed.
Her thin, mangy body shakes and shakes.
The soul of an old poet meanders in the gutters
with the sad voice of a shivering ghost.

A bell tolls in self-pity, as a hissing log
accompanies, in falsetto, the snot-nosed pendulum,
and, in a deck reeking of stale perfumes,

the poisonous legacy of a dropsical old hag,
the suave jack of hearts and the queen of spades,
gossip wickedly about their old love affairs.



I. SPLEEN

Mr Jones won’t rest till he can piss
thundering urnsfull, sans hesiter;
thinks no one has a prostate big as his.
He must call me twenty times a day.

Ms Kat’s still cold and tired. She must be Swiss.
Her thyroid’s fine. I wish she’d go away.
Old Mr Poet rambles. Likes to kiss.
Arrested once again ? What can I say.

Plus Mrs Bell feels sorry for herself.
She has a cold. She’s nasal as an elf.
I’m choking on her cheap Woolworth’s perfume.

Increase their diuretics. Seduce your nurse.
It’s only gonorrhea, could be worse.
Death flirts with Love in the packed waiting room.


LXXVI. SPLEEN

I have more memories than a thousand year old man.

A huge desk, drawers stuffed with balance sheets,
poems, love letters, subpoenas, romances,
and thick locks of hair rolled up in receipts,
hides fewer secrets than my sad skull.
It’s a pyramid, an immense cavern
that holds more dead than a common grave.
-- I am the cemetary even the moon hates
where, like remorse, long worms drag themselves along
and always attack my most dear dearly departed first.
I am an old boudoir full of threadbare roses.
Here lies a jumble of loud, outdated styles.
And piteous pastels and exsanguinated landscapes
inhale in solitude the fumes of uncorked flasks.
Nothing rivals the length of these limping days
when, under the heavy flakes of years,
boredom, fruit of a dismal indifference,
assumes the proportions of immortality.
-- From now on, life, you’re nothing but
granite menaced on all sides by frightful waves,
nodding off in the depths of a foggy Sahara;
an old sphinx ignored by a indifferent world,
left off the maps, and to whose ferocious hilarity
only the rays of a sinking sun are audience.


II. SPLEEN

Nothing shocks me. Nope. I’ve seen it all.

All humours, blood, bile, lymph and melanchol.
Every complaint from scurf to fallen womb,
lies pickled in my brain as in a tomb
between commodes and wooden legs and phlegm.
The almost-dead are plucking at my hem
as I pass among them on my morning rounds.
-- Others snooze inside the charnel grounds
of memory, that moonless helminths’ hill
strewn with all the latest useless pills.
I am a sickroom full of bloody noses.
The body seems to sigh, then decomposes.
A Norman Rockwell print sags on my wall:
young Johnnie huffing isopropanol.
What’s longer than a clinic afternoon ?
Patients blizzard through consulting rooms;
boredom, bastard son of apathy,
pins me, wriggling, to mortality.

-- Adieu, compassion ! I pronounce you dead,
a chunk of rock besieged by overfed
dyspepsiacs and ever-hungry ghosts.
I’m an old sawbones, despised by HMOs,
AMA-reject, whose midnight guffaws fall
flat, face down, in the empty clinic hall.



LXXVII. SPLEEN

I am like the king of a rainy country,
rich, but impotent, young and nevertheless ancient,
who, contemptuous of his brown-nosing tutors,
bores himself with his dogs and his other beasts.
Nothing amuses him, neither gamebird nor falcon,
not even the subjects dying beneath his balcony.
The poet laureate’s most grotesque ditty
doesn’t animate the features of this cruel invalid.
His fleur-de-lised bed has become his tomb,
and even the courtesans, to whom every prince is fair,
can no longer find lingerie exotic enough
to pull a leer from this young skeleton.
The wise man who fashioned him from gold
never could refine out all the impurities,
and not even an old-fashioned Roman blood bath, the sort
about which all potentates, in their dotage, reminisce,
could rewarm that dazed cadaver
in whom, instead of blood, the green water of Lethe flows.


III. SPLEEN

I’m like the god with features bright as gold
(well-paid, powerless, infantile and old)
who scorns his white-coat colleagues’ obsequies,
preferring to consort with poetries.
Nothing amuses him, not gout or flu,
not wards of patients requiring a Code Blue.
The wildest case report, replete with gore
and exotic bacteria: quelle bore.
His diploma’ed office has become a tomb.
Cartoon nurses couldn’t pierce his gloom
with white starched bosoms, adulating sighs,
and nylon skirts ascending sleek, white thighs.
Mentors plucked him squalling from pre-med.
He should have stuck with English Lit instead.
No brilliant diagnosis or great case
can animate his masked and stony face --
Leptospirosis cannot wake the dead.
(He quaffs from River Lethe, takes to bed.)


LXXVIII. SPLEEN

When the cast iron sky weighs like a lid
on a mind in the thrall of boredom,
and when, from the whole surrounding horizon,
a black day lifts, sadder than any night;

when the world has become a damp dungeon
in which hope, like a bat, flits to and fro
brushing the walls with its timid wings
and knocking its head on rotten ceilings;

when the rain, splaying its long trails,
imitates the bars of a vast prison,
and a silent populace of squalid spiders
comes to root its filaments deep into our brain,

the clocks leap with a sudden fury
and launch a frightening clamor skyward,
wandering, exiled spirits
apply themselves afresh to their relentless whining

-- and long hearses, to neither drumbeat nor dirge,
file slowly through me: Hope,
vanquished, weeps, and atrocious anguish, that despot,
hangs its black drape over my bent neck.


IV. SPLEEN

Ennui is small and has a child-proof lid.
Its skull collapses on each new-born thought.
Its belt’s cinched far beyond the tightest fit.
Its life’s in acronymn on microdot.

Its world’s a hospital, all curtains drawn.
They barely flutter with departing breath.
Its ceilings spatter red when Doctor John
nicks the carotid. Oops. That’s one for Death.

Ennui is where a million IV lines
surround you like a clutch of prison bars,
and EEG wires’ spidery designs
burn into your brain. You’re seeing stars ?

But, listen -- a whole wardfull of afflicted
has risen up and seized the doctors’ lounge.
Summon Psych ! They have to be evicted !
A blast of Thorazine will knock them down !

That’s better. Now secure the coffin lids.
I mean tuck them in. Tee hee. A slip.
And when we’ve pinned them down on our fine grids,
we’ll twirl our black, silk scarves, and then we’ll nip.

Boston.com / News / Boston Globe / Opinion / Op-ed / Bible lessons these clergy forgot

Today is the constitutional convention that takes up an amendment that would enshrine in Massachusetts' constitution a clause that prohibits a class of people from having a civil right enjoyed by the majority. A clause that mandates discrimination. I find it disheartening and shameful. The increasingly byzantine and hysterical contortions of Representative Travis, Speaker Finneran, Governor Romney, Archbishop O'Malley, Loathsome Activist Ron Crews and their neo-Phelpsian ilk have been painful to watch. Needless to say, Dubya, increasingly scrutinized for his mendacious, wrongheaded and thanatocentric policies, has come out in favor of a federal constitutional amendment defining marriage. It's easier to pander to the fundamentalist base than to defend his morally bankrupt and toxic policies.

Ideas for amending the Massachusetts amendment, or proposing legislation clearly contrary to the court's mandate are flying thick and fast. One can only hope that a majority of our legislators are people who value fairness and justice.

My senator, Susan Fargo, according to her office, opposes the amendment. My representative, Peter Koutoujian, also plans to vote against it, although the person to whom I spoke seemed less willing to state this uncategorically.

One of the media images that bothered me most recently was a photo of a demonstration, Church-sponsored, in which a child -- looked like a 12 or 13 year old girl -- was waving a sign that said "Adam and Eve Not Adam And Steve," a phrase straight from the neanderthal playbook of homophobic hate rhetoric. I cannot imagine a child coming up with such bile. I was reminded of Topeka's infamous and demonic Reverand Fred Phelps whose awful, hate-mongering demonstrations usually include a gaggle of his children and grandchildren, all bearing signs with text so obscene and awful I will not repeat it here.

In the progressive future I like to imagine, history books will list Travis, Finneran, O'Malley, Romney, Crews and their neo-Phelpsian followers as comprising a doomed last bastion of reactionary and malignant bigotry.

But do read the Jackson piece.

Bartleby, Dearest

what the world needs now is love sweet love


i. First, Some Didactics

Weeping after orgasm is a classic symptom
of Masochistic Personality Disorder (DSM-III).
In the 1980’s this condition was renamed
Self-Defeating Personality Disorder,
and was relegated to the appendix of DSM-IIIR,
out of concern for its potential forensic misapplication,
in situations of alleged spousal abuse.
(It should go without saying, gentlemen,
that these masochistic and self-defeating diatheses
are predominantly female afflictions.)
Neither diagnosis appears in DSM-IV, but we are confident
that our ongoing statistically rigorous nosological researches
will clinch their syndromic validity
and earn them back their rightful niche in DSM-V,
in Cluster C on Axis II somewhere between
301.6 (Dependant) and 301.82 (Avoidant).
That being said, Masochistic Personality Disorder
must be distinguished from Masochism itself (302.83)
which, along with necrophilia, zoophilia,
klismaphilia, urophilia, coprophilia,
frotteurism, exhibitionism, fetishism and the like
remains, I am pleased to report, a bona fide Paraphilia,
that is to say, a perversion. In these disorders,
which only rarely afflict females,
a meticulous diagnostic evaluation must include
a transducer (either a thin metal ring
or a mercury-in-rubber strain gauge)
placed around the penis ,
exposure of the patient to various audiovisual stimuli
depicting paraphilic and appropriate sexual scenes,
and measurement of the comparative degree of penile erection
elicited by each. Castration ? Stereotaxic neurosurgery ?
Well, because of certain legal and ethical concerns
inevitably and predictably raised
by the irreversible destruction of gonadal and/or brain tissue,
and by the paucity of statistically demonstrable benefit
of these procedures, their use at present
has, unfortunately, been somewhat limited.


ii. The Case Report

I was caught
weeping after orgasm
to a degree unjustified
by the usual post-coital tristesse.

They say I am beside myself,
and beyond help. I ask
what’s mine other than my dowry ?
They offer paraphernalia. Belt and spoon.

I have tried to inhabit the slit
between Fat Tuesday
and Ash Wednesday
but I don’t fit.

Does one sink faster
into the body
on whips and Perrier
or on heavy cream ?

You’d think
that the thin would sink needle-like
while the fat float. Nothing’s
that simple.

Oh, I understand the body’s contradictions
only too well. The bipolar
mortifications of pleasure and pain,
of yes and no.

There is a certain voluptuousness of refusal,
a certain ascetic of consent,
an aesthetic of both that comprises
such disparate parapoetics as sky- and sand- writing.

Still, there’s one parakeet left in paradise,
Little St. Pete, within whose garden walls,
we’re safe from both the Father and the Son,
and from our own pratfalls.

Nobody knows
the degradations I must imagine.
Nobody knows,
not even Jesus.

(Always use bleach.
Void after sex.
Do not use while bathing,
or sleeping.)

The ictus fades
like a siren that has temporarily obliterated
everything but the darkness.
To be sure, the room

slowly reconstitutes itself each time,
even after godhead,
the dresser safely beside the lamp, etc.
But there is that moment, that fissure

of impossible inquisition --
what is pleasure
what is pain
where is God

that even crucifixion can’t answer
since nothing’s narrow enough to needle the slit
between flesh and divinity.
Is that a paradox or a paranoia ?

Personally, I think god is a pun,
a Parousia of a paronomasia --
an accidental gaudeamus igitur.
But I am out of my gourd, after all,

and I neither sink nor float
but only sing a sweet, midstream refrain --
orally, orally, orally, orally,
everything down the drain --

they say there is a pill for it,
a paragnosis, a sinecure.
Ludicrous, I thought, but said
I’m game.

? 1997

Lines 27-39 in section 1 are a loose and overembroidered paraphrase of text found Becker JV, Kavoussi RJ: Sexual Disorders, in Textbook of Psychiatry. Edited by Talbott JA, Hales RE, Yudovsky SC, Washington DC, American Psychiatic Press, 1988.

The title of the piece piqued my attention instantly: Why I didn't become a doctor. Ambivalence about practicing medicine is one of my favorite topics, and stories about people who, as Philip Larkin puts it, "...chucked up everything/ and just cleared off" ignite in me a heady mixture of fascination, envy and anxiety. Julie Leung writes of her horror at the apparant hard heartedness of the emergency room staff after a homeless man is brought in, moribund, and dies. A sophomore in an eight year medicine/humanities program, she sees him

...stripped of his clothes, nearly naked, legs together but arms outstretched, looking like some kind of strange Christ...

and is astonished by the lack of emotion shown by the ER doctors and nurses. And although other personal considerations fueled her eventual decision to leave the program, this powerful image of abandoned suffering represented what was emotionally intolerable to her about that ER experience, and medicine: the sometimes icy distance between patient and provider.

I imagine that if she had remained in medicine she would have found a way to preserve her compassion and empathy, and also learned that empathy can (and sometimes must) operate behind a countenance of reserve.

In 1977 I was an intern in a community hospital, headed for a psychiatry residency. I was doing an ER rotation with a fellow pre-psych intern, and, although I forget the details of the case, I remember that an infant had just died. Right there in the ER. There's nothing quite as awful. The nurses were traumatized, distraught. My fellow intern, noting this, noting how "business as usual" has shuddered to a halt, made a loud and disparaging comment that included the phrase

"...decompensation over the issue of a dead baby..."

I'll just say he's lucky to have made it out of the ER that day without being torn limb from limb. I suspect that his breathtakingly insensitive comment was a defense against his own overwhelming feelings. One would hate to imagine a psychiatrist so unwilling to acknowledge and resonate with distress, so eager to pigeonhole it as "decompensation" over an "issue."

Julie links to a piece on Hermes - A Resident's Life , second year medical resident Victor Van Hee's extremely well-written weblog. He's a wonderful writer, darkly witty and observant, and sounds like an insightful and compassionate doctor. His post also caught my eye. It's called "A Great Case," and is about a case review of a young person dying of meningococcemia, a swift and devastating bloodstream infection. The title gave me a jolt.

Any doctor who has had or seen or even heard tell of a patient with meningococcemia never forgets it.

I had such a patient during my residency in the late 1970's. He was a middle eastern jeweler, a young man. I remember the detail of his packet of jewels residing safe in the hospital vault as the jeweler unraveled swiftly in the ICU.

I remember doing a skin scraping and slide of the ugly, almost visibly advancing purple skin lesions -- called for good reason purpura fulminans -- and how a shudder of horror passed through me when I saw the oddly beautiful double bean shaped pink coccobacilli through the microscope lens.

I also remember the next day's morning report , the meeting where residents gather and present the previous night's admissions. Our chief was a pipe-smoking, tweedy, bow-tie sporting thyroidologist, a pleasant, somewhat dusty, smart and enthusiastic man, whose favorite phrase was

A Great Case

He used it so often that year that I came to imagine him carrying a large, dusty valise. The jeweler with meningococcemia was, of course, a great case. And, as the sleepy resident who presented it at report, it became my great case. Even years later Dr. R. would remind me of it, my great case, the jeweler who died (after many days of terrible suffering) of meningococcal sepsis.

For me, "great case" is a portmanteau phrase that carries within it that dusty thyroidologist whose pipe fumes I can conjure to this day. Also, in its fusty depths, is the jeweler, dying, fulminant purple, and his packet of jewels, occulted in the hospital administrator's vault. And myself, the resident, peering through the microscope at the oddly beautiful coccus, horror struck by what it signified.

Years later, hearing of a similar patient (a girl, 16) who had come through our hospital's ER overnight (word of such great cases spreads like wildfire) I remembered the jeweler, and Dr R. with his large valise. I thought about the second limb of my residency that I'd undertaken at the doddering age of 40 after the world's longest maternity leave. How staining slides in the empty micro lab in the wee hours had seemed a blissful refuge from the demands of the wards.

And I shoved it all into the fusty valise of this poem.

Gram Stain


for I. R.

Purpura fulminans. She scrapes a bit
of flesh from one dark lesion’s leading edge,
and spreads it on a thin oblong of glass.
The lab, at 3 am, is empty, still,
except for the dull throb, the metered hiss,
the intermittant click of instruments.
The redolence of agar, warmed microbes
spreading over plates and clouding flasks,
milkens the basement air, reminding her
and her breasts of the infant sleeping, home.

Gram stain (c. 1860, Christian Gram)
is a task that any intern knows by heart.
Which really means, she thinks, by hand and brain.
She leans to stainless steel, adjusts the stream
of water (gentle, cold). Uncaps the lamp
whose woven wick leads spirits into flame
atop a thick glass bulb, a zungensprach
whose bluish heat will fix the stolen flesh
to glass, Pompei without its coat of soot.

First comes crystal violet. She decants.
The livid fluid drowns, obliterates.
She counts -- one onethousand, two onethousand --
recalling lightning, and how she’d time the gap
between it and thunder, terror-struck, to tell
how close the storm was. Mother ? Fast asleep.
Fulminans, it split the purple sky,
photographic negative of how
the purple lesions split her patient’s flesh
white from white, so swiftly she could see
the fingers gloving purple, the slender flank,
barely sixteen, now wise beyond its years,
putting on the horrid, tattered lace
of a certain betrothal. Time to rinse.

Next, is Gram’s iodine, brown but kin
to violet. It blackens starch and stings,
astringent, medicinal. She counts again.
Recalls Paré’s humeur fuligineux ,
the sooty, brackish humour that meant death,
modernizes it to DIC,
disseminated intravascular
coagulation, when the whole works
clots and bleeds at once, the clotting cascade
become Niagara, and then recalls
how every cliff and cataract reminds
a mother of her infant’s perilous
sojourn upon the earth. She shivers, yawns.
Thinks of the silent woman by the bed
behind the weft of tubing in which her child
sleeps, and in which both seem caught. Now rinse.

This is the tricky step. Decolorize.
Too long and the caught flesh will wane to ghost,
too short and it’s an inkblot, both everything
and nothing. It takes intuition, eye.
The rods and cocci come out pink or blue
according to their kind, gram-negative
or positive. Like us, they’re named for stain.
Rinse. A name’s a stain, a drain. The brain’s
so easily misled by likeness, rhyme.
A bruise is not a flower, and breath’s not time.

Last comes the counterstain, the safranin.
She counts again. The embalmed cells enrouge.
I undertake, she thinks. It undertows.
Her fingers, carelessly ungloved, are red
on splattered purple, on raw pinkish beige.
She counts. Her shoulders bend beneath the weight
of hospital. She likes it underground,
amidst the caged, proliferating germs,
things with no business but their own to mind
busily, mindlessly, endlessly, thousand.
She counts and breathes regret. The final rinse.

Then blots between the leaves of bibulous
paper, red and wrinkled as if by fall,
and looks, holding the slide up to the light --
a pinkish whorl caught on transparency,
the fingerprint that solves the heinous crime
but cannot ever resurrect the corpse.
She knows what’s there, what fateful, slashing sword
undoes the body’s weave so thoroughly,
terribly, swiftly, fulminans, more
fulminans than a Papal fulminare ,
not war or condemnation or a flower
blooming on a girl, but just a Gram-
negative diplococcus, bean-shaped,
able to undo the body utterly,
within hours, within a breath. The mother sits,
she thinks, and listens to the bloody falls
just a bit downstream from where her child
hangs caught midchannel in frail branch and vine.
Penicillen, pencil, little brush
seem useless against this inexorable
flow and gravity. And microscope.

Three fifteen, she thinks, is the worst time.
Immersion oil bathes eye and lens and slide
in highest power. She twists the focus, fine,
and is ashamed to find them beautiful --
hard, fuschia, twinned, stippling a field
of pink and blue nucleated honeycomb:
Neisseria meningitidis, akin
to N. gonorrhea, named for Neisser
(1855-1916)
who was a German syphilologist,
as syphilis was named for the hero
of “Syphilis Sive Morbus Gallicus,”
the sorely afflicted shepherd, Syphilus.
Named by Girolamo Fracastoro,
a doctor-poet of Verona,
circa 1530, who was in turn
named by his mother, for something round
or spinning, for mud or olives, a fracas-
maker, bull, brother of beavers, Pollux,
swordsman, Hieronymous, holy name --
who knows ? How did his name stain him ? A name,
a dusty cabinet, piled bibelots.
Her baby, she thinks, she hopes, must be asleep.
After names there comes the bedside watch.
She tries to count the hours left till home,
loses count, and tosses out the slide.
Glass clinks on glass. She’ll take the stairs. L’chaim.

4.12.97