The Wanderer

The Wanderer

“It’s really up your alley,” said John.  “You know, you make a sort of specialty with the oddballs, the cases that fall a little off the beaten track.  And this one has some interesting features.  It may be a fugue state—there are certainly some dis-associative elements operating here.  And there’s clearly dysthymia and depression operating as well.  It would be challenge for you…”

In plain language—somebody had been dumped in the ER, half frozen, half cogent.  He presented with a scattered story—something about love lost, about disappearing suns, about a tree.  He imagined his tears flowing into the river, to flow past his previous happiness.

Daignosis: possible major depression, possible short term schizoaffective disorder, possible fugue.  He was placed on 15 minute suicide watch, and a battalion of blood tests were done—all negative, except, remarkably, for the VDRL.

Syhphilis.

“It seems to me,” I said, “that is more up Infectious  Dease’s ally than Psych.  What do we know about treating third stage syphilis?  Let the ID boys take him, evaluate him, get him to his baseline.    What residual symptomology may be treatable, or it may be organic, at this point.  After Neurology sees him, then we can make a plan to see if it’s something Psych can deal with.  But at this point, any admit to our ward is premature.  We’re crammed as it is with all the borderlines and depressives and chronic schizos who have flooded into the pysch unit to get out of the freezing weather…. “

“ID won’t see him before a psych consult has been done….”’

“What?  That’s bullshit!  The guy’s testing up positive for syphilis, and ID won’t see him?  Who’s the attending?”

“Leskowitz….”

“ Leskowitz—right, it would be.  A guy who learned one thing in Med school—how to turf the most difficult patients off his wards.  A patient comes in with fulminant tuberculosis and a hang nail, and Leskowotz insists on a podiatry consult first.”

A few days before Christmas, it was just another turf war.  Yeah, docs are trained to cure, to heal—we devote ourselves to our healing arts.  But Christmas is Christmas—with families and kids and presents under the tree to be opened by your five kids, whose faces you’ve forgotten and names you can barely remember.  So it’s turf and dump, the week before Christmas.  Anyone who positively won’t die you send home:  that’s a dump.  Anyone who can be sent to another ward: that’s a turf.

“All right,” I said, playing the game, what’s the guy’s name?  I’ll see him, make an evaluation, and turn him over to ID….  Fortunately, tertiary syphilis is highly infectious, right?”

“Wrong.”

“What?  How can it NOT be?”

“One of the mysteries of the disease.  The first and second stages—yes, and highly so.  In the latent stage, no.  And then the third stage is also no.  You remember, it breaks down into the rule of thirds:  gummatous  syphilis, cardiosyphilis, and late neuro syphilis.  And no, none of them are contagious….””

  “Shit,” John was right.

So I headed down to ER, down to find a good reason to keep him off my floor….  

First clinical visit

Clinical History of Patient X

Age: 55

Sex: Male

Race / Ethnicity: White American

Allergies: Possible paradoxical reaction to Buproprion

Referring Psychiatrist: Jorge Sánchez Cruz, MD

Medications: Atacand 16 mg. QD

                    Norvasc 2.5 mg. at HS

                     Lexapro 20 mg. QD

                     Klonopin 1 mg. TID

                     Dalmane 30 mg. at HS

Chief Complaint: “They think I’m worrying too much about Schubert.”

Clinical Notes:  The patient evidenced hostility from the moment he entered the office.

“And the first problem I have with you,” he said, pointing his finger directly at me “is your ridiculous name.   Weinstein  indeed,” he snorted.

It was evident that he had started a negative transference, thus I was careful to be non-threatening.

“Perhaps you could tell me, X, what issue you have with my name….”

“Have you no German, Sir?  Or even any curiosity about your surname?  You must know what it means!”

His nostrils were flared.

“Perhaps you could tell me….”

“ Of course I could tell you,” he snapped.  “There’s no perhaps about it.  Wein is exactly what you’d think—an alcoholic beverage produced by fermenting grapes.   Stein—a vessel used to consume beer.   Thus, you are walking around advertising yourself as a moron who drinks wine from a beer vessel.  And it is to you that I am to entrust my psyche?”

I decided to allow him to pursue this topic.

“And what would you like to call me?”

“Well, what’s your tipple?”

“I beg your pardon?”

“Your drink, Doctor—what do you drink?”

“I have an occasional glass of wine, socially,” I said.

“I detest social drinking,” he snarled.  “A binge, yes.  Constant inebriation—much to recommend it.  But social drinking is, in a word, for wimps.  However, since it’s wine you ‘socially’ drink, your name will now be Weinkelchglas.  Not bad, actually.  Though you might change to beer, in which case you could be the somewhat easier Bierstein.   Your choice, Sir.”

“Let us now,” I said, trying to control my temper (my own negative counter-transference had begun) “return to the reason for your visit here, today.  Dr. Sánchez notes that you seem preoccupied with Schubert.”

“Let’s get one thing straight, Doctor,” said X, leaning across my desk.  “I do not like the word seem.  It’s a word that, well, only a social drinker would use. I am, or I am not.  I do not seem.  And yes, I’m certainly worried about Schubert.  There’s certainly good reason to be….”

“Schubert—the German composer?”

“AUSTRIAN, AND MORE, VIENNESE!  Known in German, Sir, as Wein—Dr. Weinkelchglas.  God’s blood, have you NO education?”

“Harvard Medical School, class of ’83,” I said.

“Not an unknown school,” he acknowledged.  “Well, we know you have no German.  Greek?”

“No,” I said.

“Latin?”

“Nor that,” I returned.

“You are, then, merely schooled.  Educated, much less learned, you are not.”

“You change topics frequently,” I said.  “Could we return to your preoccupation with Schubert, the, err, Viennese composer?”

It was then he cracked.  Tears streamed down his face, twisted with anguish. 

“ Drei sonnen sah ich am Himmel stehn.  I saw three suns stand in the sky. Now two are gone.  Ging nur die dritt’ erst hinterdrein!  Would that the third might follow!  I would feel better in the darkness!”

Notes:  Poor impulse control, evident poor self image (as evidenced by his need to seem superior) and probable psychosis.  Will add an antipsychotic, Haldol, 5 mg. TID to medication regimen.

  
         

Second Session

Session Two

The patient appeared less hostile on the second visit—no doubt the therapeutic effects of the Haldol were starting.  I tried to put him at ease.

“And how are we feeling today?”

“We don’t know, do we?  How could we?  I barely know what I am feeling, and cannot, of course, speak for you.  How are you?”

“ Is your preoccupation with Schubert, the…err….Viennese composer continuing?”

“I’m hardly preoccupied,” he said.  “Deeply interested, of course.  Well, who wouldn’t be?  Everybody should be interested in Schubert.”

“I don’t know the composer,” I said.  “Perhaps you could fill me in?”

“Certainly I could fill you in.  Would you like the Wikipedia version or my version?  Or perhaps,” this said with a sneer, “for a doctor who is only schooled, the Wikipedia version might be the only one possible….”

I had forgotten his dislike of the word perhaps. 

“A bit of hostility still remains,” I said, deciding to confront him at last.

“I am not hostile.  I admit to acerbic.  Rebarbative as well.  Prickly, should the previous words be too advanced for a Harvard graduate.  But hardly hostile.”

I let this pass….

“Schubert?” I say.   

“Ah, Schubert,” he says, his face relaxing.  “Viennese, as we know.  His father, a school teacher.  The mother, the daughter of a locksmith.  Dates: 1797 to 1828, he died at age 31—having two years less than Mozart.  Cause of death: typhoid fever, though he was also afflicted with syphilis.   A terrible businessman, who barely got anything published, and that on unfavorable terms—unfavorable for him, not his publisher.  Known perhaps best for his lieder—art songs, in German.  Prolific—600 plus songs, nine symphonies, 15 quartets, a string quintet that is assuredly one of the greatest chamber works in the whole canon of Western music.  Six masses, and 21 piano sonatas.  He dies in virtual obscurity, broke, but surrounded by friends who deeply admired him.  Oh, and just incidentally, he composes the two greatest song cycles in the world.  That enough?”

“It seems a bit manic,” I venture.

“Your word, doctor.  Mine would be possessed, a genius that may never come again….”

“Thank you,” I said.  “So now I know Schubert.”

He jumps to his feet. 

“You know NOTHING about Schubert!” he roars.  “I’ve been giving you the briefest sketch of his life.  People spend their LIVES trying to understand Schubert, and there are mysteries that will, I believe, ever remain locked.  What have you ever heard of Schubert’s music, my good philistine doctor?”

“Not much,” I say.  “Didn’t he write the Unfinished Symphony?”

“Of course,” says X.  “Dismissed by some, beloved by the masses.  I personally like it….” 

Ahh—perhaps the basis for a clinical bond!

“So perhaps we could have your version of Schubert?”

“Mine is of little interest,” he responds.  “My good doctor, have you no curiosity?  Wouldn’t you like, for once in your life, to enter into a masterpiece?  To experience something that is greater, truer than anything you or I will ever do?  I could play you one song—ONE song—that had he written nothing else would have established him as one of the greatest composers of all time.”

“I’d like to hear it,” I say, though really, I don’t much like classical music.

“Nothing easier,” says X, and pulls his iPhone from his pocket.  He fiddles with it, and then shows me the following clip from youtube.  We listen, and blessedly, it’s short.

“So,” says X.  “You now have been initiated.  You have heard one of over a thousand compositions of Schubert.  Your impression, please?”

“Well,” I say,  “speaking clinically, it sounds deeply sad.  Depressive, I would say.”

“You know, doctor, I am far less interested in your clinical impressions than in your reaction as a man, a person.  But I am perhaps being unfair.  No one can grasp the song without knowing the lyrics.  Let’s listen again, this time with the lyrics, German and English.”

He hands me the liner notes.

Heil’ge Nacht, du sinkest nieder; Nieder wallen auch die Träume Wie dein Mondlicht durch die Räume, Durch der Menschen stille Brust. Die belauschen sie mit Lust; Rufen, wenn der Tag erwacht: Kehre wieder, heil’ge Nacht! Holde Träume, kehret wieder!

“And now,” he says, let’s turn to another singer, with the lyrics in English.  Much slower, and a bit more operatic.  Well, it would be—Fleming, of course.  But here, she does a fine job.

We listen again.  And I am still more mystified. 

“The title of the song, by the way, is Nacht und Traume—Night and Dreams.  Tell me, my good psychiatrist, isn’t that rather up your ally?  You do do stuff with dreams, don’t you?”

“I’m feeling a little out of my league,” I say.

“I’m delighted to know that,” says X.  “It’s a poem that is seemingly simple, and yet Schubert brings out the most amazing depths in it….  Consider it just as a poem.”

Holy night, you sink down; Dreams, too, drift down Like your moonlight through space, Through the quiet hearts of men; They listen with delight Calling out when day awakens: Return, holy night! Fair dreams, return!

“Really, not much to it.  But I listen to it often, on those many nights when Holy night does not  drift down.  I suffer insomnia, you see….”

“Ahh,”  I say, “a sedative may be called for.  Something more than the Dalmane.  But tell me, what does this song, this poem, mean to you?”

Again, as he had in the first session, X dissolves in tears.

“Dreams,” he says, weeping.  “Have you never had dreams?   And had them die?  And wish, more than anything else for their return?  This is Schubert, in his moment of darkest sorrow—lost and yearning—imploring God to return him to his path, and restore his dreams.  And filled with despair, he manages to suggest the possibility of hope, of redemption.  A feeling I, frankly, do not share”

Clinical note:  Will add halcyon 2 mg. for sleep