To talk of diseases is a sort of Arabian Nights entertainment.
--William Osler
The physician is concerned (unlike the naturalist) . . . with a single organism, the human subject, striving to preserve its identity in adverse circumstances.
--Ivy McKenzie
Preface
"The last thing one settles in writing a book," Pascal observes, "is what one should put in first." So, having written, a title and two epigraphs, I must now examine what I have done--and why.
The doubleness of the epigraphs and the contrast between them--indeed the contrast which Ivy McKenzie draws between the physician and the naturalist--corresponds to a certain doubleness in me: that I feel myself a naturalist and a physician both; and that I am equally interested in diseases and people; perhaps, too, that I am equally, if inadequately, a theorist and dramatist, am equally drawn to the scientific and the romantic, and continually see both in the human condition, not least in that quintessential human condition of sickness--animals get diseases, but only man falls radically into sickness.
My work, my life, is all with the sick--but the sick and their sickness drives me to thoughts which, perhaps, I might otherwise not have. So much so that I am compelled to ask, with Nietzsche: "As for sickness: are we not almost tempted to ask whether we could get along without it?"--and to see the questions it raises as fundamental in nature. Constantly my patients drive me to question, and constantly my questions drive me to patients--thus in the stories or studies which follow there is a continual movement from one to the other.
Studies, yes; why stories, or cases? Hippocrates introduced the historical conception of disease, the idea that diseases have a course, from their first intimations to their climax or crisis, and thence to their happy or fatal resolution. Hippocrates thus introduced the case history, a description, or depiction, of the natural history of disease--precisely expressed by the old word pathography. Such histories are a form of natural history--but they tell us nothing about the individual and his history; they convey nothing of the person, and experience of the person, as he faces, and struggles to survive, his disease. There is no "subject" in a narrow case history; modern case histories allude to the subject in a cursory phrase ("a trisomic albino female of 21") which could as well refer to a rat as a human being. To restore the human subject at the center--the suffering, afflicted, fighting, human subject--we must deepen a case history to a narrative or tale: only then do we have a "who" as well as a "what," a real person, a patient, in relation to disease--in relation to the physical.
The patient's essential being is very relevant in the higher reaches of neurology, and in psychology; for here the patient's personhood is essentially involved, and the study of disease and of identity cannot be disjoined. Such disorders and their depiction and study, indeed entail a new discipline, which we may call the "neurology of identity," for it deals with the neural foundations of the self, the age-old problem of mind and brain. It is possible that there must, of
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