There is a grand tradition of physicians who are also great writers and philosophers. When his first book, Catharsis, was published in English, critics from Seamus Heaney to Czeslaw Milosz stood to applaud. Now Andrzej Szczeklik has followed with an ever deeper and more accomplished book.
It has become unfortunately rare for a scientist or doctor to find his grounding in a broad understanding of literature and the humanities. But in Kore, the author insists that only with a curiosity thoroughly at home in both worlds can one expect to discover what we should mean about sickness and about the soul. No tedious academic, Szczeklik writes with the grace of a poet and the ease of a fine storyteller. Anecdotes drawn from a personal immersion in art, music, and literature are woven with reports on experimental medicine and daily clinical experience. From DNA and the re-creation of the Spanish Flu virus, to contemporary research in genetics, cancer, neurology, and the AIDS virus, from Symptoms and Shadows, to Dying and Death, to Enchantment of Love, every chapter of this book is alive and engaging. The result is a life-affirming work of science, philosophy, art, and spirituality.
“No medical experience necessary: readers need only approach with a love of the human body and an understanding of how it relates to emotion and story . . . Readers may find it difficult to keep up, but few are likely to forget this book.” —Publishers Weekly
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SYMPTOMS AND SHADOWS
To tap and to listen, to look and to feel,
To make the eyes open and seek out the soul,
To hear out the breathing, to see fleeting clues,
To grasp just how simple the crux of it proves.
Coming home one evening, Raphael felt unwell and was seized by shivering and fever. Even though he had never known illness before, he sensed the approach of death. He received extreme unction and wrote his will, and a few days later he was no longer alive. He died on Good Friday, on his thirty-seventh birthday, at the height of his fame and universal adoration. Before dying, he said farewell to the woman he loved, entrusting her care to his faithful servant. He left us her portrait. Her name was Margherita, and she was known as La Fornarina, because she was the daughter of a baker (or fornaio in Italian).
From the picture a half-naked brunette looks out at us, her smooth raven-black hair wrapped in a turban. She has large black eyes and an inscrutable expression on her face. The light is falling from the right, and her gaze is most surely directed at the artist. There is a narrow gold and sapphire bracelet around her left arm with the name Raphael on it, "perhaps more than just the artist's signature." She has bared her breast and covered her belly in a veil, her hips in a pink skirt. Her pose is sensual and innocent all at once. Behind her, against the black backdrop of the night, grows flourishing myrtle, the favorite plant of Aphrodite, goddess of love.
The woman's hand is resting on her naked left breast, with the fingers pointing towards the side of it and the armpit. If we follow this pointer, we might notice a slightly darker coloring at the edge of the breast, which is a very pale shade of blue. However, it is not a shadow, because the skin is drawn tight, bulging as if there is a lump, and so is the underarm area on the same side. If we take the analysis further by applying some special photographic techniques, it turns out that to render this bit of the portrait Raphael laid at least nine colors on top of each other, including some dark shades, while on the other side two colors were enough, pink and cream. A medical diagnosis was made for the first time in 2002, which declared that it was cancer of the left breast with probable metastasis to the axillary lymph nodes.
Was he the only one who knew? Or did she know too? Did they know what THIS meant? As the poet Czeslaw Milosz says, THIS is like:
... the immobile face of someone who has just understood that he's been abandoned forever.
Or the irrevocable verdict of the doctor.
This. Which signifies knocking against a stone wall and knowing the wall will not yield to any imploration.
Where do we get the bold idea of exposing the truth, casting THIS before the eyes of the world? It took the world four hundred and fifty years to notice and recognize Raphael's intention, though of course the accuracy of this medical diagnosis is debatable. It is not so much the actual diagnosis that comes into question as the fact that someone could go so far as to reveal sheer despair, so wholly and utterly — THIS.
The adored Raphael is buried in the Pantheon. His epitaph was composed by Cardinal Pietro Bembo, demonstrating the Renaissance style in all its splendor; in Thomas Hardy's version it reads: "Here's one in whom Nature feared — faint at such vying — / Eclipse while he lived, and decease at his dying." These words echo with arguments that have been debated since Aristotle — whether art can only imitate nature, or whether, by creating it anew, it can master and perfect it. In Renaissance times and the centuries that followed, this argument about the boundaries of art also applied to the art of medicine.
What about La Fornarina, so greatly loved? The woman whose type of beauty appears in many of Raphael's works, in his most beautiful female figures? What was her fate? She was not allowed to take part in her lover's funeral because she was not joined to him by a church marriage. Only one bit of information has survived: an entry in the records of the convent of Sant' Apollonia in Rome dated 18 August 1520. On that day she crossed the threshold of the convent, and the gates closed behind her, never to reopen.
Historians of medicine tell us that, although women have suffered from breast cancer since ancient times, no description has been found that distinguishes it from other diseases of the mammary gland, neither in antiquity, nor for the next one-and-a-half millennia. Nor do we find it in Andreas Vesalius and Juan Valverde's wonderful Renaissance anatomical atlases, treasure-houses of medical symptoms. Only in the seventeenth century was a description of the clinical symptoms first published, enabling the differential diagnosis of breast cancer. And so Raphael noticed it one hundred years earlier, before the eyes of doctors had distinguished it from among a multitude of mammary gland conditions.
I have been looking at Raphael's work since birth. Above my parents' bed hung a medallion with a replica of his Madonna, and at the school I attended in Krakow, the Bartlomiej Nowodworski Lycée, which boasts an over four-hundred-year-old tradition of educating kings, poets and scholars, the ceiling in the vast entrance hall was covered in a fresco depicting The School of Athens. I do not think we ever had time to take a close look at it, neither in the mornings as we rushed to the start of classes at the last moment, nor in the breaks between lessons, as at the first sound of the bell we ran down the steps, through the theatrical hall and into the playground, where two games reigned supreme: soccer and zoska (also known as "footbag"). Zoska was played with a small, leaden metal ball, pierced in two places by a thin wire, with a woolen pom-pom attached to it to guarantee the airworthiness of this addictive toy as it was tossed by the foot. At the time we never gave any thought to The School of Athens or Raphael, or to the fact that in 1507 Pope Julius II invited him and some other renowned artists to renovate the Apostolic Palace. The visiting artists were sent to the Pope's private library, to a room known as the Stanza della Segnatura. After seeing only a few sketches by the twenty-four-year-old artist, the Pope was delighted, ordered the frescoes painted by the other artists to be "cast to the ground" and entrusted Raphael with the decoration of the entire apartment. Inside the tondi in the Stanza's vault we can see allegories of Theology, Philosophy, Justice and Poetry, linked to themes depicted on the walls. The fresco called The School of Athens corresponds to Philosophy. Inside a spacious, open building, crowned with mighty barrel vaults as a reference to Donato Bramante's design for the new Saint Peter's Basilica, the philosophers are holding discussions in various groups. From the center of the picture two figures are walking towards us — Plato, with Timaeus in one hand and the other pointing to heaven, the transcendental seat of Being and the Idea; and beside him Aristotle, with his hand stretched ahead, between heaven and earth, to demonstrate that the Idea lies within the reality of the senses. A little lower, on one side of the steps, sits Pythagoras, surrounded by his pupils, presenting musical proportions, and on the other Euclid is leaning over a writing tablet with a compass in his hand, initiating some youths into the mysteries of geometry.
Only one man is dressed in contemporary clothing. We see him in the foreground, sitting on the steps, leaning his head on his hand; deep in thought, he is writing something in a notebook. This figure, identified with Heraclitus, is generally regarded as a portrait of Michelangelo in the years when the Sistine Chapel frescoes were being painted. He is wearing tall boots made of soft leather turned down below the knees. There are several lumps on his right knee. They look hard and compact, with no trace of redness or inflammation. To the doctor's eye they are a typical symptom of a distinctive disease. As we know that Michelangelo suffered from attacks of nephrolithiasis (kidney stones), we can accept with a high degree of probability that the lumpy growths on his knees are the hallmarks of podagra, in other words, gout. Lead could cause the disease to develop; it is said that while painting the Sistine Chapel he lived for weeks on end on bread and wine, which in those days was kept in lead vats.
And so illness showed its face to the eyes of a brilliant artist. More often, however, it stays hidden inside us, frightening us by remaining invisible. The doctor tries, briefly, to encourage it to reveal signs that he can use to build a diagnosis, define and name his adversary. The art of medicine depends inter alia on exposing the symptoms of disease. Just as a magician summons up spirits at a small, spinning table, so a doctor summons up the symptoms of an illness. But can we force an illness to drop its guard by tickling its foot? Yes, replied Joseph Babinski, and with this statement, based on his discovery of the so-called plantar reflex, he had a decisive influence on the development of neurology in the early twentieth century.
After making his discovery, Babinski presented the contemporary picture of neurology in a lecture addressed to the Royal Society in London. He began with a quotation from Don Quixote. One evening, after a long day of exhausting rambling, the knight errant stopped at the door of an inn. "Who's there?" shouted the publican, without turning the lock. In reply our hero presented his titles: "Duque de Béjar, Marques de Gibraleon, Conde de Bañalca-zar y Bañares, Visconde de la Puebla de Alcocer, Señor de las Villas de Capilla, Curiel y Burguillos." The publican replied that to his regret he could not lodge so many people, and thereby deprived himself of a guest who might have procured him great profit.
The same sort of unfortunate episode, continued Babinski, awaits the student of medicine, as he tries to find room in his memory for the names of all the reflexes of the lower limbs. And here he reeled off about two dozen names that to spare the Reader we shall not mention. Admittedly, doctors had had a few hundred years to write down this long list of reflexes. They had begun to understand them thanks to Descartes, who was the first to comprehend what reflexes are — the automatic, stereotypical functions that do not involve "the intervention of our soul." And in a drawing showing a man retracting his foot from a blazing bonfire, he drew the path of a reflex: from the outer edge (the heel) to the central nervous system, and back to the muscle (the calf).
* * *
Babinski owes his place in the history of medicine not so much to the fact that he brought order to a seemingly infinite number of limb reflexes, whose clinical value remained doubtful moreover, as to the discovery of the new symptom that bears his name. Retracting the leg in response to irritation of the sole of the foot had long since been familiar. Depending on the intensity of the stimulus, a dorsal bend of the foot was accompanied by a bend in the knee and the hip. No one paid any attention to the movements of the toes, nor were they ever mentioned in passing, until Babinski examined the response of the big toe to pricking or rubbing the sole, and noticed a difference between an upwards movement of the toe in disorders of the nervous system and a downwards movement among healthy people. He proved that this upwards movement, straightening the big toe, is an unusually sensitive indicator of disorders in the functions of the pyramidal system, along which all sorts of nerve routes run. He discovered what is in many people's view the most important of the symptoms that reveal disease of the central nervous system.
Joseph Babinski was born in Paris in 1857. His parents were Poles who had been forced to emigrate from Poland, and had met and married in France. His father, an engineer, even traveled to Peru for his work in order to secure a living for his young family. Not long after completing his studies, Babinski became first assistant to Jean Martin Charcot, who was at the height of his fame. Examining masses of disabled inmates at the Salpêtrière Hospital, including their brains and spinal cords whenever the chance arose, Charcot and his fellow workers identified many nervous diseases known to this day, such as multiple sclerosis. In 1890 Babinski left Salpêtrière to take the post of senior registrar in the neurology department at La Pitié Hospital, where he would continue to work until he retired thirty years later. Tall, statuesque and blue-eyed, "he had none of the typical Gallic panache." He would arrive at the hospital at nine-thirty by droshky, or in later years by car, with a taciturn chauffeur, change into a white tunic and proceed in silence to his consulting room, a converted four-bed hospital ward with chairs installed for his guests from France and abroad. He would sit with his back to the wall, within reach of a small table where his examination instruments lay: a neurologist's hammer, vibrating forks, a pincushion full of needles, test tubes containing hot and cold water and a stimulation apparatus using a constant or variable electrical current. Lined up in the corridor, the patients came in after entirely undressing behind a screen. Babinski would start by silently examining the patient, and then making some terse comments on his posture, gait and movements. After gathering a brief medical history, he would prompt a series of symptoms with the help of the hammer, needles or electrical stimulation, while an assistant noted down his laconic remarks. One day a dejected patient came to see him; once some galvanic electrodes had been applied to his temples he livened up, with his head bouncing now to one side, now the other, depending in which direction the current was flowing. Finally, Babinski completed the examination without saying a word. "Next!" he cried. But the amazed patient exchanged two words in a whisper with the nurse behind the screen and, just as he was, still naked, returned to Babinski's presence. Knowing that time is money, he asked one fundamental question. Pointing at the organ farthest from his head, located at the other end of his body, he asked: "Can't you find a way to liven that up a bit?"
Babinski deserves the credit not just for discovering the plantar reflex, but also for describing a whole gamut of symptoms that make up the whole of modern neurological semiology. His clinical demonstrations in the hospital amphitheater drew in crowds of people. Showered in the most prestigious international awards, hewon fame in Europe and both Americas. "I am proud to have two motherlands," he said. "To one I owe my knowledge, and to the other the roots of my Polish soul." He asked to be buried in the Polish cemetery at Montmorency in the Paris suburbs. Towards the end of his life, he regarded his greatest achievement to have been paving the way for the first generation of French neurosurgeons. What he had succeeded in doing was to diagnose and precisely localize a tumor in the spinal cord, showing the neurosurgeon the exact spot where he should operate. He did this by pricking the back with his needles, finding sensation dysfunctions and observing the bending movements of the lower limbs. The master clinician had once again summoned up the spirit of the illness, diagnosed it and brought about a cure for the patient.
Before a doctor sets about the examination that we call objective — in other words, looking, feeling, tapping and listening — he talks to the patient, listens to his answers and gets to know the history of the illness. He helps the patient to "be free of forgetfulness." This is the root of the Greek word defining the truth, aletheia. Greek thought was permeated with the belief that the truth lives inside us. On the architrave of the temple at Delphi the ancients wrote: "Know Thyself," and like Plato they believed the truth is about remembering, or anamnesis. Meanwhile, to the truth itself they attributed a liberating force. In this sense the truth, as revealed by a patient telling a doctor his medical history, enables a diagnosis by being presented to the doctor. In almost half of all cases the diagnosis can be made from a skillfully gathered history of the illness. The rest is just its confirmation.
Sometimes it is hard for the patient to make himself heard. The doctor is in a hurry; he has his own worries, and simply isn't listening. Just like me, when at the age of seven my younger son Wojtek longed to have a tortoise. All his friends at school had either a cat or a dog, or at least a hamster, a guinea pig or a mouse. But he had no pets, and at home we refused to hear another word about that tortoise. Until finally ... When he was in second grade at elementary school he was given an assignment to write about: "The Animals at My Home." My son wrote a short piece, just one sentence: "At our house there are nothing but moths." That very day we bought him a tortoise. Only a week later, there were seven of them in the house. Dear Reader, in time of illness may you never have to resort to such extremes to have the doctor listen to you!(Continues…)
Excerpted from "Kore"
Copyright © 2012 Andrzej Szczeklik.
Excerpted by permission of Counterpoint.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.
Table of Contents
SYMPTOMS AND SHADOWS,
ABOUT THE BRAIN,
IN SEARCH OF THE SOUL,
THE REFLECTED WORLD INSIDE US,
THE ARCANA OF ART AND THE RIGORS OF SCIENCE,
GENETICS AND CANCER,
THE TRUTHS OF BIOLOGY AND FAITH,
ON DYING AND DEATH,
THE ENCHANTMENT OF LOVE,