Marginal Thoughts

Now that my salad days are merely photos staring forlornly at me from a tattered album, I sometimes wonder what they would think of the one squinting back. Would it be as difficult looking forward in time, as it is in looking back? Not only do features change, but so do goals. Thoughts. I am no more the bright-eyed child petting the dog in the picture than he is the wizened old man desperately trying to remember him. So what, except for the chromosomes that are slowly losing their telomeres, is permanent enough to link us together?

I think about that a lot, nowadays; perhaps I am drafting my own eulogy, although I’d prefer not to put it in those terms. There are always clues we leave for those who follow, but can we leave a trail for those who are in front? A diary might help, I suppose, but in my case I was sure my mother would find it along with the magazines I had to hide; it simply wasn’t worth the risk.

So my childhood followed obediently behind me like a silent shadow, detected only if I turned around. I regret that now, of course, but not when I was young.  I would never have thought that my past would seem as loosely attached as the buttons on my shirt are nowadays; sometimes I think there are more memories sewn to the books I’ve read than to the experiences I’ve no doubt had but haven’t specially saved and organized on shelves…

I was thinking of that recently, as I cast my eyes over some familiar book-covers. If only life was as revisitable as the covered books seem to be… I doubt if I’m still as easily recognizable as the stories. The titles I read were varied -perhaps even precocious- and I suppose they should have cast some light on the younger me, but they could as easily have been the futile attempts of a short, bespectacled boy’s attempts at braggadocio.

I have vague and ill-defined memories of reading the Compact Edition of the Oxford English Dictionary on weekends hunting for obscure words I could use in class: words such as ‘tarn’, ‘lugubrious’, ‘threnody’ and even ‘sesquipedalian’ briefly materialized in the linguistic mist when I thought more about those days. Still, maybe that was just a phase; surely I wasn’t that embarrassingly desperate the whole time. But who was I then?

Without ancient bones, or cave art to map the changes though, how can I now chart the evolution of my thought through what seems, from this end, to have been a rewarding, if idiosyncratic, life? Only the occasional photograph remains of those days. I’ve moved a lot, I suppose, and books seem to maintain their integrity in the dust of relocation that the loose scraps of unorganized photos do not. Well, at least that’s how I’ve rationalized it over the years.

So, here I am, approaching the terminus wondering about who it was who travelled along the largely solo route. I have to hope it’s not dementia kicking in, nor the result of expunging undesirable aspects of my personality. No,  it’s more of a philosophical conundrum: how do I know if I am the same person over the years? There is a chromosomal continuity perhaps, no doubt traceable despite the random copying errors, but how about the I? What knits all the I’s together -or must I just accept that they are the same ?

I was reminded of the almost apocryphal destruction of ancient knowledge that was stored in the great library in Alexandria when it was destroyed by fire around 48 BCE by Caesar. How could I ever really know who I was if there are no records of it? My books -or at least the ones I have managed to keep- are all I have of those days.

And then it occurred to me that I might have written comments in them: marginalia. Not in my medical textbooks, of course. Those I underlined, I remember -underlined and then wrote précis on foolscap pads to prepare for exams. Nothing personal in those – at least nothing sentimental; nothing of lasting value.

I decided to search for some of my favourite authors from high school and university. I started with Alan Watts -a writer I devoured in my late high school days, but the only book I could still find on my shelves of his was The Wisdom of Insecurity, and it was bare of comments. Then I turned to Hermann Hesse –Steppenwolf– but apart from a ‘Thank you for supporting the Girl Guides’ card hidden as a bookmark on page 134, it too, was bereft of clues about who I used to be -except that I have maintained my love of Girl Guide cookies through the years.

I moved on to my years in Medical School with my collection of the books of the famous Dr. Lewis Thomas (who I initially learned about through his column in the New England Journal of Medicine), but although I loved his style and ideas, there were, alas, no personal marks -indeed, nothing but the crinkled and sometimes smudged pages that bore witness to my passage.

I almost gave up at that point -there were just too many books- but in a final grab, I liberated Loren Eiseley’s The Unexpected Universe from a collection I found on an Ikea bookcase along with some old LPs. Unfortunately, there were no comments in the margins, no little snippets of my thoughts about the prose or images of the author -nothing quaint and revealing- but there were a few tick marks in the margins beside sentences or metaphors I’d evidently found appealing. Then, in a chapter titled The Hidden Teacher, looking more closely at the little marks I’d made to draw my attention should I ever pass that way again, I was suddenly captured as of old. It was Eiseley describing how he’d been taught a profound lesson by a spider and its web. He suddenly understood, after touching its web, that ‘spider was circumscribed by spider ideas; its universe was spider universe. All outside was irrational, extraneous, at best, raw material for spider.’ And as he proceeded on his way along the gully he had been exploring, he realized that in the world of the spider, he did not exist. And similarly, for the white blood cells of his blood, the conscious ‘I’ of which he was aware, had no significance to them either. He was, instead, ‘a kind of chemical web that brought meaningful messages to them…that among the many universes in which the world of living creatures existed… we were creatures of many different dimensions passing through each other’s lives like ghosts through doors.’ Something surfaced in my mind -something that had once stirred me to reverence was performing its magic once more.

I started to read the book again and began to remember what I was -what I am: I am the ghost passing through the dimensions of a different time, following the same thread, and caught in the identical web I wove so many years ago.

There is far more to me -or any of us- than the changing face in the mirror…

The Solopsist

I have always been influenced by something Lewis Thomas, the American polymath writer-physician once said at a lecture I attended. He felt he would be better served by a doctor who had read Shakespeare than someone who had merely focussed all of his formative years on learning medicine. His point, I think, was that to really help people you had to understand who they were, what they thought, how they lived. We are all more than our bodies.

Me? I have always loved philosophy, cherished its Greek etymological roots: love of wisdom, and at least pretended I understood how it might help me to interact with my patients: to accept all points of view with equanimity –or to spell it as Sir William Osler did in his famous essay, Aequanimitas –imperturbability.

Philosophy helps you to do that, but only if you don’t get too enmeshed in the details. Only if you don’t privilege one tenet over another. Only if you never accept that you are at the end of the journey. Or meet someone who is

My conversations with patients have changed over the years from that of an expert trying to impress, to a teacher trying to listen -the difference between an encyclopedia and a manual, I suppose. Part of it is age, I’m sure, but a better part is the belief that, as Osler put it: “Listen to your patient, he is telling you the diagnosis.” And although directive listening works best, sometimes the topic turns an unexpected corner and a tangent is entered. I like tangents but not in the office -they can terminally entangle the discussion. They are like blackberry bushes in a field: I try to stay away from them.

There was a patient who wouldn’t let me, though. A PhD candidate in Philosophy, she had come to see me because of pelvic pain. And while she readily conceded that she was under considerable stress writing her dissertation, she felt that her problem was reality-based. I should have just written it down; I shouldn’t have asked what she meant…

“Reality is the sum total of all that is,”  she said, settling back all too comfortably in her chair. “The question, of course, is does it include potentiality –all that might be, or could be imagined to be?”

Of course.

She closed her eyes, for a moment as if digesting the profundity of what she had just said, and then opened them suddenly and stared at the ceiling. “But our realities differ, don’t they? I mean, you inhabit a different mental world than me; you can no more apprehend my sensations than I can yours. We are on different sides of a wall.”

She had to be kidding; I didn’t ask anything like that. But nonetheless, I felt it incumbent upon me to defend my profession –my humanity, for that matter. I decided to sit back in my chair as well- fight opaque answer with precise question. “But surely if you really believed that I couldn’t appreciate your pain, you wouldn’t have come here.” I then pasted on my most innocent smile. “And anyway, I don’t have to feel your pain, just accept that you are experiencing it and take it from there.” I put on a more contemplative, but satisfied smile.

My answer didn’t faze her in the slightest. I think she had her rebuttal ready before my smile had even fully blossomed. It started with a deep theatrical sigh. “Do you ever wonder if we define the world, doctor –our own world, that is?” She was sitting on the opposite side of the desk from me, but suddenly she leaned forward and put her elbows on it to fix me with a stare that would have done Medusa proud. I even stiffened reflexively.

“Don’t we all define our worlds?” I said, rather proud of my response.

“Yes, but differently.” She looked as intense as her words. “Pain has a different meaning to each of us: a different feeling, a different impact… it is only an If  to anybody but myself: If, as you say, you have pain; if as you assert, the pain is seven out of ten… If all of these things are as you tell me, I have only your word to go on. There is no objective way of demonstrating your thesis. So aren’t you left with the same undefinable as you started..?”

Wow. And to think I was only going to ask her how long she’d had the pain. She ended her explanation rather tentatively, thank god, because I had lost her shortly after her first attempt at clarification. I began to wonder if this dissemblage was a PhD syndrome: full of sound and fury, yet signifying nothing –practice for the defence of her thesis. Equivocation. Obfuscation. Playing with words like others play with cards.

Sometimes, however, it is necessary to find out more about the pain than its meaning. I wanted to pin her down on the more mundane aspects of her symptoms: more like where than why. Or when, not if. It occurred to me that her road to if  was not the road to solution and I was trying to figure out how to phrase it more philosophically when she straightened in her chair as if she’d suddenly received an electric jolt and stabbed me with her eyes.

“I realize that my approach to pain is different from yours, doctor, but the reason just occurred to me: I have defined it that way. Not you; not your reality. Mine… I am the one at fault.”

I tended to agree with her, although I probably wouldn’t have put it that way. “So…” -I sensed an opportunity when her face wrinkled as she thought through the ramifications of her enlightenment… A word-gap- “Where, exactly does…”

But she saw through my plan, and the door closed again. “You see I create the reality in which I suffer…” She paused, but not long enough for me to remember what I was going to ask, let alone to say it. “And so by coming here, I define you in a way… Both you and your response… Do you see what I mean?” She said it with such hope in her face that I almost said yes.

And then, just as suddenly, her face fell on hard times and the intensity disappeared. “But despite my solopsism, I still have pain.” Gradually, her expression refocussed like a magnifying glass and I could see her deep brown eyes dissolve in tears. “Can you help me even from your side of the wall?”

Solopsism? I smiled a real smile and nodded. I looked up the word as soon as I got home.