Last time we talked about narrative and
healing. Today, let's pick up a related idea: To
understand the place of narrative in medicine, it
may help to understand the metaphors that shape
medicine in the first place.
To see how metaphor shapes technology, I'll
start, not with medicine, but with clocks: The
circular face of a sundial, its shadow moving left
to right, was copied into water-clock faces --
hands moving around a twelve-hour dial.
Then, around AD 1300, the tick-tock mechanical
escapement radically improved clock accuracy and
compactness. But, changed as they were, clocks
still had dials, bells, and gears. Medieval
writers said almost nothing about the new
mechanism inside, so historians still aren't
exactly sure when that change took place.
You see, the outward form, the clock face,
could not change, because that's where the
metaphor was expressed.
Around 1920 we replaced mechanical escapements
with the steady oscillation of alternating
current. Accuracy took another leap forward, but
clocks still looked the same.
My quartz crystal watch not only has the
circular face of a sundial or a water clock; it
also has a second hand that moves in little jumps
as though it were controlled by an escapement
mechanism. Designers know, on a visceral level,
that the meeting ground between user and machine
should change as little as possible.
So what about digital clocks? They offer a more
precise readout than analog clocks. They're
easier for children to read. Linear time -- time
as a sequence of rising numbers -- that's pure
simplicity, but it's simplicity in the same way a
tree is simpler than a forest.
Circular dials paint a picture of Earth's
rotation. They model our experience of passing
time. They're a lovely analog of reality. In a
digital display, night never falls. Time just
advances, without features, minute after minute.
The competition between analog and digital
readout might seem to balance. But, what do you
wear on your wrists? The fascinating truth is,
the digital clock has already lost in that
competition. Digital clocks simply can't compete
with the metaphorical power and visual grace of
the circling motion of an analog face.
Many technologies look good for a while, then
get left -- Betamax, dirigibles, LP's, autogyros,
and digital clocks. So what does survive, and
why? To predict the death or survival of a
technology you certainly must ask if it's
functional. But that, by itself, is never enough.
You have to ask if it's a metaphor for something
more than function. Only after a technology has
touched us as metaphor will it find a way to
persist from one generation to the next.
Try another technology -- the book. The book,
as we know it, was developed by the Attilids in
Pergamon when the Egyptians cut off their papyrus
supply. They had to begin writing on sheepskin.
And it lends itself better to being folded into
pages and sewn into a book than being rolled into
a scroll the way papyrus was.
The book turned out to be a splendid new compact
information-storage medium -- so good, it created
a new technological metaphor. But bear in mind
that the scroll, which it replaced, survives, even
today, as its own technological metaphor. But the
book was a whole new user interface, and one we
will not give up today.
When Gutenberg began printing with movable type,
he made print look just like the work of scribes.
He counterfeited manuscript books. We still
replicate the old manuscript books today. We fold
pages into gatherings, sew gatherings together,
and lace them between hard covers. Movable type
made books cheap and abundant. Yet we readers
still receive information just the way we did in
Pergamon, 2000 years ago.
Friends ask me, "How much change will we
undergo?" Well, where the user meets the machine
is the one place we won't tolerate change, even
though the machine itself is mutating into
something so different as to redirect human
Once the machine becomes metaphor, the user
interface stops changing. When I work at my
computer, I use the awkward old QWERTY typewriter
keyboard. A century-old arrangement. The place
where I meet the machine, imperfect as it is,
remains, and it will not be abandoned.
Pianos evolved from harpsichord improvements.
But they were soon something wholly different.
Pianos are so different from harpsichords that you
still need a harpsichord when you want to hear
All the best technologies survive their
replacements that way. Live concerts survive
recordings. Pens survive word processors.
In 1990, everyone expected to be reading
electronic books in the near future. Now
computers have already leap-frogged that
technology. Before we had a decent electronic
book, the world-wide-web was on its way to
providing everything we might ever hope to get
Screen resolution and illustrations are
improving, the supply of texts is rocketing
upward. Now we have both sound and motion.
As we leave the limitations of the paper book,
its electronic equivalent is already
unrecognizably different. And that's exactly why
the paper book will have to survive after all.
Paper books will keep right on doing what they've
always done so well. They take you into the
author's mind. You give yourself over to her
Your mind frames the pictures and plays the
music. You feel organic cloth and paper against
your fingers. What the computer offers has as
much in common with the paper book as the
horseless carriage has in common with the horse.
But what do paper books have that computers
won't soon have as well? Fix the screen, fix the
portability, find means for dog-earing your place,
then what's left? The answer lies in the
metaphor. Not only has the book long since found
its metaphorical place in our lives, the computer
has found its metaphorical place as well.
We all switch between the roles of parent and
child. We need some control over things, but we
also need to submit to other people's knowledge.
In some things, we should play the parent. In
others, we'd better know how to be a child. And
the child says, "Tell me a story."
The book is our metaphorical mentor.
The computer is our metaphorical servant.
The story we choose might be a Gothic novel. It
might be a math textbook. In either case we give
ourselves over to the story-teller for a time. We
do that when we read a book, go to the theater,
even listen to a concert.
Computer communications are quite another
matter. The computer does our bidding. We say,
"Go and do. Buy me an airplane ticket. Give me a
stock quotation. Tell me if the library has a
book. Pass this message to a friend." The
computer dances to our tune. We are in control.
When you and I go to the computer for text
material, it's to look things up. It's not to let
words wash over us. The computer is far better
than a book if you want to find things.
Insofar as paper books function as simple
repositories of fact -- dictionaries, handbooks,
indexes, -- they've already given way to
computers. But the sort of book we submit
ourselves to will have to remain written out and
To learn, we become as children. We seek out
our own ignorance. Now and then we follow the
mind of someone who knows what we do not. We yield
to the rhythm of the story-teller.
Printed books let us put control aside for a
while. That's the wonderful gift books offer. But
the metaphor of the computer has already been set.
Whatever we can do with electronic media, we
simply will not use them as mentors.
Now, what has all this to do with medicine and
narrative? Last time, one of you asked me about
Scott Montgomery's book, The Scientific Voice.
That question drives right to the heart of the
matter. Let's look at his argument:
Montgomery dives into the language of science,
and what he finds is anything but scientific
detachment. He tracks the way the language of
science bends science itself to fit cultural norms
He gives examples: psychology, Japanese science,
how we've studied the moon in terms of the
language we use to describe it. Then there's his
chapter on medicine and language.
Example, when Harvey studied blood flow in the
17th century, most people thought blood made one
pass through the body -- that it was generated,
then consumed, in various tissues. Harvey showed
that blood moved in a closed loop, and he called
that motion circulation. But he wasn't first.
When others suggested a closed loop, it hadn't
caught on. Blood didn't circulate until Harvey
gave us the right word.
A huge shift took place in the metaphors of
modern medicine around 1870, and Louis Pasteur had
a lot to do with it. Early-19th-century doctors
still said the plague infected people or lay upon
them. It didn't attack them or strike them down.
That's what armies did, not diseases.
When Pasteur was young, disease was caused by an
excess of irritation or an overabundance of vital
force. But, just as he was articulating his germ
theory, the language of Europe was being shot
through with military metaphors. Politicians had
also started using metaphors that cast the nation-state
as a living being. Bad policy was a disease in the body politic.
So germs became an invading army. While the
Prussians lay siege to Paris, Pasteur was saying
that, in fermentation, germs laid siege to beer
and wine. He pressed the analogy relentlessly.
And when he wrote on public affairs, he said
France had been enfeebled by revolution and
rendered sterile by political theory.
For over a century, medicine has used those
metaphors. AIDS stalks us; it uses many
strategies in its attack. It invades and kills T-cells.
Disease strikes the body's defenses. As doctors became
soldiers at war with illness, the metaphor carried into medical practice.
Alternative medicine is less a body of technical
knowledge than it is an attempt at linguistic
reform. But, as it tries to claim legitimacy, it
too slips back into military metaphors. It calls
on the mind to marshal forces of good in the
battleground of our body.
The only way we'll bring medicine into better
alignment with our human nature, Montgomery says,
is by heightening awareness. Just as we've had to
do in areas of sexism and racism, we have to be
aware of the words we use.
Medicine can be changed and, indeed, it must be.
The military metaphor has run to the end of its
usefulness. But we won't be able to make the
needed changes until we've created a new language
of medical discourse -- until we've framed new
Let's look at another linguistic and cultural
shift in medicine: This one had gotten well
underway by the time of Pasteur. As we'd entered
the 17th century, physicians had forgotten most of
the Hippocratic spirit of empiricism. The cure of
disease turned less on observation than on
exercises in logic. Like Hippocrates, physicians
still believed treatment should address the whole
body, but they'd let that idea wander strangely
They believed disease was caused by gross
imbalances of body fluxes and humors. They
concentrated on treating these abstractions rather
than what their eyes and other senses told them.
During the 1600s, that began changing in Italy,
the new center of medical science and anatomy.
Italian anatomists (of whom the Englishman Harvey
was one, by the way -- he studied there) were
learning how the body worked, but not how to
localize disease. They kept trying to cure the
patient by adjusting body humors.
As the seventeenth century ended, a young man
named Giovanni Morgagni entered medical school at
Bologna. He graduated in 1701. From then on, he
worked to make sense of disease, using anatomy and
Sixty years later he published a book titled:
The Seats and Causes of Disease Investigated by
Anatomy. In it, he set the foundations of
pathological anatomy. The key word in his title
was Seats. Morgagni showed that understanding
disease meant seeing where it's seated within the
Doctor Reiser sums up Morgagni's new doctrine
with a great phrase. Morgagni, he says, told us
to look for the lesion within.
Four parts of Morgagni's book dealt with the
head, the belly, the thorax, and generalized
disease. But it was the fifth, a meticulous index,
that was key to the other four.
By including that index, Morgagni kept sight of
the whole body as he led us to seats of illness in
its various parts.
He gave us far more than a museum of case
histories. He offered a road map at the same time
he took us on the trip. When Morgagni was done,
clinicians and scientists alike had been offered
means for tracing their way back to the common
origins of symptoms.
Morgagni showed, beyond doubt, that specific
disorders cause illness and death. Ruptured
appendixes, syphilis of the aorta, epidural
hematoma. A lifetime of compassion and clear
thinking underlay this chamber of horrors. Modern
medical thinking unfolds, case by case, as Morgagni
gives us a new way to see illness.
His work was as radical and revolutionary as it
was steady and methodical. Morgagni's religious
and humanitarian convictions drove him to work
without haste and without rest until he was 89.
He was still going strong when he died of a stroke
Morgagni told doctors to look for the lesion
within. He called them to start identifying
disease with abnormalities we can't see from
outside. To do that, he'd found a new purpose for
dissection. Doctors had dissected since Galen.
But they'd only done it after the fact to see how
the body worked.
The problem was, Morgagni couldn't yet change
medicine because doctors still had no means for
looking inside the bodies of living patients. And
without means, they also had no concept.
So Stanley Reiser asks you to imagine yourself
as a late-18th-century doctor with a patient who
complains of, say, a pain in his side. Whatever's
wrong, all you can do is count his pulse and feel
his forehead. You can look for changes in skin
tone. You can listen to his own report of
symptoms. The only information you can conceive
of collecting is external.
A big step away from that mindset occurred one
day in 1816. A young French doctor, René Laënnec,
was trying to diagnose a heart disorder in an
obese young woman. He'd tried thumping her chest,
but she was too heavy.
Even that was radical behavior for a doctor 200
years ago. Laënnec was engaging in more physical
contact than was generally accepted. And, with his
overweight patient, the sound told him nothing.
If Laënnec was radical, he wasn't radical enough
to take the next logical step of putting an ear to
the young lady's chest. That would've really
crossed the line of acceptable behavior. So what
was he to do!
Laënnec had an idea. He rolled a sheaf of
papers into a tube. He placed one end on her
chest and his ear on the other end. He was able
to make out what was going on in her heart. He'd
just created the first stethoscope. Three years
later he published a book describing his design of
a wooden stethoscope and its use.
By the 1830s, stethoscopes appeared with
pliable rubber tubes, then binaural ones with
earplugs. And, in counterpoint, debate raged over
the changing tactics of diagnosis.
Understand Laënnec's dilemma with that patient:
It wouldn't have been a dilemma for most doctors
around him. In 1816, few doctors considered such
diagnostics as thumping the thorax -- much less
putting an ear to the heart.
Diagnoses were based on looking at a patient and
listening to the patient's own story. Doctors
seldom questioned what patients said about
themselves. Physical contact seldom went beyond
counting a pulse or touching a forehead.
Of course Laënnec's ideas about thumping,
feeling, and placing an ear to a patient went way
back to Hippocrates. Hippocrates believed that
all our senses should be used in diagnosis.
An ancient Greek doctor might've diagnosed
diabetes by tasting a patient's urine. That kind
of intimacy did not appeal to early-19th-century
Now stethoscopes let doctors keep their distance
and still engage actual symptoms. You know
perfectly well that stethoscopes don't really do
better than an ear to the chest -- but they do
give you distance.
This simple new instrument became the signal to
begin developing the techniques of a whole new
kind of medicine -- one in which doctors by-passed
the patient's story and looked inside the
patient's body for direct evidence of disease --
for the lesion within.
After stethoscopes came ophthalmoscopes,
laryngoscopes, X-rays, CAT-scans, and MRI. The
odd thing about all that is that it has, at last,
intensified the old debate over how much
doctor/patient intimacy is appropriate.
The stethoscope once promised to bridge the gap,
to give some contact with patients' symptoms back
to doctors. But it also gave doctors a way to
stand even further away from patients.
Now the fun begins. For these new instruments
of internal exploration all had about them an
indisputable masculinity. They were almost all
phallic in construction and use.
They entered the body. With them came a
masculine vocabulary. The thrust of the 19th-century doctor was to engage in combat with
disease. He waged war upon it. In an odd way,
Morgagni and Laënnec had set us up to accept
Lest you think I speak Freudian clap-trap here,
I ask you to look at forceps: In the 18th
century, babies were largely delivered by
midwives. And midwives were, as they had always
been, the agents of family planning. They
instructed women in means of birth control and
even helped them to terminate pregnancies.
But a new force was rising during those years.
It was the force of mercantile economics.
Mercantilism used two kinds of exploitation to
balance trade. One was the use of colonies to
supply raw materials.
The other kind of exploitation was creating a
large lower class to manufacture goods for sale.
That meant fostering childbirth among the poor.
So midwives collided with the mercantile agenda.
Historian Lhonda Schiebinger tells how university-educated physicians -- all males -- took an
interest in childbirth.
You see, midwives had no access to schooling.
They were often illiterate. They trained by
apprenticeship. Now the medical schools created
a new professional called a man-midwife, and they
armed him with surgical instruments, whose use was
denied to women.
And so, armed with a forceps, means for entering
the body, the man midwife began assisting
birthing. Forceps could certainly be a blessing.
But, like many of the drugs in our arsenal
(interesting word) today, doctors overused them
and damaged babies.
Midwives had worked around difficult births with
gentle tricks of repositioning. Man-midwives were
often reckless with their tools. Birth assistance
changed from succor among women to a profitable
By the mid-18th century, medical professionals
had midwifery under attack. In 1760 a midwife
wrote a book on birthing. In it, she angrily
charged that men were trying to "forge the phantom
of incapacity" in women's minds.
Still, stethoscopes and forceps gave doctors
permission to redirect medical attention inside
the patient. Down through the 1800s, doctors
became increasingly aware of the various lesions
within: cancers, ulcers, embolisms.
During the 19th century, doctors' offices sprouted all
kinds of new instruments to help them look into
patients throats, eyes and ears -- trying to get
at the elusive lesion within the body.
Then that great moment in 1895: Wilhelm
Roentgen, working with cathode ray tubes, suddenly
found he had a kind of ray that could "see"
through flesh, but not through bone. He gave us
the X-ray, and seldom has anything so taken the
This new marvel set the inventive muse in
motion. Right away magazine cartoons celebrated
the idea. A man uses an X-ray viewer to see
through a lady's hat at the theater -- that sort
of thing. Soon we'd all have X-ray viewers, and
great the mischief would be.
The very next year a company came out with lead
panties to protect women from prying eyes. A
would-be poet wrote,
Not worth your while
That false, sweet smile,
Which o'er your features plays:
Thy heart of steel
I can reveal
By my cathodic rays!
By the time I was a little boy, that'd turned
into stories about Superman's X-ray eyes.
Meanwhile, real X-rays were cheap and accessible.
I didn't have X-ray eyes, but I could X-ray my
feet in new shoes at the department store. That
didn't last long: we were just catching on to the
terrible hazards of X-rays. But in 1896 futurists
had seized at the possibilities of seeing through
opacity. That year, the president of Stanford
University suggested we might soon use X-rays to
read thoughts. Was that satire or serious? We
Edison was deadly serious when he set out to
focus enough X-rays on the human skull to watch
the brain at work.
So scientists and science-fictionists alike
seized this new marvel with the speed of gossip.
Most important, Roentgen really had given doctors
a new and seemingly non-invasive means for looking
right at the elusive lesion within.
And so, joining with Pasteur's military
metaphor, medicine has focused increasingly
accurate rays, ultrasound, and fiber-optical
devices on the precise lesion within our bodies.
We pay a price for any new technology, and we've
certainly paid a price for this close focus.
Doctors and lay people alike are beginning to
see that we need better means for focusing on the
whole human organism. We cannot keep reducing
illness to detached points within the body.
Disease does not exist in simple isolation. But
medicine will have to struggle to find its way
back to the tough problem of curing the whole body
-- instead of just one piece of it.
Now back to the idea of narrative -- my own
narrative: The dilemma of modern medicine came
home to me in a dramatic way on the evening of
last February 15. I was attacked by a hit-and-run
driver while I was walking my dogs. A driver came
at me under full acceleration, onto the grass, and
tried to kill me. The police guessed it was a
gang initiation rite.
The impact broke up the fibulas in both legs,
and it absolutely trashed my left tibia. So the
surgeons ran a titanium tube down my tibia,
spearing its rubble like shish kebab, and they
screwed the tube in place.
Then, five days after the surgery, I suffered a
stabbing pain in my chest and an inability to
breathe. I'd suffered a pulmonary embolism. The
trauma had kicked loose a blood clot.
Seven more days in the hospital on blood
thinners and aggressive pulmonary therapy. Seven
more days getting my blood oxygen level back to
I was lucky to be in the hands of the crack
Herman Hospital trauma team -- Red Duke's
operation. Surgeons, pulmonary specialists,
hematologists, radiologists, all converged and
compared notes in a delicate ballet.
They pinpointed the lesions within me. But with
carefully choreographed teamwork they also
reconstructed my body as a single organism.
Today, I'm in a fine state of repair just
because doctors are finally creating strategies
for seeing the whole body at the same time they
focus upon the lesion within.
At the same time, it was clear that the hardest
part of that process was sustaining the liaison
among specialists. They did a good job of
unifying their work while I was in the hospital.
But it was forced cooperation.
Each medical professional was focused on one
specialty. Cooperation was built into the
structure of the trauma team but it didn't come
naturally or easily. And, once I left the
hospital, I also left that coordination of
Now it was up to me to be sure the fragments of
my recovery were synchronized: That my blood
thinners were managed, that my bones were knitting
on schedule and my muscles were rebuilding, that
I used pain medication intelligently, and that I
dealt with the aspect of my recovery that medicine
was quickest to ignore -- the post-traumatic
stress of having been nearly murdered.
Now an internist steered me through specialists.
But a patient still has to travel from specialist
to specialist -- to people who only talk with one
another through the patient. And, it's woe betide
a patient who trusts the coordination of his
treatment to a traveling chart. That's asking for
trouble. My narrative was the only binding tissue
in the managed care process.
Medicine has learned to find the lesion within
-- the specific locus of trouble. But now
medicine must master the terribly important task
of putting those pieces together.
I am poignantly aware, after my own recent
experience, just how very good you all are at
pinpointing the seats of illness within. And you
are very good.
But 21st century medicine faces a great gaping
problem. How can medicine continue to be as adept
as it is at locating the seat of disease or trauma
-- and now find means for addressing the whole
The harmony of body and mind, is an essential
part of healing the wound. Fail to find that
unity, and the wound to the body will remain
unhealed long after the skin has closed.
In the near wake of my assault, people
constantly stopped to ask, "How are you doing?"
After a while I realized that I wasn't helping
anyone by playing the game, so I tried something.
I answered one colleague by saying, "My leg hurts
like Hell, and I'm so frigging tired of crutches
I could sit down and cry." So what do you think
He said, "Oh yes, well -- but you are getting
better, aren't you!" Friends needed my
reassurance. What'd happened to me frightened
them. They needed for me to allay their fear.
And of course I'd done the same thing a thousand
times when friends of mine were hurt
Now my story now elicited their stories. When
I listened carefully I suddenly heard, for the
first time, the pain that friends had been
suffering in silence around me.
For years I'd been next to useless to friends
with cancers, and other mind and body altering
ills. Now they opened up to me. The exchange of
stories granted me intimacy with friends that I'd
never had before. So I underwent massive change.
I saw my own mortality; I saw the goodness of
people around me.
Meanwhile, my forever-flawed leg still hurts
just enough to be a constant reminder of my new
Today's 19th century medical metaphors make it
so hard for medicine to deal with these issues.
Masculine medicine, 19th and 20th century
medicine, equates doctors with warriors -- hurling
their spears and arrows at disease. You wrap the
patient on the operating table in surgical linens
that hide the face from view. War is objective
business -- conducted in a detached way. You
don't look at the enemy's face or consider his
The regimen of authority and obedience is forged
in medical school just the way it was forged when
I was in army boot camp. Both institutions use
the tool of sleep deprivation to mold recruits to
the chain of command. Both are profoundly male
The result is that medicine is equipped to do a
big part of the healing process -- chiefly that
part which does not require the stereotypical
female virtues of succor and compassion. Medicine
is at its best when it can treat the body without
reference to the mind.
But, in the end, the body will not be healed
independently of the mind. Not even so elementary
thing as a broken leg. Today, I thank those
skillful surgeons and pulmonary therapists who
worked on me.
But I also thank myself -- for putting optimism
and determination into the healing process. If my
mind had been in a slightly worse place, what
happened to me could've brought me down.
If I'd believed that my doctors' healing powers
were the whole story, I would've been over-drugged, beaten by pain and disability, fearful of
using my damaged leg, and (worst of all) out of
contact with the psychic wound I'd been dealt.
If I hadn't recognized the missing elements in
modern medicine, and found my own means for
patching them in, my wound would have been far
greater than it was. If I hadn't sought out
people who could actually hear my own narrative,
I would've strangled on the horror of what'd
happened to me.
I am forever grateful to the medical
professionals who began my healing process, but I
lament their inability to work beyond the first
steps in that process.
You students will've achieved nothing if you
simply join this existing world of 20th century
medicine. You are obliged to change it as well.
That change will take place. But what is true of
any revolution will be true here:
The only people who survive revolutionary change
are the ones who help to bring it about.
SOME ADDITIONAL SOURCES
Montgomery, S. C., The Scientific Voice. New York: The Guilford
Press, 1996. (See especially, Chapter 3.)
Reiser, S. J., Medicine and the Reign of Technology, Cambridge:
Cambridge University Press, 1978.
Knight, N., "'The New Light': X-rays and Medical Futurism,"
Imagining Tomorrow: History, Technology, and the American
Future, (Joseph Corn, ed.) Cambridge, Mass.: MIT Press, 1986,