"The Hippocratic eye will see
In nakedness, Anatomy"
Robert Graves, the Naked and the nude
In waiting for the desolate solitude of Winter, I discover that I am found wanting. The broad incantation of " Know harm, do no harm", a modification of Hippocrates' old dictum, comes to mind. In this modern world, tearing itself apart with its own self consuming destruction, borrowing from antiquated tradition is a necessity. The world of medicine, interspersed with borrowed wisdom from eras gone past, often remembers Hippocrates, reducing him to a few bywords scribbled hastily as a guiding light and not much else. Galen's old adage, that a good doctor is a philosopher, bears repeating. If we must first "do no harm," we must know what harm is.
The complex theories of the world, both old and new, didn't penetrate the mist over the forgotten town where I studied medicine. The mist settled over the town one morning, in late autumn and I found myself, stethoscope in hand walking across the courtyard of our city hospital. My lab coat draped over my shoulders, my hair tied in a ponytail, my wispy moustache bristling in the wind, I was the visual reminder that youth is wasted on the young. Aside from my propensity for wearing overcoats and combat boots, I found myself developing a strange propensity towards a lack of optimism, a condition most medical students entering clinical training know all too well.
I was young then.
The silent courtyard of the hospital stretched out before me, the entrance to the hospital wing was at a distance made greater by the cold. Upon entering the dimly lit corridor of the Internal Medicine ward, sombre silence blanketed the long corridors, descending much like the mist outside.
I was tasked with introducing myself to a patient, taking a history, performing a physical examination, and reporting my findings to the senior doctor in charge. I walked down a along desolate corridor to enter a ward, where a lone patient lay on a bed. The muted television on the wall was showing a broadcast of some animal show. The bright swathes of the Savannah stood in stark contrast to the cold damp of the room. The ceiling light didn't work. A lone window overlooked an overgrown field. In the distance, a strip of an abandoned village loomed, forever out of reach.
The patient was a fifty seven year old retired military officer, admitted for an acute episode of delirium following liver failure. He had been diagnosed with alcoholism first, the diagnosis of liver failure came shortly after. He had liver cirrhosis, a complete scarring of liver tissue, and it was suspected that his liver cirrhosis had progressed to liver cancer. Inoperable, in the end stage, a terminal diagnosis in the very meaning of the word. After a brief introduction he allowed me to examine him. His abdomen was distended, fluid had collected in the spaces between the intestines and the muscles. His abdomen streaked with the engorged veins in a view we have come to call "Caput Medusae", borrowed from the Greek myth of Medusa, whose hair was a collection of snakes and whose eyes would turn men into stone. The long forced tradition of borrowing from antiquity in medicine manifested itself again, this time as a physical marking of disease.
I asked the patient his family history. His father had died of liver failure too, diagnosed with alcoholism, and so had his mother. He had two adult children and he had heard he had grandchildren, but he did not know them or their medical history. They had been estranged for years. I asked him if he needed anything, he politely told me that he didn't. I reviewed my notes, scribbling down disparate words in the hopes of presenting as complete a picture as I could. The patient looked at me from the bed, with an expression I came to later recognize as the curiosity of seeing a foreign medical student in Bulgaria. That look still remains in the eyes of other patients as I introduce myself, or assist in emergencies throughout the city.
The story of alcoholism in Eastern Europe is not new. It is a public health concern, no doubt on some agenda in some vague public health organization somewhere. Almost all of my patients consume alcohol everyday. The senior doctors often instructed us to ask about alcohol consumption and not to express surprise at the quantity admitted to by patients, or put much stock into it. The actual quantity was almost always much higher. Bracing myself for the deep winters, and recollecting the winters I had spent in Pleven, I had come to recognize and accept it much like one accepts the weather. Of course, that kind of resignation is not encouraged in the broader medical community, and calls for "more must be done" echo from the rooftops. They remain words, complicated airflow, without any corpus or direction.
The patient asked me how long I had lived in Bulgaria. As of that morning, I had spent just under three years in Bulgaria. I had not visited home, always delaying my visits due to exams, or some other abstract medical mission. Little did I know that I would spend almost eight years in Bulgaria, and I am glad I didn't know this at that time. I had kept up my spirits by the promise of seeing my own country again, holding on to it like a feverish dream. I was young then and that was my only saving grace. Years later, I have long since given up on the idea of home, of returns, of country and nationhood. Those words are distractions, complicated airflow borne out of the deeper follies of human culture.
"They say that I shouldn't have much hope", said the patient.
I couldn't respond. As a medical student, I was not authorized to make comments about diagnoses, or what I thought of them. The patient looked at the window outside and hoped he could see spring.
That hope was an unfulfilled dream. He died later that week, from complications of end stage liver failure.
As news of the world comes to us, what salve do we have but to think of the world, and to introspect on our own perception of it. As we see upon our screens the same crimes of destruction and cruelty meted out to the defenceless, what must we do but think and think deeply? As the world transforms itself, guided by technology, it makes the same mistakes with more brutal accuracy. While bombs reduce hospitals to rubble across the theatres of war stretching from time zone to time zone, a phenomenon no longer bound by geography, what else must doctors do, but think and introspect and then act?
I think of the broad incantations of medicine, the long traditions of Hippocratic oaths and medical ethics. The processes of death, of birth, the physiology of suffering. The field of medicine is fertile with the experiences that drive us to the decisions we make. I often think of the patient's hope for spring, unfulfilled, in the mist of autumn. There are countless other hopes, extinguished through no fault of their own, and as doctors we are asked to bear witness and to serve. The complicated airflow of words that make for easy digestion on our screens need no further praise or attention. If we must think of the nature of suffering and tragedy, we have to look no further than our colleagues and our patients from whom we inadvertently learn about the human condition, its strange fragility and its constant biological desire of hoping for a future.
Everything must begin with philosophy