ABSTRACT

An increasing proportion of health professionals and scholars of the humanities is interesting to the Narrative Based Medicine. The terms used indicate a mode of coping with the disease aims to understand its meaning in an overall, systematic, broader and more respectful of the patient. The Narrative Based Medicine fortifies clinical practice with the narrative competence to recognize, absorb, metabolize, interpret, and become aware of the stories of the disease. Health professionals can acquire these skills through courses of medical humanities that include the use of different types of narrative text. Narrative medicine uses also literary texts in order to improve narrative and empathic ability of clinicians. This perspective also allows considering the Chekhovian literary work within a holistic vision linking scientific background and literary creativity. The material used for this study is the tale The Typhus by A. Čhekhov adapted from Novels and Theater. The text analysis is conducted with the logical and conceptual tools derived from the Psychology of Art and Creativity and in the perspective of narrative based medicine. In the story we are examining the Russian writer, who never gave up being a medical officer throughout his life, manages to make a perfect synthesis between the scientific background and his literary creativity, combining a careful clinical description of the symptoms of the typhus with evocative depictions of the characters and the environment he captured with brushstrokes capable of creating a picture having a purely artistic value and meaning. Narrative based medicine, which also makes use of narrative about the disease written by physicians or patients or even by medical patients, is a good opportunity for the medicine to go beyond the technocratic vision of the scientific evidence and draw closer to the wholeness of the experience of individual patients.

Keywords:Medicine and Literature, Narrative Based Medicine, Health, Psychology, Disease

1. Introduction

The relationship between medicine and literature unfolds in countless values and points of contact are so many, seems unrealistic to do a report proposing to treat the subject in a comprehensive manner. Our intent on this occasion is just to offer some insights, to emphasize the strong bond that unites medicine to literature and possible future developments and the benefits that can be drawn from this recognition, hoping that the reader does not get disappointed by the partiality of the work. Just to emphasize how literature offers us great opportunities, we want to quote some lines from the novel Atonement [1] who, being an expert storyteller, in a few words, summarize the relationship between medicine and literature: “Birth, death, and in the middle a path of fragility. Beginning and end, these phenomena which occupied a doctor, and so did the literature”. As the text shown, literature and medicine shared the main themes and, moreover, not surprisingly, since ancient Apollo was both the God of medicine and the arts. On the one hand, then the medicine has, in the relationship with the patient, intuitive aspects that the approach to art, on the other hand, the literature is often inspired by the medicine and this is also reflected in the very language of the two disciplines and their history. Proof of this is the fact that many of the novels that tell of “adventures health” are written by doctors or patients or even by medical patients. Suffice it to mention, in this regard, names like Bulgakov, Chekhov or Cronin. The plague of the past centuries to tuberculosis of nineteenth and twentieth centuries, no less than in ancient times, the disease has always been a subject for literary par excellence. The subject has been treated either as a background to the events narrated and expression of the time, both as a scientific and medical testimony; the most interesting aspect of the story of the disease is, in any case, usually the direct experience, the way in which it is subjectively experienced by the main characters of the story or novel. This becomes especially true in the current society where the sick person is not a clinical object but a subject who claims the right and the ability to access all of the available scientific proposals for purposes of health or well-being, then, not only to heal the diseases. Modern Scientific medicine presents itself as a science more open to the complexity of the world and more available to communicate with different kinds of knowledge. Proof of this is the fact that an increasing proportion of health professionals and scholars of the humanities is interesting to the Narrative Based Medicine. The concept of narrative based medicine faces on the international scene in the late nineties thanks to Rachel Naomi Remen and Rita Charon. The terms used indicate a mode of coping with the disease aims to understand its meaning in an overall, systematic, broader and more respectful of the patient. The disease, in fact, often imprisons the patient in a fixed and rigid narrative of itself, does not see the possibility of making a path true and authentic to the rediscovery of oneself and one’s relationship with others. Write and tell his drama to others may help the patient to reconstitute his identity. In this, the narrative based medicine has emerged as a new mode of operation for clinical medicine, using textual and interpretive skills of the patient but also the physician. Reference [2] shows that evidence-based medicine, that formulates diagnosis from the symptoms that the patient experiences, does not take into account all aspects characterizing the emotional person and affect more or less directly on the state of the disease. The Narrative Based Medicine, however, fortifies clinical practice with the narrative competence to recognize, absorb, metabolize, interpret, and become aware of the stories of the disease. In this sense the Narrative Based Medicine approaching to holistic approaches, typical of non-conventional medicine, that in the face of a rigid classification of diseases, offering a subjectification of the patient, seen in all its complexity and uniqueness. It represents, in other words, the progressive opening of medicine to other sciences such as sociology, psychology, anthropology, once an integral part of medical knowledge. Narrative based medicine can be applied in various areas: the existential and relational history of the patient’s experience, the partnership between doctor and patient and the significance of the disease [3] . It is an approach that enriches the medical act thanks to the stories of patients, doctors, nurses and those working in the “planet health”, but also due to their ability to tell the aspects of health and disease in their varied emotional representations. They are rightfully part of the narrative based medicine even the stories about patients and doctors, health and disease: short stories or films, made mostly by narrators who do not have health professional experience, but with their “secular” vision often imbued with personal experiences of suffering, make it clear to health professionals, regardless of their professional affiliation, that medicine is not only cure diseases, but also take care of the suffering people [4] .

2. Results

Scientific knowledge is, undoubtedly, essential to explain the disease and to prepare care solutions and adequate rehabilitation, enabling a patient to achieve the highest possible level of well being. But this knowledge—as has long since been brought to light, even in fields other than medicine—are insufficient to fully understand human experience, such as that of the disease. In other words, an experience of illness can not be scientifically explained, but only understood in its singularity; to capture this experience are necessary observational skills, interpretation and construction of the meaning of the experience of illness. It is necessary, in short, an ability to go in depth in the analysis of such experience, which first requires a careful observation of the patient and then a digging ability well below the surface of the pathological phenomenon and of the clinical signs and symptoms with which it is presented. This ability to “dig” in a story of the disease, to understand it in depth, to go beyond a superficial dimension of the biomedical facts, developing different interpretations and connections with one’s human experience, requires the development of a “narrative competence”, i.e. the ability to capture the sense of a story (of disease). This competence consists of a combination of textual, creative and emotional skills of the physician and, as in the case of relational skills, it can not be based only on natural talent but it requires constant practice and the possibility of comparison [5] . Health professionals can acquire these skills through courses of medical humanities that include the use of different types of narrative text (fictional or non-fictional, autobiographical or not autobiographical, clinical). The training of the physician may then pass through literature, that is able to draw on emotional experiences and narratives that can make us reflect on the difficult role of the patient, but also on the equally difficult role of the physician. In particular, we believe that the narratives which have as their object the medicine, offering from an “outside” perspective the emotional, psychological, anthropological, ethical and philosophical questions of illness and suffering, can assist the physician in understanding and sharing of experiences of the patient and educate the management of his emotions. The stories of illness help us to see the world through the perspective of a patient who lives with their discomfort and make us reflect on the purpose of our profession. On this line of thought, we have found it useful and inspiring reflect on a short story, The Typhus, [6] born from the experience of a physician and writer of the nineteenth century: Chekhov. The choice does not depend on the idealization of past times and the charm of the good physician of the nineteenth century, humanist and human, who knew how to listen, understand, encourage, because not yet overwhelmed by the stress and the bureaucracy of modern times, not yet been seduced by the technocratic ideology. The reason is rather the surprising actuality and the extreme psychological subtlety of the story that contains much more than the title seems to imply that is, the exposure of a case of typhoid. In it the attention of the physician-writer goes far beyond the symptom and turns to the person as a whole, exploring his experience, his life context, the texture of family and social relations in which he is enmeshed. The aim of this work is to offer the reader the opportunity to consider medicine and literature not as a reality separated, but, following many current trends, as just formally different fields underlying similar and integrated ways of working of the mind. This perspective also allows to consider the Chekhovian text within a holistic vision linking the nosographic context to the artistic suggestions and combining them in only one message in which the Author offers himself as a physician and an artist at the same time. In the story we are examining the Russian writer, who never gave up being a medical officer throughout his life, manages to make a perfect synthesis between the scientific background and his literary creativity, combining a careful clinical description of the symptoms of the typhus with evocative depictions of the characters and the environment he captured with brushstrokes capable of creating a picture having a purely artistic value and meaning. Our examination of the text starts from the meeting of the officer Klimov with a Finn sitting in front of him on the train. Klimov is at an early stage of his disease and for this reason the Finn’s behavior (who keeps sucking his pipe talking about the same matter) unintentionally makes more unpleasant the feeling of his sickness, typical of a pathology which, by acting on the central nervous system, impairs also the perception of reality. The word “typhus”, derived from ancient Greek, refers to a state of mental confusion: in fact, the protagonist is in a state of disorientation with an initial delirious process [7] in which the pipe and the monotonous speech of the Finn become seriously disturbing elements for the mind, also because they are acquired, in figurative symbolic terms, on a paleological basis [8] . With a sharp psychological insight the Author describes a particular condition of the mind affected by the pathogen toxin altering the whole mental activity and causing a general sense of mental uneasiness. This analysis can make us understand how “a stream of ideas” or better the overlapping of images which get blurred as the conscious faculty has become unable to grasp the differences, distinguishing, often by means of mere shades of meaning, an image from the other. This explains the phrase “Unpleasant people these Finns and Greeks—he thought—they are completely useless, and good for nothing. They have just a physical place on the globe”; from this follows the initial phase of delirium, the contents of which, however, reveal signs of aggression and an unconscious aversion towards other men. Strictly connected with the clinical case is also the psychosomatic reaction of nausea that involves the body. The mind, that gradually loses its lucidity, tries to think about other peoples and, in this particular case, about the Italians and the French. But the nausea, regarded as a negativistic alteration of the relationship with reality, also affects these peoples and the emerging reductive picture is equally negative: just a small organ for Italy, a naked woman for France. These are the most widely known images at the time, but not really significant for both peoples. Then the analysis goes on with a detailed description of the symptoms of the disease, that reveal a deep medical background and a special bent in dealing with them to treat psychology, emphasized by the way in which the Author places the real nature of delirium in the general context of the symptoms: the brain loss of mental clearness is the central fact; this is surrounded by other symptoms as a dry mouth, a severe asthenia, a deep sense of general illness [9] . The mental dimension of “clouding” is accompanied by a space-time alteration and also creep in illusory images that are an alteration of reality or clearly hallucinations. The night, with its suggestions of darkness, shows the state of mental confusion. From a psychological point of view also the stop at the Spirovo station is of great interest. Klimov can drink some water, which actually does not quench his thirst, but, on seeing people eating, he feels a very strong sense of nausea. Here the artist Čhekhov enriches the clinical picture with some images that may have a particular symbolic meaning. The smell of the roast may become unpleasant as a consequence of the alteration of his perception, but the mouths that chew, creating a further dimension of rejection, may be a metaphor of that particular vegetative human typology of “walking corpses”, that is antithetical to the Author’s personal frame of mind. However, it is possible to consider his nausea as an unconscious sense of rejection and fear of the “death’s ghost” triggered by his disease. Consequently, the mind in trouble, as a defense mechanism of the Ego that is afraid to lose the whole control on itself, therefore tries to find shelter among images or memories to which he could anchor his own cognitive abilities. Therefore Klimov has recourse to the image of his aunt, his sister and the orderly Pavel as well as of his soft and fresh bed with a cool water jug in order to give himself the strength not to surrender to delirium. But, despite everything, “a nightmare’s heavy torpor seized him and paralysed his limbs”. It was the morning light to make possible a recovery of consciousness. This can be brought about by two causes: a recession of the fever with symptoms in the morning and an improvement of the perceptive abilities due to the much higher brightness in the environment. But, in any case, the Ego does not have and cannot have the full control of himself and the young man gets off the train “mechanically” with the strange feeling that it was another person and not himself to leave the train. This is an important psychological notation: the Ego of a person recognizes as his own the image in the mirror only if this image has the well known usual features [10] . In this sense Klimov, who keeps in his mind a set of imaginary and allucinatory elements and lives an altered space-time dimension, may experience a state of alienation of the Self that induces him almost to materialize a stranger different from him (this brings to mind all the complicated literary discourse on the double and the concept of split personality. See [11] . Then, with his usual fine intuition, Čhekhov describes Klimov’s going back home, emphasizing once again the confused and hallucinatory state for which the young man cannot distinguish between “memories” and “current reality”. Then, reappear the Finn, the lady with the white teeth, the smell of roasted meat, a sergeant major and everyone is talking, gesturing, smoking. By this time the typhus has exploded with all its vigour and the subsequent description of the disease, although adherent to a medical record with a remarkable accuracy worthy of a doctor who has a wide experience in this field (among other things, Čhekhov had definitely been treating patients with typhus, as well as typhoid, a disease that, along with the cholera, was a fact endemic in the late nineteenth century), does not seem less effective if compared to the deeper and wider creative inspiration of the Author. It is interesting to notice that it is hardly possible to distinguish between day and night (see, in this regard, in The Betrothed [12] , Lucy in the military hospital that saw, during the culmination of the disease, also in a confused way, what was happening in his room), the succession of visions concerning the people he had met and also the appearance, in broad daylight, of the regimental chaplain in the act of making the sign of the cross. Through the description of the background and the objects of the real world Čhekhov can make a picture of the climax of the disease but, above all, as noted by [13] , he manages to reveal the state of mind of the protagonist, who is confused and gripped by the fear of a possible incumbent death. The story continues with the evocative description of man’s return to life: “his whole being, from head to toe, was invaded by the feeling of an infinite happiness and a joy of life, such as the first man may have felt when he was created and saw the world for the first time”. The powerful strength of selfpreservation shakes the psychic dynamic. The Ego is the witness of its own rebirth and instinctual energy, as a primordial extra-conscious force, dominates his mind. The joy of living, of being, in the sense of existing as a living creature, which is also a primordial feeling, resembles the experience of the human being who first opened his eyes over the infinite variety of the world. This psychological dimension of getting “back to life”, which are beyond rationality and logic and where only an exciting and irrational joy of living prevails, leads to enhance even the smallest things due to a particular form of “regression”. As a child, therefore, Klimov explores the little world surrounding him and every “trifle” bears a great significance because it “marks” the resumption of his contact with a reality that is “new, exciting and changeable as the life that comes back”. Similarly, although in opposite conditions, another Chekhovian character, Tuzenbach, in The Three Sisters, [14] before a duel in which he knows that he is doomed to die, appreciates every minor aspect of his existence. This proves that, whether you observe the world for the first time, whether it emerges from a state of unconsciousness or coma, his mind lives a similar infantile and instinctual dimension. And as a child Klimov, motivated by the joy of living, reverses the nausea in pleasure. He now considers all the men as good men and urge to smoke as the Finnish and even eat. The doctor, alter ego of the Author, understands this positive metamorphosis and calls him by the diminutive “little child”. As it is typical in the Chekhovian fiction, there is a sudden turnaround and the end of the story takes on dramatic tones described with poetic images of great effectiveness. Klimov’s sister, Katja, infected by her brother, is already dead and buried, and with a few strokes the artist Čhekhov is able to translate in figurative terms all the sufferings and pains of his old aunt, depicted with her head bowed due to the fall of her protective cap, which also made the graying of her head visible. At the cognitive level Klimov becomes aware of the “terrible and unexpected” news of his sister’s death but he is unable to give it an emotional charge: “he cried, and laughed and soon began to complain that they did not give him anything to eat”. Actually, he is still in a mental dimension in which the Ego, subjugated by the emotional and irrational forces, over which the instinctual blind desire to live prevails, cannot recover the capacity to suffer. But, after a week, when the totally restored Ego resumes its position of hegemony over other his mental abilities, “Klimov began to cry” and leaned his forehead against the window frame. His disease, his nightmares and the “animal” rebirth are exhausted by now and the Čhekhovian character becomes utterly aware of his pain for “an irrecoverable loss”. The words with which the story ends—“an irrecoverable loss”—point to the fact that for a lonely man (the aunt of Klimov is very old), the loss of a “traveling companion” and the consequent loss of an opportunity for dialogue and support, as well that an affective loss, represent for the mind the fall of an essential point of reference in the difficult path of existence.

3. Discussion

The psychologist can conclude that the characters of the story examined are more alive than living creatures and that, even if Chekhov says in The Seagul [15] that life should be represented not as it is but as we see in dreams, he, in fact, represents it with a concreteness that is stronger than the reality itself. The most interesting aspect of this story, what makes it extraordinarily modern, there seems to be the fact that the doctor Chekhov, taking the capacity of the writer, manages to get out of self-centered presumption and to consider the events from the perspective of the patient, turning his attention not only to the symptoms but to the person as a whole, considering his emotions, reactions, and his living environment. The aesthetic experience that is offered by the physician-writer teaches us to see what is happening around and that we often fail to perceive. Chekhov is, in fact able, to mediate an understanding not analytical but overall, not deductive logical but intuitive. He does see things, events and people simply because they exist, not to give a reason or justify or condemn, or discover the causes; just to give an account of their lives and to draw attention to the value, like all lives, deserve.

4. Conclusion

Following the line of thought of [16] -[19] , we consider the medical humanities, therefore, not as something extra to medicine, or worse, compensatory (of excessive technological development), but as something that helps operators to see their professional work more in terms of complexity, the different shades of ambiguity and possibility. In other words, the medical humanities, from our point of view, can contribute strongly to the formation of highly professional behavior, which, in addition to specific knowledge and skills, requires the ability to tolerate ambiguity, to observe their thoughts and feelings, to acknowledge the error and be able to make an integrated judgment on a particular clinical problem. Reading stories of illness as the one examined provides the clinician with the opportunity to immerse them in the experience of the other, facilitating the understanding of his perspective. These stories convey their meaning based not only on the ideas that are expressed in them, but also and especially from emotions in that they are present (anger, sadness, joy, fear, sense of injustice, etc.). The recognition of these emotions, by health professionals, can help reduce the distance between themselves and the patient that a number of factors (language, culture, socio-economic class, gender, etc.) could instead implement and encourage, therefore, a more empathic approach to the patient [20] . Also thanks to the process of recognition of emotions that takes place in the reading of narratives of illness, can be stimulated a process of reflection on their way to see the disease, on their own values and their own pre-understandings or even on their own bias. The reading of a text that can be based on feelings, emotions and feelings related, can awaken the sensitivity of the reader in the research and understanding of the sick person rather than the disease itself, allowing the physician, as noted by [21] , to bring the experience even read in the hospital wards.

References