Tuesday, June 5, 2007

Lessons in Medical Humanism: The Case of Montaigne

Michel de Montaigne, the great French humanist and inventor of the personal essay, suffered from frequent and severe renal colic. He wrote about his illness in his travel journal and in his last and greatest essay, "Of Experience." In his illness narratives, Montaigne integrated disease and suffering into his life and art. He humanized rather than conquered his disease. A mature humanism replaced his youthful Stoic philosophy of detachment and disengagement and provides a worthy model for our own medical humanism.

The cultivation of medical humanism has become an urgent need. We look to it to ameliorate the problems of contemporary medicine—the untrammeled marketplace, the coldness of scientific materialism, the incivility in the workplace—by grounding us in our humanity and bridging the gap between ourselves and our work. The fundamental science on which we base our care is a world away from the everyday life of our patients and ourselves. Mere humanism sometimes seems no more than a moral afterthought. Does it have a chance of success?
It is instructive to look back at an individual case, that of a man we might call the first modern humanist and, perhaps, the greatest of humanists. His case is especially relevant because chronic illness may have played a decisive role in shaping his outlook. Michel de Montaigne (1533–1592), the great Renaissance writer, had renal colic. His illness challenged his early Stoicism, which required him to conquer his pain and transcend human suffering. Stoicism, an ancient philosophy that became an important current in 16th-century humanism, recommended disengagement from emotion. But Montaigne's kidney stones also challenged him, as a humanist, to retain and embrace his humanity—which is the opposite of "transcending" it. Frame (1) has argued that the experience of nephrolithiasis, among other things, seeded a phase change in Montaigne: a transition from an elitist Renaissance Stoicism to a warmer humanism that, I would argue, anticipates our own. Montaigne's mature humanism replaced an ideology of detachment and disengagement and provides a worthy model for our own medical humanism.

Montaigne wrote in detail about his kidney stones in his travel journal (2) and in his last and greatest essay, "Of Experience" (3). Healy (4) interprets these writings as an illness narrative, a means of gaining control over his illness, a self-healing through language (4). Montaigne certainly sought control over his suffering through language, but in all his essays, he sought control over his soul. The experience of stone disease was yet another occasion for doing so, more difficult but not different in principle. Indeed, in "Of Experience," the passages on stones are seamlessly interwoven with other observations about his habits; his health; and one of his favorite subjects, the instability of the mind. Self-healing is implicit in the broader project of acquiring self-knowledge.

In the Renaissance, humanists looked back to antiquity and found aspirations, values, and pleasures—rationality and free inquiry, love of art and beauty, cultivation of the body—that differed from those of the Church. This humanism had a potentially subversive implication: It stands in contrast to the divine and emphasizes this world rather than the next. Yet Renaissance humanism was not heretical. Humanists labored to reconcile the new learning with Christian faith, and even the Inquisition, which closely guarded the dogma of the church, had no difficulty accepting Montaigne's brand of humanism. People have argued about his belief, but modern scholarship favors the idea that Montaigne was a good and practicing Catholic. Even his Stoicism, potentially heretical in emphasizing rationality rather than revelation, was reconciled with Catholic doctrine by the Flemish scholar Justus Lipsius, with whom Montaigne corresponded (5). Only with the trial of Galileo, and the beginning of experimental science, does the gulf between humanist inquiry and the Church become too wide to bridge.

In this context, our contemporary notion of medical humanism occupies a paradoxical place. Medical humanism can be traced back to Hippocrates, but it assumes its current form only in relation to the ascendancy of biomedical science. Medical humanism has taken on the general humanist sense of being grounded in everyday human experience—interpersonal communication, emotional engagement—in contrast not to the divine, but to science. At least in biomedicine (although not in secular humanism generally), science has replaced religion as the reigning orthodoxy with which humanism has a quarrel. Like our Renaissance forebears, medical humanists do not overtly challenge the reigning orthodoxy. Medical humanists are not against science. We want an accommodation, not a revolution.

Montaigne lived in a time of political and religious turbulence and of periodic epidemics of plague. At 30 years of age, he lost a friend, Étienne de la Boétie, with whom he had an unusually deep bond. As a humanist, he was preoccupied with meeting death courageously, as la Boétie did, in the manner of the ancient Stoics (6). In his earlier writings, Montaigne was concerned with making his life an exemplary preparation for death, transcending the body and the "common way," the everyday life of ordinary people. The ideal of Stoicism was the sage (sophos), whose goal is virtue and whose means are austere rationality and apatheia (disengagement from emotion). In Stoicism, only the sage is free; the rest of humanity is enslaved. Montaigne's early Stoicism was an elitist, rational, and detached humanism, humanist in the Renaissance sense of recovering ancient thought but not in the modern (and medical humanist) sense of sharing in ordinary human experience.

Montaigne's father died of kidney stones, and for a long time, Montaigne dreaded that he, too, would suffer from them (7). In 1578, at 45 years of age, his stone diathesis begins. What an irony: Could there be a greater challenge to the would-be Stoic than the pain of renal colic, the pain that, as we learn in medical school, is most severe of all? Renal colic could have reinforced Stoic withdrawal from the body's exigencies. But in his later essays, demurring from Platonic or Stoic elevation of the soul, Montaigne affirms nature, the body, and common humanity as the basis of a good life. He rejects the pretensions of the mind, whether to knowledge, rationality, or apatheia. He has learned that, in the extremity of renal colic, Stoic disengagement is no more than acting and posturing (1). He also learns that some stones, for whatever reason, pass without much pain at all, and he is thankful for that. He gets on with his life remarkably well, which is perhaps another argument that the stones provide against Stoicism. He has no need to detach himself from his body; although he suffers often and grievously, he finds, to his surprise, that he can live his life between these intervals of pain, and often during them. Nor do the stones kill him, as they did his father; rather, Montaigne dies of a throat infection.

Montaigne's skepticism is well known. Skepticism is in the intellectual air of his time, but it coexists with naive belief. In narratives of exploration, fabulous tales are conflated with the truth, and the recent discovery of the New World shows received opinion to be untrustworthy. Copernicus demonstrates, as will Galileo, that neither the evidence of the senses nor the elaborate productions of reason yields reliable knowledge. In Montaigne's view, the mind is too unstable, and the world too various, to permit certain knowledge; the philosophers' notion that reason is the highest human faculty is a kind of vanity. (Paradoxically, this humility lays the foundations of modern science. Bacon's program for acquiring practical knowledge and Descartes's quest for certainty are, in part, reactions to Montaigne's skepticism.) In this context, Montaigne turns his attention to that which is closest: himself. He follows the Socratic advice to know oneself but, unlike Socrates, believes that the self is the only thing he can try to know. It is worth remembering that the term "essay," a genre that Montaigne invented, is derived from the French word essai, meaning "attempt." Like Socrates, he can try, although he may not necessarily succeed. This attempt at self-knowledge is hard labor. The self may be near at hand, but it is elusive: Mind and memory are unreliable and are the dupes of emotion, vanity, illness, and habit.

Montaigne's skepticism is fed by the failures of his physicians. He claims to have inherited "the antipathy I have for their art" from his father and grandfather (8). No example of the vanity of reason, the substitution of systems and theory for real knowledge, could be more apt than protoscientific medicine. Montaigne delights, he tells us, in pretending to have symptoms that he has had (and gotten over without medical intervention), so that he might laugh at his physicians' prophecies of doom if he does not follow their instructions (3). Montaigne is his own physician. "I do little consulting about the ailments I feel, for these doctors are domineering when they have you at their mercy" (3). A famous Italian physician, a lecturer at Pisa, tells him that "medicine is nothing compared to the baths"—except for bloodletting (2). An Arab whom he befriends at Rome gives him powders to combat the stones (2), but Montaigne never says whether he used them. At one point, he finds it useful to "hold the urine from passing and squeeze the prick a little, so that it may come out more vigorously. The seigneur de Langon showed me this remedy at Arsac" (2).

Montaigne does not believe that there is benefit in noxious medications and restrictive diets. Medical care that diminishes the pleasures of life is inimical to him (3):

I do not like to cure trouble by trouble; I hate remedies that are more nuisance than the disease. To be subjected to the stone and subjected to abstaining from the pleasure of eating oysters, those are two troubles for one. The disease pinches us on one side, the rule on the other. Since there is a risk in making a mistake, let us risk it rather in the pursuit of pleasure. The world does the opposite, and thinks nothing beneficial that is not painful; it is suspicious of ease.

In 1580–1581, Montaigne takes a journey of 17 months, mainly in Italy, briefly in Switzerland and Germany. He is accompanied by his brother, his brother-in-law, several other gentlemen, and numerous servants. His purpose in making the journey is to visit the baths in hope of treatment for his stones (3). He keeps a travel journal, which was not intended for publication and was not discovered until 1774.

He describes his stone episodes in matter-of-fact language that resembles the unadorned narratives of Hippocratic case descriptions. "On Saturday morning, October 21st, I ejected another stone, which stopped a while in the passage but nevertheless came out without pain or difficulty. This one was rather round than otherwise, hard and massive, but harsh and rough, white inside and red outside, much bigger than a grain" (2). He is taking notes on the stones, perhaps to record information that may prove useful in managing them, or at least to reassure himself about them (3). He is a connoisseur of the stones he recovers: "Massive" is obviously the description of a man who has seen many before it. The stones are often red, and he often passes gravel and sludge. These details suggest that he had uric acid stones, as does this observation from "Of Experience" (3): "[The stone is] the commonest ailment of men of my time of life ... it preferably attacks the great, it is essentially noble and dignified." This class distinction is plausible: Only the nobility had access to the high-protein and high-purine diets that predispose to uric acid and calcium stones and that, in modern developed countries, are no longer confined to the rich.

Montaigne describes the waters and baths in great detail, including their temperature and taste, their putative benefits, and their customs of use. He also records the amount of water that he drinks and passes. He seems to regard the water as medicinal when ingested in small amounts, although on occasion he drinks and passes large quantities (which he measures by weight); he also believes that bathing in the water will help him. In general, he does not follow the oldest advice of all, Hippocrates' injunction to drink fluids. We know from the essays that Montaigne was in the habit of drinking only 3 glasses a day. For him, "taking the waters" usually meant bathing in or sipping them rather than forcing them.

In "Of Experience," Montaigne turns his attention to his body—his health—and commends the superiority of experience over reason. If experience has the better of reason anywhere, he says, it must be in health and medicine. In this debate, he anticipates the 18th- and 19th-century opposition of systematization and empiricism. He also exemplifies the premodern idea, well known in ancient Greece, that a layman could be as knowledgeable about medicine as a physician. He reviews the habits and practices that he has adopted to maintain his health and writes of his stones in detail in this context.

Montaigne plays a game: His logical mind must persuade his imagination that the stones are a blessing. The imagination, always ready to take comfort in rationalizations, will be his dupe. He will use the arbitrariness and instability of the mind, its tendency to make its own reality, to his advantage: to show the beneficence of nature and the body, even in pain. He shows an appreciation for the stones for the following reasons (3).

It is natural that the body fail with age. "It is a common necessity—otherwise would it not have been a new miracle performed for me?"

He thinks of the stone not as an affliction but as an honor: It is "the commonest ailment of men of my time of life," and because "it preferably attacks the great, it is essentially noble and dignified."

During stone passage, he can show off his courage in front of his friends. "There is pleasure in hearing people say about you, ‘There indeed is strength, there is fortitude!’"

His enforced suffering keeps "virtue in breath and in practice. Put the case this way, that nature is bearing and pushing you into that glorious school, which you would never have entered of your own free will." That is, the stone provides him with valuable training in Stoicism.

The stone warns him of mortality and leaves him healthy in the interval, to profit from the lesson. "[E]ven if it set before you the picture of imminent death, would it not be a kind service for a man of that age to bring him home to meditations upon his end?" And later: "We have no cause for complaint about illnesses that divide the time fairly with health." This remains true today. Typically, stone passage causes severe pain but not permanent kidney damage. Between episodes, the patient is in good health.

He suspects that age will bring an end to his stone diathesis. "The years have evidently made some of my rheums dry up. Why not these excrements that provide material for the gravel?" A reasonable speculation for which there is some basis: Urinary calcium excretion decreases with age. However, stone diathesis does not abate (8).

The stone brings no other illnesses in its train; indeed, Montaigne believes that it may have chased some others off. It keeps other diseases at bay because of the associated vomiting or the stone passage itself, both being the discharge of bad humors. Unlike fever, it leaves the mind clear.

The stone is entirely obvious to the senses; "it is a disease in which we have little to guess about," an uncertainty that could only lead the mind astray. This is true in the sense that one can hold the stone in hand, an obvious proof of the diagnosis. But as to its causation, even today we have only partial knowledge.

Finally, as in the travel journal, he notes that he can go about his business despite the stone, "play, dine, run, do this and do that too." He calls this "playing my game," while the stone plays its own game.

All of these rationalizations are put so lightly that it is difficult to know what is serious and what is jest. But that is the point: Montaigne's writing is another instance of "playing" with the stone. He keeps suffering at an ironic distance. He exemplifies the Renaissance virtue of sprezzatura, making the difficult look easy.

Playing with the stone is more difficult for us than for Montaigne. Like his grave and humorless physicians, we take physical suffering too seriously to make light of it. Because physicians can now relieve pain and remove stones and prevent their formation, suffering imposes an obligation on us to end it. Anything less is an accusation against our attentiveness or skill. The terms "patient" and "patience" derive from the Latin word pati, to endure, but neither patient nor physician has any patience for suffering. Suffering loses prestige when it is not thought to be necessary.

Illness offered Montaigne opportunities for spiritual growth, in acquainting oneself with and preparing for death while living fully; for writing and irony; and in the simplest, most natural, and yet remarkable way, for pleasure (3).

But is there anything so sweet as that sudden change, when from extreme pain, by the voiding of my stone, I come to recover as if by lightning the beautiful light of health, so free and so full, as happens in our sudden and sharpest attacks of colic? Is there anything in this pain we suffer that can be said to counterbalance the pleasure of such sudden improvement? How much more beautiful health seems to me after illness, when they are so near and contiguous that I can recognize them in each other's presence in their proudest array, when they vie with each other, as if to oppose each other squarely! Just as the Stoics say that vices are brought into the world usefully to give value to virtue and assist it, we can say, with better reason and less bold conjecture, that nature has lent us pain for the honor and service of pleasure and painlessness.

Stone passage typifies the interdependence of pain and pleasure, a favorite theme of Montaigne. Pain enhances pleasure, another argument against Stoic rejection of the body (3).

We must learn to endure what we cannot avoid. Our life is composed, like the harmony of the world, of contrary things, also of different tones, sweet and harsh, sharp and flat, soft and loud. If a musician liked only one kind, what would he have to say? He must know how to use them together and blend them. And so must we do with good and evil, which are consubstantial with our life. Our existence is impossible without this mixture, and one element is no less necessary for it than the other. To try to kick against natural necessity is to imitate the folly of Ctesiphon, who undertook a kicking match with his mule.

Like pleasure and pain, life and death are brought face to face in the experience of the stone. "If you do not embrace death, at least you shake hands with it once a month" (3). As the last of Montaigne's essays, "On Experience" reads like a leave-taking. The stone, Montaigne tells us, weakens the body and leaves it better prepared for death. "Consider how artfully and gently the stone weans you from life and detaches you from the world ... " (3). There is less of life in his aging body to surrender: "God is merciful to those whose life he takes away bit by bit; that is the only benefit of old age. The last death will be all the less complete and painful; by then it will kill only a half or a quarter of a man" (3). The stone is "the picture of imminent death." In his concluding pages, Montaigne endorses natural, well-rounded, everyday life—life that does not slight the body for the sake of the soul (3): "There is nothing so beautiful and legitimate as to play the man well and properly, no knowledge so hard to acquire as the knowledge of how to live this life well and naturally; and the most barbarous of our maladies is to despise our existence." These words could serve as the manifesto of modern secular humanism: Do not despise life in the name of a political ideology, religious doctrine, or "higher" calling of any kind.

Stone disease rarely causes death now. Renal colic is no longer a conjunction of life and death in that sense (even if at moments it makes the sufferer feel as if death were preferable). But the stone is still an emblem of death, a memento mori. Before it passes, it lies dormant and quiet within the soft tissues, a hard, lifeless thing. Even before it forms, it exists as a possibility that flesh could regress to. One of the oldest problems of living things is to keep in solution the dust from which we evolved. With the phase change from solute to crystal, something in the living tissue returns to where it began: death in life, life in death. Montaigne shows us what it means to humanize suffering and death rather than demonize them. In some ways, he anticipates another great humanist, Viktor Frankl, the psychiatrist who found self-realization even in the Nazi death camps; Frankl taught that suffering, like love and work, is one of the ways by which human beings make meaning (9).

Montaigne was eminently a practical man, and were he alive today, I believe that he would take the advice of scientifically minded physicians who had some good to offer him. Yet I can imagine his humanist attitudes persisting in the teeth of scientific medicine. I cannot see him submitting to a restrictive diet without a fight. I cannot see him, for that matter, submitting to "domineering" physicians. He would take some or all of his care into his own hands. I can even see him welcoming stone passage, at least occasionally, to test himself in the school of virtue, to enhance pleasure with the contrast of pain, to meditate on his death.

He would grant the practical power of science. I think he would even admire its humility, as embodied in the saying of Claude Bernard: "We can do more than we can know" (10). But I see Montaigne harboring a deep reservation about scientific medicine. Whether in the delusory theorizing of his own day or in the molecular mechanisms of ours, science transcends the everyday world of ordinary human experience. Our science is pure, simple, abstract, and beautiful; it is not like our lives. Effective medical science has no place for the transformative power of suffering, and it has difficulty coming to terms with death. I suspect that Montaigne might regard scientific medicine, for all its power, as not so different from the medicine of his own day: a high calling or specialized knowledge in whose name we "despise our existence," that is, disengage from lived human experience. Montaigne "played with the stone" and lived it, too—a means to virtue and wisdom and an occasion for good humor and even pleasure. So, he might admonish us: Do what you can to get rid of illness and suffering, but accept and even welcome them as well.

Could physicians dedicated to the relief of suffering also welcome it? Montaigne shows us how. We could use suffering to test ourselves in our contemporary school of virtue, to stretch our capacity for empathy. We could enhance the pleasure of successful treatment by feeling, as deeply as possible, the patient's pain and then relief. We could welcome suffering as an opportunity to demonstrate perseverance, heroism, or skill. We could regard suffering as a reason for faith or a reason for doubt. What we may not do is disengage from or transcend suffering in the name of conquering illness and death, or feel that impersonality and disengagement are the price of rational intervention. We must prize what F. Scott Fitzgerald said characterized a first-rate intelligence: the ability to hold 2 opposing ideas in the mind at the same time and still function.


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