by Sofie Vandamme

04 November, 2003

THINK WITH A STORY: ‘the magic skin’ of Honoré the Balzac.

The relevance of the 19th century realism for narrative ethics.

Sofie Vandamme

To think with a personal story of illness: narrative ethics

In 1997 Anne Hudson Jones wrote a review article in the Lancet on the development of ‘literature and medicine’. In that article she explains how literature was initially ‘used’ in medical education in order to “help to develop students’ capacity for empathy, to enhance their skills in interpretation, and to complement the teaching of traditional medical ethics” (Lancet, p.1243). In the eighties, the accent of the narrative enquiry moved from education to research on the narrative character of the medical practice itself. And from the nineties on, the medical interest in narrativity tended more and more to a form of narrative ethics focussing on “the ethical implications of a narrative conception of the physician-patient relationship”

Currently, Arthur Frank is elaborating some new ideas of narrative ethics. The ethical aspect leans to the existential aspect of being ill and, according to Frank, that goes beyond the clinical medical encounters. More precisely, the narrative ethics is seen as an alternative to the clinical ethics. Ethics is indeed a matter of narrativity because, according to this theory, it is in the personal narrative of ill people that one can read what it means to be ill. It is a moral inquiry for the doctor and the caregivers to interpret these stories in order to understand what happens when one becomes ill. For this reason stories are ethical by nature. That is why narrative ethics is conceived as a form of moral inquiry that requires ‘thinking with stories’.

The evolution from ‘literature and medicine’ towards ‘narrative ethics’, is enforcing the initial educational goals of ‘literature and medicine’ as described by Anne Hudson Jones : to improve the empathic attitude of medical students and medical doctors. But the position out of which narrative ethics want to achieve that aspiration has changed through the years. They no longer formulate alternatives for the traditional ‘principle’ ethics by using literature, but narrative ethics develops an ethical alternative for the medical perception of illness. The narrative nature of this ethic is fundamental, because stories of illness and especially patient stories evoke an ethical attitude toward those people who are suffering from illness. Consequently, the multitude of genres as used in the early years of the ‘literature and medicine’ educational project has disappeared. Because of the empirical actual value of autobiographical accounts, those testimonial stories are far more powerful to communicate the moral message of the narrative ethics: ‘think with the patient’s story in order to understand what it means to be ill’…

In this presentation, I first want to question this concept of ‘thinking with stories’ as an ethical narrative activity. Next, I want to show that the empirical references of a story or the autobiographical genre are non-conclusive criteria for interpreting illness stories as being relevant for the narrative ethics in medicine. Finally , I want to show that the persuasiveness of the narrative ethics is not bounded to the genre of the story, but is rather a question of the perspective out of which a story is read.

I want to consider these ideas through an example of ‘thinking with a fictional story’, a fragment of The magic skin written in 1831 by the French novelist Honoré de Balzac. The ‘consultation’, as this scene is called, tells the story of the rich marquis De Valentin, suffering from a mysterious but very serious illness, who fears that his days are counted. In an ultimate effort to avert his fate, he is consulting three medical doctors at the same time.

This fragment illustrates how a fictional story of a fictional disease can be illustrating what it means to be ill. But it is especially interesting because it deals with the subject of narrative ethics not as an alternative for the medical story of illness, but because the medical discourse itself is the subject of the story.

The ‘medical story’: a medical gaze on disease

Paris. 1830. We are in the midst of the scientific revolution in medicine. Various theories and epistemic models are in a strong competition. As well in the field of psychiatry as in the domain of pathology radical paradigm changes are following one after another. The most important changes that gave the initial impetus to modern medicine are the clinical perspective organized in large part by the paradigms of pathological anatomy and ‘moral treatment’ for the mental illness that were developed by Bichat, Cabanis, Broussaus, Pinel…

But the 19th century is also on the literary platform known for its innovations. Balzac has played an important role in the development of realism. He was the first author using the nascent scientific theories in his literary work in order to develop a better understanding of the human world. His novels are reflecting the epistemic plays that were at order in the ‘scientific’ world, but at the same time Balzac is criticizing scientific claims to knowledge. In 1831 he publishes The magic skin.

The main character of this book, the rich and snobbish marquis Raphael de Valentin, is driven by a very simple but universal desire: fame, money and women. But precisely his desire leads him to his destruction: every time he fulfils his desire he loses his vitality. Day by day Raphaels’ condition is aggravating. Towards the novel’s end, when Raphael is near death from his successive wishes, he is so despaired about his different mysterious mental and physical complains, that he insists to be examined by the best doctors of Paris. In the scientific turmoil of the beginning of the 19th century, Raphael de Valentin is insecure about what kind of medical doctor - or better: what kind of medical doctrine - he has to consult in order to know what is happening to him. He decides to ask all of them.

“Valentin had summoned the oracles of modern medicine, so that he might have the last word of science. Thanks to his wealth and title, there stood before him three embodied theories; human knowledge fluctuated round the three points. Three of the doctors brought among them the complete circle of medical philosophy; they represented the points of conflict round which the battle raged, between Spiritualism, Analysis, and goodness knows what in the way of mocking Eclecticism.”

It’s significant that Balzac uses the word ‘oracles of modern medicine’ because each of the medical ideologies had a different conception of disease to defend. According to the organicist, disease is purely a matter of material, physical condition of the organism. For the spiritualists on the other hand, illness is the result of a general unbalanced life of an individual. The last category, the empiricist belief in their own perceptions, and all the rest is doubtful. Each of these theories is personalized by the figures of the doctors Brisset, Cameristus and Maugredie, pseudonyms of famous historical figures in medical history.

The first doctor, the organicist Brisset, is a synonym for the French pathologist Broussais. As Broussais was effectively a successor of Cabanis and Bichat, Balzac introduces this character as follows:

“The illustrious Brisset, the successor of Cabanis and Bichat, head of the Organic School, a doctor popular with believers in material and positive science, who see in man a complete individual, subject solely to the

laws of his own particular organization; and who consider that his normal condition and abnormal states of disease can both be traced to obvious causes.”

Two years before The magic skin Broussais

published De L’irritation et de la folie. According to his theory, mental diseases depend on irritation of local organs, as a result of a general unbalance. When doctor Brisset asks to Raphael whether he has been ‘leading a dissipated life’, it is clear that he is referring to Broussais’ theory of mental illness. The same goes for Brissets diagnosis: Brisset sees what Broussais always saw: inflammation (especially from the gastric system) leads to irritation and gives finally rise to monomania:

“He is exhausted, I say, by too much brain-work, by irregular courses, and by the repeated use of too powerful stimulants. Violent exertion of body and mind has demoralized the whole system. It is easy, gentlemen, to recognize in the symptoms of the face and body generally intense irritation of the stomach, an affection of the great sympathetic nerve, acute sensibility of the epigastric region, and contraction of the right and left hypochondriac. … The progressive deterioration wrought in the epigastric region, the seat of vitality, has vitiated the whole system. Thence, by continuous fevered vibrations, the disorder has reached the brain by means of the nervous plexus, hence the excessive irritation in that organ. There is monomania.”

As soon as Brisset has made his statement, another agent of the medical science, the spiritualist doctor Caméristus, is examining Raphael de Valentin. It is generally assumed that Caméristus is a pseudonym of Rémacier. In this scene he is the counterpart of Brisset because he is presented as an adherent of Jan Baptista van Helmont, a physician and physiologist who was at the beginning of the 17th century, one of the first to apply chemical principles to questions of human health and disease. But at the same time Van Helmont was mystically inclined and introduced a system of supernatural agencies that preside over and direct the affairs of the body.

“Doctor Cameristus, a man of creeds and enthusiasms, the head of the "Vitalists," a romantic champion of the esoteric doctrines of Van Helmont, discerned a lofty informing principle in human life, a mysterious and inexplicable phenomenon which mocks at the scalpel, deceives the surgeon, eludes the drugs of the pharmacopoeia, the formulae of algebra, the demonstrations of anatomy, and derides all our efforts; a sort of invisible, intangible flame, which, obeying some divinely appointed law, will often linger on in a body in our opinion devoted to death, while it takes flight from an organization well fitted for prolonged existence.”

According to this theory, disease is not caused by organic defaults, but it is purely a matter of mental disruption. In the case of Rapael, it is the mind that has attacked the epigaster, the locus of the life force.

"The divine spark, the transitory intelligence which holds the organism together, which is the source of the will, the inspiration of life, has ceased to regulate the daily phenomena of the mechanism and the functions of every organ; thence arise all the complications which my learned colleague has so thoroughly appreciated. The epigastric region does not affect the brain but the brain affects the epigastric region.”

Finally, the third and last doctor, Maugendie, observes the patient. He is a septic and closely resembling the experimental physiologist Magendie. Being an empiricist, he only beliefs what he sees with his own eyes.

“He found something sensible in every theory, and embraced none of them, claiming that the best of all systems of medicine was to have none at all, and to stick to facts.”

Consequently, he is the only one who has his doubts about the illness of Raphael, at least in so far that he can’t see hard facts of disease.

“As for knowing whether his epigastric region has affected his brain, or his brain his epigastric region, we shall find that out, perhaps, whenever he dies”.

To put it briefly, Balzac gives a quick overview of each of the three existing medical doctrines. The concrete arguments that are used in this fragment are retraceable in the theoretical controversies in the medical journals of that time, like la Gazette médical de Paris or La revue médicale historique et philosophique

[1]. Thus far, Balzac is writing reality here. It can even be said that he is writing medical history through the putting on stage of the controversies between the medical ideologies at the beginning of the 19th century. He is writing a medical story by confronting those 3 medical ideologies at the bedside of Rafael the Valentin, each of them with their own medical gaze on disease.

Think about the medical story: an allegory

After these short introductions of each of the medical theories represented by the 3 doctors, Balzac falls into a grotesque exaggeration.

The doctor Brisset blows up Brouissais’ theory of inflammation causing mental illness. The irritation of the stomach gets out of hand.

“Strictly speaking, there is no stomach left, and so the man has disappeared. The brain is atrophied because the man digests no longer.”

Doctor Brisset amply proposes Broussais’ usual treatments like leeches diets and bloodletting.

“If you put leeches at once on the epigastrium, and reduce the irritation in that part, which is the very seat of man's life, and if you diet the patient, the monomania will leave him.”

The opposite of this ‘organic’ treatment, the “moral treatment”, recalling the psychiatrist Pinel, proposed by Cameristus is presented in an adapted, woolly language.

“From the softness of a wet sponge to the hardness of pumice-stone there are infinite fine degrees of difference. Man is just like that. Between the sponge-like organizations of the lymphatic and the vigorous iron muscles of such men as are destined for a long life, what a margin for errors for the single inflexible system of a lowering treatment to commit; a system that reduces the capacities of the human frame, which you always conclude have been over-excited. Let us look for the origin of the disease in the mental and not in the physical viscera. A doctor is an inspired being, endowed by God with a special gift--the power to read the secrets of vitality; just as the prophet has received the eyes that foresee the future, the poet his faculty of evoking nature, and the musician the power of arranging sounds in an harmonious order that is possibly a copy of an ideal harmony on high."

Maugredie, the empiricist is the only doctor who puts forward not to lose sight of the patient. But this remark isn’t inspired by a feeling of empathy, but by a very pragmatic (and morbid) reason.

“The patient suffers from monomania; very good, I am quite of that opinion," he said, "but he has two hundred thousand a year; monomaniacs of that kind are very uncommon. As for knowing whether his

epigastric region has affected his brain, or his brain his epigastric region, we shall find that out, perhaps, whenever he dies.”

Balzacs descriptions of the medical doctrines leans close to a satire because of the exaggerations, especially in the argumentation that leads to the diagnosis – the verdict for Valentin. It is hard to believe that Balzac would describe reality here.

But it is precisely through this ‘fictionalisation’ of the reality, that he is writing about medicine. By bringing those three different theories together in one and the same case in an overstated depiction, Balzac is questioning the real nature of disease. He shows how each of these doctrines perceives reality through the eyes of their own theory. And how disease is that what the paradigm says it is.

It is precisely because in this scene three different medical doctrines are confronted with one and the same ‘’case”, that the contours out of which disease is medically recognized becomes clear. This fragment illustrates how medical knowledge is determined by its paradigm. That’s why this story is an allegory of knowledge. Knowledge about illness is relative to the perspective provided by an epistemic doctrine.

To think with a medical story: narrative ethics

Although this scene is mostly interpreted as an illustration of controversies of the medical doctrines of the beginning of the 19th century or as an allegory of knowledge, there is also another way of ‘thinking about this story’. It is a critical way of thinking, going beyond the representations of the medical doctrines. According to this third way of ‘thinking with this story’, we can read that Balzac criticizes that medical doctors, being scientist, only see the disease, while the patient goes out of sight. He does so in three different ways.

Firstly, Balzac persists that the medical gaze on illness is very limited through the setting of the tree medical paradigms at the bedside of Valentin and the ironical overtone of the story. He shows how medical scientists are focussing on the disease and how they are blind for the suffering of the patient. Balzac’s story deals at the first place with the medical gaze on disease where the person of Raphael de Valentin is of no importance. The same goes for his feelings, his anxiety and his insecurity. But he is also mentioning the perspective of Valentin. And from that point of view, Raphaels expectations towards medicine are indeed under discussion. While Raphael is listening in de corridor to the dispute about the nature of his disease, he thinks:

“Man's 'it is,' and 'it is not,' is always on my track; it is the Carymary Carymara of Rabelais for evermore: my disorder is spiritual, Carymary, or material, Carymara. Shall I live?

Secondly, Balzac is describing the antagonist of the three ‘medical scientists’ through the figure of doctor Horace de Biancon, the friend of Raphael and doctor in attendance. Biancon really cares about his friend and he is desperately trying to help him. But by depicting Biancon as a ‘soft’ and naïve doctor, too young to know the tricks of the trade, Balzac makes clear that ‘real modern medicine’ is matter of ‘hard science’ and not of weak compassion.

“There was deep, unconcealed distress, and grave compassion in Horace Bianchon's face. He had been a doctor for too short a time to be untouched by suffering and unmoved by a deathbed; he had not learned to keep back the sympathetic tears that obscure a man's clear vision and prevent him from seizing like the general of an army, upon the

auspicious moment for victory, in utter disregard of the groans of dying men.”

Thirdly, the character of Valentin, presented as the helpless research object of the medical scientists, shows that the medical story is only one side of the picture. From the first sentence on, Balzac stresses the cool and anonymous medical approach. Valentin is introduced in a similar way as a research object under a microscope.

“Raphael found himself seated in an armchair, placed in the window in the full light of day. Four doctors stood round him, each in turn trying his pulse, feeling him over, and questioning him with apparent interest.”

Throughout the whole examination Raphael de Valentin is of no importance. He has no right to answer the inquiries of the three professors. Only doctor Biancon is addressed and has the right to speak about the disease of Valentin.

“All Valentin's observation could discover no trace of a feeling for his troubles in any of the three doctors. The three received every answer in silence, scanned him unconcernedly, and interrogated him unsympathetically. Politeness did not conceal their indifference; whether deliberation or certainty was the cause, their words at any rate came so seldom and so languidly, that at times Raphael thought that their attention was wandering.”

Balzacs designates medical practice as a matter of finding a suitable diagnosis, as an activity the doctors perform with an absolute indifference and excluded from any involvement.

“After spending about half an hour over taking in some sort the measure of the patient and the complaint, much as a tailor measures a young man for a coat when he orders his wedding outfit, the authorities uttered several commonplaces, and even talked of politics.”

The ‘modern’ doctor, incorporated in the character of doctor Brisset, clearly formulates the core activity of modern medical practice: to compare the symptoms of this example with other cases. He has no time to waste, because his other patients in the clinic are waiting. Valentin is an interesting case as long as his symptoms are fitting in the existing clinical picture.

"Permit me, gentlemen," said Brisset, as they entered, "to give you my own opinion at once. I neither wish to force it upon you nor to have it discussed. In the first place, it is unbiased, concise, and based on an exact similarity that exists between one of my own patients and the subject that we have been called in to examine; and, moreover, I am expected at my hospital.”

As the examination and the discussion goes on, Raphael de Valentin is on the verge of despair. His believe in modern medicine took a terrible knock.

"What is the good of science?" Raphael moaned. "Here is my recovery halting between a string of beads and a rosary of leeches…”

Finally, the three medical doctors are coming to terms. The diagnosis is reported to the patient as compromise of the three medical doctrines. After the requisite payment, the 3 professors are leaving. Soon followed by Raphael de Valentin, leaving for eternity…

According to this interpretation, we can conclude that this story has ethical relevance. It is an appeal for a more humane and patient-centered medical approach. It is a case of narrative ethics, but not in the conventional way. First of all, because it is not an empirical grounded story of an ill person dealing with existential aspects of being ill that goes beyond the clinical encounter. But especially because it a realistic story with two levels.

On one hand Balzac is representing medical reality in the quick overviews of several reigning medical doctrines. He is thinking about medical reality in the way he puts these different medical doctrines on stage. Here the story no longer is reality, but an allegory reflecting on the relativity of medical knowledge.

On the other hand, this story is pure fiction. This is partially a matter of style. E.g. the irony and the enlargement Balzac uses. But it is especially the character and the illness of Raphael de Valentin that is a concocted story: The marquis does not exist, neither his magic skin nor his mysterious illness.

But it is precisely this fictional figure in this fragment that is referring to reality, more precisely to the reality of modern medicine. Through the uncomfortable experiences of Raphael the Valentin, attention is drawn to the fact that that modern medicine is not only a matter of defining disease. But it is pointing to the fact that modern medicine also has a subject, an ill person with huge expectations towards the medicine: to help him, to cure him, to relieve him from pain and suffering, to recognise the insecure and anxious ill person behind the medical disease. That is the moral question at stake in narrative ethics. This example shows that this is not exclusively a matter of personal stories of illness, nor that dealing with this kind of moral questions are an alternative for the medical discourse. The example elaborated here, shows that a fictional story about medicine of the 19th century of a fictional character suffering from a fictional disease can be as persuasive as a personal account of illness.

Although Raphael de Valentin ‘died’ probably somewhere in the 1830 ies., or he never died – because it is ‘only’ a story, his story is of all times and of all places. But therefore we don’t have to ask the question ‘what is in a story’, but we just have ‘to think with a story’.

Out of that perspective, the fictional stories of Balzac have an actual relevance. Not because they are describing reality, but because they are reflecting about reality. That is how we can understand Balzac – as he writes in the preface of The magic skin - that fiction is reality in that sense that the writer has to have “I don’t know what kind of concentric mirror where, according to his fantasies, the world is reflected.”

Thus far some reflections on a fictional story, making us think about medicine, about medical knowledge …and about narrative ethics.

[1] Cabanes (96-97)

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