Читать книгу The Blue Man and Other Stories of the Skin - Robert A. Norman - Страница 8

PREFACE

To cure sometimes, to relieve often, to comfort always.

—Attributed to Edward Livingston Trudeau

Throughout my medical career, I have kept two sets of records: one of patients’ clinical notes, the other of patients’ stories. Along the way, I began to write my own stories. I have hammered out essays for Discover magazine, written and edited five textbooks of dermatology, and been a preceptor for a few hundred medical residents, medical students, and undergraduate students who ask endless questions and increase my own knowledge while feeding their own.

This book focuses on the dynamic qualities of the skin and the people who inhabit it. Included are stories about the life of the skin, tales of fascinating and mysterious patients, meditations on cultural issues including skin color, and thoughts about the future of the skin. I try to speak for the skin, since it cannot speak for itself, and show you how lucky we are to have such an amazing natural covering. Our skin is our partner, nourishing and protecting us, teaching us about the world, and serving as a record of our lives. We should take the opportunity to learn what the skin has to teach and how we can best serve each other.

Each day I try to heal the pain, both psychological and physical, that illness of the skin causes people. As a physician, I am often required to peel away possibilities to get to the source of my patient’s medical problem and repair what has been disturbed or broken. Each problem—and each appointment—is preceded by a story. Recently a man came to see me complaining about a “growth on my arm giving me pain.” In the exam room, my medical assistant gently pulled off the man’s ragged, home-rigged dressing and revealed a profusely bleeding half-dollar-sized skin cancer. I let him know that I could surgically remove it right then, and he agreed. But beyond this nasty growth I could envision a whole history, including a lack of funds and transportation, that had kept him from seeking a remedy. A few days later an eight-year-old girl came to my office with severe atopic dermatitis and a horrible itch. She had been out of school for three weeks—and her mother had been unable to go to work during much of that time, due to lack of sleep and trying to care for her child. With each patient’s story, the narrative proceeds to a resolution and hopefully some relief from the burden of a disease that elicits pain, itch, or other disturbance in quality of life for the patient and family.

On many days, my primary role is that of a nurturer. I often have to explain that many skin diseases are chronic in nature and only palliative care can be provided. Although there may be a perception that skin conditions only minimally affect patients, those who have protracted and severe conditions often endure serious psychosocial repercussions. All the activities of daily living—including work, sleep, hobbies, and social contact—may be harshly disturbed. Using the Dermatology Life Quality Index, the Beck Depression Inventory, and other quality-of-life measures, researchers have confirmed that those suffering from prolonged skin disease often endure significant impairments of work, school, and personal relationships.

In my stories and in my daily work, the patient is at the center, and the disease is a supporting actor. In the words of one of my heroes, William Carlos Williams, I get to “witness the words being born” while listening to my patients describe what bothers them and why they are seeking help. If I pay close attention and ask the pertinent questions, I can become a part of the birthing process; later, at my writing desk, I am able to record and perhaps better comprehend what has been said and done. In the exam room I’m confronted with themes from the marriage of medicine and literature, reflections on what is happening today in medicine and the world, and questions about how each person lives and interprets personal problems. Although these observations and conversations primarily take place during my exam of a patient, the history that precedes each problem has occurred over years or decades—my job is to take the kernel of a patient’s story that I can glimpse in the exam room and make it come to life in my writing.

On the journey across these pages, I will ask many questions. What can we do to protect our skin and ourselves? How will the skin of the future be different? How does skin color affect social position and how can diseases such as albinism impose real punishment? How do people with skin diseases see themselves and their opportunities in life, and how do their lives change as a result of their conditions? How do people cope with having bodies or diseases that aren’t “normal” in our culture? My overall purpose is to showcase the wonders of the skin, the agony of certain diseases and their attendant social and psychological toll, and provide some insight into how the skin and our perception of it influence our social, cultural, spiritual, and physical being—and how we can learn and grow from our new knowledge.

Why would someone choose dermatology as a career? In his introduction to The Life of the Skin: What It Hides, What It Reveals, and How It Communicates, by Arthur K. Balin and Loretta Pratt Balin, the famous dermatologist Albert Kligman wrote, “When I began, the field of dermatology was a swamp of snakes and nonsense, magic and folklore. The cynical view used to be that people went into dermatology so they didn’t have to be awakened at night to go care for patients.” He continues, “Modern dermatology is rooted in science and developing at an Olympic pace. These days the highest-ranking students apply for dermatology residencies. To become a dermatologist now, a student has to be highly educated and conversant in the fields of psychology, art, immunology, genetics, and biochemistry, to name but a few.”

As the Balins carefully point out in their book, “Dermatologists do far more than treat the skin, for the skin mirrors the health of the entire body.” By means of an eruption, itch, color change, or other sign, the skin can alert us to a problem in the deeper organs. For the visually oriented, the signs and patterns of skin disease signal the diagnosis. But dermatology is also tactile: I often guide the fingertips of medical students to help them touch the sandpaper-like feel of a precancerous skin lesion, the warmth of an area of inflammation, or the blanching of a vascular lesion.

Finally, as Kligman points out, dermatologists also have to know psychology. I see people at their most vulnerable, devastated as many are by their appearance. There is a gratification for both me and my patient from seeing the results of our work, either rapidly, when removing a skin cancer, or over time, when treating psoriasis or cystic acne.

I have divided the book into two parts. I start at the surface, with the enormously dynamic and lifesaving nature of the skin itself. Part 1, “Our Vital Skin,” highlights the skin in its many amazing roles. I’ll investigate how our skin defines us, what we need to do to protect it, what unseen creatures live on it, and how crucial structures within it have determined the course of history.

Part 2, “Living in Our Skins,” goes deeper, into how we deal with skin diseases, the social and psychological issues of skin as social entertainment, and how the skin reveals and communicates our wishes and burdens. The focus here is on how skin color, disease, or irregularity can affect social position, self-esteem, and a person’s opportunities in life. In this section, we’ll see how our skin in all its glory and vagaries—from extra ears to imaginary parasites—manifests itself in our lives and culture.

Throughout, we’ll see that skin has a direct cultural influence on every generation. It is a canopy for each individual and for all of humanity, stretching over us and encompassing the whole range of shape, color, and disturbance, from idiosyncratic, rare diseases to the broad experience of entire societies.