In medicine, there has been a steady flow, a slow accretion, of knowledge that has been discovered and applied through trial and error, across cultures and time, to the hopeful profit of all through the earnest labor of many. This occurred by degrees, over the centuries, from the earliest observations of nature within the ancient world, on to men like the great second century Roman physician Galen. From there it flowed to the Muslim guardians and transmitters of ancient wisdom in 9th century Baghdad in the form of men like al-Razi, on to Constantinople, and back again to early Renaissance Europe. In this meandering way, medicine has surged forth and run like a gradually widening river wending its way through time and space into the present era. Great and learned people such as the Jewish philosopher and physician Maimonides to the more mystic Paracelsus, all played a role in widening and deepening the river as it sluiced and surged forward, contributing to its ever-quickening current. Once the Renaissance began, the work of thinkers like Vesalius and Harvey; Pasteur and Osler, pushed it ever faster on toward the modern era. If we are possessed with such gratitude as to remember from whence we came, we physicians discover that we are the inheritors and stewards of a great fund of knowledge that was painstakingly discovered and pulled from the mystery of the world around us, often at the steep cost of a legion of patients, suffering over these many centuries of time, no longer remembered but to whom we remain forever deeply indebted. It is one of our great tasks and obligations therefore, to feed the fire of the wisdom of those who came before us, and to do so both within the crucible of tradition and simultaneously also always striving forward to build upon this vast edifice in our own unique way. We are duty-bound to those who came before us to add our own insights and contributions as we carry the torch on to the next generation of physicians. We are as a wave or a whirlpool, perhaps the splash of a raindrop, in a great flood; transient but still integral; here but for an instant but adding to the great profundity from which we arose in a way that is indelibly ours, sui generis, and necessary.
Of course, medicine is not unique in this way at all. History is naturally seen through a similar lens. How can one understand the rise of Napoleon without any knowledge of the French Revolution? Or the blood bath of the Somme without seeing the ramifications of Gavrilo Princip’s pistol near the Latin Bridge in Sarajevo? Law, whether British common law or US constitutional law, proceeds in a similar manner, slowly and case by case, through the establishment of precedent based on previous jurisprudence and careful legal consideration. Finally, philosophy also grows and changes and flows in a such a way. Socrates inspires Plato who inspires Aristotle who inspires many, but especially St. Thomas Aquinas and the Scholastics. There is the Cartesian turn and then Spinoza, Hume, Leibniz, Bacon, Kant and with Enlightenment science the world has changed again.
One lovely example of this progression of knowledge, but one that crosses categories from philosophy to poetry to medicine, begins with the great Medieval realist and Oxford man, John Duns Scotus (1265/66-1308), also known classically as Doctor Subtilis or the subtle doctor, for his elegant and nuanced arguments. Duns Scotus spoke of an object’s haecceitas or as Copleston defines it, an “object’s thisness or principle of individuation.” (1) Duns Scotus, for reasons of metaphysical Scholasticism and realism, was eager to deny a true distinction between an object’s essence and existence. In place of this, he described a “formal objective distinction” that was not a true distinction, per se. As Copleston puts it, “there is a formal objective distinction between the human nature and ‘Socratesness’ or haecceitas in Socrates, but not a real distinction, so that the human nature can be considered simply as such, without reference to individuality or to universality.” (2) To put it another way, there is a formal distinction between the haecceitas, or individuated object (the man Socrates) and the general object (Socrates as a man). “It is necessary to suppose such a distinction, since otherwise, that is, if the nature were of itself individual, if it were, for example, of itself the nature of Socrates, there would be no objective foundation, no valid ground for our universal statements.” (3)
Duns Scotus is clear that this is not a true distinction, but rather a formal one only, and it allows him to still speak of universal judgments (of human beings generally) while preserving the realism of individual entities in the world (of Socrates, for instance). While the finer points of these types of Scholastic hair splitting may be debated, the important concept I want to highlight is Scotus’ idea of haecceitas, or thisness. The Canadian philosopher Charles Taylor writes that “each particular thing has its own force which maintains it in its “thisness” (haecceitas). (4) It is this idea of thisness, or haecceitas, which inspired the Victorian-era poet Gerard Manley Hopkins.
Hopkins (1844-1889) was also an Oxford man, became a Catholic priest, and was a great admirer of Scotus. While he never published any poetry in his lifetime, it became popular in the twentieth century due to both his unique “sprung rhythm” style, which mimicked the pattern of human speech, and due to his theory of inscape. Inscape, a portmanteau of sorts combining the word landscape with that of the inner self, is the way of describing the force and soul of another being-human or otherwise. Hopkins wrote of the haecceitas of things, of their inscape as he saw it, in poetic form allowing the reader to feel the force of that particular thisness in one fantastic and magnificent poetic blast. Consider a skylark in his poem “The Sea and the Skylark”
Left hand, off land, I hear the lark ascend,
His rash-fresh re-winded new-skeined score
In crisps of curl off wild winch whirl, and pour
And pelt music, till none’s to spill nor spend. (5)
One can imagine not just seeing and hearing the skylark but almost being the skylark, singing into the buffeting wind on the shore, such has Hopkins captured its inscape in his verse.
Here, in his poem “Pied Beauty,” is another lovely example of the inscape he grasps in dappled creatures and objects: skies, trout, the landscape, various trades, finches’ wings, etc.
Glory be to God for dappled things-
For skies of couple-colour as a brinded cow;
For rose-moles all in stipple upon trout that swim;
Fresh-firecoal chestnut-falls; finches’ wings;
Landscape plotted and pieced - fold, fallow, and plough;
And all trades, their gear, and tackle, and trim.
All things counter, original, spare, strange;
Whatever is fickle, freckled (who knows how?)
With swift, slow; sweet, sour; adazzle, dim;
He fathers-forth whose beauty is past change:
Praise him. (6)
Notice that the inscape can be found not just from a living creature but from any object in the world. Another lovely example of this is his poem “Inversnaid”, in which he describes a stream passing through a wooded glen.
Degged with dew, dappled with dew,
Are the groins of the braes that the brook treads through,
Wiry heathpacks, flitches of fern,
And the beadbonny ash that sits over the burn.
What would the world be, once bereft
Of wet and of wildness? Let them be left,
O let them be left, wildness and wet;
Long live the weeds and the wilderness yet. (7)
Here inscape can be found not just in another human being but in the living plant life, “flitches of fern” and “wiry heathpack”, that surrounds the gurgling brook. In these tight descriptive phrases there is an almost instantaneous recognition of what the poet means, not just denotatively but connotatively with a deeper, metaphorical resonance. But what does this have to do with bedside medicine? With the care of our fellow human beings?
The physician and philosopher Jacob Needleman, in his wonderful book The Way of the Physician, notes a time when he, as a physician, was called to take care of a sheikh. There is in what follows a beautiful description of an intuitive comprehension of what Hopkins might have called, the sheikh’s inscape, or what Duns Scotus would have described as his haecceitas. As Needleman writes,
…his eyes were like fire, even in the darkness. I began to feel queasy and a little nauseated. I left that room and him as soon as decorum would permit. But what I took from that meeting was very precious to me-the certainty that people do in fact have emanations of a very distinct and material nature. I had experienced this fact before, but it had always been mixed with mental and emotional reactions of respect and admiration for people who had certain moral qualities that evoked trust in me. The sheik, however, had, for me, only negative personal qualities and therefore in my conscious mind I was dead set against finding anything at all remarkable in him. But I simply could not deny that he had affected my body. Although I left the house hating him, I could not deny that my body was filled with a certain kind of energy that had nothing to do with my mental and emotional reactions. (8)
This highly negative and malevolent intuition of the man’s inscape is nevertheless an example of the phenomenon which I am attempting to describe-a phenomenon that is critical to the successful practice of medicine generally, and emergency medicine specifically. Of course, whether an inscape be positive or negative is irrelevant to the fundamental concept that an emergency physician is there to treat any and all who may wash up on our doorstep one day. It should go without saying that we will take care of all of them to the best of our abilities. However, the greater point remains that a human being, a patient, carries an inner landscape within them and that even just a glimpse of this character by the astute physician will redound in spades upon both the patient and the physician through the medium of that critical interspace that exists between them, and which is the heart of that singularly human interaction between two human beings generally, and a physician and a patient specifically.
To work in the emergency department means, of course, that this beautiful interaction recurs again and again on any given shift, with each encounter offering a chance for the patient to partake in the process of being healed in their affliction and the physician the opportunity to grow and learn about the breadth and depth of the human condition and the ways in which one might treat their fellow man. Both patient and physician are made better by an honest and genuine encounter. To put it another way, the optimal result is that both people are made a little more whole and are a little more knowledgeable and well through their encounter with each other.
As such, one of the greatest joys, and challenges, of working in the emergency department must be the sheer number of people, the incredible diversity of encounters, that one will experience as an emergency physician. Could it be that anyone has ever had such an opportunity to know so many different people and to learn about the vast complexity of the human condition as the emergency physician working today? On any given shift, the emergency physician may encounter any small part of the astonishing breadth of humanity; from newborns to centenarians of any race, creed, or nationality, all gathered together in one place, in the hopes of having some problem, from small to life-threatening, addressed and hopefully treated successfully. There is a peculiar kind of muted and satisfying joy in attempting to interact with such a flood of human life. To do it well takes practice, acceptance, humility, curiosity, and empathy. To do this well is a combination of both rarefied and scientific detachment and quickly-earned intimacy and trust. There is a subconscious recognition of the haecceitas, or inscape, of the other person in the room-a kind of learning that cannot be found in a textbook but must be earned in the thrash and wildness of human interactions. Each unique inscape is added to a growing tapestry of humanity and provides the physician with just a little more knowledge of his subject within a universe that can never be fully known but must always also be a part of us. It requires both the ability to step in and learn critical details of a patient’s life followed by the capacity to step back and apply that trusted empirical information to this specific patient at this specific moment in time and within the unique contextual structure of their lives.
The concept of “intimate detachment” is difficult to convey, perhaps a similar Hopkinsian portmanteau like “intachment” may be of assistance. It is a process of being wholly involved with the patient even when you’ve just met them, and even when the department is insanely busy and hovering around you as a presence in the back of your mind. It requires the ability to simultaneously lean out to try and grasp the whole of a person while also leaning in and obtaining specific, detailed, and scientific information , which can then be applied back to the whole individual in front of you, but now within the context of their life, as you have begun to discover it at that moment in time. As I have written at greater length before, there is a certain leaning out to grasp an intuitive whole, followed by a lean in to obtain inductive and empirical information, followed by a final lean out to apply all that information back to your initial impression and overall gestalt of the clinical scenario before you. This takes time and practice and seeing thousands of patients to fully understand and I am sure I am still in the process of learning how to do it better, but I do believe that this process, or something like it, is what distinguishes an expert from a novice or even a physician of average competence in the emergency department.
Intachment, as I see it, is not the same as Dun Scotus’ haeccitas or Hopkins’ inscape but rather a process, or a means, of discovering the inscape or haeccitas of any particular human being. Like any process, it can be learned and taught with varying degrees of success to the medical student or resident with an interest in emergency medicine.
A trick I try to tell my residents and medical students is to take 15 or 30 seconds to stand outside the doorway to observe the patient, preferably with as few preconceptions as possible and with the patient initially unaware of your presence. This gives one intuitive insight into the “overall whole” of the patient prior to leaning in and gathering information and scientific data which can later be applied back upon one’s initial impression. As I have mentioned before, the patient’s gait, speech, clothing, interactions with others, and overall carriage can provide a universe of information for those who know how to look but learning how to look takes time. Over time, however, one’s accuracy and intuition can be molded and trained and the way in which one sees patients will slowly change. Of course, how we attend to patients, similarly to how we attend to the world, will change how we see them, and importantly, will change us as the observer.
It would appear to be a two way road then. Our attention determines how we see our patients and, over time and through the process of seeing many patients, these interactions help to shape how we pay attention in the future. As the philosopher Iain McGilchrist puts it in his astonishing magnum opus “The Matter With Things,”
‘As a man is, so he sees’, wrote William Blake. Who we are, then, determines how we see. And how we see determines what we find. (9)
It would appear that how we pay attention is of the utmost importance and the process of intachment is a method of paying attention in which the physician can capture the haeccitas, or individual thisness, or inscape of a patient; a way of drawing out the beauty of the individual both within the context of that particular clinical scenario and within the universal and critical science of medicine that has been wrested from nature over the centuries.
So Medieval philosophy lends itself to Victorian poetry which lends itself to modern medicine. The world from such a perspective becomes a wild and interconnected place, and if we are careful and quiet and observant we can hopefully use this knowledge in the service of our patients. If we are especially prudent and conscientious, maybe we can add to this broad river that we find ourselves drawing from and, in some small way, serve as a resource for those who come after us. Well, perhaps that is the hope anyway, that
When old age shall this generation waste,
Thou shalt remain, in midst of other woe
Than ours, a friend to man… (10)
1) Copleston, F. A History of Philosophy. Vol 2. Medieval Philosophy. London, UK. Bloomsbury Continuum, 1950. pg. 511
2) Ibid., pg 511-512.
3) Ibid., pg 512.
4) Taylor, C. Cosmic Connections. Cambridge, MA and London, UK. The Belknap Press of Harvard University, 2024. Ch. 7. pg. 165
5) https://hopkinspoetry.com/poem/the-sea-and-the-skylark/
6) https://hopkinspoetry.com/poem/pied-beauty/
7) https://hopkinspoetry.com/poem/inversnaid/
8) Needleman, J. The Way of the Physician. New York, NY. USA. Harpers and Row, Publishing, Inc. 1985. pg 162-163.
9) McGilchrist, I. The Matter With Things. Vol. 1. The Ways to Truth. London, UK. Perspectiva Press, 2021. pg. 67.
10) Keats, J. Ode On A Grecian Urn
Wonderful antidote to patients being "just another number or specimen". Nicely crafted piece!