Medicine and Imagination

On Poiesis and Perception in Clinical Practice

NEESHEE PANDIT MAY 23

This essay explores the poetic and perceptual basis of medical practice. I propose a subjective value for medical praxis and its accompanying notions of efficacy. Section I discusses medicine as an imaginative practice. Section II explores the heart as an organ of perception. Section III is loosely inspired by Michel Foucault’s Birth of the Clinic, and re-structures his critique. Section IV examines medical perception in the artwork of Pablo Picasso. Section V unravels the tension between esoteric and empirical conceptions of anatomy in Tibetan medicine and Chinese medicine, concluding the essay.

Embedded in my arguments is a critique of scientific materialism, which I assert as a failure of imagination. In discussing medicine and imagination, I am not suggesting that medicine is false. Rather, my intention is to blur the boundaries between the real and un-real, and to view medical practice as a perceptual, rather than literalist, happening.

In Asian medical practice, we encounter these epistemological issues every day. Physicians in any system (Chinese, Tibetan, Indian, etc.) will invariably arrive at different diagnoses for the same patient. Different practitioners of the same medicine will each imagine a unique treatment, even in a diagnostic consensus. For some practitioners, this subjective variability is unsettling because it implies a fluid epistemology. The idea that for something to be true it must be objective and unchanging is the naive realism of empirical knowing. I argue that these concrete forms of “knowing” are not more real than the differential diagnoses of Asian medical practice.

I. Imagining Medicine

Medicine arises from our collective imagination. Medicine contains no objective truth—only a subjective value. Its province is the clinic, a topography whose features depend on polis and psyche, person and place. Medicine is who we are and what we envision, our gaze and our grasping. There is no medicine without the imaginal, no therapy without the mundus imaginalis.

Medicine is an artificium, a making of art, its practitioners artists and artisans. They hold the careful craft of theory in their hands, carrying the delicate instrument of healing. Clinic is thus a form of theatre, an open space of viewing, in which a play is acted upon the image of the patient, whose story gives us the primary myth of the bedside art.

In the West, medicine has suffered its miscarriage, its aesthetic lost in the materiality of examination and the mundanity of datum. The Western gaze has turned to the microscopic, not the microcosmic. Its scope perceives the minute constituents yet fails the whole in every part. We have lost our imagination to an indelible scrutiny of reductions, our spirit nothing more than irreducible particles, the imaginal dead in the scientific. Such a gaze can only regard what is visible; the smallest objective unit becomes the component rather than the constellation.

Without imagination, we are left to the devices of linear thinking and physical causality. Eastern medical traditions appear as nothing more than primitive archaisms, pre-scientific and pre-rational enterprises, old-world ideas outdated with every advance of objective knowledge.

The susceptibility of the East to the West is due to a failure of imagination, a perceptual loss replaced by the empirical call of progress. Westernization has devoured the imagination of the old world to erect a stage for its own standing, towering high above history. But we will miss the mark if we idealize the East over the West. Only understanding can build a bridge across continental divides and develop a diverse biome of knowledge. We need the pragmatism of medical pluralism, not the naiveté of “integrative” medicine but a co-existence and co-mingling that gives habitation for a manifold imagination.

II. The Locus of Imagination

The birth of the clinic is the death of medical perception.¹ We need not clinics in the conventional sense, white-walled and white-coated, hanging in the stale sanitized airs of surgical steel. Such laboratories of inspection are mere arenas of experimentation with the body-as-object, subjected to trial and tribulation. The clinic has become so mechanistic that its procedures are performable by lifeless entities whose accuracy and precision become the displaced values we no longer even hope to attain.

Nature is in the bottle; the sample is in the test tube, stored behind the closed walls of inspection. We grow animals for organs for a cure. But nothing can fulfill our organic loss, now so masked from the natural airs. Even our failures have no tragedy. Loss or gain, a statistic, peer-reviewed for publication.

The orangutan who applies a paste to his wounds surprises the medical mind whose suppositions of sentience are worthlessly opaque.² We are the injury against a natural intelligence, and our cure is traumatic, agape at the ape who lives the laws of nature without any data at all. What sort of sickness has possessed us? The orangutan is cornered against all odds, habitat destroyed by machines for profit, while their intelligence is admired from the distance of the next news cycle. There is no remedy for our abstraction, its discontent has become the seed of civilization, now flowering unseeded under a manufactured light.

The orangutan teaches us that the medical imagination belongs to nature itself. The orangutan’s intuition is not reducible to biological instinct or cranial anatomy. The orangutan’s medicine belongs to intuition and imagination in a world of relatedness—not constructed but perceived and construed. Healing is intrinsic to life, not only in the instincts of biology but through the insights of the heart.

“In the ancient world the organ of perception was the heart . . . The heart’s way of perceiving is both a sensing and imagining. To sense penetratingly we must imagine, and to imagine accurately we must sense”.³ In the heart, we discover medicine as aisthesis, an aesthetic response of sensation and imagination. The pulsing beneath our fingers, the palpatory sensibility, the color, sound, odor, and emotion—impressions translated into treatments.

To move with the heart toward the world shifts psychotherapy from conceiving itself as a science to imagining itself more like an aesthetic activity. If unconsciousness can be redefined as insensitivity and the unconscious as the anesthetic, then training for psychotherapy requires sophistication of perception.⁴

We can substitute “medicine” for “psychotherapy” in the above quotation and discover the same meaning. “The awakened heart is the locus of imagining”, l’immagine del cuor.⁵ The heart is the mythical emperor enthroned in the chest, the supreme controller of perception, the utmost source of imagination. Thus, imagination abides in the heart, suspended in the center like an inverted lotus bud, flowering in place. Diagnosis requires the sensitivity of refined perceptions, twelve organs at our fingertips. Medicine is thus a visionary practice, calling us to imagine the invisible and feel and shape the unseen contours of soma and psyche.

The true clinic is not a location but a space, a container for the emergence of the unconscious—not necessarily for analysis or even diagnosis, but for giving form to an invisible cache of meaning through shared perception. The clinical imagination is the vessel of therapy, the alchemical encounter and cauldron of change. Thus, medicine necessitates a “poetic basis of mind”.⁶ From a poetic basis of mind, we craft in hand and speech a poiesis of healing.

III. The Rebirth of the Clinic

Tests, trials, and case studies create the illusion and goal of an objective diagnosis. Our imagings have no imagination. They show us a vacant physiology of functional parts and organic failures of nerve, waiting for repair in a mechanic’s clinical garage. The colonoscopy of culture gives us nothing more than a post-clinical bag for our wastes. Tests, trials, and case studies are the products of industrial aphantasia and the bleak antiseptic rooms it operates within.

No form of calculated veracity can stabilize the therapeutic ground from subjective variability. Medicine engenders a surrealism that consistently blurs the lines of treatment and blends the shape of bodies. There is no likelihood or probability that is meaningful, yet every therapeutic act is suffused with meaning. Our theories are open to interpretation and available to imagination.

The myopia of medical realism renders the most ghastly pallor in a sanatorium of sensation. Only imagination gives color to the monochrome world, where plays of light embed our grasp within its folds. The clinic, a room with time and space for the soul and spirit, a human prism within a sphere of many angles.

The death of the clinic is the rebirth of imagination, of clinic as theatre, a symbolic unfolding and aesthetic enactment, a prophetic dream that vividly re-imagines the patient and their cure. Clinic as theatre opens the landscape of diagnostic and therapeutic possibilities, where every diagnosis is accurate and every intervention efficacious. We are the instruments of change who need no further assessment. Diagnosis thus becomes an intersubjective perception, a sensation of resonance, a wordless understanding. “An image is not what one sees, but the way in which one sees”.⁷

Born again, the clinic engenders immediacy and immanence, the nexus of medicine and imagination, seeking neither diagnosis nor prognosis but the present image, which itself contains the multitudes of time and space in a perfect summary.

IV. Medical Perception in the Art of Picasso

In the Head of the Medical Student, Picasso paints the pupil with an oblong face. One eye is closed and black, the other remains open and white. This dichotomy pictures a dual perception—one eye sees in dreams, the other sees in waking. From the dreaming eye, tears flow in lines, while the other half is dry. The figure is given a single ear on the dreaming side, where the student listens to the imagination. The student’s face is a highlighted contrast between light and dark, waking and dreaming, reality and imagination. The painting was a preparatory sketch for Picasso’s famous work, Les Demoiselles d’Avignon, a painting that depicts five prostitutes of which two are masked.

In a study preceding the artwork, the medical student is depicted entering from the left, brown-suited and holding a textbook. A sailor is depicted at the center of the composition. The sailor represents the libido, perceiving women through lust as objects of desire. The medical student, however, holds a different gaze: he sees the women analytically and anatomically.

In the final image, the two men are absent, and only women hold the perceptual gaze. On the right are two masked women who depict Picasso’s fear of contracting syphilis. There is a tension between the three prostitutes on the left and the fear of infection on the right. Painted before the advent of antibiotics, Picasso’s concern appears historical. The medical student is absent, but his gaze remains in the perceptual context of imaginary disease.

Picasso’s paternal uncle, Dr. Salvador Ruiz, was a physician. He gave financial support for Picasso’s enrollment at the Instituto da Guarda. The director of the institute, Dr. Ramon Perez Couteles, was also a physician. Picasso was known to suffer from aural migraines, since termed “Pablo Picasso syndrome”—the suggestion being that Picasso’s surrealist cubism was the result of migraine-driven distortions. However, such a view would pathologize Picasso’s art and reduce its imaginative qualities to nothing more than sickness itself. We can surmise that Picasso’s concerns are more complex than either his migraine or his relationships. His paintings imagine the subject in reminiscences of the real world, blurring the lines and shapes of perceptual knowing. The Head of the Medical Student is an intimate portrait of the medical imagination, standing between worlds, listening and feeling the duality of perception and conception. In the original sketch, the student’s gaze is self-contained—it has no object of analysis. The purity of the subject stands naked, without ornament, and even without body. We have only the sensorium of the head and the blue subtlety of the heart.

V. Esoteric and Empirical Anatomy in Asian Medicine

In the Tibetan medical tradition, we encounter the historical intersection of imagination and a growing empiricism. For the Tibetans, medicine was an episteme that grew directly out of the Tantric imagination—the human body composed of unseen channels and plexuses. By the seventeenth-century, Tibetan physicians began dissecting corpses, birthing a new anatomical imagination, informed by the visible. Scholars challenged the authority of textual knowledge against a knowable empiricism, that “textual knowledge could be bettered or even contravened by empirical evidence”.⁸ Medical dissection failed to reveal the location of Tantric channels in the body, leading to new epistemological issues in Tibetan medical knowledge.

One example is a disagreement on the number of bones: the seventeenth-century physician, Darmo, counted 365 bones in the dissected body, but the classical source-text of the Four Treatises counts 360. “Much of South Asian medicine seems to have agreed that the number of bones in the human body is 360, but the great Ayurvedic classic Suśruta avers instead that there are 300”.⁹ This debate illustrates the critical disagreement between traditional and empirical schools of thought—“360” is nine multiplied by twelve, its imagines the human body as a reflection of the cosmos, specifically the solar cycle of twelve months in a year.

In another example, the Four Treatises differentiates the location of the Heart by gender: the Heart is said to tip to the right in women. As a result, the Heart pulse is read on opposite sides for men and women. The Four Treatises states:

First check the [male] patient’s left arm with the physicians right [hand]:
Under the index finger, check the heart and small intestine channels
Under the middle finger, the spleen and stomach channels
Under the ring finger, the left kidney and samse[‘u].¹⁰

Thus far, the pulse positions mostly mirror the Chinese pulse system, with the exception of the spleen and stomach channels which are placed on the patient’s right arm and palpated with the physicians left middle finger. Chinese texts place the Liver / Gallbladder on the patient’s left middle position, which the Tibetans place on the patient’s right middle position. The text continues:

For females reverse the index fingers and the two channels [that they examine] from right to left.
Why? While the lungs and heart are not on the right or left sides,
The tip of the heart faces [differently in males and females] in that way
[one to the right, one to the left].
The rest of the foregoing [instructions] are the same, since the locations are [similarly] disposed [in males and females].¹¹

The idea presented here is that the heart tips toward the right in female anatomy. Therefore, the physician should read the heart pulse on the right hand of a female patient, but in the traditional left position for a male patient.¹² Such notions are hardly verifiable with literalist anatomy, because they do not reflect empirical notions. The tipping of the heart is a reflection of the Tibetan cultural imagination, especially as codified in Tantric anatomical doctrines. In the Tibetan yogic tradition of Dzogchen, for example, we find similar variations in pranayama instructions, where the Tantric anatomy of men and women is differentiated. We see this Tantric differentiation at play in Zurkhawa’s justification:

Each pair of solid and hollow organs are connected to light and shade,
since the hollow organs follow on the solid ones.
The way these abide is evident and then not evident
like the inside and outside of the curve of a rainbow.
The reversing of method and primal awareness with respect to the
heart tip
is due to the power of roma.¹³

Zurkhawa’s explanation is archetypally classical: the heart tips to the right in women because the roma channel is dominant in them. The roma channel is identical to the pingala nadi of Indian yoga. The roma channel runs parallel to the right side of the spine, opens into the right nostril, and conducts the fire element. In Tantric systems, women are regarded as fire / sun / compassion, and men as water / moon / wisdom. Thus, the tipping of the heart and its transference in medical pulse diagnosis evidences the Tantric imagination of Tibetan medical theory.

In Chinese medicine, the movement toward rational empiricism was heralded with the birth of the Han Dynasty classics, textual sources that remain at the heart of the tradition. By the time of the Nei Jing, the Chinese medical epistemic had consciously moved away from demonological notions of health and disease and toward an observable hermeneutic of systematic correspondences.¹⁴ The idea that Heaven and Earth are in correspondence with each other brought medicine into a naturalistic domain that was evident instead of concealed.

The Chinese medical tradition now stands, much like the Tibetan medical tradition, between the lines of esoteric and empirical anatomies. For example, the classical concept of the Triple Burner is given in the Nan Jing as an “organ with a name but no form”.¹⁵ Physicians will never find the Triple Burner in the dissected corpse, but it remains an important physiological concept in the Chinese medical imagination. Does the apparent absence of meridians, qi, and the Triple Burner in a cadaver imply that these concepts are un-real forms of magical thinking?

Modern research attempts to graft these invisible notions into the concretism of empirical anatomy. Meridians are reduced to afferent and efferent nerve pathways, Tibetan channels to the cardiovascular system, qi to the piezoelectricity of the fascia, the Triple Burner to the interstitium. When cadavers became the subject of medical perception, its locus became the dead instead of the living. Literalism has displaced the medical imagination and sublimated its concern from an irreducible eros of life to a morbid fascination with the instinct of death.

From formless physiologies to symbolic anatomies, our imagination forges a new craft and ethic of medical perception. Medicine has more to do with a participation mystique than a matter of method. Medical meaning is archaeological and anthropological, historical and cultural. Imagination is the perception of the real, the true, and the beautiful. In its hands, we craft every kind of beauty, justice, and destiny—heart to heart.

© 2024 Neeshee Pandit
7127 Flagstaff Rd, Boulder, CO 80302