"That year Diderot began to publish his Encyclopedia, and the first insane asylum was founded in London"

"So the counting out began, to separate the sane, who veil themselves in words, from the insane"

"Poets had to learn tightrope-walking"

"And just to make sure, officious dimwits began to publish instructions on how to be normal."

Miroslav Holub [1]

Much serious literature is capable of eliciting reflection on the meaning of alienation-a sense of being something other than normal, of being outside of culturally accepted boundaries. Why focus on alienation in an essay about the literature of medicine?

When considering literature, both the work that physicians must read and that which they choose to read, one might ask, What are the alienating circumstances that inform these literatures? Pain, to be sure. Death and disease and disability. But these are not the only situations that lead to exclusion from the mainstream. What about racism, sexism, political and economic powerlessness, or profound psychological trauma? For any given work being read, any, several, or all of these issues may be found because they are the things that trouble us and, thus, they are the things of which we speak and write. Common to all of them is personal alienation, either self-imposed or created by the dominant society in which the "other," the alien, lives.

I suggest that because we physicians deal, in our professional lives, with some of the more common sources of both temporary and permanent alienation, we should turn our attention to the lessons to be learned from those who become separated from the community, to the special pain that narrative discontinuity-an unanticipated disruption of one's projected life story-contributes to suffering. I submit that examples of alienation may be found in our daily reading wherever we choose to look for them, even in literature not specifically related to illness. Presented here are some representative examples, written or spoken from the position of a real or a fictional "other" (one who considers himself or herself as residing outside of the cultural mainstream) that illustrate the concept of alienation and the personal pain that it imposes. The astute reader will be able to enlarge on this simply by paying close attention to the words, the thoughts, and the reactions of humans whose stories appear in a widely disparate body of literature.

First, and most obvious to us as medical professionals, is the alienation brought on by illness or disability. Howard Brody, in Stories of Sickness [2], uses characters in classic fiction-such as Thomas Mann's The Magic Mountain and The Cancer Ward by Alexander Solzhenitsyn-to create a paradigm of the voyage through illness with a view toward its interruption of one's life plan. Brody contends that each of us lives a narrative in progress that does not usually include chapters that anticipate and allow for discontinuity. Thus, what becomes of our sense of place, of significance, of belonging, when we are no longer able to work, to tend to our regular duties, or to enjoy the pleasures that bond us with normal, healthy society? Not only are persons involved in the self-absorption of dealing with an illness or disability forced to turn their attention from "business as usual," but they lose, at least temporarily, their reciprocal relationships with their peers as their world view shrinks and they become more egocentric. The outcome is a solitude that even further disenfranchises the sufferer. Those around him or her may feel sorry, but life must go on, and there is more to it than a single being's pain and need. The ill one becomes progressively less engaged outside of himself or herself, creating an ever deepening chasm of exclusion.

Do you remember Gregor Samsa, the white-collar worker created by Franz Kafka who wakens one morning to find himself changed into a giant, hardshelled bug [3]? One can laugh or cry at his plight as he makes plans to roll out of bed and go to work as if his multiple, funny little legs and misshapen body were irrelevant. However, it is hard not to take his ridiculous situation seriously as he begins to recognize and ponder the implications of his inability to be productive. The reader observes the drain on his family's resources and, ultimately, witnesses Samsa's exclusive concern with his own daily activities of survival as the family becomes less and less tolerant of the effect of his existence on the normalcy of their lives. Samsa's father, mother, and sister close him in his room until, one day, he is found dead. In response to his demise, they go into the countryside to celebrate their liberation from responsibility for something as alien as their transformed son and brother. If we choose to read Samsa's altered state in "The Metamorphosis" as a metaphor for disability, the concept of alienation wrought by being physically "different" is clearly apparent.

Sylvia Plath, writing as the fictional Esther Greenwood in The Bell Jar [4], describes her psychological alienation from the contemporary world as she becomes depressed and contemplates suicide. Being enclosed in a "bell jar" (her illness) distorts everything she sees and bars her from the world. Even as she recovers, she expresses fear that one day the bell jar may again descend around her-a fear that Plath herself lived with and about which she wrote much of her poetry-and a fear that proved to be prophetic.

These observations made from serious fiction may be tested against events in real life. In his classic work on the meaning, manifestations, and management of suffering related to illness, Eric Cassell points to the centrality of personhood. Personhood, according to Cassell [5], comprises multiple facets and

"All the aspects of personhood-the lived past, the family's lived past, culture and society, roles, the instrumental dimension, associations and relationships, the body, the unconscious mind, the political being, the secret life, the perceived future, and the transcendent being dimension-are susceptible to damage and loss."

The damage or loss contributes to suffering. Suffering loss-alone, because it is his or her loss alone-creates the sufferer's sense of alienation from the world.

Let us consider a nonfiction genre as a source of illustrations of alienating experiences-the autobiographical narrative of illness, the first-person account of what it means to lose one's health as our culture defines health:

"When I go for my biannual mammogram, I forget that all the women in that waiting room do not have cancer. So my comments comparing those magazines to the ones in Radiation Oncology are met with a shocked silence. Their eyes suddenly do not see me. Subtle shifts in their postures shoulder me away. Their attention flees from me as salt on the surface of oily water flees from pepper ... [6]"

Middlebrook discovers how her disease, as if it were contagious or disgusting, "shoulders" her out of the circles of women who consider themselves free of breast cancer.

William Styron shares his fear of alienation as he sinks deeper and deeper into his first episode of profound depression, narrated in Darkness Visible: Memoir of Madness [7].

"The loss of self-esteem is a celebrated symptom, and my own sense of self had all but disappeared, along with any self-reliance. This loss can quickly degenerate into dependence, and from dependence into infantile dread. One dreads the loss of all things, all people close and dear. There is an acute fear of abandonment [8]."

Styron's close friends "politely" ignore him; he recognizes that his wife treats him like a child because of his helplessness. He has been removed from his familiar world and his work. He sees no purpose in his empty life. Styron recovers and apparently rejoins his previous world without concern for residual alienation.

An examination of testimonies of Holocaust survivors and some of the work done with Vietnam War veterans show that not all recoveries from an alienating interruption of life's narrative are as complete as Styron's seems to be. There is an indication that the memories accompanying profound narrative discontinuity can prohibit a full, unconditional return to the mainstream. Langer [9] asserts that "The heroic self, by definition, helps to create its own tragedy and to live or die by the consequences." Descent into the Nazi death camps was not a voluntary voyage, and many survivors and witnesses have been unable to achieve a heroic return to society. In his study of Holocaust testimonies, Langer characterizes this absence of triumphant victory over adversity-"unheroic memory"-as the genesis of a permanent strain on future relationships with family, friends, and associates. He points out that many Holocaust witnesses describe feeling unrelenting shame for having done nothing to help fellow prisoners or even, in some instances, for having directly contributed to the pain or deaths of other sufferers. The concept of "you cannot do nothing" is so alien to the self-reliant western mind, dominated as it is by the idea of the individual person as agent of his or her fate, that its centrality to the camp experience results in permanent moral disorientation. Neither did the sufferers design their descents into hell, nor do they feel that they handled their stay or return heroically. They seem unable to forgive themselves, and they carry this burden throughout their post-Holocaust lives, forever alienated from the world to which they return.

Similarly, Vietnam veterans, in attempting to resolve their "survivor conflict," find that to do so they must believe that the war had purpose and significance beyond the immediate horrors they witnessed. If they cannot accomplish this resolution, a task that is often made impossible by U.S. society's ambivalence about the country's role in the war, they are unable to experience "renewed feelings of continuity or symbolic immortality side by side with [their] residual survivor pain and conflict" [10].

In addition to stories of illness and trauma, we encounter the literature of exclusion by virtue of race, sex, or economic difference. For example, works of fiction, biographies, and histories of the 19th century are replete with the tales of women who are excluded from universities, professional societies, and academic endeavors, to say nothing of the voting franchise. Middle-class women, who may have been bored or rendered neurotic by the inactivity of their domestic lives, were pronounced "sick" by the perplexed male hierarchy. They were given an enforced sick role and were excluded from reading, writing, or productive intercourse with the outside world until they either took up their pallets and went cheerfully back to their domestic lives or were declared hopelessly incurable "cases." Whatever the outcome, the women who wrote of these experiences were painfully aware of the chasm that separated them from the active, engaged, busy world of a developing nation with exciting new intellectual horizons to be explored. Some representative examples of this body of literature include Charlotte Perkins Gilman's The Yellow Wallpaper and Other Writings (1892), Kate Chopin's The Awakening (1899), and a historical study of middle-class women in the late 19th century, Invalid Women: Figuring Feminine Illness in American Fiction and Culture, 1840-1940, by Diane Price Herndl (Chapel Hill: Univ of North Carolina Pr; 1993).

These women were kept carefully "protected" by their late Victorian culture and thus were alienated from the hustle and bustle of the real world. Vestiges of this estrangement remain today, despite the acquisition of the right to vote and the opening of doors to schools and professions. The Associated Press, in a New York byline dated 18 December 1996, reviewed the status of sex-based income differentials: "Women nationwide make 71 cents for every dollar earned by a man." In a culture that defines success in economic terms, this Figure makes women in the United States less than three quarters whole, which is disabling in both physical and emotional terms.

Another source of alienation, common to the ill as well as to survivors of trauma and culturally marginalized persons, has to do with the belief that no one but another who has similarly suffered can understand or relate to the alienating experience. This idea may, in fact, be closely linked to the common adage that only the physician who has suffered can truly empathize with his or her patients.

Edith P., speaking of her Holocaust trauma [11], tries to describe how her life narrative has fragmented her into two persons-a split that she defines as abnormal and that separates her and other survivors from the mainstream:

"... you can't excise it, it's like, like there's another skin beneath this skin and that skin is called Auschwitz, and you cannot shed it, you know ... .I mean I will tell you that it's harder in many ways because ... because we carry this. I am not like you. You have one vision of life and I have two."

Magda F., in testimony [12], recalls trying to tell her family about her Holocaust experience:

"If somebody would tell me this story, I would say "she's lying, or he's lying," because this can't be true ... because this could not happen. Because to understand us, somebody has to go through with it. Because nobody, but nobody fully understands us. You can't. No [matter] how much sympathy you give me when I'm talking here, or you understand ... you're trying to understand me, I know, but I don't think you could. I don't think so ..."

Reflecting on his own experience as well as that of other Holocaust survivors, Primo Levi [13] cites a common dream in which the prisoner anticipates his homecoming, his attempt to describe his experiences to a loved one: "[The survivors] were not believed, indeed were not listened to. In the most typical and cruelest form [of the dream], the interlocutor turned and left in silence." Lifton observed [10], in his work with Vietnam War veterans, that at some level they can fully trust only those who have shared their experience, yet in each this trust may live side by side with suspicion, which is probably related to unresolved suspicion of self. The poetry and fiction of the war, that written by the surviving warriors, is riddled with references to the inability of the nonparticipant to comprehend the psychological price extracted from the combatant.

Because many of us have not made descents into the realm of narrative discontinuity and alienation, how can we begin to understand its significance to our patients? Literature may become a useful tool for physicians by enabling the cultivation of the fine art of creative imagination. We are limited only by the extent of our ability to imagine, to live (if only vicariously) in the shoes of an "other." As we read the newspapers, watch a movie, peruse a novel, or study a medical case history, we can come closer to the psychology of alienation.

As an experiment in the creativity of your own imagination, visualize a scenario that spotlights one who is visibly different from those around him or her. Imagine a man in a wheelchair as he tenaciously, if not patiently, tries to edge up over an icy curb. Watch the perspiration bead on his forehead, the veins and tendons standing in stark relief above the straining muscles of his forearm. See his eyes dart sidewise, narrow and suspicious, when he senses that you are observing his despair. Does he feel like a mainstream member of the society that strides freely and easily past him or stops to offer to accomplish, with an effortless push, what he has been unable to achieve? Unlikely. Whether it manifests as anger, sullen withdrawal, frustration, or hopelessness, the man in the chair recognizes that he does not fit into the predetermined shape of the standard mold. Would we dare to imagine, with this man, how apart he must feel?

Langer writes: "A statement like ‘to understand, you have to go through it,’ however authentic its inspiration, underestimates the sympathetic power of the imagination. Perhaps it is time to grant that power the role it deserves" [14]. And by so doing we can use the literature of medicine, as well as the broader narratives of mankind, to place ourselves one step closer to the role of healer.