- Two PhD astronomers bring 2-year-old Tyco to show me the mole on his palm. I pronounce it benign and tell the little fellow, "Your boo-boo is okay." Tyco's face darkens. "No boo-boo!" he yells. "No boo-boo!"
- At 52, Hortense has many facial brown spots for me to laser off. "Don't take off that one!" she says. "It's always been there. I like it."
What do these patients have in common? Hortense likes one spot, because it's always been there (or so she thinks). Therefore, it is Hortense.
She wants the other spots off for the reciprocal reason: they are Not-Hortense. They came later, and they don't belong.
Little Tyco demonstrates how early the Self/Nonself sense can develop. Already, at the age of 2, he knows the spot on his palm is not a boo-boo. To be precise, a boo-boo is something that's wrong, that shouldn't be there. He knows his mole should be there. It is Tyco. When Tyco grows up, he will never have it removed if he can help it.
The decision that people make about What Belongs applies to acquired lesions as well.
Consider Carmine, a cardiologist who takes off his shirt to reveal a big, black melanoma right in the middle of his back. Not only that—his wife is with him! When spouses often send each other in for trivial changes, how could these two have both overlooked something so blatant?
Simple. "That's been there for years," says Carmine. His wife agrees. At some point, they both decided the spot was part of Carmine. From then on, they stopped looking. It just belonged there.
Or take Perry. He asks me to zap a tiny spot on his nose. Two years later, he shows up with a big, ulcerated basal cell. Is he blind? Are his friends?
No. "You told me it was okay," he points out, "so I assumed it was supposed to do that."
The Self/Nonself dichotomy actually applies not just to lesions, congenital or acquired, but to all sorts of symptoms. People develop a strong sense of their Constitution, a kind of Health Personality that is uniquely and recognizably their own. You can hear this in the following kinds of statements people make about themselves:
- General. "I'm the kind of person who… (gets sick all the time/is healthy as a horse)."
- System specific. "I've always had… (good skin/terrible skin, beautiful hair/thin hair)."
- Disease specific. "Why should I have acne? I never had it before!" "Why should I get eczema? I don't get rashes." "Oh, I figured it was eczema. I've always had skin issues."
Patients say things like this all the time. In our medical view of disease, anything can happen to anyone. By contrast, patients make sense of things by deciding that some things happen to certain kinds of people. That's just them. What's worrisome is when something happens to someone who it shouldn't happen to. That's just not them.
In other words, people somehow develop a deep, unshakable sense of what kind of individuals they are.
They might overlook abnormalities for long periods, sometimes to their detriment, just because in their own minds, these signs or symptoms belong there. What worries them is any deviation or something new that shouldn't be there—a new spot, an unaccustomed itch, and so on.
This Self/Nonself distinction is one of many reasons that we can't count on our patients to report the signs and symptoms that are important to us. If they think, "Hey, that's just Me," they might keep quiet.
The philosopher tells us: Know thyself. Our patients do. We should know ourselves—and them, too.