4 Feb, 09 | by BMJ
It is fairly widely accepted that medicine is both a science and an art, that it lays claim to a rigorous evidence-based method, while recognising the impact of irreducibly human capacities on healing, capacities like emotion and belief that do not fit easily into a world of verifiability and fact. As a science it aspires to neutrality and objectivity, bringing the same unruffled gaze to illness that astronomers bring to distant supernovae: here, arguably, curiosity is the only legitimate emotion. What it shares with art, however, over and above the requirement for skill and judgment, is the knowledge that damaged bodies are also suffering human beings, and a medicine that fails to recognise this will fall short of its therapeutic goals. Healing, it would seem, is a richer and more complex process than is suggested by the components and processes to which the body can be reduced.
In some ways medicine is uncomfortable with this two-handed approach. The history of medicine over the last century or so has been, in part, a struggle to achieve the authority of science, and to use that authority to claim professional hegemony over the practice of healing. It has fought to flush out the merely intuitive or the actively mendacious, to rid the field of quacks and herbalists, faith healers and the purveyors of snake oil.
In this clear Enlightenment light, the idea of gender sits a little uneasily. Biological sex is one thing but the idea that the gender of the doctor should have an effect on therapeutic outcomes is quite another. Surely the cool eye of the scientist knows no such merely human divisions? And yet even in very straightforward ways, gender makes its mark in medicine: female GPs are praised for their sensitivity and tact, and surgery still attracts slightly more than its fair share of alpha males.
These thoughts were triggered by an essay ‘Surgeon’s Hall’ by the Scottish poet and travel writer Kathleen Jamie. Part of her 2005 collection Findings, it is a quiet meditation on a collection of surgical specimens held by the Royal College of Surgeons in Edinburgh. ‘For two, perhaps three hours,’ she writes, ‘I have been gazing in silence at the objects in jars, privileged to be alone, moving from shelf to shelf in the calm light.’ It is also, although not directly, a meditation on the place of emotion in medicine, of the professional disciplining, or perhaps attenuation, of ordinary human feeling. Not being a doctor, not accustomed to seeing the body as a field for scientific enquiry, she brings to her slow scrutiny the language of everyday human contact and concern. Acknowledging that the only bodies she will previously have been intimate with are those of lovers or children, she writes:
The act of unmediated, unhurried examination has hitherto been an act of love. Perhaps as a consequence, or perhaps because given the opportunity we do indeed feel for all of suffering humanity, a stranger’s arm with his corroding carcinoma, a diseased breast, a kidney taken from a man gassed on the Western Front, all call forth the same plain tenderness.
In this superb essay there are many subtle antitheses at work: between the timelessness of the ‘fixed’ specimens and the flux of biological growth and decay; between the surprising beauty of some of the specimens and the suffering of the people from whom they were taken. ‘At certain shelves… you have to bend and look closer, without knowing what you might see. It will be pale and strange, and possibly quite beautiful. It will be someone’s catastrophe and death.’ Yet the antithesis that stayed with me after reading the essay had to do with gender, with a female eye gazing on these fragments of human bodies and wondering at the minds and motives of the men – for the early surgeons and anatomists were almost exclusively men – who harvested them. ‘Dr John Barclay,’ she writes, ‘was a man who could take up a tiny scalpel and flay, most delicately, the corpse of a small child until nothing remained but arteries and veins running to and from their destinations.’ Partly this gendered tension stems from Jamie’s language, her choice of metaphor. Of an early slice of preserved kidney she writes, ‘silver threads of mercury fan through the tissue, illustrating its blood vessels. It is quite lovely; one could wear it as a brooch.’ The finger bones of a four-month-old foetus are ‘as fine as dressmakers’ pins.’ And then there is the final breaking through of withheld emotion: ‘but at the (Siamese) twins, finally, I wanted it all to stop. Here at last I want to stop gazing and just open the jar and take the twins out, to blow life into them, tell them it’s okay; we can do something now.’ It would not be lost on Jamie that our ability ‘to do something now’ stems from those early surgeons and anatomists, stems precisely from their ability to ‘flay, most delicately, the corpse of a small child.’
Jamie’s essay offers two possible points of synthesis or reconciliation for the tensions that run through it. The first is aesthetic. The collection is housed in a hall designed by the Scottish architect William Playfair. ‘Like the specimens it contains, it too is fixed. Its proportions cleave to the unchanging truths of mathematics.’ In the neoclassical restraint of its architecture, in the discretion of its soft light, it joins the precision of science with a quiet respect – ‘compassion’ is Jamie’s word – for the human dimension of the collection it houses.
The second synthesis relates to the profession of medicine and the disciplining of a doctor’s ordinary feelings. At the close of the essay Jamie refers to a Victorian novel by the Edinburgh doctor John Brown. The novel, ‘Rab and his friends’, contains an early description of surgery, a mastectomy to remove a cancerous breast. Referring to the surgical students desperate for a view of the operation, Brown writes, ‘Don’t think them heartless… they get over their professional horrors and into their proper work, and in them pity as an emotion ending in itself, or at least in tears and a long drawn breath lessens, while pity as a motive is quickened and gains power and purpose. It is well for poor human nature that it is so.’
Jamie’s essay is not didactic. It ends with no final truth, no obvious moral. Its delight lies not in any message but in the wonder of her eye and in the fineness of her writing. To anyone with the slightest interest in the human dimension of medicine I recommend it without reservation.