You don't need to be signed in to read BMJ Blogs, but you can register here to receive updates about other BMJ products and services via our site.

Who are we as Doctors? Why an exploration of our significance can lead to better care by Benjamin Janaway

27 Nov, 14 | by BMJ

Recently I lost a patient. A lady in her 60’s whose hand I held for months and who’s passing will stand as a turning point in my career.

Having spent several months working in oncology my view of the role of a doctor has been tested time and time again. Publically observed heuristics of the role of doctors, portrayed subjectively in television and film, novels and novellas, are the hippocratically charged and dutiful healers. Both a font of knowledge and diary of experience, the doctor is seen as a paternalistic figure and eternal purveyor of the omnipotent band aid.

In some cases, within primary care and acute medicine, this may indeed be the case. Early recognition of pathological processes expressed through familiar clinical paradigms allows for rapid reversal of such malady, leading to objective improvement of the patient and maintenance of this social perception. However my experience of secondary and tertiary care of patients with chronic conditions tells a different story.

These patients, when viewed holistically as both the sum of their experience and the filtered view of our own experience, take on significance both within day to day clinical care and the greater role of disease in their lives. Identification with disease, as I have previously mentioned, is a natural and almost unavoidable consequence of the maladaptive nature of the human mind. Our natural insecurities, developed arguably within Jungian theory to inspire adaptive development, can be argued to be destructive when applied to modern day context.

The presence of disease is not just an event in a person’s life, but an event with added context and personally subjective significance. For example, a broken hand means more to a pianist than a footballer. The subjective significance of a change in health status can be explained by the patient’s reliance on past experience and their perceived importance of such a change within the context of their entire lives. The identification of their lives with the change is what the patient sees, but the objective measurement taken by clinicians is usually less in depth.

In terms of cancer, this identification can be both freeing and incarcerating. I have worked with a number of patients, young, old, religious or atheistic with a number of different cancers of varying aggression. Some of these patients were at the start of a journey with an indefinite end, and some were at the end of a journey of indefinite meaning. For some, the end of a long fight, although sad, had changed their lives dramatically and they had lived more in a short time than they had in their lives.

My own grandfather had been diagnosed with multiple myeloma a few years ago and passed away earlier this year. Being both his grandson and a doctor in training was a balancing act, knowing more about the practical and prognostic side of his care and tempering my expectations with that of him and my family. I found this process infinitely difficult and adaptive, learning from my emotional responses better ways to address his own needs and questions.

I would like to say that one of the many lessons I learned from him is that a stoic disposition and optimistic attitude in the face of uncertainty is a great strength. Life goes on between our plans, and our aspirations and reality do not necessarily correlate and it is up to us to meet these changes head on, learn what we can and move on the future. In the treatment of cancer, and the management of my patients, this stoic and optimistic attitude, balanced with an understanding of the patients own identification and experience of disease, is most useful.

So when we consider our own significance within the patient’s experience we must remember the paternalistic view of the omnipotent healer, but also realise that we play only a part in the production of their lives. We are second to the protagonist, and must realise the overall significance of our words on actions not just on the objective clinical state of the patient, but the holistic sphere of their entire disease experience.

More and more I have realised my role as a junior physician and frontline carer is to support the expectations of the patient within a realistic schema. To attempt to best understand their view, but present it to them within a spectrum of experience based on my continued learning and reflection. The omnipotent heuristic can therefore be argued to be of less importance than the archetypal omnibenevolent. As doctors our roles are to first understand the patient and their own judgement of disease significance, and tailor our treatment and interaction in an empathetic and individualised way.

We try to act in the patients best interests, and that means not only to address the physical aspects of their disease but the entire holistic side. Within oncology, this idea takes on extreme importance, as often the societal view of cancer and its ultimate path takes hold in a patients mind. For some it is a challenge, for some freeing, and for others a less positive conclusion. Whatever the view taken, it is up to us as doctors to realise our lines in the script of the patient’s life when this plot twist comes.

For my lady, and for my grandfather, the advent of their disease granted them a new perspective and through long discussion with both I realised the beauty of a new view. Their priorities and expectations changed and they lived without fear. This realisation painted my day to day communication with both and I would hope played a part in making the last years of their lives not just bearable, but an experience they could learn from and leave their mark on the world.

For me, their mark is on my heart, a sign saying ‘Listen and stay open’.

The opinions expressed in this article are those of the author and may not represent those of SDHCT. No patient identifiable information is included.

Correspondence: Dr BM Janaway, Flat 4, Castle Chambers, 147 Union Street, Torquay, Devon TQ1 4BT

The Reading Room

25 Nov, 14 | by cquigley

 

The Bad Doctor

A graphic novel by Ian Williams

Reviewed by Dr Ian Fussell

The Bad Doctor cover final  (1)

 

The Bad Doctor is the debut graphic novel by Ian Williams, himself a pretty good doctor, I reckon, by the insight and humanity shown throughout this book. It was published in June 2014 by Myriad Editions and is a beautifully presented book.

Ian is a physician working in General Practice and GU Medicine in Brighton. He is also the founder of the website graphicmedicine.org for which he coined the term “Graphic Medicine.” Following his training in medicine he studied fine art and achieved a first in an MA in Medical Humanities.

Not unlike the classic graphic novel Maus by Art Spiegelman, The Bad Doctor tells a number of stories simultaneously: that of Iwan James as a GP, Iwan as a sufferer of OCD, and Iwan as a troubled child. We also join Iwan on cycling rides, both alone and with his friend, during which they chew over life’s difficulties. As in Maus, these stories are all related and give the reader an insight into the person Iwan really is. This is what makes the novel stand out and retains the reader’s interest and engagement.

Throughout the novel we are exposed to some of the dilemmas and challenges experienced by a GP living in a small rural community and some of the problems experienced when working closely with partners who you can both hate and fall in love with. Relationships with work colleagues are always complicated and emotionally charged and this novel clearly demonstrates this.

We see young Iwan develop from an angst ridden teenager who loves heavy metal and worries that his behavior is the cause of certain traumatic events, into a man and a doctor who continues to be angst ridden. He fantasises about shooting himself and becomes possibly impaired by obsessive-compulsive disorder, a trait that somewhat perversely may actually benefit patient care.

We witness Iwan struggle with the dilemmas faced by GPs every day, including unpredictable medical emergencies, terminal care, signing shotgun licenses and managing bereavement. He cares about his patients and is naturally empathetic and not afraid to use self-disclosure as a therapeutic tool.

Rather like good poetry, comics and graphic novels can convey difficult and emotive subjects in a way that gives the reader a deeper understanding of the message. Explaining what GPs actually do, to our politicians and the media, by our leaders nearly always inadvertently sounds clichéd and trite and seldom succeeds, despite almost all the population having experienced going to the doctor’s at some point in their lives. Perhaps graphics should be used as a powerful political lever in our profession.

The monochrome drawings are deceptively simple and the text is minimal. This helps make the book very accessible and a pleasure to read. Each chapter starts with an icon that sets the scene for the following chapter.

It would be an oversight not to mention cycling. How many doctors do we all know that cycle or exercise therapeutically, if not obsessively? The benefits of spending time exercising and with friends are so obvious in this novel, that if not already doing so, doctors should be encouraged to start immediately!

Ian Williams Bad Doctor page 70 (1)

I also enjoyed the connection between Iwan as an adult and Iwan as a child. Now with access to social media, music streaming sites and platforms such as You Tube, looking back has never been easier, but this novel adds deeper meaning to this and shows how our young lives and older selves are a continuum rather than distinctly separate entities.

As a 50 year old, a cyclist and a GP living in a rural community who saw Ozzy Osborne on his first tour, it was impossible not to love this book. Ian Williams has possibly written a future classic, which must surely be added to the curriculum of all GP training schemes and might even help our leaders explain what GPs actually do.

 

Ian Williams Bad Doctor town (1)

 

Ian, let’s have some more.

Tell us Dr Smith’s story.

 

 

The Bad Doctor by Ian Williams.

Published by Myriad Editions, 2014.

Tender: On Taking Ownership of Death and Dying by Catherine Oakley

16 Nov, 14 | by BMJ

Lynette Wallworth’s Tender: On taking ownership of death and dying

A particular highlight in the documentary category at this year’s BFI London Film Festival was the UK premiere of Tender, which follows a community group in the Australian town of Port Kembla as it seeks to establish its own, not-for-profit, bespoke funeral service. Directed by artist and filmmaker Lynette Wallworth, the film was a finalist in the Grierson Award Documentary Competition, created to recognise films with integrity, originality and social or cultural significance.

The Port Kembla community’s efforts to reclaim death from the control of multi-national corporations represents an audacious confrontation with deeply-entrenched taboos and carries a difficult but important message: we need to talk about death and dying, because fear inhibits our capacity to decide how we want to mourn or be mourned. The time between death and burial in Australia can be as little as two to three days, and the film shows that this is a period in which practical and financial decisions with enormous implications are made, often in the acute shock of grief. The community leaders in Port Kembla work to reintroduce choice into this process with characteristic determination, spirit and irreverence. Opening a workshop aimed at demystifying legal issues surrounding death and dying, the speaker breaks the ice with a reassurance that when it comes to death, “Nobody fails and everyone gets a certificate at the end”. In another bleakly comic moment, an elderly member of the community showcases one of eight homemade compacted-cardboard coffins she has commissioned, hand-decorated and designed for further customization by her family after her death.

The group’s endeavour to transform encounters with mortality is made profoundly personal as they come to terms with the deteriorating health of their much-loved caretaker Nigel, following a diagnosis of terminal cancer. In this context, their enterprise reveals a tension between the expressed and unexpressed wishes of the dying individual and the choices made by their family and friends. This extraordinarily moving and intimate portrait, beautifully accompanied by a non-intrusive soundtrack from Nick Cave and Warren Ellis, suggests that a health and social system which aims to prolong life at all costs, can in some cases divert patients and their loved ones from the inevitability of death.

Port Kembla is a steel-mining town set in a landscape dominated by factory-stacks, and the community’s challenge to the corporate monopoly on death also raises difficult questions about capitalist ownership of the human body. Reflecting on his life, Nigel expresses regret at the dearth of employment options that were available to him as a young man growing up in Port Kembla. In the post-screening Q&A, Wallworth emphasized the human tragedies generated by an industry “which so dominates a community that it chews up the lives of men.”

The film’s title plays on the multiple semantic possibilities of the word ‘tender'; often used to denote a person who tends or waits upon another, but sometimes, also, in reference to an offer of money for services rendered. As an adjective, it describes physical material that is “soft or delicate in texture, yielding easily to force or pressure.”[1] As such, ‘Tender’ epitomises the film’s central concerns with palliative care, the death care industry and the materiality of necrosis. It is this latter element which underscores the film’s most powerful scene; shot as a sequence of still photographic images, it encourages the viewer to reflect on the sanitization and technologization of death and what the manifold benefits of alternative encounters might be.

Since the film’s release in Australia, other local communities have begun to model themselves on Port Kembla and, Wallworth says, the film is, among other things, “a document containing a lot of information”, a blueprint for other local communities to embark on similar projects. Beyond this, Tender should also stand more widely as remarkable inspiration to seek new meaning and purpose in life, from facing death so nakedly.

Tender is currently seeking a UK distributor for limited release. A DVD of the film is available through the website http://www.tenderdocumentary.com.au/

Tender_17 - picnic

[1] Oxford English Dictionary Online.

 

Catherine Oakley is a doctoral researcher in the Department of English and Related Literature at the University of York, UK, where her thesis investigates the interrelationship between medicine, literary fiction and early cinema throughout the period 1880-1925. She is convenor of the ‘Rethinking Disability on Screen’ symposium, to be held at the University of York in May 2015 (rethinkingdisabilityonscreen.com).

Neurological Disorders on Film by Catherine Oakley

16 Nov, 14 | by BMJ

Neurological Disorders on Film at the 58th British Film Institute (BFI) London Film Festival, October 2014

Film and television have long explored narratives involving neurological disorders, but have achieved only patchy success in engaging with the emotional, physical and social implications of this category of impairments. The BFI London Film Festival (LFF) has previously proven a key platform for the work for international filmmakers offering new perspectives on healthcare, chronic illness and disability, and this year – its 58th – was no exception.

Indian drama Margarita, with a Straw arrived at the LFF fresh from its premiere at the Toronto International Film Festival (4th-14th September 2014), trailing an accolade for Best Script at the Sundance Festival Screenwriter’s Lab. It tells the story of Laila (Kalki Koechlin), a teenager and student from Delhi with cerebral palsy who wins a scholarship at New York University. There, she meets young blind activist Khanum (Sayani Gupta) and their close friendship gradually develops into a sexual relationship.

Koechlin and Gupta – both able-bodied actors – prepared intensively for the physical and psychological demands of their respective roles. Koechlin spent two-and-a-half months living in a wheelchair, while Gupta received sensory training with the National Association of the Blind in India (www.nabindia.org). The casting of able-bodied actors in disabled roles continues to be a contested trend in the film industry, and in the post-screening Q&A, Director, Producer and Screenwriter Shonali Bose explained she had initially searched for disabled actors but hadn’t found anyone she felt had been right for the roles.

This debate notwithstanding, both actors turn in terrific performances as two young women struggling with the dual stigma of disability and same-sex desire; struggles which intensify when Laila returns home to her conservative family, in a country where homosexuality is prohibited by law. The concept of ‘normality’ poses continuing challenges to Laila’s emotional honesty as she explores her own identity in relation to these twin categories of ‘otherness’. Early in the film, an intimate close-up registers her consternation and discomfort as two men lift her wheelchair up a set of stairs, complaining about the inconvenience of the faulty lift. Moments like this feature occasionally, registering the insensitivity and tokenism of some perceptions of impairment, but the film’s primary focus is on Laila as a capable and charismatic individual. She is a young woman alive to the sensuality of everyday experiences, from the auditory pleasure of a crowded music gig, to the sensory gratification of a warm bath. Like most teenagers, she is also full of sexual curiosity, and these desires are strikingly visualized in a rear-view shot of her silhouetted before her bedroom window against the night sky, masturbating in her wheelchair. Bose notes that “in India, we haven’t dealt with the sexuality of the disabled, and that excited me as a film-maker”[1], and Margarita will be released there in early 2015. This commendable film is marginally compromised by its closing scenes, in which Laila’s ultimate acceptance of herself is clumsily communicated, but nevertheless offers an arresting portrayal of a vibrant and tenacious young woman, who happens to have cerebral palsy.

In British director Bryn Higgins’s Electricity, Agyness Deyn plays central character Lily O’Connor, a young woman with epilepsy searching for her lost brother. The film, supported by the Wellcome Trust and produced in consultation with the Epilepsy Society (www.epilepsysociety.org.uk), is the latest instalment in a long history of screen representations of epilepsy, including Cleopatra (dir. Joseph L. Mankiewicz, 1963), …First Do No Harm (dir. Jim Abrahams, 1997), The Lost Prince (dir. Stephen Poliakoff, 2003) and Zach, a Film About Epilepsy (dir. Christian de Rezendes, 2009). The physical tonic-clonic convulsions that accompany electrical over-activity in the brain have drawn interest from filmmakers since the early twentieth century, and in 2007, sociologist Professor Toba Schwaber Kerson, concerned about what she believed were stigmatizing depictions of epilepsy on screen, assembled a dataset comprising over 250 films and television series from Europe, America and Asia. She noted common themes across the sample; the portrayal of epilepsy often functioned to add moments of drama to the storyline, or to construct specific types of characters (typically insane, violent and/or victimized). According to her interpretation, many films used epilepsy “to enhance the voyeuristic experience of the film audience as they watch the actions of those having seizures.”[2] Given these tendencies, the challenge for directors seeking to depict epilepsy on film is to strike a responsible balance between conceding – and utilizing – this enduring visual fascination with seizures, and encouraging an audience to move beyond this spectacle to consider the lived experiences of those managing the condition.

Electricity is based on the book of the same name by Ray Robinson, which made use of visual forms by drawing on the conventions of visual poetry or shape poetry, in which the typographical arrangement of words is used as an additional expressive element. Some individuals with Temporal Lobe epilepsy experience ‘Alice in Wonderland syndrome’, characterized by temporary distortion of sensory modalities, and Lily’s hallucinatory episodes register the phantasmagorical nature of these perceptual phenomena. Higgins fully exploits cinema’s potential to visualize subjective experience through technical creativity; point-of-view shots from Lily’s perspective are visceral and immersive; surroundings bend and warp, and abstract close-ups of everyday objects suggest physical and cognitive dissociation. In other instances, stylized sequences depict sharp flashes of light enveloping Lily’s body, transporting both character and viewer from familiar environments into the realms of illusion. Jump cuts from one location to another – floor to bed, pavement to hospital – draw the audience into Lily’s world of amnesia and lost time. It is these innovations, in an otherwise uninspiring narrative of family drama, that suggest a promising new direction filmmakers might take in representing epilepsy on screen.

 

Margarita, with a Straw is showing at the Talinn Black Nights Film Festival, Estonia, on 24th, 25th and 27th November, 2014 (http://2014.poff.ee/eng/films/programmes.p/international-official-competition/margarita-with-a-straw) and at the Brisbane Asia Pacific Film Festival, on the 6th, 12th and 14th December, 2014 (http://brisbaneasiapacificfilmfestival.com/film-archive/margarita-with-a-straw/). It will be released in India in early 2015.

Electricity is showing as part of the 12th Cinecity Brighton Film Festival, 9pm on November 24th (www.cine-city.co.uk). It is releasing in the UK through Soda Pictures on December 5th 2014.

 

[1] Leslie Felperin, “Margarita, with a Straw: ‘The sexuality of the disabled excited me as a film-maker'”. www.theguardian.com. Thursday 23 October 2014.

 

[2] Toba Schwaber Kerson. “Lasting impressions of seizures and epilepsy in film and on television.” The Epilepsy Report 2 (June): 7-13. (9)

 

Catherine Oakley is a doctoral researcher in the Department of English and Related Literature at the University of York, UK, where her thesis investigates the interrelationship between medicine, literary fiction and early cinema throughout the period 1880-1925. She is convenor of the ‘Rethinking Disability on Screen’ symposium, to be held at the University of York in May 2015 (rethinkingdisabilityonscreen.com).

CFP: Postgraduate Medical Humanities Conference 2015 (University of Exeter, 20-21 July 2015)

11 Nov, 14 | by Deborah Bowman

CFP: Postgraduate Medical Humanities Conference 2015
University of Exeter, 20-21 July 2015
Confirmed Keynote Speakers:
Professor Stuart Murray, University of Leeds
Dr Roberta Bivins, University of Warwick
Building on the success of last year’s Postgraduate Medical Humanities Conference, this conference aims to bring together researchers from a variety of disciplines in a manner that reflects the broad scope of exciting research being carried out in the field of the medical humanities at present. We therefore welcome abstracts on any aspect of the medical humanities from postgraduates working in all disciplines, including but not restricted to English Literature, History, Film, Classics, and Art History. We also strongly encourage proposals from students training in a medical discipline (including trainee doctors, carers, psychiatrists, and other practitioners) who are interested in the medical humanities.
While this call is open to papers on all topics within the wide medical humanities remit, we would specifically like proposals on themes of contemporary importance within the field, such as the development of medicine and/or the medical humanities in India and China; representations of medicine in graphic novels; and ageing.
The conference will provide a forum for postgraduate scholars to exchange ideas and share their research in a friendly and engaging environment. The event will also allow delegates to discuss their work with senior academics in the field, including keynote speakers and other members of the Exeter Centre for Medical History.
The event will close with a roundtable discussion, featuring our keynote speakers and other esteemed members of the Centre for Medical History. This session will draw together the themes arising from the conference and reflect on future directions of research in the medical humanities.
There will also be a workshop led by Ryan Sweet and Betsy Lewis-Holmes (co-organisers of the forthcoming event Exewhirr) on public engagement.
We invite applicants to submit abstracts of up to 300 words (for 20-minute previously unpublished papers) to pgmedhums@exeter.ac.uk by Friday 19 December 2014 with “PGMH 2015 Conference Abstract” written in the subject line of the email. We also welcome panel and workshop proposals. Such proposals should include 300-word abstracts for up to four speakers in addition to a 500-word overview that explains the aims and rationale for the session.
We hope to be able to offer a small number of travel bursaries, which will be announced closer to the event.

Ryan Sweet

PhD Candidate

University of Exeter

eProfile: http://www.eprofile.ex.ac.uk/ryansweet/Academia.eduexeter.academia.edu/RyanSweet

Twitter: @RyanCSweet

 

Dr Khalid Ali: ‘Stroke, music and love: A review of “The possibilities are endless” film 5*’

27 Oct, 14 | by Ayesha Ahmad

Following Andrew Marr’s recent stroke and successful return to work, stroke and its consequences have been a national topic; stroke survivors and their families in the UK have gained hope that a stroke does not necessarily mean an end to one’s career or life. On the 29th of October 2014, the World Stroke Organization (WSO) celebrates the “World Stroke Day” through several international events to increase awareness about stroke and support stroke survivors and their carers across the world (http://www.world-stroke.org/newsletter/latest-updates/18-news/latest-updates/230-world-stroke-day-2014).

more…

Poetry, Science and Medicine

19 Oct, 14 | by cquigley

 

Through the Door is a collaborative project involving Archives for London and Poet in the City. Six poets have been commissioned to create new works based on archives that include those of St Paul’s Cathedral and The British Library.

This week I attended a reading from the selection of poems – The Bone Ship – that the poet Mario Petrucci created from his exploration of the archives of The Royal College of Surgeons of England.

The archives contain not only records of the College’s activity, but also hold many collections of letters, diaries (including those of grave robbers), photographs and drawings relating to medicine and surgery from the 16th to the 20th century. The patient files of the First World War plastic surgeon Sir Harold Gillies are also part of the archive.

Mario Petrucci is impressively not only a renowned poet, but also an ecologist and a PhD physicist. The 11 poems that constitute The Bone Ship address issues around war wounds and facial reconstruction during WW1, venereal disease amongst British troops in India, radical surgical techniques, as well as grave digging and body snatching.

Subtitled ‘Poetry and Anatomy’, Petrucci’s poetry extends beyond the physical aspects of the operative procedure and the confines of the human body:

‘Much of the archive material I studied drew a deeply complex, visceral response’ (p.69)

As a result, the poems evoke much compassion around and within the stark language – ‘enucleate’, ‘excise’, ‘snipped’, ‘stripped’ – of surgery.

From Surgical love:

This breast dissected

to beached ribs. My bone ship.

Heart bails alone for you its last salt heat.

 

Hip and thigh.

That softer flesh. To cinerator.

Crematorium. Dust and ash. And oh

 

in their jars these parts so prolonged. But

the sum shall throng in you

wherever you are.

 

And from Methods:

Kneel or recline

for tests that long to bless – what in moderation

 

we tolerate must heal in excess.

 

Also in Methods, Petrucci clearly demonstrates the capacity of poetry to uniquely convey what might otherwise be ineffable:

Malign cells that fraternize

to dominance in cervix, larynx, skin.

Petrucci speaks of a ‘textual music’ in his poetry, which facilitates an understanding that is not dependent on literal meaning. The power of sound within The Bone Ship is perhaps most apparent in P 56, the title reflecting the number of the record recounting the surgeon John Hunter’s transplant of a human tooth into the comb of a cockerel:

Did those jelly-blood

 

teeth in their leather-red comb dryly pliantly rough to touch

wobble with undervalued pain as much as

 

the congealed curls of these girls unhealed?

Similarly in Bullets:

Palpate for a thrill.

With stethoscope hear the bruit.

Exert your will.

The Bone Ship arose from the exploration of an archive, yet it is also about more than history in its consideration of us as embodied beings and as it delves into the suffering that our humanness can entail.

Petrucci speaks of the ‘porous membranes between poetry and science’, which The Bone Ship successfully explores. There have been similar collaborative projects, including the collection sequences and pathogens, which arose from a ‘Poetry Meets Biomedical Science’ venture between poets and scientists, and also includes works from Mario Petrucci.

The poetry collection Pocket Horizon contains the works of seven poets and was inspired by objects from the history of science and medicine, for example Richard Barnett’s That the Heart is a Fist based on one of the original 1815 stethoscopes:

Beating, pounding, pumping – such hard words,

So plump, so tense with action

A dialogue between poetry, medicine and science is an important one, each discipline potentially illuminating the other and enhancing our ability to understand our experiences. In Sylvia Plath’s The Surgeon at 2 a.m., the poet writes from the perspective of a surgeon who sees the patient not as a person but as the sum of her body parts:

It is a garden I have to do with—tubers and fruits

Oozing their jammy substances,

A mat of roots.

Removed body parts – ‘pathological salami’ – are ‘entombed in an icebox’.

Poetry can redress imbalance and restore equilibrium. There is a danger in the dialogue between poetry and disciplines such as medicine and science that the conversation veers to one side. The ‘porous membranes’ that Petrucci so eloquently describes need to allow for a bi-directional flow, thus ensuring that all mutually benefit from the exchange.

 

The Bone Ship: In Through the Door: New Poetry from London’s Archives. Southampton: Indigo Press Limited, 2014.

sequences and pathogens. Litmus Publishing, 2013

Pocket Horizon. Scarborough: Valley Press, 2013

 

Columba Quigley

Parkinson’s Disease and Being Human: Through a Lens

7 Oct, 14 | by Deborah Bowman

‘Over the Hill’ at Create Gallery

New England House New England Street, Brighton, BN1 4GH

until 17 October

 

Tim Andrews was working as a solicitor when he was diagnosed in 2006 with Parkinson’s Disease and was obliged to retire. The following year he responded to an ad in Time Out for ‘real-life’ nude models – as opposed to professionals – and enjoyed the experience so much that he carried on responding to similar ads. Volunteering to be photographed soon developed into a project in which Tim became the active subject in charge of a (still expanding) portfolio of work by more than 300 photographers. Photographs and films by nearly sixty of these artists are currently on show at Create Gallery in Brighton.

This project is extraordinary for several reasons but most importantly because the quality and range of work is outstanding. It would be unfair to mention a selection of names or personal favourites, so do look at Tim’s blog for more information http://timandrewsoverthehill.blogspot.co.uk

The fact that all these lenses have been pointed at a single human subject transforms the collection of art works into one giant multi-faceted portrait not only of a man, but of everyman. Tim is Tim in all the shots, he says, adding that he has not had to act a part for any of them. Instead he feels that every photograph shows a different side of him. It is this quality of confrontation with each camera, open collaboration with each photographer (eloquently described by Tim in his narrative captions accompanying the photographs), which brings integrity to the collection. In a way that is both more natural and more deliberate than with most portraiture, Tim is not so much the subject as the co-maker of each photograph.

He is clear that although he set out to be ‘photographed by different people during the course of my illness’ he now feels that ‘it has not been my intention to document my illness but rather to document myself at a time when I happen to be ill’. I think both intentions are palpable in the wholehearted way that Tim has made his life into an art project. There is memorializing and there is documentary inherent in the business of recording our bodies with cameras. There is also, in Tim’s case, intense playfulness and a rare ability to reimagine, and have reimagined for him, a body – a self – that is simultaneously seriously unwell and vibrantly alive.

In his speech at the opening of the exhibition, Tim thanked those who had taken the photographs, those who had helped him put on the show, those who have treated and continue to treat his illness. He also said thank you to Parkinson’s Disease, because as he put it ‘without it, none of us would be here this evening’.

In a society which insists most of the time on presenting our relationship with incurable illness as a battleground where campaigns are lost or won, this ability to own and even to embrace what happens in the diseased body is remarkable. Tim’s way of seeking wholeness through creation and re-creation is an inspiring example of living well with disease. The exhibition itself is a stunning showcase of photographic talent.

 

Clare Best

Writer in Residence, University of Brighton, 2014-15

www.clarebest.co.uk

http://selfportraitwithoutbreasts.wordpress.com

Ayesha Ahmad: Silence—A Woman’s Wound

26 Sep, 14 | by Ayesha Ahmad

In a healing relationship with the wounded, we are witnesses; we are bearers of witnessing those moments when another reveals their vulnerability, and when we recognise such vulnerability then we find the unanswered voices. The foundation of any healing is when we close our eyes without losing the perception of how the other— how you— are suffering.

When we hear stories from the mouths of the women who bear the words every day of their lives about violence, there is also a profound silence of the dead— the voice of the fallen woman. The fallen woman has not disappeared, nor vanished, but she has been taken; she is a stolen breath, a stolen heart, a stolen soul, and now, now she is a stolen story.

The fallen woman, when she lived, lived between life and death. Before she fell, she lived her narrative­—she embodied every word. Her strength carried her, she became the body that was carved onto her life and shadowed by society. And, the fallen woman, she stood before she fell. She told. She told the story of her silence. This story travelled from her and her silence no longer shrouded her or protected her. Her silence fell from her, and then she too fell.

Who pushed her?

Society.

more…

Guest Essay: “A mind diseased”: Examining the evolution of madness using Shakespeare’s Macbeth by Sarah Ahmed

31 Aug, 14 | by BMJ

 

INTRODUCTION

Over the years, our understanding of what it means to be mad has evolved. Ancient civilisations held the belief that madness was as a result of spiritual possession; the Enlightenment’s concept of rationality remade madness into an external manifestation of internal grief; in the last century we have started to develop biological theories of mental health as we begin to understand more about how the brain works on a synaptic level.[1] It has even been suggested by prolific writers such as Szasz and Foucault that madness is not a disease at all but rather “a cultural construct, sustained by a grid of administrative and medico-psychiatric practices”.[1 (p.3)] It follows that as our understanding of madness has developed, so too have our readings and interpretations of madness in literature as we apply new theories of illness to fictional characters (perhaps in an attempt to empathise more strongly). Bossler said that “Shakespeare’s characters have always been a fertile field for the application of psychological principles”[2 (p.436)] and Shakespeare’s graphic descriptors of a “mind diseased”[3 (5.3.41)] have leant Macbeth to continuous reinterpretation.

In many readings of Macbeth the play has been approached using a particular literary theory or frame of reference. For example, Freud and his followers have analysed the play using the lens of psychoanalysm,[4] prion-based theories of madness have been applied to the text[5] and some have suggested that Macbeth’s madness is a result of battle fatigue.[2] Alternatively the play has been analysed using an approach more in line with New Historic theories of interpretation by considering the historical and social context of the time: the humoral theory of health[6, 7] has been applied to the play and the characters’ dramatic evolutions have been examined from a religious[8] or gendered perspective.[6] Each interpretation presents a new way of understanding old characters and each will be explored below as we examine how our understanding of madness has evolved and argue that if a frame of reference is important to our understanding of Macbeth, a deeper appreciation might be achieved by considering the notion of madness from the perspective of the Elizabethans.

 

FRAMES OF REFERENCE

By simply using a literary approach it is clear both Macbeth and Lady Macbeth undergo dramatic evolutions over the course of the play, be this into madness or something else. Macbeth, who is initially seen to cower beneath his wife’s ambition, “grows ever more frightening…as he becomes the nothing he projects”; conversely, Lady Macbeth implodes and withdraws from society.[9 (p522)]

Macbeth’s decline begins almost immediately following the couple’s decision to take the crown – the great warrior Macbeth is seen to be anxious about the proposed murder, saying “If it were done when ‘tis done, then ‘twere well/It were done quickly”.[3 (1.7.1-2)] Even before the murder his worries manifest themselves as hallucinations when he sees the now famous “dagger of the mind”,[3 (2.1.38)] which first appears clean before being doused with “gouts of blood”.[3 (2.1.46)] His deterioration progresses when he returns to the stage after murdering the King and claims auditory hallucinations, hearing “a voice cry, ‘Sleep no more:/Macbeth does murder sleep”’.[3 (2.2.38-39)] In saying this Macbeth becomes almost premonitory (like the Weird Sisters) as he does indeed suffer sleep disturbances later on, a “symptom” which is often quoted in discussions of his madness.

Lady Macbeth’s fall is more measured and gradual – whilst Macbeth is hearing noises she admonishes him as she would “shame/ To wear a heart so white”.[3 (2.2.67-68)] Here the colour white has connotations not only of innocence and purity but of cowardice; it evokes the white feathers of World War One which were given to the men refusing to enlist. Most of Lady Macbeth’s dramatic evolution occurs off-stage as is typified by the change in her mode of speech. In the banquet scene of Act3 Scene 4 Lady Macbeth’s gravitas and assurance is obvious in how she address the nobles in verse:

Think of this, good peers,

But as a thing of custom. ‘Tis no other,

Only it spoils the pleasure of the time.[3 (3.4.96-98)]

She is the very embodiment of regality. This is contrasted against Act 5 where she speaks only in prose. In Shakespeare’s plays prose was often reserved for the lower classes, or for conversations between characters who are knew each other well, such as Rosalind and Celia in As You Like It.[10] It was also used in the speech of characters who were mad or feigning insanity, as verse was apparently “too regular and orderly for expressing madness”.[10] As such Hamlet, Ophelia and King Lear all speak in prose at some point in their respective plays.

 

The (d)evolutions of Macbeth and his wife have also been subject to particular frames of reference. A psychoanalytic reading would suggest that Macbeth’s madness is due to a “psychic catastrophe”,[4 (p. 1483)] which is a direct result of his murder of the King. In this reading the King acted not only as Macbeth’s Superego, but that of the whole country, representing “the unifying power which bound the warrior’s destructiveness and directed it towards external enemies in order to preserve stability in the kingdom”.[4 (p.1488)] This goes some way to explaining why Macbeth is so affected by this particular killing as the King was not only his head of state but the means through which “Belladonna’s bridegroom”[3 (1.2.54)] could funnel his inner destructive nature. Conversely, the witches represent a “malignant regression to primitive states of mind”[4 (p.1484] and the other extreme of Macbeth’s psychic spectrum. In taking heed of their premonitions Macbeth turns towards his Id; in returning to them for help and validation Macbeth gives in to his base nature.

A Freudian reading doesn’t label Macbeth’s behaviour with a diagnosis but instead strives to understand why the Thane behaves the way he does. A Freudian would believe that Shakespeare merely described behaviour which he had observed in mankind but never had a frame of reference to explain what he saw; Freud’s theory provides this context.[4] The ease with which some of Shakespeare’s plays lend themselves to a Freudian interpretation has been used as evidence for this view with the most famous example being Hamlet and its connection to the Oedipus story. This idea that Shakespeare described human nature accurately but was missing the terminology to explain what he saw has been used repeatedly in various literary theories and evokes Lawrence Olivier’s famous proclamation that Shakespeare was, or is, “the nearest thing in incarnation to the eye of God.”

 

More recent theories of madness, which have originated as our understanding of both biology and psychology has developed, have also been applied to Macbeth. One such theory is that Macbeth suffered from Creutzfeldt-Jakob disease (CJD), or another similar prion disease.[5] The paper which proposed this theory was published in the Clinical Infectious Diseases Journal, highlighting how a person’s background can be used to form the frames of reference they use in their interpretation not only of the scientific world but of literature. It is important to note that the authors of the paper admit that Shakespeare may not have intended Macbeth’s dramatic evolution to mirror the natural history of a prion disease; similar to advocates of psychoanalysm they believe the playwright showed “an uncannily prescient understanding of prion disease transmission via exposure to neural tissues”[5 (p.299)]but lacked the context to explain it. The variety of human and animal offal present in the witches’ brew is considered the possible source of transmission.[5]

In creating their theory that Macbeth may have suffered from CJD the authors look beyond the usual symptoms of traditional madness – sleep disturbances and hallucinations – and find quotative evidence for more specific indicators of prion disease such as “neurological and cognitive deterioration”[5 (p299)] as well as “myoclonus and involuntary movements”.[5 (p.301)] However in most of the examples found it is possible to take what Shakespeare wrote and interpret it as a metaphor. For example, evidence for myoclonus is found in the following quote:

Take any shape but that, and my firm nerves

Shall never tremble. Or be alive again,

And dare me to the desert with thy sword;

If trembling I inhabit then, protest me

The baby of a girl.[3 (3.4.102-103)]

It may be that Shakespeare intended the reader to take the above literally and imagine Macbeth trembling; conversely it is just as likely that he meant it as a metaphor and Macbeth trembles in fear of the Ghost – even today we use similar expressions. After all, Shakespeare was foremost a poet. The following quote has also been attributed to myoclonus: “Then comes my fit again. I had else been perfect”.[3 (3.4.20)] It is similarly ambiguous as there is nothing in the script to suggest that Macbeth has an actual fit; it is more likely to metaphorically psychological in nature.

 

In a similar fashion, Macbeth’s dramatic evolution has been attributed to a diagnosis of battle fatigue.[2] Similar to explaining Macbeth’s madness as CJD, or even in examining it through the lens of psychoanalysm, the theory’s creator admits that although Shakespeare may not have set out to describe a case of battle fatigue, “the only thing new about [attributing a diagnosis of battle fatigue] is its name. Human nature remains the same”.[2 (p436)] Again it is interesting to note that the author of this paper is a military veteran.

The symptoms of battle fatigue are similar to those of traditional madness and CJD – “obsession of anxiety, jumpiness and inability to sleep”;[2 (p.437) however Macbeth has also been exposed to all the causes of battle fatigue.[2] The ceaseless toil of first the war and then the murder, combined with Macbeth’s powerful imagination, tips the balance of sanity towards dominant thoughts of blood and war.[2]Macbeth’s subsequent murders are explained as him returning to the place where he has known most success – the battlefield – in an attempt to cure himself of his malady; he tries to find peace by doing what he does best, except now he “enjoyed killing others too much to kill himself”.[2 (p437)]

 

IS IT ENOUGH?

In each of the above theories Macbeth is interpreted using a particular frame of thought; as was particularly prominent with the CJD and battle fatigue examples the frames of reference were drawn from the author’s life experiences. It is interesting to note that in each of the above readings it was claimed that Shakespeare merely described human nature (admittedly with some finesse and precision); what each new theory brings is context based on new interpretations of madness. Applying contemporary theories of (psychological) illness to diagnose literary characters is a phenomenon which is not just limited to Macbeth, or even to Shakespeare’s work: Winnie the Pooh’s Pooh and Piglet have been diagnosed with ADHD and General Anxiety Disorder respectively;[11] it has been suggested that Darcy may place on the Autistic Spectrum.[12] It is possible that our current biological theories will one day be disproved and appear outdated to future generations, and highly probable that as we develop new theories of madness these too will be applied to fictional characters, and we will have new ways of interpreting the actions of the Thane and his Lady.

However it is also probable that Shakespeare intentionally modelled his characters around Elizabethan notions of madness; unfortunately we can never know what Shakespeare meant when he described “a mind diseased”.[3 (5.3.41)] However by accepting that Shakespeare was an accurate portrayer of human nature we can begin to understand what Elizabethans thought about madness by examining the play in its historical and social context. Braunmuller agreed by saying that critical “claims are often false to the play’s complex relation with the social and political circumstances in which it was first written and first performed”.[3 (p.1)]Knowing more about these circumstances could be hugely useful, not only in giving readers a deeper understanding of the play but in showing us how mental illness was viewed in the 1500s/1600s. It is in this vein which we will continue.

 

HISTORICAL AND SOCIAL CONTEXT

Medicine, health and the medical professions feature heavily in Shakespeare’s plays and those of his contemporaries,[13] and “it has long been recognized that England in the period from 1580 to 1640 was fascinated with madness”.[6 (p.316)] However it has been suggested that Shakespeare’s knowledge is greater than that of a regular Elizabethan.[14] The reasons for this stretch beyond the scope of this essay but it can be assumed that Shakespeare knew about current theories of health and illness. It was during the Elizabethan era that madness started to become medicalised and was seen as humoral in nature; it was also associated with gender and religion. Each of these viewpoints have been used to interpret Shakespeare’s work.

 

Humoral theory stated that melancholy, now known as depression, was caused by an excess of black bile, the humor associated with winter and dryness. This resulted in a combination of “passivity, unsociability, fury, stupidity, paranoia, lust, anger, mania, but especially sorrow and fear”.[6 (p.319)] Most of these, in varying combinations, are seen in Macbeth and Lady Macbeth after they decide to kill the King. The use of humoral metaphors has been explored extensively in Shakespeare; in Macbeth it is especially with relation to Lady Macbeth and her ambitious nature.[7]

 

Despite more “scientific” theories it was also around this time that madness began to become gendered – although the frame of reference may have shifted from religion to reason, women were still seen as weak, second class citizens.[6] Melancholy in its purest form was associated with “the upper class, the literate, the masculine”.[6 (p. 319)] Conversely women were thought to suffer from melancholy’s sister, hysteria.[6] This idiosyncrasy can be clearly seen in Shakespeare’s Hamlet where Hamlet’s (possibly feigned) madness is always seen to be quite noble in nature – he is never anything less than the distressed Prince of Denmark – whereas Ophelia’s is seen almost to be “beautiful, sweet, lovable, pathetic”.[6 (p. 322)]

This gendered madness can also be seen in Lady Macbeth’s descent, which holds many similarities with Ophelia’s madness. Like Ophelia, Lady Macbeth speaks in riddles and without apprehension of her surroundings; both repeat key phrases in their deliriums with Lady Macbeth meditating on all the blood her and her husband have spilt; both return to the stage in their mad stage in the second half of the play after a prolonged absence; both their lives end in apparent suicides. The women of the play become “cultural scapegoats”[6 (p. 328)] as Lady Macbeth’s sex automatically acquaints her with the “so withered and so wild”[3 (1.3.38)] Weird Sisters. Conversely we sympathise with Macbeth, seeing him “not as the victim of a revengeful God, but as a victim of Macbeth himself”.[8 (p. xxii)] This is because Macbeth’s madness and feverish passion is seen as manly – at the start of the play even the strong Lady Macbeth expresses a desire to be “unsex[ed]”,[3 (1.5.39)] to possess the cruelty associated with ambition which her husband seemingly possesses.

 

The role of religion also plays an important part in the play. Although the theories of Enlightenment had started to permeate into society, religion and God still strongly influenced the way in which people interpreted their world. With this in mind it is possible to see the dramatic evolutions of Macbeth and his wife as religious punishments given due to breaches in their God-given consciences. It has been suggested that “the external phenomena associated with conscience manifest themselves more clearly in Macbeth and his wife than in any other of Shakespeare’s dramatic personages”.[8 (p. ix)] Madness aside, there are many Christian references throughout Macbeth. Lady Macbeth advises her husband to “look like th’innocent flower,/But be a serpent under’t”[3 (1.5.63-64)] in a reference to the story of Adam and Eve in the Garden of Eden. By counselling her husband to be a serpent she equates murder with its patron, the Devil. In preparation for the murder Macbeth reassures himself that Duncan’s ‘virtues/Will plead like angels”.[3 (1.7.18-19)] Lennox wishes that “a swift blessing/May soon return to this our suffering country”,[3 (4.1.48-49)] suggesting that holy salvation is needed to save Scotland from Macbeth’s unholy crimes. The fact that the Doctor advises Lady Macbeth “more needs…the divine than the physician”[3 (5.1.64)] has been used as evidence to suggest that “Shakespeare wanted us to view her condition as the result of remorse, as the outcome of her guilty conscience”.[8 (p. 15)] However this statement can be viewed in one of two ways – either the Doctor is aware that Lady Macbeth has committed unholy crimes and so needs spiritual retribution more than a medical solution; it could also suggest that the Doctor believes all cases of somnambulism to be spiritual in nature and so recommends a divine solution.

Perhaps this conflict between religion and science is indicative of Shakespeare’s own, confused beliefs. It is not impossible that he realised that “by constructing a language through which madness can be represented, the popular theatre facilitated the circulation of the discourse; by italicizing the language of madness, it encouraged its interrogation and transformation”.[6 (p. 338)] Especially true in the Elizabethan age this is particularly poignant today; theatre provides us with a way of interpreting health and disease – it allows us to be privy to people’s perceptions of illness and influences how the public view a certain disease.

 

THE EVOLUTION OF MADNESS: A CONCLUSION

As we develop new ways of understanding health and disease we have returned to old texts to apply our knowledge. This is especially true with regards to psychological illness, and Shakespeare’s work is often subjected to these new readings. You can chart the evolution of madness through critical interpretations of Macbeth; the same applies for readings of depression in Hamlet or dementia in King Lear. On one hand it is interesting to consider why we do this – scientifically speaking quotes from Shakespeare do not count very highly on the ladder of evidence based medicine. I like to think it’s a question of human nature and empathy. We can be so affected by the actions of a fictional character that we are moved to tears or laughter; characters become real to us and we want to know why they behave the way they do, both to satisfy our human curiosity and to perhaps explain why we are so emotionally affected by fiction.

It is also interesting that many of the theories we have explored use the same quotes as evidence; one line can be interpreted in many different ways. Most of the authors considered have admitted this – human nature remains constant and we simply assign different labels to it. Perhaps madness has not evolved at all, but rather as a society we have outgrown one way of thinking and are eager to make our mark on the world by creating another; where better to find reassurance that what we believe is correct but in the great fictional works that define our society?

And what did Shakespeare mean when he described “a mind diseased”? Whilst every new reading brings something profound to a seminal work perhaps it is only by considering the historical and social context that we can fully appreciate what it was that the Bard was trying to convey. As much as we – as readers, critics, health care professionals – would like to diagnose his characters we should always remember that perhaps Shakespeare was simply being a writer and creating characters who would give good performances, characters which would appeal to the public’s expectations. Madness, like beauty is in the eye of the beholder: “in the drama, as in the culture outside it, madness is diagnosed by those who observe it”.[6 (p. 321)] Ultimately, readings and contexts aside, how we view a work of art is an inherently personal experience, influenced as much by our own lives as by society; perhaps it is enough that we feel something, rather than feel nothing at all.

 

References

  1. Porter R. Madness: A Brief History. Oxford: Oxford University Press; 2002
  2. Bossler R. Was Macbeth a Victim of Battle Fatigue? College English 1947; 8 (8): 436-438
  3. Shakespeare W. Braunmuller AR, editor. Macbeth. Cambridge: Cambridge University Press; 2008
  4. Tarantelli CB. “Till destruction sicken”: The catastrophe of mind in Macbeth. Int J Psychoanal 2010; 91: 1483-1501
  5. Norton SA, Paris RM, Wonderlich KJ. “Strange things I have in head”: Evidence of Prion Disease in Shakespeare’s Macbeth. Clin Infect Dis 2006; 42: 299-302
  6. Neely CT. “Documents in Madness”: Reading Madness and Gender in Shakespeare’s Tragedies and Early Modern Culture. Shakespeare Quarterly 1991; 42 (3): 315-338
  7. Fahey CJ [Internet]. Altogether governed by humours: The four ancient temperaments in Shakespeare. Graduate Theses and Dissertations 2008. URL: http://scholarcommons.usf.edu/cgi/viewcontent.cgi?article=1229&context=etd [Accessed July 2014]
  8. Toppen WH. Conscience in Shakespeare’s Macbeth. Groningen: JB Wolters; 1962
  9. Bloom H. Shakespeare: The Invention of the Human. London: Fourth Estate; 1998
  10. Schwartz DB [Internet]. Shakespearean Verse and Prose. Last Edited 2005. URL: http://cla.calpoly.edu/~dschwart/engl339/verseprose.html [Accessed 4th June 2013]
  11. Shea SE, Gordon K, Hawkins A, Kawchuk J, Smith D. Pathology in the Hundred Acre Wood: a neurodevelopmental perspective on A.A.Milne. CMAJ 2000; 163 (12): 1557-1559
  12. Bottomer PF. So Odd a Mixture: Along the Autistic Spectrum in ‘Pride and Prejudice’. London: Jessica Kingsley Publishers; 2007
  13. Spurgeon C. Shakespeare’s Imagery and what it tell us. Cambridge: Cambridge University Press; 2005
  14. Davis FM. Shakespeare’s Medical Knowledge: How Did He Acquire It? The Oxfordian 2000; 3: 45-58

 

Other sources:

Barroll JL. Artificial Persons: The Formation of Character in the Tragedies of Shakespeare. South Carolina: University of South Carolina Press; 1974

Bradley AC. Shakespearean Tragedy: Lectures on Hamlet, Othello, King Lear, Macbeth. 3rd Edition. London: Macmillan Press; 1992

 

Sarah Ahmed is a final year medical student at the University of Birmingham, UK

A version of this article will be presented at the 7th Global Conference – Madness: Probing the Boundaries at Mansfield College, Oxford ( 5th-9th September 2014).

Correspondence to: 09saraha@gmail.com

 

Medical humanities blog homepage

Medical Humanities

An international peer review journal for health professionals and researchers in medical humanities. Visit site

Latest from Medical Humanities

Latest from Medical Humanities