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Art in Arthritis by Nancy Merridew

22 Mar, 15 | by BMJ

 

 

I called Marco from the waiting room.

 

Everyone looked waxen under the fluorescent lights of Rheumatology Clinic. His olive skin looked grey. He rose like a grapevine on the trellis – thickset but gnarled through the seasons.

 

Marco helped his wife with her handbag and they walked together. Her gait was robust; his was antalgic and unhurried, though slower than he’d have liked.

 

In the consulting room we shared our introductions. I explained that I was aware of his medical history and asked “what are your biggest joint troubles today?”

 

Marco’s molten voice was rounded with a beautiful Italian accent and 80 years of life.

 

Apologising in fluent English Marco said that he didn’t speak English well and that it’s important to “talk the talk” of the doctors.

 

He looked down, reached into a shopping bag, and handed me three sheets of drawings.

 

I was stunned by beauty, utility, and clarity.

 

Brown ink outlined each picture, backfilled with camel watercolour. One image revealed the face of a younger man and the muscular shoulders of youth – his mind’s eye self-portrait.

 

Marco nodded to confirm that he had drawn them all.

 

Each drawing was anatomically correct and swelled from the parchment like parts of an amputee ghost. In some, his bones were bare. In others Marco had blended superficial features of skin with deeper structures of the appendicular skeleton.

 

A left hand floated on one page, like Adam’s in his Creation on the Sistine Chapel ceiling. Words – “Pain here” and “Here too” – were anchored by lines drawn to the hand, portraying metacarpophalangeal and proximal interphalangeal pain.

 

Figure.1_Hand.Shoulder_BMJ

Figure 1. Annotated drawings of right shoulder, face, and left hand:

  • “Pain here” [SHOULDER]
  • “Pain here” [5th METACARPOPHALANGEAL JOINT]
  • “Here too” [2nd METACARPOPHALANGEAL JOINT]
  • “Pain here” [FINGER]

 

Six weeks earlier a rheumatologist had diagnosed Marco with recurrence of polymyalgia rheumatica, with shoulder and small joint features, and with a possible component of new onset rheumatoid arthritis. Recurrent carpal tunnel syndrome was diagnosed in his right hand.

 

On the other pages Marco had drawn his hips, knees, and feet, and annotated their aches with cursive writing.

 

These bones it seems that they are coming apart. When I walk for about ¾ of an hour then it start to give pain. Swells up and gets quite hot. The knee.

 

Figure.2_Knee.Foot_BMJ

Figure 2. Annotated drawings of foot and knee:

  • “Pain here especially at night.” [KNEE]
  • “These bones it seems that they are comming (sic) apart. When I walk for about ¾ of an hour then it start (sic) to give pain. Swells up and gets quite hot. The knee.” [KNEE; TIBIOFIBULAR JOINT]
  • “Pain here last for days on both feet. Not all the time” [TALUS]

 

Marco was seen in the hospital’s Orthopaedic Clinic for severe osteoarthritis of his knees.

 

A carpenter, who still bent those knees to work, Marco explained that he once did a Fine Arts degree to support his business. Beyond that expertise, his careful handling of the autographed pictures revealed an artist.

 

The edge of one page cut through the word “foot” at “foo” which perhaps reflected Marco’s life.

 

Born during the Great Depression he was of the frugal generation – practical, resourceful, industrious. I wondered if Marco had ever rationed paper as a luxury, each sheet precious and saved for handsome cabinet designs.

 

Perhaps as an artist, unwilling to share flaws, he had cropped a larger page of sketches.

 

Figure.3_Hip.Foot_BMJ

Figure 3. Annotated drawings of right foot, pelvis and right lower limb:

  • “Both feet hurt at times” [FOOT]
  • “Pain in here sometimes not all the time” [HIP JOINTS BILATERALLY]
  • “Right leg. Pain here” [FEMORAL HEAD, TIBIAL PLATEAU]

 

I was enthralled.

 

Marco’s eyes danced like bubbles from the surface of Prosecco – the muted pleasure of artistic pride.

 

Already he had offered his pictures to me three times as a gift.

 

Yet I had declined as it seemed too generous. I thanked Marco and encouraged him to keep bringing the drawings to appointments given their clinical value.

 

I completed the history.

 

Marco’s main concerns were steroid-related weight gain, although his arthralgia had improved.

 

As he talked I noticed subdued hand gestures. Given his Italian heritage, perhaps Marco suffered a cultural version of locked-in syndrome from the pain that restricted his upper limbs.

 

After completing the physical examination, I liaised with my registrar about Marco’s clinical plan. In a makeshift gallery behind the consulting suites I showed his artworks to the rheumatologists.

 

They advised that I could keep the pictures, and to take photocopies for the medical record. I made an extra copy either for me or for his art portfolio.

 

I returned to the clinic room. Marco’s wife, who had been silent, was keen to hear the consultants’ opinions of his drawings.

 

She beamed on learning that they were unanimously said to be “the most beautiful ever seen in clinic”, and particularly enjoyed by the Head Professor of Rheumatology.

 

Again Marco offered his pictures and this time I accepted with delight.

 

Smiling, he received his own copies as I explained his treatment changes and follow-up plan. We shook hands. Those aching hands created beauty and conveyed exceptional insights.

 

I watched as he left with his wife and wondered about their lives, leaving Italy to bring their charisma to Melbourne.

 

Two days later I framed the drawings – an exquisite medical document and gift. They hang in my home and evoke Marco’s grace, eloquence, and vitality.

 

* * *

 

Acknowledgements and Postscript

 

Marco, a pseudonym, has consented to the release of his artworks for the purposes of this article. See Figures 1, 2, and 3. Sincere thanks to the patient for his generosity and insights.

 

Thanks to Dr Thomas Lawson Haskell BMBS for his excellent photography of the drawings.

 

Correspondence: Dr Nancy Louisa Gwen Merridew BA BSc MBBS DTMH

Basic Physician Trainee, Launceston General Hospital

PO Box 1328, Launceston, Tasmania, Australia 7250

Nancy.Merridew@gmail.com

Tiger Country (Hampstead Theatre): A Review by Aneka Popat

13 Jan, 15 | by Deborah Bowman

 

 

For some, the workplace is synonymous with shiny desks, immaculate windows and a calm open sea of computers, complete with the reassuring hubbub of Monday morning gossip. Yet, for those that work in the capital’s hospitals, the workplace is a jungle where the gleam of a scalpel and the unforgiving glare of ward lighting mark the territory. We are in Tiger Country, a world where instinct stirs and we flirt with fate.

 

Nina Raine’s Tiger Country is a thrilling drama about professionalism, prejudice, romance, ambition and failure in an overburdened health service. It is far from the hyperbolic depictions of television soaps. It is frank and honest, exploring not only the daily challenges of a busy London hospital, but also the impact on the individual of being there both literally and metaphorically.

 

The emotional core of the play is with two ambitious female doctors, at different stages of their training, but each determined to succeed. Emily (Ruth Everett), a junior doctor, represents Tiger Country’s young blood. Though rigorous and thorough in all she does, we see her vulnerabilities as she attempts to juggle her professional identity and her relationship with medic boyfriend James (Luke Thompson). In contrast, Vashti (Indira Verma), the single and driven urology registrar rediscovers the identity that was increasingly obscured behind the surgical mask.

 

Raine seamlessly integrates medic ‘slang’, and inside jokes in her docu-play and avoids caricatures. The 14-strong cast creates a working hospital in all its diversity and detail. The squeaky wheels of hospital beds, the disposable coffee cup beside the computer station and the power walks of staff contribute to a stylistically sensitive set. The audience sits either side of the stage and is immersed in the frantic hospital environment. Fergus O’Hare deserves a special commendation for his sound design with Bollywood numbers sitting alongside the melodies of Nitin Sawhney.

 

Tiger Country is a sharp and quick-witted play about hospital culture. It offers more than a view of hospitals and the NHS. The piece is an intelligent examination of the human cost and achievements of medicine.

 

Tiger Country is at Hampstead Theatre until 17th January: http://www.hampsteadtheatre.com/whats-on/2014/tiger-country/

 

Aneka Popat, 4th Year Medical Student

St George’s, University of London

m1000780@sgul.ac.uk

 

 

Letting go of ourselves; how opening our minds will let us understand our patients by Benjamin Janaway

10 Jan, 15 | by BMJ

 

Empathy is described by Webster’s dictionary as ‘the feeling that you understand and share another person’s experiences and emotions’ 1, the subjective knowledge that you can be inside the mind of another and feel things as they do. I would argue that although this is a beautiful concept, due to the variation of people’s experiences, the stories of their lives and their dreams and aspirations, no one can ever truly empathise before letting go of themselves.

In my work I often hear long stories, sometimes connected, mostly unconnected, with the physical symptoms that a patient displays. It is more often than not, as previously discussed in another of my articles, the change in a patients way of life is their main concern, not the physical problem causing it. It is the subjective perception of an objective physical or mental change that presents the drama within his or her own mind.

Through my extra academic work into philosophy, psychology, neurology and through reading classical literature, I have noted a basic human desire to label and explain the external world with reference to ourselves. This message is conveyed in either parable or direct prose from religious texts, to Stephen Hawking’s ‘A Brief History of Time’, where Hawking quotes;

Humanities deepest desire for knowledge is justification enough for our continuing quest. Our goal is nothing less than a complete description of the universe we live in2.’

Hawking’s grace with words beautifully expresses an underlying psychological process that may at times burden our brains but at the same time paint the canvas of our deepest dreams and questions. We wish to know the universe to know our purpose, to know ourselves, to explain changes in the universe we see to give us some inkling of their significance, and how we our significant.

Happiness, sadness, anger and many more are all primal responses to the complexity of the universe we see, something deep within us, explained through psychology as conditioned responses, through anatomy as limbic activation3 and through literature as the beauty of things. We paint our image of the universe with our own brush, the paint coloured by our own lives.

Those who have read ‘Love in the Time of Cholera’ will know the bitter beauty of a life spent in the shadow of unrequited love, and you may have your own judgements about Florentino Ariza and his choices4. Some may argue that his life spent in waiting represents the purest of human love, the greatest that our minds and words can create, is a life well spent. Others may argue that his life was wasted, opportunities missed in the false deification of a lost summer love. I would argue that you are both right, that your interpretation is based on your own understanding of your universe and your own values. Florentino represents a longing deep in all of us to connect with another, and in a deeper way, to connect with the universe itself.

I would argue that it is the variation in our perspectives that makes for the rich tapestry that humanity will leave hanging in our corner of the universe. Each story told is simply strand intertwined with a million others, and as doctors we have the privilege of becoming part of many. Realising that our thoughts are simply are own, our own opinion and ascribed our own value is a step in the right direction to understanding others, that standing back from your square in the tapestry allows you to see the entire works.

For a patient, a word I abhor and wish to replace with ‘John, Mary, or whoever’, their strand is redirected by illness, however minor or major, and ends leaving a different mark on their universe, a frayed edge or missed thread. For my time in oncology, seeing those facing death with bravery and pride, the last threads of their ebbing strands glowed brighter than ever before as the wonderful healthcare staff helped them tread their own path.

In treating these amazing people I learned to forget about my own views of the world, my own assumptions of the universe, to clear my mind and listen to not just their words, but what they wished to convey with them. To paraphrase a famous spiritualist, words are signposts pointing to something5, and are often taken further than what they actually mean. ­To fully understand the emotional context conveyed in a word one must lose their own assumed reaction and critique their own understanding, their own mind created connection, and see things anew.

Seeing things anew, letting go of your own views and trying to learn and understand those of the patient is the closest I argue that we can come to true empathy. Even suffering the same ailment does not mean you see the disease the same way; it does not paint the same story or change your view in the same way. In the end medicine is not just dealing with disease, it is dealing with the minds and dreams of those, who through forgetting ourselves, and we are simply part of one cosmic consciousness. We are all painters, each with our own brushes and colours, but only by letting go of our own can we pick up another’s.

At the beginning of this article I quoted Webster’s definition of empathy, but I now propose a minor amendment,

‘the process by which letting go of your own view, you may understand and share another person’s experiences and emotions’.

By seeing the universe through the eyes of another, we can see how their story changes and how we can help shape their narrative, guide their thread, or steady their hand, in making the mark they wish to leave on this universe. That, I argue, is our empirical job as doctors, to help people be who they wish to be. So as healthcare professionals, junior or senior, how do we achieve this? Greet each new person with the zest you approach a new novel, without assumption, without preconception and with open arms and mind.

ben.janaway@nhs.net

The opinions above represent those of the author and do not necessarily reflect those of SDHCT or associated NHS affiliates.

 

References

  • http://www.merriam-webster.com First accessed 27/12/14
  • Hawking, S. A Brief History of Time, 1988, Bantam Books, Transworld Publishers, England
  • Peters, S, The Chimp Paradox, 2011, Ebury Publishing, England
  • Marquez, G G, Love in the Time of Cholera, re-published 2008, Penguin, Australia
  • Tolle, E, The Power of now’, 2001, Hodder Publishers, England

Gamal Hassan: “Stoker’s plight: Is Murderous Instinct Nature or Nurture?”

20 Dec, 14 | by Ayesha Ahmad

A review of the film “Stoker” USA 2013 directed by Park Chan-Wook

Mental illness and its impact on individuals and families have inspired film-makers from all around the world. “Stoker” directed by the visionary film maker Park Chan-Wook (of “Old boy” fame, http://en.wikipedia.org/wiki/Oldboy_(2003_film) is a family drama with a different twist.

more…

Khalid Ali: “In the Shadow of Guardians: A Review of ‘Radiator’ and ‘My Old Lady'”

20 Dec, 14 | by Ayesha Ahmad

“Radiator” screened at the London Film Festival October 2014, star rating: 4* directed by Tom Browne, due to be released in 2015

“My old lady” is currently in general release in the UK, star rating: 3*, directed by Israel Horovitz, http://cohenmedia.net/films/my-old-lady

The Oxford dictionary defines the word “guardian” as ” a person who is legally responsible for the care of someone who is unable to manage their own affairs, especially a child whose parents have died”. Two new British films “Radiator” and “My old lady” explore the role reversal of a “guardian” in two families when children take over the caring role for their frail parents.

more…

The Good Surgeon by Shekinah Elmore

19 Dec, 14 | by Deborah Bowman

 
I don’t know what to do with my life. I love surgery and I love people. It is frequently implied to me, without much subtlety, that those values are steeply at odds. “Surgery? I’m surprised! You’re so patient, you take time to explain things, and you don’t seem to get frustrated.” The resident had just met me for the first time, watching me explain the importance of anti-hypertenisve medications to one of my patients at a primary care clinic in a small and underserved town near Boston. I sighed at her comments, and couldn’t help but laugh. Did surgeons have such a bad reputation?
I already knew the answer. When I briefly flirted with pre-medicine as an undergraduate, I loved working in the emergency department. I was drawn to the excitement and adrenaline, but liked equally the time talking with patients, making them feel comfortable in challenging, frightening times. By the time I finally committed to medicine, after working in public health and living abroad, I quickly became hooked on anatomy. I was always the first of my team to lab, having carefully read the planned dissection for the day. I had noticed on the first day of lab that our cadaver had on the brightest, most perfect red toe polish. I often wondered silently about her life as I searched for her nerves and vessels. Anatomy was beautiful, but I enjoyed working with people. I never considered surgery. In a weird twist of fate, our anatomy professor had auctioned off her old copy of Schwartz’s Principle of Surgery, I ended up buying it because I was so drawn to the cover, the weight, or so I tell myself. My professor found out that I’d bought her prized volume, asking with glee “Are you going to be a surgeon?!” I remember mumbling something only slightly more gentle than “absolutely not” and awkwardly backing away from the encounter. Surgery just didn’t make sense.

The stereotypes that we carry about surgeons are densely layered and deeply cultural. We imagine the surgeon as arrogant, technically masterful, controlling, and perhaps even quick to anger. But, he, and it is generally a “he” that stars in our fictions, is this way because it is best for the patient. By taking control and “fixing the problem,” he has obviated the need for bedside manner. For compassion. When we imagine a good surgeon, we do not often imagine a “good” doctor.
When I was diagnosed with breast cancer a few years ago, my first visit was with a surgeon. She was patient. She took the time to explain the treatment options. She did not seem frustrated. I felt comforted and optimistic. And, several weeks later, when she called to give me the news that I’d been dreading, that the PET scan showed an area of uptake in my lung, I could hear the pain in her voice. I was in shock, alone in my apartment, splayed out on the bedroom floor and reeling from the emotional equivalent of vertigo. “We will make it through this” she said with a strength that resonated with a place inside me that I had not yet begun access.
When things got better, in a very relative sense, and the nodule in my lung turned out to be a primary tumor and not a metastasis, I visited a thoracic surgeon. Though imposingly tall and perhaps a little hulking, he was boisterous and smiled easily. He held my hand tightly as I went off to sleep. I remember his voice in the recovery room saying that things had gone well. He was at my beside every morning throughout my hospital stay. His visits were quick, but always meaningful as he perched on the side of my bed and updated me on the plans for that day.
Despite my experiences with these good surgeons, these good doctors, I had still felt the burden of stereotype pulling me away from surgery. As a person concerned with empathy, with the humanities, as a woman, I had been surreptitiously and insidiously taught that surgery would not be the right fit. Now, at the beginning of my fourth year, despite these pervasive generalizations, I know that surgery is a wonderful option for any medical student.
Certainly, the personalities of surgeons likely differ, on average, from the personalities of specialties considered more person-centered. But, empathy, or the ability to imagine the experience of the other, is not out of reach for any physician or surgeon. The dance is delicate. To understand the situation of the other, to take it to heart, but to not be immobilized by it, even to push it to the corner of our minds if it impedes our service to best interests of the patient. But, to connect with a person, and then to participate in his or her operation has never really felt counterintuitive to me, and I would imagine that this is the case for most surgeons.
In fact, the most memorable surgery of my third year was a gastric bypass performed for a patient that I had known through my primary care clinic for the entire year. I squeezed her hand in the preoperative area, telling her that we would take the best care of her. In the operating room, I didn’t wince when incisions were made or closed. I was wrapt with the beauty of the surgery, thinking to myself often that this would finally help her joint pain and hypertension. Help her move again. This was the surgery that she and I had been waiting for all year.
I hope that my caring, my love of people, and my patience will be valuable, regardless of whether or not I choose to spend part of my time in the operating room. I hope that we, as a profession that includes both physician and surgeon, can ensure that the empathetic student is not deterred from surgery. And, moreover, that the empathetic surgeons, of whom there are many, can be recognized as teaching us all what it means to be good doctors.

 

Short Bio:

 

Shekinah Elmore is a fourth year at Harvard Medical School. Her creative work has been published in Third Space, the College Hill Independent, and JAMA. She was awarded first prize in the 10th Annual Michael E. DeBakey Medical Student Poetry Contest for her poem “gnosis,” and an honorable mention in the 2013 Arnold P. Gold Humanism in Medicine Essay Contest for an earlier version of “The Good Surgeon.” She is thankful to the many good surgeons who have been her carers and teachers, and looks forward to working with many more in her career in oncology. Correspondence at shekinah@hms.harvard.edu.

 

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…

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

 

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