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The healing touch in an era of personalised medicine

As data powers a revolution in personalised medicine, surgeon David Cranston asks if we are risk of dehumanising medicine?

David Cranston is emeritus Professor of Surgery at Oxford University. As well as publishing academically, he has has also authored books on John Radcliffe, and mentoring.

A doctor looks thoughtful will holding a stethoscope to their ears.
Photo by Nappy on Unsplash.

In 1877 Arthur Conan Doyle was sitting in one of Dr Joseph Bell’s outpatient clinics in Edinburgh as a medical student, when a lady came in with a child, carrying a small coat. Dr Bell asked her how the crossing of the Firth of Forth had been on the ferry that morning. Looking sightly askance she replied;  

 “Fine thank you sir.”  

 He then went on to ask what she had done with her younger child who came with her.  

Looking more astonished she said:   

“I left him with my aunt who lives in Edinburgh.   

Bell goes on to ask if she walked through the Botanic Gardens on the way to his clinic and if she still worked in the Linoleum factory and to both these questions she answered in the affirmative.  

Turning to the students he explained  

“I could tell from her accent that she came from across the Firth of Forth and the only way across is by the ferry. You noticed that she was carrying a coat which was obviously too small for the child she had with her, which suggested she had another younger child and had left him somewhere. The only place when you see the red mud that she has on her boots is in the Botanic Gardens  and the skin rash on her hands is typical of workers in the  Linoleum factory.   

It was this study of the diagnostic methods of Dr Joseph Bell led Conan Doyle to create the character of Sherlock Holmes.  

A hundred years later and I was young doctor. In 1977 there were no CT or MRI scanners. We were taught the importance of taking a detailed history and examination. Including the social history. We would recognise the RAF tie and the silver (silk producing) caterpillar badge on the lapel of a patient jacket.  We would ask him when he joined the caterpillar club and how many times he had had to bail out of his plane when he was shot down during the war – a life saved by a silk parachute. We would notice the North Devon accent in a lady and ask when she moved to Oxford.  

The patient’s history gave 70% of the diagnosis, examination another 20% and investigation the final 10%. Patients came with symptoms and the doctor made a presumptive diagnosis – often correct - which was confirmed by the investigations. Screening for disease in patients with no symptoms was in its infancy and diseases were diagnosed by talking to the patients and eliciting a clear history and doing a meticulous examination. No longer is that the case.     

At the close of my career, as a renal cancer surgeon, most people came in with a diagnosis already made on the basis of a CT scan, and often small kidney cancers were picked up incidentally with no symptoms. The time spent talking to patients was reduced. On one hand it means more patients can be seen but on the other the personal contact and empathy can be lost.  

Patients lying in in bed have sometimes been ignored. The consultant and the team standing around the foot of the patient’s bed discussing their cases amongst themselves. Or, once off the ward, speaking of the thyroid cancer in bed three or the colon cancer in bed two. Yet patients are people too with histories behind them and woe betide the medic, or indeed the government, who forgets that.  

With computer aided diagnosis, electronic patient records and more sophisticated investigation the patient can easily become even more remote. An object rather than a person.  

We speak today of more personalised medicine with every person having tailored treatment of the basis of whole genome sequencing and knowing each individual’s make up. But we need to be sure that this does not lead to less personalised medicine by forgetting the whole person, body mind and spirit.  

Post Covid, more consultations are done online or over the telephone -often with a doctor you do not know and have never met. Technology has tended to increase the distance between the doctor and patient. The mechanisation of scientific medicine is here to stay, but the patient may well feel that the doctor is more interested in her disease than in herself as a person. History taking and examination is less important in terms of diagnosis and remote medicine means that personal contact including examination and touch are removed.  

Touching has always been an important part of healing. Sir Peter Medawar, who won the Nobel prize for medicine sums it up well. He asks:  

‘What did doctors do with those many infections whose progress was rapid and whose outcome was usually lethal?   

He replies:  

'For one thing, they practised a little magic, dancing around the bedside, making smoke, chanting incomprehensibilities and touching the patient everywhere.? This touching was the real professional secret, never acknowledged as the central essential skill.'

Touch has been rated as the oldest and most effective act of healing.   

Touch can reduce pain, anxiety, and depression, and there are occasions when one can communicate far more through touch than in words, for there are times when no words are good enough or holy enough to minister to someone’s pain.   

Yet today touching any patient without clear permission can make people ill at ease and mistrustful and risk justified accusation. It is a tightrope many have to walk very carefully. In an age of whole-person care it is imperative that the right balance be struck. There’s an ancient story that illustrates the power of that human connection in the healing process. 

When a leper approached Jesus in desperation, Jesus did not simply offer a healing word from safe distance. he stretched out his hand and touched him. He felt deeply for lepers cut off from all human contact. He touched the untouchables.   

William Osler a Canadian physician who was one of the founding fathers of the Johns Hopkins Hospital in Baltimore, and ended up as Regius Professor of Medicine in Oxford,  said:  

“It is more important to know about the patient who has the disease than the disease that has the patient”.  

For all the advantages modern medicine has to offer, it is vital to find ways to retain that personal element of medicine. Patients are people too. 

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Mental Health
5 min read

Mental health: the art that move us from ostracism to empathy

Four current London exhibitions show the move towards compassion.

Susan is a writer specialising in visual arts and contributes to Art Quarterly, The Tablet, Church Times and Discover Britain.

A painting of a haunted looking old man dressed in an imagined military uniform.
A Man Suffering from Delusion of Military Rank.
Théodore Géricault, Public domain, via Wikimedia Commons.

Portrayals of mental health were revolutionised from the nineteenth century onwards. While previous generations had focused on the ostracism of those suffering mental illness, and the fear their condition aroused in others, modern artists began to focus on the dignity and humanity of sufferers. Four current London exhibitions show this move towards compassion. 

On display at the Courtauld’s Goya to Impressionism, Theodore Gericault’s A Man Suffering from Delusion of Military Rank, c.1819 -22, shows the artist’s sensitive response to ‘monomania’, the term coined in the early 1800s for people living with a single delusional obsession. It is thought this painting is part of a series of portraits on fixations including A Child Snatcher, A Kleptomaniac, A Woman Addicted to Gambling and A Woman Suffering from Obsessive Envy, the face of the last rendered in an unsettling green tinge. 

The circumstances surrounding the painting of the series remain mysterious. The timing coincides with Romantic painter Gericault completing his most famous work, the monumental The Raft of the Medusa, 1818-19, depicting 15 survivors of a shipwreck, who had been adrift on a makeshift raft, originally containing 147 passengers, from the French frigate Meduse. Gericault’s preparation for the canvas included visiting morgues to check on the colour of decomposing flesh and building a model of the doomed raft. His difficulties in completing the huge work, over 23 feet long, and the possibility some of his close family may have suffered from mental illness, have supported the belief Gericault painted A Man Suffering from Delusion of Military Rank, and related portraits for personal reasons, possibly out of gratitude to the physician who cared for his family. But there is now doubt if Dr Etienne-Jean Georget commissioned the painting, and whether he was chief physician at Saltpetriere asylum in Paris. 

Even if a biographical motivation for the series falls down, and there is no way of knowing if the subjects of the portraits were individuals living with mental health conditions, these portraits remain unique in early nineteenth century painting. People deemed at the very margins of society are portrayed in the same manner as the most powerful, in half-length portraits emphasising their dignity and humanity, over their social estrangement and health challenges. 

The Raft of the Medusa, Louvre, Paris. 

A painting shows a wreck of a rafter holding survivors and corpses.

Van Gogh’s mutilation of his own ear is interwoven into his biography and his art. In The Ward in the Hospital at Arles and The Courtyard of the Hospital at Arles, both 1889, the artist depicted the interior and exterior of the institution where nuns cared for him, during his mental health crisis. The paintings’ significance to his recovery is shown by Van Gogh taking them with him when he moved to another psychiatric facility 25 kilometres away at Saint-Remy-de-Provence. 

Blue is the dominant colour of The Ward, permeating the walls, the beamed ceiling, the crucifix and the door underneath it, and several patients. wear dark blue clothing, including the two nursing Sisters at the centre of the scene, whose Order of St Augustine black and white habits, have been realised in darkest blue. Van Gogh described the long ward as ‘the room of those suffering from fever’, most probably referring to patients with mental illness. The painting was reworked during the artist’s admittance at Saint-Remy-de-Provence, with the symbolic empty chair used in other works to represent him and his housemate Paul Gauguin added to the foreground, together figures gathered around a stove. The return to the painting was prompted by reading Dostoevsky’s The House of the Dead, a fictionalised account of the author’s spell in a Siberian prison, and the book’s characters may have provided the inspiration for the huddled men. 

The Courtyard of the Hospital at Arles captures the grace of the hospital’s Renaissance building, by depicting the inner courtyard from the vantage point of the first-floor gallery. From this aerial angled viewpoint, the garden’s bright flora, radiating from a central pond, spreads out in all directions. Van Gogh’s description of the scene to his sister Willemien, hints at their Bible reading, clergy childhood: ‘It is therefore a painting full of flowers and springtime greenery. Three dark and sad tree trunks however run through it like snakes…’ 

Van Gogh’s images of healing were from memory rather than life, and document his own mental health recovery:  

‘I can assure you that a few days in hospital were very interesting and one perhaps learns how to live from the sick.’ 

The Ward, Vincent van Gogh, Public domain, via Wikimedia Commons.

Van Gogh's painting of a mental ward in a hospital

Edvard Munch's Portraits, Evening 1888, shows the artist’s sister Laura, who had been hospitalised for mental illness, on and off, since adolescence. Although Laura is lost in her own world, staring fixedly ahead against a coastal landscape, the affection of the artist for the subject is palpable. Fashionably dressed in straw hat and summer dress, Laura’s dignity anchors the composition. Munch documented his own breakdown after alcohol poisoning in a portrait of Daniel Jacobson. His full-length portrayal of the doctor, arms akimbo, drew the reaction: ‘just look at the picture he has painted of me, it’s stark raving mad.’ Munch’s fascination with the doctor-patient relationship is evident in Lucien Dedichen and Jappe Nilssen, 1925-6, where Dedichen’s looming, purple presence, overshadows the diminutive, seated patient. 

Portrait, Evening. Museo Nacional Thyssen-Bornemisza, Madrid.

A painting of a  pensive young woman sitting and staring across a lawn.

Mental health and delusion form the wellspring of Grayson Perry’s Delusion’s of Grandeur. The artist responds to the Wallace’s flamboyant rococo collection in the persona of Shirley Smith, a character believing she is the rightful heir of the Wallace Collection. Eighteenth century style ceramics are decorated with outline figures resembling the Simpsons. Perry creates a family tree for Shirley from the Wallace’s miniatures, A Tree in the Landscape where every member has a condition from the American psychiatric guide Diagnostic and Statistical Manual of Mental Disorders. 

Grayson Perry, Untitled Drawing, Courtesy the artist and Victoria Miro. 

A image of a woman against a detailed red background.

In Alison Watt: From Light at Pitzhanger Manor, the artist’s still lifes of roses, fabrics and death masks responds to the collection of Regency architect Sir John Soane, and the ever-present fragility and complexity of human life and psychological flourishing. “With a rose it is impossible not to be aware of human intervention. Roses are bred, altered outside of nature and given names. In the history of painting the rose can be read as a symbol of beauty, innocence and transience, but also of decline and decay, echoing Soane’s preoccupation with themes of death and memorialisaton.” 

With the scientific and medical advances of the nineteenth century, life in all its psychological complexity, could supplant death as artists’ inexhaustible fount of inspiration. 

Le Ciel, Alison Watt.

A diseased rose.

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