Brian Hurwitz and Magdalena Szpilman reflect on the seen and unseen dimensions of translation in the medical medical humanities. While Hurwitz examines the power of pretence in Classical medicine, Szpilman highlights the potency of the visual scream in 1980s Poland and today.
Understanding Graeco-Roman Treatments by Pretence: A Translational Strategy
Accounts of Graeco-Roman mock treatments juxtapose the display of sleights of hand to readers and the concealment of these trick manoeuvres from patients. The Hippocratic treatise, Epidemics 6 provides a stark example of such dupery: “If the ear aches, wrap wool around your fingers, pour on warm oil, then put the wool in the palm of the hand and put it over the ear so that something will seem to him to come out. Then throw it in the fire. A deception” (Hippocrates of Cos 1994, 242–243).
This enactive description draws attention to the interplay of power, dependence and gullibility in the doctor patient relationships of antiquity and hints that, in certain circumstances, patients could reliably be expected to misread the intentions and gestures of their doctors (Hurwitz, forthcoming). To contemporary eyes, the manoeuvre described in Epidemics 6.5.7 resembles an enacted placebo, a dummy procedure indistinguishable from an authentic treatment (Shapiro 1964; King 1998; Hutchinson and Moerman 2018).
The enactment in Epidemics 6.5.7 runs counter to Hippocratic commitments to treatments that intervene in bodily processes believed to cause disease, and has provoked debate among classicists concerning its lineage and place in Hippocratic thought and practice (Jouanna 2012; Lloyd 2000). While a medical humanities grasp of the scenario needs to take account of exegetical and hermeneutical issues, it should also attempt to understand medical encounters from patients’ points of view. One way of doing this is to ask what would happen were the patient to become aware of how a felt discharge from their ear had been engendered and choreographed? If the patient became aware of the manoeuvre’s purpose and technique, would she feel shocked, let down, affronted, or angry? Could such awareness provoke laughter, ridicule and/or denunciation of the doctor?
Posing such questions shifts attention away from the perspective of the narrator – who is almost coincident with a Hippocratic physician – to that of the patient and how make believe can be engendered by physical manoeuvres. Attempts at answering such experiential and epistemic questions could draw on the reactions of other patients in similar circumstances, if available (Thumiger 2018), otherwise they depend on hypothetical, speculative or fictive processes (Green 2017). And responses ascertained only through surmise run the risk of projecting contemporary patterns of thinking and emotions on to the patient (Thumiger 2016).
However, thinking through the reactions of a generic patient can be perspective shifting. Galen, a Graeco-Roman physician and prolific commentator on Hippocratic texts, who practised in Rome in the second century CE, recounts that “a doctor who was summoned to treat a woman who thought she had swallowed a snake (. . .) gave her an emetic drug and then, unbeknownst to her, dropped a dead snake into the basin into which she had vomited and thereby rid her of this delusion” (Vagelpohl and Swain 2016, 2: 259). How might this patient react to learning of the provenance of the snake in her vomit? The knowledge would rupture her internalised understanding of events consequent on treatment, at the point between her seeing the snake in the vomit and closure of a sequence of events given by: “snake in my innards,” “I took the emetic,” “snake in my vomit,” “I vomited up the snake.”
Learning how the snake arrived in the vomit would radically alter her understanding of the swallowed snake’s whereabouts, which would switch closure of the sequence to “snake still inside me.” This would leave the woman no better off than where she started. It could actually leave her worse off, because what she believed she’d accomplished through her own visceral agency with the help of the emetic, she would realise was only an illusion, perpetrated on her by her doctor. Causally, the emetic’s role, as not only an unnecessary treatment but one that was entirely beside the point, would be thrown into relief, which would prevent interpretation of the of the snake’s presence in the woman’s vomit as evidence of her excretion of it. In short, the ordering in her treatment would unravel, which would likely lead to a return of her symptoms.
To modern sensibilities, accounts of medical pretences can appear somewhat ludicrous, pantomimic parodies of authentic medical practices, but the ground plan of each enacts a catharsis – a therapeutic process embedded in Graeco-Roman thought and culture – which leads to expulsion of the causes of diseases, such as corrupted humours and foreign bodies, in the form of a discharge, excretion or extraction (Parker 1983; von Staden 2007). Though outlier approaches to medical therapies, the credibility of mock treatments would have rested on fluent imitations of established therapeutic formulas, lending them typicality, if not a veneer of normality (Hurwitz, forthcoming).
Counterfactual reasoning offers a hypothetical way of translating and transvaluing accounts ordered from medical perspectives, by introducing the possible points of view of patients (Wenzlhuemer 2009). Though it may appear to provide a route to getting closer to their thoughts, emotions and reactions, it cannot get inside the mentalities of individuals. However, by creating inlets into accounts of such treatments, this form of reasoning enables contours of plausible, contrastive perspectives to be foreshadowed, from which new bearings on the interplay of patients’ understandings of their ailments and medical intentions and enactments come into focus.
The Physician’s Visual Scream
This picture of Prof. Zbigniew Religa and his team after their first successful heart transplant speaks more than a thousand words.
Zbigniew Religa was a Polish cardiac surgeon who was the first in the country to perform a successful heart transplant, on November 5, 1985. Such a procedure was a breakthrough and a huge achievement in transplantology – and all the more in the makeshift and archaic reality of 1980s Communist Poland, its eighteen months of martial law, food stamps and almost empty grocery store shelves; ration stamps without which you couldn’t even buy a pair of shoes. In such a crude reality, a young, ambitious cardiac surgeon decided to build his cardiosurgical clinic in Zabrze and start performing heart transplants.
The image shows Religa still in his scrubs, mask and gloves on, watching over the unconscious patient attached to about a million tubes, his life is in Religa’s hands – and it will be for quite some time. We see the professor’s pose, emanating exhaustion. His eyes, the only visible part of his face, remain alert and attentive after several long hours of surgery.
But the background of the picture speaks even louder. Behind the foregrounded figures, we see Prof. Religa’s exhausted assistant, sleeping in the corner of the operating room. A young surgeon who has lost his battle with sleep, the adrenaline boost wearing off. Him falling asleep is not a defeat, however, but a silent scream. Long working hours at full capacity of body and mind have taken their toll. Here, the body was the first to scream for a break, to seek an imperative rest. When the scream of the body goes unheard, the mind may give up, leading to complete burnout (Carroll 2018).
No words but a whole story.
How is this picture a silent scream of a physician?
It summarizes the whole series of events which lead to that particular moment in time and this exceptional picture, named by National Geographic one of the hundred best pictures in history (Rare Historical Photos 2021). The photo captures an outdated operating room, typical of the failing Polish healthcare system of the 1980s. It is also a record of a moment of enormous success, the price of which was a million moments of frustration and disappointment. How could Religa even think of building an advanced cardiosurgical clinic in a country in which you could hardly obtain hospital beds, let alone high-tech surgical equipment? Nonetheless, it seems that his biggest opponent was the commonly held beliefs of the public, as depicted in Krzysztof Rak’s 2014 film, Bogowie (Gods), based on the life and career of Prof. Zbigniew Religa:
Wife (of the first transplant patient): Won’t he be different with this new heart?
Zembala: (. . .) he will be healthier (. . .).
Wife: I’m afraid (. . .) he won’t recognize me or stop loving me.
Zembala: (. . .) nowadays, transplantation is routine.
Wife: But the feelings are in the heart.
Zembala: I believe that they are in the head.
Wife: What about love?
Zembala: You are a believer, right? (. . .) We fix bodies only; you are talking about the soul. (. . .). The heart is a pump. Amazing, but only a pump.Palkowski 2014. Author’s translation.
Indeed, when Religa first suggests starting a heart transplant program to his mentor, Prof. Wacław Sitkowski, he is told that cutting out the beating heart from a human being is morally dubious.
The vast majority of Polish physicians of the 1980s opposed the idea of heart transplants, not for substantive reasons but for moral ones. It was difficult for them to understand that a beating heart was not what made a human being alive. The heart was an incontestable symbol of life and humanity. “You know that the heart in our country is a relic,” says Sitkowski, in the film. “But we both know that it’s a muscle,” replies Religa (Palkowski 2014. Author’s translation).
Physicians often need to face common beliefs, superstitions, misconceptions, but what might be even more difficult is the powerlessness they experience in many instances. The limitations of medicine impose humbleness. “Patients and their loved ones swim together with physicians in a sea of feelings. Each needs to keep an eye on a neutral shore where flags are planted to warn of perilous emotional currents,” according to Jerome Groopman (2008, 58).
One day I was in the office with an ENT surgeon. He had just come in with a file of medical records of a patient whose husband was waiting outside the office. I kept quiet and watched the surgeon’s face becoming more and more grim. He read through the records and started to type on his computer’s keyboard. Typing angrily, as if he wanted the keyboard to absorb all of his frustration and helplessness. Every potential solution seemed futile, surgery or no surgery. Facing the patient’s disappointment. Facing his own limits, the limits of medicine, the limits of surgery.
Physicians are often deprived of their humanity when expected to move on regardless of the emotional burden of the situation. “Above all, I must not play at God,” says the Hippocratic Oath (Lasagna 1964, n. p.), yet this is still who physicians are expected to be – they are expected to act as if their healing powers were limitless. The human face of a physician expressed in gestures, body language, gaze – this is what I witness in my line of work as a medical interpreter. I can sometimes see the visual scream of those gestures, but the question remains of how to make it heard.
About the authors
Brian Hurwitz trained as a general practitioner and worked in an inner London practice for 30 years. His research interests include narrative studies in relation to medical practice, ethics, law and the logic and literary form of case reports and anecdotes. In 2008, he co-founded and co-directed the Centre for the Humanities and Health at King’s College London, a multidisciplinary research unit offering master’s, PhD and postdoctoral training for humanities scholars, bioscientists and health professionals.
Magdalena Szpilman was awarded her PhD by the Artes Liberales Faculty of the University of Warsaw for a dissertation entitled Doctor-Patient Communication as a Symptom of Damaged Humanity: A Point of Departure for Doctor-Oriented Narrative Medicine, which analyses the image of a physician in literature and film as well as medical communication and its impact on physicians’ wellbeing. For 15 years she has been working as a translator and an interpreter and, since 2018, as a medical interpreter in London. Her passion is being a vital facilitator of medical communication.
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*Photograph originally published in National Geographic, having been voted picture of the year 1987, and sourced from Rare Historical Photos. Photograph reproduced for non-commercial, academic purposes. Not for commercial reproduction.