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), one of the points mentioned is “the effect of dermatologic disease on morbidity and on well-being and quality of life.” In a particular respect, dermatoses place an extra burden on the patient because of the associated negative feedback visible disease carries: if somebody is embarrassed he/she may blush, and if aware that he/she was seen by others in his/her embarrassment, the blushing will deepen. The same holds for other visible stigmata. Entirely symptomless eruptions, for example, vitiligo, may in this way create an unbearable burden on the patient and make him a social outcast, especially in non-Caucasian persons. Visibility therefore adds a multiplication factor to the burden by anything displayed to the observer. On the dermatologist this latter fact places an extra responsibility vis-à-vis his or her patient. The vicious circle of the patients' psychological mechanisms must be broken and information, solace, explanation—and camouflage—must be offered. The new field of lifestyle dermatology may have a spectrum of ways at hand.
The first documented historical patient afflicted with visible morbidity on his skin, Job, became a paradigm for all related problems, between man and himself, man and other men, and man and G-d (
). The Book of Job is a core chapter of the Old Testament (Tanakh), a poetic patchwork story, most likely written during the Babylonian exile and later supplemented by additions. It was drawn up to exemplify the ways of the Lord of Israel to Jews and Gentiles, using the Aramaic and Hebrew languages (
). Throughout history this text has been used to illustrate human suffering, especially in and to the just. Illustrations of Job in his plight and misery, alone or faced by his friends and the accuser (the devil), abound in Jewish, Christian, and Islamic scriptures over the centuries, as miniatures, paintings, etchings, and sculptures. For the purpose of this article we selected a picture of Job and his friends from the 12th century (Figure 1). Job is seen in the nude, entirely afflicted with skin lesions and with a disfigured face. This is a rarity from a Riesenbibel, lit. Giant Bible, with pages more than half a meter in height. In most miniatures Job displays some ulcers or even no skin lesions at all, and often he is partly dressed. Also the additional facial disfigurement is unusual and the fact that no letters of a text surround the picture. Finally, the sheer size of the miniature is enormous: 22×31 cm, equaling about 9×12 in. It originated in the Salzburg area in the 1100s and since about that time was kept in the monastery of Admont in rural Styria, Austria (founded 1074). It carried the inventory manuscript number of 4 in a library holding 200,000 volumes today, by itself another token of itsage and importance. In 1937, in a time of need and economic crisis, the Giant Bible was sold to the Austrian National Library where it is kept today and who have the copyright.
Since the dawn of times nobody under the sun can escape pain and suffering. At this point at the latest, pride comes to a halt and philosophy sets in, “Hitherto shalt thou come; but no further” (ad-po havo w-lo thosif, Job 38:11), and the “why” and “why now,”“why me,” is posed; openly, secretly; by day and by night. World literature is full of examples and the Book of Job is one of the oldest available sources and a poetic one.
Job's isolation and “treatment” was not just physiology or pathology. Pain and suffering was seen as burden but at the same time as a purifying process that nevertheless confers hope. Job is strong because he believes there is the light of faith to help him go through it. The religious concept of suffering and healing encompasses the wholeness of life and death, exemplified in the mode of expecting salvation at the end of life.
Whom do we believe today? Where are our hopes? Whom do we turn to when everything that medicine can do is done and we are still suffering. Who will listen and who will hear us, as Job was heard. Is science offering all the solace we need. Are we prepared to overcome and endure the burden? Is our isolation from the community different from Job's or is it even worse (and we have no hope no light no solace).
The Art of Healing: The Space Between Objective and Subjective
He found me very well; for me, I was still feeling sick. Mdela Porte, in a letter to Dr S. Tissot, May 27, 1781, original in French: “Il me trouva très bien; pour moi, je me sentais toujours malade.”(
Burden of skin disease is our heading. All three words should be addressed.
○ Disease is a pathologic process followed by clinical, psychological, social, economic, and other sequelae. Disease is a burden inflicted upon man. Suffering is an inevitable consequence of falling ill; a complex phenomenon and suffering means passion, derived from the Latin deponens verb, patior, -iri, to feel pain and discomfort. Medicine's role is to alleviate the latter.
○ Treatment requires knowledge of the character of the diseases and means to tackle with it. But healing after all, still is an art.
○ Skin disease is special for one single important reason: visibility, a feature not necessarily paralleling its severity and creating problems of its own.
Diseases and sickness will stay with us, for good. There is no way to credibly assure ourselves or our patients that medicine and research will conquer the threat of falling seriously ill. AIDS, toxic shock syndrome, Legionnaires' disease, the ubiquitous papilloma viruses, toxic epidermal necrolysis, SARS, and all the melanomas and lymphomas—to name but a few of the dangerous threats.
Altogether, to focus on the burden of skin disease in this particular sense of being not only a disease, but also being visible, makes all manifestations on the surface a special burden (and causes additional suffering) to the bearer. Job was smitten with lesions from head to toe (Job 2:7). The disease was sudden, widespread, itchy, and disfiguring (Job2:8–12). His friends did not recognize him any more. Interestingly, the word for itch and scratching, l-hithgared, one of the specific symptoms occurring only in skin, is a so-called hapax legomenon, that is, a word occurring only once in a given text (here the Old Testament). We have dealt with this topic years ago (
), which alludes to the Biblical figure's ailments and suffering.
The perspectives of philosophy, the principles of therapy, and the art of healing remain of overall importance, as ever. And is this a new aspect? No, not whatsoever! “First therefore, amongst so many great foundations of colleges in Europe, I find it strange that they are all dedicated to professions, and none left free to arts and sciences at large,” wrote Francis Bacon (1561–1626) and, after alluding to the ancient fable ofMenenius Agrippa and to universality (Livy II:32, 8–12) continued, “so if any man think philosophy and universality to be idle studies, he doth not consider that all professions are from thence served and supplied” (
The humanities of which philosophy is the essence equip us for the personal contact with patients, warrant the intimate spiritual exchange of information and counseling and the building of mutual trust, which is the most time-consuming effort in our stratagems. We must be able to offer examples, from history, from poetry, from theater, or from proverbs; confer solace; or allude to the ways of Heaven or the wording of the Scriptures. We must point out that doctors and medicine cannot replace the Almighty. And all that despite the rapid progress of biotechnology. This role of philosophy has been dangerously diminished in recent decades and has been replaced by computer data. Patients' brains operate with figures and values beyond their comprehension, unable by themselves to offer guidance. Here modern medicine is called upon to step in and make every effort to return to the age-proven explanations and paradigms of literature, belief, and human touch. But it is not enough. We need the humanities in medical education as a mandatory constituent. We need to teach (and to learn) how to approach our patients and how to present patients not only with laboratory data, but also with solace, hope, and belief. In line with the current medical humanities movement, the engagement of medical students with history, art, and literature will enable them to overcome the gap between patient and experimental results, a must for winning trust of the patient. The patients' discourse should be properly promoted and legitimized. In contrast, philosophy and familiarity with human nature is necessary toconvince patients that not everything is possible, not all diseases can be prevented, and not all may be cured.
We started our commentary with Francis Bacon. We close with some of his visions of the sciences and the future outlined in his treatise The New Atlantis, an Utopian novel. On the imaginary island of Bensalem, Bacon located a society which housed an universal research institution, Salomon's House or the College of the Six Days' Work (
), where all thinkable ways of research were conducted and the results of which exchanged and collected with and from all the world, reserving even the right of scientists to withhold results of their research from the state if deemed necessary because of destructive potential. “The prolongation of life, the restitution of youth, the retardation of age, the curing of diseases counted incurable, the mitigation of pain, … the altering of complexions, the increasing and exalting of the intellectual parts, the drawing of new foods out of substances not now in use,” were some of the goals, and it was declared that the “End of our Foundation is the knowledge of Causes and secret motions of things; and the enlarging of the bounds of Human Empire, to the effecting of all things possible” (
). No modest goal as it were 400 years ago and a sign of optimism no smaller than ours today. Sure, we made some progress since but no “end” is in sight anywhere. We need the humanities, philosophy, belief, and the art of healing, and we should be humble.
References
Chren M.M.
Weinstock M.A.
Call for papers—Focus issue: Burden of skin disease.
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