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Page 1: The relationship between the arts and medicine · Cassell (in his classic work, The Place of the Humanities in Medicine7) that the humanities have always been part of medicine

The relationship between the arts andmedicineP Anne Scott University of Stirling

AbstractIn this paper some of the intriguing links between thearts and medicine are explored. As a starting point Iconsider the notion of whole person understanding asarticulated by Downie in an article entitled“Literature and medicine”, published in the Journalof Medical Ethics in 1991.1 I suggest that the artscan contribute to whole person understanding in atleast three ways. The arts may stimulate: (a) insightinto common patterns of response (shared humanexperiences); (b) insight into individual diVerence oruniqueness, and (c) enrichment of the language andthought of the practitioner.

Much literature which explores the relationshipbetween the arts and medicine tends to focus on thevalue of the arts in increasing our understanding ofthe particular individual, “whole personunderstanding” in Downie’s sense of the word. This,however, assumes that “whole person understanding”should focus only on the unique in the individual.This view is, I think, mistaken. If we take the notionof “whole person” seriously then we must recognisethat which is unique but also that which humansmay share. I suggest that this broader view is of thegreatest importance in any consideration of therelationship between the arts and medicine.(J Med Ethics: Medical Humanities 2000;26:3–8)Keywords: Arts; literature; medicine; humane practice

IntroductionMy initial interest in the links between the arts andmedicine derived from an examination of variousapproaches to teaching ethics to undergraduatenursing and medical students. While examiningthe literature on the teaching of health care ethics,I began to discover a diVerence in the pattern ofapproach between the United Kingdom (UK) andthe United States of America(USA). Within theUK when ethics was taught in nursing or medicalprogrammes a professional philosopher and/or ahospital chaplain was engaged to teach a specifiednumber of sessions, usually on topics such asabortion, assisted reproduction, euthanasia andthe ethics of transplants. Such programmes werebecoming increasingly sophisticated and mightalso include some sessions on Kantian duty-based

moral theory and Utilitarianism. In the late 1980swhen Kenneth Boyd was completing The PondReport,2 all ethics teaching in medical curricula inthe UK was on an elective basis. The UnitedKingdom Central Council for Nursing, Mid-wifery and Health Visiting (UKCC) had gonemuch further by insisting that in the developmentof new nursing and midwifery programmes a cer-tain number of contact hours must be spent onprofessional, ethical and legal issues in nursing.3

However, in the USA increasingly the teachingof ethics, particularly to medical students, tendedto be embedded in more broad-based medicalhumanities programmes which included history,law, and the arts (with a particular focus on litera-ture) as well as philosophical ethics.

Why turn to the arts in medical or nursing edu-cation? Surely there is already enough in theserespective curricula without demanding evenmore content be added and absorbed? Perhaps so.Indeed, when I began to use literature and film inmy teaching of health care ethics, initially I did itfor the simple reason that this seemed to be a moreeVective way to help students identify andconsider ethical issues.

In essence I used this material as part of a con-sciousness raising activity. Use of literature or filmbrought certain issues into sharp focus, makingthem more alive for students. Students werepresented with characters, some of whom theyimmediately identified with, such as the studentnurse portrayed near the beginning of Whose Lifeis it Anyway? 4 Alternatively they gained insightinto the perspective, pain and frustration of acharacter like Ken Harrison, who in the normalcourse of events could easily be labelled a trouble-some, uncooperative patient whom staV mightendeavour to avoid. The arts—drama, short story,or a poem—might be used, in Alan Bennett’spoignant phrase, to highlight the “casual crueltiesroutine inflicts”.5

In her book Heroism as a Nursing Value6 VassilikiLanara draws attention to the influence whichclassical Greek Literature had on the developmentof nursing and particularly on the development ofnursing’s focus on holistic patient care. From my

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first contact with nursing I was brought up on adiet which emphasised (a) the vocational influ-ence of the religious orders with its elevation ofservice and obedience, and (b) the army influ-ence, again focusing on service, obedience andadding discipline. In 20th century versions ofnursing history the most prominent character inthe development of nursing in Ireland and the UKis Florence Nightingale. Thus Lanara’s emphasison the impact of early Greek literature providedan entirely new insight into nursing’s historicalevolution.

Lanara’s argument supports the claim of EricCassell (in his classic work, The Place of theHumanities in Medicine7) that the humanities havealways been part of medicine. Cassell goes on tostate:

“They (the humanities) will play an increasinglyimportant, necessary and specific role as medicineevolves beyond its present romance with technol-ogy towards a more balanced view of the originand treatment of illness.”8

Perhaps Cassell is right at least to the extent thatthe humanities will be increasingly important formedical and health care education. There is agrowing interest in this area around the UK. Thisis evidenced for example in the development ofthe Centre for the Arts and Humanities in Healthand Medicine at the University of Durham. Newmedical curricula appear to leave open the possi-bility of a strong humanities influence in under-graduate medical education.9 There are also anumber of nursing programmes that includeelements of the humanities as part of the corecurriculum.10

Why the humanities?However, it does need to be asked why we shouldapplaud a swing to increased humanities input inhealth professionals’ education. Perhaps we maytake as a starting point for this discussion a paperby Downie entitled “Literature and medicine”.1 Inthis article Professor Downie suggests that thereare four types of connection between literatureand medicine. One type of connection benefits lit-erature; another provides entertainment value; athird type potentially provides insight to the vari-ous professions regarding how they stand in thepublic perception; and finally a fourth type can behelpful to the practice of medicine (and, I suggest,nursing) by providing glimpses of what Downieterms “whole person understanding”.

Downie points out that many authors andpoets, indeed some who have made significantcontributions, were also medical doctors, forexample Dante and Chekhov. A number of these

have brought to their literary works the insightswhich the practice of medicine provides. Illness,disease and the medical context also provide themixture of emotion, drama, irony, humour, bloodand gore which is grist to the mill of the novel,play, film and indeed TV serial. They are alsomeat and drink for the artist.

Public stereotypeIt is within a similar context that insight may begained in terms of the public stereotype andstanding of various professional groups. Indeedthere are a number of glimpses of diVerentapproaches to the practitioner-patient relation-ship in films such as Passionfish11 and Whose Life isit Anyway? 4 I have found that the presentation ofclips from these two films generates considerablymore discussion, and seems to leave a muchstronger impression, than simply suggesting thatstudents read and discuss the models ofprofessional-patient relationships described inSzasz and Hollander12 Veatch13 or Morse.14 Suchinsights into particular approaches to that rela-tionship are probably of general interest to profes-sional bodies; beyond this they are of direct inter-est to the neophyte practitioner attempting to finduseful role models for practice.

It is the fourth type of connection between thearts and medicine, discussed by Downie,1 whichinterests me in particular. Downie argues that it isthis connection which illuminates what he refersto as the “whole person approach” to medicalpractice. He contrasts the whole person approachwith the scientific approach to medicine. The lat-ter, he suggests, sees medicine’s concerns asfocused on general patterns, order and uniformity.

Downie goes on to suggest that one of the rec-ognised strengths of medicine is its science orien-tation: the attempt to move between observationof patterns, hypothesis testing and theory (ormodel) development regarding the causes andpotential treatments for disease. The primaryfocus is on the body, body systems and generalpatterns of disease and response. This focus isuseful, necessary, and has brought importantadvances in diagnosis and in chemotherapeuticand surgical intervention. However, Downieclaims that this approach, while valid and clearlyuseful, is insuYcient. While the focus is on thegeneral pattern, the specific need and particularityof the individual patient is in constant danger ofbeing missed. Greenhaugh and Hurwitz15 providea number of useful examples of this supposedlyreductionist type of practice. (There is aninteresting debate to be undertaken regarding theaccuracy of describing medical science as reduc-tionist. It might be argued to the contrary that

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medical research is in fact largely systems-basedand therefore holist in the classic social sciencesense of this term.16 However, this debate is foranother day.)

For the purposes of our present discussion letus grant that Downie is correct in his claim, thatbecause of the focus on general patterns of diseaseand response in medical science and practice, thespecific need and particularity of the individualpatient is in constant danger of being missed.Downie argues that “whole person understand-ing” requires two things: (i) knowledge of the per-son’s biography (or extended case history), and(ii) some imaginative sympathy with that biogra-phy.

He argues that the disciplines which developand extend whole person understanding are “his-tory and literature in all its aspects... .Thehumanities rather than the social sciences, areconcerned with the particularity of situations andwith their meaning and that concern is the way towhole person understanding.”17

Whole person understandingIt seems apposite at this point to consider why onewould want “whole person understanding” inmedicine or nursing. I suggest that nurses havenever found dealing only with general patterns ofresponse as easy as Downie seems to suggest—asit were in some sense divorcing the mind from thebody and dealing only with the physical. Despiteour current literature’s many references to the illsof the task-allocation method of organisingnursing work,18 the notion of providing comfortand care has permeated the nursing approach—atleast in terms of rhetoric and education. Thenotion of comfort and care has traditionally beenarticulated in terms that made the psychosocialand spiritual dimension of patient care explicit.For example, in the development of nursingresearch over the past 20 years, one sees a clearshift in the USA, Australia, and the UK. This shiftis away from the traditional scientific researchmethodology, found in medicine and socialscience, to more narrative-based methodologiessuch as grounded theory,19 phenomenology20 andhermeneutics.21 The move indicates clear at-tempts by nurse researchers and scholars torecognise and learn from individual patients,regarding their particular experience and percep-tions of illness, disease and treatment.

However, why is this particularisation of the ill-ness experience thought necessary in the educa-tion of health care practitioners? The answer is, inmany ways, quite straightforward. Practitionersare daily confronted with complex individualswho may be experiencing significant anxiety, vul-

nerability and fear, because of some real or imag-ined disease or illness. These individuals normallypresent to the doctor or the nurse in the belief thatthe professional can do something to help to makethe individuals’ experience or indeed their livesbetter. Gordon Allport argued22 that each personis like every other person, like some other people,like no other person. Each of us contains within usboth general patterns and the particular, thatwhich is peculiar to me and my context.

Contribution of the artsThe arts, particularly literature, may contributehere in at least three separate, but inter-linked,ways. The arts may stimulate: (a) insight intocommon patterns of response (common or sharedhuman experience); (b) insight into individualdiVerence or uniqueness, and/or (c) enrichment oflanguage and thought.

(A) INSIGHT INTO COMMON PATTERNS OF RESPONSE

A work of art potentially provides one withsuYcient imaginative insight to recognise generalpatterns of emotion and human response, whichare not reducible to purely physical, biologicalmechanisms. Therefore while literature providesus with rich characterisation which can providerole models, it also appeals to something akin tothe Jungian collective unconscious, to the arche-typal stories of human existence. As Gardnerargues: “Art rediscovers, generation by genera-tion, what is necessary to humanness”.23

Therefore it is not simply the case that science,medical science included, forces one to focus ongeneral patterns of disease, behaviours andresponse, while the arts force us to focus on theparticular. Literature also includes some image ofthe general, some often strong image of that whichwe share as human beings; some insight into thehuman condition as such—otherwise one wouldhave diYculty relating to much literature andworks of art. I believe I disagree with Downie onthis last point. Downie’s focus is exclusively on theparticular, which he argues gives “whole personunderstanding”. He suggests that to argue thatliterature can do more, within this context, ismerely to fall into the danger of being accused ofsuggesting that the arts do badly what sciencedoes well. Yet he does in passing state the follow-ing: “Whereas science, including social science,proceeds by induction from specific instances togeneralised (often idealised) patterns, literatureexplores unique situations which may includeconflict of values. It thereby enables us to acquireinsights into universal human predicaments.”17

I am challenged at this point to consider thediVerence between Downie’s specific instances of

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inductive thought and the unique situations whichhe suggests leads to insight into aspects of“universal human predicaments”. Are explorationand insight solely confined to the arts, and isinduction the preserve of science? Scientists suchas Ian Fleming or the astronomer Jocelyn Bell maywell recognise more of the artistic in scientific dis-covery than Downie’s analysis would suggest. Ithink perhaps a more accurate suggestion is thatthe arts do diVerently that which science some-times does well. If one considers medical scienceor human sciences in general—psychology, sociol-ogy and so forth—all of these sciences areconcerned with human behaviour and/or experi-ence. Is this a subject matter diVerent from thatwhich concerns the artist? The contrasting notionthat the arts do badly that which science does wellwould seem to be based on a mistaken assumptionthat what is of interest regarding human percep-tion, emotion, awareness and response is entirelyindividualistic, utterly unique and particular.However, it may be useful to use a piece of litera-ture to challenge this stance. Reflect for a momenton one’s response to the following passage fromJohn Bayley’s account of trying to cope with hiswife, the late Iris Murdoch, while she suVeredAlzheimer’s disease.

“The agony of travel nowadays. ... I am fumblingin my wallet, checking the tickets. They are hardto separate, and after shuZing them wildly againand again I can still find only one return ticket.The whole system is absurd; why must they giveus four separate tickets when two would do? It’sdefinitely not there. I rush to the ticket oYce,where a queue is made to unwind in serpentinefashion between rope barriers. My ticket man hasdrawn his little curtain and gone oV. Thecustomer at the other guichet seemed to want around the world ticket, and to be in no hurryabout getting it. He and the ticket clerk canvassthe possibilities in leisurely fashion. Iris clutchesme anxiously, urging us to run to a train which hasjust come in, the wrong train I hope. At last theticket man is free. I produce the receipt and thedelinquent tickets. No, he can do nothing—itwasn’t his sale. I turn away in despair. Why can’twe just go home?

“Iris has not understood the problem and keepsurging me towards the wrong train. ...

“On the train I keep counting the tickets. Theelderly couple opposite look sympathetically atIris. I am clearly the one who’s become a problem.

“Utterly exhausted and drenched in sweat.Vague heart sensations too. And the whole thingso trivial.”24

Personally this passage stimulates a vivid entericsympathy based on memories of similar personalstruggles to retain control in public—amidst tod-dler, baby, buggy, and bags in busy train andunderground stations, with awkward narrowturnstiles, jostling crowds, bewildered childrenand personal isolation. Neither experience, Bay-ley’s nor mine, is entirely unique; each is at leastpartially an image of a common human sense ofpersonal isolation and powerlessness.

(B) INSIGHT INTO INDIVIDUAL DIFFERENCE/UNIQUENESS

The second way in which the arts may contributeis by providing detailed insight into the lives andconcerns of others. Thus exposure to the arts mayhelp produce a tolerance for ambiguity andindividual diVerence.

Downie suggests that:

“We learn from literature by imaginative identifi-cation with the situations or characters inliterature, and by having our imaginationsstretched through being made to enter into unfa-miliar situations or to see points of view other thanour own. Learning of this kind is generative of adeep understanding which is essential to humanedoctoring.”25

Why then is this deeper understanding essential tohumane practice? I have argued elsewhere26 thatthe answer to this question is connected to issuesof role enactment and moral strategy. Imaginativeidentification or, as I term it, activity of the moralimagination is essential to good health care prac-tice. It is activity of the moral imagination thatenables the practitioner to connect with a patientat the level of human understanding and compas-sion. This understanding and compassion is anecessary element in humane nursing or medicalpractice.

An important relationship between art andnursing or medicine is therefore one that enablesthe moral imagination of the practitioner to bestimulated and developed in such a manner thatsensitive, compassionate, constructive care is thelikely result. Alzheimer’s disease or herpes en-cephalitis are clear examples of the humanly dev-astating conditions the diagnosis and treatment ofwhich highlight the importance of rigorous scien-tific investigation. Such investigation seems fun-damental to any attempt to find a treatment for(or means of preventing) the human misery andloss wrought by these conditions which attack ahuman life and produce physical evidence ofdestruction and atrophy in the cerebral cortex.How this brain destruction is connected with thechanges of human personality and intellect is little

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understood, except we know that human memoryis crucially involved. How these conditions areexperienced by suVerers is also little understood,though there is mounting evidence of the distress,fear and anxiety which may exist in both suVerersand their loved ones.

“There are so many doubts and illusions and con-cealments in any close relationship. Even in ourpresent situation they can come as an unexpectedshock. Her tears sometimes seem to signify awhole inner world which Iris is determined tokeep from me and shield me from. There is some-thing ghastly in the feeling of relief that this can’tbe so: yet the illusion of such an inner world stillthere—if it is an illusion—can’t help hauntingme.”27

Bayley goes on aptly to describe the problem formedicine as science and art:

“Showing me a tracing from the most elaborate ofthe brain scans Iris underwent a year or so ago, thedoctor indicated the area of atrophy at the top.The doctors were pleased by the clearness of theindication. I thought then—the old foolish idea ofthe amazon—that her brainworld had lost itsunknown mysteries, all the hidden life that hadgone on in it. It had been there, physically andgeographically there. And now it had proved to beempty. The grey substance that sustained its mys-teries had ceased to function, whatever a ‘func-tion’, in there, can possibly mean.“Twice Iris had said to Peter Conradi that shefeels now that she is ‘sailing into darkness’... Itseems to convey a terrible lucidity about what wasgoing on. But can one be conscious in such a waywithout possessing the consciousness that canproduce such language? If consciousness can goon producing such words, why not more, equallylucid?

“Were I an expert on the brain I should find ithard to believe in such flashes of lucidityrevealing, as it were, a whole silent but consciousand watching world. It would be as if—to use aclumsy analogy from my hidden city in thejungle—a flash of lightning were to reveal itsexistence, and then the explorers found that itdidn’t exist after all.

“The words which Iris used with such natural-ness and brilliance cannot be stacked theresilently, sending out an occasional signal. Or canthey?”28

Medicine as scientific practice needs to seekunderstanding of the degenerative, destructivephysiological processes at work, in order to try toprevent, ameliorate or relieve the symptoms.Medicine as art needs to recognise the human

being who is experiencing the symptoms, whichparticular symptoms the individual is experienc-ing and what that experience is like for thisparticular individual, in order to ensure thatprescription is accurate, acceptable and likely tobe complied with.

(C) THOUGHT AND LANGUAGE

A further aspect of the contribution that the arts,particularly literature, makes to health carepractice is that literature enriches the languageand thus the thought processes of practitioners; ina manner which provides a wealth of concepts andideas with which to think about and conceptualisepatient care. This is in fact illustrated in the shortpassage quoted above from Bayley’s memoir toIris Murdoch—for example the image of “sailinginto darkness”. This notion of the importance oflanguage and the connections between thelanguage we use and the manner in which wethink has long occupied scholars in a number ofdisciplines from cognitive developmental psychol-ogy to moral philosophy.

In the area of moral philosophy, the late IrisMurdoch herself29 and the philosopher CoraDiamond30 have, among others, argued that we aresuVering from a vocabulary so reduced in the rel-evant concepts that it cannot support appropriatediscussion of the moral problems and crises whichconfront human beings.

Having a suYciently rich vocabulary to supporta language of patient care is, I believe, profoundlyimportant. This is because of the as yet poorlyunderstood connection between thought and lan-guage. That thought and language are connectedis undeniable. How that connection works isanother question. As the Russian psychologistVygotsky states: “Thought undergoes manychanges as it turns into speech. It does not merelyfind expression in speech; it finds reality andform.”31

In a similar vein the philosopher of educationP H Hirst reminds us: “In so far then as we canmeaningfully be said to think in anything—wethink in words”.32 We need many words to thinkbeyond demyelination or dysfunctional neuro-transmitters to begin to appreciate the humanbeing, experience and triumphs of our patients.

In terms of patient care I suggest that one of themost useful assignments to set students who havejust covered the pathophysiology of a chronicdebilitating illness is to read Kafka’sMetamorphosis,33 or, for the student of depressiveillness, Janice Galloway’s The Trick is to KeepBreathing.34

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ConclusionThere are numerous works of literature whichprovide rich characterisation and role models asfood for the spirit, and stimulus to the moralimagination. There are also numerous workswhich provide, sometimes ironically, insight intothe practitioner-patient relationship and indeedinto the human condition. Good literature willalso enrich our language with words, concepts andvisions of human existence. This I believesummarises the relationship between the arts andmedicine.

“True art is moral: it seeks to improve life and notdebase it. It seeks to hold oV, at least for a while,the twilight of the gods and us!”35

Is this not also the goal of nursing and medicine?M Therese Southgate—physician and former

deputy editor of the Journal of the American Medi-cal Association may usefully have the final word:

“Medicine and art have a common goal: to com-plete what nature cannot bring to a finish ... toreach the ideal ... to heal creation. This is done bypaying attention. The physician attends thepatient; the artist attends nature ... . If we areattentive in looking, in listening and in waiting,then sooner or later something in the depths ofourselves will respond. Art, like medicine, is notan arrival; it’s a search. This is why, perhaps, wecall medicine itself an art.”36

P Anne Scott,RGN,BA(Hons),MSc,PhD, is SeniorLecturer, Department of Nursing and Midwifery,University of Stirling, Stirling FK9 4LA.

References1 Downie RS. Literature and medicine. Journal of Medical Ethics

1991;17:93-6, 98.2 Boyd KM, ed. The Pond Report. Report of a working party on the

teaching of medical ethics. London: IME Publications, 1987.3 United Kingdom Central Committee for Nursing and Health

Visiting. Project 2000: a new preparation for nursing, midwiferyand health visiting. London: UKCC, 1986.

4 Whose life is it anyway? A John Badham Film, based on the stageplay, Whose life is it anyway? by Brian Clark. Los Angeles:MGM production, 1989.

5 Bennett A. Untold stories London Review of Books 1999;21,19:11–16.

6 Lanara VA. Heroism as a nursing value: a philosophical perspective[2nd ed]. Athens: G Paponikolaon SA, 1996.

7 Cassell EJ. The place of the humanities in medicine. Hasting-on-Hudson, New York: The Hastings Centre, 1984.

8 See reference 7:167.9 General Medical Council. Tomorrows’s doctors—

recommendations on undergraduate medical education. London:General Medical Council, 1993.

10 Darbyshire P. Understanding caring through arts andhumanities: a medical/nursing humanities approach to promot-ing alternative experiences of thinking and learning. Journal ofAdvanced Nursing 1994;19:856-63.

11 Passionfish. A John Sales Film. Los Angeles: Miramax Produc-tions, 1992.

12 Szasz TS, Hollander MH. The basic models of the doctor -patient relationship. Archives of Internal Medicine 1956;97:585.

13 Veatch RM. Models for ethical medicine in a revolutionary age.The Hastings Centre Report 1972;3:3.

14 Morse JM Negotiating commitment and involvement in thenurse-patient relationship. Journal of Advanced Nursing, 1991;16,4:455-68.

15 Greenhaugh T, Hurwitz B. Why study narrative? In: Green-haugh T, Hurwitz B, eds. Narrative based medicine: dialogue anddiscourse in clinical practice. London: BMJ Books, 1998: 3-16.

16 Phillips DC. Holistic thought in social science. California:Stanford University Press, 1977.

17 See reference 1: 95.18 Ford P, Walsh M. New rituals for old: nursing through the looking

glass. Oxford: Butterworth Heinemann, 1994.19 Melia KM. Learning and working: the occupational socialisation of

nurses. London: Tavistock Publications Ltd, 1987.20 Madjar I, Walton JA, eds. Nursing and the experience of illness:

phenomenology in practice. London: Routledge, 1999.21 Benner P, ed. Interprepretive phenomenology. New York: Sage,

1994.22 Allport G. Becoming: basic considerations for a psychology of

personality. New Haven: Yale University Press, 1955.23 Gardner J. On moral fiction. New York: Basic Books/Harper

Collins, 1978.24 Bayley J. Iris: a memoir of Iris Murdoch. London: Duckworth,

1998.25 See reference 1: 9626 Scott PA. Imagination in practice. Journal of Medical Ethics

1997; 23,1:45-50.27 See reference 24:178.28 See reference 24:179.29 Murdoch I. Metaphysics as a guide to morals. London: Chatto

and Windus Ltd, 1992.30 Diamond C. Losing your concepts. Ethics 1988;98:255-77.31 Vygotsky L. Thought and language. [Translated by Alex

Kozulin]. Massachusetts: MIT Press, 1986.32 Hirst PH. Knowledge and the curriculum. London: Routledge &

Kegan Paul, 1974.33 Kafka F. Metamorphosis and other stories.[Translated by Willa

and Edwun Muir]. London: Minerva, 1992.34 Galloway J. The trick is to keep breathing. London: Minerva,

1989.35 See reference 23:5.36 Southgate MT, Quoted in Downie RS, ed. The healing arts.

Oxford: Oxford University Press, 1994: xvii.

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The relationship between the arts and medicine

P Anne Scott

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