Art of Medicine: anagogico more

Introduction

In June 1944, during the Second World War, the art historian Erwin Panofsky (1892 to 1968) wrote an essay about the abbey church of Saint-Denis*. He described how, in the Middle Ages, Abbot Suger (1081 to 1151) rebuilt his abbey church near Paris, shaping an architectural style now known as “Gothic” (1). Suger believed that taking pleasure in the beauty of the visible work of art could transport people to an invisible, higher world. Suger wrote that this world was reached anagogico more. Here more can be translated as “in the manner of”, anagoge as “ascent”, and therefore, anagogico more as “in an anagogic” or “uplifting way”. Anagogy comes from the ancient Greek ἀναγωγή/anagoge, meaning “to ascend”. In medieval Latin, anagogia referred to the highest level of textual interpretation, moving away from the literal meaning toward a deeper, higher sense. Suger’s idea of anagogy was rooted in the thinking of his time. Today, however, we can use his idea of anagogy to look at two ascents in the professional lives of physicians. One ascent is the visible career that requires overcoming hurdles and disillusions. The other ascent is the invisible anagogy that requires recognizing the beauty of medicine (Figure 1).

Figure 1 Anagogical window. Detail of a stained-glass window from the crypt of the abbey church of Saint-Denis, France, second quarter of 12th century. The window is now on display at the Musée Cluny, Paris, and the picture is available on Wikimedia with Free License of use. Source: https://commons.wikimedia.org/wiki/File:Paris_-_MNMA_Vitrail_02.jpg. Since the early Middle Ages, and still in the times of Abbot Suger, some strands of thought considered light as the emanation of a higher world, and colors pointed to an absolute beauty. Stained glass windows were intended to capture light, and give the matter of glass an own divine luminosity. According to Abbot Suger’s idea of anagogy, the beauty of colors served as a vehicle that transported the viewer to a higher world. For St. Bernard of Clairvaux, however, an important contemporary of Suger, colors meant the same as their supposed Latin word origin “celare”, namely “to conceal”. Bernard recognized colors as a source of falsity and disillusion, and he banned them from the churches of his order, instead of using them as a vehicle of elevation (2).

Two ascents

We follow the paths of three people from their youth to professional independence as physicians. The first is a schoolboy who is asked to step up to the operating table during his internship and receives much praise for his assistance. The second is the young daughter of an estranged couple who, in talking to her new pediatrician, feels for the first time in her life that a human being sees her and wants to be there for her. The third is a boy who returns from soccer with knee pain and is saved from death from osteosarcoma by his family physician. In the course of their youth, the three young people develop a dreamlike idea that they may be physicians one day.

Goals

At some point of their lives, the dreamlike notion turns into a concrete desire to actually become physicians. But this wish presents them with a hurdle: Will I be admitted to medical school? This question can become a struggle over school grades and aptitude tests. Perhaps they despair at the falsity of a medical school, which seems like Eurystheus hiding from them in a storage jar, devising inhumanly difficult tasks in order to prevent them from climbing Mount Olympus. But perhaps the three will recognize the beauty of the goals of medicine that reliably side with human health and wellbeing. For those who recognize its beauty, the goals of medicine become part of the goals of their own lives. This is the anagogy of goals.

Knowledge

The three beginners finally have their first day in medical school, and now wish to successfully complete their studies. This wish presents them with a hurdle: “Will I pass the state exam?” This question can become a struggle over multiple-choice questions and exams. Perhaps they despair at the falsity of a knowledge that behaves like the one-eyed giant Polyphemus, who first refuses them hospitality and instead wants to devour them and who, after they escape by blinding him, takes revenge by sending them on a years-long odyssey. But perhaps the three recognize the beauty of medical knowledge, which makes the weal and woe of man understandable from the molecule to the soul. For those who recognize its beauty, medical knowledge becomes part of their own understanding of humanity. This is the anagogy of knowledge.

Skills

The three students manage to complete their studies and they get a position as residents. Now they want to become medical consultants. This wish presents them with a hurdle: Will I be eligible to take the specialist exam? This question can become a struggle to fill a logbook with practices and techniques from the specialty catalog. Perhaps the three despair at the falsity of medical skills that seems to them like the beguiling song of Sirens, tempting them to become unfaithful to the goals of medicine. But perhaps the three recognize the beauty of a medical skills that always find a way to help people with disease. For those who recognize its beauty, the medical method becomes part of their own way of dealing with people. This is the anagogy of skill.

Independence

The three consultants make it through the specialist exam, and now want an independent professional position. The first wants to become a partner in a private practice, the second a senior physician, and the third a chief physician. This wish presents them with a hurdle: Will I get the position I want? This question can become a struggle over job profiles, money and personal liking. Perhaps the three, in search of an independent position, despair of the falsity of a society that, like the gods of Olympus, burst into a long, immense laughter when they saw Hephaestus, the limping god of blacksmithing being betrayed by his beautiful wife Aphrodite. But perhaps the three recognize the beauty of a medical position, which stands up for humanity in society. For those who recognize its beauty, the medical position becomes a part of his own dealings with the society. This is the anagogy of independence.

Meaning

Eventually, the three reach the position of their wishes. But the success of their careers still leaves them with a question: “Am I happy?” They look around and they cannot see a hurdle. Now they look at their daily lives as professionals. Perhaps, in their search for happiness, the three despair of the falsity of their life, which seems to them like the life of clever Sisyphus, who got the god of death drunk, tied him up and prevented him from doing his work, and who now has to torment himself senselessly, rolling a huge boulder up the mountain, which, having reached the top, keeps rolling down the same path. However, the career path that has led the three up does not have to lead them down. The three may be happy and recognize the beauty in the meaning of their professional lives, which is to truly be there for people when they experience health suffering. This is the anagogy of meaning. And these are the ascents of the physician, the visible career and the invisible anagogy.

Art of medicine

Abbot Suger tells us that the vision of the beauty of artfully crafted material calls him away from external cares. He says, “It seems to me that I see myself dwelling, as it were, in some strange region of the universe which neither exists entirely in the slime of the earth nor entirely in the purity of Heaven; and that […] I can be transported from this inferior to that higher world in an anagogical manner.” (1). The recognition of the beauty of the visible things led Suger to a higher world.

In our everyday professional lives, we struggle with the hurdles of medical career. In this struggle, we encounter falsity and despair. But in this struggle we also encounter beauty. Those who see this beauty can reach a higher world and achieve an artful practice of medicine, anagogico more.

Author’s statement

Yskert von Kodolitsch is cardiologist and attending physician and Eike Sebastian Debus is a senior vascular surgeon, both at the University Heart and Vascular Center Hamburg. Both physicians share an interest in medical education and the art of medicine. Alberto Virdis is an art historian with profound expertise in medieval art and philosophy. He performed extensive research on medieval culture and anagogy.

Acknowledgments

The authors would like to express their sincere gratitude to Professor Peter N. Robinson (The Jackson Laboratory for Genomic Medicine, 10 Discovery Drive Farmington, CT 06032, USA) and Olliver Pfenning, PhD (Squadron Commander 2nd Frigate Squadron, German Navy, Wilhelmshaven, Germany), for their thoughtful comments on this manuscript.

Funding: None.

Footnote

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://cdt.amegroups.com/article/view/10.21037/cdt-23-260/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

^*Panofsky was a German Jew who fled to the United States to escape the Nazi anti-Semitic laws. He wrote his essay when he was a professor at Princeton. Panofsky wanted to publish the essay on the occasion of the 800th anniversary of the consecration of the choir of Saint-Denis, but the publication was postponed because the presses of Princeton University were busy printing the so-called “Manhattan Project”, the official report on the development of the atomic bomb. This may explain why Panofsky’s essay was read as a metaphor for a new humanism that sought to counter the barbarism of war with the beauty of art (see Ref. 1).

References

1. Panofsky E. On the Abbey Church of St.-Denis and Its Art Treasures: Second Edition edited by Panofsky-Soergel, Gerda. Princeton, New Jersey, USA: Princeton University Press; 1979.
2. Virdis A. Color in Suger’s Saint-Denis: Matter and Light. Convivium 2021;8:78-95. [Crossref]