The Art of Medical Diagnosis. Lessons on Interpretation of Signs from Italian High Renaissance Paintings

Marcin Śniadecki; Anna Malitowska; Oliwia Musielak; Jarosław Meyer-Szary; Paweł Guzik; Zuzanna Boyke; Cynthia Aristei

doi:10.20944/preprints202411.0182.v1

Submitted:

02 November 2024

Posted:

04 November 2024

You are already at the latest version

Abstract

Medicine is struggling with the constantly rising incidence of breast cancer. The key in this fight is to be able to speed up diagnosis, as rapid diagnosis reduces the number of aggressive or advanced cases. For this process to be effective, it is necessary to have the right attitude towards diagnosis as a research practice. Our critical analysis of diagnosis, as a methodology of medical science, reflects on it as a research practice that is regulated in a socio-subjective way by a methodological culture. This position allows us to contrast critical methodological culture with the habitual-practical, or methodical, culture of practising diagnosis. We point to the interpretative status of medical analyses performed by medical historians by referring to Italian Renaissance painting and historical-artistic interpretations. In this field, analysing disputes between researchers as a clash of methodologies in the ways interpretation transforms signs into meanings, is a critical methodological reflection. Medicine is a diverse scientific discourse with a paradigmatic structure in which new ways of conducting diagnostic tests may appear. It is only possible to see this from the methodological level. In addition, passive respect for existing patterns of conduct hinders an exchange of views between researchers, what limits the possibility of correcting research procedures. The ultimate consequence of such passivity is an inabili/ty to improve diagnosis, which in turn, harms the interests of patients. In this regard, it is worth remembering that the paramount objective of diagnosis is not the disease, but the patient.

Keywords:

breast cancer

;

diagnosis

;

diagnostic methodology

;

methodological competence

;

sign interpretation

;

Renaissance paintings

Subject:

Medicine and Pharmacology - Oncology and Oncogenics

Introduction

Breast cancer is the most frequently diagnosed malignant tumour in the world across the entire general population, with female gender being the most at risk group [1,2]. At present, the latency period of breast cancer is getting shorter as the onset and quantity of the risk factors is increasing [3,4]. The progressive incidence of breast cancer necessarily brings about a rise in the attention paid to an early diagnosis [4,5,6,7]. When early testing and diagnosis takes place, the percentage of aggressive or advanced cancer cases decreases and the number of early-stage or low grade cancer detections increase [6, 8]. Patients go to doctors to be examined because the assumption is that doctors have the knowledge, tools and have mastered the art of interpreting symptoms and signs well enough to make a diagnosis. In breast cancer, the information from visual signs is extremely important, since diagnosis in this cancer is mainly image-based [9]. Therefore, we can advance the thesis that approaches to image interpretation play a key role in today’s medicine; and it follows, that it is worth asking appropriate questions about the role of interpretation.

Since diagnostic tests are so important in the fight against a pressing global public health problem [10], it is necessary to have the right attitude towards diagnosis as a research practice. This attitude can be summarized as involving a quartet of tasks: 1) an analysis and reconstruction of the concept of diagnosis, and of its related standards and procedures; 2) criticality towards the diagnostic process using cognitive criteria, including ethical ones; 3) the structured development of evidence-based proposals for solutions to problem situations; and 4) pragmatics, i.e., a cooperative stance towards other knowledge disciplines and institutions in order to ensure conditions for effective implementation and application of the proposed solutions in medical practice.

At the centre of our interest is how each diagnosis as a purposeful, methodical and iterative process in the sense that it is subject to constant evaluation, re-evaluation, and verification as new information flows from the development of the disease or the new results obtained from any additional tests undertaken. The quality and effectiveness (performance) of diagnostic tests depend on the degree to which they are recognized, understood, accepted, and applied.

These tasks belong to the field of methodology of science, a discipline investigating research practice with regard to the activities it comprises and their results. As such, methodology addresses both research objectives and the instructions how these objectives should be achieved by researchers. More precisely, methodology reconstructs research procedures as they are employed in practice. However, its tasks, apart from reconstruction, also include evaluation of investigation procedures as to their adequacy to the goals of a given discipline.

Thus, being competent in the discipline’s research and examination methods is not only about the ability to apply them correctly, i.e. in accordance with the state of the art, but also the ability to reflect on their validity and purposefulness. The above context encourages deepening methodological reflection on diagnosis and developing a reflective and critical attitude towards medical research practice.

Methodological Competence

Knowledge of methods, so the methodological competence, relies on the acceptance of beliefs that define the goals of research activities and characterise the activities required to achieve these goals. Since medicine, both as a scientific discipline and as medical practice, is a social phenomenon, institutionalized and regulated by professional standards, the rules of medical conduct identified by the methodology are shared and recognized as valid by medical professionals. Accepting these rules means that they determine both the objectives of professional conduct and the means of achieving them.

The rules could be reconstructed in the form of theories relating to individual stages of the research process, e.g., theories of the interpretation or generalization of research results, or knowledge about research models, thus constituting a set of rules for using specific models in the process of empirical analysis and verification of research results.

There are two attitudes in which the methodological competence can be exercised. In the first one, methodological competence is application-oriented and refers to the ability of a practitioner to follow the methodological rules suggested by the state of the art, i.e. to apply a procedure or rule in a manner appropriate to given circumstances. In the second attitude, methodological competence entails consideration of performance of applied research rules, enabling questions on their presuppositions, efficiency, and effects of the conduct resulting from the rule acceptance. In that case, methodological competence is reflection-oriented.

Knowledge of methods, while shared within a professional community, doesn’t have to be explicit. What is typical of the application-oriented attitude, being acquainted with the research rules does not necessarily mean the ability to precisely verbalize them or — even more so — to justify them theoretically. It doesn’t mean that the application-oriented attitude excludes any overt thought process. Far from it, diagnostician as a researcher makes decisions and implements them in a dynamic thought process based on the assessment of situation, anticipating consequences, etc.

In summary, it can be said that reflective methodological competence is more than just a specialized research competency.

The Art of Diagnosis

When characterising the concept of methodological competence, we will refer to the controversy surrounding the so-called medical diagnosis of High Renaissance (Cinquecento, 1500-1599) paintings as allegedly depicting breast cancer. These discussions were held in The Lancet and The Lancet Oncology. Examples include the articles The portrait of breast cancer and Raphael’s La Fornarina and Earliest evidence of malignant breast cancer in Renaissance paintings [11,12]. Considerations of Jonathan K. Nelson’s Cancer in Michelangelo’s Night. An analytical framework for retrospective diagnoses [13] form critical contribution to this discussion.

According to the Merriam-Webster dictionary, (medical) diagnosis is the art or act of identifying a disease from its signs and symptoms [14]. What is the art of diagnosis? It is an art in the technical sense, i.e., actionable knowledge of rules or a capability to act in accordance with them. When dealing with signs, diagnosis is an art or activity of interpretation.

The interpreter is then someone who operates on signs, transforming them, so that eventually, after many transformations, they provide an answer to a question, because interpreting as a cognitive (research) activity is intentional.

Interpreting as the transformation of signs is not arbitrary but methodical. We have ways to specify the criteria for correct interpretation and make them intersubjective. In medicine, more precisely, in radiological examinations of the mammary gland, interpretations of visual data such as a sequence of magnetic resonance images (MRI) are regulated by standard nomenclature and diagnostic criteria, as for instance in the use of the Breast Imaging-Reporting and Data System (BI-RADS) which serves as specialised dictionary [15]. Among other things, it defines what vocabulary should be used in the interpretation of the image. For example, the word “ovoid” cannot be used in the description of a region of interest (ROI) because BI-RADS interpretation guidelines specify the use the word “oval” to denote mass that has a rounded and a bit elongated shape (including lobulated), and “ovoid” is 3-D, and “oval” is 2-D [16]. The guidelines for the correct interpretation of an image, of course, are not limited to the use of appropriate terminology to describe a ROI, but also include diagnostic knowledge. For example, it is assumed that the correct interpretation of ductal enhancement occurring two minutes after contrast administration should be stated as a “suspicious enhancement” since in most cases it is a typical indicator of invasive ductal carcinoma [17].

Interpretation is an essential element of any research process; as a consequence, even seemingly objective scientific activities such as description or analysis are derivatives of interpretation or even its direct variants.

Meanwhile, when the authors of the articles mentioned earlier make a medical diagnosis of the elements in Raphael’s La Fornarina, Tosini’s The Night, or Maso di San Friano’s The Allegory of Fortitude, they separate their medical analysis from their interpretation of art-historical significance. Moreover, they distinguish medical analysis itself from artistic analysis, assuming the possibility of contact with an image, which is completely independent of the act of experiencing it. In other words, they ensure the possibility of adopting a pre-aesthetic and research attitude in which the essential properties of the work will be recognised, completely independent of an experience of its aesthetic properties.

In both cases, however, we are dealing with recognising meaning based on signs. Medical diagnosis using images involves a transformation of signs just as artistic analyses do. Both are interpretations, and the differences between them do not result from the characteristics of the subject of interpretation, but from the particular methods adopted. The same image can be interpreted in many ways, depending on the cognitive needs that define the problem the interpreter is facing.

Undoubtedly, the authors of medical diagnoses of the figures in the paintings interpret the properties of the depicted breast as indexical signs. In Peirce’s semiology an indexical sign (indicator or sign) would be characterised by the fact that there is a real, physical connection between the signifier and the signified [18]. Peirce’s typology takes into account three types of signs: index, icon and symbol. An iconic sign represents an object if the sign and the object are similar. Thus, a particular arrangement of colour spots on the canvas or the shape given to a block of stone by the sculptor may represent a woman’s breast because they are more or less similar to a woman’s breast. Finally, in the case of symbols, signs represent objects when there is a convention that assigns denotations to them, which means that symbols require interpretation based on specific conventions. For example, in the painting La Fornarina, the naked left breast interpreted as naked can be a symbol of beauty, truth and goodness (following the classicist convention), whereas in the Christian tradition, as left breast, it can be read as a symbol of sin (Figure 1).

We can try to look at another High Renaissance painting, i.e., The Rape of the Sabine Women by Giovanni Antonio Bazzi (known as Sodoma), through the prism of all three types of signs (Figure 2).

The painting depicts one of the founding myths of ancient Rome, i.e., the kidnapping of women from the Sabine tribe. The depicted scene is an iconic depiction of rape, which symbolizes the perversions of power and human nature itself. The iconography and symbolism are consistent with the interpretation of representations of the Sabine women’s bodies, especially their bare breasts, in terms of signs of disease signifying something deviating from the norm, and contrary to nature.

Bearing in mind the realism of High Renaissance painting, the presented deformation of the nipple or the darker colour of slightly retracted skin, can be considered as symptoms (indexical signs) of cancerous changes. Similarly as in the case of The Night or Allegory of Fortitude, we could look at another work by Sodoma, entitled The Fall of Phaeton (https://worcester.emuseum.com/objects/6465/the-fall-of-phaeton), in which one could see the same model as in The Rape of the Sabine Women - it can be assumed that there is a scar on the left breast. It is also worth mentioning that many, if not most, High Renaissance paintings depicted the symptoms of left-sided breast pathology.

Reflective methodological competence would therefore require that research on works of art suspected of representing breast cancer over the centuries be compared with the state of medical knowledge specific to a given era and ask how medical discourse relates to artistic practice. They could also be combined with biographical information that would link the figure depicted in the painting (e.g., La Fornarina) with a real person (Margherita Luti), and preferably also with the history of her illness. From a methodological point of view, it may be interesting to know how and why the interpretations provided by medical science differ from those present in the history of art.

The study of images – from medical to pictorial – requires research itself. According to Gillian Rose, reflecting on the methods that can be used to interpret visual images, is a task of a critical visual methodology [19]. The methodological approach takes into account the cultural conditions of interpretation, in particular the fact that the beliefs respected and accepted by the members of a given cultural community determine the ways of encoding and decoding signs they use. Scholars aware that what is seen and how it is seen are culturally constructed, consider their own way of looking at images.

Conclusions: Threats Posed by Limited Methodological Competence

Our analogy between historical and artistic interpretations, points to the interpretive status of medical analyses performed by medical historians. The disputes that are possible between them are disputes between methods of interpretation. A critical examination of these is possible, but at the level of critical methodological reflection.

Discoveries of the history of medicine lack response from other sciences. Art historians, in turn, ignore medical studies who comment on art. The absence of dialogue between such different disciplines, even though they refer to the same subject, is the result of the limitations of the dominant, application-oriented methodological competence.

Tacit respect for existing patterns of conduct hinders the exchange of views between researchers, which in turn limits the possibility of correcting research procedures. In the process, diagnosticians who have been trained to solve problem situations intuitively, fail to notice or accept innovative ways of conducting research. Only at the methodological level it is clear that medicine is a diverse scientific discourse with a paradigmatic structure in which new ways of conducting diagnostic tests may appear.

The ability to read images is a powerful tool at our disposal. We have to use it to preserve ever younger lives of cancer patients. In our current image-saturated culture, pictures, and their information, flash past our retinas with the speed of a swipe. The qualification of diagnostic imaging procedures as a purely technical service does not correspond to the idea of how, at least from the radiologists’ point of view, they should be operated. The personal contact with the patients and the conversation with the patients have a great impact on the quality of the diagnostics and are important for the patients to give them confidence and trust.

To draw final conclusions, both fine art image and a medical image require interpretation by the viewer, diagnostic process is a piece of art looking at the patient and his acts holistically, interpretation is the basis of medical diagnosis and requires methodological attitude, medicine is not the matter of correct but context, and evidence-based science makes interpretation objective and more in context.

Permission for publication of images

Consent for publication of images was acquired from the Galleria Nazionale d’Arte in Palazzo Barberini in Rome.

Contributors

We were all involved in the preparation, writing, and reviewing of the article.

Declaration of interests

We declare no competing interests.

Acknowledgments

The authors thank Ms. Marta Irzyk, MA, for the final editing of the text and Mr. Rob Garret, M.Sc., for language proofreading. We also thank student’ seminar participants.

References

Sung, H.; Ferlay, J.; Siegel, R.L.; Laversanne, M.; Soerjomataram, I.; Jemal, A.; et al. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J Clin. 2021, 71(3), 209–249. [CrossRef]
Goldstein, N.S.; Ziegfeld, C.R. “Risk factors and risk assessment”. In Early Diagnosis and Treatment of Cancer Series: Breast Cancer; Jacobs, L., Finlayson, C.A., eds.; Elsevier/Saunders: Philadelphia, USA, 2011; pp. 55–69.
Leis HP Jr. The diagnosis of breast cancer. CA Cancer J Clin. 1977, 27(4), 209–32. [CrossRef]
Hassaine, Y.; Jacquet, E.; Seigneurin, A.; Delafosse, P. Evolution of breast cancer incidence in young women in a French registry from 1990 to 2018: Towards a change in screening strategy? Breast Cancer Res. 2022, 24(1), 87. [CrossRef]
Ilic, L.; Haidinger, G.; Simon, J.; Hackl, M.; Schernhammer, E.; Papantoniou, K. Trends in female breast cancer incidence, mortality, and survival in Austria, with focus on age, stage, and birth cohorts (1983–2017). Sci Rep. 2022, 12, 7048. [CrossRef]
Cathcart-Rake, E.J.; Ruddy, K.J.; Bleyer, A.; Johnson, R.H. Breast Cancer in Adolescent and Young Adult Women Under the Age of 40 Years. JCO Oncol Pract. 2021, 17(6), 305–13. [CrossRef]
Evans, A.; Trimboli, R.M.; Athanasiou, A.; Balleyguier, C.; Baltzer, P.A.; Bick, U.; et al. Breast ultrasound: recommendations for information to women and referring physicians by the European Society of Breast Imaging. Insights Imaging 2018, 9(4), 449–461. [CrossRef]
Sood, R.; Rositch, A.F.; Shakoor, D.; Ambinder, E.; Pool, K.L.; Pollack, E.; et al. Ultrasound for Breast Cancer Detection Globally: A Systematic Review and Meta-Analysis. J Glob Oncol. 2019, 5, 1–17. [CrossRef]
Acciavatti, R.J.; Lee, S.H.; Reig, B.; Moy, L.; Conant, E.F.; Kontos, D.; et al. Beyond Breast Density: Risk Measures for Breast Cancer in Multiple Imaging Modalities. Radiology. 2023, 306(3), e222575. [CrossRef]
Coles, C.E.; Earl, H.; Anderson, B.O.; Barrios, C.H.; Bienz, M.; Bliss, J.M.; et al. The Lancet Breast Cancer Commission. The Lancet 2024, Volume 403, Issue 10439, 1895–1950. [CrossRef]
Espinel, K.H. The portrait of breast cancer and Raphael’s La Fornarina. The Lancet 2002 360, 2061–2063. [CrossRef]
Bianucci, R.; Perciaccante, A.; Charlier, P.; Appenzeller, O.; Lippi, D. Earliest evidence of malignant breast cancer in Renaissance paintings. The Lancet Oncology 2018, 19, 166–167. [CrossRef]
Nelson, J.K. “Cancer in Michelangelo’s Night. An Analytical Framework for Retrospective Diagnoses”. In Representing Infirmity: Diseased Bodies in Renaissance Italy; Henderson, J., Jacobs, F., Jonathan Nelson, J., eds.; Routledge: New York, USA, 2021; pp. 3–27.
Merriam-Webster. Diagnosis. Merriam-Webster.com dictionary. Available online: https://www.merriam-webster.com/dictionary/diagnosis (accessed on 24 April 2024).
Erguvan-Dogan, B.; Whitman, G.; Kushwaha, A.; Phelps, M.J.; Dempsey, P.J. BI-RADS-MRI: A Primer. AJR Am J Roentgenol. 2006 Aug, 187(2), W152–60. [CrossRef]
American College of Radiology. BI-RADS Atlas Reporting System for Breast MRI. Available online: https://www.acr.org/-/media/ACR/Files/RADS/BI-RADS/MRI-Reporting.pdf (accessed on April 24 2024).
Dietzel, M.; Baltzer, P.A.T. How to Use the Kaiser Score as a Clinical Decision Rule for Diagnosis in Multiparametric Breast MRI: a Pictorial Essay. Insights Imaging 2018, 9, 325–335. [CrossRef]
Peirce, C.S. Collected Papers of Charles Sanders Peirce: Vol. 1–2. Principles of Philosophy and Elements of Logic. Hartshorne, C., Weiss, P., eds. Cambridge: Harvard University Press: Cambridge, Massachusetts, USA, 1932.
Rose, G. Visual Methodologies. An Introduction to the Interpretation of Visual Materials. Sage Publications: London, United Kingdom, 2001, p. 5–32.

Figure 1. La Fornarina, A Portrait of a Young Woman (1518-19), oil on wood panel, Raffaello Sanzio da Urbino (1483-1520). In: Galleria Nazionale d’Arte Antica in Rome.

Figure 2. The Rape of the Sabine Women (1505-07), oil on wood panel, Giovanni Antonio Bazzi detto Sodoma (1473-1549). In: Galleria Nazionale d’Arte Antica in Rome.

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