DOCTOR-PATIENT RELATIONSHIP

Many pratitioners in 17th century were actually distillers, innkeepers, hosiers, colourers, pinmakers,
hatpressers, musicians, dyers, perfumers, tallowchandlers and tailors. Formal records of medical
qualification were very limited and although there were many practitioners, they were accepted not
because of any paper qualification but because of the service they offered.

During the 18th Century the symptom was the illness. Doctors were few in number and their patients
mainly upper class and aristocratic. The model of illness that developed was one based on the
interpretation of the patients’ individual symptoms. The doctor found that it was less necessary to
examine the patient but rather more important to be attentive to their needs and experiences
manifest in the form of their symptoms. This symptom-based model of illness ensured the
preservation of patient dominance throughout this period.

Consulting by letter was a common practice during the Enlightenment. People resorted to it either
because of the lack of physicians in their area, or with a view to obtaining advice from a famous
doctor. Owing to insufficient information, it is was not easy to draw a clear cut sociological profile of
the patients. The kind of discourse contained in these letters evokes a mistrust of sick persons
towards physicians which sounds quite familiar to us. It is commonly thought that the 18th century
patient was generally considered as a whole individual whose health and illness was interpreted in
terms of humoral medicine. In that holistic view, and especially considering the ineffectiveness of the
available treatments, the patient's discourse was central to the patient-doctor relationship.

In the 18th century, narratives were at the very root of the patient-doctor relationship. The then
widespread practice of written consultation is especially illustrative of this fact. Letters, of more than
ten pages sometimes, testify to the importance given to patients' own words. They contain many
details about the every day life of the writer, and about the course of the disease through the
perception of his or her symptom. And yet patients of the Enlightenment complain about the
“deafness” of physicians just as much as they do today.

“The relationship between the doctor and patient has a very pronounced association with the model
of illness that dominates at any given time” N.K. Jewson

During the late 18th Century the hospital became the cornerstone of medical care and along with the
rapid growth in microbiological knowledge and surgical skills during this time, a new Medicine
developed that focused not on the symptom, but rather on the accurate diagnosis of a pathological
lesion inside the body – the biomedical model of illness. This new theory suggested that the
symptom was no longer the illness, but instead acted as a unique indicator for the presence of
absence of a particular pathology. This new model required the examination of the patient's body
and the expert clinical and anatomical knowledge possessed by the doctor to formulate a diagnosis,
and thus the patient became dependent as a result. The relationship was between a dominant doctor
and a passive patient.
HOSPITALS

By the mid-1500s the monastery system was dissolving, and the hospitals had been sold to the city
and reopened as more secular institutions. Support staff members were more likely to be recruited
from former patients or local poor than from religious orders. This pattern would continue until well
into the nineteenth century. Throughout the eighteenth century hospitals opened in the larger cities
of Europe and America as industrialization developed and the middle class expanded in those
countries. Slowly, hospitals began to change from places which gave only basic care to the sick to
places that attempted to treat illness and carry out simple surgery, removal of gallstones and setting
broken bones. Some also became centres of training for doctors and surgeons. Treatment was
normally free.

TREATMENT

However little you know about the history of medicine, you’re probably aware that doctors used to
prescribe some pretty strange courses of treatment. For centuries they were famously reliant on
bleeding, a remedy based on the ancient idea that some illnesses were caused by an excess of blood.
Leeches, widely used for hundreds of years, removed only a teaspoonful of blood per application, but
physicians sometimes took more drastic measures. By opening a vein (usually in the arm) they could
remove several pints at a time if they thought it necessary.

If you were lucky enough to escape a thorough bleeding, taking medicine often wasn’t much fun
either. Commonly prescribed drugs included highly toxic compounds of mercury and arsenic, while
naturally-occurring poisons such as hemlock and deadly nightshade were also staples of the medicine
cabinet. And a volume first published in 1618, the Pharmacopoeia Londinensis, offers a fascinating
and detailed insight into what used to be considered ‘medicinal’ in seventeenth-century England. It’s
a comprehensive list of remedies commonly prescribed by doctors, all of which London apothecaries
were therefore required to stock. These ranged from herbs and fruits to minerals and numerous
animal products.

The Pharmacopoeia makes fairly extraordinary reading today, since many of the ‘medicines’ it lists
are far from pleasant. They include five varieties of urine and fourteen of blood, as well as the saliva,
sweat and fat of sundry animals – oh yes, and the ‘turds of a goose, of a dog, of a goat, of pigeons, of
a stone horse, of a hen, of swallows, of men, of women, of mice, of a peacock, of a hog, and of a
heifer.’ Can you imagine what the average apothecary’s shop must have smelt like?

Other items you might have found on the premises included frogs’ lungs, castrated cats, ants and
millipedes. Perhaps the most bizarre items were discarded nail-clippings (used to provoke vomiting),
the skulls of those who had died a violent death (a treatment for epilepsy), and powdered mummy.
And yes, that means Egyptian mummy, which was prescribed for a variety of conditions including
asthma, tuberculosis and bruising.

Potent pain management was available via opium latex, often mixed with wine and brandy to make
laudanum. In the eighteenth century, small amounts were used as a narcotic, a sedative, a cough
suppressant, or to stop up the bowels, but not for headaches. There were headache treatments,
however. Colonial medical practitioners recognized multiple types of headaches based on the
perceived cause, each with its own constellation of solutions.. For a headache caused by sinus
pressure, for example, the treatment was to induce sneezing with powered tobacco or pepper. Some
good, hard sneezing would help expel mucus from the sinuses, thus relieving the pressure.
Surgeons set broken bones, amputated extremities when necessary, and removed surface tumors,
requiring greater knowledge of anatomy. Simple breaks could be set manually, as they are today.
Before plaster casts were developed in the nineteenth century, broken bones could only be splinted.
This engraving shows more elaborate splints for broken legs. Two factors limited the scope of surgical
operations in the eighteenth century. The first was the lack of antisepsis; with no knowledge of germ
theory and thus little control for infections surgeons avoided guts and kept operations as simple and
efficient as possible. The second was pain. Furthermore, amputations lasted less then five minutes—
minimizing the risk of infection and the chances of the patient going into shock from blood loss and
pain. Limbs weren’t simply lopped off, however. Surgeons could tie off large blood vessels to reduce
blood loss, and the surgical kit we display shows the specialized knives, saws, and muscle retractors
employed by surgeons to make closed stumps around the severed bone.

What about emergency care? Some of the treatments on offer for critically ill patients were, if
anything, even more unusual.

One summer evening in 1702 the Earl of Kent was enjoying a game of bowls in Tunbridge Wells when
he fell down unconscious. Luckily a prominent London physician, Charles Goodall, was nearby and
arrived on the scene within a few minutes. He found the earl lying on the ground, apparently dead,
‘having neither pulse nor breath, but only one or two small rattlings in the throat, his eyes being
closed.’ The signs were ominous, but the doctor left nothing to chance in his efforts to save his
patient. First he bled the earl, removing slightly more than half a pint of blood from his arm. Then
snuff was poked up his nostrils and antimonial wine, a toxic brew intended to provoke vomiting, was
poured down his throat. The doctor’s plan, orthodox for the time, was to shock the earl back to life
by provoking an extreme reaction: sneezing, coughing or vomiting. These measures were
unsuccessful, so the unfortunate patient was carried indoors and yet more blood taken from him.
Next his head was shaved and a blister – a plaster smeared with a harsh caustic substance – placed
on top of it. The idea was that this would provoke blistering and so force any toxins out of the duke’s
body. Next the resourceful medic administered several spoonsful of buckthorn syrup, intended to
empty the bowels. By this point word had got around, and a number of other doctors appeared in
the room. One of them suggested that it was time to try something more extreme, so a frying pan
was sent for, heated in the fire and then applied red hot to the earl’s head. This did not provoke the
slightest reaction, leading several of those present to conclude that their patient was already dead –
and they were probably right. But Dr Goodall was still not ready to give up. At the request of the
earl’s daughter his unconscious body was taken to his own chamber and tucked up in a warm bed.
The doctors then ordered that tobacco smoke should be blown into his anus. This may sound an
eccentric thing to do, but the technique – known as Dutch fumigation – was generally regarded as
the most effective means of emergency resuscitation. This time, however, it was no use. The doctors,
realising their task was probably hopeless, tried one last thing. The bowels of a freshly-killed sheep
were wrapped around the earl’s abdomen – a desperate and thoroughly unpleasant attempt to
warm him up. All proved unavailing, and the doctors finally admitted defeat. ‘Thus fell this great and
noble peer, much lamented by all who knew his Lordship’, wrote Dr Goodall in a letter to a friend. It’s
likely that the earl had died within a few minutes of collapsing, possibly from a heart attack or stroke.
But in 1702, a century before the invention of the stethoscope, it was virtually impossible to be sure
that a patient’s heart had stopped – so resuscitation attempts often continued until there was no
conceivable doubt that they really were dead.

It’s interesting to note how much medicine changed during the eighteenth century: by 1800, virtually
all the strange remedies I’ve mentioned had fallen out of use. Doctors were starting to prescribe
substances we’d recognise as medicinal rather than badger fat or rabbit’s paw – and the idea of
blowing smoke up a patient’s bottom had certainly had its day.

CAUSES OF DEATH

They might die due to smallpox, whooping cough, accidents, measles, tuberculosis, influenza, bowel
or stomach infections.

Cholera and smallpox are often described as the most devastating epidemic diseases of that era.

CASES

What do u think how would this patient be treated in 17th and 18th century?

1. A patient 40 years old comes with a runny nose and fever to a doctor.

In this time before antibiotics, medicines were often given to treat the symptoms of the sickness, not
the sickness itself. So this patient would be treated with some antipyretics (fever reducers like willow
bark and meadowsweet).

2. A patient 30 years old comes to the doctor for abdominal pain without diarrhoea and vomiting.

APPENDICITIS – Was treated with large and repeated bloodlettings, laxative and cooling clysters
(enemas), opiates, and fomentations (warm animal compresses) to the abdomen until 1735 when
Claudius Amyand performed appendectomy in an 11-year-old boy with an inguinal hernia.

DYSENTERY – It was marked by bloody diarrhea, fever, nausea, and cramps. Because physicians did
not know what caused the disease, they treated the symptoms, often using purgatives like
turpentine or castor oil, which in fact, only made the problem worse. The disease was not
always fatal. However, it caused many deaths because of time and the treatments used.