ABSTRACT
In 1776, the Scottish philosopher David Hume, having been ill for some time, visited Bath to take the waters. He had consulted several physicians, who had made various conjectures as to the nature of his condition but had not been able to agree upon a diagnosis. The issue was not resolved until Hume’s abdomen was directly examined. This procedure was, however, not undertaken by any of his attendant physicians but by a famous surgeon: ‘John Hunter … coming accidentally to Town Dr Gusthart proposed that I should be inspected by him: He felt very sensibly [i.e. palpably] as he said a Tumour or swelling in my Liver.’1 True to his own doctrine of the priority of direct experience, Hume immediately accepted Hunter’s diagnosis: ‘This Fact, not drawn by reasoning, but obvious to the Senses, and perceived by the greatest Anatomist in Europe must be admitted as unquestionable and will alone account for my situation.’2 Hume’s physician, Dr Gusthart, did not dispute the validity of Hunter’s findings. Evidently he did not oppose physical examination in principle; nor did he doubt its relevance to medical therapy. Palpation was, however, not a procedure that he was prepared to undertake himself. Such methods were in his view, it must be supposed, the business of surgeons. Gusthart remained optimistic regarding his patient’s condition but Hume reconciled himself to Hunter’s diagnosis and duly prepared for his death, which occurred two months later. Such reluctance to undertake a thorough scrutiny of the bodies of patients was not
confined to fashionable English physicians. John Rutherford (1695-1779), Professor of the Practice of Physic at the University of Edinburgh, impressed upon his students the value of noting the patient’s facial appearance. For instance, in the course of a clinical lecture upon the case of a young woman newly admitted to the Edinburgh Royal Infirmary, he remarked: ‘If it had been daylight, I would have examined her gums and the internal canthus of her eyes … for by looking into the internal canthus and the gums and finding them in a florid state then the blood is in a good state.’3 Rutherford’s careful inspection of the woman’s face was not, however, extended to other parts of her body. He concluded, ‘The disease seems to be owing to the mismanagement she underwent in childbed. She says she was lacerated and probably it was her vagina.’ But he made no attempt to confirm his supposition with an examination of her genitalia nor, it seems, did any other member of the hospital’s staff. It is instances such as these (they could be multiplied many times over) that have led
historians to argue that diagnostic practice in the eighteenth century was generally based upon methods other than physical examination. Charles Newman argued that the
physician relied upon four basic techniques.4 First, he noted the patient’s general behaviour and demeanour, and visually inspected those parts of the body not normally hidden under clothes or bedclothes. Second, he took the pulse at the wrist, a procedure that also allowed him to ascertain whether the skin was hot, dry or clammy, and so on. Third, he inspected faeces and urine, and also, when available, blood, vomit, pus and sputum. Fourth and most importantly, he listened carefully to the patient’s account of her ailment. As Bynum put it, ‘the patient’s own description of his illness was the pivotal point in the diagnostic process’.5 Reiser has likewise concluded that, while the eighteenth-century physician might occasionally palpate, he would accord considerably less significance to the direct evidence of his senses than to his client’s verbal testimony.6 Jewson has influentially argued that the most important feature of the eighteenth-century physician’s professional context was the economic power of individual patients.7 Thus, within each consultative encounter, the physician’s behaviour at the bedside was generally constrained by the authority of his client. The patient could insist that, unless she decreed otherwise, the physician should abide by the normal social conventions governing physical contact between non-intimates. Even surgeons might have their activities at the bedside restricted by a patient’s unwillingness to allow visual inspection or manual examination of the affected parts.8
