This is a guest blog by Alison Moulds, second-year DPhil student at St Anne’s College, University of Oxford. Her thesis examines the construction of the doctor-patient relationship, and the formation of a professional identity, in nineteenth-century medical writing and fiction by doctors. She is part of the AHRC-funded project Constructing Scientific Communities.
Working in partnership with the Hunterian Museum of the Royal College of Surgeons of England, the project has guest curated an exhibition on the history of vaccination and will be running several events, including “People-Powered Medicine” (7 May 2016), a symposium about public participation in medicine and healthcare from 1800-present. More details can be found here.
[I]f you are not a keen observer of men and things, if you cannot read the book of human nature correctly, and unite knowledge of physic with an intelligent comprehension of the thoughts, feelings, and desires of mankind, […] you will be sadly deficient, even after twenty years’ experience.[i]
In the opening pages of The Young Practitioner (1890) – an advice guide for aspiring medical men – Jukes de Styrap proposes that what we might now refer to as emotional intelligence is a fundamental component of the general practitioner’s ‘bedside manner’.
The extent of his interest in the relationship between the “thoughts, feelings, and desires of mankind” and medical practice at the century’s close may surprise modern-day readers. The nineteenth century has traditionally been seen as a period in which the emotions became increasingly alienated or divorced from the practice of medicine. The era is often associated with a shift from the bedside to the clinic or laboratory; the introduction of medical and surgical instruments instituting more distance (both physical and emotional) between doctor and patient; and the ascendancy of more objective, ‘scientific’ ways of thinking and working.[ii] One might think of Francis Galton’s claim in 1874 that “[t]he man of science is deficient in the purely emotional element”.[iii]
In recent years, however, scholars working at the nexus of history, literature and medicine have challenged or revised this supposed trajectory from subjectivity to scientificity. They have pointed towards the way in which general practice in the Victorian period continued to privilege the role of interpersonal skills.[iv]
In this blog post, I will consider the ways in which the Victorian doctor was conceived as a reader or interpreter of the patient’s emotions before looking at how his or her own emotional life was conceptualised. While much can be said about emotions-as-etiology in medical discourse at this time, this post is primarily interested in how emotions figured in writing about the social aspects of medical practice, such as the doctor-patient relationship. It also largely focuses on models of general practice as opposed to hospital-based medicine.
This notion of the doctor as an interpreter of the patient’s inner emotional life has been identified and problematised in a raft of writing about historical and contemporary medical practice. For instance, in Somatic Fictions (1995), Athena Vrettos explains how
the idea that a body contained stories about an individual’s life, habits, heredity or emotions, and that doctors served as privileged interpreters of those stories provided the medical profession with a narrative structure for the revelation of social and scientific “truths”.[v]
In the history of medicine, this model of the doctor-as-reader is often associated with the profession’s rising claims to scientific authority. Yet in the opening of The Young Practitioner, de Styrap perceives an “intelligent comprehension” of emotions as something which must be yoked with “knowledge of physic”. The latter is not seen as granting immediate or unfettered access to the former.
During the Victorian period, medicine was conceived by many to be an art as much as a science. Medical writing often acknowledged an underlying empirical uncertainty to diagnosis and prognosis. The Young Practitioner cautions its young readers against over-reliance on “scientific ‘extras’, and modern instrumental and other aids to diagnosis”. It suggests that, by favouring these over “rational, subjective symptoms”, they risk ignoring the fact that “the art of curing disease is more indebted to sound judgment and common-sense bedside observation and experience than to aught else”. [vi] In “Behind the Times” (1894), a short story by Arthur Conan Doyle (himself a medical practitioner until 1890), two “young, energetic, and up-to-date” GPs find that the local community far prefers the attendance of the ageing Dr Winter. For “[h]e has the healing touch – that magnetic thing which defies explanation or analysis”.[vii] In texts such as these, the patient’s subjective experience is privileged over scientific knowledge, which is seen to be fraught and provisional.
The doctor was not merely supposed to discern or intuit his patients’ emotions. In some instances he was also expected to respond actively to their needs and preferences. De Styrap suggests that the young medical man “[s]eek to penetrate the character of each [patient], and to become an adept in adapting [his] manner and language to the case before [him]”.[viii] He feels that each patient should be able to “find in [the doctor] his ideal”. [ix] Undoubtedly there is a significant strain of romanticism in de Styrap’s writing. Reviewing his book, the BMJ notes that, “[t]he standards which he sets up for our conduct towards the public and towards each other is perhaps almost too high”, though it emphasises that “it is well that the standard should be put high”.[x]
The possible gap between rhetoric and practice should be acknowledged. In a 2007 article for Health and History, Sally Wilde suggests that much of the discourse surrounding the doctor-patient relationship was anathema to patient experience in the late nineteenth century. She describes how medical encounters in general practice and surgery involved many individuals. Patients may have included friends or family in their healthcare decisions and consulted multiple doctors. In hospital, they would have been treated by surgical teams and seen by an assortment of nurses. Wilde argues that the doctor-patient relationship was a myth perpetuated by the profession: “Doctors were concerned to establish that they had a special relationship with their patients in private practice, because their livelihoods were directly related to that relationship”.[xi] She suggests that doctors policed or regulated ideas of patient ‘ownership’ in the interests of remuneration and forming professional relationships with one another.[xii] While acknowledging a possible lacuna between medical discourse and the actual delivery of healthcare, I think it is important to emphasise medical writing’s vital role in shaping ideas about professional identity and the relationship between practitioner and patient.
Not all medical writing propounded an idealised doctor-patient encounter, moreover. While the patient’s emotional state was sometimes represented as a neatly stable and legible text waiting to be read or ‘diagnosed’, it was also understood that emotions could play a much more dynamic or even slippery role in the doctor-patient encounter. One might think of myriad instances in popular literature in which patient opinion towards the doctor and his practices is shown to be in flux. Examples include Harriet Martineau’s Deerbrook (1838), Anthony Trollope’s Doctor Thorne (1858), and George Eliot’s Middlemarch (1871-2). In these novels, patients form affective relationships with their family doctor but also move between practitioners in accordance with their thoughts and feelings about local rumour and innuendo. Ultimately, emotional responses to a doctor or medical procedure may have engendered compliance (even enthusiastic adherence) or resistance. Our exhibition on the history of vaccination at the Hunterian Museum explores public reactions to the introduction of compulsory vaccination in 1853. It shows how campaign material produced by anti-vaccinationists was often highly charged, gesturing towards the power of emotions in acts of public protest.
Furthermore, it was not only the patients who displayed unhappiness, frustration or anger towards their medical encounters in this period. Medical writing also illustrates less positive responses from the practitioners themselves. An article entitled “The Questions of Patients” – which appeared in the Midland Medical Miscellany in 1882 – amounts almost to a bitter invective against the public. It rails against “the ignorance and stupidity of patients” – particularly those from the poorer classes – including those who are “very anxious to render themselves objects of interest and pity”.[xii] The attitude displayed here is somewhat extreme, though hostility towards patients who were perceived as wasting the practitioner’s time was fairly commonplace. Prime examples of ‘nuisance’ patients included hypochondriacs, the garrulous, and those who summoned the doctor in the middle of the night for non-urgent cases.
Whether hagiographic or cynical, medical writing often tackled the role played by doctors’ own emotional lives. De Styrap instructs young men to manage and modulate their emotions in order to maintain their professionalism, while openly acknowledging that this may be challenging:
If you possess the power to control your temper, and to maintain a cool, philosophic composure under the thousand provocations given to doctors, it will confer upon you a signal advantage over those who cannot […][xiv]
In discussing the doctor’s emotional responsiveness, medical writing often emphasised the importance of qualities such as composure and authority. A satirical take on this can be found in Conan Doyle’s The Stark Munro Letters (1895) which depicts an irascible and unorthodox practitioner named Cullingworth. He tells the narrator (a more conventional young doctor) to “[b]reak your patients in early, and keep them well to heel. Never make the fatal mistake of being polite to them”.[xv] He contends that his patients have an appetite for his hot-headed and bullish demeanour – indeed they flock to his door, crowding his practice. In this extended parody, a medical character conceptualises a very different kind of bedside manner which is nevertheless somehow decidedly popular and remunerative.
Debates about the more subjective skills needed for medical practice often figured in discussions about whether women could or should work as doctors, which gathered pace from the 1860s onwards. At times, medicine was characterised as a distinctly masculine profession. In an editorial in 1870, the Medical Press and Circular describes how it requires “the highest qualities of scientific intellect” and “the knowledge of the world, the downright nerve, that have always distinguished the masculine temperament and character”. The writer contends that there are “an abundance of cases” in which the physician cures purely through “being able to ‘put his foot down’; in one word, by being a – man”.[xvi] Writers such as this implied that women would be emotionally ill-equipped to deal with the pressure of serious and emergency cases. Those in support of the medical-woman movement countered these claims, with some commentators championing the role that stereotypically ‘feminine’ characteristics could play in medical encounters. In Medical Women: A Thesis and a History (1886), Sophia Jex-Blake suggests that a male doctor may be ignorant of the “more sensitive and delicately organized feelings of his [female] patient” and that female practitioners would be better placed to respond to this.[xvii] These debates illustrate how ideas about women’s inherent emotionality could be used to either exclude them from, or embed them in, prevalent ideas about medical practice.
The emotions inhabited a fraught place in medical discourse during the Victorian period. They could be seen as antithetical or complementary to scientific attitudes. To be emotionally attuned was seen as a powerful tool for diagnosing the patient and winning his or her trust. However, excessive or uncontrollable emotionality could render both the doctor and the patient temperamental and unreliable. For a medical practitioner, learning to exercise control over one’s emotions was often seen as important in the formation of a professional identity and in relationships with one’s patients. However, this did not necessitate detachment or aloofness. Some argued that the doctor needed to be engaged with his patients, and highly adaptable, almost mercurial in his own moods and behaviour. It is significant that a good bedside manner – whether one interpreted this in terms of compassion and sympathy, or authority and command (or indeed both) – was associated with successful and remunerative practice. In a crowded medical marketplace, doctors needed to court prospective patients (at least those with money), tapping into their preferences and gaining their loyalty. Cultivating good interpersonal skills was seen to be in the interests of the patient and therefore the practitioner him/herself, a harbinger (if not guarantor) of professional and financial success. This demonstrates the reciprocity of the doctor-patient relationship, the way in which the patient’s values and priorities may have shaped writing about, and understandings of, medical interactions.
[i] Jukes de Styrap, The Young Practitioner (London: H.K. Lewis, 1890), pp. 1-2.
[ii] These histories have often been influenced by Michel Foucault, The Birth of the Clinic: An Archaeology of Medical Perception (1963) (London: Routledge, 2003).
[iii] Francis Galton, English Men of Science: Their Nature and Nurture (1874), 2nd edn (London: Frank Cass, 1970), p. 207.
[iv] Anne Digby, Making a Medical Living: Doctors and patients in the English market for medicine, 1720-1911 (Cambridge: Cambridge University Press, 1994).
[v] Athena Vrettos, Somatic Fictions: Imagining Illness in Victorian Culture (Stanford, California: Stanford University Press, 1995), p. 8.
[vi] De Styrap, pp. 76-7.
[vii] Arthur Conan Doyle, “Behind the Times,” in Round the Red Lamp, ed. by Robert Darby (Kansas City: Valancourt Books, 2007), pp. 3-7 (p. 5-6).
[viii] De Styrap, p. 32.
[ix] De Styrap, p. 32.
[x] “Review: The Young Practitioner”, British Medical Journal, 13 September 1890, pp. 632-3 (p. 633).
[xi] Sally Wilde, “The Elephants in the Doctor-Patient Relationship: Patients’ Clinical Interactions and the Changing Surgical Landscape of the 1890s”, Health and History, 9.1 (2007), pp. 2-27 (p. 17).
[xii] Wilde, p. 20.
[xiii] “The Questions of Patients”, Midland Medical Miscellany, February 1882, pp. 21-4 (pp. 23-4).
[xiv] De Styrap, p. 32.
[xv] Conan Doyle, The Stark Munro Letters (1895) (London: Amalgamated Press, 1907), p. 64.
[xvi] “Lady Doctors”, Medical Press and Circular, 23 February 1870, pp. 146-7 (p. 147).
[xvii] Sophia Jex-Blake, Medical Woman: A Thesis and a History, 2nd edn (Edinburgh: Oliphant, Anderson, & Ferrier, 1886), p.7-8.