The Day the Universe Changed - James Burke [104]
The early stethoscope in use. While the doctor’s eyes are watchful, the patient is shown to be passively obedient, not comprehending the complexities of the new medical technology.
As a result of both these developments, examination of the patient became much more detailed. Laennac examined dissected corpses for evidence of a particular disease, then listened to the activity of the relevant organ in a living patient presenting symptoms of the same diseases. By the correlation of symptom with sound he was able to identify emphysema, edema of the lungs, gangrene of the lungs, pneumonia and, above all, tuberculosis, the mass killer of the age.
Laennac had succeeded in his aim of placing internal organic lesions on the same level as surgical diseases. The British reaction indicates how far behind French hospital practice they were. ‘There is something even ludicrous,’it was said in England, ‘in the picture of a grave physician formally listening through a long tube applied to the patient’s thorax.’
By the end of the first quarter of the nineteenth century an entirely new view of disease and treatment had developed in Paris. Thanks to the success of the surgeons in localising disease and through the correlation of living symptoms with post-mortem evidence, pathological anatomy had become a scientific field of investigation. Symptoms were no longer the prime source of data, merely the surface condition provoked by the interior activity of disease which affected tissue and organs, though not necessarily the entire body.
The new techniques of examination rendered irrelevant the patient’s own view of his disease, as percussion and stethoscopic techniques gave the physician access to events inside the body of which the patient was in most cases unaware. The use of statistics made large-scale observation essential to the collection of accurate data on disease and therapy. As a result of all these advances, the relationship between doctor and patient changed radically, as did the social position of the medical profession itself. The sick patient was no longer the assessor of the doctor’s competence.
As an increasing number of clinical techniques became generally accepted, it was the medical profession which became the arbiter of the individual doctor’s performance. The most important relationship in the physician’s life was now that with his fellow-professionals. Bedside secrets gave way to a desire among doctors to share techniques and information in return for recognition and advancement in their careers. In the 1820s a battery of medical journals appeared in Paris. These encouraged the division of medical labour, as the first specialists began to concentrate on the behaviour of particular organs.
The body had been redefined as the locus of disease. The bilateral evaluation between doctor and patient had gone. The doctor was now in control. The temptation to extend that control was seductive. Already, in the eighteenth century, the revolutionaries had been aware of the need to improve the living conditions of the urban masses. Jean-Jacques Rousseau, in his Discourse on the Origins of Inequality in mid-century, had characterised illness as a feature of civilised society, attributable to the harmful effects of unhealthy environment and incompetent medicine. Society, he suggested, was naturally pathogenic.
For the first time, the meaning of the term population, as the mercantilists used it, took on the added implication of ‘commonality’, the non-noble classes, the labouring poor who were too ignorant to be responsible for their own well being. In 1818 C. F. V. G. Prunelle, lecturing in medicine at Montpellier, referred to the relationship between a healthy populace and a productive nation. Echoing Frank he advocated direct state intervention in housing, marriage, clothing, occupation, leisure, and so on, in order to ensure and maintain a healthy environment. Curative medicine should move