This essay will explore the ways in which the ‘Patient Knows Best’ approach has changed from the 18th to 19th centuries and how it has transformed the patient/doctor relationship. It will reveal the advent of dissection and how it has impacted the way we practice modern medicine, what ‘Germ Theory’ is and why the rise in laboratory medicine in hospitals is/was important. As well as discussing which a few key individuals and how they contributed to modern medicine and how the invention of significant medical implements and machines allowed vital advancements in medicine.The ‘Patient Knows Best’ approach to medical treatment has gone through many incarnations over the centuries. Even now, in the 21st century, the approach remains ever evolving.
However, this section of the composition will focus on the ‘patient knows best’ approach during the 18th and 19th centuries. During this period, one must keep in mind the medical knowledge/understanding and social status. This indicates the doctor-patient relationship could only go as far as their respective introspection, communication and the skills of the doctor could allow. Furthermore, in the 18th century, there were few doctors and those who benefited from their care were the upper class and aristocrats (Kaba et al, 2007).
This meant patients held a great deal of the power as doctors had to vie with other doctors to acquire and retain a patient. Therefore, doctors based their patient care on ‘individual symptoms’, with little need for physical examination and mainly focused on the needs of the patient. This established the dominance of the patient over the doctor and due to this imbalance the ‘Model of Illness’ was born (Kaba et al, 2007). For instance, the kind of treatment one would expect during this time was based on an ancient theory called ‘Four Humours’ which was taught and practised by doctors well into the 18th century. It was believed humours were liquids inside the body; blood, phlegm, black bile and yellow bile. Each humour had a corresponding season of the year and an element; air, water, earth and fire.
For example, spring was associated with blood, so an illness during that time meant there was too much blood (humour) in the body. Hence, the practice of bloodletting to restore the balance of the humours in the body (Dobson, pg. 9,12).However, in the late 18th century, the advent of hospitals arose which meant not only the upper class could gain medical care, but the disadvantaged could benefit from it as well. This marked the end of doctors passively treating patients. The growth in medical care, an ever-increasing knowledge of microbiology and surgical skills gave rise to a new medicine, the biomedical model of illness (Kaba et al, 2007). This meant the patient would be treated not merely based on a symptom or illness, but based on an exact diagnosis of pathology.
Doctors possessed the clinical skills and anatomical knowledge to diagnose patients thus creating a significant change in the relationship between doctor and patient. The imbalance of knowledge and skills placed the patient in a passive role which is known as the paternalistic model (Kaba et al, 2007). The paternalistic model infers the doctor is acting in the patients’ best interest and expects the patient to passively accept and follow their direction regarding diagnosis and treatment (Kaba et al, 2007).Today the patient knows best approach is still evolving as technology and communication have made the greatest impact on the doctor-patient relationship (Collins et al, 2011). Currently, it is about patient empowerment.
This means patients want clear communication, informed choice and quality of care. Making the relationship between doctor and patient more of a collaboration (Collins et al, 2011).”We study the past to understand the present; we understand the present to guide the future.” — William LundThroughout the 17th century, there were many crucial advances in the fields of pathology and vaccinations which laid the foundation for the next century (Robinson, 2011).
Regardless of those advances, the early 1800’s still remained rather medieval in the treatment of illness. The use of heavy metals, arsenic, along with using leeches or bleeding were the norm. ‘Quack’ doctors were also very popular and mainly used by those who could not afford to see a trained doctor. The ‘quacks’ were essentially salesmen who proclaimed their wares could cure may ailments (Dobson, pg. 61). However, according to Robinson (2011), there were two main things that brought progress in the prevention and cure of illnesses…cities and science. The Industrial Revolution brought factories and jobs, the steam engines provided greater mobility, therefore people were moving into the cites. The expansion of the cities wasn’t without consequence as there was overcrowding, poverty and poor sanitation.
Diseases like smallpox, typhus, tuberculosis endemic and cholera had become epidemic (Robinson, 2011). Sir Edwin Chadwick felt there was a connection between poverty and disease and due to his work, the Public Health Act 1848 was enacted, which brought local health boards, the investigation of sanitation throughout England and the setup of a General Board of Health (Robinson, 2011).In the mid-1800’s it was believed cholera was due to miasma which means bad air. However, a physician named John Snow disagreed and said cholera was not airborne but entered the body through the mouth. Snow published and presented an essay called ‘On the Mode of Communication of Cholera’ in 1849. It was not well received as he had no concrete proof, so no action was taken. Nevertheless, in 1854 Snow was able to prove his theory when there was a cholera outbreak in Soho (BBC, 2014).
He discovered that cholera was water-borne and identified this outbreak was caused by unsanitary water from a water pump. The pump was removed, and the cases of cholera reduced very quickly. Unfortunately, Snow’s germ theory of disease did not make great effect until the 1860’s (Robinson, 2011). The ‘Germ Theory’ states that diseases are caused by microorganisms which enter the body and cannot be seen without the use of a microscope (Encyclopaedia Britannica, 2017).In the late 1700’s Anton van Leeuwenhoek was a pioneer in microscopy as he was the first to make and use a microscope. He was able to discover several biological specimens such as bacteria, yeast plants, the microorganisms in a drop of water and the circulation of blood in capillaries (Vision Engineering, no year).
He also found “little animals” in samples of saliva and sputum. However, it wouldn’t be until the 19th century that the ‘little animals’ were found to be microbes that could spread disease. (Dobson, pg. 33). Further, to Van Leeuwenhoek’s work, a scientist named Robert Hooke went on to publish the first book of microscopic studies in 1665. Thanks to these men the advancements in biological science were immense (Vision Engineering, no year).The two scientists, who further contributed to the formation of John Snow’s ‘germ theory’ and microbiology are Louis Pasteur and Robert Koch (Science Museum, no year).
In 1854 Pasteur began experiments to discover why wine and beer were spoiling. He discovered it was because of bacteria and microorganisms in the liquid. In 1862 he further discovered they could be killed by being heating the liquid to 50 – 60 C then cooled. This process became known as pasteurisation and is still used today for wine, beer, milk etc (Hodkinson, 2015). With this knowledge, Pasteur began experimenting with the decaying of meat. His hypothesis was if liquid can decay due to microorganisms and bacteria than decaying meat should be caused by them as well, which Pasteur thought could be an explanation of disease in the body (Science Museum, no year). The first vaccine he discovered was in 1879 while working with a disease called chicken cholera. It was quite by chance that Pasteur discovered this as he had accidentally exposed the chickens to a weakened form of the culture.
He found the chickens had become resistant to the virus (Biography, 2018). Pasteur continued to extend the germ theory and discover more causes and vaccinations for diseases such as anthrax, cholera, TB and smallpox (Biography, 2018).Robert Koch was a physician and microbiologist whose work with anthrax, tuberculosis and his discoveries with cholera would bring the “Golden Age” of discovery (Blevins et al, 2010). Koch began working on anthrax while he was the District Medical Officer in Wollstein as anthrax had taken the lives of 528 people and 56,000 livestock in just four years. The bacteria anthrax had rod-shaped structures which were found in the blood of the plagued animals and he also provided proof that anthrax could be transmitted via injecting healthy animals (Blevins et al, 2010). Koch discovered the bacteria would change if the conditions were in a warm, moist, aerated environment. Part of the bacteria would decompose, and sections would dry into spheres which only needed a fluid for the anthrax bacteria to form again. These spheres were spores that would contaminate soil for years.
Koch was the first to uncover a cause and effect of a disease, the ‘life cycle’ of anthrax had been discovered (Blevins et al, 2010). Koch would go onto identifying that tuberculosis was a bacterium in the sputum and lungs which was passed from person to person by the infected sputum. Koch also learned that the bacteria, while needing a host to live, it could retain its pathogenicity for weeks outside of the body. Therefore, strategies were put in place regarding the disposal of items contaminated with sputum and ways to decontaminate the environment (Blevins et al, 2010). Clothing, bedsheets and clothes were to be sterilised to help the spreading of the disease (Blevins et al, 2010). Later Koch would discover, through performing nearly a hundred autopsies, that the cholera bacteria was found in the small intestines of the afflicted. Further investigation leads to find the source was contaminated water. The access to clean water showed a vast drop in the number of cholera incidences (Blevins et al, 2010).
It would have been impossible for Pasteur or Koch to make these discoveries had it not been for the microscope or the opportunities to make further advancements by working in laboratories. Not only that but the ability to improve upon the equipment or developing new ways to study microbiology allowed further progression in the field (Blevins et al, 2010). For instance, Koch made great advancements in microscopy by drying bacteria in liquid then applying dyes such as eosin, fuchsin, safranin and menthyl violet which made the bacteria easier to see.
This technique also enabled the scientist to detect morphological characteristics which would normally go undetected with a living sample (Blevins et al, 2010). Furthermore, in 1879 Koch would join the Imperial Health Office and began working on his plate technique which would create uncontaminated cultures of bacteria. Koch grew colonies of bacteria exposing them to chemicals and steam which became of great importance in the fields of disinfection and sterilization. The study also determined that while some chemicals would eradicate bacteria, others would only reduce them. The discovery of this difference would have a great impact during the antibiotic era (Blevins et al, 2010).From the 18th century, scientific contributions toward microbiology brought about the need to delve deeper into the pathology of disease. Doctors believed an autopsy could uncover a direct correlation between the symptoms and changes to pathology (Dodson, pg.
34). The use of dissecting a human cadaver as an anatomical teaching method has been done for centuries, but during the 15th century, the French were making great strides in the development of pathological anatomy. This due to the building of large hospitals after the French Revolution and had Paris quickly became known as ‘the capital of the cadaver’ and students from all over Europe and America came to study (Dodson, pg.
34). However, until the 16th century it was illegal to perform dissections in England. In 1565, until the mid-1800’s, special permission was given to a select group of physicians from the Royal College of Physicians and the Company of Barber-Surgeons to perform dissections. While this was an advancement the two groups had only ten bodies per year to share between them (Mitchell, 2011). Throughout the 16th century England, criminals who had been hung were given to the anatomists to perform dissections. However, by the 17th century, the demand for bodies became greater due to the publishing of anatomy books from Italy and France. The availability of these books would move anatomy forwards and English physicians would begin to produce original work of their own (Mitchell, 2011). In 1628 William Harvey, an English physician who performed many dissections on hanged criminals, made an immense discovery when he found that blood circulates around the body by the pumping of the heart.
He was also able to approximate how much blood was in the body (Lambert, 2017). His work, De moto Cordis et sanguinis or On the Motion of the Heart and Blood was published in 1628 (Mitchell, 2011). While there were advances in 17th-century medicine there was still a strong belief in treating disease/illness with the four humours and believed miasma caused diseases. Fortunately, advances in medicine brought a more scientific approach and the beginning of questioning the accepted ideas of medicine (Lambert, 2017).
Surgery was continuing to progress during the mid-1700’s and saw a surgeon named John Hunter invent a procedure called tracheotomy (Lambert, 2017). In 1799 it was discovered that ether relieved pain when inhaled, but it was decades later in 1842 when it was used during an operation for the first time (Mitchell, 2011).Medical schools and anatomists needed more bodies for research and training, therefore, the Murder Act 1752 was passed which legalised the dissection of executed murderers for educational and research purposes. Further, the government increased the number of crimes which were punishable by hanging. While the Murder Act 1752 was helpful, in time, due to the rapid growth in anatomical and medical training there was an even greater need for bodies (Mitchell, 2011). Some people recognised this was a way to make money and so the ‘resurrectionists’ would rob fresh graves and sell the bodies to medical and anatomy schools (Mitchell, 2011). The Anatomy Act 1832, in the hopes to curtail grave robbing, murdering or stealing bodies, legalised the dissection of unclaimed bodies from workhouses and charitable hospitals (Ghosh, 2015).
The 19th century brought rapid progress in all areas of science. The stethoscope was invented in 1816 by Rene Laennec who first used a roll of paper and later made a stethoscope of wood (Lambert, 2015). John Snow, Louis Pasteur and Robert Koch each had their own theories and made several outstanding discoveries which advanced the germ theory and microbiology as well as preventative steps and cures for diseases (Lambert, 2015).
Chloroform began being used in operations by James Simpson in 1847. In 1865, Joseph Lister would discover antiseptic surgery which was done by spraying the patient with carbolic acid during surgery. Shortly after, German physicians would discover better sterilisation procedures which meant their clothes and hands were sterilized before surgery as well as the instruments. This allowed the surgeons to perform more complicated surgeries. (Lambert, 2015). Between the 1820’s to the 1860’s, hospital medical schools were becoming the principal providers of anatomical teaching.
By 1871, there were eleven hospital anatomy schools in London and virtually no independent schools left (Mitchell, 2011). In 1858 Henry Gray, an English anatomist and surgeon published a medical textbook called ‘Gross Anatomy’ which is better known as ‘Gray’s Anatomy’. Gross anatomy is a branch of anatomy that studies the structure of organs and tissue that is visible. ‘Grey’s Anatomy’ is still in print and used today (Dodson, pg. 39). In 1895, Wilhelm Roentgen, a professor of physics in Bavaria, discovered by using electromagnetic radiation he could produce an x-ray.
The invention was an immense breakthrough for medical history and allowed the first views of how the inside anatomy of a human body worked without the need to perform a surgery (British Library, No Date). Glasgow Royal Infirmary set up the very first radiology department in 1896 and without the ability to x-ray Wilhelm Rehn would not have been able to perform the first heart surgery in 1896 (Lambert, 2015).For centuries the dissection of human cadavers has been the main teaching method of gross anatomy. However, over the past few decades, the use of dissection has decreased in favour of modern technology such as virtual dissection (Ghosh, 2015). However, without the use of dissection, we wouldn’t be where we are today. Dissection provided evidence of disease, cures, vaccinations, how our hearts pump and circulate blood throughout our bodies, advancements in technology i.e.
the x-ray machines which began a whole new field of medicine…radiography which became a revolutionary treatment for cancer. With progression came change regarding the doctor and patient. It went from patient led treatment of symptoms, to the biomedical model approach which describes the relationship as a paternalistic model where the doctor has the skills and knowledge to effectively treat the patient. Today, technology has allowed people to be more aware of illnesses and treatment options. Patients want to communicate with the doctor, be heard and be an active part of treatment options. The patient/doctor relationship will no doubt continue to change just as technology and advancements in medicine will increase.