Wednesday, February 16, 2011

History of Patient Modesty, Part 1

It is our pleasure to introduce to this blog guest columnist Jan Henderson, PhD. She is a historian of science and medicine who writes about the history of the medical profession as well as changing attitudes towards health care on her blog, The Health Culture. The following is the first of a two part series.

History of Patient Modesty - Part 1: How Bodily Exposure Went from Unacceptable to Required
Guest post by Jan Henderson, PhD
Even doctors can be embarrassed when it comes time to expose their private parts to medical personnel. In an essay that appeared in The Journal of the American Medical Association, a doctor describes her discomfort as she arrives for a colonoscopy appointment.
[A]s a person not exactly looking forward to the morning’s adventure, I found the receptionist’s demeanor and lack of eye contact wrapped me tight within a cold, impersonal cocoon. I was a subject. Though I hadn’t shared my sentiments with anyone, I felt both vulnerable and completely sheepish about having a very human reaction to such a common procedure. But this was my bottom and I was not happy to share it with others. Here to be exposed and invaded, in truth I was embarrassed and sought compassion. As anyone else would, I wanted to know that my discomfort, self-consciousness, and loss of control were understood. Instead, she exuded efficiency and delivered transparent quality assurance and poise.
The need to reveal private and intimate parts of our bodies is a routine occurrence in medical practice today. Though it may offend our modesty, we take it for granted that the embarrassing moments of a colonoscopy, a Pap test, or a prostate exam are necessary for our health.
Has it always been so? Have doctors always expected patients to disrobe? Have young male technicians always exposed the chests of female patients in need of a routine EKG? Have patients always been willing to allow doctors and their staff to view parts of the body normally seen by only the most intimate of partners?
The answer is a resounding no. Exposing the body for medical purposes is a relatively recent development. It began in the 19th century, before anyone now alive can remember. Prior to that time — for thousands of years — doctors considered it socially unacceptable and morally improper to examine an unclothed patient, especially a woman (the doctors at the time were all men). Over a period of just decades, however, doctors began to place stethoscopes on ladies’ bosoms and use visual scopes to examine the bladder, rectum, and vagina.
This was a significant change, both in the practice of medicine and in the experience of patients. How and why did this change come about? Part of the explanation comes from a change in the medical understanding of disease. A contributing factor was the erosion of a sharp distinction between physicians and surgeons. In what follows I give a brief account of why the practice of medicine changed and – in part 2 of this post — how the medical profession sought to convince patients to accept the change.
When physicians listened to patients
The practice of Western medicine, from the time of the ancient Greeks and Romans to the early 19th century, was based on the humoral theory of health and illness. The theory asserted that the interior of the body was filled with four humors or fluids: blood, yellow bile, black bile, and phlegm. When the humors were in balance – in a stable equilibrium – the individual was healthy. When out of balance, the patient became ill. This may seem quaint to us today, but note that this theory of internal balance lives on in traditional Chinese medicine and continues to inform the contemporary practice of acupuncture.
According to humoral theory, each individual could fall out of balance in a unique way, depending on the history and current circumstances of his or her life. Physicians might group illnesses into broad categories, such as fevers, fluxes (dysentery), or dropsies (edema), but the idea that many people could have the same disease (appendicitis, cirrhosis, diabetes) – though proposed in the 17th century — was not accepted until the 19th. In effect, there were as many “diseases” as there were patients.
To diagnose an illness, therefore, the physician needed to listen carefully to the patient’s account of sensations, symptoms, and life events. The patient’s narrative was considered much more important and revealing than any signs or symptoms a physician might observe. If the diagnosis was in doubt, the patient’s account took precedence over the physician’s observations.
The physical exam prior to modern medicine
In the era of humoral medicine, physicians practiced four methods of diagnosis, none of which required observing the unclothed body or touching the patient on a part of the body that was normally unexposed. The first, and most important, was eliciting the patient’s account of his or her own history.
The second was observation of the patient’s appearance, with special attention to the eyes and the face. This might include a look inside the mouth, including the tongue. Physicians would note the skin color and any peculiar behavior, listen to a cough or a wheeze, and note the smell of putrefaction, if present.
Occasionally a physician would feel an exposed part of the body for heat. Thermometers had been available since the 17th century, but the evidence they provided was not valued. A patient’s temperature did not always correspond to a subjective sense of warmth — a patient could have a fever, but feel chilled. And the patient’s account was paramount.
The third method was to feel the pulse at the wrist. Physicians did not count the number of beats in an interval of time. They listened for the quality of the pulse – how the pulse hit the fingers or varied over time. Again, this is similar to the practice of traditional Chinese medicine today.
The fourth method was to perform a visual inspection of various bodily excretions, such as urine, feces, sputum, pus, vomit, or blood.
How did such a physical exam lead to treatment of an illness? In a word, it did not. Based on experience, physicians were often able to offer a diagnosis – too much blood, too much bile – and a prognosis – a quick recovery or an imminent decline. Patients considered the prognosis valuable, since it was useful to know how long one might expect to be incapacitated.
The few treatments available – primarily bloodletting and purging – probably did more harm than good. This period is called the era of “heroic” medicine: Those who survived the treatment were heroes. For good reason, patients typically consulted physicians only when an illness seemed life threatening.
So, one reason physicians were highly respectful of patient modesty up until the 19th century was that the prevailing theory of disease did not require the patient to disrobe. Another part of the explanation involves the status of physicians in society and their social superiority to surgeons.
When surgeons got no respect
In ancient Greece and Rome, the theories of the physician and the practical skills of the surgeon were combined in one practitioner. Starting in the Middle Ages, however, when the lost writings of antiquity were rediscovered, a division occurred. Physicians acquired their medical training in universities, whereas surgeons learned their skills by serving an apprenticeship. Physicians, whose studies required proficiency in Latin, were highly regarded for their book learning and mental acumen. Surgeons, on the other hand, worked with their hands, an activity beneath the dignity of the gentleman physician.
Physicians and surgeons each treated a different class of patients. Physicians preferred members of the well-to-do upper classes. Surgeons attended to those who couldn’t afford the more expensive physicians. Each practiced medicine in a manner appropriate to their social standing and to the social standing of their patients. Physicians used their minds to theorize. Surgeons used their hands to lance boils. It would have been totally improper for a physician to ask a lady to remove her garments.
Surgeons, of necessity, did observe unclothed parts of the body. Before anesthesia and asepsis, surgery was of course quite limited. But surgeons operated on hernias, bladder stones, and anal fistulas. Even surgeons, however, were obliged to honor the wishes of a patient who was unwilling to submit to direct visual inspection or a manual exam.
In an 18th century account, a surgeon describes his treatment of a female patient. It took eight days before the patient revealed she had a tumor in her groin. “She would not allow me to see it, but told me it was as big as a small hen’s egg, and by gentle pressure of the hand receded, and never gave her any pain.” It took another four days — and then only because there was increasing pain — before the surgeon “prevailed upon her to let me see it.”
The idea that transformed medicine
In certain European countries – northern Italy, the Netherlands – the sharp distinction between physicians and surgeons began to break down in the 18th century. These new, modern doctors were willing both to theorize and to perform autopsies.
Human autopsies had been done as early as 1600. The ancient Greek understanding of human anatomy was based on animals, so human autopsies greatly improved anatomical knowledge. The most significant contribution of autopsies in the 18th century – the one that led to modern scientific medicine – was not anatomical knowledge, however. It was that physician/surgeons began to correlate the patient’s symptoms before death with what an autopsy revealed when the patient died.
The idea that a disease might be associated with a specific location in the body – in an organ or in localized tissues – had been proposed by Giovanni Battista Morgagni in his book The seats and causes of diseases investigated by anatomy, published in 1761. The “seats” in the title refers to bodily locations. Morgagni’s assertion — that internal lesions were located at specific bodily sites – was accepted only gradually over the next 100 years. This turned out to be the idea that transformed medicine from the humoral theory to the scientific medicine we know today.
Patient modesty inspires the invention of the stethoscope
Once medicine subscribed to this new anatomical approach to disease, the question became: How can we determine what’s happening inside the body by examining the outside? The attempt to answer this question prompted the invention of techniques such as percussion (tapping), auscultation (listening), and succussion (shaking the body and listening for a splash). It also led to the invention of diagnostic instruments. One of these instruments was the stethoscope, and its invention was prompted by the need to accommodate patient modesty.
In 1816, a French doctor, Rene Laënnec, was consulted by a young woman suffering from heart disease. Laënnec first tried to use percussion – tapping on the chest with the fingers – to gain information about the internal organs. This was not satisfactory, however, partly because the patient was female and partly because she was obese, which interfered with the production of meaningful sounds.
The doctor next considered an ancient technique – one that goes back to Hippocrates –that was currently making a comeback: auscultation. By placing an ear on the chest, one could listen to the sounds of the heart. In his account of the stethoscope’s discovery, Laënnec writes that he found this technique “inadmissible” because the patient was a young woman.
Then he had an inspiration. He was aware that sound can travel through a solid body, such as a piece of wood. If you scratch one end, you can hear the sound at the other end. Spying a square of paper lying nearby, he rolled it into a cylinder, placed one end on the woman’s chest near her heart, and placed the other end at his ear. He was “not a little surprised and pleased” with how clearly and distinctly he was able to hear the sounds of the heart.
An initial rift in the doctor/patient relationship
This first primitive stethoscope underwent a number of improvements over the ensuing years. It was another 20 years, however, before it was generally accepted by the medical profession. By allowing a respectable distance between doctor and patient, the stethoscope was able to overcome prevailing social conventions of modesty – at least with regard to listening to sounds inside the body.
One early stethoscope was several feet long and allowed the doctor to stand in a separate room. Most patients did not require such extremes. In 1829 a practitioner wrote of the flexible stethoscope – which allowed a greater distance than the original rigid instruments — that it could be used with ladies “in the highest ranks of society without offending fastidious delicacy.”
The stethoscope ushered in other hands-on diagnostic techniques. Percussion, for example, had been described and recommended to physicians more than 50 years before the invention of the stethoscope. It became an acceptable practice, however, only after the stethoscope’s use became common practice.
Other instruments for examining the body were developed in short order, many of them much more of an infringement on patient modesty than holding a stethoscope to the chest. Doctors were soon using scopes and specula to examine the bladder, vagina, and rectum.
The introduction and acceptance of the stethoscope was a major landmark in the history of medicine. This was not simply because of the information it provided — that was available by placing an ear on the chest. The stethoscope initiated a shift in the power relationship between doctor and patient.
No longer was the patient’s account of symptoms of primary importance. Doctors were increasingly able to diagnose an illness without any input from the patient. They became much more independent of their patients when it came to formulating a diagnosis. Medical professionals began to adopt a more self-reliant view of their abilities. This distance between doctor and patient became a salient characteristic of modern medicine.
Continued in part two.


The Nerdy Nurse said...

interesting to know that the nakedness some seem so willing to exhibit is a new phenomina in medicine.

Then again, I want my patients to be completely comfortable with any aspect of their care, and that includes the moments that require slight invasions of privacy for medical reasons.

That being said, I really wish their visitors would kindly close the bathroom door when they pee!

Joel Sherman MD said...

This is a fascinating topic which is rarely discussed or explored. It will help us reach a greater understanding of the issues we face today. I look forward to Part 2.

Jan Henderson said...

Nerdy Nurse -- I enjoyed your post on that subject. (And your images.)

Jan Henderson said...

There’s a history of attitudes towards “natural functions” that corresponds to patient modesty. As Europe emerged from the Middle Ages, many instructions were written down on how to behave properly. For example, this one from 1558:

It does not befit a modest, honorable man to prepare to relieve nature in the presence of other people, nor to do up his clothes afterward in their presence. Similarly, he will not wash his hands on returning to decent society from private places, as the reason for his washing will arouse disagreeable thoughts in people.

In the 19th century, women were reportedly ashamed to be seen going to or returning from the “necessary room,” the equivalent of what we now call a bathroom. Using words that referred to bodily flesh was considered indelicate. It got to the point where menus couldn’t mention chicken breasts.

Doug Capra said...

Two questions, Jan.
1. What were the causes of this attention to decorum and manners in the 1500's? Was it the attention that the Renaissance called to the importance of the individual and the self? I do know that all kinds of attitudes towards privacy began to change about this time.
2. To some degree, our bodily modesty has tied historically into social/class attitudes. In England (maybe other countries,too) servants were "invisible." Many of the aristocracy who had servants would consider undressing or bathing in front of servants as about embarrassing as undressing or bathing in front of their dog or cat. Any comments on that and how it might apply today?
Doug Capra

Anonymous said...

"It began in the 19th century, before anyone now alive can remember. Prior to that time — for thousands of years — doctors considered it socially unacceptable and morally improper to examine an unclothed patient, especially a woman (the doctors at the time were all men). Over a period of just decades, however, doctors began to place stethoscopes on ladies’ bosoms and use visual scopes to examine the bladder, rectum, and vagina."

The writer overlooks the fact that speculums were used by the ancient Greeks and the Romans.



Jan Henderson said...

Doug – I think the growing need for instructions on how to behave in the 1500’s came from the need to assert social/class distinctions. Here’s another example from 1570:
One should not, like rustics who have not been to court or lived among refined and honorable people, relieve oneself without shame or reserve in front of ladies, or before the doors or windows of court chambers or other rooms.

My source for this is Norbert Elias, The Civilizing Process, vol 1, The history of manners (a fascinating book). One of the things going on at the time was the creation of private places for bodily functions. Elias says the change in attitudes about modesty and manners can’t be explained by any technological fix, like indoor plumbing. There’s a lot going on socially and psychologically. The growing sense of an individual self may well be one component of this.

Yes, there seems to be a lot of evidence that upper class individuals thought nothing of disrobing in front of their servants. How might that apply today? I’m not sure, but here are some random thoughts.

I think Nerdy Nurse’s example of the family member of a patient who went into the bathroom, left the door open, continued talking to her, and used the toilet in full view is thought provoking. Does it reflect an attitude towards nurses and possibly other non-physician medical personnel? Or was it just a crude individual? Do we know what people do in their own homes in terms of closing the door? I suspect it runs the gamut from leaving the door open to being upset if the door doesn’t lock.

I had the experience once of going to a woman’s home to give her a Rosen Method bodywork session and, because she was (unbeknownst to me) a nudist, she took off her clothes and walked around naked the whole time I was there. I respect nudists, and I suspect most of them are more sensitive about imposing their nakedness on non-nudists. (I’m reading the Ruth Barcan book you recommended, and it’s fascinating.)

There are cultural differences. I’ve been to hot springs in Japan where men and women think nothing of disrobing and sitting around in the same pool. It took me a moment to accept it, but it was easier to accept than my naked client because there was nothing personal about it. There’s a difference between being naked one-on-one and being naked in a group -- assuming the nakedness in the group is voluntary and an act of free will. When it’s not, it’s a method of shaming used by those who practice torture. The free will in a group situation is probably questionable, because there’s pressure from the group. Sports physicals and group exams of young military men, as Dr. Sherman has written about here, are shaming.

Attitudes seem to change over time fairly rapidly. One of my Rosen Method teachers told me that when she studied at Esalen in the seventies, classes were conducted in the nude and everyone took it for granted. Young people took off their clothes at Woodstock. But young people today are very reluctant to reveal their bodies when other people are around. Barcan talks about how high school students don’t shower or even use the bathrooms at school.

Doug Capra said...

Excellent response, Jan. Here some of my thoughts. The modesty issues has several aspects, one of which is medical. Doctors and nurses didn't come out of nowhere -- they came out of a preexisting and changing cultural attitudes. To really understand modesty attitudes of patients, we need to study the social history of nudity and modesty and see how that interacts with the growth of medicine -- what you are doing. From what I've read, there's also the influence of the Christianity in Western culture, and attitudes toward nakedness and bodily function. Augustine was quite blunt in this regard, holding little back. But later things changed, and I think attitudes toward bodily function and modesty, at least in Western-Christian culture, emerged to a large degree from this tradition.

Jan Henderson said...

CW – Yes, medical practice in the time of the ancient Greeks and Romans was much more hands on than it was subsequently. Also, they didn’t have the physician/surgeon division. Galen was 2nd century AD, after which medical knowledge was lost in the West until the Middle Ages. So it would have been more accurate to say 1800 years. Sorry for the rhetorical exaggeration.

Suzy Furno-Maricle said...

Interesting article.
"No longer was the patient’s account of symptoms of primary importance. Doctors were increasingly able to diagnose an illness without any input from the patient. They became much more independent of their patients when it came to formulating a diagnosis. Medical professionals began to adopt a more self-reliant view of their abilities. This distance between doctor and patient became a salient characteristic of modern medicine".

I am anxious to read part two, as it seems the dilemma patients face seems to be derived from this attitude.
I believe it is worthy to note that the modern patient is changing. The chasm seems to be narrowing with volumes of available information allowing patients to feel like partners in their own care again. This leads to a return of modesty expectations as patients find their voices and question things that may have been an unspoken mystery before.

Jan Henderson said...

Suzy – Now that I’ve written this, I can see there’s a much closer tie than I’d realized between patient modesty and what I call the rift in the doctor/patient relationship. With technological advancements, doctors no longer needed to listen to patients the way they did before. This turns the patient into an object, which feels shameful (not to mention lousy). In part two, I talk about how doctors used claims of professionalism and scientific necessity to ease patients into accepting more invasive physical exams. Both of those increase the distance between doctor and patient.

I like your optimistic attitude towards how things are changing positively for more well-informed patients. The technology is always pushing doctors to new frontiers, which may make it hard for patients to keep up. I’ve been reading about Watson, the IBM computer that plays Jeopardy. The commercial purpose of that technology is to provide answers for doctors making a difficult diagnosis. And I just read an article on artificial intelligence software that allows doctors to determine which premature babies will be healthy, something too complex for physicians to do on their own. It’s always a brave new world.

I enjoy your blog. Thanks for your contributions to this subject.

mmodest said...

I am not in the medical field but have a question.I see picures of people the staff take of people in the OR .Is this legal?Im talking about every picture from the arm that is cut off to a man or woman naked.How does this happen?If I were standing next to a co-worker that took out a camera I would look at this person as a sub-human.Thinking the next person on the slab as some non emotional staff call it,Thinking maybe my next off shift they could be doing this to a loved one or me.

Joel Sherman MD said...

mmodest, many hospitals have you sign a statement on admission that permits them to take pictures, usually for purposes of documentation or education. You will likely have to read thru the statement carefully to find the clause in order to cross it out. The rare hospital that allows filming for TV is a special case. Please look at my thread on this topic on my other blog for an extensive discussion.