Madeleine Mant // The profound synergistic effect that distance—both geographic and sociocultural—plays upon health care access and outcomes is no surprise to contemporary physicians. As modern technological interventions such as eConsult, which allows patients’ cases to be ‘seen’ by a specialist without an in-person visit, become more commonplace, it is worthwhile to reflect on the historical roots of such dialogues. Letters between past physicians and patients are invaluable primary sources for anthropologists and historians of health. Indeed, the consultative letter format so entrenched in contemporary medical records appears in a nascent form in historic epistolary medicine.
During the long eighteenth century (c. 1666-1837), the symptomatological approach to illness meant that the physician’s interview with the patient—either through letters or in person—was a crucial step in diagnosis, though a physical examination of the body was not. If a physical examination did occur, it would primarily be limited to looking rather than touching; a patient’s complexion and lesions, if present, would be observed and their pulse may be taken. In the late-eighteenth and early-nineteenth centuries, the physical examination gained importance as the idea that disease could be localized in a certain organ became increasingly accepted. During the majority of the eighteenth century, however, the physician did not yet have privileged access to the patient’s illness; it was the responsibility of the patient to articulate his or her troubles, often in the form of a consultative letter. 
Letter writing was particularly common for rural patients, for whom the journey to visit a physician residing in a more populous town might be impossible, and for patients seeking advice from famous medical practitioners. The tone of such correspondence reveals individuals seeking to strike a balance between genteel pleasantries and issues of an intimate physical nature. For example, Dr. William Thomson wrote to a patient in 1776 to inquire about his unusual urination, writing:
“I am just now favoured with your letter, and will, with great pleasure pay every attention to the circumstances you mention relating to your health…but before I prescribe for you, I must beg leave to enquire a little about this frequent making of water in the morning” .
Euphemisms most frequently appear in the discussion of women’s gynaecological and menstrual issues; letters concerning “constitutional cases”  are common. Patients describe their symptoms with “almost obsessive clinical detail”  but are aware of matters of respect and class.
Consultation letters reveal clues as to how patients embodied their experience of pain. Some referred to themselves as “myself” or claimed ownership of the affected body part while others created distance, discussing a damaged or ailing appendage as “it.” Failing bodies were sometimes met with humour; David Hume, whilst dying of cancer, wrote “my body sets out tomorrow by Post for London; but whether it will arrive there is somewhat uncertain.” Joan Lane, in studying reams of diaries and correspondence kept by eighteenth-century sufferers notes that “patients’ responses to illness varied greatly, but a strongly fatalistic strand [characterizes much of the correspondence] as well as a stoicism towards personal suffering almost incomprehensible to the modern reader.” For example, a patient writing to physician James Simpson recalled his pre-anaesthetic amputation by saying that “suffering so great as I underwent cannot be expressed in words, and thus fortunately cannot be recorded.” Physician Thomas Beddoes bemoaned the fact that “language has not yet been adjusted with any degree of exactness to our inward feelings.”
Patients’ labels for their conditions reveal their assumptions about illness, its causes, and its remedies. Many conditions, from hot flashes to convulsive eye twitching to rising vapours, were described as making the patient “uneasy” or producing feelings of “oppression,” demonstrating pain’s embodiment as emotion. Writing in the late seventeenth century, Samuel Pepys kept detailed records of his bowel and stomach pains, recording that “after dinner, my pain is increasing, I was forced to go to bed; and by and by my pain is to be as great for an hour or two as ever I remember it was.” Others expressed their pain and sickness in emotional terms such as having “frights,” “apprehensions,” or “heartsickness.” Metaphors of heat and cold were also commonly invoked. Elizabeth Howland, writing to Hans Sloane in 1708, describes “a great sharpness and heat in [her] bloud.” Images of torture such as “beating,” “pricking,” and “Knawing”  are also present. The body is often described as a machine; sufferers describe a “thickening of fluids” or having a “lack of spring.” Following the 1740s, many described their suffering in reference to their nerves, bemoaning how their nerves “contracted” or “twitched,” as the nervous system became increasingly central to medical thought and explanation. Some patients’ nerves were overactive, causing them “tensions,” “spasms,” and “convulsing,” whilst others felt that their nerves were not stimulated, causing them “numbness,” “weariness,” and “despondency.”
Understanding the humoural body provides clues concerning the Georgians’ subjective and cultural experience of their bodies, or what Bourdieu termed habitus. Patients often provided detailed descriptions of the natural functions of the body, particularly evacuations of waste, demonstrating that they felt little embarrassment . The common language of humoural metaphors, such as “location, movement, pattern, intensity, emotional response, hotness or coldness, moistness or dryness, and sharpness or heaviness” , allowed physicians and patients to communicate despite possible class differences.1 Dialogues between physicians and patients created a pidgin medical lexicon. Descriptions of sickness and injury by lay people included colloquialisms, vulgarisms, and dialect-specific words while medical practitioners used what Jonathan Swift referred to as the “hard names”  of the medical establishment—the Latin and standard English terms.
Historical letters provide the means to access elements of past patients’ experiences, as they struggled both with their symptoms and the language required to communicate their conditions. Modern technological solutions such as video conference telemedicine and accessing secure electronic communication with providers have been proposed to bridge distances, while still foregrounding patients’ concerns. While the “bells and whistles [of telemedicine] are different” , the function of an eConsult interaction and a historic consultative letter are the same: maintaining relationships and continuity of contact between patients and their caregivers.
1 Interestingly, many of the possible descriptions of pain that may result from these descriptions resemble options on the McGill-Melzack Pain Questionnaire (1971) currently employed in many physicians’ practice.
Image credit: Michael Jarmoluk (Pixabay)
[1.] Porter, Roy. “The Rise of Physical Examination.” Medicine and the Five Senses, edited by W illiam F. Bynum and Roy Porter, Cambridge University Press, 1993, 179-197.
[2.] Bynum, William F.., & Porter, Roy. Medicine and the Five Senses, Cambridge University Press, 1993.
[3.] Armstrong, David. Political Anatomy of the Body: Medical Knowledge in Britain in the Twentieth Century. Cambridge University Press, 1983.
[4.] Jewson, Nicholas D. “Medical Knowledge and the Patronage System in 18th century England.” Sociology, 8, 1974, 369-385; Porter, Roy. “Laymen, Doctors and Medical Knowledge in the Eighteenth Century: The Evidence of Gentleman’s Magazine.” Patients and Practitioners: Lay Perceptions of Medicine in Pre-Industrial Society, editor Roy Porter, Cambridge University Press, 1985, 283-314.
[5.] Louis-Courvoisier, Micheline & Mauron, Alexandre. “‘He found me very well; for me, I was still feeling sick’: The Strange Worlds of Physicians and Patients in the 18th and 21st centuries.” Journal of Medical Ethics: Medical Humanities, 28, 2002, 9-13.
[6.] Gregory, John. On the Duties and Qualifications of a Physician. 2nd ed., London, 1820, 21.
[7.] Lane, Joan. “‘The doctor scolds me’: The Diaries and Correspondence of Patients in Eighteenth Century England.” Patients and Practitioners: Lay Perceptions of Medicine in Pre-Industrial Society, editor Roy Porter, Cambridge University Press, 1985, 205-248, 222.
[8.] Wild, Wayne. Doctor-Patient Correspondence in Eighteenth-century Britain: A Change in Rhetoric and Relationship. Studies in Eighteenth Century Culture, 29, 2000, 47-64, 48.
[9.] Bakan, David. Disease, Pain, and Sacrifice: Toward a Psychology of Suffering, University of Chicago Press, 1968.
[10.] Hume, David. The Letters of David Hume Volume II 1766-1776., editor J.Y.T. Greig, Oxford University Press, 1932, 315.
[11.] Lane, 217.
[12.] Quoted in: Loudon, Irvine. Medical Care and the General Practitioner 1750-1850. Oxford: Clarendon Press, 1986, 73.
[13.] Quoted in: Porter, Roy. “‘Expressing yourself ill’: the language of sickness in Georgian England.” Language, Self, and Society: A Social History of Language, editors P. Burke and Roy Porter, Polity Press, 1991, 276-299, 282.
[14.] Smith, Lisa Wynne. ‘An account of an unaccountable distemper’: The Experience of Pain in Early Eighteenth-century England and France. Eighteenth-Century Studies, 41, 2008, 459-480, 463-4.
[15.] Pepys, Samuel. The Diary of Samuel Pepys, Vol. 4: 1663, editors R. Latham & W.G. Matthews, University of California Press, 2000, 463-4.
[16.] Smith, 464.
[17.] Quoted in Smith, 465.
[18.] Smith, 467, 469.
[19.] Pilloud, Séverine, & Louis-Courvoisier, Micheline. “The Intimate Experience of the Body in the Eighteenth century: Between Interiority and Exteriority.” Medical History, 47, 2003, 451-472, 460.
[20.] Stolberg, Michael. An Unmanly Vice: Self-pollution, Anxiety, and the Body in the Eighteenth Century. Social History of Medicine, 13, 2000, 1-21, 20.
[22.] Pilloud & Louis-Courvoisier, 464.
[23.] Bourdieu, Pierre. Outline of a Theory of Practice. Cambridge University Press, 1977.
[24.] Duden, Barbara. The Woman Beneath the Skin: a Doctor’s Patients in Eighteenth-Century Germany. Harvard University Press, 1991.
[25.] Smith, 465.
[26.] Swift, Jonathan. Journal to Stella, editor H. Williams, Oxford University Press, 1948, 512.
. MacDonald, Susan, personal communication, 23 January 2019. Dr. MacDonald is one of the physicians responsible for bringing eConsult to the Canadian province of Newfoundland and Labrador.