The Doctor Will See You Now...

Would you rather overhear your doctor tell your nurse “The brain aneurysm in room 338 needs your attention” or “Mike in room 338 is feeling unnerved and could really use some support?”  

Your response to this question reflects what is now recognized as the “medical gaze.”  The “medical gaze” reflects the relationship between doctor and patient, wherein a suffering patient relies on an authoritative and knowledgeable caretaker. And yet this idea that a doctor sees a patient as a collection of symptoms or pathologies – perhaps instead of seeing them as a whole person – represents historical and social change. French philosopher Michel Foucault developed the phrase in 1963 to portray the 19th century medical profession and its shifts from earlier orientations of medical practice.  Foucault claims that the concept of the medical gaze can be summed up in the shift from physicians asking patients “What is ailing you?” to asking, instead, “Where does it hurt?”  The first question is meant to encompass how a disease, pain, or symptoms affect the entirety of the patient and his life; the second question focuses on parts and symptoms, not the whole person.  

While Foucault has made a powerful point, in this exhibit we explore how medical gaze is dynamic, reflective of the partnership between physician and patient, and not always solely focused on parts or cures.

In earlier periods of medical history, especially Medieval and Renaissance sources we explore in this exhibit, the medical profession’s understanding of the patient was portrayed in more humanistic terms. Images and texts often focused on the connection between mind and body in relation to a person’s life experiences – and even to things like religion and astrology, in which understandings of health and illness were imbedded.  In many of these early sources, it is as if the doctor gains understanding of the patient through his overall life story or place in society.  This may be attributed to not only societal views of medicine, but also a lack of modern medical knowledge, technology, and techniques at that time.  

These images reflecting earlier versions of the medical gaze contrast with later depictions of patients as a collection of parts, or a disease category rather than a person. Foucault explains, “Facilitated by the medical technologies that frame and focus the physicians’ optical grasp of the patient, the medical gaze abstracts the suffering person from her sociological context and reframes her as a ‘case’ or a ‘condition’” (2003: 23) The doctor, in this case, strives for disease treatment, but not necessarily patient care.

The texts in this exhibit highlight the cycles and trends of the medical gaze throughout history.  We begin in 1500, a time when medicine was represented as more humanistic, capturing the value of life experiences and the relationship between, mind and body, soul and society.  We then take you on a journey through time, exploring the medical world’s transition into specializations, which serve to create further distance within interpersonal doctor-patient relationships by concentrating on parts in need of attention rather than a whole person in need of empathic treatment.  Finally, we will explore the revolution of the medical gaze, revisiting the ways that 15th and 16th century values of humanistic medicine have resurfaced, while also taking advantage of modern advancements in medical knowledge and science.

1. A Caregiver’s Guide (Joannes de Ketham, Fasciculus Medicine.  Venice: Joannem et Gregoriu de Gregoriis Fratres, 1500.) Incunabula 74
    
   1. 1500: Ketham’s Fasciculus Medicine, the first published medical textbook with anatomical illustrations, teaches doctors how to administer care to best help the afflicted person. A picture within the text portrays doctors tending closely and carefully to a patient.  Since the illustration above depicts the full body instead of individual afflicted body parts, medicine at this time focused on how these afflicted parts affect the person as a whole. Although doctors must examine afflictions to individual regions of the body, they most importantly must investigate how all afflictions compose the patient’s overall condition.
2. Peeling Away the Layers (Juan de Valverde.  Anatomia del Corpo Humano.  Rome: A. Salamanca et A. Lafrerj, 1560.) Rare Book QM21 .V35 
    
   1. 1560: Notice how this illustration now focuses on the layers of the body. The medical gaze narrows: by studying musculature and the nervous system, doctors form a comprehensive view of the individual’s condition and whole-body health. We begin to see a division of the body, while maintaining a humanistic, or personal, view of medicine.
3. Instruction Manual (Jean Cruveilhier.  Anatomia Pathologique du Corps Humain.  Paris: J. B. Bailliere, 1829-42.) Rare Book RB33 .C96 (2 volumes)
    
   1. 1842: 300 years later, medical textbook artists stray from sketching the natural curves of the body covered in muscles or skin. Instead, they create colorful illustrations of diseased ovaries and pathologic hearts.  The illustrations not only suggest the beginning of specialized fields in medicine, but also portray “normal” versus “abnormal” body structures.  Doctors learn not so much individualized patient care, but rather comparative views of patient symptoms reflective of determined “standards.”
4. The Manual Fails (Ann Kalmbach.  My Nine Migraine Cures.  Rochester: Visual Studies Workshop, 1987.) Sherman Special N7433.4.K35 A4 1987 (not available at Rauner)
    
   1. 1987: “Aspirin - NOT BETTER YET.”  My Nine Migraine Cures expresses the frustrations that patients when they suffer from symptoms that doctors cannot treat. With this more modern turn in the medical gaze, doctors pay less attention to patient narratives and fail to listen, which can undermine finding the most effective treatment.  They resort to prescriptions that “normally” work, such as Aspirin for headaches.  In this case, as anthropologist Susan Greenhalgh explains, there exists a “disjunction between the physician’s narrow view of his task as finding and fixing disease, and the patient’s larger view of her illness as part of a life that needs to be put in order” (2001). When “normal” treatments do not work, doctors cannot provide further care if they do not understand the patient’s narrative.
5. Patient Speaks (Martha Hall.  Legacy.  Orr’s Island: M. Hall, 2001.) Presses H166hale 
    
   1. 2001: The book may be small, but the message is bold: “Your books will be your legacy.”  A week before Dartmouth Tuck Business School graduation, Martha Hall was diagnosed with breast cancer.  Working for better cancer patient care, she founded the Cancer Community Center in South Portland, Maine.  She represents her frustrations toward the medical community in her artist books, revealing her doctors’ insufficient support. Hall takes healing into her own hands by standing up for herself, demanding better care. If she does not speak up for herself, no one will.  ATTENTION, Hall screams. There is a need to reform the medical gaze.
6. Physician Answers (Martha Hall.  Voices: Five Doctors Speak.  Orr’s Island: M. Hall, 2001.) Sherman Special N7433.4.H355 V65 1998 (not available at Rauner)
    
   1. 2001: Good news! The language implemented by this particular doctor on this page of Martha Hall’s Voices inspires a transition back towards patient-centered care in the medical profession.  The rhetoric a doctor uses in a conversation with a patient easily dictates the direction of the discussion and the patient’s comfort with sharing more information about himself.  Although this particular page shines hope on the situation of the current medical gaze, many of the other pages reflect lack of personalization by four other doctors.  The contrast works to represent the reality of the variation in the medical gaze.

The anatomy lab, where first-year medical students dissect human cadavers, has long been a mainstay of medical education. Over the years, the environment of the lab has changed, as have the demographics and procurement methods of cadavers. This shift has affected students’ perceptions of the bodies they study. While previous generations often knew the source of their cadavers—prisons, poorhouses, or local graves—and treated them according to social norms, today’s students view cadavers with impersonal respect, knowing little about their backgrounds.

Founded in 1798, Dartmouth Medical College demonstrates this evolution. In the 18th and 19th centuries, demand for human cadavers led to the practice of grave robbing, which afforded students the opportunity to view real (albeit decomposing) cadavers. To the medical students, such acts were seen as justifiable: the victims were poor people and criminals who did not garner respect in life or in death. Consequently, students may have studied their cadavers with a sense of moral superiority; these attitudes may have translated into how they later treated live patients. Grave robbing declined by the end of the 1800s, though the bodies of the poor were still sold to medical schools. By the later 19^th and early 20^th century, donating one’s body to science was possible. However, body donation was unpopular until the 1960s.

Now, whole-body donation is considered an ultimate act of altruism, and it no longer carries the same social and moral taboos. Additionally, today’s anatomy lab is a clinical environment where cadavers appear more homogenous. In places like Geisel Medical School today, body donors are largely older, white, and affluent. In addition to demographics, embalming methods also create a sense of uniformity. Like biomedicine as a whole, the anatomy lab has become an increasingly controlled setting, leading to respectful treatment of cadavers, but also a form of depersonalization that can make it more difficult to identify social determinants of disease and death.

1. “Grave robbing in New England” DC Hist A637 .W3
   1. In 1796, Dartmouth College announced plans to open a medical school. It is no coincidence that, the very same year, the New Hampshire legislature enacted the state’s first laws regarding grave robbing. Before the relatively recent rise of whole-body donation, medical students often relied on stolen corpses for their anatomical studies. This book, written in 1945, describes the history of this practice. Public burial plots, known as potter’s fields, were common targets, as were the graves of criminals. Authorities rarely investigated a disturbed grave in a public plot.
2. “Apology” Letter from Dartmouth Students. Manuscript 810900.6
    
   1. In this 1810 letter to Dartmouth faculty, medical students apologize for an “unhappy occurrence:” namely, an instance of grave robbing that occurred in Norwich, VT. Though the students nominally acknowledge the feelings of the townspeople whose graves had been robbed, they also imply that grave robbing was a necessary action. The students write, “...It shall be our studious care that nothing of the kind, in future, shall attach itself to our department.” Indeed, they seem to regret not that they robbed a grave, but that they were caught!
3. Dissecting the Northwood Murderer. Photofile: Medical School -- Dissection
    
   1. In 1874, students at Dartmouth Medical College had a rare opportunity: they dissected a serial killer. Franklin Evans, known as the Northwood Murderer, was convicted of killing two young girls, and was thought to be responsible for five other deaths. Upon being sentenced to death, Evans’ last request was that his body be sold to Dartmouth College for dissection. When Evans was put on trial, he was asked why he had killed the two girls. His reason? He wanted to examine their bodies to learn about human anatomy. It is likely that medical students were considering their cadaver’s infamous past as they studied his body.
4. New York Times Covers Grave Robbing at Dartmouth
   1. One of the most recent instances of grave robbing at Dartmouth occurred in 1895. Medical students were made aware of the fresh grave of a Norwich man who had recently committed suicide. They disinterred the body, but they were inexperienced at the practice and were caught. Medical college faculty bailed them out. One student involved in this affair, John Gifford, was appointed as a lecturer at the medical school (perhaps as compensation for his grave robbing efforts). He later became a prominent physician.
5. Students Pose with Bodies. Photofile: Medical School -- Dissection
    
   1. Today, students study cadavers in a controlled, clinical setting. But students at Dartmouth Medical College in 1908 performed their work in a less-restrictive environment. At this point, students were often studying bodies of the socioeconomically disadvantaged. Poorhouses sold bodies that went unclaimed by family members. In this picture, pipe-smoking students pose with their cadavers. In the back corner, a cadaver is sitting, lifelike, holding a canoe paddle. One student holds his cadaver’s hand as he props up the body. Though the cadavers are posed to appear alive, they are not humanized as much as objectified.
6. Photographs by Ernest Foss. MS-1243
    
   1. By the mid-1900s, whole-body donation was emerging but still rare. This photo album, created by medical student Ernest Foss in 1935, depicts scenes from the anatomy lab: students carefully dissect cadavers, discuss structures with professors, and, in this photograph, showcase their morbid sense of humor. In general, the environment looks more like that of a modern-day lab than the previous photographs, though some students still smoke pipes as they work.
7. Medical Instruments and Tools Having Belonged to H. O. Smith, Non-Graduate, Dartmouth Class of 1886. Smith O. Henry. Dartmouth College. Realia 191
8. “The Silent Lecture” by Thomas Flynn (Geisel '19)
    
   1. Today, whole-body donation is considered to be an altruistic act, and the cadavers used for dissection are treated with respect. Anatomy curricula go to great lengths to humanize cadavers, albeit within the clinical environment of the lab. One example of this is the “My First Patient” letters that first-year Geisel School of Medicine students write about their experiences in the lab, with “their” cadavers. Thomas Flynn, Med’19, wrote this poem about his cadaver. The work showcases the humanity that Flynn saw in the body, but also raises a contradiction: Though medical students become intimately familiar with the physical characteristics of their cadavers, they know very little about their lives and social positions. Similarly, the arena of biomedicine emphasizes standard practice over individually-tailored care, making it at times more challenging for doctors to consider the unique experience and background of a patient.