The Healing Arts
The state of the art
At the beginning of the nineteenth century, medicine still relied very heavily upon humoral theory, so that treatments such as bleeding and purging remained very prevalent for a wide range of conditions, and the concept of miasmas as responsible for disease transmission, although certain conditions, e.g. venereal diseases, were understood as communicated by contagion from an infected individual.
While miasmatic theory did lead to the removal of sources of noxious smells with some impact upon public health, this was by no means a universal panacea. It was not until 1854 that Dr John Snow proved that cholera was waterborne. Germ theory in its modern sense did not arise until the 1860s.
There had been some advances in effective treatment of certain conditions from empirical observations. Cinchona bark (fever bark) was efficacious in attacks of malaria and other fevers. It took some while for James Lind’s work on the prevention of scurvy and other issues of health in the Navy to be taken up but they were eventually accepted. Digitalis, extracted from the foxglove, had been known to be of use in treating dropsy since classical times, and was put on a scientific and more reliable basis by the studies of William Withering, published in 1785. Variolation against smallpox - inoculation with a mild strain of smallpox - had been introduced to Britain from Turkey by Lady Mary Wortley Montagu in the early eighteenth century. It was, though not without considerable controversy, superseded by Edward Jenner’s promotion of vaccination - infection with the harmless related disease of cowpox.
There were limits as to how far surgery could advance prior to effective anaesthesia or the understanding of germ theory that would lead to the development of antiseptic procedures. However, anatomical knowledge had greatly developed, and leading surgeons displayed considerable skill. They were obliged to operate extremely rapidly to avoid the patient going into shock, and sepsis remained a risk. While the developments of the later part of the century led to a historical narrative that suggested emergence from a benighted era of bloody butchery, Peter Stanley, in For fear of pain: British surgery, 1790-1850 (Rodopi, 2003) has argued that surgeons had developed significant operative skills and were more humane in their practice and attitudes than this gave credit for. There are, however, very few patient narratives of what it was like to undergoing an operation under these conditions: the 1811 letter by the novelist Fanny Burney (Mme D’Arblay) giving an account of her mastectomy is a very rare example.
Anaesthesia for surgical operations was not introduced into the UK until 1846, having already been pioneered in the USA - the early experiments of Davey and Faraday with nitrous oxide had led to recreational ‘laughing gas parties’ but not medical uses. However it then rapidly became used - Dr John Snow, also known for his work on cholera, administered chloroform to Queen Victoria for the birth of Prince Leopold in 1853. Approaching the problem from a different angle, Dr John Elliotson made great claims for mesmerism, both for suppressing pain in surgery, and its more general benefits.
As far as pain relief went, there was opium, widely available in particular in its tincture form as laudanum. It was addictive and had numerous side-effects.
In diagnostic methods, the stethoscope, invented by Rene Laennec in 1816, was gradually gaining acceptance and its design being improved.
‘Taking the waters’: going to a spa town, or, increasingly, the seaside, where the mineral waters or sea-bathing were alleged to convey some benefit to health. In some instances and for some ailments it is entirely possible that the waters did have some ameliorative effect. These towns also became resorts for general recreation and entertainment. Change of air and rest in new surroundings may have led to improved well-being, or at least allowed the healing powers of nature to do their work.
Medical education was becoming increasingly formalised, rather than being on an apprenticeship/household model. This meant that various opportunities which had existed during the eighteenth century for women to be recognised as healers beyond their domestic role were vanishing. The medical profession fell into three main categories:
Physicians: these were the elite, with a classical education from Oxford or Cambridge, and would not perform surgical operations.
Surgeons: in England, these had long shed their association with barbers and become a learned profession: the College of Surgeons of London was granted a Royal Charter in 1800.
Apothecaries, who compounded drugs: in 1815 the Apothecaries Act gave the Society of Apothecaries the right to grant a licence to practice medicine, on the basis of sound education and training.
Many entrants to the profession who could not aspire to the expensive elite education necessary to qualify as a physician, trained in surgery and acquired the licentiate of the Apothecaries: these ‘surgeon-apothecaries’ were the original general practitioners.
There were also numerous practitioners who specialised in some particular treatment (e.g. oculists) as well as outright quacks.
Although midwifery continued to be an overwhelmingly female profession, surgeons and surgeon-apothecaries increasingly pursued training in obstetrics.
During the eighteenth century, a number of hospitals were founded upon a charitable basis to supplement the services provided by the ancient Royal hospitals of St Bartholomew’s and St Thomas’s established in the Middle Ages and the provision under the Poor Laws for those who were eligible. These hospitals also provided facilities for medical education.
The rise in formal medical education and the importance of anatomy was faced by a crisis in the supply of bodies for dissection, either for teaching or research purposes. Only the bodies of executed criminals were permitted to be dissected, and by the early decades of the nineteenth century, the imposition of the capital penalty had declined considerably. This led to the development of the illict trade of ‘body-snatchers’ or ‘resurrection-men’ who would dig up recently buried bodies from graveyards and convey them to anatomists. However, the 1832 Anatomy Act finally instituted a system of licensing to practice anatomy with government inspectors, and made provision for legal access to unclaimed bodies for dissection for the purposes of medical education and advancement of scientific knowledge - also some individuals, notably Jeremy Bentham, left their bodies in their wills for dissection.
Nurses at this period often have a bad reputation (we may blame Dickens for some of this in his depiction of Sairey Gamp and Betsy Prig), but in 1840 Elizabeth Fry set up the Institution of Protestant Nursing Sisters to provide for the better training of nurses. The idea was that they should nurse patients in their own homes and were employed by the wealthy as well as serving among the poor.
Following the inception of the New Poor Law 1834, Edwin Chadwick, secretary to the Poor Law Commissioners, had observed that reasons to do with health, including infectious disease, was a major factor leading the poor to seek poor relief. He proposed various sanitary measures to improve public health. The campaigning of the Health of Towns Association, and the approach of a new wave of epidemic cholera, led to the passing of the 1848 Public Health Act, which provided a framework for action but did not compel it. This enabled the setting up of Local Boards of Health with extensive powers to control sewers, clean the streets, regulate environmental health risks including slaughterhouses, and ensure the proper supply of water to their districts. The Medical Officers of Health appointed by these boards (who had to be qualified doctors) produced annual reports which constitute a valuable source for the history of many aspects of urban life in nineteenth-century Britain: see, for example, London’s Pulse.
L.A. Hall, FRHistS