7
Feb

Doctors in the Regency By Alicia Rasley

Old St. Thomas's Hospital, Southwark

Old St. Thomas's Hospital, Southwark

Doctors in the Regency By Alicia Rasley

 The first realization about medicine in the Regency era is that it bears almost no resemblance to modern medicine. The great discoveries that have helped most of our great-grandparents live long enough to create our grandparents were yet to be discovered.

What historian Roy Porter calls “The Three A’s” were developed later in the 19th Century and into the 20th:

❖ Anaesthesia

❖ Antiseptics (and antisepsis)

❖ Antibiotics (ultimately)

So when you imagine a medical practice without those three, well, you’ll probably think of Regency-era physicians as not much advanced since the Middle Age alchemists and astrologers.

You would be wrong, of course. In fact, most the knowledge that led to the discoveries of germs, immunization, and pain medication existed in the Regency era. It just hadn’t been codified and institutionalized enough to be written down and accepted as standard practice or lead to lab research.

But many doctors everywhere already knew that, for example, washing their hands before removing a bullet or delivering a baby would lead to decreased chance of infection. They knew this not from textbooks or med school, but from their own observations and experience, and the wisdom passed on to them from older physicians and midwives and nurses. An experienced doctor would know also that bodies stop bleeding after death, and the more curious might link this to the cessation of the heart’s pumping.

One (Jenner) even realized that a bit of an infectious agent (pox) could immunize the body against a more virulent form of the disease. (It took almost 200 years, but his discovery eventually eradicated one of the most dangerous diseases in the world, and all those of us who still have the pock mark of the smallpox vaccination on our arm or butt can appreciate how far we’ve come.)

In fact, the Regency-era doctor had many folk remedies and tried-and-true practices at hand. Surgery (albeit without effective anesthesia—yes, the patient would usually just get very drunk!) had been practiced for two thousand years. DaVinci and many other scientists and artists had discovered much about anatomy (just don’t ask where they got the bodies). There was little in the way of medicine besides the same herbal remedies healers had been using for centuries. But physicians had discovered the paradoxical benefits of poison—that is, the use of toxins to “kill” disease (though often it killed the patient too). So arsenic, mercury, and heavy metals like gold were used to treat many diseases, especially venereal diseases. They were actually occasionally effective, though the pain they caused might have created a placebo effect (if it hurt so bad, it had to be helping).

Medical Education

While much of medical knowledge was acquired from tradition, Regency Britain had a number of important medicals schools, most then (as now) associated with major hospitals. For example, one of the oldest medical schools in the world (12th Century) was situated in St. Bart’s, the old hospital just outside the London city wall. Here students received clinical training on the most difficult cases, for hospitals were so full of contagion, few patients would go there unless they were in a very bad way. So new young physicians might not have much training in the more routine conditions they’d mostly be faced with in their eventual practice.

The Regency era saw a growing professionalization of the medical career. While many medical men could still practice without formal education, many young men chose to attend medical school to qualify in the newly licensed professions of physician and apothecary (pharmacist).

Not all “doctors” were physicians. Some were called merely “surgeons.”

English: Statue Of John Keats-Guys Hospital-London

Statue of John Keats at Guy's Hospital, London.

 

Surgeons didn’t necessarily perform surgeries in the modern sense, as they were more what we’d now call “GPs” or general practitioners, treating the common ailments of ordinary people. These men served an internship with an older doctor, learning on the job. One rather memorable example is the great Romantic (late Regency-era) poet John Keats, who at 16 became the apprentice to a Mr. Thomas Hammond, a general surgeon. Keats was a fairly typical apprentice (except for the great poetical talent) in that he was of the lower middle class (grandson of a livery stable owner) and educated beyond grammar school.

As medical historian Dr. Arpan K Banerjee reports, Keats was fortunate (and so are his readers!) that his apprenticeship was not difficult and allowed him plenty of time to write poetry.

John Keats, by William Hilton (died 1839). See...

John Keats by William Hilton

He was even allowed release time by his indulgent master to attend more classes at his old school. His duties seem to have been fairly menial, cleaning the surgery (the examining room) and tending to the surgeon’s horses. But he must also have had some training, for in 1814 after two years, he left the apprenticeship with enough knowledge to set up as a surgeon.

Fortunately for English literature, the law changed the next year requiring a five-year apprencticeship and a six-month training course to be licensed as a surgeon. Keats apparently still had his aim as a medical career, and he applied to medical school, which kept him in London where he could meet Leigh Hunt, the editor who published his first poems.

From Keats’s experience, we can learn a lot about Regency-era medical education. For example, Banerjee writes that Keats paid 25 pounds 4 shillings (a considerable sum equivalent to about six months wages for many workers) for a 12-month course of study at Guy’s Hospital in Southwark (just south of the Thames, very close to the site of Shakespeare’s Globe Theater). Guy’s was, and is now, one of the more prestigious of medical schools.

Keats took anatomy, physiology, and surgery, and to earn more money became a “dresser” at the hospital. This job appears to have little to do with dressing the doctors, but much to do with applying dressings to wounds. Dressers were doctors’ assistants, performing minor surgical tasks and taking notes. After a year of schooling, Keats qualified to take the apothecary exam and passed. Apothecaries were pharmacists, mixing medications to sell to the public. Keats could have continued with his education to become a physician, or stopped then and set up shop as an apothecary. But—the writers among us might recognize this sequence of events—he got his first acceptance letter (for a sonnet), and quit medicine forever.

Banerjee concludes, “John Keats is surely the only Licentiate of the Society of Apothecaries to be a member of the select pantheon of great poets of the English language. Few others in this pantheon lived a shorter life than he, yet Keats managed to qualify as a doctor in this time in addition to producing a prolific poetic output.”

Notice that Banerjee refers to Keats as a “doctor” though he did not complete the medical training needed to be a physician. In fact, there were three medical roles for men: surgeon, apothecary, and physician. Keats qualified only for the first two of those, but they were all considered to be “doctors”. However, to attain the position of physician during the Regency, a student would need another year of education or more, and hospital training. And Keats, as we all know, chose poetry instead.

During the Regency, surgeons and apothecaries were titled “Mr.” as in “Mr. Keats.” Only those who qualified as physicians were allowed the title of “Dr.”

Guy’s (which united with St. Thomas during Keats’s years) was probably the most prestigious of medical schools in the kingdom. However, Edinburgh was also known for giving an exceptional medical education, and many of the most prominent 19th Century physicians (including Conan Doyle) trained there.

After medical school, a physician could take further training and become a “consulting physician,” brought in by other doctors to diagnose and recommend treatment in complicated cases.

Medical Instruments

Doctor's Saws and forceps

Doctor's Saws and forceps

Regency-era doctors used black leather medical bags to store many of the instruments used by doctors today—lancets and scalpels and primitive syringes (mostly used, I’m afraid, to inject mercury into penises to cure venereal diseases). There were also weird and frightening instruments fortunately no longer used, like bleeding cups and uterine probes.

The stethoscope, that ubiquitous marker of a medical career, was invented in the middle of the Regency (1815-16) by a slightly prim French physician, who boasted the quadruple-barreled name Rene Theophile-Hyacinthe Laennec.

One day, when he needed to examine an obese young woman, Laennec hesitated to put his head to her chest. Remembering that you can hear a pin scraping one end of a plank by putting your ear to the other end, he came up with the idea for a stethoscope prototype. He rolled a stack of paper into a cylinder, pressed one end to the patient’s chest, and held his ear to the other end.

“I was surprised and pleased to hear the beating of the heart much more clearly than if I had applied my ear directly to the chest,” Laennec said in 1816.

Laennec’s first manufactured stethoscope was a simple wooden tube. A succession of different designs followed his, including, eventually, a “binaural” type with two ear pieces.

Of course, Laennec probably wasn’t the first physician to use a “hearing tube” to listen for a heartbeat, just the first to mass-manufacture it for sale. Your Regency-era physician, even if he had no access to a medical-instrument mail order catalog, could certainly devise his own stethoscope with a rolled-up journal or a river reed. (Reeds, btw, were also useful as primitive catheters, used to treat bladder impactions even back in the middle ages.)

The blood pressure cuff had not yet been invented; however, most doctors understood the concept of blood pressure as the intensity of the pumping in the body. They could make assessments based on observation of pulse and flushing. In fact, the most effective instrument was still the doctor’s own body, his fingers testing the pulse, his eyes assessing the color of the skin or feces or urine, his hand recording his observation for later contemplation.

Medical Practice

Washing bench and Bandage Roller

Washing bench and Bandage Roller

Most doctors in the Regency era were surgeons of the older sort, those who had learned their craft through apprenticeships and hands-on experience. They served villages and towns, and in most areas of London too.  However, “physicians” would be the medical professionals sought after by the ton for their greater training and expertise (and price).

Still, the life of a physician was considerably different than experienced today. For one thing, a medical career didn’t put a doctor squarely in the elite as it might today. A few were knighted, mostly for doctoring the royal family or for coming up with some important medical advance.  But few physicians would be invited to ton parties, except those perhaps who tended to the duke or the countess and might be needed in a crisis.

He could make an adequate living, equivalent perhaps to that of a sea-captain (300 pounds a year), or if a specialist or “consulting physician” earn considerably more, up to 2000 pounds after the Regency. But physicians didn’t become wealthy then, for theirs was a mostly retail practice—housecalls to sick patients, holding “surgery” for those able to walk in to the office. Payment was generally by the incident (sometimes with barter of farm goods or other services). But some physicians had something of a “subscription practice,” what we’d now call “concierge medical treatment,” where the richer families paid a fee per annum to keep him on retainer.

A slightly later (mid-century) account of a young physician’s practice can be found in
Middlemarch, where the promising young doctor Mr. Lydgate is thought to have married “up” when he weds the daughter of minor (untitled) gentry.  As he was just starting his practice in a new town (rather than taking over his father’s or uncle’s or mentor’s practice, which was more common), he had to woo the landed families in the area, sometimes seducing them away from established physicians. Though Middlemarch takes place a few decades after the Regency, its account of a village surgeon tells of a life similar to that of Regency practitioners.

Physicians and surgeons did have privileges (as now) in hospitals. However, hospitals were mostly in the cities, and seldom used by most of the populace. In fact, they were long considered sources of contagion. Just superimpose a Google map of hospitals in London over the map of old London. Most hospitals are, even now, outside of where the old City gates would have been, because they were where plague, TB, and other infectious patients would be sent.

Most doctors in the Regency era practiced in villages and towns, and seldom visited a hospital. Many did try to keep up with medical advances, such as they were in that time before the “age of miracles,” before medicine became a science.

Medical Learning on the Job

The great 17th Century doctor William Harvey famously told his students, “Don’t think, try.” This advice demonstrates how doctors in the centuries before the great modern advances still managed to practice good medicine and even cure diseases.

The network of physician correspondence and medical journals of the period shows the Regency patient or physician was not relegated to leech applications and mustard poultices. In fact, without ringing the Walgreens to order up a Cipro prescription, a Regency-era physician had plenty of tools at his diaposal (yes, they were almost all “him,” but there were women nurses, midwives, and healers then).  Just remember, though, that medical knowledge was mostly inductively attained then, through experience, observation, and experimentation.

“Inductive” means making conclusions from evidence.  For example (going ahead a couple decades), Florence Nightingale used the evidence of many battlefield hospital deaths by infection to start an experiment of “clean water and clean hands”.  Just that cut deaths from 42% to 2% in four months, an outcome striking enough, and visible enough, to get her discoveries published and promulgated. However, she would probably not have been the first health care worker to have noticed this. So yes, a Regency doctor could certainly wash his hands between patients. He might not know exactly why, but he’ll know it helps save lives.

Another example, reported by Robert and Nancy Mayer, is the treatment of scurvy by ships’ surgeons in the Royal Navy. Some ship surgeons noticed how sufferers craved green vegetables, and correctly supposed that filling up on fresh produce during landfalls would cure the disease. Other surgeons, trying to figure out how to maintain health during long voyages, settled on citric juice and crystals as easily preserved nostrums.  They didn’t have to know much about vitamins to observe the health benefits of fruits and vegetables.

Physicians of this pre-modern period were always observing and sharing realizations and revelations in the Regency-equivalent of an internet list, the formal journals put out by medical societies and the informal networks of posted letters and reports. For example, the letters of Edward Jenner (the small pox guy) show that he was constantly sending and receiving letters from other doctors speculating about medical issues and reporting on observations. In one letter, Jenner anticipated (in the 18th century!) modern cardiology when he traced heart problems to arterial narrowing. Many of these informal physician correspondences are collected in medical school libraries and the Royal College of Physicians.

Medical journals were also sources of information and research for doctors in the Regency period. However, these journals could be expensive, so poorer doctors might share a subscription and post the issues back and forth. A scanned copy of the very first (1809) issue of the Journal of the Royal Society of Medicine “Medico-Chirurgical Transactions” can be found here at the NIH’s Pub Med Central, which has been digitizing millions of pages of medical journals. This includes an article titled “A case of violent and obstinate Cough, cured by a preparation of Iron“.  The Royal Navy surgeons, who were responsible for the health of a hundred thousand seamen, had several journals for reading and reporting. Even more common was the circulation of surgeons’ logs and private journals. Accounts of these have been collected in the British National Archives.

Doctors also learned by experimenting, sometimes to the detriment of the current patient.  Stephen Maturin, the ever-curious physician in the Patrick O’Brian “Aubrey” series (a must read) once reported to his captain about a “successful” surgery where he and another surgeon had tried out a new technique in opening up and stitching together a wound. Captain Aubrey said gladly, “Mr. Brown came through, then.” But Stephen shakes his head. Well, no, the patient died—but the operation was still a success, because they’d learned from it.

In fact, earlier medicine tends to come to the right conclusions for the wrong reasons—keep that in mind when you want to have the physician explain his miracles. The medieval concept of “bile,” for example, turns out not to be so determinative, but the physicians then were certainly correct that certain bodily fluids could transmit disease.  Use this “right for the wrong reason” to help your doctor soothe his patients. For instance, the novelist Umberto Eco has two madhouse doctors discussing a profoundly hypochondriac patient. These doctors believe in the late 19th C magnetism therapy, where a steel rod is placed against the flesh of a patient to “attract” the disease away from the body.  Of course, we would think of this as a big scam, but guess what? It worked. Why? Those doctors didn’t know what the “placebo effect” was, but the “double-blind placebo” has always been a solution to some mental illnesses. If both the doctor and the patient believe this will work, well, why not try it?  Maybe the “cure” is psychological, but maybe the illness is too.

Where Are the Women?

Women practiced medicine too, but generally not as physicians until the middle of the 19th Century. Before that, women were confined mostly to allied health roles, acting as midwives and nurses as well as herbal healers. None of these women (until Florence Nightingale in the 1840s) achieved the prestige and fame of physicians. But then, as now, the survival of sick patients often depended much more on the nursing than the doctoring.

Until after the Regency, most British babies were delivered by midwives, women who might or might not have had nursing training, but were usually educated as apprentices to older midwives. Midwives were often blamed for obstetrical problems and maternal deaths, but in fact, until antisepsis and c-sections, most doctors didn’t always have successful deliveries either. Midwives were also suspect because they had knowledge of herbs and practices that could cause abortions.

In fact, for centuries herbal knowledge had been acquired and passed on by women herbalists and healers.  In fact, we should never forget that physicians had the benefit of a couple thousands of years worth of herbal knowledge. In fact, many of the most effective medications had long  been derived from plants.  Peruvian bark, for example (“powdered and mixed with wine”), was known to cure malaria; it wasn’t until the advance of modern chemistry later in the 19th Century that the bark was discovered to contain quinine (still used as a treatment).  Similarly, “Jesuit’s or willow bark” was used as a painkiller and fever-break. We now know the synthetic counterpart of this as “aspirin.”

You won’t be surprised to hear that women performed important medical work but were generally denied the prestige and title of “doctor.” There was, however, at least one woman who was called “Doctor” and achieved some measure of renown: James Miranda Barry. Yes, she had to masquerade as a man through medical school and her entire career as a military doctor.  Interestingly, her most lasting legacy might have been her work improving the obstetrical surgery of the c-section, and was known as the first doctor to perform this surgery and attain the result of both mother and child surviving. It wasn’t till she died that her “perfect femaleness” was noted by the charwoman who prepared the body for burial.

She might have been the first woman doctor in Britain, but she wasn’t the last. Like so many other medical miracles, the first women’s medical school in London came in the latter half of the 19th Century, later graduating many of the most prominent early women physicians.

But in the time of the Regency, there was only Doctor (Miss) James Barry, and thousands of unstoried women who practiced openly as nurses, midwives, and herbalists.

St. Thomas's Hospital 1830

St. Thomas's Hospital 1830

Implications for Regency Romance Writers

 While of course Regency writers want to be historically accurate, there’s enough play here that our doctor characters can truly be healers and not killers. Just remember what Harvey said, “Don’t think, try.” Long before medical science proved that clean hands meant better outcomes, some doctors and nurses and midwives had already observed that and changed their practice to allow for frequent handwashing.

 And you writers can definitely have your 1815 doctor observe the battlefield at Waterloo and notice that some of those fallen had friends there to bundle them up and get them out of the rain. A priest might attribute their greater survival rate to the friends’ prayers, but your doctor doesn’t have to know about “shock” to suspect that getting a patient warm and out of the mud helps the outcome.

From the time of Hippocrates, doctors have been trained to observe and record, take careful notes and make judgements based on their experience. And from ancient times, and particularly in the Regency, British doctors shared that experience formally and informally, contributing incalculably to the great bulk of medical knowledge.

After all, the “Age of Miracles” of the mid- and late 19th Century happened because of the close observation and sharing of experience of doctors during and before the Regency. Our Regency doctor characters might not have lived to see anaesthesia, antisepsis, and antibiotics, but their more meticulous practices certainly made the Three A’s more likely.

Alicia Rasley

Alicia Rasley is a RITA-award winning Regency novelist who has been published by major publishers such as Dell, NAL, and Kensington. Her women’s fiction novel The Year She Fell has twice been a Kindle bestseller in the fiction category. Her articles on writing and the Regency period have been widely distributed, and many are collected on her website, www.rasley.com

You can check out her Regency novels on her Kindle Page. She is currently at work on a Regency mystery romance with a doctor hero who always washes his hands.

 

An In-Depth Explanation of Medical Treatment in Aubrey’s Royal Navy

Indiana University School of Medicine Library of Medical History

http://library.medicine.iu.edu/special-collections-and-services-container/history-of-medicine/

 

2 Comments:

[…] My hero suffered from severe wounds, and I had to research if they had painkillers then or he would indeed have suffered even more horribly. Or how his wounds would’ve been treated. Here’s a site about medicine: http://main.thebeaumonde.com/archives/2392 […]

January 29, 2013 at 10:11 am Researching History « Jenna Rose Ellis reply

This post was very helpful (and distracting) in giving an educational history to my novel’s Dr. Watson! Okay, so it’s just fan fiction, and a twisted one at that since I’ve set Sherlock Holmes in the Regency period, but it’s been great fun learning some of the little details for the time period (lots and lots of romance writers’ blogs). I’ve been collecting the weirdest notes on everything from Luigi Galvani to a diary from a body snatcher to virtual Regency dress-up dolls. I’ll have to add this to my list. Thanks!

April 5, 2013 at 1:47 am Sally reply
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