Take this ‘slug’ of medicine

Medical historian Suzie Grogan unearths what today’s surgeons and GP predecessors were treating – and charging – in the 18th and 19th centuries.

From the relative comfort of the 21st century and the medical advances we enjoy now, it is both horrific and fascinating to learn about the conditions, concerns and ‘cures’ that were part of life – and death – for our forebears.

Some illnesses and diseases prevalent in the 18th and 19th century we rarely see today. Some have different names and many are now deemed to be minor inconveniences rather than life-threatening conditions.

Real progress was not made in the treatment of some of these conditions until the development of antibiotics in the 1920s, and some were still causing death and lifelong health problems well into the 20th century.

So what could the 18th and early 19th century medic hope to ‘cure’? In Medical Care and the General Practitioner 1750-1850, Irvine Louden states that the only specific treatments that we would consider useful in the 21st century are quinine (effective in treating malaria), digitalis (to treat dropsy, possibly as a result of heart failure), fresh fruit and vegetables (for scurvy and their obvious health benefits) and opium (as a pain relief, a sedative or even as a stimulant).

In addition, the smallpox vaccine developed in this period saved millions of lives.

So when the list of treatments regularly offered by doctors is examined, there was, at best, a vast quantity of generally harmless but unnecessary – and often ghastly – medicines consumed and, at worst, a number of potentially deadly poisons taken.

For example, The Old Oper­ating Theatre Museum in London’s St Thomas Street offers an 18th century recipe for the treatment of a ‘venereal disease’: snail water.

 SNAIL WATER

• Take Garden-Snails cleansed and bruised 6 gallons,
• Earthworms washed and bruised 3 gallons,
• Of common Wormwood, Ground-Ivy, and Carduus [Aster], each one pound,
• Penniroyal, Juniper-berries, Fennel seeds, Aniseeds, each half a pound,
• Cloves and Cubebs [a pepper] bruised, each 3 ounces,
• Spirit of Wine and Spring-water, of each 8 Gallons,
• Digest them together for the space of 24 hours,
• And then draw it off in a common Alembick (a still).

Many old cartoons and prints suggest that, in many cases, practitioners were well aware of the limitations of the remedies they prescribed, often at significant cost to the patient.

Richard Smith, chief surgeon at the Bristol Royal Infirmary from 1835 to 1843, was, as a surgeon rather than a physician, scathing:

‘Even the London and Edinburgh pharmacopoeias were loaded with a miserable farrago of useless trash … Three-fourths of the medicines purchased of the druggist were mere adulterations … opium, antimony, mercury and many others when needful, of course, employed … but the great bulk of bottles were mere placebos…’ (from Louden p 64).

When the dispensing of medicines formed the larger part of a medical man’s income, it is possible some were exploiting the health anxieties of their patients, particularly if they were physician to a wealthy family or individual.

Only a minority of doctors charged for the medicines alone – most would add a call-out fee and additional charges should procedures such as bleeding, or a clyster (an enema), be required.

Efficacious potion

But with a population prone to hypochondria and with death ever present in their lives, it is hardly surprising if, when a livelihood depended on it, a doctor prescribed a potion or lotion not yet proved to be efficacious.

Besides, as in the 21st century, the placebo effect often produced seemingly good results.

Helpless as they were in the face of infections, fevers and countless other debilitating diseases, doctors resorted to preparations that they knew offered, at the very least, comfort to the concerned patient.

For many, the mere presence of the doctor by the sickbed produced restorative effects and much of their work was simply to reassure.
Surgery

London surgeons were known to charge hundreds of pounds for an operation, but these were not to treat conditions most often seen by the local GP.

His surgical work was regular and payment was often for small amounts. The fees, if not the treatment, were broadly the same for both rich and poor patient, and across the country.

Gunshot wound

For example, William Pulsford of Wells charged one-and-a-half guineas to treat a child who had dislocated their wrist falling from a tree and five guineas for a gunshot wound to the hand.

Opening an abscess could cost anything from five shillings to one-and-a-half guineas, and the on-going treatment for an ulcerated leg cost 14 guineas over two-and-a-half years. Parish work was charged out at the same rate as private work and in 1757, it made Pulsford more than 20 guineas.

A GP’s income was dependent on fees from a number of different sources and William Pulsford was practising at a time when the old Poor Law administration was still relatively generous.

As competition grew, fees could not go up in line with increased costs, so it is difficult to compare the fees of 1757 with those of later periods.

However, five shillings paid in 1757 would be worth approximately £20 in 2015 and might be two days wages for a skilled artisan of the time.

The man-midwife

By the end of the 18th century, local GPs or surgeons had taken on this role, at least in market towns and more rural areas. There may still have been a fair ratio of midwives to doctors, but by the turn of the century, it was rare to find a surgeon-apothecary who was not also a man-midwife.

During the 18th century, the rise of obstetrics as a suitable subject for study and the role of the midwife proper for a man was dramatic. In an increasingly competitive market, it was a new discipline to seek expertise in and an area within which, if successful, a new and fruitful source of patients would result.

Many people felt strongly that the place by the side of a woman during childbirth should be taken by a woman. There was not just anger from midwives, who saw their position taken away. Many doctors felt that attendance at a long, and probably natural, labour was a waste of valuable time, which a doctor could better spend on other patients who needed him for a genuine medical reason.

‘Unmanly role’

Others felt there was something ‘unmanly’ about a doctor who wanted to take on this role. Some thought there were what we would now refer to as gender politics involved, in that, as a man had been the primary cause of the discomfort and any possible complications, he could not justify further intervention.

The significant rise in importance of the man-midwife is all the more remarkable for the lack of support offered by the colleges and corporations for those taking up obstetrics.

Scotland accepted the importance of the subject to their students and offered courses in obstetrics long before it was accepted south of the border, where arguments about who was responsible for training also held up education and research.

The physicians at the Royal College believed the messy business to be the province of the surgeon, although they would deign to be involved if there were problems during the pregnancy or after the birth.

Lower ranks

Surgeons were not keen to take on the role either. The Company of Surgeons, later the Royal College of Surgeons, wanted to restrict their members to undertaking ‘pure’ surgery, but, in reality, neither branch of the profession considered it a ‘manly’ role and it was therefore work only fit for the lower ranks.

This attitude continued into the 19th century and eventually, the role became one central to the general practice.

It was, of course, easier for the female midwife to examine a woman fully. Some allowed the woman to choose the birthing position she found most comfortable and the birthing stool was a common item used, offering a comfortable position and allowing gravity to assist in the delivery.

As the male midwife became more common, the generally accepted position for delivery was changed to one that many would find far less comfortable. The woman had to lie on her side, with her face away from the doctor in attendance.

Charming manner

Doctors were also more reluctant to undertake abdominal examinations in case it led to accusations of impropriety, an issue that could lead to life-threatening misdiagnosis.

A man must also develop a charming bedside manner to ensure the patient’s confidence and many did this by ordering about the female nurse – who might once have been the midwife – or lady’s maid.

Midwives of the early 18th century sensed that they might be partly responsible for the ‘fashion’ for having a man at the birth. Lack of confidence in difficult cases often led a midwife to call in a doctor before it was necessary and thus pass any credit for her own skill to the man-midwife.

It seems likely the male midwife was better able to listen to a woman’s general concerns about the medical aspects of childbirth and able to calm them, seeming to be more of a friend than a nurse.

Women were, and still are, influenced by their friend’s experience of childbirth and once a man-midwife had safely delivered a number of babies in his area, he was most likely the subject of conversations at female gatherings. Man-midwives did rather well by word-of-mouth recommendations.

But the man-midwife was not always the triumphant master of his female counterpart. For many doctors, the role was an unpleasant chore; something that had to be taken on if the practice was to be profitable.

‘The man-midwife … cannot be compensated at all by the mere lying-in fee, unless it leads to other business. I know of no surgeon who would not willingly have given up attending midwifery cases provided he could retain the family in other respects…’ (Richard Smith of Bristol, quoted in Louden).

Without sleep

Certainly, in many country areas, the doctor had to attend when called, regardless of whether his skills were required or not.

Matthew Flinders of Lincoln­shire notes in his diary that he had spent 40 hours without sleep, attending two normal births. This was at a fee between just 10s 6d and a guinea per case.

Looking at the Weekes family letters, it was clear that they charged a higher fee to wealthier patients – 15s for a parish baby and five guineas for delivery to a wealthier family, although the higher fee would doubtless include considerably more ante-natal and post-natal care and attendance at false alarms could not be charged as extra.

Other records, such as those of Danvers Ward of Bristol, indicate that a man may work in the field simply for the love of it. Ward was clearly keen on the obstetric arm of his practice. Records show that over a third of his cases were obstetric and in one year he delivered 121 women, at a fee of between half a guinea and three guineas.

And despite the lengthy period usually necessary to deliver a baby and the speedy nature of many of his other non-obstetric cases – dental extractions and abscesses for example – his average fee in both cases was around 14s 6d.

He, and other doctors, also delivered babies free of charge to the poorest families, indicating a genuine love for childbirth.

☛

Adapted from Death Disease & Dissection – the life of a surgeon apothecary 1750-1850, by Suzie Grogan. Pen & Sword Books Ltd, ISBN 1473823536, Price £12.99

 

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• See ‘The rise of the industrious GP’

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