Hospital Life in Enlightenment Scotland: Care and Teaching at the Royal Infirmary of Edinburgh (Cambridge Studies in the History of Medicine) 0521305187, 9780521305181

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Hospital life in Enlightenment Scotland CARE AND TEACHING AT THE ROYAL INFIRMARY OF EDINBURGH

GUENTER B. RISSE University of Wisconsin

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CAMBRIDGE UNIVERSE.1 CAMBRIDGE

LONDON

NEW YORK

MELBOURNE

NEW ROCl

SYDNEY

233482’

Contents

List of tables and figures Acknowledgments

1

2

3

4

page ix

xiii

Introduction

I

The sick poor and voluntary hospitals “Desirous of accommodation in the house”: the road to hospital admission The origins of the British hospital movement The Royal Infirmary of Edinburgh

7

Hospital staff and the admission of patients Who attends the sick? infirmary professionals and their helpers “The patient comes into our hands”: admissions process

7 11 25

60 60

82

Patients and their diseases Entering diagnoses in the General Register The spectrum of diseases at the infirmary, 1770-1800 Length of hospitalization

119 119

Hospital care: state of the medical art Principles of eighteenth-century therapeutics The context of hospital care Therapeutic effects of hospitalization The use of drugs Physical methods Exercise Dietetics Effects of treatment Complications

177 177 182 186 189 202 219 220 226 227

121 172

Contents

viii

Discharge from the hospital Conclusion 5

Clinical instruction Background Organization and enrollment Students and clinical teaching Clinical teaching and the patients Instructional objectives The didactic role of autopsies The teaching of surgery and midwifery Edinburgh and Europe contrasted Conclusion Epilogue General considerations Medical therapeutics Eighteenth-century hospitals: for better or worse? The “birth” of the clinic The final blessing

228 238 240 241 242 246 249 257 261 266 272 277

279 279 283 287 291 294

APPENDIXES

A Sources B Selected clinical cases C Clinical teaching D Drug usage at the infirmary: the example of Dr. Andrew Duncan, Sr., by J. Worth Estes Notes Index

296 303 340 35i 385 436

:

List of tables and figures s

TABLES 1.1 1.2

r-3 i-4 i-5 1.6

i-7

2.2 2.3

2.4

3-1 3-2

3-3

3-4 3-5

4-2

Income of the infirmary, 1770-1800 page 36 Infirmary revenues from the sale of admission tickets to students and apprentices, 1770-1800 39 Expenses of the infirmary, 1770—1800 40 Official statistics of the infirmary, 1760-1800 46 General Register of Patients: sample of entries for 1770 52 General Register of Patients: sample of entries for 1790 53 General Register of Patients: disease categories employed in 1770 54 Occupations of infirmary patients 88 Country ward for women, November 1784February 1785 9i Soldiers under the care of the physicians-inordinary, 1776 96 Servants’ ward for women, December 1784— 102 February 1785 Frequency of the most common diseases recorded in the General Register of Patients, 1770—1800 120 Sex distribution for the most common diseases recorded in the General Register of Patients, 122 1770-1800 Average length of stay in the infirmary, 1770-1800, by complaint 173 Average length of stay in the infirmary, 1770-1800, by year 174 Number of patients hospitalized for short stays, 1770-1800 174 182 Sedative regimen 183 Stimulant regimen

I

X

Tables and figures

Drugs used at the infirmary, 1771-1799 Physical methods used at the infirmary, 1771-1799 Venesections at the infirmary, 1771-1779 General Register of Patients: discharges, 1770-1800 General Register of Patients: patients dismissed “by desire,” 1770-1800 General Register of Patients: patients listed 4-8 as dead, 1770-1800 General Register of Patients: patients dismissed 49 as “improper,” 1770-1800 4.10 General Register of Patients: patients dismissed “for irregularities,” 1770-1800 General Register of Patients: patients dismissed “by advice,” 1770-1800 Enrollment for clinical lectures at the infirmary, 5-i

4-3 4-4 4-5 4.6 4-7

1770-1800

5-2

5-3 5-4 A. 1 A. 2

Enrollment for clinical lectures at the infirmary, 1794-1800 Cases from the teaching ward, 1771—1799 Deaths and autopsies at the infirmary, 1770-1800 Drug use in the teaching ward of the infirmary, early 1795 Use of nondrug treatments in the teaching ward of the infirmary, winter 1795

192 203 207 228 234 23 5

236 238 238

245

246 256 264 352 355

FIGURES

Case of Catherine Henderson Floor plan of the infirmary, fourth story, 1740 General Register of Patients: sample page, August 1785 2.1 Advertisement from the Edinburgh Evening Courant, March 8, 1775 Admission of soldiers, 1770-1800 2.2 Distribution of medical and surgical cases, 3-i 1770-1800 A.1 Clinical course of Alexander F., diagnosis of rheumatismus A.2 Clinical course of Daniel R., diagnosis of phthisis catarrhalis A.3 Clinical course of Leslie C., diagnosis of quartan fever A.4 Clinical course ofJames L., diagnosis of hydrothorax and dropsy

1.1

1.1 1.2

6 32

5i 83 94 124

35

Acknowledgments

ment at the University of Wisconsin goes my appreciation for introducing me to the world of codes and computers. Several colleagues took particular interest in my project and deserve spe­ cial thanks. Foremost among them is Stephanie Blackden, then a postdoc­ toral research fellow at the History of Medicine and Science Unit in Edin­ burgh, who repeatedly checked patients’ lists, microfilmed documents, and generously shared her expertise in Scottish history. Useful suggestions came from David Hamilton, Helen Brock, William B. Howie, and Haldane P. Tait. Nearer to home I am indebted to Glenn Sonnedecker, John Parascandola, and J. Worth Estes for their valuable advice regarding eighteenth­ century pharmacy and prescription routines. My thanks also to Toby Gel­ fand, who read the chapter on medical education, and Ann G. Carmichael, who viewed early drafts of the chapters concerned with diseases and medi­ cal practice. Particular thanks go to the Program Committee of the Ameri­ can Association for the History of Medicine responsible for organizing the fifty-third annual meeting in Boston and selecting my paper on Edinburgh hospital practice. Favorable responses to my presentation provided the nec­ essary impetus to pursue further research and conceive of an entire book devoted to the subject. I would also like to thank Charles Rosenberg, who not only encouraged me to complete the project but also promptly read my first draft and made valuable suggestions to improve the manuscript. I would like to acknowledge the assistance of both the University of Wis­ consin Medical School and the American Philosophical Society for granting me two research awards that made travel to Edinburgh possible in 1977 and again in 1982. To Lloyd G. Stevenson, Lester S. King, Rosemary Stevens, and William Coleman I extend my appreciation for supporting the project and recommending me for the latter awards. Carolyn F. Hackler flawlessly typed the entire manuscript, successfully deciphering my handwritten notes and instructions. Her devotion to the project and numberless hours in front of the word processor were key ingredients in rendering the text into its final form. Last but not least I want to express deep gratitude to my family for put­ ting up with my absences during long hours of research, computations, and writing. Without their encouragement this book would probably never have been completed.

Madison, Wisconsin

Introduction

In contemporary society university-affiliated hospitals play a central role in the progress of medicine. They are often vast bureaucratic enterprises at­ tempting to balance the needs of patient care with those of professional education, all within the context and resources of the society that they have pledged to serve. At the same time, modern university hospitals are poised at the cutting edge of advances in the medical sciences, decisively contribut­ ing to the design and performance of clinical research. Thus, as convergent points of science, education, and practice, these establishments usually con­ fer distinction on the institutions of higher learning to which they are linked and high professional status on their teachers, while attracting hopeful pa­ tients to the wards from near and far. Because of their importance, univer­ sity hospitals are not only local architectural landmarks noted on maps or depicted on postcards but also sources of convenient employment and civic pride.1 Quite similar characteristics can be noted for the hospital that constitutes the focal point of this study: the Royal Infirmary of Edinburgh. As will be seen, its inception in 1729 and its subsequent development were the culmi­ nation of years of fund-raising by several groups with differing interests and agendas. British infirmaries were part of a comprehensive program to institutionalize the poor under the banner of a vigorous philanthropic movement fueled by religious and humanistic concerns. Whatever the ex­ pense involved, erecting such hospitals also seemed to make economic sense to eighteenth-century leaders, who believed that medical efforts could re­ store sizable numbers of workers to their previous health and productivity, thereby decreasing welfare costs and even expanding the population. Lead­ ing physicians and surgeons, in turn, recognized the usefulness of such hos­ pitals for the clinical instruction of future health professionals.2 The development of both the Royal Infirmary and the Edinburgh Medi­ cal School owes a great deal to the scientific and educational ideas adopted by the Scottish Enlightenment. In less than a century after the Union of 1707 with England, Scotland underwent a dramatic transformation from a poor, backward country into a prosperous British province. At the same

2

Hospital life in Enlightenment Scotland

time, Edinburgh, no longer the seat of royalty, became known as the “Ath­ ens of the North,” the hub of a remarkable social and cultural development. With broad participation of aristocrats, literati, philosophers, lawyers, and medical men, Edinburgh played a leading role in the formulation of a new Scottish ideology of self-improvement.3 Medicine played an important role within the framework of ideas guiding the Scottish Enlightenment. Medical men actively participated in the edu­ cational program launched in the 1720s that was designed to provide useful knowledge to Scottish citizens. In fact, after 1750 the University of Edin­ burgh became a prominent international center of medical learning, a mecca not only for industrious Scots but also for English students, especially those barred from Oxford and Cambridge for religious reasons. In addition, for­ eigners eagerly flocked to Edinburgh for the purpose of attending medical lectures, arriving from other European countries and America with their letters of introduction.4 From its inception, the Edinburgh infirmary became meshed into this educational program. Its wards provided not only opportunities for the ob­ servation of individuals afflicted with diseases common to Scotland but oc­ casions to watch and learn from those entrusted with the care of the sick. Beginning in 1732, discussion, analysis, and publication of individual clini­ cal cases seen in the hospital contributed to the practical training of the medical profession.5 Thus, from the very beginning, the infirmary took its place among Edinburgh’s institutions devoted to educational pursuits, a group that also included the university and several learned societies.6 In spite of its modest size, the hospital in time became an important factor in the success of medical education at Edinburgh. As the medical faculty expanded after mid-century and the number of matriculating students rose dramatically, the infirmary furnished the locus for an organized clinical teaching program that combined bedside instruction with systematic lec­ tures and that had few peers in Europe. In 1748 the hospital began to spon­ sor a course of clinical lectures under university auspices, devoted to the formal discussion of important infirmary cases and given by the most pres­ tigious Edinburgh professors.7 Besides participating in the training of future medical professionals, the Edinburgh infirmary also responded to the economic improvement plans of the Scottish Enlightenment. One of the ostensible reasons given for its creation was the idea that providing hospital care for the working poor would be financially advantageous both to them and to society at large. Helping patients recover in an institutional setting such as the infirmary would decrease the impact of sickness on their lives and those of their de­ pendents. If cures could be achieved, the poor would presumably return to productive jobs and thus avoid becoming public burdens. Such purely eco­ nomic considerations, widely held in Britain and elsewhere as part of the mercantilist doctrine, were closely linked to questions of public welfare.

Introduction

3

Edinburgh’s governing class also strongly adhered to the humanitarian pre­ cepts of the Enlightenment; they demonstrated through their sponsorship of the infirmary their sense of responsibility for protecting the lower ranks of society.8 Another consideration with strong economic implications was the flow of Scottish students and their money to England and other European coun­ tries for the completion of medical studies. Copying the Dutch model of a hospital-based clinical instruction, the founders of the Edinburgh infirmary made such studies available locally, eventually setting up (in 1750) an inde­ pendent teaching ward to be directed by a university professor during the academic year. As more foreign students came to study in Edinburgh dur­ ing the 1770s and 1780s, this unit was increased in size, and hospital reve­ nues obtained from the sale of admission tickets to the students helped pay a substantial portion of the infirmary’s operating expenses. During the second half of the eighteenth century, the Edinburgh infir­ mary therefore became part of the city’s network of influence, patronage, and power. Appointments to its governing board and medical staff con­ ferred prestige and furthered social and professional status. Among the managers and subscribers were key figures of Edinburgh's governmental and intellectual circles. Its roster of volunteer and salaried physicians and surgeons contained the names of the most prominent individuals then prac­ ticing in the capital. The same criteria were applied in the selection of ordi­ nary physicians, medical and surgical clerks, and student dressers. Financial arrangements with both the Royal Army and Navy during wartime and before brought substantial revenues to the hospital, as well as the goodwill of powerful commissioners, many of them Edinburgh graduates. At one point, the infirmary even turned lender for the municipal government, giv­ ing to the city fathers funds originally earmarked by the king for invalid soldiers. Lastly, one must see the Edinburgh infirmary as an important factor in the conscious drive toward modernity and national achievement fueled by the Scottish Enlightenment. Its establishment in 1729 as the first such insti­ tution in Britain outside London was meant to indicate that Edinburgh could provide its sick poor with the type of charitable assistance that was available in the English capital. Decades later, as is demonstrated by the large flow of foreign students through its wards, the infirmary became well known beyond the borders of Scotland, and its organization, architecture, and staff were taken as models for similar institutions in Britain and abroad.9 Con­ temporaries were impressed by its cleanliness, low mortality, and valuable in-house pharmacopoeia.10 In that sense, the Royal Infirmary of Edinburgh fulfilled the most ambitious goals of the Enlightenment reformers who sought to promote the good of the old kingdom and make Scotland look respect­ able in the eyes of the world. Eighteenth-century hospitals have not fared well in the historical litera-

4

Hospital life in Enlightenment Scotland

ture. With few exceptions, one simply finds single narratives of particular institutions written in commemoration of special anniversaries. These ac­ counts are mostly repositories of information about prominent persons and events shaping the hospital or tales of scientific progress depicting techno­ logical innovations. Building plans, staff rosters, and extant regulations sprinkle the overall story, which usually unfolds outside the social and po­ litical context of the times.” Unfortunately, such purely descriptive and anecdotal histories of hospi­ tals have hitherto failed to probe the actual nature and mechanisms of hos­ pital confinement during the eighteenth century. Patients and diseases are usually relegated to a few statistical charts without analysis. Comments about medical treatment appear seldom and then are summarily dismissed as “crude compilations of a blundering empiricism.”12 The tendency has been to stress the great progress made in medicine since that time of wanton bleeding and purging. Based on a number of historical accounts, the standard contemporary judgment is that eighteenth-century hospitals were “hot-beds of infection” and “gateways to death.” This impression, articulated by widely read au­ thors such as Thomas McKeown13 and Michel Foucault,14 now unfortu­ nately permeates much of the general literature on hospitals, casting a dark shadow on all eighteenth-century efforts to care for the sick.15 At that time the value of hospital confinement had already prompted lively discussions, but before blanket indictments are made the problem needs further analysis and definition. In his comprehensive study of British infirmaries, Brian Abel-Smith re­ marked that “little is known about what hospitals actually did for particular patients and diseases.” At the same time, however, he expressed the hope that “detailed analysis of the case records of individual hospitals” would eventually furnish information about those who were admitted, their ail­ ments, and their treatment.16 Given the often fragmentary evidence still available, Abel-Smith’s recommendations have hitherto been difficult to implement. Many eighteenth-century British hospitals kept admissions and financial records as part of their accountability to charitable subscribers, but the practice of writing down periodic notes about the institutional progress of patients was still in its preliminary stages and never implemented on a wide scale. Whatever survived the vagaries of time in the form of registers, minutes, and reports often fell victim to more recent paper-recycling efforts undertaken during wartime shortages. In the case of the Edinburgh infirmary, however, scholars can find a vir­ tual bonanza of documentation, at least for the period 1770-1800, which constitutes the focus of this work. Given the hospital’s prominence in Edin­ burgh society and medical education, its authorities were forced to develop a detailed accounting system, including a register of patients, individual ward journals, and yearly statistics concerning admissions, discharges, and

Introduction

5

deaths. Moreover, the hospital managers kept extensive minutes of their monthly meetings, issued yearly financial reports, published updated rules to regulate the flow of patients through the institution, and determined du­ ties of the medical and ancillary staff. Since the hospital was affiliated with the University of Edinburgh, additional information can be obtained from official academic regulations and student matriculation records. Most important of all, the present attempt to reconstruct the activities taking place in the Royal Infirmary of Edinburgh relies on records left by medical students who enrolled in the course of clinical lectures given in the hospital. These students were periodically allowed to copy from official records complete cases of patients admitted to the teaching ward. Each case history contained the name of the individual, symptomatology, diagnosis, treatment, and daily progress notes describing the entire clinical evolution, together with adjustments in therapy. The copying was usually executed prior to presentation and discussion of these patients by professors in charge of the teaching ward and the clinical course. Moreover, several students took down verbatim all the remarks made in class by these academics, thereby providing another unique and invaluable document for the study of eigh­ teenth-century diagnostics and therapeutics (see Figure 1.1 and Appendixes A and B). Fourteen student casebooks copied between 1771 and 1799 and contain­ ing 808 individual clinical histories constitute the core of the data utilized for the present analysis. They were supplemented by the 3,047 entries ran­ domly extracted from the surviving folios of the infirmary’s General Reg­ ister of Patients for the same years. Together they furnish a great deal of information about the kind of patients admitted to the hospital, including age, sex, and occupation. Admission and discharge dates allow for esti­ mates of length of hospitalization, types of discharge, and mortality rates. Effects of the medical regimen and clinical complications can be gathered from the patient histories. Finally, from remarks made by the Edinburgh professors during their clinical lectures, we can gain a good understanding of the reasons given for therapeutic intervention and choice of specific modes of treatment. All of these materials permit an in-depth examination of hospital life at the Royal Infirmary of Edinburgh during the last decades of the eighteenth century. Diseases seen in the wards have here retained their original desig­ nations and medical meanings, merely being brought together into catego­ ries arranged by bodily systems. This approach should provide readers with a general overview of the disease ecology encountered in the institution. Many historians succumb to the temptation of retrospective medical diag­ noses, using specific modern criteria and terminology to recast older and ambiguous disease entities. The resulting distortion of historical data often proves misleading, creating additional problems of interpretation. Lastly, attention has been given to both the content and methods of the

6

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