Overview of English medical practice between 1700 and 1850

Except in obstetrics, medical care did not change in any fundamental way during the 150 years between 1700 and 1850.  There were inventions, such as the stethoscope invented by the French physician Laennec in 1819, which altered how patients were examined, but until the acceptance of the concept of infectious disease in the second half of the 19th Century, the theory of medical treatments remained essentially unchanged.  This stagnation was worsened by the Napoleonic Wars, which significantly decreased travel in continental Europe by English physicians and so limited the transmission of medical knowledge from Paris and Vienna, major centers of medical advancement of the time.

Physicians were trained in England at medical schools; the only requirement for admission was the ability to pay the tuition and learning was limited to attending lectures.  There were few or no practical or hand-on teaching sessions as physicians did not perform any procedures or surgeries.  In some cities in Scotland and on the Continent a medical diploma could be obtained by mail order.  This separation of medical and surgical treatment was the result of societal mores which prevented “gentlemen” from working with their hands, a situation that began in the middle ages (when the only surgeons were barbers, who had the sharp knives).

Surgeons in the Georgian Era had long been separated from barbers, but they continued to be a completely separate branch of medical care from the physicians.  Surgeons were not required to go to medical school, but were trained by apprenticeship like any other trade.  For this reason, professional surgeons have always been called “Mr.” in England, unlike physicians, who are called “Dr.”  This has translated in modern practice to an English surgeon attending medical school and being called “Dr.” until he finishes his surgical training, at which time he goes back to “Mr.”  As the 18th Century progressed, more and more surgeons attended lectures in medical schools and gradually became more professional about their field, but until the development of anesthesia (ether) and sterile technique in the second half-centurythey were limited in what they could do.

Most of the practice of surgeons was in setting bones, removing bullets, stitching up wounds, and bleeding patients.  An important part of the practice in the first half of the 18th Century was in obstetrics; when a midwife gave up on a difficult case and either the mother or child was going to die the surgeon was called in to try and save one of them.  Not surprisingly, the association in the minds of the public between surgeons and obstetrics was that of death.

Apothecaries, or pharmacists as they are now known, were not legal practitioners of medicine, but they were the people who had the drugs and common usage in the 18th and 19th Centuries was for people who did not have a physician, or who could not afford a physician, to ask the apothecary for advice.  As time went on he was called to peoples’ houses to prescribe for those who were ill, and many upper class households used an apothecary for the servants and a physician for the family.  The apothecary could not legally charge for his advice, but only for the drugs which he prescribed.  It was not until 1815 that a law was passed requiring licensing of apothecaries, but the law was universally despised by medical practitioners and was rarely enforced because of the great confusion of responsibility for the enforcement of the law.

Midwives, until the second half of the 18th Century, were almost always women who gained some experience delivering babies and who gained their job by default of other practitioners.  Then male surgeons, who were already considered tradesmen, began infringing on this all-female monopoly and brought medical science (such as it was) into the practice of what is now known as obstetrics.  This change was largely brought about by the demands of the gentry and peers for healthy heirs to their estates.  This was so important in the smooth inheritance of vast amounts of English land that the man-midwives, or accoucheurs, were actually accepted into the upper echelons of society in a way that no other surgeons had been.  No accoucheur would have been invited to dinner by the haute ton, but one, William Knightley, was knighted for his service to the crown (he was the Prince Regent’s personal practitioner at the time) and was actually given a post as advisor to the Regent in government matters.  Clearly, he was seen by the Regent as a man of acumen and wisdom.

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The history of opium in medical practice.

Poppy photo courtesy Shaun Dovey

Pain relief has been one of the primary goals of medical care since humankind began and physicians have been debating the best way to accomplish this goal since ancient Egyptian physicians first wrote down their treatments and discussed them with their colleagues.  Opium, derived from the sticky sap in the immature seed pods of the opium poppy, was the most widely used medication in the Georgian, Regency, and Victorian Era for two very good reasons: it relieved pain and it was inexpensive.

Laudanum, a strong tincture containing 10% opium contained all the alkaloids of opium, primarily morphine, was widely used and could be obtained without a prescription.  It was very potent and was used for both pain and to quiet “nervous” disorders, which we would now call anxiety disorders.  It was also the only medication available to help people sleep.  Morphine and its derivatives work by binding to receptors in the brain which normally bind natural endorphins, produced by the body to relieve pain.  The action of morphine is much stronger than endorphins and will override the action of the endorphins.  Not surprisingly, most households of the gentry and upper classes would have this useful drug in the house in case of need.

Another formulation containing tincture of opium was paregoric.  This was a complex mixture first formulated by Jakob Le Mort in the early 18th Century for the treatment of asthma, and contained “honey, licorice, flowers of Benjamin, opium, camphor, oil of aniseed, salt of tartar and spirit of wine.” By the 19th Century, paregoric was primarily used for gastrointestinal disorders such as diarrhea and the intestinal cramps associated with it (usually called abdominal colic at that time).  In this case, a side effect of the opium was what provided the relief:  opium and all of it’s relatives (including heroin, oxycodone, hydrocodone and codeine) cause the intestines to stop their peristalsis, the rhythmic progression of contractions which move the  ingested food through the length of the intestines, promoting breakdown and mixing of food into a form which could be absorbed into the rest of the body.  Cramping during a bout of diarrhea is caused by lack of coordination or spasm in these muscles, resulting in pain and expulsion of the waste products before the colon can absorb the excess water and make stools of a normal consistency.

The downside to this very effective class of pain relievers is constipation (also from suppression of peristalsis), drowsiness, and the potential for addiction. With the ready availability of laudanum and paregoric, addiction was a significant risk for users.

Both laudanum and paregoric are still available in the US and England (although by prescription only) but they are rarely prescribed since the development of non-narcotic anti-diarrheal agents such as loperamide in the mid-Twentieth Century.

18th Century medicine: how a poisonous flower became a life-saver

Common foxglove (Digitalis purpurea)

As the 18th Century gave way to the 19th, the list of medications available to treat patients was very limited and many diseases were treated with non-pharmaceutical methods, such as bleeding and poultices.  Physicians generally practiced in cities where they could command a steady income, and apothecaries (pharmacists) treated those who did not have access to trained physicians.  In addition, there were often women who had learned traditional lore about herbs and their actions and would treat patients.  Not surprisingly, the trained physicians regarded these herbal healers (sometimes called witches) with disdain and discounted the ability of their possets and extracts to treat patients.  This is the story of what happened when a physician was open-minded enough to see what occurred  when an elderly herbalist treated one of his patients who was afflicted with congestive heart failure.

William Withering (1741-1799) was a traditional practitioner who had studied at the prestigious Edinburgh Medical School and was eventually named physician to Birmingham Hospital.  One of the frustrations of medical practice was the inability to treat dropsy, a now archaic term for edema, or swelling, and caused by heart failure, liver failure or kidney failure.  Cardiac dropsy, now called c0ngestive heart failure, was caused by the heart weakening and being unable to move the fluid load of the body as well as is necessary for health.  This failure would also limit how well the kidneys could excrete excess fluid as not enough blood was reaching them.  Patients would develop swelling in their ankles, which would become worse and worse until the heart failed completely or developed an irregular beat and the patient died.

When Withering’s patient was treated by the herbalist, he noticed that the patient improved.  He talked to the herbalist and found that she was using a concoction containing 20 different herbs for the dropsy.  He was an inquisitive physician, and tested the various ingredients alone until he deduced which one was actually active in cardiac dropsy:  an extract from the leaves of the common foxglove (digitalis pupurea).

Foxglove is a common and attractive garden flower, and was well-known to be highly poisonous if ingested; consuming just one of the upper leaves was enough to kill an adult human.  Withering carefully studied the dosage and action of the extract of foxglove leaves (called digitalin or digitalis) and found that it induced the heart to beat both more steadily and more strongly.  This improvement in the efficiency of the heart action helped reduce the swelling in patients and allowed them to return to a more normal life.  William Withering is thus credited with one of the major breakthroughs in medical therapeutics in 1785, but the road to medical history was not without a few bumps.  One of the patients that Withering had studied was referred by Withering’s friend Erasmus Darwin, and Darwin jumped in ahead of Withering in the publication of the results of the digitalis tests.  Fortunately, Withering had submitted his paper to the College of Physicians in London two months earlier, so he is given credit for the study.  Not surprisingly, his friendship with Erasmus Darwin did not survive.

As is well known in modern medicine, any medication can be toxic if taken in excess.  The dose that is high enough to be effective and low enough to not be toxic is called the therapeutic window.  Unfortunately, the therapeutic window for digitalis is very narrow so the dose must be very tightly controlled to produce the physiologic effect needed without harming the patient.  One of the difficulties with using digitalis that was extracted from foxglove in the 18th and 19th Centuries, was that the amount of the drug contained in the plant would vary with age of the plant and soil and weather conditions, so it had to be used very cautiously, and many herbalists avoided it.

Digitalis is still used to treat weak and irregular heart function and the activity of the medication is now standardized, but it must still be used with great caution.  Signs of overdose include nausea, vomiting, severe headache, diarrhea, hallucinations and other cerebral dysfunctions (included an unusual visual disturbance which causes everything to appear more yellow than normal).  The heart rate can be increased or decreased in an overdose, depending on how high the blood level is.  Newer medicines that have a more favorable therapeutic window are usually used today, but digitalis still has a place in the physician’s armamentarium.