1.2 The poor as patients
Patients' accounts of hospital life in the early modern period are notoriously thin on the ground, so historians have turned to other sources. These include hospital registers, which became more detailed and accurate in the eighteenth century, and the notebooks of medical students, who were increasingly attracted to hospitals for on-the-job training. Both types of document have been extensively used to throw light on the daily routine of patients and the treatment they received. Here I draw extensively on the work of the historian Guenter Risse (1999) in relation to the Edinburgh Royal Infirmary.
The Royal Infirmary – a voluntary hospital – opened in Edinburgh in the 1740s. It was housed in an entirely new, four-storey building and replaced a much smaller hospital, which had been founded in 1729. The building comprised a central admissions room, several separate wards, lodging for the nurses, a kitchen and a pharmacy, as well as an amphitheatre, which was used for lectures, surgery and religious services. The city was prosperous and donations were generous: in addition to donations from a wide range of private benefactors, the hospital received money from the city guilds and the church (Figure 1). The hospital also had the full backing of the local college of physicians and of the university medical faculty. Edinburgh was fast becoming one of the most important and lively centres of medical education in the British Isles. The construction of this large hospital improved the teaching facilities and helped young physicians to expand their skills.
Read ‘’, and then answer the following questions:
- What took place during the admission process?
- Why was Professor Cullen interested in Janet Williamson's case?
- What treatment did Janet receive?
Janet Williamson was a servant who had little or no family in Edinburgh. Feeling unwell, she applied to the infirmary for help. Admission was a two-stage process and took place in a purpose-built room. First, a patient had to prove that he or she was worthy of assistance. Janet presumably had a letter of recommendation which testified that she had a sponsor and therefore was deserving of admission; however, the name of her patron is not recorded. Risse suggests that her master may have contributed to the hospital's Servants' Fund. The second step was a medical check. The physician had to verify that she really was sick – faking an illness was a practice abhorred by the governors. The medical check also determined whether her symptoms matched the range of diseases that the hospital was prepared to treat. The hospital's policy was to avoid admitting patients who were suffering from incurable or contagious diseases. Two points worth noting are the entirely secular nature of the admission process and the complexity of the record keeping.
Professor William Cullen, who taught medicine at the university, was also in charge of the teaching ward at the infirmary. Janet was suffering from fever, and was admitted during a period in which Cullen was preparing a series of lectures on this disease. Cullen was keen to select interesting cases to present to his students, and so Janet was admitted to the teaching ward, where his lectures took place.
Janet was seen by Cullen, who took her pulse and prescribed bloodletting, emetics, enemas – still among the most popular medical procedures – and a special diet. A nurse looked after her, especially when she was delirious, and gave her regular fomentations of the legs and feet. Bloodletting was carried out by medical students. To treat Janet's cough, Cullen prescribed an expectorant, and he also ordered a blister to be raised on her back. Blistering was a time-honoured remedy to stimulate the body's reaction to a fever, but Cullen offered a new explanation for its efficacy. The treatment that Janet received seems to have been extremely thorough, and was probably no different from that which Cullen offered to his wealthy private clients.
So, the reason we know so much about Janet Williamson is because Cullen used the details of her case as teaching material, basing his lectures on the medical notes of patients in the ward register. However, this is probably the closest we can ever hope to get to the actual experience of patients in an eighteenth-century hospital. Even Risse, who investigated this subject in great depth, was forced to admit that many of his conclusions were the fruit of guesswork.
As the century drew to an end, and physicians gained the upper hand in hospitals, the use of patients as teaching material became normal practice, and the relationship between medicine and poverty took a new turn. Historians have argued that, in the nineteenth century, hospital patients – a group of people who usually had no family connections or means of support – became the object of growing medical experimentation. Fundamental changes in medical knowledge and practice took place in hospitals, including new ways of examining patients and regular post-mortem dissections, which in turn led to the establishment of a new discipline: pathological anatomy. These changes have been hailed as among the most important medical advances of their time, and it was the bodies of the hospitalised poor that made them possible (Risse, 1999, pp. 329–31).