Patients, Practitioners, Lodgers

 

L0017887 A medical practitioner taking a girl's pulse and holding a f

When we are unwell we go to specialised centres for medical treatment, clinics or hospitals. If our condition constrains us to the house a doctor may visit us at home and once we have been to a consultation we may continue our treatment at home. For the most part however our interactions with medical practitioners occur in dedicated medicalised areas. This was not always the case in early modern England; consultations could happen in the home or by letter, or in the practitioner’s place of residence. Now this might seem like a trivial point to consider, but the places in which certain social interactions occur can be very important. Today’s blog is about the problems that may have occurred when patients and practitioners became lodgers in someone else’s home.

In his fascinating article ‘Men Controlling Bodies’ Robert Weston considers the relationship between the male medical practitioner and their patients.1 He shows that male patients were of a higher status than their medical practitioners. Weston suggests it may have been particularly difficult for patients to relinquish control of their bodies to someone of a lower status, which could lead to patients contesting the treatment that was recommended for them.2 It would appear from the sources I have looked at so far that the place in which consultations took place may have been woven into these issues.

The ‘home’ or ‘household’ was very important to early modern society: it was a centraV0048351 King Charles II, standing.l feature of  ideas of patriarchy. The father as head of a household was likened to the monarch at the head of the country. Everyone residing within the home was under his authority and were his responsibility. So being the head of household was one of the ways in which men could fulfill their duties and demonstrate patriarchal power. The question therefore is did this understanding of the household affect the relationship male patients had with medical practitioners?

In some cases medical practitioners to moved into the houses of those they treated. The son of the famous chemical practitioner Jean Baptiste Van Helmont, Francis Mercury, moved into Ragley Hall at the invitation of Lord Conway in order to treat Lady Anne Conway’s inveterate headaches. Lord Conway was rarely at home and the presence of the medical practitioner began to cause some scandal within the home. Francis Mercury began to host Quaker meetings at the house and rumours circulated that Lady Anne had turned Quaker. Her good friend Henry Moore became so concerned about these rumours that he wrote to Lord Conway to ascertain the truth, although it turned out Lord Conway knew little of what was occurring and accepted his wife’s word that although meetings were happening she had not taken up a new religion.3 Although I have not come across any evidence in the published Conway letters, these problems may have affected the perception of the Lord Conway’s ability to order his household.

In surgical treatises, however, it seems more common for patients to reside within the house of a medical practitioner or lodgings allocated by them. In this case the patient had to submit his bodily authority to that of the practitioner, and had to live within his household under his patriarchal authority.

One reason for a patient being moved into a medical man’s home was precisely because they would not accept the authority of a medical practitioner and did not follow their recommendations. In the following example the ‘naughty’ patient who was supposed to finish his course of treatment, for a breakout over his head, with bathing was removed to lodgings chosen by the medical practitioner so that he could make sure that he followed the treatment regime dictated. Although, he is not in the house of the surgeon himself, it is assumed that once living in someone else’s house under someone else’s authority the patient will be more malleable and tractable:

‘but he supposing the latter course [bathing] needless, broke off unknown to me. About two months after he was brought to me more diseased, and upon enquiry into the cause I found he had taken too great a liberty of eating and drinking during his Cure.’ ‘To avoid which inconvinience now I lodged him in a house where there was a more strict guard of him’. 4

It was also possible for patients to defy the diagnosis or treatment of the medical practitioner by removing themselves from the physician or surgeon’s house; creating a physical distance between them and allowing the patient to resume authority and control over his own body. Richard Wiseman recorded that:

L0005341 Ulrich von Hutten in in bed, suffering from syphilis.

A patient in bed, suffering from syphilis

‘A Man about 34 years old, of a full body, came to London, and lodged himself and his Wife in the house of his Physician, he being indisposed with an inflammation on his belly to the left Groin, pretending he had over-heated his body by disorder of drinking. He was advised to keep to his bed, and dispose himself to a breathing sweat. After a day or two he complained more of his pain, upon which account I visited him, and saw the inflammation discussed on his belly, but there remained a tumour in his Groin near supporated’. After some purges and other treatments Wiseman continues, ‘But the Physicians and my discoursing with the Patient of his Disease he grew passionate, and denied it to be Venreal; and a day or two after removed out of his lodgings two or three miles into the Country, and to avoid the Discovery of his Disease, he dismist me, and entertained another Chirurgeon, who complyed, and promised in a few days to cure him without the help of internal Remedies: But after all his endeavours another Chirurgeon was Consulted, by whose advice the Patient was put into a course of Antivenereals at last, and cured of that, but grew otherwise Diseased, and lived not many years.’ 5

So we can see from these examples that perhaps the placing of the patient within the home of a physician or surgeon increased the authority of the practitioner and enhanced the submission of bodily control by the patient. This however, was not always welcome and perhaps caused tension between the two parties. It is also apparent that supplying, seeking and moving lodgings provided both patients and practitioners with a means of adjusting the treatment regime to suit their own needs and purposes.

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1 Robert Weston, ‘Men Controlling Bodies: Medical Consultation by Letter in France, 1680-1780’ in (eds) Susan Broomhall and Jacqueline Van Gent Governing Masculinities in the Early Modern Period: Regulating Selves and Others (Ashgate: Farnham and Burlington, 2011), pp. 227-246

2 Robert Weston, ‘Men Controlling Bodies’, p. 236.

3 Conway Letters: The Correspondence of Anne, Viscountess Conway, Henry More, and their Friends, 1642-1684. ed. Marjorie Hope Nicolson (London: Oxford University Press, 1930)

4 Richard Wiseman, Severall Chirurgical Treatises (London, 1676), p. 36.

5 Richard Wiseman, Severall Chirurgical Treatises, p. 27.

© Copyright Jennifer Evans, all rights reserved

11 Responses so far.

  1. David Harley says:
    My word. A big topic indeed, and a neglected one. I hope we can discuss this at some length.

    Midwives fetched into gentry households, often from long distances, often for two or three weeks, especially for the first delivery. Men-midwives booked in advance by gentry households in the country.

    Higher status patients, with servants or specially hired nurse attendants, did not usually need to be taken into the homes of surgeons. They just needed daily visits and clear instructions. The surgeon/apothecary or surgeon/physician with a riding practice had a clear advantage in such cases. [e.g. Thomas White, father of the celebrated Charles White of Manchester]

    What were the relationships between the patient, the local practitioner, and the metropolitan panjandrum consulted by letter? Was the local, however well qualified, just improving his (and his metropolitan consultant’s) status, or was he perhaps also acting as a surrogate, like a nurse?

    Was it really a matter of enhancing status and authority when the surgeon (or other practitioner) took in patients as lodgers? Surely not. These were less affluent or even poor patients, unless the patient had come from the country to a major city for a specific operation. The household of the surgeon could provide and charge for a wide range of services, in such cases, especially if the overseers of the poor from some parish were paying the bill.

    Were physicians such as the younger Helmont or Locke taken into aristocratic households purely as servant/physicians? I think not. Anne Conway was a valetudinarian, but Helmont was surely more than just an alchemical physician to her. He was a philosophical and religious interlocutor, just as Locke was a philosophical and political interlocutor for Shaftesbury.

    The role of royal physicians has perhaps been misunderstood. Given the range of choices available, why did kings, queens and princes choose the particular practitioners, especially the physicians, that they did? I mean the physicians ordinary, not the physicians extraordinary who might be called in for particular kinds of case.

    Another thing that is often overlooked is that the physician or apothecary to the local gentry or the nobility might gain in reputation, but he was also likely to go bankrupt, as high status households operated on credit. A practitioner often had to wait for payment until the estate went through probate. An urban apothecary might have plenty of small bad debts on his books, but a gentry practitioner could be owed huge amounts.

    • admin says:
      Yes David, I think this is going to need much more careful unpicking and problematising, these were literally my first thoughts on things. I tend to agree about the authority issue – would patients have even seen it as giving over any kind of authority? but there is certainly a tension in surgical sources about following orders – of course this is partially a narrative trope designed to absolve surgeons (and other practitioners) of blame if the cure didn’t work, i.e. the patient remained ill because they had not followed orders rather than any failure on the operators part.

      The impression I got from the Conway letters is that while Helmont stayed for a variety of reasons he initially was introduced in order to solve Anne’s headaches (although this may well obscure other reasons not documented in this kind of source ) he then treated a range of lower status patients in the Conway’s home, before the ‘Quaker’ issue began to arise. What struck me in the letters was the absence of Lord Conway and his apparent ignorance of what was going on in his home.

      However, what really interests me is this idea of lodgings. I had always thought as you say that wealthy patients remained at home, but I think surgical observations may allow us to broaden the picture. Many of them detail patients living in different areas/places/homes and moving about during treatment. In several cases the patient was ‘moved’ by the surgeon in order to make sure that correct treatment happened. As my study is on masculinity, manhood and patriarchy I naturally wondered where those things would fit into this. I would appreciate any further ideas or comments you might have – as I say I really only stumbled across this and I’m now adding it to the project as a research question. I am going to look up the various practitioners you mention and I think a comparison with midwives could indeed be very fruitful.

      Maybe the credit issue is worth following up as well – is there any suggestion that physicians stayed with their clients in order to lower their own costs/save themselves money ? I would be intrigued to hear what you think on this issue.

      Finally since writing this I have been reading the British Library medical handbills, and many of those include the statement that the physician has lodgings if desired, so I am now wondering if this is more related to venereal disease and is part of the trope of needing to hide away while being treated.

      Thank you for all these interesting thoughts. I really think this could be an interesting topic to pursue

  2. David Harley says:
    Some quick thoughts.

    Surgical cases might require more constant attention, by the surgeon or an apprentice, than cases in pysic. They might also involve a patient who had travelled quite some distance, to obtain the services of an expert in lithotomy or eye surgery, for example.

    Surgeons who practised general surgery had to develop a more compelling authority than most phytsicians could muster. They were telling patients to submit to excruciating pain, in hopes of a questionable result. More suited to a brusque Tory than to a sensitive Whig or nonconformist.

    Although I lacked personal papers, you might compare my papers on John Tylston (in journal The 17th C) and Henry Bracken (in The Codification of Medical Morality vol.) 1. See also paper on medical disputes, in Medical Enlightenment.

    I would draw attention to the stress of Whig physicians such as William Hunter on the power of Nature. [cf. Puritan radicals such as Sydenham] Vis medicatrix naturae. Hardly surprising that Elizabeth Nihell, with her constant insistence on Nature/Divine Providence, should choose to consult with Hunter in difficult cases.

    Last thought for now. In C17 and early C18, wealthy country families would book an eminent midwife to stay for 2 or 3 weeks, especially for the first delivery. As death was more likely in such cases than otherwise, a co-religionist would be preferred. Thereafter, a Catholic family would be content with a Quaker, a Baptist or a tolerant (esp Jacobite) Anglican, as they would not insist on C of E baptism or report the presence of secret priests. Unlike the wet nurse, pre-bboked resident midwives would eat at the family table. [Brief discussion in my Lancs and Ches midwives piece, in Marland, ed.)

    The same would apply to male practioners to a lesser extent, but especially in critical cases. There are historians of early modern medicine who deny either any such preferences or insist on the existence of large blocks, such as “Christian” or “Protestant”. I daresay members of each group have their reasons, deliberate or not, which may well have extra-historical roots. {No names, no pack drill}

    The shift to man-midwifery has been misunderstood as a medical conspiracy or as a matter of fashion. Each may have a degree of truth, but demand pull has received less attention than supply push. In the early 18th C, we see Tory aristocrats paying large sums for the services of Hugh Chamberlen, because they are not his regular patients. It is not fashion that is on their minds but the gentleness of his touch and his charming manners. There is an assumption that the Chamberlens were useing the forceps all the time, but this seems false. They appear to have attended in company with a midwife, for ocular inspection, and to have intervened as little as possible, Though Hugh changed sides politically, his methods came from a Calvinist family, accustomed to waiting on God/Nature.

    Judith Lewis, In the Family Way: Childbearing in the British Aristocracy, 1760-1860, provides material on how the better class of man-midwives might stay for days and be taken into the confidence of an aristocratic or upper gentry family, even perhaps marrying into it or into some other respectable family.

  3. […] Patients, practitioners, and lodgers in Early Modern History. […]
  4. […] cholera in the nineteenth century. Jennifer Evans considered the intriguing relationships between doctors and patients in the early modern period, and the way the location of treatment affected their position (anyone fancy staying with their […]
  5. David Harley says:

    It occurs to me that surgeons were more in need of escape clauses and hedging comments than physicians were.

    Pomata on Bologna and Pelling on London have shown us a little of the scope and significance of contracts conditional upon cure in early modern medicine. The pay and, even more so, the reputation of surgeons rested upon visible action taken to rectify or alleviate visible ailments. By contrast, physicians were remunerated for advice and attendance.

    The tardy payment of bills by the gentry might make the income of physicians tenuous, but they were less open to denunciation as frauds unless either they did not follow the rules of art, as learned physicians acceptable to their peers, or an autopsy revealed a major and obvious misdiagnosis. The fierce debate before and after the death of Henry, Prince of Wales, gives a good impression of what might be at stake.

    Surgeons often had to tell their patients that it was necessary to submit to a painful and risky operation. This required a great deal of personal assurance, to dominate the patient and the family without offending them by an exhibition of arrogance. The obvious excuse for failure was the failure of the patient or attendants to follow instructions to the letter. In view of the likelihood that nurses would be unlettered, in many cases, this was probably not a difficult position to argue. Having the patient in the surgeon’s own home or nearby lodgings, and provided with a nurse of the surgeon’s own choosing, probably limited this escape.

    Physicians, on the other hand, had complex signs to read and complex decisions about therapy to make. Even after Sydenham’s revolution in etiology, every patient was different. Only in the case of diseases of occult causation, those which seemed to take little notice of humours and constitutions, such as plague and the French pox, was there any reduction in the complexity of medical semiotics.

    The opening phrases of the Latin version of Hippocrates’ first aphorism were familiar enough, but it continues by stating the need to do not only what was right but also to make the patient, the attendants, and the externals (i.e. the six non-naturals, in later parlance) cooperate. A physician was not only unlikely to spend much time with a patient, or to make much use of the sense of touch, he might even be dependent upon letters and messengers. The ubiquitous flask of urine retained its significance for patients long after physicians had rejected its universal utility.

    Hippocrates, Aphorism 1 — Vita brevis, ars longa, occasio praeceps, experimentum periculosum, iudicium difficile.

    However, provided all the rules of diagnosis and therapy had been followed, and no over-optimistic prognosis made, the physician could usually rest not just in the obscurity of medical philosophy but in the ineffable wisdom of divine providence. The doctor might prescribe, but God would decide. [see the sermon of Prince Henry’s chaplain, upon the breaking up of the household; also the self-presentation of John Tylston, the godly doctor of the Henry family]

    Ecclesiasticus (Sirach) 38 was perhaps the deutero-canonical text most frequently cited by Calvinist preachers in England.
    1 Honour a physician with the honour due unto him for the uses which ye may have of him: for the Lord hath created him.
    2 For of the most High cometh healing, and he shall receive honour of the king.

    • admin says:
      Thank you for yet more useful insights. I was thinking similar things about the contractual nature of the medical relationship ( a friend of mine Hannah Newton is looking at recovery and we have been talking about these issues of when a patient was cured/healed/better)

      I was also thinking similar things about the ways in which surgeons/physicians justified/explained away failed treatments- it was the patients fault for getting up too soon, for eating the wrong things etc. This as you say would be more difficult to do if the patient was in the house under direct care of either the surgeon or someone appointed by them. But I wondered if some of these stories still fitted this narrative. As in the example in the post – this patient was bad and their cure suffered so I (the wonderful surgeon that I am) moved them under my own roof and they were cured.
      I think I will need to go through a lot more systematically and compare and contrast the different observations that involve a discussion of where the patient was. This could fit with what you say, they were more in need of escape clauses and so could highlight that the patient had moved away failed to complete treatment. A lot of the ones I have looked at so far were also venereal disease cures so contrasting with other types of illness to measure the frequency of the ‘housing’ issue might be one way to progress

  6. David Harley says:
    You are, I suspect, thinking of venereal diseases as defined now. Throw away “syphilis” and think of “the French pox,” or whatever.

    How was the ailment defined? What signs would the patient present to his or her practitioner? How would he arrange them as symptoms? What would constitute a satisfactory outcome?

    One might well contract for a cure, but our notion of cure doesn’t have to be theirs. Remember, the patient is thinking in terms of visible or otherwise perceived symptoms, even if a well-read physician might have an eye to occult contagion by some invisible agent.

    • admin says:
      I can see why you might think that but I am well aware of the complexities of ‘venereal disease’ in the period I have been teaching on it for many years and have often read through things on venereal disease for my research. Thank you for all your comments on this thread. I just need to find some time now to follow them all up.
  7. David Harley says:
    “which we can assume rarely worked ” was what perhaps misled me. It sent me into kneejerk historicist mode.

    My careless assumptions rarely work out well, or leave the impatient in a good state.

    I must break my habit, and apologize.

    • admin says:
      Thanks David,
      I know I felt funny writing that myself, but for the sake of an outreach blog I wasn’t sure how far to go into the nuance of whether remedies worked or not. I may in fact sneak in now and change this.

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