A Patient Interaction

An aurist’s assertion of authority could at times be intimidating for deaf patients. An anecdote by a Reverend J. Richard about his “deaf and nervous friend” best demonstrates this intimidation. The friend was too timid to oppose or contradict an opponent, and said “yes” to everything or “no” everything, answering questions as he “conjectured the answer to be desired.” Hearing of John Harrison Curtis and the Royal Dispensary for Diseases of the Ear (RDDE), Richardson encouraged his friend to apply for a consultation. As Richardson narrates the story,

Mr. Curtis was a man who from long experience was able to form a correct idea of the character as well as the people who made applications for his service, and he soon discovered that the new applicant was not a very wise man. Mr. Curtis in his practice adopted rather the vigorous energy by which Dr. Radcliffe was distinguished than the persuasive lenity with which modern practitioners in nervous cases are accustomed to treat fine ladies and gentlemen [i.e. in reference to the list of questions]. He took patients by storm rather than by protracted advances, and in the case of my deaf and nervous acquaintance, he came in contract with the man who was of all others least calculated to withstand his robustness.[1]

The practice at the RDDE was to employ a rigid criteria for examining patients, a move that Curtis deemed would be beneficial for the aurist to properly diagnose an ailment and employ the most effective treatment. Examination began with a series of questions Curtis drew up in accordance with the plan of his friend Dr. Schmaltz of Dresden; he intended the questions to assist his correspondence with distance patients in order to possess a full and detailed history of their ailment, but as evident from Richardson’s anecdote, Curtis also used some aspects of the questions in his daily practice. Richardson describes the experience of his friend at the appointment, supposedly as retold by the friend:

[Curtis] seated the patient in a chair in which patients were placed during examination, and after various questions proceeded thus:–

‘You hear what I say to-day better than you did yesterday?’

‘Yes, sir.’

‘You hear what I say without difficulty; don’t you?’

‘Yes, sir.’

‘What’s your name?’

‘Yes, sir.’

‘How old are you?’

‘Yes, sir.’

The practitioner was growing irate, the patient was trembling with fear, he could hear nothing, but concluded that his safety depended on the acquiescence of his responses. The practitioner was resolved not to be so easily satisfied; he pulled out his watch, and held it to the ear of the patient.

‘Do you hear that watch tick?’

‘Yes, sir.’

‘That’s a d____d lie, for it doesn’t go.’

The patient, though he could not hear the words of Mr.  Curtis, was aware something was wrong. He got out of the chair and out of the house as fast as he could, and never troubled the owner of them again with his presence.”[2]


 NOTES

[1] J. Richardson, Recollections, Political, Literary, Dramatic, and Miscellaneous of the Last half-Century, Volume II (London: C. Mitchell, 1856), 290.

[2] Richardson, Recollections, 291-292.

Advertisements

A Wartime Medical Dispenser

The Napoleonic Wars brought John Harrison Curtis’ studies to a standstill, as he became one of thousands of young men conscripted to fight against Napoleonic advances towards Britain. With his medical learning in hand, Curtis enlisted in the Royal Navy in 1808, to obtain his qualifications as surgeon and extend his medical skills. Since 1745, the Royal College of Surgeons in London, Edinburgh and Dublin, and the Navy held close associations with each other as the College was responsible for examining naval surgeons for active service. To be admitted as surgeon in the navy, candidates had to obtain a certificate of competence from the College and then be subjected to a two-hour oral examination at Somerset House.[1]  Certification did not automatically guarantee membership to the College, but in some cases it enabled candidates qualified for civilian practice once they were discharged.[2] According to the College Examination Books, Curtis took the exam at four different occasions: he was “referred” for further examination on February 5, 1808, and took two more exams on June 17 and December 16 of the same year. [3] He eventually obtained his qualifications on May 19, 1809, as Surgeon 5th Rate—the lowest rank, similar to an apprentice—in the Royal Navy and was immediately assigned as medical dispenser with the Navy Medical Staff.

After a brief stint at the depôt for French prisoners at Stapleton, Curtis was transferred to Haslar Hospital at Portsmouth, the navy’s most advanced and properly equipped hospital for officers and seamen. Built on a low-lying peninsula and dressed with Portland stone, the double block of buildings were raised three stories high, with two wings each measuring 560ft, making the hospital the largest brick building in Britain.[4] The quadrangle and hospital grounds were surrounded by a wall 12ft in height and guarded by the military patrol to deter desertion. The two wings contained 84 wards, each with its own water closet and washing area, a remarkable contribution to the antisepsis revolution in surgical wards. Only a fifth of the patients were admitted for surgical cases; the rest were treated for general medical complaints, including bronchitis, coughs, scurvy, typhus, and other ailments consistent with prolonged exposure to cold, damp air. Serving the Royal Navy from 1753, the institution was designed to accommodate 1,800 patients, but with an annual turnover of 9,000/year, the hospital was often overcrowded and poorly staffed.   A physician, two surgeons, a number of assistants and one dispenser staffed the hospital, although after 1795, the establishment included several more physicians, surgeons, surgeon’s mates, a number of administrative officers and assistants, and dispensers.[5]

 

History_Image
Naval Hospital at Haslar, Portsmouth (from http://www.royalhaslar.com)

By the time Curtis was stationed at Haslar, army causalities from the Peninsular Campaign overflowed the wards, earning the hospital a reputation of exemplar military service. It also meant there were numerous medical and surgical cases for a young and earnest practitioner to observe, analyze, and treat; the navy, in other words, allowed opportunities for medical and surgical observations and experiments, which in peacetime would otherwise be difficult to proceed. The social disparities between physicians and surgeons still remained, however, and even in 1798 a well-trained doctor could be dismissive of a surgeon’s ability.[6] As Margarette Lincoln notes, until 1805, naval surgeons were licensed strictly for naval surgery, and held warrants, rather than commissions, as officers, and their rank and salary were subjected to mismanagement and poor payouts. Although some surgeons found eventual success in civilian practice, for the most part, many were subjected to dismissal at the end of the war and struggled to receive their pensions. Even though Curtis’ low ranking as a medical dispenser meant he apprenticed under surgeons at Haslar, he was placed on the half-pay list, and categorized as a doctor in the Navy, possibly referencing mismanagement of naval lists, or evidence of a promotion; either way, there’s little evidence of Curtis’ time at Haslar so it’s difficult to ascertain exactly what his role was as a medical dispenser apart from simply dispensing medicine.[7]

As a dispenser, Curtis obtained surgical and clinical expertise to serve him well in his later civilian work. The role of a medical dispenser was generally to make up medicines for a prescription written by a physician or by a surgeon; in some cases, surgical training enabled the dispenser to work as a surgical assistant, especially when the hospital was understaffed. Curtis’ medical education prior to commission was typical for prospective surgeons during the early nineteenth century: attendance at lectures at the teaching hospitals in London, in such establishments as St. Thomas’ and St. Bartholomew’s Hospitals, or in other private school, were sufficient for aptitude in a variety of surgical knowledge. Training in these wards were restricted to mere copying of case notes or observations of operations and surgical dressers; students were not required to perform operations, but had to attend courses of lectures on anatomy and surgery in order to demonstrate their proficiency.[8]

For the most part, the dispenser’s responsibilities were no different than that of the apothecary; anyone licensed by the Society of Apothecaries could prescribe for a patient, but only in naval hospitals were individuals called “dispensers” while everywhere else they were an “apothecary.”[9] The situation began to change during the late eighteenth century, as dispensers often served as assistants to physicians or surgeons, to the point that to avoid further confusion, in 1794 it was proposed that dispensers who also served as assistants would hereafter be titled “Medical Assistants” and be granted a salary of ₤100 per annum.[10] A further revision occurred in 1805 by an Order in Council, declaring all “Visiting Assistants,” “Assistant Surgeons,” and “Assisting Dispensers” were to be called “Hospital Mates” or “Surgeon Mates” and were to receive 6s. 6d. per day in full pay, and 2s. 0d. per day for half pay, and must qualify for hospital appointments by examination from the Royal College of Surgeons.[11] They also had to wear a distinguishing uniform though a new title and a new uniform could little to alter the rigid social class of Georgian Britain and the inferior social standing that dispensers were often placed amongst.[12]

One major attraction of naval service was the knowledge that once surgeons or surgeon mates were placed on half-pay and dismissed from their commission, they could set up a civilian practice without further examination from the Royal College of Surgeons, by virtue of their vast experience of medical practice than any civilian counterpart.[13] Curtis was commissioned as a dispenser at Haslar during the “hottest period of the…war, namely, after the battle of Trafalgar, and during the expedition to Walcheren.”[14] He had the ample opportunity to examine as many as 200 soldiers that were admitted within twenty-four hours as the troops arrived from Corunna, afflicted with pneumonia and dysentery, and many of them severely wounded. Many more were afflicted with classes of diseases peculiar to sailors and soldiers. Moreover, since medical officers at Haslar were prohibited from attending to private patients, their attention was mainly directed to surgical operations and to the numerous cases of diseases that came before them daily, a focus, Curtis noted, that contributed to the excellence of the hospital’s medical reputation as well as in its treatment of patients.


NOTES

[1] David McLean, Surgeons of the Fleet: The Royal Navy and its Medics from Trafalgar to Jutland (London & New York: I.B. Tauris, 2010), 23.

[2] Christopher Lloyd and Jack L.S. Coulter, Medicine and the Navy 1200-1900 (London: E&S Livingstone, 1963).

[3] Court of Examiners, 1809. The Archives of Royal College of Surgeons of England (with thanks to archivist Louise King).

[4] Bale Vale and Griffith Edwards, Physician to the Fleet; The Life and Times of Thomas Trotter, 1760-1832 (Suffolk; The Bordell Press, 2011), 87.

[5] McLean, Surgeons of the Fleet, 7.

[6] Margarette Lincoln, “The Medical Profession and Representations of the Navy, 1750-1815,” in British Military and Naval Medicine, 1600-1830, ed. Geoffrey L. Hudson (New York: Rodopi, 2007), 201-226; 202.

[7] National Archives, Kew: ADM 45/31/650 (1853-1854), No. 650:  John Harrison Curtis, Doctor on Half Pay List, who died, 24 November 1852 (Notes on executor’s application for money owed by the Royal Navy). Anytime an officer applied for commission, warrant, or pension, the Navy pay office would issue a certificate confirming his qualifying service—this became the only evidence of a Navy register until at least the 1830s when official registers were introduced. Regulation to half-pay also dismissed commissions from the navy.

[8] W. Bonnici, “Early 19th Century Maltese Doctors in the Service of the Crown,” Journal of the Army of Medical Corps 143 (1997): 171-175; 171.

[9] Christopher Lloyd and Jack L.S. Coulter, Medicine and the Navy 1200-1900: Volume III—1714-1815 (Edinburgh & London: E. & S. Livingstone Ltd., 1961), 52.

[10] Lloyd and Coulter, Medicine and the Navy 1200-1900: Volume III, 52.

[11] Lloyd and Coulter, Medicine and the Navy 1200-1900: Volume III, 52.

[12] Christopher Lloyd and Jack L.S. Coulter, Medicine and the Navy: 1200-1900: Volume IV—1815-1900 (Edinburgh & London: E. & S. Livingstone Ltd., 1963), 12.

[13] Lloyd and Coulter, Medicine and the Navy 1200-1900: Volume IV, 21. Stricter regulations for qualifications for both naval and civilian practice did not occur until 1831 as the Order in Council required that all candidates should not only require a certificate of competency from the Royal Colleges of Surgeons of England, Edinburgh, or Dublin, or from the Faculty of Physicians and Surgeons of Glasgow, but must also undergo further examination from the Naval Medical Service (23).

[14] John Harrison Curtis, Observations on the Preservation of Health, 2nd Edition (London: Henry Renshaw, 1838), 123.

Diagnostic Instruments & Surgical Authority

On 29 October 1839 the Bankruptcy Register listed John Harrison Curtis as a “bookseller.” By 1841, Curtis lost his patrons and his career was pretty much in shambles and his Dispensary was sold to the aurist William Harvey.

The invention of the cephaloscope and the publication of his treatise on the instrument were aimed as an approach for him to revive his career. In 1842, Curtis wrote a letter to Sir Robert Peel (1788-1850), a former patient of his who he appealed for assistance. In the letter, Curtis refers to his On the Cephaloscope (1842) as evidence enough for his merits for an appointment to Queen Victoria’s household as Surgeon-Aural surgeon-in-Ordinary.

But the treatise itself doesn’t spend much time discussing the merits of the instrument—most of the book is spent outlining the basic physiology and anatomy of the ear, the cranium, and the organs of the voice, explaining that the details are “absolutely necessary in order [for] the proper application of the instrument.”[i] In the chapter on the cephaloscope, Curtis spends little time actually discussing the merits of his instrument in practice, or providing extended cases studies of its application. But these details seem relevant, if not required, for Curtis to his credibility to other aurists. In particular, his long explanation of the augmentation of sound seems superfluous, but it appears to be central for his explanation of the design of his instruments.

The fact that Curtis used an instrument—as opposed to another “miraculous cure” or nostrum or surgical procedure—to extend his authority is noteworthy. It reveals much into the embodiment of medical and surgical authority within material objects and how instruments can be used as rhetorical devices. The cephaloscope, above all, was more of a symbol of orthodoxy for Curtis; as historian John Harley Warner points out, instruments that were presented as symbols of unity were means for preserving confidence at times of severe professional dislocation. Movements towards a more unified specialty based on Parisan pathological anatomy and diagnosis, became crucial epistemological and rhetorical shifts for aurists; by appealing to notions of “science” and “professional” they were in fact redefining the boundaries between the newer type of aurists like Toynbee, and those like Curtis who held on to their passive practices. Diagnostic instruments in aural surgery thus rested not on some abstract notions of what constituted as evidence for aurists, but rather on how authority could be asserted through material objects.[ii] These instruments served more than the mark of a surgeon. They were a symbol of the aurist’s skills and his judgment, considered to be more valuable to the public than a diploma or certificate, which could easily be forged.

The durability of any diagnostic instrument rested on a practitioners’ power to correlate what was heard or observed, with specific disease symptoms. The stethoscope for instance, not only unified the medical profession and transformed the patient-practitioner relationship, but it popularized a new skill for diagnosis—auscultation—which required the practitioner to make use of his auditory senses. Of course, the practitioner had to be trained for such a skill.[iii] Curtis hoped to do the same for aurists: since diagnostic instruments in aural surgery were long plagued with the problem of limited examination due to insufficient light source, he argued the cephaloscope could remedy this limitation by appealing to the aurist’s other sense. Sounds could convey images of internal anatomy, revealing damages to the structure of the ear, blockages in the ear or Eustachian tubes, or evidence of lesions brought by other diseases. Moreover, the cephaloscope was a far safer diagnostic tool than the speculum, forceps, or even Eustachian catheter, all of which, if improperly used, could cause pain and suffering in the patient. The reticent state of British aural surgery in the 1840s, however, made it difficult to construct a profession unified by a material expression of its authority. Nearly all aurists agreed diagnosis was the key to improving the state of aural surgery and securing their authority as specialists; more precise instruments would allow them to forge their skills as diagnosticians, and thus, prescribe more effective medical or surgical treatments. But some aurists, like Toynbee, concentrated on dissection in order to improve their clinical understanding of ear diseases; others, like Wright, recommended language training as alternatives to surgical treatments.


[i] Curtis, On the Cephaloscope, 1.

[ii] Jennifer Stanton, “Introduction: On Theory and Practice,” in Innovations in Health and Medicine: Diffusion and Resistance in the Twentieth Century, ed. Jennifer Stanton (London & New York: Routledge, 2002).

[iii] W.F. Bynum and Roy Porter (eds), Medicine and the Five Senses (Cambridge: Cambridge University Press, 1993).

Acoustic Instruments

I’ve pretty much been chained to my desk these days, struggling to write the most difficult chapter of my dissertation, which broadly focuses on the historiography of medical specialties and professionalization. The chapter also provides an analysis of how diagnostic instruments (and other medical technologies) served as a nexus for the crystallization of specialist medical identities in the case of aural surgery in early 19C London.

I’ll share some tidbits as I go along, but for the meantime, I ran across a quote by John Harrison Curtis, who, despite having earned a reputation for his acoustic instruments–particularly his hearing trumpet–became severely critical of the use of acoustic instruments as a replacement for surgical and medical treatments for ear diseases. That is, Curtis insisted the deaf population should not turn to instruments until all other medical means have been exhausted:

Acoustic instruments, like surgical operations, should always e the last things resorted to. Hundreds have permanently lost their hearing through using instruments, who might, by proper treatment adopted early, and adhered to, have been restored to the full possession of that important and valuable function.

…The constant use of any fixed acoustic instrument exhausted the energy of the auditory nerve, and will, sooner or later, lead to irremediable deafness, which no instrument can assist.

Advice to the Deaf (1841)

A fulfilled career

Twenty-five years have elapsed since I commenced this line of practice; and I have every reason to be satisfied with what I have accomplished in that period. I leave it to the profession to say what was the state of aural surgery before I commenced practice, and what had been done to increase our knowledge of the diseases which affect that organ, and the treatment which should be adopted. I have been followed by many persons of talent not only in this country, but on the Continent, both by regular and irregular members of the profession, and I have had the gratification to know that I have rendered much service to many of my fellow-creatures from the highest to the lowest, and have mitigated such human suffering. From the intercourse I have had with the heads of profession in this country and on the Continent, I have obtained that information which does not fall to the lot of many; and if I look back with satisfaction to what I have accomplished in the last twenty-five years, I look forward with pleasure to what I may accomplish in the next twenty-five years, should God spare my life.

John Harrison Curtis, On the Cephaloscope (1842)