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Trollope Eliot and their doctors

Rodney Turner

An extended version of the article (see 'Trollope's doctors' on the menu to the left) written in 2000 as a talk for the Trollope Society in London and subsequently published in their magazine the Trollopian. More information about the author.  Part 1 is here; Part 2.

The careers of two leading nineteenth century novelists, Anthony Trollope and George Eliot, spanned the middle years of Victorian England. Trollope was born in 1815, four years before Eliot, and died in 1882, two years after her death. They were on good terms, met frequently, and liked and admired one another’s work. Most of their novels were set in nineteenth century England (and in Ireland in Trollope’s case), and they each wrote revealing accounts of the society which they were familiar with. That society included doctors and, as illness and death were commonplace, authors could not avoid bringing them into their tales of contemporary life. As they must have relied in part upon memories of individuals they had known, studying the doctors featured in their novels could indicate how they felt about the medical profession and its practitioners.Before proceeding, it is useful to summarise the state of medicine nationally during the years in which they were writing.

Nineteenth Century Medicine in Britain

In the early years of the century, British doctors were deployed in a hierarchy which had changed little since medieval times. At the apex of the profession, not least in their own opinion, were the physicians. Graduates of Oxford or Cambridge Universities and communicants of the Church of England, they had studied the classics, materia medica (today’s pharmacology) and botany, this being relevant since most drug treatment was based on substances derived from plants. Medical teaching consisted of formal lectures delivered by senior physicians and was based on principles laid down by Hippocrates and Galen long ago. Bedside instruction was seldom a feature.

University graduates were highly privileged men (there were no women doctors until late in the century). As Fellows of the Royal College of Physicians, founded in 1518, Oxbridge doctors regulated medical practice in London and for a seven mile radius outside it, allowing new entrants to practise there only after they had passed an oral examination conducted in Latin. Doctors who had completed their medical studies elsewhere could join the College only as licentiates and as non-voting members.

By 1800 the Royal College had become little more than a gentlemen’s club, and the number of applications to study medicine at Oxbridge colleges was falling. Many aspiring students, including those who were not members of the Church of England, sought their medical education at more enlightened and less traditional universities in Scotland, France, Holland and Germany, where the curriculum was broader and involved closer contact with the sick.

Ranked below the physicians were the surgeons. From 1540 they had been part of the United Company of Barbers and Surgeons, but in 1745 they founded their own Company of Surgeons, which was raised to the status of a Royal College in 1800. Surgeons were a disparate group. Some of them possessed a medical degree but most did not; they had served as apprentices to senior colleagues and this, plus a knowledge of anatomy, was all that was legally required in order to practise surgery. For many, it was a part-time occupation, much of their work being similar to that of apothecaries. Some advertised veterinary work as well as the care of human patients.

The lowest rung on the professional ladder was occupied by the apothecaries. Their origins were in trade, and many of them combined the sale of drugs with other occupations. The Society of Apothecaries awarded its membership to candidates who had served an apprenticeship which was generally shorter and cheaper than that required of aspiring surgeons. Apothecaries were allowed to prescribe drugs, but were required to understand sufficient Latin to dispense prescriptions written by physicians, and to have some knowledge of chemistry and botany. Many had no formal qualifications at all and dispensed advice and drugs without restraint. The part played in health care by these unlicensed practitioners was shared in free-for-all competition with an army of herbalists, bonesetters, clergy, wise women and an assortment of charlatans and quacks. It was unregulated chaos.

A major change occurred in 1815 with the passage through Parliament of the Apothecaries Act. This recognised the right of the Society of Apothecaries to grant licences to students who had completed an apprenticeship, worked in hospital and passed an examination. It marked the first step towards the evolution of the modern general practitioner, as the new breed became known. Most of them came from humble backgrounds, and their modest origins and low social status were not readily forgotten. Doubts about their ability and competence persisted even though the Act legitimised the right of licensed apothecaries to be addressed as Doctor. Unlicensed apothecaries were allowed to continue advertising their services to the public, so the Act did little to erase the common perception of a medical hierarchy of skill and expertise. The term “apothecary” was used in a disparaging sense for many years after the Act by critics sceptical about general practitioners, who were still widely regarded as unqualified and possessing inferior knowledge and skill.

It was another forty years before the next professional reform took place. In 1858 the Medical Act ratified the degrees and licentiates awarded by different colleges and universtities, according them all equal status. The General Medical Council was set up to maintain a register of all qualified doctors, and was given power to investigate allegations of professional malpractice or misconduct. Doctors were not allowed to advertise, and standards of teaching and examination of students were kept under review. No attempt was made to reduce the number of unorthodox practitioners, whose services the public rermained free to purchase, but unqualified healers were prohibited from holding office in asylums and public or Poor Law institutions.

Britain’s increasing population meant that more doctors were needed, and the number of general practitioners rose. For many life was hard. They were often unable to afford to marry until they were forty years old or more unless private means enabled them to purchase a practice. Most had to wait until a senior partner died or retired, meanwhile doing the bulk of the practice work for a meagre return. Some of them supplemented their income by attending workhouses or Poor Law institutions. Roy Porter described the nineteenth century general practitioner as “a highly vulnerable individual in a competitive buyer’s market in which it was not uncommon to undercut each other or to poach patients. For an outsider, the prospects of rising up the profession to become a top consultant were negligible; such eminences still came largely from a self-selecting and self-perpetuating few.”

Doctors who acquired a high reputation attained wealth and recognition, sometimes becoming society favourites. At first most were physicians, but in the second half of the century leading surgeons also gained high regard. Between 1850 and 1883 thiirty-six doctors were knighted, fifteen were made baronets and one, the surgeon Joseph Lister, was granted a peerage.

The enhanced social status of privileged doctors was due in part to an explosion in scientific knowledge throughout Western Europe, where most medical advances resulted from observation and research in hospitals. Scientists whose work contributed to progress included Laennec, who pioneered the use of the stethoscope in 1819; Semmelweiss (1845) showed antisepsis to be effective in controlling puerperal fever; Pasteur (1857) formulated the germ theory of disease and developed a vaccine against rabies; Virchow (1858) identified microscopic change in cells as fundamental to an understanding of the causes of disease; and Claude Bernard (1865) advanced the knowledge of physiology through laboratory work and animal experimentats. Lister (1867) lowered the mortality of surgical operations by using a carbolic antiseptic spray, and was rewarded not only with a peerage but also with the Order of Merit and the presidency of the Royal Society. General anaesthesia with ether and chloroform converted operations hitherto impossible into relatively safe procedures. British doctors who described eponymous diseases included Addison, Bright, Hodgkin, Paget and Parkinson. The first medical journal to be printed in Britain, The Lancet, appeared in 1823, enabling new findings and theories to be described and discussed.

These were some of the advances made while Trollope and Eliot were writing. But new ideas and techniques were slow to percolate through to everyday practice, and general practitioners contributed little to improvements in public health. There were exceptions: John Snow charted cases of cholera in his London practice during the epidemic of 1854 and, noting that the victims obtained their water from the same pump, removed its handle and prevented further spread of the disease. But general practitioners were handicapped by the deficiencies of an education which was both inadequate and inappropriate for the job they were trying to do. Professionally isolated, they had few opportunities and little incentive to change their style of practice. They trusted to experience, which all too often meant repeating the same mistakes with increased assurance. Physical examination of patients was limited to feeling the pulse, inspecting the tongue and observing the features. Unable to influence the course of most illnesses, they could easily make things worse by injudicious advice and inappropriate treatment. There were two main methods of managing illness; stimulants, chiefly opium and alcohol: or “lowering measures” such as bloodletting, leeches, blistering and purgatives. Both were potentially dangerous and generally futile. Ignorance was concealed by using Latin phrases and meaningless jargon.

Of more immediate benefit to the public was a series of progressive social measures. In 1838 registration of births, marriages and deaths in England and Wales was made compulsory, thus laying the foundation of statistical studies of health in the community. Successive Acts of Parliament sought to curb the exploitation of child labour and to alleviate some of the worst hardships and hazards of industrial labour. In 1842 a report by Edwin Chadwick, a lawyer, outlined a series of measures essential for health, and as a result the Public Health Act, passed by Parliament six years later, imposed on local authorities a duty to supply clean water and to organise the hygienic disposal of sewage. Sir John Simon, the first Medical Officer of Health to the City of London and later Chief Medical Officer to the Local Government Board, oversaw many improvements including a much expanded programme of vaccination against smallpox and the first epidemiological studies of disease in the community.

Despite these measures, the average expectation of life at birth increased only modestly in England, from under forty in 1800 to forty-four in 1899.The infant mortality rate was higher in 1899 than at any time in the previous sixty years, and in some inner city districts more than half of all babies died before their first birthday. Industrialisation encouraged migration from the countryside into towns and cities where working people lived in overcrowded, insanitary slums, while in rural areas living conditions were generally bleak and primitive. Epidemics of measles, whoopiing cough, diphtheria, typhoid, cholera and gastroenteritis caused havoc, especially among children. Tuberculosis flourished in overcrowded and malnourished communities. Venereal diseases were widespread. Poverty and ignorance were universal, contraception was rudimentary or non-existent, and large familiies were the rule. Such was life in Victorian England whrn Anthony Trollope and George Eliot began to write.

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Anthony Trollope’s Family

nthony was the fifth of his parents’ seven children, one sister having died before he was born. One of his brothers died from tuberculosis at the age of eleven when Anthony was nine, and another at twenty-three from the same complaint in 1834. His sister Emily, aged eighteen, died in 1836, also from tuberculosis, as did his surviving sister, Cecilia, in 1849 at the age of thirty-one. Four of Cecilia’s five children died, aged between five and eleven, once again from consumption. Her widowed husband remarried, only to lose his second wife to puerperal fever a year later. Ten years later he married for a third time, and a child of this marriage died too. Trollope’s surviving brother’s wife died aged forty-two after a long illness, and their daughter succumbed from puerperal fever at twenty-eight. Anthony’s wife’s sister died at forty, predeceased by her husband.

Dominating the early years of Anthony and his siblings was their father. Thomas Anthony Trollope, a barrister by profession, had an extraordinary capacity for upsetting people. He bullied his sons and fell out with colleagues at work. Monumentally incompetent in practical matters, he attempted successive money-making ventures, but ignorance and inefficiency resulted in disaster each time. He suffered from chronic abdominal pain for which he treated himself with large doses of calomel, a toxic compound containing mercury, which may have exacerbated his symptoms. His psychiatric condition was probably either a severe personality disorder or a paranoid psychosis. He fled to Belgium to escape bankruptcy, became bedridden, and died unlamented in1835, aged sixty-one. Trollope’s elder brother delivered a chilling verdict on his father. He wrote, “I do not think it would be an exaggeration to say that for many years no person came into my father’s presence who did not forthwith desire to escape from it.” Anthony’s verdict on his father was no less depressing: “Everything went wrong with him. The touch of his hand semed to create failure. But the worst curse to him of all was a temper so irritable that even those he loved the best could not endure it. His life as I knew it was one long tragedy.”

The complaints from which the Trollopes suffered – tuberculosis, puerperal sepsis and psychiatric illness – were alike in being unresponsive to treatment at that time. Doctors must have been frequent visitors to the household, and repeated encounters with them must have been both dispiriting and costly. Thus Trollope had ample first-hand opportunity to form opinions about the shortcomings of contemporary medicine and the inability of its practitioners to relieve distress and suffering.

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George Eliot’s Family

Mary Anne Evans was born in 1819, the third child of her father, Robert Evans, a Warwickshire land agent, and his second wife. Illness and premature death dogged the family. Evans’s first wife had died in 1809, aged thirty-one, shortly after delivering her third child. The child died too, leaving Evans with two small daughters. In 1813 he remarried. Two sons followed before Mary Anne, but twin boys born in 1821 both died in infancy. When she was sixteen, Mary Anne was brought home from school to care for her mother, who was mortally ill from cancer and died six weeks later, aged forty-eight. As she lay dying, her husband was stricken with renal colic, caused by a kidney stone. Writing to a friend, Mary Anne said, “I am thankful to say that he is now considered out of danger, though very much reduced by frequent bleeding and very powerful medicines.”

Mary Anne’s half-sisters married and left home, leaving her to run the household and care for her ailing father and her brothers. When one half-sister, Chrissey, had a miscarriage, Mary Anne wrote, “Our dear sister is in a very weak state from a kind of affliction second only to a confinement.” Her father had further attacks of renal pain treated by his doctor, John Bury, with leeches and medicines. Finally he became ill from heart failure, and Mary Anne wrote, “Mr Bury has put Father on a different diet . . . (he) has a blister on his chest which I trust has already done a little good.” Evans, a difficult and demanding patient, died in 1849, and Bury wrote admiringly of his daughter’s care of her father during his long illness. His own daughter became a lifelong friend of Mary Anne, who trusted Bury and was grateful to him for his efforts to treat her father.

Three months after Robert Evans’s death, Chrissey’s five year old daughter died from scarlet fever, and in 1852 her husband, a general practitioner, died from tuberculosis at the age of forty-three, leaving his widow with six chiildren aged between one and sixteen. Four years later Chrissey and a seven year old daughter developed typhus. The little girl died but Chrissey survived, only to die from tuberculosis, aged forty-seven, in 1857. A nine-year old daughter followed her a year later, while a son aged sixteen had been drowned at sea in 1856.

In1854 Mary Ann (now calling herself Marian) began to live openly with GH Lewes, The misfortunes of her famiily persisted. Her half-brother Robert and her half-sister’s husband both died in 1864, and in 1869 Lewes’s son Thornie, who had been farming in Natal, returned home ill with severe backache and loss of weight. Sir James Paget and Dr John Reynolds, Professor of Medicine at University College Hospital, were consulted and diagnosed spinal tuberculosis. The only treatment was cod liver oil and morphine, and Thornie died, aged twenty-five, after five months of pain and suffering in which he was nursed by his step-mother. Lewes’s youngest son remained in South Africa and died, also from tuberculosis, in 1875, aged twenty-nine. When Eliot’s life writing career was almost over; George Lewes, with whom she had lived contentedly for more than twenty years, became ill. An initial diagnosis by Paget of piles was soon amended to one of “thickening of the mucous membrane”, a euphemism for bowel cancer. He died in 1878.

Illness and death were never far distant during Eliot’s life, and doctors must have been familiar to her as they attended her relations. Her life was beset by other difficulties. Her education was terminated prematurely. “Holy War” erupted in 1842 after she rejected the strict evangelical doctrines ro which her father adhered, causing a major crisis and temporary separation from him. Abortive love affairs were followed by ostracism and notoriety when she went to live with Lewes; her brother broke off relations with her and did not speak to her for twenty years.

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Health and Careers

Both Trollope and Eliot were fortunate to escape the hazards to health common in their day. Trollope enjoyed robust health throughout his life until his last years. In 1873, aged fifty-eight and troubled by deafness, he wrote to a friend, “I fear I have lost the hearing of one ear for always . . . Oh dear! One does not understand it at all. Why should anything go wrong in our bodies? Why should we not be all beautiful? Why should there be decay? - why death? - and, oh, why, damnation?” This was probably nothing more than a slightly petulant, humorous complaint about the effects of advancing age, for he was not afraid of dying: in a late novel, The Fixed Period, he even flirted with the idea of euthanasia for those living into their sixties. Perhaps the memory of his mother, who died aged eighty-four after some years clouded by dementia, had concentrated his mind on the subject. In his last years the effects of good living made themselves felt. He was overweight, a heavy smoker, ate and drank heartily, and probably had high blood pressure. In 1881, aged sixty-eight, he suffered a paralytic stroke and died a month later.

George Eliot shared Trollope’s good fortune in growing up without any major physical illness, but emotional instability was a problem throughout her life. She first showed signs of it in childhood when, a talented pianist, she would burst into tears of shyness and embarrassment after performing for visitors. Thereafter she was subject to headaches, sickness and depression, especially when she was writing. She disliked attending large gatherings and was upset by any alteration in routine. When she was nineteen she attended a dance, describing in a letter to a friend what happened. “The oppressive noise . . . produced first headache and then that most wretched and most unpitied of afflictions, hysteria, so that I regularly disgraced myself.” Writing from Geneva in 1849, she complained that “my health has been very wretched here, partly owing to the unreasonable hours - 10 o’clock for breakfast and 6 for dinner.” It is surprising to find a woman of thirty disturbed by such a trivial matter. Two months later she lamented that “my want of health has caused me to renounce all application.” In 1852, reviewing and editing in London, she wrote that “the opera, Chiswick Flower Show, the French play, and the Lyceum all in one week brought their natural consequence of headache and hysteria all yesterday. At five o’clock I felt sure that life was unendurable and that I must consider the most feasible method of suicide as soon as the revises are gone to press. This morning, however, the weather and I are much better.” Adverse weather, be it cold, excessively warm, wet or foggy, made her miserable and depressed. She had no doubt about the nature of the complaint, writing, “My troubles are purely psychological – self-dissatisfaction and despair of achieving anything worth doing.”

Lewes suffered from similar spells of illness in which he was afflicted with headaches, sickness, pain and tinnitus. Ill-health became a feature of their lives together, each relying on the other for sympathy, concern and care. Again, Eliot had no doubt about the cause of Lewes’s illness, writing that “there is nothing organically wrong, but he has been continually suffering, as I have, from the malaise of indigestion.” They each lived with an abiding fear of inability to continue working. Medical advice was to rest, avoid “intellectual strain”, and even to forsake all reading until the symptoms went away. Eliot was always fearful lest illness should prevent her from completing work in hand, from producing material on time for her publisher, or for bringing her novels to a conclusion satisfying to critics, readers and herself. Her diary entries for1865 tell a dismal story: “The weather was cold, and I was often ailing. I am in deep depression, feeling powerless . . . the last fortnight has been almost unproductive from bad health.”

Her interests, stimulated by extensive reading and a wide circle of intellectual friends, were numerous. Literature, music, science and medicine were among them, so that she met eminent people from all walks of life. Among doctors whom she knew socially, and in some cases professionally as well, were the Leeds physician Clifford Allbutt, who pioneered the use of the clinical thermometer; Sir James Paget, Sir James Clark, Sir Henry Holland and Dr Neil Arnott, all leading physicians; Sir Andrew Clark, a future President of the Royal College of Physicians; John Elliotson, one of the first British doctors to use a stethoscope; and the neurologist Hughlings Jackson. She watched a dissection of a human brain during a visit to Oxford, a highly unusual interest for a Victorian woman. There were connections with medicine close to home too. Lewes had been a medical student, and although he abandoned his studies without qualifying as a doctor he retained an interest in the subject. He had many medical friends and wrote books on physiology and psychology. Eliot’s sister Chrissey was married to a general practitioner; a lifelong friend, Maria Congreve, was the daughter of the Evans’s family doctor, John Bury; and Lewes’s son Charles became engaged to the granddaughter of the medical reformer Thomas Southwood Smith. Eliot was therefore better informed about the current state of medicine than were most of her contemporaries and certainly more so than Trollope.

In their constant search for improved health she and Lewes also had recourse to unorthodox treatments. They visited spa towns both at home and abroad, believed that sea air was beneficial, and toyed briefly with spiritualism. Her death, at the age of sixty-one, was sudden. Intermittent pain in her left kidney had troubled her for years, causing her to take opiates for relief. Seven months after her marriage to John Cross she complained of a sore throat, and three days later she died. Told of her death, Trollope wrote, “I did love her very dearly: that I admired her was a matter of course.”

The style and routine adopted by the two novelists could hardly have been more different. Trollope set himself a daily target of words written at a steady pace. As one novel was ended he was ready to start the next, publishing forty-seven in thirty-five years. In his Autobiography he admits to occasional interruptions in the flow of words. “There are usually some hours of agonising doubt, almost of despair – so at least it has been for me – or perhaps some days.” But his industrious work record shows that writer’s block was not a problem for him. “Work to him,” wrote his brother Tom, another prolific author, “was a necessity and a satisfaction.” George Eliot’s nine novels were completed only after much agonising and self-doubt about the quality of her work. Her output would have been much less without the encouragement and support of Lewes. The contrast between the methods adopted by the two authors could hardly have been more marked, forTrollope never lacked self-confidence, writing for a set period every day and starting on a new book immediately on finishing its predecessor.

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Continued in Part 2 ... Fictional Illness, Fictional Doctors, Two Exceptions, Conclusions.  Go to part 2