BBC Free Thinking Feature: Bamburgh Castle Surgery, c. 1770-1800

Over the past few years I’ve been working on the records of a unique eighteenth-century medical institution. The eighteenth century saw the rise of institutional medicine, first in the form of hospitals and infirmaries, and later dispensaries. The former were large, imposing buildings in a town landscape, housing inpatients and treating surgical cases, as well as other conditions. Dispensaries were smaller, sometimes occupying existing buildings, but generally acted as outpatient services where the poor could be given medicines, patched up if necessary, and sent on their way.

Both hospitals and dispensaries were funded by subscription. Subscribers were invited to pledge an annual sum of money, put towards the building, running and upkeep of the institution. In return, subscribers had the right to recommend patients for treatment, according to the size of their donation. Unlike today, patients could not simply turn up at the doors, unless in absolute emergency. Instead, they required a certificate of permission, signed by a subscriber and, as such, could be difficult to access at times.

Image from Wikimedia Commons

Also, institutions were firmly urban in nature. They were closely bound up with the civic ambitions of Georgian towns. A hospital could be a strong statement about a town’s importance and beneficence to the poor. ‘See how kindly we look upon our poor objects’.

Unsurprisingly demand for these facilities was high. Even outside London, annual admissions could number in the thousands. Especially in the crowded and often unsanitary conditions of towns, conditions like epidemic fevers were rife.

But one medical institution stood apart – both literally and notionally – from the rest. In the 1770s, Dr John Sharp, Archdeacon of Northumberland, philanthropist, and member of a family which included a prominent surgeon and famous anti-slavery campaigner (Granville Sharp) was a trustee of a large charitable fund established by the late Nathaniel Lord Crewe. Crewe had set aside large amounts of money from land revenues, stipulating in his will that these were to be put to charitable use.

Image from Wikimedia Commons

One of the properties was the dilapidated medieval Leviathan of Bamburgh Castle. Undertaking a massive programme of restoration, Dr John Sharp adapted the castle to a variety of charitable uses, including a school, corn charity, home for shipwrecked sailors and the surgery/infirmary.

With his brother’s advice (a surgeon at St Bartholomew’s hospital in London), Sharp equipped Bamburgh with the very latest in medical technologies, including an ‘electrical machine’ for literally electrocuting patients back to health, a full stock of medicines and equipment, and other modern apparatus such as the ‘machine for the recovery of the apparently dead’ – used to try and revive the recently-drowned.

Last year I visited Bamburgh and made a short radio programme for BBC Radio 3, which is now available online.

Click on the link and then the ‘play’ icon in the new page to access the programme

For more about Bamburgh and its facilities, you can also click here for my ‘History Today’ article about Dr Sharp and his medical charity.

Overcrowded and Underfunded: 18th-Century Hospitals and the NHS Crisis

The problem of overcrowded hospitals in Britain is now an annually recurring one. Every year, especially in winter, operations are cancelled, treatments postponed and patients sent home because there simply isn’t bed space for them. A combination of increased admissions of the elderly in the winter months, seasonal outbreaks such as flu and norovirus, and the impact of weather-related accidents all serve to pile on the pressure to an already-embattled healthcare system.

According to the BBC, NHS and social care services are ‘at breaking point’, with an open letter warning the government that ‘things cannot go on like this’.http://www.bbc.co.uk/news/uk-29501588. The story is now a perennial one. Every year (and in fact every couple of months) a mix of underfunding, overcrowding and staff stress puts the NHS in the headlines. Winter almost always exacerbates the problem. A year ago the outgoing NHS Chief Executive David Nicholson warned that the “toxic overcrowding” of accident and emergency departments in Britain not only impacted upon service levels but could have far more serious effects including higher levels of patient mortality and unsustainable levels of staff stress. The president of the ‘College of Emergency Medicine’ went even further, stating that the whole system was sailing dangerous close to complete failure. With the Daily Telegraph claiming that many patients were afraid to ask for help from staff pushed almost to their limits, the United Kingdom is perhaps still in the midst of what it last year called, “David Cameron’s care crisis”.

Image from http://www.TheGuardian.com

It is indeed easy to think of this situation as a uniquely modern one, linked to the seemingly continual squeeze on budgets. Surely this wouldn’t have happened in the past, where well-run hospitals staffed by starchy matrons ran their (spotlessly clean) wards with military precision? In fact, if we peer back through time to hospitals even before the NHS, the situation can look remarkably familiar.

In 1772 Dr John Sharp, a philanthropist and trustee of the charity established by the late Lord Crewe, established a charitable infirmary in the impressive medieval castle at Bamburgh on the north east coast of England. Sharp’s brother William was a celebrated surgeon at St Bartholomew’s hospital in London and so the infirmary was able to benefit from the advice of a top medical man. As such it was equipped with the latest medical technologies, from mechanically operated hot and cold seawater baths to electrical machines and even an infirmary carriage to take invalid patients down to the beach for a restorative dip. In terms of many other institutions this was state of the art.

Many hospitals of the time relied on subscriptions – donations by wealthy benefactors – for their building and running. For patients to be admitted required a letter of recommendation from a subscriber. It was therefore very difficult just to turn up and ask for treatment. Bamburgh was different. Funded completely by the charity it had an open surgery – effectively an accident and emergency centre – on weekends, which meant that anyone, but especially the poor, could attend and be seen with relative ease. A quick note from a local clergyman confirming their status as a poor ‘object’ was sufficient. Unsurprisingly, though, this very accessibility meant that it was extremely popular.

In the first year of the charity, the numbers of patients through its doors was a modest 206. In 1775 this had more than doubled, and in 1781 it treated 1106. By the end of that decade, the infirmary was regularly treating more than 1500 patients every year, and was expending more than £250 every year on treatments and drugs. As well as outpatients, the infirmary contained around 20 beds. To give some perspective, these numbers were at times comparable with some of the ‘flagship’ hospitals in major Georgian towns such as Bath and Birmingham.

A staff consisting of a surgeon, two assistants and several ancillary staff, alone catered for the influx of patients. On any given attendance day between 60 and 100 patients could attend, and this put immense strain on both facilities and staff. In 1784 a freezing winter and ‘melancholy weather’ caused many poor people to perish, and admissions to rise dramatically. Outbreaks of infection also increased the pressure. The ‘malignant smallpox’ in neighbouring parishes was a constant threat to families, while the winter of 1782 also brought an outbreak of influenza at the neighbouring military barracks at Belford. This elicited a plea for infected soldiers to be treated at Bamburgh – a request declined by Dr Sharp for fear of infecting the rest of his patients.

The resident surgeon, Dr Cockayne, keenly felt these increasing pressures. Writing to Dr Sharp in the 1780s he noted both the continual increase in duties and the ‘vast number of patients admitted’ all of which added to his great worry and trouble. In the politest possible terms he asked for a rise in his wages, a request that led to him moving from ad hoc payments to a permanent wage.

The overcrowding at Bamburgh certainly chimes with the problems faced by the NHS on a daily basis. In simple terms there are simply too few staff to look after too many patients. The demands of an ever-changing medical environment increase the workload for staff, and these lead to further questions about pay and conditions. But it is interesting to consider that while Bamburgh infirmary faced the same socio-medical conditions as do hospitals today the question of funding was markedly different. Bamburgh was a well-funded institution. It had abundant money to spend on facilities and equipment and did so. And yet, the pressures of increasing numbers, and the unpredictability of admissions, still threatened to overwhelm it. Does this suggest that at least some problems are not simply reducible to finance?

Many suggestions have been put forward, from streamlining the allocation of beds to increasing the range of conditions treatable by pharmacists and GPs and even treating some conditions in the patient’s own homes. Whatever the answer it is clear that hospital overcrowding is not a new problem. Medical professionals in the past were all too familiar with the challenge of meeting increasing and uneven demand with limited resources.

Negotiating a pay rise – 18th-century style!

In my last post I talked about letters from medics who were seeking jobs. Another second day in the archives yesterday yielded another crop of prospective employees, some of whom this time didn’t even know if there was a vacancy, but applied for it anyway. But another aspect of employment that we don’t often get a glimpse of in the past is that of pay-bargaining.

What happens when, after several years of work, you feel that you’re no longer getting paid what you deserve? Actually there are whole websites devoted to the etiquette of negotiating a pay rise with your boss. There is always the union to fall back on if it all goes wrong. How, though, did people do this for themselves. It was a tricky process. Don’t ask and you risk being stuck with your menial salary. Push your luck and you might end up by offending your employer and losing your position.

A letter from Dr Cockayne, surgeon-apothecary at the Bamburgh infirmary, gives us a brief insight. It’s 17th October 1782, and the doctor has been employed at the Infirmary for a little over six years. Up until now he has been paid regularly but on an ad hoc basis for his attendance on Wednesdays and Saturdays. In the ten years since its opening, the infirmary has witnessed a massive jump in from 206 in 1772 to 1500 in 1782. Small wonder that Dr Cockayne felt a little underpaid! His letter to the Reverend John Sharp reveals the delicate path he had to tread. He began on safe ground:

“Honoured Sir,
I hope you will pardon my boldness in addressing you upon this occasion, nothing but the consciousness of my own insufficiency, and your known candour, and continual kindness shewn to me upon every occasion could ever have induced me to ask so great a favour. At the same time it meets with your Disapprobation that alone will be sufficient to make me think no more of it.

It is now five years since by your kind patronage I was appointed surgeon to your dispensary. I hope during that time I have not neglected my duty but endeavoured to discharge my trust to the best of my abilities. The duties of the dispensary have continually increased year after year, and the vast number of patients admitted this year will shew to every one its great utility and at the same time the increas’d [need] and trouble so great an increase of business must necessarily give me.

If these considerations are of any weight, the favour I am going to ask will not I hope be look’d upon as presumptuous in some addition according to your better judgement in my salary. It was my duty to beg your advice upon this matter. I intended several times to have spoken to you of it when I was at the castle, but had always found myself incapable without some previous notcice to you of my intention. I therefore take this opportunity of addressing you.

I believe entirely upon your goodness and wisdom as to the fitness of my Request which if gained will be an addition to the many undeserved favours already confer’d upon me and a meanes of making me happier and easier in life. If not, I am content and shall still retain for ever a greatfull sense of your goodness in the mean time I beg leave to subscribe myself, honoured sir, your obliged humble servant, W. Cockayne.”

This was a skilful piece of negotiation and the relationship between employer and employed is interesting here. In the first paragraph, for example, he indulged in a little ego-stroking but was swift to mention that he would stop at once if he thought that Dr Sharp would be aggrieved. Sharp is almost a paternal figure, whose approval is continually sought.

Then he moved on and set out his grievances, pointing out the strains that the sheer volume of extra patient numbers had put upon him. The last part of the letter called for humility- and Cockayne had it in spades. Without “wishing to be presumptuous” and relying on Sharp’s “better judgement” Cockayne almost slipped in the fact that he wanted more money. Arguing that he had effectively been too afraid to ask in person, he tried to gain Sharp’s sympathy for his plight. If he got his money, Cockayne would he “happier and easier in life”. If not, he would “still retain a sense of your goodness” and would continue in his role regardless. Clever. But did it work?

No…at least not at once. For several years afterwards Cockayne continued on his ad hoc salary until, in 1785, he was granted an annual salary of £85 – a not insubstantial sum. Interestingly, though, he remained on that salary until at least 1810, the only increment being the addition of an extra 10 shillings in the 1790s – hardly enough to make a material difference.

So another story of the twists and turns of employment for medical practitioners in the eighteenth century. Who knows what other little gems are lurking in the archives.

Do you need a doctor? Applying for medical jobs in the eighteenth century

Filling in job application forms must rank as one of the world’s least rewarding pastimes…unless, of course, you get the job! There is the matter of displaying your own competence for the role, addressing your experience, evidence of your skills, ability to fit in with the recruiting organisation and, importantly, providing people who will attest to your obvious brilliance. It feels like a very modern thing to do. Whilst we increasingly acknowledge that people in the past could be ambitious, we don’t often get chance to actually glimpse the process in action – especially the further back you go. Some fantastic sources in Northumberland Archives, though, give us the chance to do just that. Better still, the aspiring job applicants were medical practitioners!

In 1774 a vacancy arose for the position of Surgeon-Apothecary at an infirmary in North East Britain. The infirmary was a charitable institution set up for the ‘relief of the sick and lame poor’, and was located in the magnificently austere Bamburgh Castle on the Northumbrian coast. The post had become available on the departure of the previous incumbent and, on the face of it, might not have seemed an ideal move. But something about this job appears to have resonated with the practitioner population of late eighteenth-century northern Britain. Perhaps it was the chance to work with the Reverend Dr John Sharp – administrator of the Lord Crewe Trust and the man who established the infirmary. Perhaps it was a genuine desire to do good for the poor people of rural Northumberland, who were far the nearest hospital in Newcastle. Or perhaps it was the lure of a decent salary and some authority within in institution, with their own staff to command! Whichever it was, news of the job appears to have spread fast, and letters poured in to Dr Sharp. Typical of the speculative applicants was Arthur Gair from Alnwick. Keeping his letter short and to the point, Gair nonetheless threw his hat firmly into the ring:

“25th June 1774. Reverend Sir, As I am informed the place of Surgeon-Apothecary for the Charity of Bambro’ Castle is now vacant, I beg leave to offer myself as a Candidate for the same & till I have the pleasure of paying my respects to you at the Castle which I intend to do on Monday next, I take this method to declare myself , reverend Sir, your most obedient and humble servant”.

(Image from the excellent Bamburgh Castle Research Project blog = http://bamburghresearchproject.wordpress.com/2012/12/07/an-18-century-bamburgh-castle-scandal/)

Others were less circumspect. Only three days later than Gair, the good Dr Sharp received the following letter from a Dr William Rennick. Unlike Gair, Rennick was not one to hide his light under a bushel.

“I beg leave to signify, that as there are rather too many physical practitioners in this place, I should be inclined to settle in Belford provided I could be favoured with the benefit, lately possessed by Mr Edmonton, at Bamborough – If you are willing to permit me to succeed him on satisfactory recommendation I should ever make it my study to merit your approbation of my conduct, and to display a grateful sense of the solicited obligation. I have been settled here as a Surgeon-Apothecary & man midwife near two years; my qualification in which professions, as well as the tenor of my moral conduct will, I flatter myself, bear the strictest enquiry. I am a native of Berwick & married. My attendance on some particular patients prevents my being able to wait on you in person.
I am with respectful esteem, Sir, your most humble servant”

Rennick’s was a slightly unusual pitch; pointing out that there was too much competition in his area was perhaps a risky pitch. But the rest of his letter is a work of polite (if slightly oily!) genius. Stressing that he would ‘ever make it my study’ to make his boss happy, it is possible to overdo it…and Rennick overdid it!

Some applicants were keen to provide character references. William Stoddart of Alnwick endorsed John Wilson’s application, stating Wilson was a “young man of sobriety and diligence in his profession. I would by no means have given you the trouble of this, but I could not tell how to deny him what I thought I might say with so much truth”. One William Green also tried his hand with a ‘celebrity’ referee – persuading a powerful local gentleman, Sir John Eden of County Durham, to write him a reference. “As there is a vacancy in the Castle of Bambrough” Eden wrote “I am desir’d to recommend to your notice Mr William Green”. That Eden was ‘desir’d’ to recommend Green suggests that his reference was not given entirely without coercion.

It is also interesting, however, just how far news spread. John Sharp’s brother Dr William Sharp was a prominent surgeon in St Bartholomew’s Hospital in London, and often advised his brother on medical matters relating to the infirmary. In September 1774, William was visited by a naval surgeon, originally from the Bambrough area, who had learned of the position and asked William to petition his brother on his behalf. Although William did not know the man personally, “appearances were in his favour”.
Ultimately all of these approaches, entreaties and salutations were in vain; the job was filled and the successful candidate was a Dr Trumbull, for a time, before the role was taken by the aptly-named ‘Mr Cockayne’!

The letters are fascinating though, as they add a further dimension to the process whereby practitioners actively sought new positions in the eighteenth century, and shed some light on the methods they used to bolster their chances. We don’t know how the post was advertised, if at all – there is some evidence that the infirmary used the Newcastle Courant from time to time to share news and progress – but it is clear that some sort of grapevine existed. Many of the applicants stress how they have ‘heard’ about the vacant position – another reminder of the power of early-modern social networks.

The next time you’re applying for a job, perhaps take a line from some of these medics. Will you try the ‘short and sweet’ approach of William Gair, or the florid prose of Mr Rennick?! In either case, may your applications be more successful than theirs!