ISSUE 5.2 (SUMMER 2009)


All The Lancet’s Men:  Reactionary Gentleman Physicians Vs.  Radical General Practitioners in the Lancet, 1823-1832

By Debbie Harrison, Birkbeck College, University of London

The high standard held up to the public mind by the College of Physicians, which gave its peculiar sanction to the expensive and highly-rarefied medical instruction obtained by graduates of Oxford and Cambridge, did not hinder quackery from having an excellent time of it.  (Eliot Middlemarch 136)

Expertise in the scientific bases of medicine could confer a substitute status to the trappings of gentility and access to patronage enjoyed by elite physicians.  (Furst 349)

<1>In George Eliot’s Middlemarch, the reforming zeal of the town’s new general practitioner, Tertius Lydgate, marks him down as “one of the ‘Lancet’s’ men.” (Eliot 147)  The novel, set in 1829-1832, theorises the fractured, quarrelsome and reactionary nature of the medical fraternity towards the end of the first stormy decade of the Lancet’s history, which begins in 1823.  In the humanitarian Lydgate, Eliot embodies the journal’s ambitions to improve medical education, to promote scientific advance, to serve the poor, and to raise the standards of professional ethics by eradicating malpractice, nepotism and quackery.  Eliot’s epithet, “one of the ‘Lancet’s’ men,” encapsulates the hostility and fear of the medical establishment — the gentlemanly Middlemarch physicians Dr Sprague and Dr Minchin and the struggling surgeons Mr Wench and Mr Toller — towards the disciples of change epitomised by the precocious and rebellious journal.  Lydgate’s refusal to harness his career to his family’s social status, his outspoken criticism of the self-serving medical fraternity, his very public success in overturning the clinical diagnoses of his fellow practitioners, and his determination to place scientific advance and public service above personal advantage, represent a powerful endorsement of the Lancet at a time when the nature of masculine authority in relation to the medical profession and to the public it ostensibly served was undergoing rigorous scrutiny. 

<2>Significantly, as a Lancet’s man, Lydgate symbolises the journal’s vision for the new generation of male general practitioners, who deliberately — and combatively — combined the roles of surgeon and physician:

His ambition is to overcome the “irrational severance” of pursuits that had bedevilled his predecessors.  He would combine the then separate functions of medical doctor [physician] and surgeon, thus coupling diagnostic expertise with technical skill and anatomical exploration.(1)

With their avant-garde medical training at the universities of London, Edinburgh and Paris, and their keen interest in scientific discovery, general practitioners represented a radical alternative to England’s tradition of the gentleman-physician and the “trade” of the surgeon.  In the post-revolutionary years Paris was the epicentre of medical research.  It was also the centre of reform and by 1830 the archaic distinction between physician and surgeon had been abolished, centralised control of the profession established, the importance of hospital teaching promoted, and the formal study of pathology and morbid anatomy sanctioned — reforms the Lancet supported wholeheartedly.  To suggest Lydgate was one of the Lancet’s men, therefore, was to align him with foreign ways and a dangerously outspoken critic of the establishment, Thomas Wakley, the founding editor of the new journal.  The apparently simple epithet indicated to Eliot’s readers that Lydgate, like his historical counterpart Wakley, was set on a course that would make him some very powerful enemies.  In the final analysis, Wakley holds true to his calling and is instrumental in a coup in which the radical man of science triumphs over the reactionary gentleman practitioner.  In this we see very clearly two versions of the masculine medical profession formed through differing class backgrounds set at odds with one another. Sadly, for all his altruistic and scientific ambitions, Lydgate ultimately abandons selfless vocation in favour of social aspiration, vanquished by the combined forces of a medical scandal and a materialistic, scheming wife. Perhaps this belligerent new masculinity was not as independent of society as it liked to think.

<3>In what follows, I consider more closely the concept of masculine authority in relation to the medical profession in the first decade of the Lancet.  The journal entered medical history at a pivotal point and demonstrated a near-pathological obsession with the decimation of the exclusive gentleman’s club that constituted the medical fraternity in the early years in the nineteenth century.  Through the Lancet Wakley asserted a new and inclusive masculine authority that equated professional status with a self-disciplined and meritocratic vocation that was linked to clinical and scientific expertise rather than to class and wealth.  As an activist fighting on the frontiers of modern medicine, Wakley also established a clear socio-political voice for the journal through his bold and boisterous brand of confrontational and investigative journalism, which reflected the growing importance of forensic medicine to the legal process and foregrounded the connection between public health and the vigour of the nation as a whole.  That the Lancet was condemned by the old school as aggressive, offensive and radical came as no surprise to Wakley, who, as the first highly visible editor of a medical journal, courted controversy as part of a thoroughly modern marketing strategy for the periodical press.(2)

Lancet: “A sharp surgical instrument to cut out the dross”

<4>Thomas Wakley, like the fictional Lydgate, did not come from a medical family: he was the son of a prosperous Devonshire farmer and a product of the advanced medical education provided by Edinburgh University.  Wakley practiced as a surgeon briefly in London before launching the Lancet on 5 October 1823.  With the encouragement of William Cobbett, his determined that the journal would be a vehicle for sweeping reform: “A lancet can be an arched window to let in the light or it can be a sharp surgical instrument to cut out the dross and I intend to use it in both senses”.(3)

<5>Wakley set out to educate, to celebrate medical and scientific advance, and, importantly, to entertain.  From its humble beginnings in a room in the offices of the printing firm Hutchinson & Co., the Lancet’s investigative journalism and its dedication to social justice attracted immediate recognition and controversy in equal measure.  Available via subscription and from booksellers, by 1825 it had a circulation of four thousand and by 1827 almost twelve thousand; today, as one of the world’s leading independent medical publications with almost two million registered online users and a print run of more than thirty-seven thousand, it still celebrates its brilliant and rebellious founding editor. Wakley’s legacy to the history of the nineteenth-century periodical and to medical journalism is profound, as I hope to demonstrate through an analysis of his early use of what today we would call name-and-shame investigative journalism.  My specific focus is threefold: the attack on elitism and protectionism, the fight to establish the right to a professional education for all, and the exposure of malpractice — which Wakley linked directly to nepotism.  The combined effect of these campaigns was to discredit the concept of a unified medical fraternity and to establish the authority of the modern medical profession in the figure of the general practitioner.  Importantly, the journal also provided a new forum for the exchange of scientific and medical knowledge: it championed John Elliotson’s introduction of the stethoscope, Erasmus Wilson’s pioneering research on dermatology and William Farr’s innovative use of medical statistics, among other innovations. 

<6>In the first decade, Wakley’s successful campaigns to change the law on copyright and to expose the malpractice and cronyism endemic in the Royal College of Surgeons shook the medical establishment to its protectionist foundations.  In comparison, the competition — the Medical and Physical Journal, the Medico-Chirurgical Review, and the London Medical Repository, all edited by London physicians — appeared to be little more than the reactionary guardians of an antiquated medical tradition, “written to please the eminent few rather than the profession at large”. (Sprigge 77)(4) And just as Lydgate was viewed with suspicion and envy by his local peers, “it was only to be expected that the progress of the young and lusty Lancet was viewed with hate and jealousy by the rival medical publications.” (Brook 11)

<7>The startling rhetoric of modern investigative journalism introduced by the Lancet is evident from the outset, as is the journal’s aggressive dedication to social justice.  In the first issue, Wakley announced an investigation into the decidedly unethical affairs of one Dr Collyer. (Lancet “Dr. Collyer” 12)(5) Within a matter of weeks his ruthless campaign had pierced the veil of secrecy with which miscarriages of justice on the part of elite practitioners were frequently shrouded.  The fact that Collyer’s crime was salacious and shocking and was described in such detail immediately distinguished the journal from anything its competitors had ever published.  Wakley’s provocative rhetorical technique — he promised to “give the full particulars in our next Number — at least such parts as will admit of publication” — served to whet the appetite of existing readers and ensure the subscription of many more.  In this he anticipates the style of investigative journalism used by W.T.  Stead in the Pall Mall Gazette’s fin-de-siècle exposé of underage prostitution in “The Maiden Tribute of Modern Babylon.” (1885)

<8>Dr. Collyer, Wakley made clear, was guilty of homosexual assaults on innocent working men — a guilt exacerbated by the physician’s rebuttal of the charges, which in turn cast doubts upon the morals of his hitherto silent victims.  In the second edition of the Lancet Wakley published lengthy extracts from the “Depositions of several young labourers” in this “loathsome and disgusting” case under a heading that listed the physician’s many qualifications, in order to emphasise Collyer’s social and professional immunity as one of the hitherto protected elite. (Lancet “The Reverend Dr. Collyer” 46) In the extracts of the Examinants’ statements, the extensive use of asterisks to denote omissions of specific anatomical language adds to the compelling and persuasive style of the reporting:

Dr. Collyer then laid the thumb and fingers of his right hand upon the [eleven asterisks here], asking Examinant if he felt any sensation, to which he replied, “No”; that Dr. Collyer then practiced a continuance of such treatment, repeated his former question, till at length there was a [eighteen asterisks here] that Examinant was in a great perspiration and tremor; that he was alarmed thereat, when Dr. Collyer observed, “This shows you have got a free passage,” […].  (ibid. 47)

<9>Disingenuously Wakley observes, “What will be thought of these depositions we know not.  But altogether we consider the affair to be one of the most extraordinary that ever excited public attention” (ibid. 54); and he asks disarmingly if “it is customary for a physician to bathe in the same waters [public baths] as his patient?” (ibid. 56)  The moral tone of his conclusion anticipates the brand of propaganda employed by the Chartists — a movement Wakley tacitly supported:

Thus, the poor men engaged in this transaction have had an opportunity of publishing their statements as well as the rich man his; and, knowing as we do, the infamous treatment that these injured individuals have received from some of the partisans of the Rev.  Doctor, we should have been guilty of a double act of injustice, had we withheld from the world their exculpatory depositions.  (ibid. 56-7)

Intellectual rigour and a breathtaking degree of arrogance

<10>The New Doctor that emerges from a study of Wakley’s journal and early career cuts an intriguing figure that combines humanitarianism, intellectual rigour and a zeal for reform with a breathtaking degree of arrogance and aggression that resulted in ten court cases in the first decade of publishing.  Wakley was armed with a thick skin, a strong constitution, and a formidable physique: he was quite prepared to meet physical resistance when he was banned from access to London hospitals, to the alarm of his gentlemanly opponents.(6) Deliberately provocative, during its first decade the Lancet became:

a duelling ground for a series of fierce encounters between the editor and the members of the privileged classes in medicine.  […] From the beginning the hospital surgeons and physicians were ranged in an unbroken phalanx in opposition to the new, and, as they considered it, mischievous print.  […] They denounced him as a literary pirate and a disseminator of moral garbage.  (Sprigge 81-82)

The epithets “literary pirate” and “disseminator of moral garbage” have a familiar ring to the twenty-first-century reader familiar with criticisms of the tabloid press, and the military language Sprigge used is suggestive of the aggressive masculinity Wakley adopts.  But to appreciate why the Lancet attracted such a venomous response from the medical establishment almost two centuries ago it is necessary to understand the nature of the corruption and protectionism inherent in the tripartite structure of the medical fraternity at the time of the Lancet’s launch.  In the early decades of the nineteenth century, power was not centralised but instead was devolved into three separate institutions.  These in turn dictated the career path of the practitioner and precluded the very concept of a general practitioner such as the fictional Lydgate, who was eminently qualified to provide the services of both physician and surgeon.  Put simply, physicians practiced “medicine” and diagnosed the internal complaints; surgeons practiced a manual trade — surgery — and treated external disorders.  It was an anachronistic separation of medical treatment that Wakley (and Lydgate) recognised as serving the interests of the practitioner and not the patient.  If Wakley was combative, then, his claim was that he was fighting not for himself but for his patients.

<11>Under this tripartite system a medical practitioner’s social status was conferred by education and allegiance.  Most influential of the three institutions were the physicians — the “gentlemen” members of the Royal College of Physicians.  Physicians attended the universities of Cambridge and Oxford, where they received a classical education befitting their position in society and for whom “an inadequate knowledge of medicine was secondary to such qualities as social standing and moral principles.” (Furst 343)  From a social perspective surgeons were considered to be second in rank after the physicians, although by the 1820s the elite had successfully distanced themselves from their “saw-bones” heritage and, as prominent members of the Royal College of Surgeons, enjoyed the social status of physicians.  Top surgeons also controlled senior appointments to the London hospitals and had a lucrative near-monopoly on medical education.  The third element in the tripartite fraternity was the apothecary, who dispensed drugs and whose trade, therefore, was closely linked to the work of the physicians and surgeons.  In practice many apothecaries and surgeons acted as general practitioners to the poor and working classes but although they examined and advised patients, by law the only charge they could make was for the medicines they prescribed. 

<12>The Lancet’s challenge to the establishment was made clear in the preface to the inaugural issue (thirty-six pages with no wrapper) in which Wakley announced the inclusivity of the new journal and pilloried the elitism of the London Colleges of Physicians and Surgeons in colourful and disrespectful language that presented the Lancet as much like a chivalrous lance wielded by a heroic St George against an ancient dragon to rescue the Oona of Truth and the patient’s good:

We shall exclude from our pages the semibarbarous phraseology of the Schools, and adopt as its substitute, plain English diction.  In this attempt, we are well aware that we shall be assailed by much interested opposition.  But, notwithstanding this, we will fearlessly discharge our duty.  We hope the age of “Mental Delusion” has passed, and that mystery and concealment will no longer be encouraged.  Indeed, we trust that mystery and ignorance will shortly be considered synonyms.  Ceremonies, and signs, have now lost their charms; hieroglyphics, and gilded serpents, their power to deceive. (Lancet “Preface” 2)

The tone did not change during the course of the first decade of publishing.  In 1831 — one of the years in which Lydgate was practicing in Middlemarch — Wakley published an editorial under the heading “A Rare Whack at the Voracious Bats,” in which he lambasted the leaders of the colleges of physicians and surgeons as “crafty, intriguing, corrupt, avaricious, cowardly, plundering, rapacious, soul-betraying, dirty-minded BATS.” (Lancet “A Rare Whack” 2)  Among other crimes, he charged the “BATS” with exploiting medical training in order to line their own pockets and charging for lectures and the certificates issued on attendance (or not, as the case might be), which in turn were required by students in order to pass the qualifying exams:

<13>The twenty-one members of the College Council [of the Royal College of Surgeons] appointed themselves and their relatives and apprentices to all the anatomy and surgery lectureships, and they pocketed all the fees.  Wearing still another hat, they also functioned as examiners, taking large fees from the qualifying examinees.  […] No roll call was ever taken in classes, and no exams were given before the qualifying exam.  As Wakley pointed out, it was possible to buy certificates, never attend a class, and still pass the perfunctory exam for qualification.  Under such conditions, the RCS graduate might be almost as inadequately prepared as the out-and-out quack. (Bostetter 281)

<14>As far as the BATS were concerned, Wakley was anything but a gentleman: his war on elitism undermined their fraternal solidarity and threatened the lucrative income associated with the control of medical education, while his war on nepotism exposed to public scrutiny the inequity and also the danger of the system of patrilineage.  Patrilineage, according to Wakley, promoted the incompetent to senior positions, with the inevitable result in botched operations. 

<15>Wakley’s first preface also sets out his plans to “convey to the Public, and to the distant Practitioners as well as to Students in Medicine and Surgery, reports of the Metropolitan Lectures” and in this he provided a unique new service to the scattered medical community outside of London. (Lancet “Preface” 1)  A top medical education in the 1820s relied heavily on access to the best lecturers in the field of surgery.  The fact that these lectures were held in London precluded the attendance of provincial students and practitioners.  And so Wakley printed the most interesting lectures in their entirety on a weekly basis, thus enabling subscribers to build up a formidable textbook of modern surgical practice.  His major achievement in this venture was to formalise a loophole in copyright laws that enabled him to publish verbatim — and without permission — the lectures delivered by top London surgeons to fee-paying students.  The wealthy apprentices might pay three guineas for the privilege of attending the surgical lectures of Sir Astley Cooper, senior surgeon at Sir Thomas’s Hospital and Sergeant-Surgeon to the King; Wakley’s subscribers got them for sixpence a week. 

<16>All who wrote for the Lancet, including the secret note-taker at medical lectures, adopted the distinctive style of Wakley’s investigative techniques and literary panache.(7) The dominant style for the publication of lectures was reportage, creating an inclusive “rhetoric of immediate experience” for subscribers, with its emphasis on human actors and its close attention to the detail of the surroundings and mood. (Atkinson 339). This, for example, is how the Lancet introduces Sir Astley’s lecture on inflammation:

The Theatre tonight is crowded to excess; not a single seat unoccupied; indeed many gentlemen are at the doors, peeping over each other’s shoulders, unable to gain what is termed “a footing within the walls”: notwithstanding, however, the numerous audience, there is no noise, no rioting, no idlers, — all seem to be fully impressed with the important nature of their profession, and the profound, undivided attention that it requires. (Lancet “St. Thomas’s Hospital” 42)

This particular lecture was attended by some four hundred fee-paying students, which gives an indication of the earning potential associated with the medical education business and why top surgeons wanted to protect their franchise. The Lancet’s masculinity was based on a heroic opposition to such implicit trade (while disavowing its own lucrative dependence on the trade of advertising of course).

“Good God, is it possible?”: Objections to verbatim lecture reports

<17>Apart from their evident educational value, the Lancet’s style of reporting injected a note of humour, much to the appreciation of readers and the annoyance of lecturers.  Indeed the verbatim transcripts frequently made the esteemed lecturer a laughing stock due to the inclusion of expletives, slips of the tongue, and asides in parentheses describing the attendees’ vocal responses.  While Sir Astley Cooper — a very experienced lecturer — had little to fear from the publication of transcripts, John Abernethy, St Bartholomew’s senior surgeon and second only in reputation after Astley, objected very strongly and for good reason.  Attendees might overlook his idiosyncratic delivery but in print he came across as a buffoon, as is evident in the following extract in which Abernethy builds up towards a description of the causes of erysipelas, a bacterial skin infection also known as St Anthony’s fire:

But oh! What are they? [the causes] I should be glad to ask, who can tell? […] I am never afraid to speak what is in my mind, and I think I am right; but if I am wrong I shall be very happy to have my errors pointed out and corrected.  I’ll be hanged if erysipelas is not always a result of a disordered state of the digestive organs.  […] It is not I alone who am so mad as you may think me, in saying that erysipelas depends upon the causes I have mentioned; there are others who think much the same, there is RICHTER, the German surgeon: they do not think he is crazy too, I should think.  […] 

Going one day round the hospital I saw a patient who had an ulcerated leg, as if it had been of ten years’ standing.  What do you call this? I asked.  Oh! said the dresser, it is a case of erysipelas and he only came in last week.  Good God, said I, is it possible? […]

These are very good medicines, this calomel and jalap, and this is also a very good way of getting them down; especially in tetanus and with mad folks; you may push a gag between their teeth, and then put the physic upon their tongue with a spatula; shut their mouths, and, egad! it must go down. (Lancet “Surgical Lectures”)

<18>Uncertain as to which student in the audience was in the Lancet’s employ, Abernethy made himself even more ridiculous by giving a lecture in the dark in order to thwart the secret note-taker.  Needless to say, the Lancet’s “man” discovered the puerile plot and was not deterred.(8)  Under the heading “‘All in the Dark’ at St.  Bartholomew’s Hospital,” the Lancet reported:

The proposal to put out the lights was received with much opposition; for it should be understood that the majority of the students at Bartholomew’s have too much rationality, too much independence, to become the tools of a few half-witted, silly, hospital loungers […]. (Lancet “‘All in the Dark’” 141)

On being plunged into darkness, the lecture hall descended into chaos: “Cries of lights — No lights — Order — Light the lamps — Chair — No Chair — Hats off — Stop them; stop them.” (ibid.)  The hapless chairman of the meeting is described with a lively mixture of medical terminology and mockery:

Short in stature, meagre and pale in countenance, visual orbs defective, with mental weakness still greater than his physical, did this poor little man commence with the following speech.  […] What did the crater of this parturient mountain produce? Nothing, save sounds as weak as the buz [sic] of a humming-bird, as un-meaning as the cackle of a goose. 

[…] “Really, gentlemen,” said the able Chairman, “unless you do behave better, it is impossible to get through this very important business [of preventing the Lancet’s reports]; and you know, that if The Lancet should get hold of this evening’s meeting, it will have the laugh against us — you know it is very severe.” “It has already,” said a gentleman opposite.  (Great laughter and applause.) (ibid. 141 and 143)

Wakley, who mockingly described Abernethy’s lectures as “A Bartholomew Fair,” was banned from the United Hospitals: he retaliated by publishing further accounts of “Hole and Corner” activities, arguing persuasively that surgical procedures kept secret from the public gaze concealed unprofessional motives, which at best smacked of incompetence and at worst of serious malpractice. (Lancet, ‘A Bartholomew Fair’ and “More ‘Hole and Corner’ Doings”)

<19>Abernethy challenged Wakley’s right to publish his lectures but although he succeeded in securing an injunction in the Court of Chancery, he lost his case when he made the mistake of offering to resign as St.  Bartholomew’s hospital surgeon on the condition that he keep his lecturing position.  The hospital governors refused and stressed that the lectures were part of the public role of a hospital surgeon.  This gave Wakley the ammunition he needed and he appealed to the Court of Chancery for a review on the grounds that by the hospital governors’ own definition the lectures were a public benefit and therefore were not covered by the 1814 Copyright Act.  He won.  Wakley’s victory, which he described in the Lancet as “the triumph of principle in a legal struggle,” demonstrated his ability to scrutinise in public the authority and character of a leading London surgeon — and to find it wanting:

“The very head and front” of our offending is the minute fidelity of our reports, nay, their identity with the complainant’s own lectures.  Mr Abernethy is not such a Narcissus as to be enamoured with his own likeness, yet he has pined, like Narcissus, ever since he beheld his own literary image in The Lancet.  We are guilty, upon Mr. Abernethy’s own shewing, not of distorting or misrepresenting his intellectual features, but of exhibiting them with too much truth and fidelity. (Lancet “Injunction Dissolved” 358, 360-61)

<20>Wakley’s triumph had important implications for the dissemination of medical education through the Lancet.  It also put pressure on lecturers to improve their presentations: “Putting medical incompetents under the Lancet searchlight and letting them reveal their own inadequacies was one of Wakley’s most effective journalistic techniques.” (Bostetter 278)  Moreover, it was a very astute move on Wakley’s part to incorporate the teachings of eminent lecturers in the Lancet: it provided good copy, a genuine educational service, and disarmed his critics by making it impossible to ridicule the journal as a whole.

<21>A subsequent victim of the Lancet’s name-and-shame campaign to raise educational standards was Anthony White of Westminster Hospital, whose neglect of his duties as a lecturer was legendary.  In a letter to the editor, signed “Inquisitor” of Westminster Hospital, the writer states that White turned up for only one lecture in three months and attacked the combination of the laziness and preferential treatment given to private practice that White typified.  The tone of the letter, like many of the Lancet’s own editorials, anticipates the satirical style of the modern publication Private Eye:

I have heard it suggested that his private practice is so great as to interfere with his attendance at the hospital; or that, perhaps, the natural sluggishness of disposition of which he is accused, operates in keeping him away.  In either case, much as would be lost by the cessation, would it not be better that Mr. White should relinquish his office in favour of some more active, or less occupied, practitioner? […] surely the pupils and establishment are more indebted to the man of acknowledged ability, whose presence may be relied on within half and hour or an hour of his stated time, than to one of even more brilliant acquirements, who does not condescend to visit them at all. (Lancet “Inattention” 346)

Quack medicines analysed and malpractice exposed

<22>Apart from printing surgical lectures, Wakley enhanced the dissemination of medical knowledge by reporting international news under the regular series entitled “Medical and Surgical Intelligence,” in which the Lancet provided “a correct description of all the important Cases that may occur, whether in England or on any part of the civilized Continent”. (Lancet “Preface” 1)  This emphasis on international reporting made significant inroads on the parochial paternalism of the medical fraternity in Britain.  Equally innovative was the forensic analysis reported under the heading “Compositions of Quack Medicines,” which broke the silence on the closely-guarded secret ingredients in proprietary medicines such as Dalby’s Carminative, Dafy’s Elixire and Scot’s Pills.(9)  But it was the journal’s reports on malpractice in hospital wards and in bungled surgical operations that caused the most extensive damage to the establishment.  A lengthy investigation into the inquest of a patient who died in St. George’s Hospital in May 1825 revealed that an attempt to bleed the patient had resulted in the severance of an artery and that the bandaging to stem the flow had exacerbated the damage by causing inflammation, which in turn led to mortification:

The artery was punctured, the arm bound up to stop the haemorrhage, the bandage tied so tightly, that the circulation of the blood became completely stopped, and upon the removal of the bandage, three days afterwards, the arm was found in the most horrid state of inflammation and mortification. (Lancet “City” 229)

The Lancet’s verdict, “Died from accidentally opening an artery in the arm, and from the want of proper attentions” (ibid.), was damning, as was the conclusion that this was a case in which “a human being […] lost his life through ignorance and inattention in one of our Public Hospitals.” (ibid.)

<23>Wakley made a clear and persuasive connection between systemic nepotism and malpractice.  His most audacious exposé in these early years was Sir Astley Cooper, who promoted family and favourites to senior hospital positions.  Ironically, it was Sir Astley himself who provided Wakley with the necessary ammunition.  In his response to the Lancet’s coverage of his condemnation of the use of mercury in the treatment of gonorrhoea at Guy’s Hospital, Sir Astley took advantage of a meeting of the surgeons of the Borough Hospitals to stress that he did not include certain surgeons in his criticism.  Wakley reprinted the speech:

“Who are the men, gentlemen, against whom it has been supposed that these observations were directed? Are they men whom I could possibly feel disposed to injure? Mr.TRAVERS is my apprentice, Mr.GREEN is my godson, Mr.TYRRELL is my nephew, Mr. KEY is my nephew, Mr. MORGAN was my apprentice.  I feel proud in having such men around me, and I believe that at no former period has the surgical department of these hospitals [St Thomas’s and Guy’s] been so well filled as it is by them.” (Lancet “Sir Astley Cooper” 240)

The Lancet proceeded to examine the implications of Sir Astley’s defence:

Sir ASTLEY has very satisfactorily shewn that he could not possibly be actuated by any unfriendly feeling towards the family party, who have acquired exclusive possession of the professional distinctions and emoluments of these institutions — a party united to each other, not only by the amiable ties of consanguinity, but by the no less delightful vinculum of a common participation in £3,600, which they annually extract from the pockets of the students.  Who can believe for a moment that Sir ASTLEY intended to disturb the pleasant domestic arrangement which he has described, or that he could have meant to embitter its fruits, by grafting the apple of discord on the following chirurgico-genealogical tree? —

Sir A.  COOPER, paterfamilias.

Mr. TRAVERS, Sir A.’s apprentice.

Mr TYRRELL, Sir A.’s nephew and apprentice.

Mr. KEY, Sir A.’s nephew and apprentice.

Mr. MORGAN, Sir A.’s apprentice.

Mr. GREEN, Sir A.’s god-son. (ibid. 241-2)

<24>The day after this article appeared, Green, Travers and Tyrrell barred Wakley from St.  Thomas’s Hospital.  Wakley promptly responded by branding them “The Three Ninnyhammers.” (Sprigge 111)

<25>In March 1828 Wakley published his investigation into the incompetence of another member of the Cooper “chirurgico-genealogical tree” — Sir Astley’s nephew, Bransby Cooper.  “The operation of lithotomy, by Mr. Bransby Cooper, which lasted nearly one hour!!” described a procedure for the removal of a stone in a hollow organ, such as the bladder or kidney, via the perineum, which generally could be expected to take between one and six minutes. (Lancet “Operation of lithotomy” 959)(10)  The report describes the surgeon as  “one of the privileged order — a Hospital surgeon — nephew and surgeon, and surgeon because he is ‘nephew’” (ibid.).  After an initial incision in the perineum followed by the insertion of forceps, Bransby Cooper, unable to locate the bladder, cried out, with unintentional irony, “give me my uncle’s knife”, and proceeded to enlarge the incision and to try again with a range of different forceps, muttering “Good God!” and “O dear! O dear!”:

Such were the hurried exclamations of the operator.  Every now and then there was a cry of, Hush! which was succeeded by the stillness of death, broken only by the horrible squash, squash, of the forceps in the perineum.  (ibid.)

Bearing in mind that surgery at this time was conducted without anaesthesia and antiseptics, and that the patient was bound helpless to the operating table, such accounts revealed the horrific consequences of bungled operations.  This particular patient died twenty-nine hours after the operation and the Lancet’s report on the post-mortem placed the blame entirely on Bransby Cooper’s incompetence, which, it claimed “excited no ordinary sensation in the minds of the public, as well as among the operator’s professional brethren”. (Lancet “Mr. B. Cooper’s Case” 20)

<26>Bransby Cooper published a refutation of the allegations in an advertisement in The Times and the Morning Herald, which was supported by the signatures of one-third of the students who had witnessed the operation.  Wakley reproduced the text in the Lancet and argued that the case was not merely about the process by which ranks closed to protect professional incompetence but that it had far wider implications for public health.  His conclusion, which carefully distinguishes between fraternal protectionism and scientific objectivity, mimics the style of a judge’s summary in court:

The question to which the manner in which the late operation was performed is calculated to give rise, is not a question between Mr. BRANSBY COOPER and his pupils, but it is a question between a surgeon, holding a high and responsible situation in Guy’s Hospital, and the public.  Of Mr. BRANSBY COOPER’s amenity of manners, and kindness of disposition, we entertain no doubt; […].  But the question is not whether Mr. BRANSBY COOPER is popular among his pupils, but whether he performed the late operation with that degree of skill, which the public has a right to expect from a surgeon of Guy’s Hospital; whether, in short, […] the unfortunate patient lost his life, not because his case was really one of extraordinary difficulty, but because it was the turn of a surgeon to operate, who is indebted for his elevation to the influence of a corrupt system, and who, whatever may be his private virtues, would never have been placed in a situation of such deep responsibility as that which he now occupies, had he not been the nephew of Sir Astley Cooper.  This is the question, the only question, in which the public is interested.  (ibid. 20-21)

<27>In a bid to repair his damaged reputation and to assert the authority of the traditional medical practitioner over the radical editor, Cooper sued Wakley for malicious libel, claiming two thousand pounds in damages.  He appointed as counsel Sir James Scarlett, who was noted for his opposition to the radical press.(11)  In a spirited court battle Wakley defended himself in person and argued successfully that the defendant had the right to begin “in cases in which the defendant admitted guilt but pleaded justification without pleading the general issue.” (ibid. 285)  His plea was admitted, thus establishing a precedent for journalists to open such cases and thereby avoiding the scathing attacks by counsel that usually commenced the proceedings and influenced the jury.  In this case the jury awarded Bransby Cooper a derisory one hundred pounds — a far cry from the two thousand claimed.  Wakley’s total expenses of more than four hundred pounds — including the sum awarded in damages — were paid for by public subscription. (Sprigge 155)  From this point onwards the Lancet publicised the results of all of Wakley’s campaigns that resulted in court cases, thus bringing the legal process directly into the scope of investigative and forensic medical journalism and establishing a literary strategy that the editor would exploit to the full when he became Coroner for West Middlesex in 1839.

<28>In due course, the Lancet would play an important part in the establishment of a meritocratic medical profession based on national qualifications that combined the hitherto separate roles of physician and surgeon in the figure of the general practitioner — reforms formalised by the Medical Act of 1858, which also introduced a national register of qualified practitioners — another of Wakley’s campaign objectives.  Importantly, and thanks largely to Wakley, medical education was able to include anatomy more easily and openly from 1832, with the implementation of the Anatomy Act.(12)  Previously the only legal source had been the bodies of murderers subjected to capital punishment.(13)  Demand from anatomy schools — estimated at some two-thousand corpses a year — far exceeded supply, a fraught situation that led to the scandal of the resurrectionists, who stole corpses from graveyards, and to the murders committed by Burke and Hare in Edinburgh in 1828. (see Lancet “The Late horrible Murders in Edinburgh”)  Following the trial of Burke and Hare, Wakley was instrumental in the establishment of a Select Committee on anatomy and criticised the government for the delay in introducing the new legislation:

Burke & Hare, therefore, it is said are the real authors of the measure, and that which would never have been sanctioned by the deliberate wisdom of Parliament, is about to be extorted from its fears.  […] It would have been well if this fear had been manifested and acted upon before sixteen human beings had fallen victim to the supineness of the Government & Legislature.  It required no extraordinary sagacity to foresee, that the worst consequences must inevitably result from the system of traffic between resurrectionists and anatomists, which the executive government has so long suffered to exist.  Government is already in a great degree responsible for the crime which it has fostered by its negligence, and even encouraged by a system of forbearance. (Lancet “Mr Warburton’s Bill” 818)(14)

<29>The anatomy question demonstrated Wakley’s political potential, which he pursued with considerable success when he was elected to Parliament as the Independent Radical for Finsbury in 1835, where his maiden speech helped to secure a free pardon for the Tolpuddle Martyrs.  In 1839 he became the coroner for West Middlesex, the first doctor to be appointed to a position traditionally held by lawyers and in which he shocked the nation when his inquest and jury recorded that the brutal flogging of John Frederick White, a private soldier, was the cause of death.(15) Wakley’s three-pronged attack via the pen, the House, and the coroner’s post-mortem slab succeeded in reforming a litany of medical, political and social injustices:

Soldiers flogged to death; hospital patients butchered; political offenders transported; paupers condemned to institutional slavery; foodstuffs deliberately contaminated; a medical profession unregistered, inefficiently trained, and with corruptly appointed leadership; knowledge taxed; and a dissecting room supplied by resurrectionists and murderers.  (Brook 1)

<30>In launching the Lancet, therefore, Wakley provided a public forum for a national profession of medicine, set new standards for educational content and scientific reporting, and introduced a new rhetoric of investigative journalism that had a far-reaching effect in promoting the reform of the medical establishment.  As a trained surgeon he brought medical expertise to bear on complex scientific and surgical developments; as an articulate and bold editor he exposed the hitherto largely unquestioned masculine authority of the gentlemanly tradition as a sham based upon elitism and nepotism; as a politician and coroner he extended his campaigns for social justice beyond the realms of print and into the House of Commons and the courts.  He continued as editor of the Lancet for thirty-nine years until his death in 1862, fiery and controversial to the last.

<31>Yet Wakley’s prescription for the cure of the corrupt medical fraternity was not easy to swallow, particularly in the early years, even for a fictional paradigm like Lydgate.  Considered in the light of the Lancet’s radical journalism, which Eliot studied meticulously, it is evident that the gentleman-physicians in Middlemarch are deliberately positioned as at best antiquated and parochial, and at worst corrupt.(16)  Lydgate’s radical challenge to the fraternity is equally authentic, as is his pursuit of clinical and scientific excellence.  Indeed Eliot romanticises the radical nature of the new doctor by suggesting that Lydgate has the potential to become one of Bunyan’s “Shining Ones” in Pilgrim’s Progress — the beacons of light who radiate moral guidance and strength but whose course is retarded by temptations and cares:

Each of these Shining Ones had to walk on the earth among neighbours who perhaps thought much more of his gait and his garments than of anything which was to give him a title to everlasting fame: each of them had his little local personal history sprinkled with small temptations and sordid cares, which made the retarding friction of his course towards final companionship with the immortals.  (Eliot 137)

<32>For Lydgate, the influence of neighbours concerned more with “his gait and garments”, the sprinkling of “small temptations” in the form of his ambitious wife Rosamond, and his involvement with the sordid cares of the banker Bulstrode, lead him to stray from Wakley’s agressively “heroic” path of discipline and integrity.  He earns a dubious reputation in Middlemarch not just among the medical practitioners: one of his gravest crimes in the eyes of the town’s gossips is his daring request to the late Mrs Goby’s relatives that he be allowed to “open the body,” thus delivering a “flagrant insult” to the memory of the venerable old lady by associating her “with the victims of Burke and Hare.” (Eliot 427)  The Shining One then becomes implicated in a medical scandal: he overlooks the suspicious death of the alcoholic Raffles because he is indebted to Bulstrode, whom Raffles is blackmailing and who, a crucial moment, provides the young doctor with the loan of the thousand pounds he needs to avert bankruptcy and social disgrace.  The banker proceeds to disobey Lydgate’s instructions and signs Raffles’s death warrant when he allows his housekeeper to administer to his alcoholic blackmailer a deadly cocktail of alcohol and opium.(17)  Lydgate suspects but does not act and when Bulstrode is publicly disgraced the doctor is implicated in a case of suspected corruption and murder.  He is forced to leave the town and proceeds to develop “an excellent practice, alternating, according to the season, between London and a Continental bathing-place.” (Eliot 781)  It is the traditional gentlemanly and wealthy practice that Rosamond has always desired and Lydgate — like Wakley — has always despised, with its “intrigues, jealousies and social trucking.” (Eliot 136)  Eliot neither condones nor condemns her fictional doctor but her summary of his life is poignant nonetheless.  Lydgate dies at the age of fifty a deeply disappointed man.  He knows full well that he has abandoned his youthful ambitions — to make great advances in pathology and to establish fever hospitals for the poor — in favour of writing a treatise on gout, “a disease which has a good deal of wealth on its side.” (Eliot 781)  In his fashionable milieu he is considered a success, “but he always regarded himself as a failure: he had not done what he once meant to do” (Eliot 781): despite his promising beginnings, as a radical reformer and “one of the ‘Lancet’s’ men,” Lydgate failed to achieve the vision of the new medical paradigm he had cherished in his youth, a vision Wakley nourished and sustained throughout his career.


(1)The Oxford Companion to Medicine notes that “the term ‘general practitioner’ was unknown in the UK before 1800 and came into use increasingly between 1820 and 1830, becoming firmly established by 1840”.  See Oxford Companion to Medicine 443; Mintz 74.(^)

(2)As Mary Bostetter notes, there had been earlier reformers “but they had no voice and no one heard them.” (282)(^)

(3), <> [accessed 20 May 2009].(^)

(4)The copy of Sprigge used here is a facsimile of the 1899 edition by Charles G. Rowland (New York: Robert E.  Krieger Publishing, 1974).  For an analysis of the Lancet’s rivals in the first decade and their response to the new journal, see Sprigge, Chapter XVII: 156-166.  The Lancet’s main rival from 1840 onwards was the Provincial Medical and Surgical Journal which changed its name to the British Medical Journal in 1855 (see Bartrip).(^)

(5)Extracts from the Lancet reproduced in this essay include the journal’s emphasis, shown in capital letters and italics.  Note: for each year there is a range of editions produced by Wakley and so readers might find that the volume and issue sequence varies from the citations here.(^)

(6)Wakley was “almost six feet tall, a trained boxer, and in good physical condition” (Bostetter 278).(^)

(7)One of the most famous of Wakley’s early contributors was the eminent surgeon James Wardrop, who wrote under the pseudonym “Brutus”.  See Sprigge 173-5.(^)

(8)The note-taker was thought to be William Lawrence, Abernethy’s assistant surgeon at St.  Bartholomew’s.  See Brook 41.(^)

(9)For the intention to include international coverage, see Lancet, “Preface” 1.  For the analysis of proprietary medicines, see, for example, “Composition of Quack Medicines,” in the same issue, 30.(^)

(10)Subscribers will have recalled that in Sir Astley’s lectures reported in the Lancet the eminent surgeon stressed the need for dexterity and gentleness of manner during an operation, neither of which is evident in Bransby Cooper’s work.  See, for example, Lancet, 5 Oct. 1823, 4.(^)

(11)Scarlett was the former Tory attorney general who had led the government fight against the radical press.  See Bostetter 284.(^)

(12)One of Lydgate’s crimes, according to Mrs Dollop, the landlady of the Tankard, was that he had “been for cutting up everybody before the breath was well out o’ their body.” (Eliot 680)(^)

(13)One of Lydgate’s heroes is Andreas Vesalius, the sixteenth-century anatomist, whom, he tells a horrified Rosamond, could only “get to know anatomy as he did […] by going to snatch bodies at night from the graveyards and places of execution.” (Eliot 429)(^)

(14) It is, perhaps, poetic justice that the law at the time of the trail permitted the bodies of executed murderers to be sent to the dissection tables, which was the fate that awaited Burke and Hare.(^)

(15)Wakley had earlier exposed the brutal flogging to death of criminals in Russia.  See Lancet “Barbarous Mode”.(^)

(16)Eliot studied the Lancet extensively for Middlemarch.  See “Quarry for ‘Middlemarch’”.(^)

(17)Lydgate draws on “Dr. Ware’s abundant experience in America as to the right way of treating cases of alcoholic poisoning such as this” (Eliot 658).  Ware’s cure for delirium tremens eschews the use of heroic quantities of opiates and spirits — the traditional treatment still favoured by the other Middlemarch practitioners.  See Ware.  Eliot refers to Ware’s text in “Quarry” in the Norton edition of Middlemarch, p.  552.(^)



Works Cited

Atkinson, Dwight.  “The Evolution of Medical Research Writing from 1735 to 1985: The Case of the Edinburgh Medical Journal”.  Applied Linguistics, 13, 1992: 337-374.

Bartrip, P.W.J.  Mirror of Medicine: A History of the British Medical Journal.  Oxford: British Medical Journal and Clarendon Press, 1990. 

Bostetter, Mary.  “The Journalism of Thomas Wakley”, in Joel H.  Weiner, ed. Innovators and Preachers: The Role of the Editor in Victorian England.  Westport, Connecticut; London: Greenwood Press, 1985: 265-292.

Brook, Charles.  Thomas Wakley.  London: The Socialist Medical Association, 1962.

Eliot, George.  Middlemarch.  1872.  ed.  David Carroll. Oxford: Oxford University Press, 1998.

[Eliot, George] “Quarry for ‘Middlemarch’” in Middlemarch, ed.  Berg G.  Hornback.  New York; London: W.  W.  Norton & Company, 2000: 539-569.

Furst, Lilian R.  “Struggling for Medical Reform in Middlemarch.” Nineteenth-Century Literature.  Vol.  48, No.  3 (December 1993): 341-361.

Lancet.  “A Bartholomew Fair.” 30 Oct. 1824: 141-4. 

---.  ‘“All in the Dark” at St.  Bartholomew’s Hospital.” 30 Oct. 1824: 141-143.

---.  “A Rare Whack at the Voracious Bats.” 1 Oct. 1831: 1-16.           

---.  “Barbarous Mode of Punishing Criminals in Russia.” 12 Oct. 1823: 63-4.

---.  “City and Liberty of Westminster, in the County of Middlesex.” 28 May 1825: 227-230.

---.  “Composition of Quack Medicines.” Oct. 5 1823: 30.

---.  “Dr. Collyer.” 5 Oct. 1823: 12.

---.  “Inattention of Mr.  White to his duties at the Westminster Hospital.” 29 May 1830: 346

---.  “Injunction Dissolved: Triumph of the Medical Press.” 3 December 1825: 358-363. 

---.  “More ‘Hole and Corner’ Doings.” 28 May 1825: 225-237.

---.  “Mr.  B.  Cooper’s Case of Lithotomy.” 5 April 1828: 20-22.

---.  “Mr Warburton’s Bill.” 28 March 1829: 818-821.

---.  “Preface.” 5 Oct. 1823: 1-2.

---.  “The Late horrible Murders in Edinburgh, to Obtain Subjects for Dissection.” 3 Jan. 1829:424-431.

---.  “The operation of lithotomy, by Mr. Bransby Cooper, which lasted nearly one hour!!” 29 March 1828: 959-60

---.  “The Reverend Dr. Collyer, D.D.  L.L.D.  F.A.S.  &c.”12 Oct. 1823: 46-57.

---.  “Sir Astley Cooper, and the Surgeons of the Borough Hospital,” 22 May 1824: 239-243.

---. “St.  Thomas’s Hospital: Wednesday Evening, Oct.  8, 1823.” 12 Oct. 1823: 42-46.

---.  “Surgical Lectures Delivered by Mr.  Abernethy.” 11 Dec. 1824: 321-326.
“”.  <>.  Accessed 20 May 2009.

Mintz, Alan.  George Eliot and the Novel of Vocation.  Cambridge, Massachusetts; London: Harvard University Press, 1978.

The Oxford Companion to Medicine.  John Walton, ed., in 2 vols, Vol I.  Oxford: Oxford University Press, 1986.

Sprigge, S.  Squire.  The Life and Times of Thomas Wakley.  1897.  London: Longmans, Green & Co, 1899.  The copy used here is a facsimile of the 1899 edition, ed.  Charles G.  Rowland.  NewYork: Robert E.  Krieger Publishing, 1974.

Ware, John MD. “Remarks on the History and Treatment of Delirium Tremens.” Transactions of the Massachusetts Medical Society. Boston: N.  Hale, 1831.