‘A Little Time Woud Compleat the Cure’: Broken Bones and Fracture Experiences of the Working Poor in London’s General Hospitals During the Long Eighteenth Century

‘A Little Time Woud Compleat the Cure’: Broken Bones and Fracture Experiences of the Working... Summary This article draws upon admission and discharge records from four of London’s voluntary general hospitals (St Thomas’, Guy’s, Middlesex and London) to examine the fracture causes and experiences of the working poor. The article reveals that in-patients generally spent sufficient time in the hospital for significant fracture healing to occur. The diagnosis of fracture is considered within the context of Enlightenment medical education, pathological collections and contemporary clinical nosology. Using surgeons’ and physicians’ clinical notebooks, this article illustrates the fracture treatment received in the voluntary general hospitals and the range of risk factors encountered by the working poor. fracture, patients, hospital, injury, medicine Introduction On 2 October 1725, a young woman fell down the stairs of the Monument to the Great Fire of London and broke her leg. She was carried to a surgeon in Bridge End who reduced her fracture and decided that ‘she would prove A Charity patient’.1 The next day she was admitted to St Thomas’ Hospital, becoming a patient of William Cheselden. Her leg was extended and bound and though ‘the patient complain’d much of pain, was let blood, & took a draught & was better afterwards’.2 Her treatments are described in detail, but the medical student recording her progress importantly notes that ‘A little time woud compleat [sic] the Cure.’3 This brief vignette engenders questions concerning patients’ experience with their broken bodies in Enlightenment London. This article explores the injury causes and convalescence periods of individuals suffering from fractures in the general hospitals of London, UK, during the long eighteenth century to address three questions. First, how long did fractured in-patients stay in hospital? Secondly, how did patients’ prognosis vary depending upon the fractured element? Thirdly, what risk factors were responsible for broken bones during the long eighteenth century? This work contributes to recent literature concerning physical impairment in eighteenth-century England by focusing on one type of bodily injury.4 Fractures may affect an individual’s ability to walk, gesture and complete their occupation. Unlike other long-term disabling injuries or infectious conditions, which have received more attention in the literature, fractures being treated in hospital are acute injuries. Their effects range from minor annoyances to fatalities; they are quotidian risks for individuals working and navigating urban spaces. Fractures, even in eighteenth-century hospital records, were subsumed under broad categories such as ‘traumatic conditions’ and ‘accidents and injuries’; these groupings also included myriad unrelated cases ranging from animal bites to burns to one incident of ‘catgut flying into eye while mending musical instrument’, belying the unique nature of fractures as a cause of injury.5 This investigation focuses exclusively on fractures as a unique data source to illuminate the experiences of working class individuals navigating the medical marketplace of London during the long eighteenth century. Many historical accounts have characterised eighteenth-century hospitals as ‘gateways to death’, stating that ‘the chief indictment of hospital work at this period is not that it did no good, but that it positively did harm’.6 The reputation and impact of eighteenth-century medical care continues to be re-examined in medical historical literature and this study contributes to a deeper understanding of the care provided in London’s general hospitals with a focus on fractures, an understudied area of medical historiography.7 Fractures are a useful lens through which to examine the past. Physicians and surgeons working during the ‘long’ eighteenth century were operating under a nosological system that defined fractures as bones forcibly divided into segments. This definition is similar to a modern clinical definition of fracture, suggesting that fractures are reasons for hospital admission that transcend time more easily than, for example, diagnoses of ‘foul’ diseases that may encompass many venereal complaints or conditions that are often unfamiliar to modern eyes, such as St Vitus’s Dance. Several sources of evidence suggest that fractures were a relatively common theme in medical education and that a diagnosis of ‘fracture’ or ‘broken’ recorded in the historic hospital admission records accurately refers to a broken bone. Medical students were certainly exposed to education concerning fractures. Surgical student Charles Oxley at St Thomas’ Hospital recorded in his notebook, covering the years 1725 and 1726, detailed descriptions of the causes and treatments of cranial, femoral, tibial and fibular fractures.8 The pathological collections at institutions such as St Bartholomew’s and Westminster hospitals and the Royal College of Surgeons are an indirect source of evidence suggesting that physicians and surgeons at the general hospitals would have been well versed in the appearance of fractures. The Westminster Hospital pathology collection, which had its roots in the eighteenth century, by the nineteenth century was 38.8 per cent comprised of fracture examples (19/49 total).9 Potentially the proportion of anatomical samples representing fractures may have been so high because curators thought they were particularly important, or perhaps fractures were among the most common conditions affecting bone at the time.10 Another possibility is that fractures were relatively simple to observe and identify in living patients.11 Almost exactly half of the Royal College of Surgeons anatomy and pathology collection (pre-1886) were fractures (1,016/2,036 = 49.9 per cent).12 The St Bartholomew’s Anatomical Museum descriptive catalogue from 1846 includes over 200 descriptions of fracture specimens, ranging from minor metacarpal fractures to dramatic long bone and skull fractures.13 Many were healed antemortem fractures, and include patient histories, such as a male individual who suffered a midshaft humeral fracture four years before his death. He was ‘so little impaired by the fracture that [he] worked as a sailor to the time of his death’.14 Several authors have discussed the complex nature of studying disease in the past and applying retrospective diagnoses.15 One must consider the modern biological diagnosis and the social diagnosis used by individuals in the past. Information gleaned from surgeons’ casebooks and catalogues of contemporary anatomical collections suggests that surgeons had a robust comprehension of fracture causes and treatments that is comparable to modern understandings. The diagnosis of fractures depended upon the ‘patient’s history of injury, pain and loss of function, physical findings of deformity, loss of normal motion, false motion, crepitus, visible bone fragments in a wound, swelling, and ecchymosis’.16 Similarly, the healing of a fracture was indicated by ‘a palpable nontender callus and the loss of false motion’.17 Drawing upon admission and discharge records from St Thomas’, Guy’s, the Middlesex and the London, four of London’s general hospitals, as well as contemporary surgeons’ and physicians’ notebooks, this paper illuminates the fracture causes and experiences of the working poor. The Working Poor and General Hospitals As the population of London grew over the long eighteenth century (c. 1688–1837), so did the number of hospitals. By the 1780s, there were seven general hospitals totalling approximately 2,000 beds and offering medical care to the labouring poor in London.18 Hospitals aided in getting family breadwinners in a fit state to work and isolated ill individuals from overcrowded homes, but without general improvements in living standards they could not singlehandedly improve the nation’s health.19 Two of the general hospitals, St Bartholomew’s and St Thomas’, boasted medieval origins (c. 1123 and c. 1173 respectively), and along with Guy’s Hospital (founded in 1725), were independently endowed.20 In contrast, the Westminster, St George’s, the London and the Middlesex depended upon donations, subscriptions and fund-raising events to provide charitable care for London’s poor. These voluntary hospitals were founded upon ‘a wave of philanthropy by those who wished not merely to alleviate distress but to restore the afflicted to respectable and independent citizenhood’.21 General hospitals provided care for injuries and illnesses deemed curable, commonly excluding the following types of cases: ‘no woman big with child, no children under seven years of age (except in cases of compound fractures, amputations, or cutting for the stone), no persons disordered in their senses, or suspected to have Smallpox, Itch, or other infectious distempers, or who are judged to be in a consumptive, asthmatic, or dying condition’.22 Essentially the hospitals were attempting to limit the admittance of ‘burdens on the house’; that is, chronic or incurable cases that might turn the hospital facilities into almshouses.23 The voluntary hospitals were not the only source of medical care for fractures. Dispensaries were a key part of the medical marketplace of London and of England more broadly after 1769. They provided out-patient medical care on a charitable basis and by 1800 there were 21 in London and 22 elsewhere in Britain.24 Loudon argues that the stricter admission policies of the hospitals resulted in a higher intake of surgical cases (including accident cases such as fractures), whereas the more accessible dispensaries, which admitted patients more than one day a week and had more limited lists of exclusions, tended to treat more medical cases, such as fevers and gastrointestinal issues.25 This notion is borne out quantitatively: surgical cases comprised only between 1.5 and 3.8 per cent of the total cases admitted by the Bristol Dispensary, Exeter Dispensary, Bamburgh Castle Dispensary and London’s Public Dispensary.26 Withey cautions that broad comparisons drawn between institutions must be made carefully since recording procedures varied from one dispensary to the next and the categories of disease recorded are ‘essentially arbitrary’; the similarly low numbers of surgical/accident patients, however, are striking.27 The lack of in-patient facilities likely made dispensaries a less attractive option to patients suffering the major fractures found in the voluntary hospital records. The lack of category differentiation means that the number of cases of fracture is unknown, emphasising the importance of the present study and the possibilities for future research within the detailed records of London’s voluntary hospitals. Various contemporary sources note that individuals accepted into the general hospitals should be ‘deserving’ or ‘worthy objects of charity’, since the hospitals were serving to ‘[recover] future wealth potentially lost to the nation’.28 John Bellers, writing in 1714, aptly characterised the social class differentiation inherent in the hospital system by stating that ‘it is as much the duty of the poor to labour when they are able as it is for the rich to help them when they are sick’.29 Historians have wrestled with labelling the ‘poor’, since this group of people was not homogenous or clearly differentiated.30 Poverty was ‘fluid and subjective in its definition’ and people could change statuses throughout their life course.31 The working poor were a varied group of people, including those who were dependent upon wage labour and those who received poor relief or charity.32 The poor made their living in what has been variously termed an ‘economy of makeshifts’ and a mixed economy of welfare, terms for the ‘patchy, desperate and sometimes failing strategies of the poor for material survival’.33 Fracture Treatment During the Long Eighteenth Century When examining historical hospital records and physicians’ diagnoses, it is necessary to have an understanding of contemporary nosology. Eighteenth-century physicians conceived of disease diagnoses as a form of taxonomy including classes, orders, genera and species, following the example of botanists. The three authors whose texts had the greatest effect on the nosological framework of the eighteenth century were Carl von Linné, François Boissier de Sauvages and William Cullen, who sought to classify diseases based upon symptomological signs (understood at the time to include perceptible lesions and bodily changes), autopsy results and theory.34 The results were often confusing and unnecessarily complex; Sauvages, for example, identified 17 different varieties of cough. Fractures were classified under the order ‘Plagae’, which also included contusions, fissures, ruptures and amputations, and defined fractures as the violent and mechanical separation of bones into fragments.35 Cullen divided disease into four classes, Pyrexias (e.g., fevers, local inflammations including catarrh and types of dysentery), Neuroses (nervous ailments e.g. apoplexy, convulsions), Cachexias (e.g. emaciations, swellings, discolourations including scrofula, syphilis and scurvy), and Locales (collection of eight orders describing other conditions that could not otherwise be categorised (e.g. hernia, loss of appetite, cancer). Fractures, according to Cullen, fell under the order Locales and were defined as ‘bones broken into large fragments’.36 Despite operating under a humoral philosophy, Enlightenment medical practitioners appear to have been able to identify and treat fractures successfully. Simple, or closed, fracture treatment was a routine procedure for contemporary surgeons. The mechanism of healing may not have been fully understood, but bone was known to be a living structure following the work of Clopton Havers and John Belchier.37 Bone growth was a topic of scholarly interest; Stephen Hales noted that bones grew in length due to growth at the epiphyses and John Hunter posited that during growth new bone was laid down and absorbed.38 Antonio Scarpa observed that bone formation at a fracture site is similar to growth occurring during normal skeletal growth and development.39 The mechanism of fracture healing was not completely understood; indeed, details of fracture healing are still being investigated in modern clinical studies, since the osteoblasts and osteoclasts, cells integral to bone growth and maintenance, and osteoid, the uncalcified matrix of bone, were not described in the medical literature until the mid-nineteenth century.40 Fractures were most commonly splinted by a surgeon and allowed time to heal on their own. Sir Benjamin Brodie, the celebrated nineteenth-century surgeon at St George’s, used the example of a fractured olecranon to illustrate the ease with which most fractures were treated, stating that ‘the bone should be retained in a proper situation by means of a bandage, and the arm kept extended by means of a splint, and no other treatment is required’.41 Closed fractures do not seem to have been regarded with much alarm. Correspondence between the agent of a country estate and his master in London in 1727 notes the following incident: 8 May 1727: yesterday about 3 o’clock the poor nurse fell down in the stone court, it being wet and slippery, and broke both the bones of her arm about 3 inches above her right hand. I sent immediately for Mr Fryer, who came and set it before eight … 11 May 1727: the nurse is intirely [sic] free from pain.42 Treatment for closed fractures involved the reduction of the fracture and splinting or bandaging the injury with either wooden splints or junks (straw wrapped tightly in cotton cloth) to reduce or prevent movement of the fractured bone. Grauer and Roberts’s anthropological study of healed long bone fractures in medieval individuals concluded that medieval individuals in York, England must have practised fracture immobilization.43 Indeed, the treatment for fractures changed little throughout the medieval and post-medieval periods before the advent of germ theory and the discovery of X-rays in 1895. Percivall Pott, the leading surgeon in London following the death of William Cheselden, advocated in his book Some Few General Remarks on Fractures and Dislocations, that a fractured limb should be placed in the position in which the muscles are in the greatest state of relaxation to reduce the displacement of fracture fragments.44 Admission records from the Westminster Hospital reveal a variety of strategies for dealing with individuals with fractures. Bandages, rest and the application of cold compresses ‘to keep down the temperature of the leg’ were prescribed, along with the application of heat, purges, bleedings, poultices and sometimes amputation.45 James Howard, a boy of 12 admitted on 31 May 1818 for a fractured humerus, was prescribed ‘nothing but quiet’, until his discharge on 12 July 1818.46 The cost of fracture treatment was an important consideration; complicated fractures could prove expensive. Labourer Sarah Stacey suffered ‘an extremely bad compound fracture of the Os Humerus’ after being run over by a carriage in 1774.47 Her employer footed the bill (£21. 9 s. 2d), the equivalent of Sarah’s annual wages, for a surgeon to treat her nearly every day for three months to avoid amputation. Complicated injuries, such as compound fractures, wherein the fractured bone communicated with air through a flesh wound, were regarded with more trepidation. These injuries often necessitated amputation, a complicated and dangerous undertaking, particularly before the introduction of anaesthesia in 1847, the acceptance of germ theory and the introduction of antibiotic measures in surgery. Surgeons understood that the introduction of air to the fractured area was dangerous and could lead to sepsis.48 John Hunter encouraged the sealing of compound wounds with lint soaked in the fractured patient’s own blood.49 Amputations were a common and greatly feared undertaking and patients were often unwilling to view surgery as a viable option.50 Much medical and popular literature exists suggesting that practitioners should avoid amputation where possible, epitomised in a 1794 article from Gentleman’s Magazine, a popular news and opinion periodical, describing the case of an elderly collier who had suffered a compound fracture of his right leg. He refused amputation but was walking with crutches after two months of home care. The author concludes that ‘however necessary and right speedy amputation may be in great hospitals … this narrative affords a striking proof of the necessity there is for great deliberation in cases where amputation may be thought necessary’.51 John Hunter, the preeminent Scottish surgeon, spoke of the surgeon’s dilemma when he stated that ‘with regard to operations, we should know when they will relieve, and when nothing but operations will relieve. We should know when the habit [of the patient] will bear an operation—this is sometimes almost impossible to ascertain.’52 Admission and Discharge Records of the Voluntary General Hospitals Admission and discharge records have survived and are available for consultation from four of the general hospitals during the long eighteenth century: the London, Middlesex, St Thomas’ and Guy’s (Table 1). Registration, note taking, and record-keeping were important to the general hospital movement. Francis Clifton, a member of the Royal College of Physicians of London, recommended that physicians should write casebooks as they are ‘the plainest and surest way of practicing and improving physic’.53 Clifton recommended listing the age, sex, temperament, occupation, symptoms, treatments and outcome of the patient’s progress so that physicians would no longer rely upon their memories alone to diagnose disease and would eventually ‘come to know diseases so perfectly that it will be impossible for them to miss their reward’.54 The hospitals were accountable to their charitable subscribers and thus it was vital to have a general register to calculate annual admissions, deaths and discharges.55 Table 1. Admission and discharge records, arranged by hospital and range of dates Hospital Record type Range of dates available St Thomas’ Admission and discharge records 20 January 1774–10 February 1774 8 December 1774–9 February 1775 30 March 1775–27 April 1775 24 August 1775–7 September 1775 29 February 1776–8 August 1776 25 October 1781–10 January 1782 10 January 1782–25 July 1782 25 December 1783–3 June 1784 11 January 1787–4 September 1788 26 March 1789–13 May 1790 16 September 1790–16 June 1791 12 December 1793–15 October 1795 26 May 1796–22 June 1797 20 December 1798–13 November 1800 Guy’s Admission, discharge, and accident records 28 July 1813–26 December 1838 London Admission and discharge records 1 January 1760–31 December 1760 4 January 1791–25 December 1792 16 July 1805–24 December 1805 Middlesex Apothecary admission and discharge records 4 March 1760–25 December 1764 9 April 1771–2 December 1788 Hospital Record type Range of dates available St Thomas’ Admission and discharge records 20 January 1774–10 February 1774 8 December 1774–9 February 1775 30 March 1775–27 April 1775 24 August 1775–7 September 1775 29 February 1776–8 August 1776 25 October 1781–10 January 1782 10 January 1782–25 July 1782 25 December 1783–3 June 1784 11 January 1787–4 September 1788 26 March 1789–13 May 1790 16 September 1790–16 June 1791 12 December 1793–15 October 1795 26 May 1796–22 June 1797 20 December 1798–13 November 1800 Guy’s Admission, discharge, and accident records 28 July 1813–26 December 1838 London Admission and discharge records 1 January 1760–31 December 1760 4 January 1791–25 December 1792 16 July 1805–24 December 1805 Middlesex Apothecary admission and discharge records 4 March 1760–25 December 1764 9 April 1771–2 December 1788 Primary sources: St Thomas’ and Guy’s Hospital (London Metropolitan Archives): H01/ST/B/003/001, H01/ST/B/003/002, H01/ST/B/003/003, H01/ST/B/003/004, H01/ST/B/003/005, H01/ST/B/003/006, H01/ST/B/003/007, H01/ST/B/003/008, H01/ST/B/003/009, H01/ST/B/003/010, H01/ST/B/003/011, H01/ST/B/003/012, H09/GY/B1/16/1, H09/GY/B1/17/1, H09/GY/B1/18, H09/GY/B1/19/1, H09/GY/B1/20; Middlesex Hospital (University College London Hospitals NHS Trust): Middlesex Hospital Apothecary Reports, Volumes 1–4; London Hospital (Royal London Hospital Museum and Archives): LH/M/1/1/ 1760, LH/M/1/2 1791–1792. Table 1. Admission and discharge records, arranged by hospital and range of dates Hospital Record type Range of dates available St Thomas’ Admission and discharge records 20 January 1774–10 February 1774 8 December 1774–9 February 1775 30 March 1775–27 April 1775 24 August 1775–7 September 1775 29 February 1776–8 August 1776 25 October 1781–10 January 1782 10 January 1782–25 July 1782 25 December 1783–3 June 1784 11 January 1787–4 September 1788 26 March 1789–13 May 1790 16 September 1790–16 June 1791 12 December 1793–15 October 1795 26 May 1796–22 June 1797 20 December 1798–13 November 1800 Guy’s Admission, discharge, and accident records 28 July 1813–26 December 1838 London Admission and discharge records 1 January 1760–31 December 1760 4 January 1791–25 December 1792 16 July 1805–24 December 1805 Middlesex Apothecary admission and discharge records 4 March 1760–25 December 1764 9 April 1771–2 December 1788 Hospital Record type Range of dates available St Thomas’ Admission and discharge records 20 January 1774–10 February 1774 8 December 1774–9 February 1775 30 March 1775–27 April 1775 24 August 1775–7 September 1775 29 February 1776–8 August 1776 25 October 1781–10 January 1782 10 January 1782–25 July 1782 25 December 1783–3 June 1784 11 January 1787–4 September 1788 26 March 1789–13 May 1790 16 September 1790–16 June 1791 12 December 1793–15 October 1795 26 May 1796–22 June 1797 20 December 1798–13 November 1800 Guy’s Admission, discharge, and accident records 28 July 1813–26 December 1838 London Admission and discharge records 1 January 1760–31 December 1760 4 January 1791–25 December 1792 16 July 1805–24 December 1805 Middlesex Apothecary admission and discharge records 4 March 1760–25 December 1764 9 April 1771–2 December 1788 Primary sources: St Thomas’ and Guy’s Hospital (London Metropolitan Archives): H01/ST/B/003/001, H01/ST/B/003/002, H01/ST/B/003/003, H01/ST/B/003/004, H01/ST/B/003/005, H01/ST/B/003/006, H01/ST/B/003/007, H01/ST/B/003/008, H01/ST/B/003/009, H01/ST/B/003/010, H01/ST/B/003/011, H01/ST/B/003/012, H09/GY/B1/16/1, H09/GY/B1/17/1, H09/GY/B1/18, H09/GY/B1/19/1, H09/GY/B1/20; Middlesex Hospital (University College London Hospitals NHS Trust): Middlesex Hospital Apothecary Reports, Volumes 1–4; London Hospital (Royal London Hospital Museum and Archives): LH/M/1/1/ 1760, LH/M/1/2 1791–1792. In this investigation, reasons for admission that indicate an individual had a ‘fracture’ or a ‘broken’ body element were recorded as fractures, while elements that were recorded as ‘bruised’, ‘hurt’, or ‘injured’ were not. It is possible that an individual may have been admitted to hospital with an injury that appeared bruised or lacerated but was actually a fracture; therefore, the fracture prevalence recorded likely underestimates the number of fractures treated in the general hospitals. The length of stay in hospital was determined by tracking individual patients through their admission and eventual discharge. While the records for the London Hospital list a patient’s date of admission and discharge in the same ledger, as well as an outcome of ‘cured’ or ‘died’, Guy’s, St Thomas’ and the Middlesex do not. Lists of individuals with fractures were compiled as they were discovered in the weekly admission registers and these names were individually cross-referenced with the names found in the weekly discharge lists. In this manner, the fate of each individual with a fracture was determined and a database of all individuals admitted to the hospitals for fractures (Table 2) was created. This allowed for the search of common names (e.g. John Smith, William Williams) to determine if these individuals were admitted to hospital around the same time (suggesting that the admissions likely represented two different individuals) or if one John Smith was admitted after another John Smith had been discharged, raising the possibility that it was the same individual readmitted to the same hospital. The closed (Table 3) and compound fractures (Table 4) were considered separately because compound fractures are considerably more complicated and dangerous than closed fractures and generally required longer hospital stays. Table 2. Sample size of individuals in hospital for fractures Hospital Males Females Total London 224 84 308 Middlesex 617 272 889 St Thomas’ 621 121 742 Guy’s 2,452 666 3,118 Total 3,914 1,143 5,057 Hospital Males Females Total London 224 84 308 Middlesex 617 272 889 St Thomas’ 621 121 742 Guy’s 2,452 666 3,118 Total 3,914 1,143 5,057 Table 2. Sample size of individuals in hospital for fractures Hospital Males Females Total London 224 84 308 Middlesex 617 272 889 St Thomas’ 621 121 742 Guy’s 2,452 666 3,118 Total 3,914 1,143 5,057 Hospital Males Females Total London 224 84 308 Middlesex 617 272 889 St Thomas’ 621 121 742 Guy’s 2,452 666 3,118 Total 3,914 1,143 5,057 Table 3. Average number of days in hospital organised by closed fracture location Males Females Fracture location L MSX St T G’s Mean L MSX St T G’s Mean Skull/Face 19 (2) 48.7 (30) 56.2 (34) 58.2 (19) 53.1 (85) 7 (1) 71.6 (9) 36 (5) 31.1 (9) 46.3 (24) Jaw 32 (4) 27.8 (10) 33.2 (20) 34.4 (33) 32.9 (67) 0 27 (1) 36 (1) 24.2 (9) 25.5 (11) Neck 0 0 0 0 0 0 0 0 83 (1) 83 (1) Clavicle 21.8 (13) 30 (9) 43.4 (39) 30.6 (126) 32.6 (187) 26.3 (3) 31.5 (2) 57 (1) 31.9 (27) 32.1 (33) Shoulder 0 99 (2) 26.7 (6) 27.2 (29) 31 (37) 0 0 29 (2) 96.8 (4) 74.2 (6) Arm 31.3 (21) 40.7 (63) 50.4 (120) 46.1 (524) 45.9 (728) 30.9 (13) 62.8 (41) 47.2 (35) 48.8 (191) 49.8 (280) Hand 0 35.8 (4) 55.1 (11) 42.0 (38) 44.3 (53) 0 0 143.3 (3) 29.5 (6) 67.4 (9) Spine/Back 0 0 176 (3) 293.3 (3) 234.7 (6) 0 0 0 0 0 Sternum 0 0 0 17.3 (4) 17.3 (4) 0 0 0 0 0 Rib/Ribs 23.7 (37) 22.5 (40) 35.2 (77) 30.5 (303) 30.0 (457) 20.0 (7) 22.8 (13) 34.3 (8) 22.0 (59) 23.1 (87) Hip 0 0 15 (1) 64.2 (9) 59.3 (10) 0 25 (1) 0 0 25 (1) Femur/Thigh 52.6 (37) 64.4 (116) 77.0 (79) 85.8 (337) 78.0 (569) 60.3 (6) 65.3 (35) 77.5 (13) 73.3 (94) 71.3 (148) Knee/Patella 40.7 (12) 44.7 (17) 52.6 (19) 74.0 (76) 63.5 (124) 61.4 (5) 65.3 (26) 66.6 (8) 69.0 (22) 66.5 (61) Leg 58.8 (85) 58.2 (280) 75.7 (193) 68.3 (832) 66.7 (1,390) 51.5 (43) 65.9 (133) 81.1 (40) 70.0 (227) 68.0 (443) Foot 105 (1) 27.8 (8) 47.0 (11) 47.2 (25) 45.0 (45) 0 38.3 (3) 40.2 (5) 40.3 (6) 39.9 (14) Stump 0 0 0 10 (1) 10 (1) 0 0 0 0 0 Males Females Fracture location L MSX St T G’s Mean L MSX St T G’s Mean Skull/Face 19 (2) 48.7 (30) 56.2 (34) 58.2 (19) 53.1 (85) 7 (1) 71.6 (9) 36 (5) 31.1 (9) 46.3 (24) Jaw 32 (4) 27.8 (10) 33.2 (20) 34.4 (33) 32.9 (67) 0 27 (1) 36 (1) 24.2 (9) 25.5 (11) Neck 0 0 0 0 0 0 0 0 83 (1) 83 (1) Clavicle 21.8 (13) 30 (9) 43.4 (39) 30.6 (126) 32.6 (187) 26.3 (3) 31.5 (2) 57 (1) 31.9 (27) 32.1 (33) Shoulder 0 99 (2) 26.7 (6) 27.2 (29) 31 (37) 0 0 29 (2) 96.8 (4) 74.2 (6) Arm 31.3 (21) 40.7 (63) 50.4 (120) 46.1 (524) 45.9 (728) 30.9 (13) 62.8 (41) 47.2 (35) 48.8 (191) 49.8 (280) Hand 0 35.8 (4) 55.1 (11) 42.0 (38) 44.3 (53) 0 0 143.3 (3) 29.5 (6) 67.4 (9) Spine/Back 0 0 176 (3) 293.3 (3) 234.7 (6) 0 0 0 0 0 Sternum 0 0 0 17.3 (4) 17.3 (4) 0 0 0 0 0 Rib/Ribs 23.7 (37) 22.5 (40) 35.2 (77) 30.5 (303) 30.0 (457) 20.0 (7) 22.8 (13) 34.3 (8) 22.0 (59) 23.1 (87) Hip 0 0 15 (1) 64.2 (9) 59.3 (10) 0 25 (1) 0 0 25 (1) Femur/Thigh 52.6 (37) 64.4 (116) 77.0 (79) 85.8 (337) 78.0 (569) 60.3 (6) 65.3 (35) 77.5 (13) 73.3 (94) 71.3 (148) Knee/Patella 40.7 (12) 44.7 (17) 52.6 (19) 74.0 (76) 63.5 (124) 61.4 (5) 65.3 (26) 66.6 (8) 69.0 (22) 66.5 (61) Leg 58.8 (85) 58.2 (280) 75.7 (193) 68.3 (832) 66.7 (1,390) 51.5 (43) 65.9 (133) 81.1 (40) 70.0 (227) 68.0 (443) Foot 105 (1) 27.8 (8) 47.0 (11) 47.2 (25) 45.0 (45) 0 38.3 (3) 40.2 (5) 40.3 (6) 39.9 (14) Stump 0 0 0 10 (1) 10 (1) 0 0 0 0 0 L = London, MSX = Middlesex, St T = St Thomas’, G’s = Guy’s. The results were determined by summing the total number of days spent in hospital for each fractured element for each hospital and dividing by the number of individuals listed as being admitted for each fractured body element to the hospital. The mean was determined by summing the total number of days spent in hospital by all individuals with the fractured element and dividing by the total number of individuals admitted to all hospitals for each fractured body element. Table 3. Average number of days in hospital organised by closed fracture location Males Females Fracture location L MSX St T G’s Mean L MSX St T G’s Mean Skull/Face 19 (2) 48.7 (30) 56.2 (34) 58.2 (19) 53.1 (85) 7 (1) 71.6 (9) 36 (5) 31.1 (9) 46.3 (24) Jaw 32 (4) 27.8 (10) 33.2 (20) 34.4 (33) 32.9 (67) 0 27 (1) 36 (1) 24.2 (9) 25.5 (11) Neck 0 0 0 0 0 0 0 0 83 (1) 83 (1) Clavicle 21.8 (13) 30 (9) 43.4 (39) 30.6 (126) 32.6 (187) 26.3 (3) 31.5 (2) 57 (1) 31.9 (27) 32.1 (33) Shoulder 0 99 (2) 26.7 (6) 27.2 (29) 31 (37) 0 0 29 (2) 96.8 (4) 74.2 (6) Arm 31.3 (21) 40.7 (63) 50.4 (120) 46.1 (524) 45.9 (728) 30.9 (13) 62.8 (41) 47.2 (35) 48.8 (191) 49.8 (280) Hand 0 35.8 (4) 55.1 (11) 42.0 (38) 44.3 (53) 0 0 143.3 (3) 29.5 (6) 67.4 (9) Spine/Back 0 0 176 (3) 293.3 (3) 234.7 (6) 0 0 0 0 0 Sternum 0 0 0 17.3 (4) 17.3 (4) 0 0 0 0 0 Rib/Ribs 23.7 (37) 22.5 (40) 35.2 (77) 30.5 (303) 30.0 (457) 20.0 (7) 22.8 (13) 34.3 (8) 22.0 (59) 23.1 (87) Hip 0 0 15 (1) 64.2 (9) 59.3 (10) 0 25 (1) 0 0 25 (1) Femur/Thigh 52.6 (37) 64.4 (116) 77.0 (79) 85.8 (337) 78.0 (569) 60.3 (6) 65.3 (35) 77.5 (13) 73.3 (94) 71.3 (148) Knee/Patella 40.7 (12) 44.7 (17) 52.6 (19) 74.0 (76) 63.5 (124) 61.4 (5) 65.3 (26) 66.6 (8) 69.0 (22) 66.5 (61) Leg 58.8 (85) 58.2 (280) 75.7 (193) 68.3 (832) 66.7 (1,390) 51.5 (43) 65.9 (133) 81.1 (40) 70.0 (227) 68.0 (443) Foot 105 (1) 27.8 (8) 47.0 (11) 47.2 (25) 45.0 (45) 0 38.3 (3) 40.2 (5) 40.3 (6) 39.9 (14) Stump 0 0 0 10 (1) 10 (1) 0 0 0 0 0 Males Females Fracture location L MSX St T G’s Mean L MSX St T G’s Mean Skull/Face 19 (2) 48.7 (30) 56.2 (34) 58.2 (19) 53.1 (85) 7 (1) 71.6 (9) 36 (5) 31.1 (9) 46.3 (24) Jaw 32 (4) 27.8 (10) 33.2 (20) 34.4 (33) 32.9 (67) 0 27 (1) 36 (1) 24.2 (9) 25.5 (11) Neck 0 0 0 0 0 0 0 0 83 (1) 83 (1) Clavicle 21.8 (13) 30 (9) 43.4 (39) 30.6 (126) 32.6 (187) 26.3 (3) 31.5 (2) 57 (1) 31.9 (27) 32.1 (33) Shoulder 0 99 (2) 26.7 (6) 27.2 (29) 31 (37) 0 0 29 (2) 96.8 (4) 74.2 (6) Arm 31.3 (21) 40.7 (63) 50.4 (120) 46.1 (524) 45.9 (728) 30.9 (13) 62.8 (41) 47.2 (35) 48.8 (191) 49.8 (280) Hand 0 35.8 (4) 55.1 (11) 42.0 (38) 44.3 (53) 0 0 143.3 (3) 29.5 (6) 67.4 (9) Spine/Back 0 0 176 (3) 293.3 (3) 234.7 (6) 0 0 0 0 0 Sternum 0 0 0 17.3 (4) 17.3 (4) 0 0 0 0 0 Rib/Ribs 23.7 (37) 22.5 (40) 35.2 (77) 30.5 (303) 30.0 (457) 20.0 (7) 22.8 (13) 34.3 (8) 22.0 (59) 23.1 (87) Hip 0 0 15 (1) 64.2 (9) 59.3 (10) 0 25 (1) 0 0 25 (1) Femur/Thigh 52.6 (37) 64.4 (116) 77.0 (79) 85.8 (337) 78.0 (569) 60.3 (6) 65.3 (35) 77.5 (13) 73.3 (94) 71.3 (148) Knee/Patella 40.7 (12) 44.7 (17) 52.6 (19) 74.0 (76) 63.5 (124) 61.4 (5) 65.3 (26) 66.6 (8) 69.0 (22) 66.5 (61) Leg 58.8 (85) 58.2 (280) 75.7 (193) 68.3 (832) 66.7 (1,390) 51.5 (43) 65.9 (133) 81.1 (40) 70.0 (227) 68.0 (443) Foot 105 (1) 27.8 (8) 47.0 (11) 47.2 (25) 45.0 (45) 0 38.3 (3) 40.2 (5) 40.3 (6) 39.9 (14) Stump 0 0 0 10 (1) 10 (1) 0 0 0 0 0 L = London, MSX = Middlesex, St T = St Thomas’, G’s = Guy’s. The results were determined by summing the total number of days spent in hospital for each fractured element for each hospital and dividing by the number of individuals listed as being admitted for each fractured body element to the hospital. The mean was determined by summing the total number of days spent in hospital by all individuals with the fractured element and dividing by the total number of individuals admitted to all hospitals for each fractured body element. Table 4. Average number of days in hospital organised by compound fracture location Males Females Fracture location RL MSX St T G’s Mean RL MSX St T G’s Mean Skull/Head 0 0 0 70.0 (10) 70.0 (10) 0 0 0 0 0 Jaw 0 0 0 115 (1) 115 (1) 0 0 0 161 (1) 161 (1) Clavicle 0 253 (1) 0 94.0 (1) 173.5 (2) 0 0 0 0 0 Arm 101 (4) 63.0 (3) 57.0 (2) 103.9 (8) 90.5 (17) 16.0 (1) 33.0 (1) 0 65.0 (2) 44.8 (4) Hand 0 0 0 40.0 (10) 40.0 (10) 0 0 0 39.0 (1) 39.0 (1) Femur/Thigh 0 144 (1) 0 118 (8) 120.9 (9) 0 0 0 108 (1) 108 (1) Leg 128.1 (7) 113.7 (32) 114.2 (6) 126.2 (50) 121.4 (95) 81.6 (5) 109.2 (6) 0 161.4 (5) 116.9 (16) Foot 10.0 (1) 17.0 (1) 0 45.2 (5) 36.1 (7) 0 57.0 (1) 0 38.0 (1) 47.5 (2) Males Females Fracture location RL MSX St T G’s Mean RL MSX St T G’s Mean Skull/Head 0 0 0 70.0 (10) 70.0 (10) 0 0 0 0 0 Jaw 0 0 0 115 (1) 115 (1) 0 0 0 161 (1) 161 (1) Clavicle 0 253 (1) 0 94.0 (1) 173.5 (2) 0 0 0 0 0 Arm 101 (4) 63.0 (3) 57.0 (2) 103.9 (8) 90.5 (17) 16.0 (1) 33.0 (1) 0 65.0 (2) 44.8 (4) Hand 0 0 0 40.0 (10) 40.0 (10) 0 0 0 39.0 (1) 39.0 (1) Femur/Thigh 0 144 (1) 0 118 (8) 120.9 (9) 0 0 0 108 (1) 108 (1) Leg 128.1 (7) 113.7 (32) 114.2 (6) 126.2 (50) 121.4 (95) 81.6 (5) 109.2 (6) 0 161.4 (5) 116.9 (16) Foot 10.0 (1) 17.0 (1) 0 45.2 (5) 36.1 (7) 0 57.0 (1) 0 38.0 (1) 47.5 (2) L = London, MSX = Middlesex, St T = St Thomas’, G’s = Guy’s. The results were determined by summing the total number of days spent in hospital for each fractured element for each hospital and dividing by the number of individuals listed as being admitted for each fractured body element to the hospital. The mean was determined by summing the total number of days spent in hospital by all individuals with the fractured element and dividing by the total number of individuals admitted to all hospitals for each fractured body element. Table 4. Average number of days in hospital organised by compound fracture location Males Females Fracture location RL MSX St T G’s Mean RL MSX St T G’s Mean Skull/Head 0 0 0 70.0 (10) 70.0 (10) 0 0 0 0 0 Jaw 0 0 0 115 (1) 115 (1) 0 0 0 161 (1) 161 (1) Clavicle 0 253 (1) 0 94.0 (1) 173.5 (2) 0 0 0 0 0 Arm 101 (4) 63.0 (3) 57.0 (2) 103.9 (8) 90.5 (17) 16.0 (1) 33.0 (1) 0 65.0 (2) 44.8 (4) Hand 0 0 0 40.0 (10) 40.0 (10) 0 0 0 39.0 (1) 39.0 (1) Femur/Thigh 0 144 (1) 0 118 (8) 120.9 (9) 0 0 0 108 (1) 108 (1) Leg 128.1 (7) 113.7 (32) 114.2 (6) 126.2 (50) 121.4 (95) 81.6 (5) 109.2 (6) 0 161.4 (5) 116.9 (16) Foot 10.0 (1) 17.0 (1) 0 45.2 (5) 36.1 (7) 0 57.0 (1) 0 38.0 (1) 47.5 (2) Males Females Fracture location RL MSX St T G’s Mean RL MSX St T G’s Mean Skull/Head 0 0 0 70.0 (10) 70.0 (10) 0 0 0 0 0 Jaw 0 0 0 115 (1) 115 (1) 0 0 0 161 (1) 161 (1) Clavicle 0 253 (1) 0 94.0 (1) 173.5 (2) 0 0 0 0 0 Arm 101 (4) 63.0 (3) 57.0 (2) 103.9 (8) 90.5 (17) 16.0 (1) 33.0 (1) 0 65.0 (2) 44.8 (4) Hand 0 0 0 40.0 (10) 40.0 (10) 0 0 0 39.0 (1) 39.0 (1) Femur/Thigh 0 144 (1) 0 118 (8) 120.9 (9) 0 0 0 108 (1) 108 (1) Leg 128.1 (7) 113.7 (32) 114.2 (6) 126.2 (50) 121.4 (95) 81.6 (5) 109.2 (6) 0 161.4 (5) 116.9 (16) Foot 10.0 (1) 17.0 (1) 0 45.2 (5) 36.1 (7) 0 57.0 (1) 0 38.0 (1) 47.5 (2) L = London, MSX = Middlesex, St T = St Thomas’, G’s = Guy’s. The results were determined by summing the total number of days spent in hospital for each fractured element for each hospital and dividing by the number of individuals listed as being admitted for each fractured body element to the hospital. The mean was determined by summing the total number of days spent in hospital by all individuals with the fractured element and dividing by the total number of individuals admitted to all hospitals for each fractured body element. The discharge records revealed a variety of fates. Individuals may have been: (1) discharged from the hospitals, (2) made out-patients (this information is only consistently available for the Middlesex Hospital), or (3) become lost to observation (due to death, self-discharge or because the discharge records were missing). Patients were discharged for a variety of reasons including being ‘cured’, being ‘relieved’, leaving by their own desire or being forcibly discharged for irregular behaviour. Individuals who were admitted due to ‘multiple fractures’ or unknown fractures were excluded from this investigation. Risse observed at the Royal Infirmary of Edinburgh that the term ‘cured’ was used liberally, and often applied to patients ‘who appeared to be on the mend’.56 Lengthy hospital visits were undesirable for the governors of hospitals who recognised that statistics demonstrating patient turnover and many ‘cured’ individuals were good for publicity.57 Newton, in her current and forthcoming work, engages with the word ‘cure’, noting that the words ‘recover’, ‘heal’ and ‘deliver’ were often used synonymously by early modern English medical practitioners.58 Information on patient prognosis post-discharge is often difficult to locate; thus, it is critical to remember that being discharged did not necessarily equate with a patient being entirely healed and healthy. The sex of the individuals admitted to the general hospitals was determined through examination of given names. The London and Middlesex admissions were recorded in a chronological list for each week, not by sex. The Guy’s and St Thomas’ admission lists were generally organised into male and female lists, but the list of names for which reasons for admission were recorded were often not organised into groups differentiated by sex. In the case of the London Hospital records, additional clues were provided under the occupation column, since many women were recorded as being a ‘Sailors Wife’, ‘Labourers Wife’ or a ‘Washerwoman’. Individuals whose given names were recorded only as a first initial were assigned a sex if they were included in a sex-based list of names. In the instances where sex estimation was not possible, the individuals were removed from the final sample group. Juvenile individuals were identified and excluded from the study sample. The differentiation between children and adults is a social categorisation that has changed through time to evolve into contemporary conceptions of childhood.59 Juveniles do not make up a large proportion of those admitted to the general hospitals. Most entered the records when their mothers were admitted to hospital and were thus not counted in the total admitted to hospital. The Middlesex admitted a small number of children, but noted their age or youth in each case; for example, ‘Jno [John] an infant’ was admitted to the Middlesex on 23 April 1760 with a fractured thigh and later (no date recorded) made an out-patient.60 The London Hospital appears to have allowed more children to be admitted than the other hospitals.61 Thankfully, the London Hospital records include the age of admitted individuals and thus exclusion was relatively straightforward. In the Guy’s and St Thomas’ records, where ages were not regularly recorded, all individuals noted as ‘infant’ or ‘child’ were removed from the final sample and all remaining individuals were assumed to be adults. It is possible that some juvenile individuals made it into the final sample because the hospital clerks responsible for the admissions registers did not identify them as children. Broken Bones: Length of Stay in Hospital The total number of individuals suffering a fracture who could confidently be assigned admission and discharge dates was 5,057, 3,914 males and 1,143 females (Table 2). It was not unexpected to find more males seeking hospital care for fractures than females. Risse found that almost 80 per cent of the fracture cases admitted to the Royal Infirmary of Edinburgh were males.62 Table 3 displays the average length of hospital stays for individuals entering the hospital with a closed fracture. Certain body elements were pooled in Tables 3 and 4. The Skull/Head category includes all individuals admitted for skull, head, cranium, eye, zygomatic, maxilla and nose fractures. The arm category includes all fractures labelled arm, humerus, radius, ulna and elbow. The hand group comprises hand, metacarpal, wrist, finger and thumb fractures. The pelvis category includes all fractures to the pelvis, ilium and hip. The femur/thigh category is separated from the leg category; the surgeons’ and physicians’ notebooks consulted consistently used the term ‘leg’ to describe fractures of the lower leg, or of the tibia and/or fibula. The femur/thigh group therefore exclusively refers to femoral fractures and the leg group comprises fractures labelled as leg, tibia and fibula. The foot group includes fractures to the ankle, foot, toe and calcaneus. The longest average hospital stay for males was for fractures of the back and/or spine at 234.7 days (n = 6). Closed fractures of the lower limbs generally resulted in longer average hospital stays than closed fractures of the upper limbs. For instance, fractures to the femur/thigh in males resulted in an average hospital stay of 78 days (n = 569), versus the average hospital stay of 45.9 days for a fractured arm. Fractures resulting in shorter hospital stays were to elements such as the ribs (30.0 days, n = 457) and sternum (17.3 days, n = 4). For females, the longest average hospital stay (83.0 days) was for a single fractured neck. The average hospital stay for fractures to the scapulae/shoulders (74.2 days, n = 6) is much higher than the males due to an outlier. When the outlying individual is removed the new average hospital stay for females is 49.4 days. Similar to the male results, the average hospital stays for fractured femora/thighs (71.3 days, n = 148) and the other lower limb bones are generally longer than fractures to the upper limb (e.g. arm, 49.8 days, n = 280). Table 4 displays the average length of stay for individuals who suffered a compound fracture and sought treatment at the Middlesex or the London Hospital. An outlier in the clavicle (n = 2) category caused the average length of stay for this compound fractured element in males to be relatively high (173.5 days). With the outlier removed the average length is 94.0 days for a compound clavicle fracture. The average length of stay for long bones of the leg (femur/thigh, n = 9; leg, n = 95) in males resulted in a hospital stay of 120.9 and 121.4 days respectively, whereas compound fractures of the arm (n = 17) resulted in an average stay of 90.5 days. The element with the longest average hospital stay was for a female (n = 1) with a compound jaw fracture. As found in the male sample, the average hospital stay for compound fractures of the long bones (108.0 days, femur/thigh, n = 1; 116.9 days, leg, n = 16) was longer than that for a compound fracture of the arm at 44.8 days (n = 4). The data regarding length of stay in the hospitals were also interrogated to study the relative fatality of fracture types. Admissions for the London and the Middlesex Hospitals listed a result for the majority of hospital admissions (i.e. died, cured, made out-patient) and, therefore, it is possible to determine what proportion of compound and closed fracture types were fatal at these institutions. The pooled London and Middlesex data are found in Table 5. Table 5. Proportion of fatal fractures from the London and the Middlesex hospitals Males Females Fracture ocation Fatal fractures Total fractures Fatal fractures Total fractures Compound fractures  Arm — — 1 (20.0%) 5  Thigh 1 (50.0%) 2 — —  Leg 16 (28.6%) 56 6 (35.3%) 17 Closed fractures  Skull/Head 24 (44.4%) 54 8 (44.4%) 18  Spine/Back 5 (100%) 5 — —  Arm 3 (3.5%) 86 2 (3.7%) 54  Rib 9 (10.5%) 86 — —  Thigh 10 (6.2%) 161 4 (8.9%) 45  Leg 10 (2.7%) 370 7 (3.9%) 181  Knee/Patella 2 (6.5%) 31 1 (3.1%) 32  Toe 1 (20.0%) 5 — — Males Females Fracture ocation Fatal fractures Total fractures Fatal fractures Total fractures Compound fractures  Arm — — 1 (20.0%) 5  Thigh 1 (50.0%) 2 — —  Leg 16 (28.6%) 56 6 (35.3%) 17 Closed fractures  Skull/Head 24 (44.4%) 54 8 (44.4%) 18  Spine/Back 5 (100%) 5 — —  Arm 3 (3.5%) 86 2 (3.7%) 54  Rib 9 (10.5%) 86 — —  Thigh 10 (6.2%) 161 4 (8.9%) 45  Leg 10 (2.7%) 370 7 (3.9%) 181  Knee/Patella 2 (6.5%) 31 1 (3.1%) 32  Toe 1 (20.0%) 5 — — Table 5. Proportion of fatal fractures from the London and the Middlesex hospitals Males Females Fracture ocation Fatal fractures Total fractures Fatal fractures Total fractures Compound fractures  Arm — — 1 (20.0%) 5  Thigh 1 (50.0%) 2 — —  Leg 16 (28.6%) 56 6 (35.3%) 17 Closed fractures  Skull/Head 24 (44.4%) 54 8 (44.4%) 18  Spine/Back 5 (100%) 5 — —  Arm 3 (3.5%) 86 2 (3.7%) 54  Rib 9 (10.5%) 86 — —  Thigh 10 (6.2%) 161 4 (8.9%) 45  Leg 10 (2.7%) 370 7 (3.9%) 181  Knee/Patella 2 (6.5%) 31 1 (3.1%) 32  Toe 1 (20.0%) 5 — — Males Females Fracture ocation Fatal fractures Total fractures Fatal fractures Total fractures Compound fractures  Arm — — 1 (20.0%) 5  Thigh 1 (50.0%) 2 — —  Leg 16 (28.6%) 56 6 (35.3%) 17 Closed fractures  Skull/Head 24 (44.4%) 54 8 (44.4%) 18  Spine/Back 5 (100%) 5 — —  Arm 3 (3.5%) 86 2 (3.7%) 54  Rib 9 (10.5%) 86 — —  Thigh 10 (6.2%) 161 4 (8.9%) 45  Leg 10 (2.7%) 370 7 (3.9%) 181  Knee/Patella 2 (6.5%) 31 1 (3.1%) 32  Toe 1 (20.0%) 5 — — Spine, or back, fractures had the highest proportion (100.0 per cent) of fatal cases at the London and Middlesex Hospitals. Interestingly, there were individuals who entered St Thomas’ and Guy’s Hospitals with spinal fractures who were eventually discharged, but the five individuals who were admitted to the Middlesex or the London were all fatalities. There were only two compound femoral fractures in the London and Middlesex admissions, but one was fatal for a proportion of 50.0 per cent fatality. Fractures of the skull were fatal in 44.4 per cent of cases for both males and females. Fracture Experiences The length of stay results reveal that the average patient admitted to a general hospital in London due to fracture spent long enough (i.e. four to six weeks) in hospital for significant healing to take place, based upon modern clinical estimations.63 Individuals sought hospital care for fractures from head to toe. Contemporary surgeons’ and physicians’ notebooks provide ample detail concerning the causes of such fractures and attempted means of treatment. Some, such as fractures to the cranium and spine tended to be dramatic injuries. The skull fractures described in the historical record are most often devastating injuries, resulting in copious bleeding and loss of consciousness. John West, age 78, entered St George’s Hospital on 5 April 1821 under the supervision of Benjamin Brodie after a cranial injury: About an hour before his admission he was thrown from off a stage coach and pitched upon his head—he was picked up immediately but was found quite insensible. As soon as, the pulse had got a surgeon bled him but I do not know to how much—he was brought into St Georges about 9 oClock. Insensible, pupils dilated; but he was very [unmanageable], flinging about his arms & legs in every direction.64 Brodie attempted to trephine the wound, but to no avail; John West died the same day. The records describe individuals entering hospital with cranial fractures due to accidental falls, blunt force trauma due to falling objects, motor vehicle accidents (e.g. falling from a stage coach, having a stage coach roll over an individual’s skull) and assaults. Fractures to the spine or back that appeared in the London and Middlesex admittance records were all fatal, with individuals lingering from between three and 19 days before death. The individuals admitted to St Thomas’ and Guy’s Hospitals with spinal fractures who were eventually discharged had an average convalescence period of 234.7 days (Table 3), demonstrating the severity of the injury and the lengthy periods of convalescence that were sometimes accommodated at the general hospitals. On 23 June 1827, James Barnett fell from a haystack about ten feet high, fracturing his spine and sternum. He spent five restless days in St George’s Hospital before dying of his injuries.65 Brodie noted after autopsy that the ‘spinal cord was seen stretched across an angle formed by the upper portion of bone being thrown forward’.66 Thomas Gardner, age 61, fatally fractured his back by falling onto a curbstone and died at St Bartholomew’s Hospital.67 Henry Fine, a sailor, slipped while descending a staircase, but was ‘unable to recover himself on account of a recent injury to left hand’, the result being that ‘he fell backwards down two steps and hit the upper part of his neck on the edge of the step’.68 Although he remained ‘quite sensible’ and was able ‘to drink and speak plain till a short time previous to his death’, he still passed away.69 An autopsy revealed a fracture to the body and neural arch of the sixth cervical vertebra as well as the articular facets of the fifth cervical vertebra. Other individuals suffered fatal spinal fractures due to being thrown from horses, falling through a trap door onto their backs or being knocked down by a coach.70 In contrast, closed fractures to the limbs apparently did not inspire equal distress and were dealt with through reduction and immobilisation with rollers or arm board/splints.71 James Knowles, age 23, arrived at St Bartholomew’s Hospital, having fractured the same day his right radius and ulna about the middle. The extremities of the upper and lower portions overlapped, the lower portion when the arm was placed prone was down in a direction from the lower extremity of the radius to the coronoid process of the ulna. Attempts at reduction produced extreme pain, the arm was therefore laid on a splint in its unnatural position, and kept covered with a poultice: the slightest degree of extension was made each day and what was thus gained was secured by the application of broad strapping. Under this treatment the arm was brought into its proper position in 14 days and united favorably and without delay.72 Rib fractures are described in surgeons’ notebooks from the long eighteenth century as a common injury. Brodie noted that ‘the yielding motion of the ribs prevents their being fractured so often as they would else be, but from their being so much exposed to injury, the fracture is nevertheless very frequent’.73 Patients admitted to hospital with rib fractures would be treated with ‘a bandage, passed several times round the thorax, so as to compress the ribs, and prevent their motion in respiration’.74 Individuals who died in hospital were often autopsied; surgeons could then identify exactly which ribs were fractured. Patients brought to hospital for rib fractures recounted many different types of accidents that led to their injuries. James Smith fell 24 feet from a platform to the ground onto his left side and was brought to St George’s Hospital unconscious; he was treated and after a month in bed felt weak, but was able to walk around unassisted.75 Another male died in hospital after being ‘squeezed between a wheel and a wall’, an incident which, among other injuries, broke his second through fifth ribs on the right side.76 Two individuals were admitted to St Bartholomew’s Hospital with rib fractures due to accidental falls. Dennis McCarthy, 57 years old, was described as an ‘old asthmatic man’ who ‘slipped in getting out of bed’.77 Margaret Welch, 48 years old, fractured ‘one or two’ ribs on her right side after a fall.78 She was admitted to hospital and spent 11 days resting. Brodie notes that he could hear ‘the cuputation [sic] of the broken rib … as a loud dull creak in each inspiration’.79 Industrial accidents, falls and vehicular accidents appear to be common causes of rib fractures. Rib fractures, despite their common nature, could prove dangerous; serious pulmonary complications such as flail chest, hemothorax and pneumothorax may develop due to rib fractures.80 William Jones, who was admitted to Westminster Hospital on 15 December 1818 for fractured ribs, needed to be bled ‘20 oz the night of admission & 14 oz the next day’ due to fragments of broken rib driving into the lung, causing a collapsed lung and collection of fluid.81 Two anonymous individuals, a male and female, were brought into St Bartholomew’s Hospital due to wagon-related rib injuries. A wagon had driven over the man’s left shoulder and chest, snapping six of his ribs (second–seventh, left side); this injury would prove fatal due to a ruptured lung.82 The anonymous female died two days after her injury, having been knocked down by a cab onto her stomach, breaking four of her ribs (the seventh–tenth on the left side) and rupturing her spleen in the process.83 It is likely that small-scale fractures, such as those of the phalanges, could be treated at home and did not require a hospital stay except in extraordinary circumstances. Of the individuals who did require hospitalisation, extenuating circumstances such as a compound injury might be present. David Murphy, age 33, was admitted to St Bartholomew’s with a compound dislocated thumb, which he had suffered ‘upon his left hand while descending a stair-case … in a state of drunkenness, and thus occasioned a luxation of the second phalanx of the thumb backwards with protrusion of the distal end of the first phalanx through the integuments’.84 Murphy was threatened with amputation and the physicians feared he was suffering from tetanus, but he eventually recovered through treatments of ‘two dozen leeches to the root of the thumb’, laudanum, saline solution, a bread poultice and rest.85 Fractures to the lower leg were commonly described in the surgical casebooks consulted. James Bosankoe, age 35, was brought to St Bartholomew’s Hospital with a fracture of the ‘int’l malleolus’ and lower third of the fibula, due to a wrestling injury.86 Another male, John Wilkins, age 40, entered St Bartholomew’s Hospital on 2 February with fractures of the lower third of the tibia and fibula. His ‘limb was united well and completely’ and he left on 17 March.87 Vehicular accidents often resulted in fracture; William Toller, age 47, on 8 July was ‘running after an omnibus to overtake it and jump on the step, he missed and … on the ground broke both bones to his own immediate knowledge’.88 He was deemed ‘ready to leave’ on 21 August, although the surgeon noted that there was ‘some little irregularity [in shape] from the upper portion overlapping and lying rather to the inner side of the upper portion’.89 The number of admissions due to fractures of the leg increases through time in the male and female groups.90 This is a less dramatic increase than found by Risse in the Royal Infirmary of Edinburgh, where the number of traumatic cases (a category including fractures, bruises and wounds) increased sevenfold from the 1770 s to the 1790 s.91 Risse posits that this dramatic increase may have been associated with ‘new hazards of the early Industrial Revolution’, but does not venture to suggest what these hazards may have been.92 Others have described the ‘volume of death and injury in factories, mines, building sites and shipyards’ as an indication of the ‘astonishingly low status given to the issue of safety within society as a whole’ and the fact that ‘man-made industrial accidents … were increasingly seen as a part of the expected and “normal” flow and structure of everyday social life’.93 Accidents in general were common during the long eighteenth century; Roy Porter outlines ‘tragic falls, fires, drownings, firearms explosions, mishaps with tools and knives, potions and poisons’, many of which could result in fractures or other trauma.94 Traffic accidents were seemingly ubiquitous. Elizabeth Montagu—a preeminent society salon hostess dubbed ‘Queen of the Bluestockings’ by Samuel Johnson—wrote of road hazards: ‘I shall begin to think from my frequent overturns a bone-setter a necessary part of my equipage for country visiting’.95 It is also possible that the rise in admissions due to leg fractures reflects the increasingly common practice of taking urban accident victims to hospital. The London Hospital in particular was known for accident intake due to its location ‘in the centre of one of the densest and poorest districts, and in close proximity to the Docks’.96 The hospital admission sample is directly comparable to Risse’s landmark study of the Royal Infirmary of Edinburgh.97 Risse determined that between 1770 and 1800, 20.2 per cent of all hospital admissions were categorised as surgical.98 These ‘surgical accidents’ included infectious conditions, trauma, tumours, surgical procedures and miscellaneous conditions such as animal bites and burns. Fractures were the most common surgical condition, comprising 23.4 per cent of the sample.99 There was differentiation between bruises, dislocations, fractures, sprains and wounds in the Edinburgh register, similar to the Middlesex and London hospital admission books. Fractures of the leg and arm were most common, followed by the thigh and skull, results that are similar to those observed at the Middlesex and London hospitals.100 As noted above, men comprise almost 80 per cent of cases of fracture at the Royal Infirmary of Edinburgh.101 In the current study, males comprise 77.4 per cent of all cases of fracture (Table 2). The privileging of male labour may play a role in the higher number of males entering the hospital. Part of the voluntary hospitals’ mandate was to ensure individuals could get back to work and this mercantilist focus is clearly evident in the sex-based discrepancies in admittance. Bellers coldly stated in 1714 that ‘every able industrious labourer that is capable to have children, who so untimely dies, may be accounted two hundred pounds loss to the kingdom’.102 The voluntary hospitals routinely admitted a ‘preponderance of young male patients with employment potential’, demonstrating a focus on ensuring that economically productive individuals received medical care.103 Women’s labour was not given the same priority and was in many cases viewed as ‘marginal’ or ancillary.104 Individuals’ occupations likely affect the sex-based differences in frequency of broken bones. The London Hospital admission register includes information on individual’s self-reported occupations. The occupational categories displayed in Tables 6 and 7 are adapted from Risse, who includes all labourers under the term ‘agricultural workers’.105 This is too great a generalisation of what the term ‘labourer’ could mean during the long eighteenth century, particularly in an increasingly industrialised city like London, thus the labourers have been granted their own category. Tables 6 and 7 display the occupation categories of male and female individuals admitted to the London Hospital due to fracture. Legs were the most frequently fractured category for each occupational group in the male sample, but there were no significant differences between the occupations for leg fracture frequency. Leg fractures, including injuries to the femur, tibia, fibula, knee and patella, are clearly the most likely to affect an individual’s ability to walk. Ambulation would have been crucial for an individual to get to their place of work and the majority of the occupations found in the London Hospital admission records (with the exception, perhaps, of the single recorded fiddler) would have required an individual to have freedom of movement. The female results (Table 7) provide less detail than the males because many women are categorised as being the wife of their husband’s occupation. The females working as servants and labourers (e.g. charwomen, street hawkers or dealers) were the most likely to be admitted to hospital due to a leg fracture. Table 6. Occupation categories of male individuals admitted to the London Hospital due to fracture Body area AF Trd Lbr Agr Ind Ser Misc* Cranial 4 (9.1%) 2 (3.6%) 6 (4.7%) 0 0 2 (7.1%) 1 (7.7%) Torso 4 (9.1%) 11 (20.0%) 25 (19.7%) 3 (30.0%) 0 5 (17.9%) 1 (7.7%) Arm 6 (13.6%) 10 (18.2%) 23 (18.1%) 2 (20.0%) 0 1 (3.6%) 2 (15.4%) Hand 0 0 0 0 0 0 0 Leg 29 (65.9%) 32 (58.2%) 72 (56.7%) 5 (50.0%) 1 (100.0%) 20 (71.4%) 9 (69.2%) Foot 1 (2.3%) 0 1 (0.8%) 0 0 0 0 Total 44 55 127 10 1 28 13 Body area AF Trd Lbr Agr Ind Ser Misc* Cranial 4 (9.1%) 2 (3.6%) 6 (4.7%) 0 0 2 (7.1%) 1 (7.7%) Torso 4 (9.1%) 11 (20.0%) 25 (19.7%) 3 (30.0%) 0 5 (17.9%) 1 (7.7%) Arm 6 (13.6%) 10 (18.2%) 23 (18.1%) 2 (20.0%) 0 1 (3.6%) 2 (15.4%) Hand 0 0 0 0 0 0 0 Leg 29 (65.9%) 32 (58.2%) 72 (56.7%) 5 (50.0%) 1 (100.0%) 20 (71.4%) 9 (69.2%) Foot 1 (2.3%) 0 1 (0.8%) 0 0 0 0 Total 44 55 127 10 1 28 13 * Cranial = cranial vault & facial skeleton; Torso = sternum, ribs, vertebrae, sacrum, os coxae; Arm = scapula, clavicle, humerus, radius, ulna; Leg = femur, tibia, fibula, patella; AF = armed forces; Trd = Tradesman; Lbr = Labourer; Agr = Agriculture; Ind = Industrial; Ser = Servant; Misc = Miscellaneous. Values in parentheses are percentages: number of individuals in occupation category with fractured body area / total number of individuals in occupation category. Table 6. Occupation categories of male individuals admitted to the London Hospital due to fracture Body area AF Trd Lbr Agr Ind Ser Misc* Cranial 4 (9.1%) 2 (3.6%) 6 (4.7%) 0 0 2 (7.1%) 1 (7.7%) Torso 4 (9.1%) 11 (20.0%) 25 (19.7%) 3 (30.0%) 0 5 (17.9%) 1 (7.7%) Arm 6 (13.6%) 10 (18.2%) 23 (18.1%) 2 (20.0%) 0 1 (3.6%) 2 (15.4%) Hand 0 0 0 0 0 0 0 Leg 29 (65.9%) 32 (58.2%) 72 (56.7%) 5 (50.0%) 1 (100.0%) 20 (71.4%) 9 (69.2%) Foot 1 (2.3%) 0 1 (0.8%) 0 0 0 0 Total 44 55 127 10 1 28 13 Body area AF Trd Lbr Agr Ind Ser Misc* Cranial 4 (9.1%) 2 (3.6%) 6 (4.7%) 0 0 2 (7.1%) 1 (7.7%) Torso 4 (9.1%) 11 (20.0%) 25 (19.7%) 3 (30.0%) 0 5 (17.9%) 1 (7.7%) Arm 6 (13.6%) 10 (18.2%) 23 (18.1%) 2 (20.0%) 0 1 (3.6%) 2 (15.4%) Hand 0 0 0 0 0 0 0 Leg 29 (65.9%) 32 (58.2%) 72 (56.7%) 5 (50.0%) 1 (100.0%) 20 (71.4%) 9 (69.2%) Foot 1 (2.3%) 0 1 (0.8%) 0 0 0 0 Total 44 55 127 10 1 28 13 * Cranial = cranial vault & facial skeleton; Torso = sternum, ribs, vertebrae, sacrum, os coxae; Arm = scapula, clavicle, humerus, radius, ulna; Leg = femur, tibia, fibula, patella; AF = armed forces; Trd = Tradesman; Lbr = Labourer; Agr = Agriculture; Ind = Industrial; Ser = Servant; Misc = Miscellaneous. Values in parentheses are percentages: number of individuals in occupation category with fractured body area / total number of individuals in occupation category. Table 7. Occupation categories of female individuals admitted to the London Hospital due to fracture Body area AF wife Trd wife Lbr wife Ser wife Ser Lab Trdw Widow Nurse Misc* Cranial 0 0 0 0 0 0 0 1 (6.7%) 0 0 Torso 0 0 0 0 2 (12.5%) 2 (12.5%) 0 3 (20.0%) 0 0 Arm 1 (20.0%) 7 (46.7%) 4 (28.6%) 0 2 (12.5%) 2 (12.5%) 0 2 (13.3%) 1 (20.0%) 0 Hand 0 0 0 0 0 0 0 0 0 0 Leg 4 (80.0%) 8 (53.3%) 10 (71.4%) 4 (100.0%) 12 (75.0%) 12 (75.0%) 4 (100.0%) 9 (60.0%) 4 (80.0%) 3 (100.0%) Foot 0 0 0 0 0 0 0 0 0 0 Total 5 15 14 4 16 16 4 15 5 3 Body area AF wife Trd wife Lbr wife Ser wife Ser Lab Trdw Widow Nurse Misc* Cranial 0 0 0 0 0 0 0 1 (6.7%) 0 0 Torso 0 0 0 0 2 (12.5%) 2 (12.5%) 0 3 (20.0%) 0 0 Arm 1 (20.0%) 7 (46.7%) 4 (28.6%) 0 2 (12.5%) 2 (12.5%) 0 2 (13.3%) 1 (20.0%) 0 Hand 0 0 0 0 0 0 0 0 0 0 Leg 4 (80.0%) 8 (53.3%) 10 (71.4%) 4 (100.0%) 12 (75.0%) 12 (75.0%) 4 (100.0%) 9 (60.0%) 4 (80.0%) 3 (100.0%) Foot 0 0 0 0 0 0 0 0 0 0 Total 5 15 14 4 16 16 4 15 5 3 * Cranial = cranial vault & facial skeleton; Torso = sternum, ribs, vertebrae, sacrum, os coxae; Arm = scapula, clavicle, humerus, radius, ulna; Leg = femur, tibia, fibula, patella; AF wife = Armed Forces wife; Trd wife = Tradesman’s wife; Lbr wife = Labourer’s wife; Ser wife = Servant’s wife; Ser = Servant; Lab = Labourer; Trdw = Tradeswoman; Misc = Miscellaneous + Beggar. Values in parentheses are percentages: number of individuals in occupation category with fractured body area / total number of individuals in occupation category. Table 7. Occupation categories of female individuals admitted to the London Hospital due to fracture Body area AF wife Trd wife Lbr wife Ser wife Ser Lab Trdw Widow Nurse Misc* Cranial 0 0 0 0 0 0 0 1 (6.7%) 0 0 Torso 0 0 0 0 2 (12.5%) 2 (12.5%) 0 3 (20.0%) 0 0 Arm 1 (20.0%) 7 (46.7%) 4 (28.6%) 0 2 (12.5%) 2 (12.5%) 0 2 (13.3%) 1 (20.0%) 0 Hand 0 0 0 0 0 0 0 0 0 0 Leg 4 (80.0%) 8 (53.3%) 10 (71.4%) 4 (100.0%) 12 (75.0%) 12 (75.0%) 4 (100.0%) 9 (60.0%) 4 (80.0%) 3 (100.0%) Foot 0 0 0 0 0 0 0 0 0 0 Total 5 15 14 4 16 16 4 15 5 3 Body area AF wife Trd wife Lbr wife Ser wife Ser Lab Trdw Widow Nurse Misc* Cranial 0 0 0 0 0 0 0 1 (6.7%) 0 0 Torso 0 0 0 0 2 (12.5%) 2 (12.5%) 0 3 (20.0%) 0 0 Arm 1 (20.0%) 7 (46.7%) 4 (28.6%) 0 2 (12.5%) 2 (12.5%) 0 2 (13.3%) 1 (20.0%) 0 Hand 0 0 0 0 0 0 0 0 0 0 Leg 4 (80.0%) 8 (53.3%) 10 (71.4%) 4 (100.0%) 12 (75.0%) 12 (75.0%) 4 (100.0%) 9 (60.0%) 4 (80.0%) 3 (100.0%) Foot 0 0 0 0 0 0 0 0 0 0 Total 5 15 14 4 16 16 4 15 5 3 * Cranial = cranial vault & facial skeleton; Torso = sternum, ribs, vertebrae, sacrum, os coxae; Arm = scapula, clavicle, humerus, radius, ulna; Leg = femur, tibia, fibula, patella; AF wife = Armed Forces wife; Trd wife = Tradesman’s wife; Lbr wife = Labourer’s wife; Ser wife = Servant’s wife; Ser = Servant; Lab = Labourer; Trdw = Tradeswoman; Misc = Miscellaneous + Beggar. Values in parentheses are percentages: number of individuals in occupation category with fractured body area / total number of individuals in occupation category. Robert Campbell’s 1747 treatise on occupations and their associated working conditions in London provides a snapshot of hazards that were commonly encountered by various professions.106 He writes dispassionately about the relative physical strength and mental prowess required to successfully complete various occupations. A needle- or pin-maker apparently ‘does not require to be so acute as the Instruments he makes’, while tailoring specialising in children’s coats is an area ‘chiefly engrossed by Women, who make a good Living of it: It requires a tolerable Genius, but not much Strength’.107 Physically demanding trades such as iron foundry require ‘a strong Constitution and a robust Body, to undergo the Heat of Fire, &c’.108 Specialists and tradesmen are described individually; in contrast, those described as common labourers were clearly non-specialised workers whose skills ranked lower than the tradesmen. Table 6 shows that labourers outnumber tradesman in each fracture category, suggesting that labourers were likely undertaking more hazardous work. Indeed, there is evidence that the labourer group suffered many dramatic occupational accidents, such as James Collins, age 38, who was admitted to St Bartholomew’s with a fractured skull. His accident ‘was occasioned by falling from a height of 20 ft with a heavy piece of Iron which fell across his back when he reached the ground’.109 An occupation-specific bioarchaeological study of fractures was completed on 97 male skeletons belonging to sailors or marines from the British Royal Navy from the Old Burial Ground of the Royal Hospital Greenwich. The majority (84.5 per cent) had evidence of at least one fracture, many had clearly suffered multiple incidents; the authors concluded that occupational hazards to the sailors, such as falls from the rigging, were likely causes of many of these fractures.110 Hazards and Future Research Surgeons’ casebooks and recent scholarship using the London Bills of Mortality paint a picture of long eighteenth-century London as a place fraught with hazards beyond those associated with particular occupations.111 Individuals suffered fractures due to a variety of factors such as: falls (some whilst sober, some whilst inebriated), falling objects, being crushed in crowds, collisions with motor vehicles, encounters with animals, engineering failures, industrial accidents, domestic abuse and interpersonal violence.112 The relationship between long eighteenth-century Londoners and their surroundings was clearly complex and fraught with potential hazards.113 The working poor cannot be divorced from their historical context; as Thompson writes in his meditation on the concept of class, a study of the past ‘must always be embodied in real people and in a real context’.114 Clinically, most fractures are due to accidental traumatic injury. Falls onto an outstretched hand may be the clear mechanism of injury, but the falls themselves may be accidental or intentional.115 Irregular terrain, hours of daylight, and climate have been noted in modern clinical studies as factors that may increase the risk of fracture. In addition to individuals’ age, overall health, footwear, time of day, handedness and the variety of fall, all perennial factors that affected eighteenth-century individuals.116 The wider British experience with fractures is of interest. More comparative work with a broader geographic focus is beyond the scope of this paper, but future work will certainly aid in further contextualising and understanding how typical the fractures in London were. Studies have thus far been primarily limited depending upon what datasets survive; few or no patient casebooks have survived for many provincial hospitals.117 Fractures do, however, appear as a common surgical reason for admittance in the provincial voluntary hospitals.118 Loudon examined the medical ledgers of two provincial surgeons, John Wright (Nottingham General Hospital, 1795–97) and William Pulsford (surgeon of Wells, Somerset, 1757); accidents and injuries (including fractures) were the second most and most populous category for admittance respectively.119 Kicks by horses, falls and fights were listed as causes for the general accidents category, risk factors similar to those found in the present study.120 The urban versus rural street-space is worthy of further focus; Spence notes that the street was not only a place for transportation, but ‘a social space for playing and meeting, buying and selling, begging and stealing or simply standing and staring’; this concentration of people often resulted in fractures due to vehicular collisions’.121 Concentration of individuals in certain occupations is another factor of interest; the Royal Infirmary of Edinburgh admitted many contracted sailors and soldiers, while the Bamburgh Castle Dispensary had 19 in-patient beds mostly employed for shipwrecked sailors.122 The physical as well as social landscape likely affected individuals’ fracture risks, a topic worthy of further exploration. Conclusion This is the first work to explore and quantify the length of stay experienced by individuals with fractures in London’s general hospitals, revealing the range of potential risk factors for fracture affecting the lives of the working poor. This paper demonstrates that despite differing definitions of what constituted a ‘cured’ patient, the voluntary hospitals under investigation generally allowed in-patients sufficient time for substantial fracture healing to take place. These results add credence to the historical literature reconsidering the role of the general hospital in eighteenth-century society. The article examined the prognosis of patients suffering from various fractured body elements, finding that contemporary medical practitioners successfully triaged and treated both closed and compound fractures. This paper provides a foundation for future historical and bioarchaeological comparative studies of hospital in-patients throughout Britain. Skeletal studies of fracture have revealed subtle age- and sex-based patterns, addressing topics such as injury recidivism, fatalities and interpersonal violence in Britain diachronically.123 Recent work has compared skeletal fracture data to the hospital admission records of the London Hospital, illuminating differences in the datasets regarding the frequency and distribution of fractures and how these reveal the complex nexus of human choices concerning health care in the past.124 Occupational data provide some information concerning the connection between occupation and injury; legs are the most frequently fractured element in each occupational category. Contemporary studies of occupational hygiene, such as Bernardino Ramazzini’s De Morbis Artificum Diatriba, do not focus on broken bones. This paper, therefore, makes a meaningful contribution to historical studies of occupational health and hygiene. Previous work has suggested that the general lack of safety considerations within industry during the early part of the Industrial Revolution means that accidents were seen ‘as a part of the expected and “normal” flow and structure of everyday social life’.125 The working poor could, therefore, expect to require medical care for accidents during their lifetime. Fractures are an underrepresented medical condition in previous historical investigations of the long eighteenth century. Hospital admission registers capture a moment in an individual’s life when they were motivated by their fracture to relieve their discomfort. The injuries recorded in the admission registers are acute, recent and affecting an individual’s immediate health and well-being. Studies of fractures, and other acute medical issues, grant a deeper understanding of how the working poor navigated the medical marketplace of London, revealing individual experiences within the larger tapestry of risk. Acknowledgements Thank you to Katie Ormerod (St Bartholomew’s Hospital Archives and Museum), Jonathan Evans and Richard Meunier (Royal London Hospital Museum and Archives), Annie Lindsay (University College London Hospitals NHS Trust), and the staff at the London Metropolitan Archives, Wellcome Library, Southwark Local Studies Library, Royal College of Surgeons of England and the King’s College London Archives. Thank you also to Drs Megan Brickley, Ann Herring and Juanita De Barros at McMaster University for your editorial commentary on an earlier version of this research. I am very grateful to the anonymous reviewers for their constructive and insightful comments on this paper. Madeleine Mant is a Banting SSHRC Postdoctoral Fellow in the Department of Archaeology at Memorial University. Her research involves the integrated study of human skeletal remains and historical documents to investigate how health-related events affected the lifestyles and activities of individuals in the past, particularly the poor. Funding This work was supported by a Vanier Canada Graduate Scholarship [award number 770–2012-0112]. Footnotes 1 King’s College London (hereafter KCL) GB0100 KCLCA K/TH/PP44, ‘Casebook of Charles Oxley, medical student at St. Thomas’ Hospital’, 1725–26, n.p. 2 Ibid., n.p. 3 Ibid., n.p. 4 David Turner, Disability in Eighteenth-Century England: Imagining Physical Impairment (New York: Routledge, 2012); David M. Turner, ‘Disability and Prosthetics in Eighteenth- and Early Nineteenth-Century England’, in M. Jackson, ed., The Routledge History of Disease (London and New York: Routledge, 2017), 301–19. 5 Guenter Risse, Hospital Life in Enlightenment Scotland: Care and Teaching at the Royal Infirmary of Edinburgh (Cambridge: Cambridge University Press 1986), 157; Irvine Loudon, Medical Care and the General Practitioner 1750–1850 (Oxford: Clarendon Press, 1986), 78–9. 6 Karl F. Helleiner, ‘The Vital Revolution Reconsidered’, The Canadian Journal of Economics and Political Science, 1957, 23, 1–9, at 6; Thomas McKeown and R. G. Brown, ‘Medical Evidence Related to English Population Change in the Eighteenth Century’, Population Studies, 1955, 9, 119–41, at 125. 7 See for example: John Henderson, Peregrine Horden and A. Pastore, eds, The Impact of Hospitals, 300–2000 (Frankfurt: Peter Lang, 2007); Anne Borsay and Peter Shapely, eds, Medicine, Charity and Mutual Aid: The Consumption of Health and Welfare in Britain, c. 1550–1950 (Aldershot: Ashgate, 2007); Alun Withey, ‘Medicine and Charity in Eighteenth-century Northumberland: The Early Years of the Bamburgh Castle Dispensary and Sugery, c. 1772–1802’, Social History of Medicine, 2016, 29, 467–89. 8 KCL GB0100 KCLCA K/TH/PP44. 9 Piers D. Mitchell and Vin Chauhan, ‘Understanding the Contents of the Westminster Hospital Pathology Museum in the 1800s’, in P. Mitchell, ed., Anatomical Dissection in Enlightenment England and Beyond: Autopsy, Pathology and Display (Farnham: Ashgate, 2012), 139–54, 143. 10 Ibid., 143. 11 Ibid., 143. 12 Ibid., 150. 13 St Bartholomew’s Hospital, A Descriptive Catalogue of the Anatomical Museum of St. Bartholomew’s Hospital. Volume 1. Containing the Descriptions of the Specimens Illustrative of Pathological Anatomy (London: John Churchill, 1846). 14 Ibid., 116. 15 See discussions in: Charles E. Rosenberg and Janet L. Golden, eds, Framing Disease: Studies in Cultural History (New Brunswick: Rutgers University Press, 1992); Andrew Cunningham, ‘Identifying Disease in the Past: Cutting the Gordian Knot’, Asclepio, 2002, 54, 13–34; Jon Arrizabalaga, ‘Problematizing Retrospective Diagnosis in the History of Disease’, Asclepio, 2002, 54, 51–70; Jo N. Hays, ‘Historians and Epidemics: Simple Questions, Complex Answers’, in L. K. Little, ed., Plague and the End of Antiquity: The Pandemic of 541–750 (Cambridge: Cambridge University Press, 2007), 33–56; Neil H. Metcalfe, ‘A Description of the Methods used to Obtain Information on Ancient Disease and Medicine and of How the Evidence has Survived’, Postgraduate Medical Journal, 2007, 83, 655–8; Piers D. Mitchell, ‘Retrospective Diagnosis and the Use of Historical Texts for Investigating Disease in the Past’, International Journal of Paleopathology, 2011, 1, 81–8. 16 Leonard F. Peltier, Fractures: A History and Iconography of their Treatment (San Francisco: Norman Publishing, 1990), 6. 17 Ibid., 6. 18 Joan Lane, A Social History of Medicine: Health, Healing and Disease in England, 1750–1950 (London and New York: Routledge, 2001), 82. 19 Steven Cherry, ‘Hospitals and Population Growth: Part 1 The Voluntary General Hospitals, Mortality and Local Populations in the English Provinces in the Eighteenth and Nineteenth Centuries’, Population Studies, 1980, 34, 59–75, 60. 20 Susan C. Lawrence, Charitable Knowledge: Hospital Pupils and Practitioners in Eighteenth-Century London (Cambridge: Cambridge University Press, 1996), 42. 21 Geoffrey Rivett, The Development of the London Hospital System, 1823–1982 (London: King Edward’s Hospital Fund for London, 1986), 25. 22 Quoted in Harold Hart, ‘Some Notes on the Sponsoring of Patients for Hospital Treatment under the Voluntary System’, Medical History, 1980, 24, 447–60, at 448. 23 John Aikin, Thoughts on Hospitals (London: J. Johnson, 1771), 52. 24 Bronwyn Croxson, ‘The Public and Private Faces of Eighteenth-Century London Dispensary Charity’, Medical History, 1997, 41, 127–49, at 128; Irvine Loudon, ‘The Origins and Growth of the Dispensary Movement in England’, Bulletin of the History of Medicine, 1981, 55, 322–42, at 336. 25 Loudon, ‘Origins and Growth’, 336. 26 Ibid., 338; Withey, ‘Medicine and Charity’, 485; Croxson, ‘Public and Private’, 140. 27 Withey, ‘Medicine and Charity’, 486. 28 John Woodward, To Do the Sick No Harm: A Study of the British Voluntary Hospital System to 1875 (London: Routledge and Kegan Paul, 1974), 40; Lawrence, Charitable Knowledge, 45. 29 John Bellers, Essay Towards the Improvement of Physic (London: Sowle, 1714), 6. 30 See general discussions in Lynn H. Lees, The Solidarities of Strangers: The English Poor Laws and the People (Cambridge: Cambridge University Press, 1998); Roxanne Rimstead, Remnants of Nation: On Poverty Narratives by Women (Toronto: University of Toronto Press, 2001). 31 Alysa Levene, ‘General Introduction’, in S. King, T. Nutt and A. Tomkins, eds, Narratives of the Poor in Eighteenth-Century Britain (Vol. 1) (London: Pickering & Chatto, 2006), vii–xix, ix. 32 Richard Dyson, ‘How Did the Poor Cope with Illness: Perspectives from Early Nineteenth-century Oxford’, Family & Community History, 2014, 17, 86–100, 87. 33 Alannah Tomkins and Steven King, ‘Introduction’, in S. King and A. Tomkins, eds, The Poor in England 1700–1850: An Economy of Makeshifts (Manchester: Manchester University Press, 2003), 1–38, 1; see also discussion in: Olwen H. Hufton, The Poor of Eighteenth-century France 1750–1789 (Oxford: Clarendon, 1974), Joanna Innes, ‘The “Mixed Economy of Welfare” in Early Modern England: Assessments of the Options from Hale to Malthus (c. 1683–1803)’, in M. Daunton, ed., Charity, Self-Interest and Welfare in the English Past (London: University College London Press, 1996), 139–180. 34 Carl von Linné, Genera Morborum, in Auditorium Usum (Uppsala, 1763); François Boissier de Sauvages, Nouvelles Classes de Maladies, Qui dans un Ordre Semblable à celui des Botanistes, comprennent les Genres et les Especes de Toutes les Maladies, avec Leurs Signes et Leurs Indications (Avignon, 1731); François Boissier de Sauvages, Nosologia Methodica Sistens Morborum Classes Juxta Sydenhami Mentem & Botanicorum Ordinem (Amsterdam, 1768); William Cullen, Synopsis and Nosology, Being an Arrangement of Diseases (Hartford: Nathaniel Patten, 1792). 35 Sauvages, Nosologia, 239. 36 Cullen, Synopsis, 80. 37 Clopton Havers, Osteologia Nova; or, Some New Observations of the Bones and Parts Belonging to Them (London: S. Smith, 1691); John Belchier, ‘An Account of the Bones of Animals Being Changed to a Red Colour by Aliment Only’, Philosophical Transactions of the Royal Society of London, 1735, 30, 287–300. 38 Stephen Hales, Vegetable Statistics (London: Innys & Woodward, 1717); John Hunter, The Works of John Hunter, F.R.S., with Notes, ed. J. F. Palmer (London: Longman, Rees, Orme, Brown, Green and Longman, 1835). 39 Antonii Scarpa, De Penitiori Ossium Structura Commentaries (Leipzig: J. F. Hartnoch, 1799). 40 Clinical studies: T. Einhorn and C. Lee, ‘Bone Regeneration: New Findings and Potential Clinical Applications’, Journal of the American Academy of Orthopaedic Surgeons, 2001, 9, 157–65; M. Yuasa et al., ‘Fibrinolysis is Essential for Fracture Repair and Prevention of Heterotopic Ossification’, Journal of Clinical Investigation, 2015, 125, 3117–31. Historical medical literature: John Goodsir and Harry D. S. Goodsir, Anatomical and Pathological Observations (Edinburgh: Black, 1845); R. A. Kolliker, Die Normale Resorption des Knochengewebes (Leipzig: Vogel, 1873); R. Virchow, ‘Das Normale Knochenwachsthum und die Rachitische Storung Desselben’, Virchows Archiv fur pathologische Anatomie und Physiologie und fur klinische Medizin, 1853, 5, 409–505. 41 Royal College of Surgeons (hereafter RCS) MS0470/3/1/10, ‘Surgical Cases and Commentaries Vol. 1’, 1805–07, n.p. 42 Quoted in: Joan Lane, ‘“The Doctor Scolds Me”: The Diaries and Correspondence of Patients in Eighteenth Century England’, in R. Porter, ed., Patients and Practitioners: Lay Perceptions of Medicine in Pre-Industrial Society (Cambridge: Cambridge University Press, 1985), 205–48, at 208–9. 43 Anne L. Grauer and Charlotte A. Roberts, ‘Paleoepidemiology, Healing, and Possible Treatment of Trauma in the Medieval Cemetery Population of St. Helen-on-the-Walls, York, England’, American Journal of Physical Anthropology, 1996, 100, 531–544. 44 Pervicall Pott, Some Few General Remarks on Fractures and Dislocations (London: L. Hawes, W. Clarke, and R. Collins, 1769), 19–21. 45 RCS MS0162, ‘Westminster Hospital Cases and Events’, 1802–1818, n.p. 46 Ibid., n.p. 47 Loudon, Medical Care, 84. 48 Peltier, Fractures, 98. 49 Hunter, Works of John Hunter, 441. 50 Roy Porter, ‘Laymen, Doctors and Medical Knowledge in the Eighteenth Century: The Evidence of Gentleman’s Magazine’, in R. Porter, ed., Patients and Practitioners: Lay Perceptions of Medicine in Pre-Industrial Society (Cambridge: Cambridge University Press, 1985), 283–314, 305. 51 H. Y. Carter, ‘Case of a Compound Fracture of the Leg’, Gentleman’s Magazine, 1794, 69, 448. 52 Quoted in: Anne Digby, Making a Medical Living: Doctors and Patients in the English Market for Medicine (Cambridge: Cambridge University Press, 1994), 89. 53 Francis Clifton, Tabular Observations, Recommended as the Plainest and Surest Way of Practicing and Improving Physick (London: J. Brindley, 1731), n.p. 54 Ibid., 21. 55 Risse, Hospital Life, 44. 56 Ibid., 230. 57 Ibid., 228–9. 58 Hannah Newton, ‘“Nature Concocts & Expels”: The Agents and Processes of Recovery from Disease in Early Modern England’, Social History of Medicine, 2015, 28, 465–86; Misery to Mirth: Recovery from Illness in Early Modern England, 1580–1720 (Oxford: Oxford University Press, forthcoming). 59 See discussions in: Philippe Ariès, Centuries of Childhood: A Social History of Family Life (New York: Vintage Books, 1962); Shulamith Shahar, ‘Who were Old in the Middle Ages?’, Social History of Medicine, 1993, 6, 313–41. 60 University College London Archives (hereafter UCL) Middlesex Hospital Apothecary Report, Vol. 1 (1760–64), n.p. 61 An analysis of the juvenile individuals admitted to the London Hospital can be found in Madeleine Mant, ‘Children in the London: Inpatient Care in a Voluntary General Hospital’, Medical History, in press. 62 Risse, Hospital Life, 158. 63 M. Patrice Eiff and Robert L. Hatch, ‘General Principles of Fractures Care’, in M. Patrice Eiff, ed., Fracture Management for Primary Care, 3rd edn (Philadelphia: W.B. Saunders, 2011), 5–35, 5–6. 64 RCS MS0470/3/1 62, ‘Surgical Cases and Commentaries’, 1820–60, 31. 65 RCS MS0470/3/1 51, ‘Cases and Commentaries’, 1827–49, 92. 66 Ibid., 92. 67 St Bartholomew’s Hospital Archives (hereafter St B) MR 14/14, ‘Medical Case Notes’, no date listed for volume, contents from 1831, n.p. 68 St B MR 16/1 ‘Notes on Orthopaedic Surgery’, 1835–44, 157. 69 Ibid., 157. 70 Ibid., 166, 154, 168. 71 Ibid., 49. 72 Ibid., 51. 73 RCS MS0470/3/1 38, n.p. 74 Ibid., n.p. 75 Ibid., 49, 1824–27, 248. 76 St B MR 16/1, 23. 77 Ibid., 57. 78 Ibid., 29. 79 Ibid., 29. 80 Megan Brickley, ‘Rib Fractures in the Archaeological Record: A Useful Source of Sociocultural Information?’, International Journal of Osteoarchaeology, 2006, 16, 61–75; M. Sirmali et al., ‘A Comprehensive Analysis of Traumatic Rib Fractures: Morbidity, Mortality and Management’, European Journal of Cardio-Thoracic Surgery, 2003, 24, 133–8. 81 RCS MS0162, n.p. 82 St B MR 16/1, 19. 83 Ibid., 21. 84 St. B MR 8, ‘Medical case notes of William Lawrence’, 1827–28, n.p. 85 Ibid., n.p. 86 St. B MR 16/1, 93. 87 Ibid., 94. 88 Ibid., 95. 89 Ibid., 95. 90 Madeleine Mant, ‘Slips, Trips, Falls, and Brawls: Fractures of the Working Poor in London During the Long Eighteenth Century’ (unpublished PhD thesis, McMaster University, 2016), 129. 91 Risse, Hospital Life, 158. 92 Ibid., 158. 93 Roger Cooter and Bill Luckin, ‘Accidents in History: An Introduction’, in R. Cooter and B. Luckin, eds, Accidents in History: Injuries, Fatalities and Social Relations (Amsterdam: Rodopi, 1997), 1–16, 5, 3. 94 Roy Porter, ‘Accidents in the Eighteenth Century’, in R. Cooter and B. Luckin, eds, Accidents in History: Injuries, Fatalities and Social Relations (Amsterdam: Rodopi, 1997), 90–106, 91. 95 Quoted in: Emily J. Climenson, ed., Elizabeth Montagu, the Queen of the Blue Stockings: Her Correspondence from 1720–1761 (London: John Murray, 1906), 33. 96 John S. Bristowe and Timothy Holmes, On The Hospitals of the United Kingdom (London: Privy Council Medical Officer’s Report, Appendix 15, 1863), quoted in: Woodward, To Do The Sick No Harm, 130. 97 Risse, Hospital Life. 98 Ibid., 123. 99 Ibid., 157. 100 Ibid., 158. 101 Ibid., 158. 102 Bellers, Essay, 3. 103 Anne Borsay, Medicine and Charity in Georgian Bath, A Social History of the General Infirmary, c. 1739–1830 (Aldershot: Ashgate Publishing Limited, 1999), 382–3; Mary Fissell, ‘The Physic of Charity: Health and Welfare in the West country, 1690–1834’ (unpublished PhD thesis, Pennsylvania, 1988); Risse, Hospital Life; Amanda Berry, ‘Patronage, Funding and the Hospital Patient, c. 1750–1815’ (unpublished PhD thesis, University of Oxford, 1995). 104 Merry Wiesner, Women and Gender in Early Modern Europe (Cambridge: Cambridge University Press, 1993), 86. 105 Risse, Hospital Life, 88. 106 Robert Campbell, The London Tradesman: Being a Compendious View of all the Trades, Professions, Arts, both Liberal and Mechanic, now Practised in the Cities of London and Westminster (London: T. Gardner, 1747). 107 Ibid., 256, 226. 108 Ibid., 179. 109 RCS, MS0470 49, 221. 110 Ceridwen Boston, Annsofie Witkin, Angela Boyle and David R. P. Wilkinson, ‘Safe moor’d in Greenwich tier’. A Study of the Skeletons of Royal Navy Sailors and Marines Excavated from the Royal Hospital Greenwich (Oxford: Oxford Archaeology Monograph, 2008). 111 Craig Spence, Accidents and Violence Death in Early Modern London 1650–1750 (Woodbridge: The Boydell Press, 2016). 112 RCS MS0470/3/1/10, 7; RCS MS0470/3/1 51, 70; RCS MS0470 49, 1824–27, 189; St B MR16/4 Vol. 1, ‘Notes on Medical and Surgical Subjects’, 1836–46, 13, 33, 36, 55, 94, 111; KCL GB0100 KCLCA K/TH/PP44, n.p.; Wellcome Library MS4337, 1781, 21. 113 Spence, Accidents. 114 Edward P. Thompson, The Making of the English Working Class (London: Victor Gollancz Ltd, 1963), 9. 115 Osarumwense D. Osifo, P. Iribhogbe and H. Idiodi-Thomas, ‘Falls from Heights: Epidemiology and Pattern of Injury at the Accident and Emergency Centre of the University of Benin Teaching Hospital’, Injury, 2010, 41, 544–7, 544. 116 Annalisa Alvrus, ‘Fracture Patterns among the Nubians of Semna South, Sudanese Nubia, International Journal of Osteoarchaeology, 1999, 9, 417–29; S. A. Jiménez-Brobeil, I. Al Oumaoui and P. H. du Souich, ‘Childhood Trauma in Several Populations from the Iberian Peninsula’, International Journal of Osteoarchaeology, 2007, 17, 189–98; Margaret A. Judd, ‘Continuity of Interpersonal Violence Between Nubian Communities’, American Journal of Physical Anthropology, 2006, 131, 324–33; Lynn Kilgore, Robert Jurmain and Dennis van Gerven, ‘Palaeoepidemiological Patterns of Trauma in a Medieval Nubian Population’, International Journal of Osteoarchaeology, 1997, 7, 103–14; S. D. Berry and R. R. Miller, ‘Falls: Epidemiology, Pathophysiology, and Relationship to Fracture’, Current Osteoporosis Reports, 2008, 6, 149–54; Cyrus Cooper et al., ‘Incidence of Vertebral Fractures: A Population-Based Study in Rochester, Minnesota, 1985–1989’, Journal of Bone and Mineral Research, 1992, 7, 221–7; Francesc Formiga et al., ‘Characteristics of Falls Producing Hip Fractures in Nonagenarians’, Journal of Nutrition, Health & Aging, 2008, 12, 664–7; Theresa H. M. Keegan et al., ‘Characteristics of Fallers who Fracture at the Foot, Distal Forearm, Proximal Humerus, Pelvis, and Shaft of the Tibia/Fibula Compared with Fallers who do not Fracture’, American Journal of Epidemiology, 2004, 159, 192–203; N. Niino, R. Kozakai and M. Eto, ‘Epidemiology of Falls among Community-Dwelling Elderly People’, Nippon Ronen Igakkai Zasshi/Japanese Journal of Geriatrics, 2003, 40, 484–6; C. M. Luetters et al., ‘Left-Handedness as a Risk Factor for Fractures’, Osteoporosis International, 2003, 14, 918–22; Wenjun Li et al., ‘Outdoor Falls among Middle-Aged and Older Adults: A Neglected Public Health Problem’, American Journal of Public Health, 2006, 96, 1192–8; M. Palvanen et al., ‘The Injury Mechanisms of Osteoporotic Upper Extremity Fractures among Older Adults: A Controlled Study of 287 Consecutive Patients and their 108 Controls’, Osteoporosis International, 2000, 11, 822–31. 117 Steven Cherry, ‘The Hospitals and Population Growth: The Voluntary General Hospitals, Mortality and Local Populations in the English Provinces in the Eighteenth and Nineteenth Centuries Part 2’, Population Studies, 1980, 34, 251–65, at 258. 118 Ibid., 258–9. 119 Loudon, Medical Care, 75, 78–9. 120 Ibid., 76. 121 Spence, Accidents, 113. 122 Mary Fissell, ‘The ‘Sick and Drooping Poor’ in Eighteenth-Century Bristol and its Region’, Social History of Medicine, 1989, 2, 35–58, at 49–50; Withey, ‘Medicine and Charity’, 483–4. 123 Examples include: Margaret Judd and Charlotte Roberts, ‘Fracture Trauma in a Medieval British Farming Village’, American Journal of Physical Anthropology, 1999, 109, 229–43; Rebecca Redfern, Margaret Judd and Sharon DeWitte, ‘Multiple Injury and Health in Past Societies: An Analysis of Concepts and Approaches, and Insights from a Multi-Period Study’, International Journal of Osteoarchaeology, 2016, 27, 418–29; Boston et al., Safe moor’d. 124 Madeleine Mant, ‘“Readmitted under urgent circumstance”: Uniting Archives and Bioarchaeology at the Royal London Hospital’, in Madeleine Mant and Alyson Holland, eds, Beyond the Bones: Engaging with Disparate Datasets (San Diego: Elsevier Academic Press, 2016), 37–59. 125 Cooter and Luckin, Accidents in History, 3. © The Author(s) 2018. Published by Oxford University Press on behalf of the Society for the Social History of Medicine. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Social History of Medicine Oxford University Press

‘A Little Time Woud Compleat the Cure’: Broken Bones and Fracture Experiences of the Working Poor in London’s General Hospitals During the Long Eighteenth Century

Loading next page...
 
/lp/ou_press/a-little-time-woud-compleat-the-cure-broken-bones-and-fracture-3YB1w6OYDh
Publisher
Oxford University Press
Copyright
© The Author(s) 2018. Published by Oxford University Press on behalf of the Society for the Social History of Medicine.
ISSN
0951-631X
eISSN
1477-4666
D.O.I.
10.1093/shm/hky023
Publisher site
See Article on Publisher Site

Abstract

Summary This article draws upon admission and discharge records from four of London’s voluntary general hospitals (St Thomas’, Guy’s, Middlesex and London) to examine the fracture causes and experiences of the working poor. The article reveals that in-patients generally spent sufficient time in the hospital for significant fracture healing to occur. The diagnosis of fracture is considered within the context of Enlightenment medical education, pathological collections and contemporary clinical nosology. Using surgeons’ and physicians’ clinical notebooks, this article illustrates the fracture treatment received in the voluntary general hospitals and the range of risk factors encountered by the working poor. fracture, patients, hospital, injury, medicine Introduction On 2 October 1725, a young woman fell down the stairs of the Monument to the Great Fire of London and broke her leg. She was carried to a surgeon in Bridge End who reduced her fracture and decided that ‘she would prove A Charity patient’.1 The next day she was admitted to St Thomas’ Hospital, becoming a patient of William Cheselden. Her leg was extended and bound and though ‘the patient complain’d much of pain, was let blood, & took a draught & was better afterwards’.2 Her treatments are described in detail, but the medical student recording her progress importantly notes that ‘A little time woud compleat [sic] the Cure.’3 This brief vignette engenders questions concerning patients’ experience with their broken bodies in Enlightenment London. This article explores the injury causes and convalescence periods of individuals suffering from fractures in the general hospitals of London, UK, during the long eighteenth century to address three questions. First, how long did fractured in-patients stay in hospital? Secondly, how did patients’ prognosis vary depending upon the fractured element? Thirdly, what risk factors were responsible for broken bones during the long eighteenth century? This work contributes to recent literature concerning physical impairment in eighteenth-century England by focusing on one type of bodily injury.4 Fractures may affect an individual’s ability to walk, gesture and complete their occupation. Unlike other long-term disabling injuries or infectious conditions, which have received more attention in the literature, fractures being treated in hospital are acute injuries. Their effects range from minor annoyances to fatalities; they are quotidian risks for individuals working and navigating urban spaces. Fractures, even in eighteenth-century hospital records, were subsumed under broad categories such as ‘traumatic conditions’ and ‘accidents and injuries’; these groupings also included myriad unrelated cases ranging from animal bites to burns to one incident of ‘catgut flying into eye while mending musical instrument’, belying the unique nature of fractures as a cause of injury.5 This investigation focuses exclusively on fractures as a unique data source to illuminate the experiences of working class individuals navigating the medical marketplace of London during the long eighteenth century. Many historical accounts have characterised eighteenth-century hospitals as ‘gateways to death’, stating that ‘the chief indictment of hospital work at this period is not that it did no good, but that it positively did harm’.6 The reputation and impact of eighteenth-century medical care continues to be re-examined in medical historical literature and this study contributes to a deeper understanding of the care provided in London’s general hospitals with a focus on fractures, an understudied area of medical historiography.7 Fractures are a useful lens through which to examine the past. Physicians and surgeons working during the ‘long’ eighteenth century were operating under a nosological system that defined fractures as bones forcibly divided into segments. This definition is similar to a modern clinical definition of fracture, suggesting that fractures are reasons for hospital admission that transcend time more easily than, for example, diagnoses of ‘foul’ diseases that may encompass many venereal complaints or conditions that are often unfamiliar to modern eyes, such as St Vitus’s Dance. Several sources of evidence suggest that fractures were a relatively common theme in medical education and that a diagnosis of ‘fracture’ or ‘broken’ recorded in the historic hospital admission records accurately refers to a broken bone. Medical students were certainly exposed to education concerning fractures. Surgical student Charles Oxley at St Thomas’ Hospital recorded in his notebook, covering the years 1725 and 1726, detailed descriptions of the causes and treatments of cranial, femoral, tibial and fibular fractures.8 The pathological collections at institutions such as St Bartholomew’s and Westminster hospitals and the Royal College of Surgeons are an indirect source of evidence suggesting that physicians and surgeons at the general hospitals would have been well versed in the appearance of fractures. The Westminster Hospital pathology collection, which had its roots in the eighteenth century, by the nineteenth century was 38.8 per cent comprised of fracture examples (19/49 total).9 Potentially the proportion of anatomical samples representing fractures may have been so high because curators thought they were particularly important, or perhaps fractures were among the most common conditions affecting bone at the time.10 Another possibility is that fractures were relatively simple to observe and identify in living patients.11 Almost exactly half of the Royal College of Surgeons anatomy and pathology collection (pre-1886) were fractures (1,016/2,036 = 49.9 per cent).12 The St Bartholomew’s Anatomical Museum descriptive catalogue from 1846 includes over 200 descriptions of fracture specimens, ranging from minor metacarpal fractures to dramatic long bone and skull fractures.13 Many were healed antemortem fractures, and include patient histories, such as a male individual who suffered a midshaft humeral fracture four years before his death. He was ‘so little impaired by the fracture that [he] worked as a sailor to the time of his death’.14 Several authors have discussed the complex nature of studying disease in the past and applying retrospective diagnoses.15 One must consider the modern biological diagnosis and the social diagnosis used by individuals in the past. Information gleaned from surgeons’ casebooks and catalogues of contemporary anatomical collections suggests that surgeons had a robust comprehension of fracture causes and treatments that is comparable to modern understandings. The diagnosis of fractures depended upon the ‘patient’s history of injury, pain and loss of function, physical findings of deformity, loss of normal motion, false motion, crepitus, visible bone fragments in a wound, swelling, and ecchymosis’.16 Similarly, the healing of a fracture was indicated by ‘a palpable nontender callus and the loss of false motion’.17 Drawing upon admission and discharge records from St Thomas’, Guy’s, the Middlesex and the London, four of London’s general hospitals, as well as contemporary surgeons’ and physicians’ notebooks, this paper illuminates the fracture causes and experiences of the working poor. The Working Poor and General Hospitals As the population of London grew over the long eighteenth century (c. 1688–1837), so did the number of hospitals. By the 1780s, there were seven general hospitals totalling approximately 2,000 beds and offering medical care to the labouring poor in London.18 Hospitals aided in getting family breadwinners in a fit state to work and isolated ill individuals from overcrowded homes, but without general improvements in living standards they could not singlehandedly improve the nation’s health.19 Two of the general hospitals, St Bartholomew’s and St Thomas’, boasted medieval origins (c. 1123 and c. 1173 respectively), and along with Guy’s Hospital (founded in 1725), were independently endowed.20 In contrast, the Westminster, St George’s, the London and the Middlesex depended upon donations, subscriptions and fund-raising events to provide charitable care for London’s poor. These voluntary hospitals were founded upon ‘a wave of philanthropy by those who wished not merely to alleviate distress but to restore the afflicted to respectable and independent citizenhood’.21 General hospitals provided care for injuries and illnesses deemed curable, commonly excluding the following types of cases: ‘no woman big with child, no children under seven years of age (except in cases of compound fractures, amputations, or cutting for the stone), no persons disordered in their senses, or suspected to have Smallpox, Itch, or other infectious distempers, or who are judged to be in a consumptive, asthmatic, or dying condition’.22 Essentially the hospitals were attempting to limit the admittance of ‘burdens on the house’; that is, chronic or incurable cases that might turn the hospital facilities into almshouses.23 The voluntary hospitals were not the only source of medical care for fractures. Dispensaries were a key part of the medical marketplace of London and of England more broadly after 1769. They provided out-patient medical care on a charitable basis and by 1800 there were 21 in London and 22 elsewhere in Britain.24 Loudon argues that the stricter admission policies of the hospitals resulted in a higher intake of surgical cases (including accident cases such as fractures), whereas the more accessible dispensaries, which admitted patients more than one day a week and had more limited lists of exclusions, tended to treat more medical cases, such as fevers and gastrointestinal issues.25 This notion is borne out quantitatively: surgical cases comprised only between 1.5 and 3.8 per cent of the total cases admitted by the Bristol Dispensary, Exeter Dispensary, Bamburgh Castle Dispensary and London’s Public Dispensary.26 Withey cautions that broad comparisons drawn between institutions must be made carefully since recording procedures varied from one dispensary to the next and the categories of disease recorded are ‘essentially arbitrary’; the similarly low numbers of surgical/accident patients, however, are striking.27 The lack of in-patient facilities likely made dispensaries a less attractive option to patients suffering the major fractures found in the voluntary hospital records. The lack of category differentiation means that the number of cases of fracture is unknown, emphasising the importance of the present study and the possibilities for future research within the detailed records of London’s voluntary hospitals. Various contemporary sources note that individuals accepted into the general hospitals should be ‘deserving’ or ‘worthy objects of charity’, since the hospitals were serving to ‘[recover] future wealth potentially lost to the nation’.28 John Bellers, writing in 1714, aptly characterised the social class differentiation inherent in the hospital system by stating that ‘it is as much the duty of the poor to labour when they are able as it is for the rich to help them when they are sick’.29 Historians have wrestled with labelling the ‘poor’, since this group of people was not homogenous or clearly differentiated.30 Poverty was ‘fluid and subjective in its definition’ and people could change statuses throughout their life course.31 The working poor were a varied group of people, including those who were dependent upon wage labour and those who received poor relief or charity.32 The poor made their living in what has been variously termed an ‘economy of makeshifts’ and a mixed economy of welfare, terms for the ‘patchy, desperate and sometimes failing strategies of the poor for material survival’.33 Fracture Treatment During the Long Eighteenth Century When examining historical hospital records and physicians’ diagnoses, it is necessary to have an understanding of contemporary nosology. Eighteenth-century physicians conceived of disease diagnoses as a form of taxonomy including classes, orders, genera and species, following the example of botanists. The three authors whose texts had the greatest effect on the nosological framework of the eighteenth century were Carl von Linné, François Boissier de Sauvages and William Cullen, who sought to classify diseases based upon symptomological signs (understood at the time to include perceptible lesions and bodily changes), autopsy results and theory.34 The results were often confusing and unnecessarily complex; Sauvages, for example, identified 17 different varieties of cough. Fractures were classified under the order ‘Plagae’, which also included contusions, fissures, ruptures and amputations, and defined fractures as the violent and mechanical separation of bones into fragments.35 Cullen divided disease into four classes, Pyrexias (e.g., fevers, local inflammations including catarrh and types of dysentery), Neuroses (nervous ailments e.g. apoplexy, convulsions), Cachexias (e.g. emaciations, swellings, discolourations including scrofula, syphilis and scurvy), and Locales (collection of eight orders describing other conditions that could not otherwise be categorised (e.g. hernia, loss of appetite, cancer). Fractures, according to Cullen, fell under the order Locales and were defined as ‘bones broken into large fragments’.36 Despite operating under a humoral philosophy, Enlightenment medical practitioners appear to have been able to identify and treat fractures successfully. Simple, or closed, fracture treatment was a routine procedure for contemporary surgeons. The mechanism of healing may not have been fully understood, but bone was known to be a living structure following the work of Clopton Havers and John Belchier.37 Bone growth was a topic of scholarly interest; Stephen Hales noted that bones grew in length due to growth at the epiphyses and John Hunter posited that during growth new bone was laid down and absorbed.38 Antonio Scarpa observed that bone formation at a fracture site is similar to growth occurring during normal skeletal growth and development.39 The mechanism of fracture healing was not completely understood; indeed, details of fracture healing are still being investigated in modern clinical studies, since the osteoblasts and osteoclasts, cells integral to bone growth and maintenance, and osteoid, the uncalcified matrix of bone, were not described in the medical literature until the mid-nineteenth century.40 Fractures were most commonly splinted by a surgeon and allowed time to heal on their own. Sir Benjamin Brodie, the celebrated nineteenth-century surgeon at St George’s, used the example of a fractured olecranon to illustrate the ease with which most fractures were treated, stating that ‘the bone should be retained in a proper situation by means of a bandage, and the arm kept extended by means of a splint, and no other treatment is required’.41 Closed fractures do not seem to have been regarded with much alarm. Correspondence between the agent of a country estate and his master in London in 1727 notes the following incident: 8 May 1727: yesterday about 3 o’clock the poor nurse fell down in the stone court, it being wet and slippery, and broke both the bones of her arm about 3 inches above her right hand. I sent immediately for Mr Fryer, who came and set it before eight … 11 May 1727: the nurse is intirely [sic] free from pain.42 Treatment for closed fractures involved the reduction of the fracture and splinting or bandaging the injury with either wooden splints or junks (straw wrapped tightly in cotton cloth) to reduce or prevent movement of the fractured bone. Grauer and Roberts’s anthropological study of healed long bone fractures in medieval individuals concluded that medieval individuals in York, England must have practised fracture immobilization.43 Indeed, the treatment for fractures changed little throughout the medieval and post-medieval periods before the advent of germ theory and the discovery of X-rays in 1895. Percivall Pott, the leading surgeon in London following the death of William Cheselden, advocated in his book Some Few General Remarks on Fractures and Dislocations, that a fractured limb should be placed in the position in which the muscles are in the greatest state of relaxation to reduce the displacement of fracture fragments.44 Admission records from the Westminster Hospital reveal a variety of strategies for dealing with individuals with fractures. Bandages, rest and the application of cold compresses ‘to keep down the temperature of the leg’ were prescribed, along with the application of heat, purges, bleedings, poultices and sometimes amputation.45 James Howard, a boy of 12 admitted on 31 May 1818 for a fractured humerus, was prescribed ‘nothing but quiet’, until his discharge on 12 July 1818.46 The cost of fracture treatment was an important consideration; complicated fractures could prove expensive. Labourer Sarah Stacey suffered ‘an extremely bad compound fracture of the Os Humerus’ after being run over by a carriage in 1774.47 Her employer footed the bill (£21. 9 s. 2d), the equivalent of Sarah’s annual wages, for a surgeon to treat her nearly every day for three months to avoid amputation. Complicated injuries, such as compound fractures, wherein the fractured bone communicated with air through a flesh wound, were regarded with more trepidation. These injuries often necessitated amputation, a complicated and dangerous undertaking, particularly before the introduction of anaesthesia in 1847, the acceptance of germ theory and the introduction of antibiotic measures in surgery. Surgeons understood that the introduction of air to the fractured area was dangerous and could lead to sepsis.48 John Hunter encouraged the sealing of compound wounds with lint soaked in the fractured patient’s own blood.49 Amputations were a common and greatly feared undertaking and patients were often unwilling to view surgery as a viable option.50 Much medical and popular literature exists suggesting that practitioners should avoid amputation where possible, epitomised in a 1794 article from Gentleman’s Magazine, a popular news and opinion periodical, describing the case of an elderly collier who had suffered a compound fracture of his right leg. He refused amputation but was walking with crutches after two months of home care. The author concludes that ‘however necessary and right speedy amputation may be in great hospitals … this narrative affords a striking proof of the necessity there is for great deliberation in cases where amputation may be thought necessary’.51 John Hunter, the preeminent Scottish surgeon, spoke of the surgeon’s dilemma when he stated that ‘with regard to operations, we should know when they will relieve, and when nothing but operations will relieve. We should know when the habit [of the patient] will bear an operation—this is sometimes almost impossible to ascertain.’52 Admission and Discharge Records of the Voluntary General Hospitals Admission and discharge records have survived and are available for consultation from four of the general hospitals during the long eighteenth century: the London, Middlesex, St Thomas’ and Guy’s (Table 1). Registration, note taking, and record-keeping were important to the general hospital movement. Francis Clifton, a member of the Royal College of Physicians of London, recommended that physicians should write casebooks as they are ‘the plainest and surest way of practicing and improving physic’.53 Clifton recommended listing the age, sex, temperament, occupation, symptoms, treatments and outcome of the patient’s progress so that physicians would no longer rely upon their memories alone to diagnose disease and would eventually ‘come to know diseases so perfectly that it will be impossible for them to miss their reward’.54 The hospitals were accountable to their charitable subscribers and thus it was vital to have a general register to calculate annual admissions, deaths and discharges.55 Table 1. Admission and discharge records, arranged by hospital and range of dates Hospital Record type Range of dates available St Thomas’ Admission and discharge records 20 January 1774–10 February 1774 8 December 1774–9 February 1775 30 March 1775–27 April 1775 24 August 1775–7 September 1775 29 February 1776–8 August 1776 25 October 1781–10 January 1782 10 January 1782–25 July 1782 25 December 1783–3 June 1784 11 January 1787–4 September 1788 26 March 1789–13 May 1790 16 September 1790–16 June 1791 12 December 1793–15 October 1795 26 May 1796–22 June 1797 20 December 1798–13 November 1800 Guy’s Admission, discharge, and accident records 28 July 1813–26 December 1838 London Admission and discharge records 1 January 1760–31 December 1760 4 January 1791–25 December 1792 16 July 1805–24 December 1805 Middlesex Apothecary admission and discharge records 4 March 1760–25 December 1764 9 April 1771–2 December 1788 Hospital Record type Range of dates available St Thomas’ Admission and discharge records 20 January 1774–10 February 1774 8 December 1774–9 February 1775 30 March 1775–27 April 1775 24 August 1775–7 September 1775 29 February 1776–8 August 1776 25 October 1781–10 January 1782 10 January 1782–25 July 1782 25 December 1783–3 June 1784 11 January 1787–4 September 1788 26 March 1789–13 May 1790 16 September 1790–16 June 1791 12 December 1793–15 October 1795 26 May 1796–22 June 1797 20 December 1798–13 November 1800 Guy’s Admission, discharge, and accident records 28 July 1813–26 December 1838 London Admission and discharge records 1 January 1760–31 December 1760 4 January 1791–25 December 1792 16 July 1805–24 December 1805 Middlesex Apothecary admission and discharge records 4 March 1760–25 December 1764 9 April 1771–2 December 1788 Primary sources: St Thomas’ and Guy’s Hospital (London Metropolitan Archives): H01/ST/B/003/001, H01/ST/B/003/002, H01/ST/B/003/003, H01/ST/B/003/004, H01/ST/B/003/005, H01/ST/B/003/006, H01/ST/B/003/007, H01/ST/B/003/008, H01/ST/B/003/009, H01/ST/B/003/010, H01/ST/B/003/011, H01/ST/B/003/012, H09/GY/B1/16/1, H09/GY/B1/17/1, H09/GY/B1/18, H09/GY/B1/19/1, H09/GY/B1/20; Middlesex Hospital (University College London Hospitals NHS Trust): Middlesex Hospital Apothecary Reports, Volumes 1–4; London Hospital (Royal London Hospital Museum and Archives): LH/M/1/1/ 1760, LH/M/1/2 1791–1792. Table 1. Admission and discharge records, arranged by hospital and range of dates Hospital Record type Range of dates available St Thomas’ Admission and discharge records 20 January 1774–10 February 1774 8 December 1774–9 February 1775 30 March 1775–27 April 1775 24 August 1775–7 September 1775 29 February 1776–8 August 1776 25 October 1781–10 January 1782 10 January 1782–25 July 1782 25 December 1783–3 June 1784 11 January 1787–4 September 1788 26 March 1789–13 May 1790 16 September 1790–16 June 1791 12 December 1793–15 October 1795 26 May 1796–22 June 1797 20 December 1798–13 November 1800 Guy’s Admission, discharge, and accident records 28 July 1813–26 December 1838 London Admission and discharge records 1 January 1760–31 December 1760 4 January 1791–25 December 1792 16 July 1805–24 December 1805 Middlesex Apothecary admission and discharge records 4 March 1760–25 December 1764 9 April 1771–2 December 1788 Hospital Record type Range of dates available St Thomas’ Admission and discharge records 20 January 1774–10 February 1774 8 December 1774–9 February 1775 30 March 1775–27 April 1775 24 August 1775–7 September 1775 29 February 1776–8 August 1776 25 October 1781–10 January 1782 10 January 1782–25 July 1782 25 December 1783–3 June 1784 11 January 1787–4 September 1788 26 March 1789–13 May 1790 16 September 1790–16 June 1791 12 December 1793–15 October 1795 26 May 1796–22 June 1797 20 December 1798–13 November 1800 Guy’s Admission, discharge, and accident records 28 July 1813–26 December 1838 London Admission and discharge records 1 January 1760–31 December 1760 4 January 1791–25 December 1792 16 July 1805–24 December 1805 Middlesex Apothecary admission and discharge records 4 March 1760–25 December 1764 9 April 1771–2 December 1788 Primary sources: St Thomas’ and Guy’s Hospital (London Metropolitan Archives): H01/ST/B/003/001, H01/ST/B/003/002, H01/ST/B/003/003, H01/ST/B/003/004, H01/ST/B/003/005, H01/ST/B/003/006, H01/ST/B/003/007, H01/ST/B/003/008, H01/ST/B/003/009, H01/ST/B/003/010, H01/ST/B/003/011, H01/ST/B/003/012, H09/GY/B1/16/1, H09/GY/B1/17/1, H09/GY/B1/18, H09/GY/B1/19/1, H09/GY/B1/20; Middlesex Hospital (University College London Hospitals NHS Trust): Middlesex Hospital Apothecary Reports, Volumes 1–4; London Hospital (Royal London Hospital Museum and Archives): LH/M/1/1/ 1760, LH/M/1/2 1791–1792. In this investigation, reasons for admission that indicate an individual had a ‘fracture’ or a ‘broken’ body element were recorded as fractures, while elements that were recorded as ‘bruised’, ‘hurt’, or ‘injured’ were not. It is possible that an individual may have been admitted to hospital with an injury that appeared bruised or lacerated but was actually a fracture; therefore, the fracture prevalence recorded likely underestimates the number of fractures treated in the general hospitals. The length of stay in hospital was determined by tracking individual patients through their admission and eventual discharge. While the records for the London Hospital list a patient’s date of admission and discharge in the same ledger, as well as an outcome of ‘cured’ or ‘died’, Guy’s, St Thomas’ and the Middlesex do not. Lists of individuals with fractures were compiled as they were discovered in the weekly admission registers and these names were individually cross-referenced with the names found in the weekly discharge lists. In this manner, the fate of each individual with a fracture was determined and a database of all individuals admitted to the hospitals for fractures (Table 2) was created. This allowed for the search of common names (e.g. John Smith, William Williams) to determine if these individuals were admitted to hospital around the same time (suggesting that the admissions likely represented two different individuals) or if one John Smith was admitted after another John Smith had been discharged, raising the possibility that it was the same individual readmitted to the same hospital. The closed (Table 3) and compound fractures (Table 4) were considered separately because compound fractures are considerably more complicated and dangerous than closed fractures and generally required longer hospital stays. Table 2. Sample size of individuals in hospital for fractures Hospital Males Females Total London 224 84 308 Middlesex 617 272 889 St Thomas’ 621 121 742 Guy’s 2,452 666 3,118 Total 3,914 1,143 5,057 Hospital Males Females Total London 224 84 308 Middlesex 617 272 889 St Thomas’ 621 121 742 Guy’s 2,452 666 3,118 Total 3,914 1,143 5,057 Table 2. Sample size of individuals in hospital for fractures Hospital Males Females Total London 224 84 308 Middlesex 617 272 889 St Thomas’ 621 121 742 Guy’s 2,452 666 3,118 Total 3,914 1,143 5,057 Hospital Males Females Total London 224 84 308 Middlesex 617 272 889 St Thomas’ 621 121 742 Guy’s 2,452 666 3,118 Total 3,914 1,143 5,057 Table 3. Average number of days in hospital organised by closed fracture location Males Females Fracture location L MSX St T G’s Mean L MSX St T G’s Mean Skull/Face 19 (2) 48.7 (30) 56.2 (34) 58.2 (19) 53.1 (85) 7 (1) 71.6 (9) 36 (5) 31.1 (9) 46.3 (24) Jaw 32 (4) 27.8 (10) 33.2 (20) 34.4 (33) 32.9 (67) 0 27 (1) 36 (1) 24.2 (9) 25.5 (11) Neck 0 0 0 0 0 0 0 0 83 (1) 83 (1) Clavicle 21.8 (13) 30 (9) 43.4 (39) 30.6 (126) 32.6 (187) 26.3 (3) 31.5 (2) 57 (1) 31.9 (27) 32.1 (33) Shoulder 0 99 (2) 26.7 (6) 27.2 (29) 31 (37) 0 0 29 (2) 96.8 (4) 74.2 (6) Arm 31.3 (21) 40.7 (63) 50.4 (120) 46.1 (524) 45.9 (728) 30.9 (13) 62.8 (41) 47.2 (35) 48.8 (191) 49.8 (280) Hand 0 35.8 (4) 55.1 (11) 42.0 (38) 44.3 (53) 0 0 143.3 (3) 29.5 (6) 67.4 (9) Spine/Back 0 0 176 (3) 293.3 (3) 234.7 (6) 0 0 0 0 0 Sternum 0 0 0 17.3 (4) 17.3 (4) 0 0 0 0 0 Rib/Ribs 23.7 (37) 22.5 (40) 35.2 (77) 30.5 (303) 30.0 (457) 20.0 (7) 22.8 (13) 34.3 (8) 22.0 (59) 23.1 (87) Hip 0 0 15 (1) 64.2 (9) 59.3 (10) 0 25 (1) 0 0 25 (1) Femur/Thigh 52.6 (37) 64.4 (116) 77.0 (79) 85.8 (337) 78.0 (569) 60.3 (6) 65.3 (35) 77.5 (13) 73.3 (94) 71.3 (148) Knee/Patella 40.7 (12) 44.7 (17) 52.6 (19) 74.0 (76) 63.5 (124) 61.4 (5) 65.3 (26) 66.6 (8) 69.0 (22) 66.5 (61) Leg 58.8 (85) 58.2 (280) 75.7 (193) 68.3 (832) 66.7 (1,390) 51.5 (43) 65.9 (133) 81.1 (40) 70.0 (227) 68.0 (443) Foot 105 (1) 27.8 (8) 47.0 (11) 47.2 (25) 45.0 (45) 0 38.3 (3) 40.2 (5) 40.3 (6) 39.9 (14) Stump 0 0 0 10 (1) 10 (1) 0 0 0 0 0 Males Females Fracture location L MSX St T G’s Mean L MSX St T G’s Mean Skull/Face 19 (2) 48.7 (30) 56.2 (34) 58.2 (19) 53.1 (85) 7 (1) 71.6 (9) 36 (5) 31.1 (9) 46.3 (24) Jaw 32 (4) 27.8 (10) 33.2 (20) 34.4 (33) 32.9 (67) 0 27 (1) 36 (1) 24.2 (9) 25.5 (11) Neck 0 0 0 0 0 0 0 0 83 (1) 83 (1) Clavicle 21.8 (13) 30 (9) 43.4 (39) 30.6 (126) 32.6 (187) 26.3 (3) 31.5 (2) 57 (1) 31.9 (27) 32.1 (33) Shoulder 0 99 (2) 26.7 (6) 27.2 (29) 31 (37) 0 0 29 (2) 96.8 (4) 74.2 (6) Arm 31.3 (21) 40.7 (63) 50.4 (120) 46.1 (524) 45.9 (728) 30.9 (13) 62.8 (41) 47.2 (35) 48.8 (191) 49.8 (280) Hand 0 35.8 (4) 55.1 (11) 42.0 (38) 44.3 (53) 0 0 143.3 (3) 29.5 (6) 67.4 (9) Spine/Back 0 0 176 (3) 293.3 (3) 234.7 (6) 0 0 0 0 0 Sternum 0 0 0 17.3 (4) 17.3 (4) 0 0 0 0 0 Rib/Ribs 23.7 (37) 22.5 (40) 35.2 (77) 30.5 (303) 30.0 (457) 20.0 (7) 22.8 (13) 34.3 (8) 22.0 (59) 23.1 (87) Hip 0 0 15 (1) 64.2 (9) 59.3 (10) 0 25 (1) 0 0 25 (1) Femur/Thigh 52.6 (37) 64.4 (116) 77.0 (79) 85.8 (337) 78.0 (569) 60.3 (6) 65.3 (35) 77.5 (13) 73.3 (94) 71.3 (148) Knee/Patella 40.7 (12) 44.7 (17) 52.6 (19) 74.0 (76) 63.5 (124) 61.4 (5) 65.3 (26) 66.6 (8) 69.0 (22) 66.5 (61) Leg 58.8 (85) 58.2 (280) 75.7 (193) 68.3 (832) 66.7 (1,390) 51.5 (43) 65.9 (133) 81.1 (40) 70.0 (227) 68.0 (443) Foot 105 (1) 27.8 (8) 47.0 (11) 47.2 (25) 45.0 (45) 0 38.3 (3) 40.2 (5) 40.3 (6) 39.9 (14) Stump 0 0 0 10 (1) 10 (1) 0 0 0 0 0 L = London, MSX = Middlesex, St T = St Thomas’, G’s = Guy’s. The results were determined by summing the total number of days spent in hospital for each fractured element for each hospital and dividing by the number of individuals listed as being admitted for each fractured body element to the hospital. The mean was determined by summing the total number of days spent in hospital by all individuals with the fractured element and dividing by the total number of individuals admitted to all hospitals for each fractured body element. Table 3. Average number of days in hospital organised by closed fracture location Males Females Fracture location L MSX St T G’s Mean L MSX St T G’s Mean Skull/Face 19 (2) 48.7 (30) 56.2 (34) 58.2 (19) 53.1 (85) 7 (1) 71.6 (9) 36 (5) 31.1 (9) 46.3 (24) Jaw 32 (4) 27.8 (10) 33.2 (20) 34.4 (33) 32.9 (67) 0 27 (1) 36 (1) 24.2 (9) 25.5 (11) Neck 0 0 0 0 0 0 0 0 83 (1) 83 (1) Clavicle 21.8 (13) 30 (9) 43.4 (39) 30.6 (126) 32.6 (187) 26.3 (3) 31.5 (2) 57 (1) 31.9 (27) 32.1 (33) Shoulder 0 99 (2) 26.7 (6) 27.2 (29) 31 (37) 0 0 29 (2) 96.8 (4) 74.2 (6) Arm 31.3 (21) 40.7 (63) 50.4 (120) 46.1 (524) 45.9 (728) 30.9 (13) 62.8 (41) 47.2 (35) 48.8 (191) 49.8 (280) Hand 0 35.8 (4) 55.1 (11) 42.0 (38) 44.3 (53) 0 0 143.3 (3) 29.5 (6) 67.4 (9) Spine/Back 0 0 176 (3) 293.3 (3) 234.7 (6) 0 0 0 0 0 Sternum 0 0 0 17.3 (4) 17.3 (4) 0 0 0 0 0 Rib/Ribs 23.7 (37) 22.5 (40) 35.2 (77) 30.5 (303) 30.0 (457) 20.0 (7) 22.8 (13) 34.3 (8) 22.0 (59) 23.1 (87) Hip 0 0 15 (1) 64.2 (9) 59.3 (10) 0 25 (1) 0 0 25 (1) Femur/Thigh 52.6 (37) 64.4 (116) 77.0 (79) 85.8 (337) 78.0 (569) 60.3 (6) 65.3 (35) 77.5 (13) 73.3 (94) 71.3 (148) Knee/Patella 40.7 (12) 44.7 (17) 52.6 (19) 74.0 (76) 63.5 (124) 61.4 (5) 65.3 (26) 66.6 (8) 69.0 (22) 66.5 (61) Leg 58.8 (85) 58.2 (280) 75.7 (193) 68.3 (832) 66.7 (1,390) 51.5 (43) 65.9 (133) 81.1 (40) 70.0 (227) 68.0 (443) Foot 105 (1) 27.8 (8) 47.0 (11) 47.2 (25) 45.0 (45) 0 38.3 (3) 40.2 (5) 40.3 (6) 39.9 (14) Stump 0 0 0 10 (1) 10 (1) 0 0 0 0 0 Males Females Fracture location L MSX St T G’s Mean L MSX St T G’s Mean Skull/Face 19 (2) 48.7 (30) 56.2 (34) 58.2 (19) 53.1 (85) 7 (1) 71.6 (9) 36 (5) 31.1 (9) 46.3 (24) Jaw 32 (4) 27.8 (10) 33.2 (20) 34.4 (33) 32.9 (67) 0 27 (1) 36 (1) 24.2 (9) 25.5 (11) Neck 0 0 0 0 0 0 0 0 83 (1) 83 (1) Clavicle 21.8 (13) 30 (9) 43.4 (39) 30.6 (126) 32.6 (187) 26.3 (3) 31.5 (2) 57 (1) 31.9 (27) 32.1 (33) Shoulder 0 99 (2) 26.7 (6) 27.2 (29) 31 (37) 0 0 29 (2) 96.8 (4) 74.2 (6) Arm 31.3 (21) 40.7 (63) 50.4 (120) 46.1 (524) 45.9 (728) 30.9 (13) 62.8 (41) 47.2 (35) 48.8 (191) 49.8 (280) Hand 0 35.8 (4) 55.1 (11) 42.0 (38) 44.3 (53) 0 0 143.3 (3) 29.5 (6) 67.4 (9) Spine/Back 0 0 176 (3) 293.3 (3) 234.7 (6) 0 0 0 0 0 Sternum 0 0 0 17.3 (4) 17.3 (4) 0 0 0 0 0 Rib/Ribs 23.7 (37) 22.5 (40) 35.2 (77) 30.5 (303) 30.0 (457) 20.0 (7) 22.8 (13) 34.3 (8) 22.0 (59) 23.1 (87) Hip 0 0 15 (1) 64.2 (9) 59.3 (10) 0 25 (1) 0 0 25 (1) Femur/Thigh 52.6 (37) 64.4 (116) 77.0 (79) 85.8 (337) 78.0 (569) 60.3 (6) 65.3 (35) 77.5 (13) 73.3 (94) 71.3 (148) Knee/Patella 40.7 (12) 44.7 (17) 52.6 (19) 74.0 (76) 63.5 (124) 61.4 (5) 65.3 (26) 66.6 (8) 69.0 (22) 66.5 (61) Leg 58.8 (85) 58.2 (280) 75.7 (193) 68.3 (832) 66.7 (1,390) 51.5 (43) 65.9 (133) 81.1 (40) 70.0 (227) 68.0 (443) Foot 105 (1) 27.8 (8) 47.0 (11) 47.2 (25) 45.0 (45) 0 38.3 (3) 40.2 (5) 40.3 (6) 39.9 (14) Stump 0 0 0 10 (1) 10 (1) 0 0 0 0 0 L = London, MSX = Middlesex, St T = St Thomas’, G’s = Guy’s. The results were determined by summing the total number of days spent in hospital for each fractured element for each hospital and dividing by the number of individuals listed as being admitted for each fractured body element to the hospital. The mean was determined by summing the total number of days spent in hospital by all individuals with the fractured element and dividing by the total number of individuals admitted to all hospitals for each fractured body element. Table 4. Average number of days in hospital organised by compound fracture location Males Females Fracture location RL MSX St T G’s Mean RL MSX St T G’s Mean Skull/Head 0 0 0 70.0 (10) 70.0 (10) 0 0 0 0 0 Jaw 0 0 0 115 (1) 115 (1) 0 0 0 161 (1) 161 (1) Clavicle 0 253 (1) 0 94.0 (1) 173.5 (2) 0 0 0 0 0 Arm 101 (4) 63.0 (3) 57.0 (2) 103.9 (8) 90.5 (17) 16.0 (1) 33.0 (1) 0 65.0 (2) 44.8 (4) Hand 0 0 0 40.0 (10) 40.0 (10) 0 0 0 39.0 (1) 39.0 (1) Femur/Thigh 0 144 (1) 0 118 (8) 120.9 (9) 0 0 0 108 (1) 108 (1) Leg 128.1 (7) 113.7 (32) 114.2 (6) 126.2 (50) 121.4 (95) 81.6 (5) 109.2 (6) 0 161.4 (5) 116.9 (16) Foot 10.0 (1) 17.0 (1) 0 45.2 (5) 36.1 (7) 0 57.0 (1) 0 38.0 (1) 47.5 (2) Males Females Fracture location RL MSX St T G’s Mean RL MSX St T G’s Mean Skull/Head 0 0 0 70.0 (10) 70.0 (10) 0 0 0 0 0 Jaw 0 0 0 115 (1) 115 (1) 0 0 0 161 (1) 161 (1) Clavicle 0 253 (1) 0 94.0 (1) 173.5 (2) 0 0 0 0 0 Arm 101 (4) 63.0 (3) 57.0 (2) 103.9 (8) 90.5 (17) 16.0 (1) 33.0 (1) 0 65.0 (2) 44.8 (4) Hand 0 0 0 40.0 (10) 40.0 (10) 0 0 0 39.0 (1) 39.0 (1) Femur/Thigh 0 144 (1) 0 118 (8) 120.9 (9) 0 0 0 108 (1) 108 (1) Leg 128.1 (7) 113.7 (32) 114.2 (6) 126.2 (50) 121.4 (95) 81.6 (5) 109.2 (6) 0 161.4 (5) 116.9 (16) Foot 10.0 (1) 17.0 (1) 0 45.2 (5) 36.1 (7) 0 57.0 (1) 0 38.0 (1) 47.5 (2) L = London, MSX = Middlesex, St T = St Thomas’, G’s = Guy’s. The results were determined by summing the total number of days spent in hospital for each fractured element for each hospital and dividing by the number of individuals listed as being admitted for each fractured body element to the hospital. The mean was determined by summing the total number of days spent in hospital by all individuals with the fractured element and dividing by the total number of individuals admitted to all hospitals for each fractured body element. Table 4. Average number of days in hospital organised by compound fracture location Males Females Fracture location RL MSX St T G’s Mean RL MSX St T G’s Mean Skull/Head 0 0 0 70.0 (10) 70.0 (10) 0 0 0 0 0 Jaw 0 0 0 115 (1) 115 (1) 0 0 0 161 (1) 161 (1) Clavicle 0 253 (1) 0 94.0 (1) 173.5 (2) 0 0 0 0 0 Arm 101 (4) 63.0 (3) 57.0 (2) 103.9 (8) 90.5 (17) 16.0 (1) 33.0 (1) 0 65.0 (2) 44.8 (4) Hand 0 0 0 40.0 (10) 40.0 (10) 0 0 0 39.0 (1) 39.0 (1) Femur/Thigh 0 144 (1) 0 118 (8) 120.9 (9) 0 0 0 108 (1) 108 (1) Leg 128.1 (7) 113.7 (32) 114.2 (6) 126.2 (50) 121.4 (95) 81.6 (5) 109.2 (6) 0 161.4 (5) 116.9 (16) Foot 10.0 (1) 17.0 (1) 0 45.2 (5) 36.1 (7) 0 57.0 (1) 0 38.0 (1) 47.5 (2) Males Females Fracture location RL MSX St T G’s Mean RL MSX St T G’s Mean Skull/Head 0 0 0 70.0 (10) 70.0 (10) 0 0 0 0 0 Jaw 0 0 0 115 (1) 115 (1) 0 0 0 161 (1) 161 (1) Clavicle 0 253 (1) 0 94.0 (1) 173.5 (2) 0 0 0 0 0 Arm 101 (4) 63.0 (3) 57.0 (2) 103.9 (8) 90.5 (17) 16.0 (1) 33.0 (1) 0 65.0 (2) 44.8 (4) Hand 0 0 0 40.0 (10) 40.0 (10) 0 0 0 39.0 (1) 39.0 (1) Femur/Thigh 0 144 (1) 0 118 (8) 120.9 (9) 0 0 0 108 (1) 108 (1) Leg 128.1 (7) 113.7 (32) 114.2 (6) 126.2 (50) 121.4 (95) 81.6 (5) 109.2 (6) 0 161.4 (5) 116.9 (16) Foot 10.0 (1) 17.0 (1) 0 45.2 (5) 36.1 (7) 0 57.0 (1) 0 38.0 (1) 47.5 (2) L = London, MSX = Middlesex, St T = St Thomas’, G’s = Guy’s. The results were determined by summing the total number of days spent in hospital for each fractured element for each hospital and dividing by the number of individuals listed as being admitted for each fractured body element to the hospital. The mean was determined by summing the total number of days spent in hospital by all individuals with the fractured element and dividing by the total number of individuals admitted to all hospitals for each fractured body element. The discharge records revealed a variety of fates. Individuals may have been: (1) discharged from the hospitals, (2) made out-patients (this information is only consistently available for the Middlesex Hospital), or (3) become lost to observation (due to death, self-discharge or because the discharge records were missing). Patients were discharged for a variety of reasons including being ‘cured’, being ‘relieved’, leaving by their own desire or being forcibly discharged for irregular behaviour. Individuals who were admitted due to ‘multiple fractures’ or unknown fractures were excluded from this investigation. Risse observed at the Royal Infirmary of Edinburgh that the term ‘cured’ was used liberally, and often applied to patients ‘who appeared to be on the mend’.56 Lengthy hospital visits were undesirable for the governors of hospitals who recognised that statistics demonstrating patient turnover and many ‘cured’ individuals were good for publicity.57 Newton, in her current and forthcoming work, engages with the word ‘cure’, noting that the words ‘recover’, ‘heal’ and ‘deliver’ were often used synonymously by early modern English medical practitioners.58 Information on patient prognosis post-discharge is often difficult to locate; thus, it is critical to remember that being discharged did not necessarily equate with a patient being entirely healed and healthy. The sex of the individuals admitted to the general hospitals was determined through examination of given names. The London and Middlesex admissions were recorded in a chronological list for each week, not by sex. The Guy’s and St Thomas’ admission lists were generally organised into male and female lists, but the list of names for which reasons for admission were recorded were often not organised into groups differentiated by sex. In the case of the London Hospital records, additional clues were provided under the occupation column, since many women were recorded as being a ‘Sailors Wife’, ‘Labourers Wife’ or a ‘Washerwoman’. Individuals whose given names were recorded only as a first initial were assigned a sex if they were included in a sex-based list of names. In the instances where sex estimation was not possible, the individuals were removed from the final sample group. Juvenile individuals were identified and excluded from the study sample. The differentiation between children and adults is a social categorisation that has changed through time to evolve into contemporary conceptions of childhood.59 Juveniles do not make up a large proportion of those admitted to the general hospitals. Most entered the records when their mothers were admitted to hospital and were thus not counted in the total admitted to hospital. The Middlesex admitted a small number of children, but noted their age or youth in each case; for example, ‘Jno [John] an infant’ was admitted to the Middlesex on 23 April 1760 with a fractured thigh and later (no date recorded) made an out-patient.60 The London Hospital appears to have allowed more children to be admitted than the other hospitals.61 Thankfully, the London Hospital records include the age of admitted individuals and thus exclusion was relatively straightforward. In the Guy’s and St Thomas’ records, where ages were not regularly recorded, all individuals noted as ‘infant’ or ‘child’ were removed from the final sample and all remaining individuals were assumed to be adults. It is possible that some juvenile individuals made it into the final sample because the hospital clerks responsible for the admissions registers did not identify them as children. Broken Bones: Length of Stay in Hospital The total number of individuals suffering a fracture who could confidently be assigned admission and discharge dates was 5,057, 3,914 males and 1,143 females (Table 2). It was not unexpected to find more males seeking hospital care for fractures than females. Risse found that almost 80 per cent of the fracture cases admitted to the Royal Infirmary of Edinburgh were males.62 Table 3 displays the average length of hospital stays for individuals entering the hospital with a closed fracture. Certain body elements were pooled in Tables 3 and 4. The Skull/Head category includes all individuals admitted for skull, head, cranium, eye, zygomatic, maxilla and nose fractures. The arm category includes all fractures labelled arm, humerus, radius, ulna and elbow. The hand group comprises hand, metacarpal, wrist, finger and thumb fractures. The pelvis category includes all fractures to the pelvis, ilium and hip. The femur/thigh category is separated from the leg category; the surgeons’ and physicians’ notebooks consulted consistently used the term ‘leg’ to describe fractures of the lower leg, or of the tibia and/or fibula. The femur/thigh group therefore exclusively refers to femoral fractures and the leg group comprises fractures labelled as leg, tibia and fibula. The foot group includes fractures to the ankle, foot, toe and calcaneus. The longest average hospital stay for males was for fractures of the back and/or spine at 234.7 days (n = 6). Closed fractures of the lower limbs generally resulted in longer average hospital stays than closed fractures of the upper limbs. For instance, fractures to the femur/thigh in males resulted in an average hospital stay of 78 days (n = 569), versus the average hospital stay of 45.9 days for a fractured arm. Fractures resulting in shorter hospital stays were to elements such as the ribs (30.0 days, n = 457) and sternum (17.3 days, n = 4). For females, the longest average hospital stay (83.0 days) was for a single fractured neck. The average hospital stay for fractures to the scapulae/shoulders (74.2 days, n = 6) is much higher than the males due to an outlier. When the outlying individual is removed the new average hospital stay for females is 49.4 days. Similar to the male results, the average hospital stays for fractured femora/thighs (71.3 days, n = 148) and the other lower limb bones are generally longer than fractures to the upper limb (e.g. arm, 49.8 days, n = 280). Table 4 displays the average length of stay for individuals who suffered a compound fracture and sought treatment at the Middlesex or the London Hospital. An outlier in the clavicle (n = 2) category caused the average length of stay for this compound fractured element in males to be relatively high (173.5 days). With the outlier removed the average length is 94.0 days for a compound clavicle fracture. The average length of stay for long bones of the leg (femur/thigh, n = 9; leg, n = 95) in males resulted in a hospital stay of 120.9 and 121.4 days respectively, whereas compound fractures of the arm (n = 17) resulted in an average stay of 90.5 days. The element with the longest average hospital stay was for a female (n = 1) with a compound jaw fracture. As found in the male sample, the average hospital stay for compound fractures of the long bones (108.0 days, femur/thigh, n = 1; 116.9 days, leg, n = 16) was longer than that for a compound fracture of the arm at 44.8 days (n = 4). The data regarding length of stay in the hospitals were also interrogated to study the relative fatality of fracture types. Admissions for the London and the Middlesex Hospitals listed a result for the majority of hospital admissions (i.e. died, cured, made out-patient) and, therefore, it is possible to determine what proportion of compound and closed fracture types were fatal at these institutions. The pooled London and Middlesex data are found in Table 5. Table 5. Proportion of fatal fractures from the London and the Middlesex hospitals Males Females Fracture ocation Fatal fractures Total fractures Fatal fractures Total fractures Compound fractures  Arm — — 1 (20.0%) 5  Thigh 1 (50.0%) 2 — —  Leg 16 (28.6%) 56 6 (35.3%) 17 Closed fractures  Skull/Head 24 (44.4%) 54 8 (44.4%) 18  Spine/Back 5 (100%) 5 — —  Arm 3 (3.5%) 86 2 (3.7%) 54  Rib 9 (10.5%) 86 — —  Thigh 10 (6.2%) 161 4 (8.9%) 45  Leg 10 (2.7%) 370 7 (3.9%) 181  Knee/Patella 2 (6.5%) 31 1 (3.1%) 32  Toe 1 (20.0%) 5 — — Males Females Fracture ocation Fatal fractures Total fractures Fatal fractures Total fractures Compound fractures  Arm — — 1 (20.0%) 5  Thigh 1 (50.0%) 2 — —  Leg 16 (28.6%) 56 6 (35.3%) 17 Closed fractures  Skull/Head 24 (44.4%) 54 8 (44.4%) 18  Spine/Back 5 (100%) 5 — —  Arm 3 (3.5%) 86 2 (3.7%) 54  Rib 9 (10.5%) 86 — —  Thigh 10 (6.2%) 161 4 (8.9%) 45  Leg 10 (2.7%) 370 7 (3.9%) 181  Knee/Patella 2 (6.5%) 31 1 (3.1%) 32  Toe 1 (20.0%) 5 — — Table 5. Proportion of fatal fractures from the London and the Middlesex hospitals Males Females Fracture ocation Fatal fractures Total fractures Fatal fractures Total fractures Compound fractures  Arm — — 1 (20.0%) 5  Thigh 1 (50.0%) 2 — —  Leg 16 (28.6%) 56 6 (35.3%) 17 Closed fractures  Skull/Head 24 (44.4%) 54 8 (44.4%) 18  Spine/Back 5 (100%) 5 — —  Arm 3 (3.5%) 86 2 (3.7%) 54  Rib 9 (10.5%) 86 — —  Thigh 10 (6.2%) 161 4 (8.9%) 45  Leg 10 (2.7%) 370 7 (3.9%) 181  Knee/Patella 2 (6.5%) 31 1 (3.1%) 32  Toe 1 (20.0%) 5 — — Males Females Fracture ocation Fatal fractures Total fractures Fatal fractures Total fractures Compound fractures  Arm — — 1 (20.0%) 5  Thigh 1 (50.0%) 2 — —  Leg 16 (28.6%) 56 6 (35.3%) 17 Closed fractures  Skull/Head 24 (44.4%) 54 8 (44.4%) 18  Spine/Back 5 (100%) 5 — —  Arm 3 (3.5%) 86 2 (3.7%) 54  Rib 9 (10.5%) 86 — —  Thigh 10 (6.2%) 161 4 (8.9%) 45  Leg 10 (2.7%) 370 7 (3.9%) 181  Knee/Patella 2 (6.5%) 31 1 (3.1%) 32  Toe 1 (20.0%) 5 — — Spine, or back, fractures had the highest proportion (100.0 per cent) of fatal cases at the London and Middlesex Hospitals. Interestingly, there were individuals who entered St Thomas’ and Guy’s Hospitals with spinal fractures who were eventually discharged, but the five individuals who were admitted to the Middlesex or the London were all fatalities. There were only two compound femoral fractures in the London and Middlesex admissions, but one was fatal for a proportion of 50.0 per cent fatality. Fractures of the skull were fatal in 44.4 per cent of cases for both males and females. Fracture Experiences The length of stay results reveal that the average patient admitted to a general hospital in London due to fracture spent long enough (i.e. four to six weeks) in hospital for significant healing to take place, based upon modern clinical estimations.63 Individuals sought hospital care for fractures from head to toe. Contemporary surgeons’ and physicians’ notebooks provide ample detail concerning the causes of such fractures and attempted means of treatment. Some, such as fractures to the cranium and spine tended to be dramatic injuries. The skull fractures described in the historical record are most often devastating injuries, resulting in copious bleeding and loss of consciousness. John West, age 78, entered St George’s Hospital on 5 April 1821 under the supervision of Benjamin Brodie after a cranial injury: About an hour before his admission he was thrown from off a stage coach and pitched upon his head—he was picked up immediately but was found quite insensible. As soon as, the pulse had got a surgeon bled him but I do not know to how much—he was brought into St Georges about 9 oClock. Insensible, pupils dilated; but he was very [unmanageable], flinging about his arms & legs in every direction.64 Brodie attempted to trephine the wound, but to no avail; John West died the same day. The records describe individuals entering hospital with cranial fractures due to accidental falls, blunt force trauma due to falling objects, motor vehicle accidents (e.g. falling from a stage coach, having a stage coach roll over an individual’s skull) and assaults. Fractures to the spine or back that appeared in the London and Middlesex admittance records were all fatal, with individuals lingering from between three and 19 days before death. The individuals admitted to St Thomas’ and Guy’s Hospitals with spinal fractures who were eventually discharged had an average convalescence period of 234.7 days (Table 3), demonstrating the severity of the injury and the lengthy periods of convalescence that were sometimes accommodated at the general hospitals. On 23 June 1827, James Barnett fell from a haystack about ten feet high, fracturing his spine and sternum. He spent five restless days in St George’s Hospital before dying of his injuries.65 Brodie noted after autopsy that the ‘spinal cord was seen stretched across an angle formed by the upper portion of bone being thrown forward’.66 Thomas Gardner, age 61, fatally fractured his back by falling onto a curbstone and died at St Bartholomew’s Hospital.67 Henry Fine, a sailor, slipped while descending a staircase, but was ‘unable to recover himself on account of a recent injury to left hand’, the result being that ‘he fell backwards down two steps and hit the upper part of his neck on the edge of the step’.68 Although he remained ‘quite sensible’ and was able ‘to drink and speak plain till a short time previous to his death’, he still passed away.69 An autopsy revealed a fracture to the body and neural arch of the sixth cervical vertebra as well as the articular facets of the fifth cervical vertebra. Other individuals suffered fatal spinal fractures due to being thrown from horses, falling through a trap door onto their backs or being knocked down by a coach.70 In contrast, closed fractures to the limbs apparently did not inspire equal distress and were dealt with through reduction and immobilisation with rollers or arm board/splints.71 James Knowles, age 23, arrived at St Bartholomew’s Hospital, having fractured the same day his right radius and ulna about the middle. The extremities of the upper and lower portions overlapped, the lower portion when the arm was placed prone was down in a direction from the lower extremity of the radius to the coronoid process of the ulna. Attempts at reduction produced extreme pain, the arm was therefore laid on a splint in its unnatural position, and kept covered with a poultice: the slightest degree of extension was made each day and what was thus gained was secured by the application of broad strapping. Under this treatment the arm was brought into its proper position in 14 days and united favorably and without delay.72 Rib fractures are described in surgeons’ notebooks from the long eighteenth century as a common injury. Brodie noted that ‘the yielding motion of the ribs prevents their being fractured so often as they would else be, but from their being so much exposed to injury, the fracture is nevertheless very frequent’.73 Patients admitted to hospital with rib fractures would be treated with ‘a bandage, passed several times round the thorax, so as to compress the ribs, and prevent their motion in respiration’.74 Individuals who died in hospital were often autopsied; surgeons could then identify exactly which ribs were fractured. Patients brought to hospital for rib fractures recounted many different types of accidents that led to their injuries. James Smith fell 24 feet from a platform to the ground onto his left side and was brought to St George’s Hospital unconscious; he was treated and after a month in bed felt weak, but was able to walk around unassisted.75 Another male died in hospital after being ‘squeezed between a wheel and a wall’, an incident which, among other injuries, broke his second through fifth ribs on the right side.76 Two individuals were admitted to St Bartholomew’s Hospital with rib fractures due to accidental falls. Dennis McCarthy, 57 years old, was described as an ‘old asthmatic man’ who ‘slipped in getting out of bed’.77 Margaret Welch, 48 years old, fractured ‘one or two’ ribs on her right side after a fall.78 She was admitted to hospital and spent 11 days resting. Brodie notes that he could hear ‘the cuputation [sic] of the broken rib … as a loud dull creak in each inspiration’.79 Industrial accidents, falls and vehicular accidents appear to be common causes of rib fractures. Rib fractures, despite their common nature, could prove dangerous; serious pulmonary complications such as flail chest, hemothorax and pneumothorax may develop due to rib fractures.80 William Jones, who was admitted to Westminster Hospital on 15 December 1818 for fractured ribs, needed to be bled ‘20 oz the night of admission & 14 oz the next day’ due to fragments of broken rib driving into the lung, causing a collapsed lung and collection of fluid.81 Two anonymous individuals, a male and female, were brought into St Bartholomew’s Hospital due to wagon-related rib injuries. A wagon had driven over the man’s left shoulder and chest, snapping six of his ribs (second–seventh, left side); this injury would prove fatal due to a ruptured lung.82 The anonymous female died two days after her injury, having been knocked down by a cab onto her stomach, breaking four of her ribs (the seventh–tenth on the left side) and rupturing her spleen in the process.83 It is likely that small-scale fractures, such as those of the phalanges, could be treated at home and did not require a hospital stay except in extraordinary circumstances. Of the individuals who did require hospitalisation, extenuating circumstances such as a compound injury might be present. David Murphy, age 33, was admitted to St Bartholomew’s with a compound dislocated thumb, which he had suffered ‘upon his left hand while descending a stair-case … in a state of drunkenness, and thus occasioned a luxation of the second phalanx of the thumb backwards with protrusion of the distal end of the first phalanx through the integuments’.84 Murphy was threatened with amputation and the physicians feared he was suffering from tetanus, but he eventually recovered through treatments of ‘two dozen leeches to the root of the thumb’, laudanum, saline solution, a bread poultice and rest.85 Fractures to the lower leg were commonly described in the surgical casebooks consulted. James Bosankoe, age 35, was brought to St Bartholomew’s Hospital with a fracture of the ‘int’l malleolus’ and lower third of the fibula, due to a wrestling injury.86 Another male, John Wilkins, age 40, entered St Bartholomew’s Hospital on 2 February with fractures of the lower third of the tibia and fibula. His ‘limb was united well and completely’ and he left on 17 March.87 Vehicular accidents often resulted in fracture; William Toller, age 47, on 8 July was ‘running after an omnibus to overtake it and jump on the step, he missed and … on the ground broke both bones to his own immediate knowledge’.88 He was deemed ‘ready to leave’ on 21 August, although the surgeon noted that there was ‘some little irregularity [in shape] from the upper portion overlapping and lying rather to the inner side of the upper portion’.89 The number of admissions due to fractures of the leg increases through time in the male and female groups.90 This is a less dramatic increase than found by Risse in the Royal Infirmary of Edinburgh, where the number of traumatic cases (a category including fractures, bruises and wounds) increased sevenfold from the 1770 s to the 1790 s.91 Risse posits that this dramatic increase may have been associated with ‘new hazards of the early Industrial Revolution’, but does not venture to suggest what these hazards may have been.92 Others have described the ‘volume of death and injury in factories, mines, building sites and shipyards’ as an indication of the ‘astonishingly low status given to the issue of safety within society as a whole’ and the fact that ‘man-made industrial accidents … were increasingly seen as a part of the expected and “normal” flow and structure of everyday social life’.93 Accidents in general were common during the long eighteenth century; Roy Porter outlines ‘tragic falls, fires, drownings, firearms explosions, mishaps with tools and knives, potions and poisons’, many of which could result in fractures or other trauma.94 Traffic accidents were seemingly ubiquitous. Elizabeth Montagu—a preeminent society salon hostess dubbed ‘Queen of the Bluestockings’ by Samuel Johnson—wrote of road hazards: ‘I shall begin to think from my frequent overturns a bone-setter a necessary part of my equipage for country visiting’.95 It is also possible that the rise in admissions due to leg fractures reflects the increasingly common practice of taking urban accident victims to hospital. The London Hospital in particular was known for accident intake due to its location ‘in the centre of one of the densest and poorest districts, and in close proximity to the Docks’.96 The hospital admission sample is directly comparable to Risse’s landmark study of the Royal Infirmary of Edinburgh.97 Risse determined that between 1770 and 1800, 20.2 per cent of all hospital admissions were categorised as surgical.98 These ‘surgical accidents’ included infectious conditions, trauma, tumours, surgical procedures and miscellaneous conditions such as animal bites and burns. Fractures were the most common surgical condition, comprising 23.4 per cent of the sample.99 There was differentiation between bruises, dislocations, fractures, sprains and wounds in the Edinburgh register, similar to the Middlesex and London hospital admission books. Fractures of the leg and arm were most common, followed by the thigh and skull, results that are similar to those observed at the Middlesex and London hospitals.100 As noted above, men comprise almost 80 per cent of cases of fracture at the Royal Infirmary of Edinburgh.101 In the current study, males comprise 77.4 per cent of all cases of fracture (Table 2). The privileging of male labour may play a role in the higher number of males entering the hospital. Part of the voluntary hospitals’ mandate was to ensure individuals could get back to work and this mercantilist focus is clearly evident in the sex-based discrepancies in admittance. Bellers coldly stated in 1714 that ‘every able industrious labourer that is capable to have children, who so untimely dies, may be accounted two hundred pounds loss to the kingdom’.102 The voluntary hospitals routinely admitted a ‘preponderance of young male patients with employment potential’, demonstrating a focus on ensuring that economically productive individuals received medical care.103 Women’s labour was not given the same priority and was in many cases viewed as ‘marginal’ or ancillary.104 Individuals’ occupations likely affect the sex-based differences in frequency of broken bones. The London Hospital admission register includes information on individual’s self-reported occupations. The occupational categories displayed in Tables 6 and 7 are adapted from Risse, who includes all labourers under the term ‘agricultural workers’.105 This is too great a generalisation of what the term ‘labourer’ could mean during the long eighteenth century, particularly in an increasingly industrialised city like London, thus the labourers have been granted their own category. Tables 6 and 7 display the occupation categories of male and female individuals admitted to the London Hospital due to fracture. Legs were the most frequently fractured category for each occupational group in the male sample, but there were no significant differences between the occupations for leg fracture frequency. Leg fractures, including injuries to the femur, tibia, fibula, knee and patella, are clearly the most likely to affect an individual’s ability to walk. Ambulation would have been crucial for an individual to get to their place of work and the majority of the occupations found in the London Hospital admission records (with the exception, perhaps, of the single recorded fiddler) would have required an individual to have freedom of movement. The female results (Table 7) provide less detail than the males because many women are categorised as being the wife of their husband’s occupation. The females working as servants and labourers (e.g. charwomen, street hawkers or dealers) were the most likely to be admitted to hospital due to a leg fracture. Table 6. Occupation categories of male individuals admitted to the London Hospital due to fracture Body area AF Trd Lbr Agr Ind Ser Misc* Cranial 4 (9.1%) 2 (3.6%) 6 (4.7%) 0 0 2 (7.1%) 1 (7.7%) Torso 4 (9.1%) 11 (20.0%) 25 (19.7%) 3 (30.0%) 0 5 (17.9%) 1 (7.7%) Arm 6 (13.6%) 10 (18.2%) 23 (18.1%) 2 (20.0%) 0 1 (3.6%) 2 (15.4%) Hand 0 0 0 0 0 0 0 Leg 29 (65.9%) 32 (58.2%) 72 (56.7%) 5 (50.0%) 1 (100.0%) 20 (71.4%) 9 (69.2%) Foot 1 (2.3%) 0 1 (0.8%) 0 0 0 0 Total 44 55 127 10 1 28 13 Body area AF Trd Lbr Agr Ind Ser Misc* Cranial 4 (9.1%) 2 (3.6%) 6 (4.7%) 0 0 2 (7.1%) 1 (7.7%) Torso 4 (9.1%) 11 (20.0%) 25 (19.7%) 3 (30.0%) 0 5 (17.9%) 1 (7.7%) Arm 6 (13.6%) 10 (18.2%) 23 (18.1%) 2 (20.0%) 0 1 (3.6%) 2 (15.4%) Hand 0 0 0 0 0 0 0 Leg 29 (65.9%) 32 (58.2%) 72 (56.7%) 5 (50.0%) 1 (100.0%) 20 (71.4%) 9 (69.2%) Foot 1 (2.3%) 0 1 (0.8%) 0 0 0 0 Total 44 55 127 10 1 28 13 * Cranial = cranial vault & facial skeleton; Torso = sternum, ribs, vertebrae, sacrum, os coxae; Arm = scapula, clavicle, humerus, radius, ulna; Leg = femur, tibia, fibula, patella; AF = armed forces; Trd = Tradesman; Lbr = Labourer; Agr = Agriculture; Ind = Industrial; Ser = Servant; Misc = Miscellaneous. Values in parentheses are percentages: number of individuals in occupation category with fractured body area / total number of individuals in occupation category. Table 6. Occupation categories of male individuals admitted to the London Hospital due to fracture Body area AF Trd Lbr Agr Ind Ser Misc* Cranial 4 (9.1%) 2 (3.6%) 6 (4.7%) 0 0 2 (7.1%) 1 (7.7%) Torso 4 (9.1%) 11 (20.0%) 25 (19.7%) 3 (30.0%) 0 5 (17.9%) 1 (7.7%) Arm 6 (13.6%) 10 (18.2%) 23 (18.1%) 2 (20.0%) 0 1 (3.6%) 2 (15.4%) Hand 0 0 0 0 0 0 0 Leg 29 (65.9%) 32 (58.2%) 72 (56.7%) 5 (50.0%) 1 (100.0%) 20 (71.4%) 9 (69.2%) Foot 1 (2.3%) 0 1 (0.8%) 0 0 0 0 Total 44 55 127 10 1 28 13 Body area AF Trd Lbr Agr Ind Ser Misc* Cranial 4 (9.1%) 2 (3.6%) 6 (4.7%) 0 0 2 (7.1%) 1 (7.7%) Torso 4 (9.1%) 11 (20.0%) 25 (19.7%) 3 (30.0%) 0 5 (17.9%) 1 (7.7%) Arm 6 (13.6%) 10 (18.2%) 23 (18.1%) 2 (20.0%) 0 1 (3.6%) 2 (15.4%) Hand 0 0 0 0 0 0 0 Leg 29 (65.9%) 32 (58.2%) 72 (56.7%) 5 (50.0%) 1 (100.0%) 20 (71.4%) 9 (69.2%) Foot 1 (2.3%) 0 1 (0.8%) 0 0 0 0 Total 44 55 127 10 1 28 13 * Cranial = cranial vault & facial skeleton; Torso = sternum, ribs, vertebrae, sacrum, os coxae; Arm = scapula, clavicle, humerus, radius, ulna; Leg = femur, tibia, fibula, patella; AF = armed forces; Trd = Tradesman; Lbr = Labourer; Agr = Agriculture; Ind = Industrial; Ser = Servant; Misc = Miscellaneous. Values in parentheses are percentages: number of individuals in occupation category with fractured body area / total number of individuals in occupation category. Table 7. Occupation categories of female individuals admitted to the London Hospital due to fracture Body area AF wife Trd wife Lbr wife Ser wife Ser Lab Trdw Widow Nurse Misc* Cranial 0 0 0 0 0 0 0 1 (6.7%) 0 0 Torso 0 0 0 0 2 (12.5%) 2 (12.5%) 0 3 (20.0%) 0 0 Arm 1 (20.0%) 7 (46.7%) 4 (28.6%) 0 2 (12.5%) 2 (12.5%) 0 2 (13.3%) 1 (20.0%) 0 Hand 0 0 0 0 0 0 0 0 0 0 Leg 4 (80.0%) 8 (53.3%) 10 (71.4%) 4 (100.0%) 12 (75.0%) 12 (75.0%) 4 (100.0%) 9 (60.0%) 4 (80.0%) 3 (100.0%) Foot 0 0 0 0 0 0 0 0 0 0 Total 5 15 14 4 16 16 4 15 5 3 Body area AF wife Trd wife Lbr wife Ser wife Ser Lab Trdw Widow Nurse Misc* Cranial 0 0 0 0 0 0 0 1 (6.7%) 0 0 Torso 0 0 0 0 2 (12.5%) 2 (12.5%) 0 3 (20.0%) 0 0 Arm 1 (20.0%) 7 (46.7%) 4 (28.6%) 0 2 (12.5%) 2 (12.5%) 0 2 (13.3%) 1 (20.0%) 0 Hand 0 0 0 0 0 0 0 0 0 0 Leg 4 (80.0%) 8 (53.3%) 10 (71.4%) 4 (100.0%) 12 (75.0%) 12 (75.0%) 4 (100.0%) 9 (60.0%) 4 (80.0%) 3 (100.0%) Foot 0 0 0 0 0 0 0 0 0 0 Total 5 15 14 4 16 16 4 15 5 3 * Cranial = cranial vault & facial skeleton; Torso = sternum, ribs, vertebrae, sacrum, os coxae; Arm = scapula, clavicle, humerus, radius, ulna; Leg = femur, tibia, fibula, patella; AF wife = Armed Forces wife; Trd wife = Tradesman’s wife; Lbr wife = Labourer’s wife; Ser wife = Servant’s wife; Ser = Servant; Lab = Labourer; Trdw = Tradeswoman; Misc = Miscellaneous + Beggar. Values in parentheses are percentages: number of individuals in occupation category with fractured body area / total number of individuals in occupation category. Table 7. Occupation categories of female individuals admitted to the London Hospital due to fracture Body area AF wife Trd wife Lbr wife Ser wife Ser Lab Trdw Widow Nurse Misc* Cranial 0 0 0 0 0 0 0 1 (6.7%) 0 0 Torso 0 0 0 0 2 (12.5%) 2 (12.5%) 0 3 (20.0%) 0 0 Arm 1 (20.0%) 7 (46.7%) 4 (28.6%) 0 2 (12.5%) 2 (12.5%) 0 2 (13.3%) 1 (20.0%) 0 Hand 0 0 0 0 0 0 0 0 0 0 Leg 4 (80.0%) 8 (53.3%) 10 (71.4%) 4 (100.0%) 12 (75.0%) 12 (75.0%) 4 (100.0%) 9 (60.0%) 4 (80.0%) 3 (100.0%) Foot 0 0 0 0 0 0 0 0 0 0 Total 5 15 14 4 16 16 4 15 5 3 Body area AF wife Trd wife Lbr wife Ser wife Ser Lab Trdw Widow Nurse Misc* Cranial 0 0 0 0 0 0 0 1 (6.7%) 0 0 Torso 0 0 0 0 2 (12.5%) 2 (12.5%) 0 3 (20.0%) 0 0 Arm 1 (20.0%) 7 (46.7%) 4 (28.6%) 0 2 (12.5%) 2 (12.5%) 0 2 (13.3%) 1 (20.0%) 0 Hand 0 0 0 0 0 0 0 0 0 0 Leg 4 (80.0%) 8 (53.3%) 10 (71.4%) 4 (100.0%) 12 (75.0%) 12 (75.0%) 4 (100.0%) 9 (60.0%) 4 (80.0%) 3 (100.0%) Foot 0 0 0 0 0 0 0 0 0 0 Total 5 15 14 4 16 16 4 15 5 3 * Cranial = cranial vault & facial skeleton; Torso = sternum, ribs, vertebrae, sacrum, os coxae; Arm = scapula, clavicle, humerus, radius, ulna; Leg = femur, tibia, fibula, patella; AF wife = Armed Forces wife; Trd wife = Tradesman’s wife; Lbr wife = Labourer’s wife; Ser wife = Servant’s wife; Ser = Servant; Lab = Labourer; Trdw = Tradeswoman; Misc = Miscellaneous + Beggar. Values in parentheses are percentages: number of individuals in occupation category with fractured body area / total number of individuals in occupation category. Robert Campbell’s 1747 treatise on occupations and their associated working conditions in London provides a snapshot of hazards that were commonly encountered by various professions.106 He writes dispassionately about the relative physical strength and mental prowess required to successfully complete various occupations. A needle- or pin-maker apparently ‘does not require to be so acute as the Instruments he makes’, while tailoring specialising in children’s coats is an area ‘chiefly engrossed by Women, who make a good Living of it: It requires a tolerable Genius, but not much Strength’.107 Physically demanding trades such as iron foundry require ‘a strong Constitution and a robust Body, to undergo the Heat of Fire, &c’.108 Specialists and tradesmen are described individually; in contrast, those described as common labourers were clearly non-specialised workers whose skills ranked lower than the tradesmen. Table 6 shows that labourers outnumber tradesman in each fracture category, suggesting that labourers were likely undertaking more hazardous work. Indeed, there is evidence that the labourer group suffered many dramatic occupational accidents, such as James Collins, age 38, who was admitted to St Bartholomew’s with a fractured skull. His accident ‘was occasioned by falling from a height of 20 ft with a heavy piece of Iron which fell across his back when he reached the ground’.109 An occupation-specific bioarchaeological study of fractures was completed on 97 male skeletons belonging to sailors or marines from the British Royal Navy from the Old Burial Ground of the Royal Hospital Greenwich. The majority (84.5 per cent) had evidence of at least one fracture, many had clearly suffered multiple incidents; the authors concluded that occupational hazards to the sailors, such as falls from the rigging, were likely causes of many of these fractures.110 Hazards and Future Research Surgeons’ casebooks and recent scholarship using the London Bills of Mortality paint a picture of long eighteenth-century London as a place fraught with hazards beyond those associated with particular occupations.111 Individuals suffered fractures due to a variety of factors such as: falls (some whilst sober, some whilst inebriated), falling objects, being crushed in crowds, collisions with motor vehicles, encounters with animals, engineering failures, industrial accidents, domestic abuse and interpersonal violence.112 The relationship between long eighteenth-century Londoners and their surroundings was clearly complex and fraught with potential hazards.113 The working poor cannot be divorced from their historical context; as Thompson writes in his meditation on the concept of class, a study of the past ‘must always be embodied in real people and in a real context’.114 Clinically, most fractures are due to accidental traumatic injury. Falls onto an outstretched hand may be the clear mechanism of injury, but the falls themselves may be accidental or intentional.115 Irregular terrain, hours of daylight, and climate have been noted in modern clinical studies as factors that may increase the risk of fracture. In addition to individuals’ age, overall health, footwear, time of day, handedness and the variety of fall, all perennial factors that affected eighteenth-century individuals.116 The wider British experience with fractures is of interest. More comparative work with a broader geographic focus is beyond the scope of this paper, but future work will certainly aid in further contextualising and understanding how typical the fractures in London were. Studies have thus far been primarily limited depending upon what datasets survive; few or no patient casebooks have survived for many provincial hospitals.117 Fractures do, however, appear as a common surgical reason for admittance in the provincial voluntary hospitals.118 Loudon examined the medical ledgers of two provincial surgeons, John Wright (Nottingham General Hospital, 1795–97) and William Pulsford (surgeon of Wells, Somerset, 1757); accidents and injuries (including fractures) were the second most and most populous category for admittance respectively.119 Kicks by horses, falls and fights were listed as causes for the general accidents category, risk factors similar to those found in the present study.120 The urban versus rural street-space is worthy of further focus; Spence notes that the street was not only a place for transportation, but ‘a social space for playing and meeting, buying and selling, begging and stealing or simply standing and staring’; this concentration of people often resulted in fractures due to vehicular collisions’.121 Concentration of individuals in certain occupations is another factor of interest; the Royal Infirmary of Edinburgh admitted many contracted sailors and soldiers, while the Bamburgh Castle Dispensary had 19 in-patient beds mostly employed for shipwrecked sailors.122 The physical as well as social landscape likely affected individuals’ fracture risks, a topic worthy of further exploration. Conclusion This is the first work to explore and quantify the length of stay experienced by individuals with fractures in London’s general hospitals, revealing the range of potential risk factors for fracture affecting the lives of the working poor. This paper demonstrates that despite differing definitions of what constituted a ‘cured’ patient, the voluntary hospitals under investigation generally allowed in-patients sufficient time for substantial fracture healing to take place. These results add credence to the historical literature reconsidering the role of the general hospital in eighteenth-century society. The article examined the prognosis of patients suffering from various fractured body elements, finding that contemporary medical practitioners successfully triaged and treated both closed and compound fractures. This paper provides a foundation for future historical and bioarchaeological comparative studies of hospital in-patients throughout Britain. Skeletal studies of fracture have revealed subtle age- and sex-based patterns, addressing topics such as injury recidivism, fatalities and interpersonal violence in Britain diachronically.123 Recent work has compared skeletal fracture data to the hospital admission records of the London Hospital, illuminating differences in the datasets regarding the frequency and distribution of fractures and how these reveal the complex nexus of human choices concerning health care in the past.124 Occupational data provide some information concerning the connection between occupation and injury; legs are the most frequently fractured element in each occupational category. Contemporary studies of occupational hygiene, such as Bernardino Ramazzini’s De Morbis Artificum Diatriba, do not focus on broken bones. This paper, therefore, makes a meaningful contribution to historical studies of occupational health and hygiene. Previous work has suggested that the general lack of safety considerations within industry during the early part of the Industrial Revolution means that accidents were seen ‘as a part of the expected and “normal” flow and structure of everyday social life’.125 The working poor could, therefore, expect to require medical care for accidents during their lifetime. Fractures are an underrepresented medical condition in previous historical investigations of the long eighteenth century. Hospital admission registers capture a moment in an individual’s life when they were motivated by their fracture to relieve their discomfort. The injuries recorded in the admission registers are acute, recent and affecting an individual’s immediate health and well-being. Studies of fractures, and other acute medical issues, grant a deeper understanding of how the working poor navigated the medical marketplace of London, revealing individual experiences within the larger tapestry of risk. Acknowledgements Thank you to Katie Ormerod (St Bartholomew’s Hospital Archives and Museum), Jonathan Evans and Richard Meunier (Royal London Hospital Museum and Archives), Annie Lindsay (University College London Hospitals NHS Trust), and the staff at the London Metropolitan Archives, Wellcome Library, Southwark Local Studies Library, Royal College of Surgeons of England and the King’s College London Archives. Thank you also to Drs Megan Brickley, Ann Herring and Juanita De Barros at McMaster University for your editorial commentary on an earlier version of this research. I am very grateful to the anonymous reviewers for their constructive and insightful comments on this paper. Madeleine Mant is a Banting SSHRC Postdoctoral Fellow in the Department of Archaeology at Memorial University. Her research involves the integrated study of human skeletal remains and historical documents to investigate how health-related events affected the lifestyles and activities of individuals in the past, particularly the poor. Funding This work was supported by a Vanier Canada Graduate Scholarship [award number 770–2012-0112]. Footnotes 1 King’s College London (hereafter KCL) GB0100 KCLCA K/TH/PP44, ‘Casebook of Charles Oxley, medical student at St. Thomas’ Hospital’, 1725–26, n.p. 2 Ibid., n.p. 3 Ibid., n.p. 4 David Turner, Disability in Eighteenth-Century England: Imagining Physical Impairment (New York: Routledge, 2012); David M. Turner, ‘Disability and Prosthetics in Eighteenth- and Early Nineteenth-Century England’, in M. Jackson, ed., The Routledge History of Disease (London and New York: Routledge, 2017), 301–19. 5 Guenter Risse, Hospital Life in Enlightenment Scotland: Care and Teaching at the Royal Infirmary of Edinburgh (Cambridge: Cambridge University Press 1986), 157; Irvine Loudon, Medical Care and the General Practitioner 1750–1850 (Oxford: Clarendon Press, 1986), 78–9. 6 Karl F. Helleiner, ‘The Vital Revolution Reconsidered’, The Canadian Journal of Economics and Political Science, 1957, 23, 1–9, at 6; Thomas McKeown and R. G. Brown, ‘Medical Evidence Related to English Population Change in the Eighteenth Century’, Population Studies, 1955, 9, 119–41, at 125. 7 See for example: John Henderson, Peregrine Horden and A. Pastore, eds, The Impact of Hospitals, 300–2000 (Frankfurt: Peter Lang, 2007); Anne Borsay and Peter Shapely, eds, Medicine, Charity and Mutual Aid: The Consumption of Health and Welfare in Britain, c. 1550–1950 (Aldershot: Ashgate, 2007); Alun Withey, ‘Medicine and Charity in Eighteenth-century Northumberland: The Early Years of the Bamburgh Castle Dispensary and Sugery, c. 1772–1802’, Social History of Medicine, 2016, 29, 467–89. 8 KCL GB0100 KCLCA K/TH/PP44. 9 Piers D. Mitchell and Vin Chauhan, ‘Understanding the Contents of the Westminster Hospital Pathology Museum in the 1800s’, in P. Mitchell, ed., Anatomical Dissection in Enlightenment England and Beyond: Autopsy, Pathology and Display (Farnham: Ashgate, 2012), 139–54, 143. 10 Ibid., 143. 11 Ibid., 143. 12 Ibid., 150. 13 St Bartholomew’s Hospital, A Descriptive Catalogue of the Anatomical Museum of St. Bartholomew’s Hospital. Volume 1. Containing the Descriptions of the Specimens Illustrative of Pathological Anatomy (London: John Churchill, 1846). 14 Ibid., 116. 15 See discussions in: Charles E. Rosenberg and Janet L. Golden, eds, Framing Disease: Studies in Cultural History (New Brunswick: Rutgers University Press, 1992); Andrew Cunningham, ‘Identifying Disease in the Past: Cutting the Gordian Knot’, Asclepio, 2002, 54, 13–34; Jon Arrizabalaga, ‘Problematizing Retrospective Diagnosis in the History of Disease’, Asclepio, 2002, 54, 51–70; Jo N. Hays, ‘Historians and Epidemics: Simple Questions, Complex Answers’, in L. K. Little, ed., Plague and the End of Antiquity: The Pandemic of 541–750 (Cambridge: Cambridge University Press, 2007), 33–56; Neil H. Metcalfe, ‘A Description of the Methods used to Obtain Information on Ancient Disease and Medicine and of How the Evidence has Survived’, Postgraduate Medical Journal, 2007, 83, 655–8; Piers D. Mitchell, ‘Retrospective Diagnosis and the Use of Historical Texts for Investigating Disease in the Past’, International Journal of Paleopathology, 2011, 1, 81–8. 16 Leonard F. Peltier, Fractures: A History and Iconography of their Treatment (San Francisco: Norman Publishing, 1990), 6. 17 Ibid., 6. 18 Joan Lane, A Social History of Medicine: Health, Healing and Disease in England, 1750–1950 (London and New York: Routledge, 2001), 82. 19 Steven Cherry, ‘Hospitals and Population Growth: Part 1 The Voluntary General Hospitals, Mortality and Local Populations in the English Provinces in the Eighteenth and Nineteenth Centuries’, Population Studies, 1980, 34, 59–75, 60. 20 Susan C. Lawrence, Charitable Knowledge: Hospital Pupils and Practitioners in Eighteenth-Century London (Cambridge: Cambridge University Press, 1996), 42. 21 Geoffrey Rivett, The Development of the London Hospital System, 1823–1982 (London: King Edward’s Hospital Fund for London, 1986), 25. 22 Quoted in Harold Hart, ‘Some Notes on the Sponsoring of Patients for Hospital Treatment under the Voluntary System’, Medical History, 1980, 24, 447–60, at 448. 23 John Aikin, Thoughts on Hospitals (London: J. Johnson, 1771), 52. 24 Bronwyn Croxson, ‘The Public and Private Faces of Eighteenth-Century London Dispensary Charity’, Medical History, 1997, 41, 127–49, at 128; Irvine Loudon, ‘The Origins and Growth of the Dispensary Movement in England’, Bulletin of the History of Medicine, 1981, 55, 322–42, at 336. 25 Loudon, ‘Origins and Growth’, 336. 26 Ibid., 338; Withey, ‘Medicine and Charity’, 485; Croxson, ‘Public and Private’, 140. 27 Withey, ‘Medicine and Charity’, 486. 28 John Woodward, To Do the Sick No Harm: A Study of the British Voluntary Hospital System to 1875 (London: Routledge and Kegan Paul, 1974), 40; Lawrence, Charitable Knowledge, 45. 29 John Bellers, Essay Towards the Improvement of Physic (London: Sowle, 1714), 6. 30 See general discussions in Lynn H. Lees, The Solidarities of Strangers: The English Poor Laws and the People (Cambridge: Cambridge University Press, 1998); Roxanne Rimstead, Remnants of Nation: On Poverty Narratives by Women (Toronto: University of Toronto Press, 2001). 31 Alysa Levene, ‘General Introduction’, in S. King, T. Nutt and A. Tomkins, eds, Narratives of the Poor in Eighteenth-Century Britain (Vol. 1) (London: Pickering & Chatto, 2006), vii–xix, ix. 32 Richard Dyson, ‘How Did the Poor Cope with Illness: Perspectives from Early Nineteenth-century Oxford’, Family & Community History, 2014, 17, 86–100, 87. 33 Alannah Tomkins and Steven King, ‘Introduction’, in S. King and A. Tomkins, eds, The Poor in England 1700–1850: An Economy of Makeshifts (Manchester: Manchester University Press, 2003), 1–38, 1; see also discussion in: Olwen H. Hufton, The Poor of Eighteenth-century France 1750–1789 (Oxford: Clarendon, 1974), Joanna Innes, ‘The “Mixed Economy of Welfare” in Early Modern England: Assessments of the Options from Hale to Malthus (c. 1683–1803)’, in M. Daunton, ed., Charity, Self-Interest and Welfare in the English Past (London: University College London Press, 1996), 139–180. 34 Carl von Linné, Genera Morborum, in Auditorium Usum (Uppsala, 1763); François Boissier de Sauvages, Nouvelles Classes de Maladies, Qui dans un Ordre Semblable à celui des Botanistes, comprennent les Genres et les Especes de Toutes les Maladies, avec Leurs Signes et Leurs Indications (Avignon, 1731); François Boissier de Sauvages, Nosologia Methodica Sistens Morborum Classes Juxta Sydenhami Mentem & Botanicorum Ordinem (Amsterdam, 1768); William Cullen, Synopsis and Nosology, Being an Arrangement of Diseases (Hartford: Nathaniel Patten, 1792). 35 Sauvages, Nosologia, 239. 36 Cullen, Synopsis, 80. 37 Clopton Havers, Osteologia Nova; or, Some New Observations of the Bones and Parts Belonging to Them (London: S. Smith, 1691); John Belchier, ‘An Account of the Bones of Animals Being Changed to a Red Colour by Aliment Only’, Philosophical Transactions of the Royal Society of London, 1735, 30, 287–300. 38 Stephen Hales, Vegetable Statistics (London: Innys & Woodward, 1717); John Hunter, The Works of John Hunter, F.R.S., with Notes, ed. J. F. Palmer (London: Longman, Rees, Orme, Brown, Green and Longman, 1835). 39 Antonii Scarpa, De Penitiori Ossium Structura Commentaries (Leipzig: J. F. Hartnoch, 1799). 40 Clinical studies: T. Einhorn and C. Lee, ‘Bone Regeneration: New Findings and Potential Clinical Applications’, Journal of the American Academy of Orthopaedic Surgeons, 2001, 9, 157–65; M. Yuasa et al., ‘Fibrinolysis is Essential for Fracture Repair and Prevention of Heterotopic Ossification’, Journal of Clinical Investigation, 2015, 125, 3117–31. Historical medical literature: John Goodsir and Harry D. S. Goodsir, Anatomical and Pathological Observations (Edinburgh: Black, 1845); R. A. Kolliker, Die Normale Resorption des Knochengewebes (Leipzig: Vogel, 1873); R. Virchow, ‘Das Normale Knochenwachsthum und die Rachitische Storung Desselben’, Virchows Archiv fur pathologische Anatomie und Physiologie und fur klinische Medizin, 1853, 5, 409–505. 41 Royal College of Surgeons (hereafter RCS) MS0470/3/1/10, ‘Surgical Cases and Commentaries Vol. 1’, 1805–07, n.p. 42 Quoted in: Joan Lane, ‘“The Doctor Scolds Me”: The Diaries and Correspondence of Patients in Eighteenth Century England’, in R. Porter, ed., Patients and Practitioners: Lay Perceptions of Medicine in Pre-Industrial Society (Cambridge: Cambridge University Press, 1985), 205–48, at 208–9. 43 Anne L. Grauer and Charlotte A. Roberts, ‘Paleoepidemiology, Healing, and Possible Treatment of Trauma in the Medieval Cemetery Population of St. Helen-on-the-Walls, York, England’, American Journal of Physical Anthropology, 1996, 100, 531–544. 44 Pervicall Pott, Some Few General Remarks on Fractures and Dislocations (London: L. Hawes, W. Clarke, and R. Collins, 1769), 19–21. 45 RCS MS0162, ‘Westminster Hospital Cases and Events’, 1802–1818, n.p. 46 Ibid., n.p. 47 Loudon, Medical Care, 84. 48 Peltier, Fractures, 98. 49 Hunter, Works of John Hunter, 441. 50 Roy Porter, ‘Laymen, Doctors and Medical Knowledge in the Eighteenth Century: The Evidence of Gentleman’s Magazine’, in R. Porter, ed., Patients and Practitioners: Lay Perceptions of Medicine in Pre-Industrial Society (Cambridge: Cambridge University Press, 1985), 283–314, 305. 51 H. Y. Carter, ‘Case of a Compound Fracture of the Leg’, Gentleman’s Magazine, 1794, 69, 448. 52 Quoted in: Anne Digby, Making a Medical Living: Doctors and Patients in the English Market for Medicine (Cambridge: Cambridge University Press, 1994), 89. 53 Francis Clifton, Tabular Observations, Recommended as the Plainest and Surest Way of Practicing and Improving Physick (London: J. Brindley, 1731), n.p. 54 Ibid., 21. 55 Risse, Hospital Life, 44. 56 Ibid., 230. 57 Ibid., 228–9. 58 Hannah Newton, ‘“Nature Concocts & Expels”: The Agents and Processes of Recovery from Disease in Early Modern England’, Social History of Medicine, 2015, 28, 465–86; Misery to Mirth: Recovery from Illness in Early Modern England, 1580–1720 (Oxford: Oxford University Press, forthcoming). 59 See discussions in: Philippe Ariès, Centuries of Childhood: A Social History of Family Life (New York: Vintage Books, 1962); Shulamith Shahar, ‘Who were Old in the Middle Ages?’, Social History of Medicine, 1993, 6, 313–41. 60 University College London Archives (hereafter UCL) Middlesex Hospital Apothecary Report, Vol. 1 (1760–64), n.p. 61 An analysis of the juvenile individuals admitted to the London Hospital can be found in Madeleine Mant, ‘Children in the London: Inpatient Care in a Voluntary General Hospital’, Medical History, in press. 62 Risse, Hospital Life, 158. 63 M. Patrice Eiff and Robert L. Hatch, ‘General Principles of Fractures Care’, in M. Patrice Eiff, ed., Fracture Management for Primary Care, 3rd edn (Philadelphia: W.B. Saunders, 2011), 5–35, 5–6. 64 RCS MS0470/3/1 62, ‘Surgical Cases and Commentaries’, 1820–60, 31. 65 RCS MS0470/3/1 51, ‘Cases and Commentaries’, 1827–49, 92. 66 Ibid., 92. 67 St Bartholomew’s Hospital Archives (hereafter St B) MR 14/14, ‘Medical Case Notes’, no date listed for volume, contents from 1831, n.p. 68 St B MR 16/1 ‘Notes on Orthopaedic Surgery’, 1835–44, 157. 69 Ibid., 157. 70 Ibid., 166, 154, 168. 71 Ibid., 49. 72 Ibid., 51. 73 RCS MS0470/3/1 38, n.p. 74 Ibid., n.p. 75 Ibid., 49, 1824–27, 248. 76 St B MR 16/1, 23. 77 Ibid., 57. 78 Ibid., 29. 79 Ibid., 29. 80 Megan Brickley, ‘Rib Fractures in the Archaeological Record: A Useful Source of Sociocultural Information?’, International Journal of Osteoarchaeology, 2006, 16, 61–75; M. Sirmali et al., ‘A Comprehensive Analysis of Traumatic Rib Fractures: Morbidity, Mortality and Management’, European Journal of Cardio-Thoracic Surgery, 2003, 24, 133–8. 81 RCS MS0162, n.p. 82 St B MR 16/1, 19. 83 Ibid., 21. 84 St. B MR 8, ‘Medical case notes of William Lawrence’, 1827–28, n.p. 85 Ibid., n.p. 86 St. B MR 16/1, 93. 87 Ibid., 94. 88 Ibid., 95. 89 Ibid., 95. 90 Madeleine Mant, ‘Slips, Trips, Falls, and Brawls: Fractures of the Working Poor in London During the Long Eighteenth Century’ (unpublished PhD thesis, McMaster University, 2016), 129. 91 Risse, Hospital Life, 158. 92 Ibid., 158. 93 Roger Cooter and Bill Luckin, ‘Accidents in History: An Introduction’, in R. Cooter and B. Luckin, eds, Accidents in History: Injuries, Fatalities and Social Relations (Amsterdam: Rodopi, 1997), 1–16, 5, 3. 94 Roy Porter, ‘Accidents in the Eighteenth Century’, in R. Cooter and B. Luckin, eds, Accidents in History: Injuries, Fatalities and Social Relations (Amsterdam: Rodopi, 1997), 90–106, 91. 95 Quoted in: Emily J. Climenson, ed., Elizabeth Montagu, the Queen of the Blue Stockings: Her Correspondence from 1720–1761 (London: John Murray, 1906), 33. 96 John S. Bristowe and Timothy Holmes, On The Hospitals of the United Kingdom (London: Privy Council Medical Officer’s Report, Appendix 15, 1863), quoted in: Woodward, To Do The Sick No Harm, 130. 97 Risse, Hospital Life. 98 Ibid., 123. 99 Ibid., 157. 100 Ibid., 158. 101 Ibid., 158. 102 Bellers, Essay, 3. 103 Anne Borsay, Medicine and Charity in Georgian Bath, A Social History of the General Infirmary, c. 1739–1830 (Aldershot: Ashgate Publishing Limited, 1999), 382–3; Mary Fissell, ‘The Physic of Charity: Health and Welfare in the West country, 1690–1834’ (unpublished PhD thesis, Pennsylvania, 1988); Risse, Hospital Life; Amanda Berry, ‘Patronage, Funding and the Hospital Patient, c. 1750–1815’ (unpublished PhD thesis, University of Oxford, 1995). 104 Merry Wiesner, Women and Gender in Early Modern Europe (Cambridge: Cambridge University Press, 1993), 86. 105 Risse, Hospital Life, 88. 106 Robert Campbell, The London Tradesman: Being a Compendious View of all the Trades, Professions, Arts, both Liberal and Mechanic, now Practised in the Cities of London and Westminster (London: T. Gardner, 1747). 107 Ibid., 256, 226. 108 Ibid., 179. 109 RCS, MS0470 49, 221. 110 Ceridwen Boston, Annsofie Witkin, Angela Boyle and David R. P. Wilkinson, ‘Safe moor’d in Greenwich tier’. A Study of the Skeletons of Royal Navy Sailors and Marines Excavated from the Royal Hospital Greenwich (Oxford: Oxford Archaeology Monograph, 2008). 111 Craig Spence, Accidents and Violence Death in Early Modern London 1650–1750 (Woodbridge: The Boydell Press, 2016). 112 RCS MS0470/3/1/10, 7; RCS MS0470/3/1 51, 70; RCS MS0470 49, 1824–27, 189; St B MR16/4 Vol. 1, ‘Notes on Medical and Surgical Subjects’, 1836–46, 13, 33, 36, 55, 94, 111; KCL GB0100 KCLCA K/TH/PP44, n.p.; Wellcome Library MS4337, 1781, 21. 113 Spence, Accidents. 114 Edward P. Thompson, The Making of the English Working Class (London: Victor Gollancz Ltd, 1963), 9. 115 Osarumwense D. Osifo, P. Iribhogbe and H. Idiodi-Thomas, ‘Falls from Heights: Epidemiology and Pattern of Injury at the Accident and Emergency Centre of the University of Benin Teaching Hospital’, Injury, 2010, 41, 544–7, 544. 116 Annalisa Alvrus, ‘Fracture Patterns among the Nubians of Semna South, Sudanese Nubia, International Journal of Osteoarchaeology, 1999, 9, 417–29; S. A. Jiménez-Brobeil, I. Al Oumaoui and P. H. du Souich, ‘Childhood Trauma in Several Populations from the Iberian Peninsula’, International Journal of Osteoarchaeology, 2007, 17, 189–98; Margaret A. Judd, ‘Continuity of Interpersonal Violence Between Nubian Communities’, American Journal of Physical Anthropology, 2006, 131, 324–33; Lynn Kilgore, Robert Jurmain and Dennis van Gerven, ‘Palaeoepidemiological Patterns of Trauma in a Medieval Nubian Population’, International Journal of Osteoarchaeology, 1997, 7, 103–14; S. D. Berry and R. R. Miller, ‘Falls: Epidemiology, Pathophysiology, and Relationship to Fracture’, Current Osteoporosis Reports, 2008, 6, 149–54; Cyrus Cooper et al., ‘Incidence of Vertebral Fractures: A Population-Based Study in Rochester, Minnesota, 1985–1989’, Journal of Bone and Mineral Research, 1992, 7, 221–7; Francesc Formiga et al., ‘Characteristics of Falls Producing Hip Fractures in Nonagenarians’, Journal of Nutrition, Health & Aging, 2008, 12, 664–7; Theresa H. M. Keegan et al., ‘Characteristics of Fallers who Fracture at the Foot, Distal Forearm, Proximal Humerus, Pelvis, and Shaft of the Tibia/Fibula Compared with Fallers who do not Fracture’, American Journal of Epidemiology, 2004, 159, 192–203; N. Niino, R. Kozakai and M. Eto, ‘Epidemiology of Falls among Community-Dwelling Elderly People’, Nippon Ronen Igakkai Zasshi/Japanese Journal of Geriatrics, 2003, 40, 484–6; C. M. Luetters et al., ‘Left-Handedness as a Risk Factor for Fractures’, Osteoporosis International, 2003, 14, 918–22; Wenjun Li et al., ‘Outdoor Falls among Middle-Aged and Older Adults: A Neglected Public Health Problem’, American Journal of Public Health, 2006, 96, 1192–8; M. Palvanen et al., ‘The Injury Mechanisms of Osteoporotic Upper Extremity Fractures among Older Adults: A Controlled Study of 287 Consecutive Patients and their 108 Controls’, Osteoporosis International, 2000, 11, 822–31. 117 Steven Cherry, ‘The Hospitals and Population Growth: The Voluntary General Hospitals, Mortality and Local Populations in the English Provinces in the Eighteenth and Nineteenth Centuries Part 2’, Population Studies, 1980, 34, 251–65, at 258. 118 Ibid., 258–9. 119 Loudon, Medical Care, 75, 78–9. 120 Ibid., 76. 121 Spence, Accidents, 113. 122 Mary Fissell, ‘The ‘Sick and Drooping Poor’ in Eighteenth-Century Bristol and its Region’, Social History of Medicine, 1989, 2, 35–58, at 49–50; Withey, ‘Medicine and Charity’, 483–4. 123 Examples include: Margaret Judd and Charlotte Roberts, ‘Fracture Trauma in a Medieval British Farming Village’, American Journal of Physical Anthropology, 1999, 109, 229–43; Rebecca Redfern, Margaret Judd and Sharon DeWitte, ‘Multiple Injury and Health in Past Societies: An Analysis of Concepts and Approaches, and Insights from a Multi-Period Study’, International Journal of Osteoarchaeology, 2016, 27, 418–29; Boston et al., Safe moor’d. 124 Madeleine Mant, ‘“Readmitted under urgent circumstance”: Uniting Archives and Bioarchaeology at the Royal London Hospital’, in Madeleine Mant and Alyson Holland, eds, Beyond the Bones: Engaging with Disparate Datasets (San Diego: Elsevier Academic Press, 2016), 37–59. 125 Cooter and Luckin, Accidents in History, 3. © The Author(s) 2018. Published by Oxford University Press on behalf of the Society for the Social History of Medicine. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

Journal

Social History of MedicineOxford University Press

Published: Apr 30, 2018

There are no references for this article.

You’re reading a free preview. Subscribe to read the entire article.


DeepDyve is your
personal research library

It’s your single place to instantly
discover and read the research
that matters to you.

Enjoy affordable access to
over 18 million articles from more than
15,000 peer-reviewed journals.

All for just $49/month

Explore the DeepDyve Library

Search

Query the DeepDyve database, plus search all of PubMed and Google Scholar seamlessly

Organize

Save any article or search result from DeepDyve, PubMed, and Google Scholar... all in one place.

Access

Get unlimited, online access to over 18 million full-text articles from more than 15,000 scientific journals.

Your journals are on DeepDyve

Read from thousands of the leading scholarly journals from SpringerNature, Elsevier, Wiley-Blackwell, Oxford University Press and more.

All the latest content is available, no embargo periods.

See the journals in your area

DeepDyve

Freelancer

DeepDyve

Pro

Price

FREE

$49/month
$360/year

Save searches from
Google Scholar,
PubMed

Create lists to
organize your research

Export lists, citations

Read DeepDyve articles

Abstract access only

Unlimited access to over
18 million full-text articles

Print

20 pages / month

PDF Discount

20% off