On the Power of Cauls, Dickens’s Doctors, and Placebos

In the first chapter (I AM BORN) of Charles Dickens’s David Copperfield, the protagonist notes that “I was born with a caul, which was advertised for sale, in the newspaper, at the low price of fifteen guineas.”

When I read this sentence a few years ago I had no idea what a caul was or why it was valuable.

A case report of a baby born “en caul” appears in the American Journal of Obstetrics and Gynecology. The accompanying photo shows a fetus completely enclosed by its amniotic sac

But David Copperfield was born with a caul which generally means there was a piece of remnant amniotic tissue around his head.

In England and Scotland during the time of Dickens, there was a strong belief among sailors that a caul was a lucky talisman that would prevent drowning.

Later in the book, David reveals his caul was purchased for five shillings by a woman who throughout her life “expressed her indignity at the impiety of mariners and others who had the presumption to go “meandering” about the world.” 

This woman was, in fact, never drowned and died in her bed at age 92 never having been found meandering on the water.

Dickensian Doctors

I have a fascination with the characters in Dickens’s novels, most particularly with the doctors he portrays.

Mr. Chillip, the doctor who attends to Mrs. Copperfield during her delivery is described brilliantly as follows:

“He was the meekest of his sex, the mildest of little men. He sidled in and out of a room, to take up the less space. He walked as softly as the Ghost in Hamlet, and more slowly. He carried his head on one side, partly in modest depreciation of himself, partly in modest propitiation of everybody else”

Dr. Chillip, like the majority of the doctors appearing in novels and movies set in the Victorian era, does not offer any of the evidence-based medicine that we take for granted. For the most part, Dickens’s doctors come into a scene, do a cursory examination and then make a vague diagnosis which is more a description of symptoms than a specific disease.

Their treatment modalities: bloodletting, purging, and potions were more likely to harm the patient than help them.

Dickens died in 1866, 8 years before Pasteur’s germ theory of disease became accepted widely and thus, did not benefit from all the improvements in health and health care that followed.

Doctors Wielding the Power of Placebo

Adam Cifu, writing for Sensible Medicine, presents the work of our physician forebears in a different light which I hadn’t previously considered.

He writes:

For thousands of years, pretty much the only treatments a doctor had to offer were placebos.

This is not to say that my predecessors were useless. They were often excellent diagnosticians. They excelled at providing prognoses, having spent years observing the natural history of diseases. The best physicians were exceptional at comforting the sick. However, they did not have much in the way of effective treatments. Focusing just on medications, there are probably fewer than a dozen therapeutics I use today that were part the arsenal of the pre-20th century doctor: aspirin, digoxin, quinine, a few vitamins…

We generally define a placebo as a harmless pill or procedure prescribed more for psychological benefit than for any physiological effect. We should be a bit more expansive with this definition. The procedure might be invasive but it might also be a particularly therapeutic interaction. Good doctoring is, to a great extent, a placebo, with no negative connotations about that word. I place enormous value on good doctoring.

Indeed, Mr. Chillip was aiding his patients by being present and concerned about their welfare:

What doctors of old used for therapy was the skillful application of placebos: exquisite bedside manner; a root or herb; bloodletting. These treatments were effective. In the last 50 years we have learned that a doctor wielding a placebo can do a pretty job at making people feel better. In general, a well-employed placebo can be expected to have a modest, short-lived effect on subjective symptoms.

An article on Dickens’s Doctors printed in the Boston Medical and Surgical Journal, Vol. clxvi, No. 25, pp. 926-928, June 20, of 1912 on the 100th anniversary of Dickens’s birth notes:

In “David Copperfield” and “Dombey and Son” we are made acquainted with types of the familyphysician. Little Mr.Chillip not only received David on his advent into this world but attends him through the measles, consoles him after his mother’s death, befriends him under the tyranny of the Murdstones, soothes the dying days of his faithful friend Barkis, and delights him on his return to London with intelligence of pastevents. Mr.Chillip was “the meekest of his sex, the mildest of little men,” but he was a good doctor, we feel sure,and as such deserves respectful memory. There has been no better statement than his of the axiom of a physician’s conduct, that “a medical man, being so much in families, ought to have neither eyes nor ears for anything but his profession.” 

Cardiologists practicing in 2023 have a remarkable number of proven or evidence-based approaches to treatment ranging from stents for acute MI to beta-blockers for heart failure. Taking time to listen to, console, and empathize with our patients further strengthens our treatment plans with the mysterious power of placebo.

Amniotically Yours,

-ACP

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2 thoughts on “On the Power of Cauls, Dickens’s Doctors, and Placebos”

  1. Dear Skeptical Cardiologist,
    Wonderful post.
    Doctors do figure widely in both British and American novels of the 19th-century. You might enjoy George Eliot’s MIDDLEMARCH which has a secondary plot about a young doctor. It’s set in England of the 1830s just as your profession is, well, professionalizing — fighting it out with apothecaries, barbers, hedge-doctors, barber-surgeons, dentists and mid-wives. It features the idealistic Dr Lydgate, who has been educated in the most modern way and is as smart as he is handsome. If he weren’t a fictional character, he would be about 10 – 20 years older than Joseph Lister. Representing the new, professional “medical man,” he won’t sell or prepare medicines but leaves this to the apothecaries whom he expects, in return, not to treat patients. The other doctors ostracize him because he makes them look greedy AND he doesn’t make as much money as he could because he refuses to directly profit from his prescriptions. He dreams of finding an evidence based treatment for “recurrent fevers” by establishing a “hospital” to investigate treatments in a controlled environment. But, when he marries for love and before his practice is well established, we see him struggle with competing demands.

    Reply
    • Mary Lou,
      Upon your suggestion I downloaded Middlemarch to my Mac. It had come across my radar previously. I found these sentences ““For the heroic times of copious bleeding and blistering had not yet departed, still less the times of thoroughgoing theory, when disease in general was called by some bad name, and treated accordingly without shilly-shally—as if, for example, it were to be called insurrection, which must not be fired on with blank-cartridge, but have its blood drawn at once. The strengtheners and the lowerers were all “clever” men in somebody’s opinion, which is really as much as can be said for any living talents. Nobody’s imagination had gone so far as to conjecture that Mr. Lydgate could know as much as Dr. Sprague and Dr. Minchin, the two physicians, who alone could offer any hope when danger was extreme, and when the smallest hope was worth a guinea. Still, I repeat, there was a general impression that Lydgate was something rather more uncommon than any general practitioner in Middlemarch. And this was true. He was but seven-and-twenty, an age at which many men are not quite common—at which they are hopeful of achievement, resolute in avoidance, thinking that Mammon shall never put a bit in their mouths and get astride their backs, but[…]”

      which your summary suggests is foreshadowing the good doctor selling out.
      This is reminiscent of the fate of Dr. Bovary who was convinced to operate on a stable boy with clubfoot with disasterous results.
      Dr. P

      Reply

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