A Social History of Medicine

Health, Healing and Disease in England, 1750-1950

Joan Lane

• Publisher: Routledge
• Year: 2012
• ISBN:
  9781135119270
• Edition: 1
• Topic: History
• Subtopic: World History
• Index: History

A Social History of Medicine traces the development of medical practice from the Industrial Revolution right through to the twentieth century.

Drawing on a wide range of source material, it charts the changing relationship between patients and practitioners over this period, exploring the impact made by institutional care, government intervention and scientific discovery.

The study illuminates the extent to which medical assistance really was available to patients over the period, by focusing on provincial areas and using local sources. It introduces a variety of contemporary medical practitioners, some of them hitherto unknown and with fascinating intricate details of their work. The text offers an extensive thematic survey, including coverage of:

* institutions such as hospitals, dispensaries, asylums and prisons
* midwifery and nursing
* infections and how changes in science have affected disease control
* contraception, war, and the NHS.

1 MEDICAL PRACTITIONERS IN EIGHTEENTH-AND NINETEENTH-CENTURY ENGLAND

DOI: 10.4324/9780203601556-2

I studied hard; learned the Linnean names and doses of drugs; attended seven surgical operations; worked from nine to nine daily, Sundays included; made mercury ointment in the old style by turning a pestle in a mortar for three days in succession, to amalgamate the quicksilver with the pig's grease; made up what the doctor called his ‘Cathartic acid bitter mixture’, as a sort of fill-up for every purgative bottle, and almost every disease that ‘flesh is heir to’; made up boluses ... drew a tooth for sixpence ... did many things during that six months which gave me a distaste for the practice of medicine ...

J. Clegg (ed.), Autobiography of a Lancashire Lawyer [John Taylor], 1883

The provision of medical attention since the early modern period in England had always been a business, with fees paid for services rendered. However, in the consumerist eighteenth century, medicine expanded fastest of all the superior occupations to become, by the Victorian period, a recognised and respected profession, with registration, professional journals and a career structure in both private practice and institutional appointments. In the early years of the eighteenth century all medical practitioners, physicians, surgeons and apothecaries, were few in proportion to the population as a whole, their unscientific treatments were invariably unsuccessful and, significantly, patients were not disposed to seek and pay for advice except in desperate circumstances. By the 1750s, however, patients increasingly came to spend money on more scientific successful medical attention as part of a higher standard of living, greater disposable income and increased life expectancy. Medicine became, with larger apprenticeship premiums, better incomes and higher social status for practitioners, an occupation which gentry or ambitious parents could choose as a career for their sons. It was an exclusively male occupation until the present century. A number of physicians had fathers who were clergy (William Small, Clifton Wintringham) and landowners (Richard Wilkes, John Johnstone). The profession's status was undeniably improved when the surgeons separated from the more menial barbers in 1745. The period produced some very grand, wealthy and famous practitioners to inspire the young apprentice or pupil as role models.

There was a significant dividing-line in Georgian England between physicians, as university-trained men, and those who had been apprenticed, the surgeons and the apothecaries. The physicians attended the universities of Oxford, Cambridge, Glasgow, Edinburgh, St Andrews or Aberdeen to gain the qualification of MD and the privileged title of ‘Doctor’; Edinburgh was particularly popular in the eighteenth century, especially when continental travel became more difficult. All non-Anglicans, whose religious beliefs barred them from British universities, might train on the continent, chiefly at Leiden, Rheims or Padua, and then practise as physicians at home, although a foreign training was clearly less favoured by the 1760s. Physicians remained at the apex of the medical pyramid, few in number, practising only in the largest towns and cities, charging high fees and accepted as gentlemen. They saw patients, gave advice and recommended treatments, but generally never performed manual tasks or dispensed medications. Surgeons and apothecaries, although originally separate occupations, increasingly joined their skills into the title of surgeon-apothecary, the equivalent of the modern general practitioner. However, specialists in these distinct branches of medicine continued to practise, especially in hospitals, while apothecaries also ran retail businesses. Apprenticeship was the means by which both became qualified through a system that had existed in England since the Norman Conquest; it was illegal to practise most occupations if unapprenticed. As an apprentice, a youth was bound for a term, usually for seven years at the age of fourteen, by his parents or guardians to a qualified master, to whom they paid a lump sum, the premium, to cover the boy's tuition, board and lodging while he was indentured. The medical apprentice clearly had to be literate and numerate, with a basic grasp of Latin. Although many apprenticeships were arranged through personal connections and by word of mouth, by the 1750s, as medicine expanded and attracted new recruits, advertising for apprentices in the local press was common, the master's name not usually disclosed. The youth lived in the master's house as part of the family and was not paid; the indenture demanded certain standards of behaviour from the apprentice and placed strict limits on his personal behaviour while he was indentured. Residence with the master was an important part of medical training, especially for hospital pupils, so that John Keats lodged with Astley Cooper, who had earlier boarded with Henry Cline.

The premium was the critical factor in deciding what career a boy might pursue, essentially what his parents could afford. Premiums were always higher in London, provincial cities and fashionable watering places, where masters could charge patients larger fees. Also, eminent men could command far bigger premiums, so that, for example, Caesar Hawkins, surgeon at St George's Hospital, took £200 with a Lancashire gentleman's son in 1736, while William Cheselden, the famous lithotomist, accepted £150, £210 and £350 with three apprentices in the years 1712–30, sums only just below those paid to attorneys and city merchants. Premiums grew as prospects of profitable medical practice increased by the early nineteenth century, so that John Keats's premium in 1810 was £210 for five years when bound, aged fourteen, to an Edmonton surgeon-apothecary. In the provinces premiums could range from £20 to £84, although £60 or £63 was most commonly recorded. When a youth was indentured to a master who held an honorary hospital post, of which there were increasing numbers by the later eighteenth century, the premium was always substantially more than to a man engaged only in private practice, so that Edward Goldwire, a surgeon at Salisbury Infirmary, took premiums of £210 in the 1750s. By the early nineteenth century, John Green Crosse, an established Norfolk practitioner, with a hospital appointment, was able to note that four apprentices lived in his family house at £100 a year each and that his ‘vacancies (were) always pre-engaged’. He himself had been apprenticed in 1806 for five years to a local practitioner with a premium of £200. A provincial surgeon with a good practice could, however, attract far larger premiums than had been paid when he himself was apprenticed; thus Robert Mynors, for whom £50 had been paid, received £157 with each of the eleven youths he indentured in Birmingham, while in 1834 Sir Astley Cooper of Guy's Hospital commented on the very large sums paid in London. Premiums were not paid when a son was apprenticed to his own father.

The details of a medical apprentice's life are largely unrecorded, although some youths kept diaries and noted the tasks they undertook, the skills they acquired and the patients they saw. Many were critical of the experience, especially at the beginning of the term when they had to perform the most humble tasks, cleaning equipment and sweeping floors, so that a prosperous London Quaker apprentice, William Lucas, with a premium of £200 in the 1820s, constantly bemoaned his miserable and physically uncomfortable life. At the lower end of medical apprenticeship, George Crabbe, the poet, working in the 1770s, resented having to walk seven miles to deliver medicines to a patient. As late as 1834 the Select Committee on Medical Education heard how a surgeon-apothecary's apprentice had to answer the door, take messages and make up medicines, while Roderick Random, Smollett's hero, was able to ‘bleed and give a clyster, spread a plaister and prepare a potion’. We know from the diary of Richard Kay of Baldingstone, near Bury, trained by his father in the 1740s, that he was allowed to attend patients on his own and often left in charge of the surgery while his father visited the sick at home. John Green Crosse noted that he rolled pills, kept the books and tended the leeches, as well as tidying the surgery. He also wrote extensive case notes all his life. Since apprenticeship was essentially a practical training, accompanying a master on his rounds was vital and the young Henry Jephson, later MD, but bound to a Nottinghamshire parish surgeon in 1812, wrote home in delight to his parents:

I can with just pleasure add that he behaved like a Gent and has promised to let me visit them alone. I assure you it has happened exactly right in my last year, as I can visit them more than I did before, indeed he advised me to pay attention to the various diseases I see, and you may depend upon my taking it.

Having survived his apprenticeship, a young tradesman would become a journeyman, while in medicine he would receive a salary to work as an assistant for a practitioner, join another man as his partner, with shared profits, or set up in practice on his own. A minority were pupils to hospital consultants in London and in the provinces. In all parts of the country there was a strong familial pattern in practice and many medical dynasties, such as the Langfords of Hereford or the Brees of Warwickshire, became prominent in the eighteenth century and were to last until the present. Marrying his master's daughter was an established means of advancing a young man's professional career, and Crosse was but one new practitioner to do so. A wife from a medical household was a considerable asset and the master, perhaps providing a smaller dowry, gained a young partner, trained in his methods, who knew the patients and would keep the practice thriving as he grew older. The master's professional secrets, especially his remedies, would be in safe hands and the newly-qualified young man would neither set up in competition nor join a rival practitioner. Additional capital could be produced for the master by selling practice goodwill to an incoming partner. The master was unlikely, however, to be able to sell practice goodwill to his son-in-law, who would usually join without payment. By having lived in the master's house, the apprentice gained a thorough understanding of practice life – especially important if he came from a non-medical family – the erratic work hours, how to deal with patients, keep case-notes and other records, assess the urgency of calls and plan a round of visits, charging accordingly. He watched his master buy, stock and dispense drugs, judging how to apply a scale of fees according to the patient's prosperity and how to negotiate for parish Poor Law work and for other institutional appointments. He also learned how to supervise apprentices and lay staff, groom, coachman or servant, none of which practical skills was described in contemporary apprenticeship manuals or medical text-books.

Setting up in practice was a critical step for surgeon-apothecaries and, as the 1783 Medical Register indicates, few men were in partnerships. In that year there were sixty-two two-man family partnerships listed (5.2 per cent), often with the younger practitioner better qualified than the senior, as well as eighty-eight partnerships (6.8 per cent) between men of different names, although perhaps linked by marriage or a former master-apprentice relationship. However, the great majority of surgeon-apothecaries, 88 per cent, worked on their own in 1783. Physicians were always in single-handed practice and the views of Erasmus Darwin MD on setting up in practice mirrored his own experiences. He suggested that the young practitioner should use all means to ‘get acquainted with people of all ranks’, decorate his shop window attractively and appear in public at the farmers’ ordinary (public dinner) on market days, at card assemblies and at dances. He also advised letters of introduction and ‘dressing to appear well; which money cannot be better laid out’. Erasmus Darwin himself had made several moves to improve his own career, which began in Nottingham, twelve miles from his family home, in 1756 after having qualified at Edinburgh. As his practice did not prosper, he moved a year later to Lichfield and gained an influential patient who introduced Darwin to the midland scientific community. He was prepared to move again in 1781 to Derby, for his second wife preferred her estate at Radbourne to living in Lichfield, and in addition a leading physician had just left Derby to live in London. When Darwin's physician son, Robert, set up in practice in 1786 at Shrewsbury the town had three senior physicians, but Erasmus was able to boast that, as ‘a great encouragement’, within the first six months the young man had fifty patients, who might conceivably have been attracted to a practitioner with such a distinguished medical name. Clearly, becoming established in practice was the most difficult period for a practitioner, and Christian Esberger confided to his journal for 1764 his doubts about his unsuccessful practice in Lincolnshire; in July he found ‘a considerable decay in my accounts; passed it off in hopes of better times to come’. By December he noted ‘I have at present hardly any patients, not one of any Significancy to confine me’ and considered moving to a nearby town where the apothecary was leaving; he never became a wealthy man.

An important step in the professionalisation of medicine was the publication of medical registers from 1779, enabling patients to choose practitioners and practitioners to contact each other. Surgeons and apothecaries had always been listed in earlier trade directories among others who provided a service, but in 1779 Samuel Foart Simmons, a London physician, published his first Medical Register. The Law List was not to appear until 1839 and Crockford's Clerical Directory until 1870. Simmons's Register was arranged on a county basis, and covered the British Isles and overseas, with a strong emphasis on the professional bodies controlling the practitioners. Simmons began by using local contacts to provide the county information, which was arranged alphabetically town by town. He noted if there were a county hospital and sometimes the existence of an asylum or dispensary. A second edition, little improved, appeared a year later but in 1783 he published the third and fullest edition, with much more detail and filling in many of the gaps of earlier versions. It is a remarkable publication, telling the reader where physicians qualified, hospital appointments held and some practitioners’ recent moves or deaths.

The 1783 register shows a striking imbalance between the different categories of men and their uneven national coverage. There were 3120 practitioners listed; the unqualified, such as barber-surgeons and bone-setters, were omitted. Of these, 363 were physicians (11.6 per cent), 2,614 were surgeon-apothecaries (83.6 per cent), with 79 apothecaries (2.5 per cent) and 64 surgeons (2.05 per cent). The physicians were concentrated in county towns, often linked to hospitals, in spas and in cathedral cities, for clerics were always particularly good patients, and, even if they were a small community, such as Wells, physicians could join an educated, congenial social group. Physicians were noticeably absent from the developing northern industrial towns but could often be found living near royal residences (Windsor, Hampton Court) or aristocratic seats (Alnwick, Castle Howard). Some spa towns, such as Brighton and Buxton, had physicians only during the season, although Bath uniquely could support fourteen permanent physicians in 1783. All practitioners lived on local road networks, to facilitate contact with their patients, for both physicians and surgeon-apothecaries travelled many miles to visit sufferers at home, presumably not always as comfortably as Erasmus Darwin in his specially-fitted coach.

Surgeon-apothecaries, the majority of practitioners, however, could be found in all areas, usually in market towns, generally in single-handed practice. Where to practise was clearly a business decision and some men can be seen moving to improve their clientèle, to avoid competition or to where a new hospital had opened. Indeed, the coming of county hospitals in provincial England in the second half of the eighteenth century made well over a hundred new career openings possible. Seven were established in the 1740s alone, twenty-nine in the whole century. A hospital definitely attracted aspiring practitioners, who would move to gain an appointment; thus John Storer (MD, Glasgow, 1771), one of three physicians in Grantham in 1783, moved to be the most junior of three physicians at the new Nottingham hospital, opened in 1782, gaining a considerable reputation in the county and practising there well into the next century. Each county infirmary had two to four physicians and the same number of surgeons and an apothecary; there were also posts at the increasing number of dispensaries that were being...

Table of contents

• Cover
• Half Title Page
• Title Page
• Copyright Page
• Table of Contents
• Illustrations and tables
• Preface
• Acknowledgement
• Introduction: medicine before the Industrial Revolution
• 1 Medical practitioners in eighteenth- and nineteenth-century England
• 2 Population and contraception
• 3 Medical care under the Old and the New Poor Law
• 4 Medical care provided by Friendly Societies
• 5 Hospitals and dispensaries
• 6 Asylums and prisons
• 7 Midwifery and nursing
• 8 Infections and disease control
• 9 The pharmaceutical industry
• 10 Medicine and war
• 11 The National Health Service
• Conclusion
• Further reading
• Index of places
• Index of medical names
• Subject index