Medical practice and the nature of work in early modern England
Jonathan Barry, February 2021
Following my Wellcome Trust-funded project on the ‘Medical World of Early Modern England, Wales and Ireland c.1500-1715’ I am writing various books on early modern medical practice, both nationally and two case studies, one of early modern Bristol, and the other of a practitioner/author William Salmon, active in London between 1663 and 1712, as well as preparing for public release a database of medical practitioners during this period, along with Peter Elmer, Alun Withey and others. In this blog I want to discuss some of the ways in which studying medical practice raises issues about the nature of work central to HERB’s programme for this year, and where evidence about the nature of work generated by medical sources is, I strongly suspect, much more informative than is the case for most other occupations, and where the corresponding historiography is also perhaps more developed than for other occupations. Rather than providing a single document, I hope it will be OK to raise a series of issues. What are the boundaries between paid and unpaid work, an occupation and a practice? What are the key features of a type of work, and how should the skills be learned? What exactly is being paid for (and how) when work is remunerated? How far is work regulated by the state, town or guild? How do urban and rural experiences differ?
An interesting first question is why I am discussing ‘medical practice’ not ‘medical work’, and why our database is of ‘medical practitioners’ not medical workers. Historiographically, the term ‘practitioner’ is intended to be a more neutral term than, say, ‘professional ‘ and to cover a range of occupational labels without privileging one of them (such as physic). In early modern usage, both ‘practitioner’ and ‘professor’ (not in an academic sense) of physic/medicine were used, as well as ‘doctor’ (officially meant to signify being an M.D. but often used more loosely), as well as physician, apothecary, surgeon, barber-surgeon etc. But to what extent does referring to practice/practitioner still mark off medicine as something different from other work, and draw upon the modern language of ‘general practice’ or of professions such as medicine and the law as having ‘practices’ not workplaces?
One possible answer is that almost everyone in the early modern period was a ‘medical worker’ in some sense, and that we reserve the term ‘practitioner’ to describe those for whom this work was a paid occupation (though not necessarily their sole or even main occupation). This is critical given that much medical care was provided in the home, particularly but not only by women (leading many to compile collections of remedies), and that providing medical care/supplies without cost was also an important aspect of charity, both personal and institutional (and this duty extended to practitioners, who were expected to cure at least some categories of poor patients gratis, or at least at a reduced fee they could afford). There was no clear boundary between medical care and the tasks of feeding and nursing/caring central to household management, and the predominant medical ideas of the period reinforced this overlap, by emphasising prevention (with diet, exercise and domestic environment central among the so-called ‘non naturals’) and treatment aimed at correcting the balance of the body’s humours/spirits. There was no clear distinction between foods and medicines in doing this, via purging, strengthening etc., while many medicines, especially herbal simples, could be ‘made’ at home. Good housekeeping was therefore central to health, so one could regard most household work as, at least partially, medical work, while most medical work took place within the household, with very little institutional care (hospitals being primarily care/residential homes for those like the old or military without a household to look after them) and medical practitioners also tended to visit patient’s homes or prescribe treatments to be administered at home by the household.
There is an ongoing debate about the correct balance to strike between emphasising domestic medical provision, and recognising the role of more specialised medical ‘practitioners’, as also of a shift from medicines produced (as well as administered) in the home to those purchased commercially, including pre-packaged medicines as well as those made up by apothecaries on prescription. As Ian Mortimer’s Exeter PhD showed (using probate accounts), pre-mortem medical expenditure rose dramatically in what he termed a 17C ‘medical revolution’, and lots of other evidence suggests a growth in both medical practitioner numbers and expenditure on commercially-produced medicines during the period 1600-1750, though the exact chronology and how far this was focussed on urban areas and/or certain parts of the country is still not clear. But it is clear that most households were not self-sufficient medically - even if ‘domestic medicine’ remained central, there was demand to sustain a large and growing set of medical practitioners, especially to cater for those medical needs seen as more serious or specialised. So, for example, bleeding was regarded as requiring a specialist, as was bonesetting or treating major wounds or accidents. In the countryside, these same skills may also have been exercised on animals, though farriers do not appear to have performed human medical tasks in towns.
Sandra Cavallo (formerly at Exeter) has labelled Italian workers of this kind ‘artisans of the body’, and drawn attention to the overlap of skills between various groups working on bodily care, only some of which we now label ‘medical’. The most extensive such overlap in England was that of the ‘barber-surgeon’, combining the barber’s work of shaving and other treatment of the skin and hair of the body with surgical work, including bleeding and treatment of wounds. The common feature here, apart from knowledge of the body’s skin and anatomy, was the necessary skill in both preparing and using sharp metal instruments, hard to keep sharp before steel was developed, as Alun Withey has shown, and their characteristic equipment was their box of instruments. Barber-surgeons learnt their practice by apprenticeship, both in the manual skills involved and in managing a shop and network of customers. This was also true of apothecaries, who prepared and sold medicines. Both groups were largely town-based, particularly apothecaries, though barber-surgeons and surgeons also went on ships and with armies, and their growth in numbers is partly explained by growing mercantile and military demand, as well as urbanization: it is less certain that they met a growing share of rural medical needs (though of course rural people went to towns for medical treatment alongside other products and services).
Both in the early modern period and in modern scholarship much of the discussion of medical work has revolved around the relationship between barber-surgery and pharmacy as medical ‘trades’, learnt by training, and the ‘profession’ of medicine, as defined by physicians who learned physic through a formal education and book learning. There is also a debate about how far individuals did practice as both barbers and surgeons, prior to the formal split between the two in Paris, London and Bristol in the 1740s: was there always a group of ‘mere surgeons’ superior to the others? Historians’ modern occupational tables differ wildly in whether they characterise all these medical occupations as professions or as services, or if they distinguish some as trades (artisan or retailing) and others as professions. In the early modern period this was a highly contested matter of hierarchy and boundary definition: the physicians wished to distinguish their ‘mental’ work from the manual, menial work of the others, so defining themselves as ‘gentlemen’ and also justifying their charging high fees essentially for diagnosis and prognosis, thus identifying the correct therapeutic and preventative regimes, leaving surgeons and apothecaries (or indeed family members) to carry out treatments or prepare medicines in line with their instructions. Yet, as their critics/satirists loved to point out, their ‘work’ was often itself menial, notably in its reliance on the observation of urine and excrement, and their success rate often questionable, lacking the evident outcomes of the barber-surgeons (in dressing wounds, mending fractures or healing skin conditions) or even the apothecaries, or indeed of numerous empirics who offered to identify and cure patients based on experience rather than formal learning/qualifications. Contemporaries found it hard not to regard the actual practices of treatment/curing as constituting medical treatment, and assuming that those who could do the latter were also capable of acting as ‘physicians’.
Particularly in London, there were constant demarcation disputes between the physicians (the elite College of Physicians), barber-surgeons and apothecaries (both with city guilds, though the Apothecaries only separated from the Grocers in 1618), as well as with other physicians who were outside the College and with all sorts of empirics and part-time healers. These disputes have generated a massive amount of both manuscript and printed evidence about the character of medical work – mostly very partisan and contradictory, but still far in excess of the evidence about how any other occupations were carried out. There is much less evidence of similar disputes outside London, though graduate physicians across the country complained constantly about competition from others who had not undertaken their long and expensive education. As Margaret Pelling and Hal Cook have demonstrated, the London physicians struggled to make their collective case amidst a largely free medical marketplace, with little sustained institutional support from either crown or civic/local authorities, though many individual physicians made very good incomes. But it seems likely that both surgeons and apothecaries in practice offered much advice and treatment of internal medical conditions, and that outside London many medical practitioners were, in effect, general practitioners, combining physic, surgery and pharmacy, just as surgeons had to do on ships. In the eighteenth century this reality was increasingly acknowledged in new forms of medical training and the emergence of terms like ‘surgeon-apothecary’, although resistance from physicians and Oxbridge conservatism, meant that it was not until the 19C that new models of education were officially introduced, centuries after they had been proposed during and after the Civil War period.
Another aspect of the disputes was the question of payment, both in terms of what was being paid for, and how payment was calculated. Was the payment for medical advice, for specific goods or services rendered or was it for (and so contingent on) a successful outcome (and if so, how measured)? Was it calculated by a period of time, by expenses incurred, or was it a contracted or voluntary payment for an agreed result? To be consistent with his model of the physician’s role, a physician could only be kept on a retainer by a patient/family, or paid a fee for medical advice (plus perhaps expenses for travel and/or attendance), ideally paid spontaneously by the grateful patient and not paid by therapeutic outcomes, but in practice even physicians often seem to have charged on these other models, while other types of practitioner might well have standard charges for particular services/products, or ‘contracted for a cure’, either directly with the patient or with their family or employers, parish or other institution. The inherent uncertainty of how long a case might last, and what would count as cure (exacerbated by the lack of a concept of a specific disease that started and finished) offered huge potential for disagreement, and led to numerous court cases, quite apart from disputes when treatment failed or patients failed to pay. All this was aggravated by the practice of ‘multiple resort’ whereby people sought medical help from a range of different practitioners simultaneously or in turn (especially if the problem persisted) and also practices of multiple consultation, especially in serious cases: this was common among physicians but also prescribed by barber-surgeon’s guilds in dangerous cases, where pursuing risky surgery was forbidden without consulting the guild’s officers. All of this related to the legal convention that medial men were entitled to payment and also protected against prosecution for causing harm or death (regardless of outcome) provided they had acted according to medical convention.
Medical practice also raises interesting questions about regulation of work. The current orthodoxy is to stress that England had a ‘medical marketplace’ characterised by a general freedom to practise, and for patients to shop around for medical services, by comparison both with other countries in the period, or the modern state’s professional regulation of medicine. But this marketplace was a contested one, with several overlapping types of regulation in place, and with patients probably influenced by qualifications and official/civic status. From the 1520s there was a national scheme of medical licensing by the church, although it was patchily applied, even to the physicians and midwives to whom it was largely restricted, with barber-surgeons and apothecaries regulated, if at all, by town guilds, although many towns lacked such guilds, or saw medical practitioners included in larger conglomerate guilds. Only in London did the state make any attempt at overall regulation of medical practice, and as noted, its attempt to create a hierarchy led by an elite College of Physicians was never very effective – the crown, the courts and civic authorities proved reluctant to reduce patient autonomy or the rights of other guildsmen. Elsewhere, it seems that medical practitioners relied largely, in the task of building a practice, on winning trust from customers by deploying social networks of kinship and experience, either through apprenticeship, partnership with an established practitioner or inheriting a practice, and this applied as much to physicians as to others, despite their claims to specialist educational qualifications, as Andrea Davies’s Exeter PhD on graduate physicians in Devon and Suffolk demonstrated. Regulation (and indeed formal training) should probably be understood as one factor within the local establishment of trust and authority, rather than treated in isolation, and it involved a complex mixture of cooperation and competition between the local practitioners, as well as with both their patients (clients/customers?) and the domestic provision of medical care.
A selection of Further Reading or click the link for a PDF for the full list
Jenner, M. and P. Wallis (eds), Medicine and the Market in England and its Colonies c.1450-1850 (2007)
Mortimer, I. The Dying and the Doctors : The Medical Revolution in Seventeenth-Century England (2009)
‘The Rural medical Marketplace in Southern England c.1570-1720’ in Jenner and Wallis 69-87
“Diocesan Licensing and Medical Practitioners in South-West England, 1660-1780”, Medical History 48 (2004), pp 49-68
‘The Triumph of the Doctors: Medical Assistance to the Dying, c.1570-1720’, Transactions of the Royal Historical Society, 15 (2005), pp.97-116
Pelling, M. The Common Lot: Medical Occupations and the Urban Poor in Early Modern England (1998)
Medical Conflicts in Early Modern London: Patronage, Physicians and Irregular Practitioners 1550 – 1640 (Oxford, 2003)
‘Apprenticeship, Health and Social Cohesion in Early Modern London.” History Workshop Journal 37 (1994) :33-56
‘Knowledge Common and Acquired: the Education of Unlicensed medical Practitioners in Early Modern London’ ’ in Vivian Nutton and Roy Porter (eds), The History of Medical Education in Britain (Amsterdam, 1995), 250-79
‘Corporatism or Individualism: Parliament, the Navy, and the Splitting of the London Barber-Surgeons’ Company in 1745’, in Gadd I. and Wallis P. (eds), Guilds and Association in Europe, 900–1900 (2002), 57–82
‘Managing Uncertainty and Privatising Apprenticeship: Status and Relationships in English Medicine, 1500–1900’, Social History of Medicine, 32.1 (2019) 34-56
Pelling, M. and C. Webster, ‘Medical Practitioners’ in Charles Webster (ed.), Health, Medicine and Mortality in the Sixteenth Century (1979) 165-236