The Medical Marketplace Hilary Marland

1. The Medical MarketplaceHilary Marland Kill or Cure Lecture Week 3

2. Keywords • Marketplace • Medical practice • Medical practitioners • Diversity of practice • Quackery • Consumerism • Competition • Patient choice • Medical treatment

3. Lecture Themes • Defining the medical marketplace • Varieties of practice and practitioner • The marketplace of the 18th century • The rise of quackery • After the 18th century We ask the question: why did British patients consult doctors in growing numbers despite healthy scepticism about their ability to cure?

4. Defining the Medical Marketplace • Margaret Pelling and Charles Webster ‘Medical Practitioners’ (1979) – referred to the 16th century • Way to deal with the confusing range of practitioners who provided medical services was to be inclusive rather than exclusive • To include under the heading ‘medical practitioner’ anyone whose living was derived largely or wholly from the treatment of sick, regardless of title, background or education • This would include not just qualified doctors but all those practising medicine in some form, including women

5. Defining the Medical Marketplace • Pelling and Webster’s approach also applicable to 17th, 18th and 19th centuries – variety of practitioners – qualified doctors, but also wide range of other healers • Midwives • Nurses • Dentists • Medicine salesmen • Chemists and druggists • Spa doctors • Early ‘specialists’ e.g. oculists, eye doctors, bonesetters

6. Defining the Medical Marketplace Approaches in the history of medicine post 1970s – moving away from the ‘grand narrative of progress’ To explore medical practice in a broad sense and not just the most successful and learned doctors and technological innovations To examine the total medical economy of particular areas/neighbourhoods and regions, also outside of main centres e.g. Jonathan Barry Bristol, Hilary Marland Wakefield and Huddersfield History from below, ‘the patient’s view’ and female practitioners, class and race

7. Advantages of the Medical Marketplace Model: (a) It provides the opportunity to place medical practice within a range of economic and social activities, to look at access to medical treatment in terms of wealth and the ability to pay, at local contexts, to explore how patients chose certain practitioners for certain ailments (Jewson’s patronage model). Examine total medical economy. (b) It allows us to shift our focus to the patient. (c) It also solves the problem of deciding who was a qualified doctor and who wasn’t in a period where much medical treatment was ineffective.

8. Objections to the Medical Marketplace Model: (a) Where we drawn the line? Do we, for example, include a grocer who happened to sell drugs, or a helpful neighbour who occasionally delivered babies? (b) Does it offer a way of distinguishing in terms of skill and expertise? (c) Do we include the fraudulent, the ineffective, and how can this be judged? (d) How much choice did patients really have?

9. Defining the Medical Marketplace • Jenner and Wallis summarise a number of different models developed by historians: • Pluralistic model (17th century, Harold Cook) – this is about diversity and is very inclusive (includes medical help from friends and family; household medicine; folk remedies; charitable clerics; astrologers, midwives, mountebanks; medicine sellers. • Commercial model (18th century, Roy Porter) – capitalist, also linked to spectacle and display, medical economy. • Service model (moving into 19th century, Irvine Loudon) – relates doctors’ behaviour and developments in therapy and practice to entrepreneurial ambitions and economic circumstances, medical labour market.

10. 2. Varieties of practice and practitioner Eighteenth Century medicine.

11. Medical Encounters (1739) Elizabeth Montagu, ‘I have swallowed the weight of an Apothecary in medicine, and what I am better for it, except more patient and less credulous, I know not. I have learnt to bear my infirmaries and not to trust to the skills of physicians for curing them’. (1761-1823) Leading surgeon-anatomist, Matthew Baillie, ‘I know better perhaps than another man, from my knowledge of anatomy, how to discover disease, but when I have done so, I don’t know better how to cure it!’ (1784) Physician, John Berkenhout, ‘I do not deny that many lives might be saved – by the skilful administration of proper medicine; but a thousand undisputable facts convince me, that the present established practice of physic in England is infinitely destructive of the lives of his Majesty’s subjects. I prefer that practice of old women, because they do not sport with edged tools; being unacquainted with the powerful articles of the Materia Medica’.

12. Physicians Surgeons Apothecaries Varieties of practice and practitioner 3-Tier Hierarchy of Practitioners

13. How Merrily We Live That Doctors Be (Robert Dighton).

14. Physicians • University trained men, ‘medical elite’ (Oxford, Cambridge, Edinburgh, Glasgow, etc or foreign universities) • Gained medical degree – MD • Offered ‘medical advice’, treated internal disorders – demanded high fees. Worked London and major centres • Did not perform surgery or dispense medicines • Entry to practice regulated by Royal College of Physicians – unreformed body associated with nepotism and corruption • Did nothing much to raise standards – many of its Fellows poorly trained • Scottish universities better standard of training or European Universities (Leiden, Paris)

15. The Company of Undertakers (William Hogarth), 1737.

16. Barber-Surgeons, 1752 (Hogarth)

17. Surgeons • Physicians looked down on surgeons – until 1745 associated with barber’s trade (barber-surgeons), hands on work. 1745 formed Company of Surgeons and link with barbers dissolved. • Royal College of Surgeons (1800 Royal Charter granted) – qualified MRCS – raised status • Primarily manual craft – apprenticeship for 5-7 years • Manual procedures – inoculation, lancing boils, bleeding patients, small number of operations, including amputations • Many surgeons became rich and famous, John and William Hunter. Could demand high fees for apprenticeship or treatment

18. Apothecaries Dispensed medicines • Trained by apprenticeship • Licensed by Apothecaries Hall or Society of Apothecaries – LSA (1815) • Task, in theory, limited to dispensing prescriptions • After 1704 (Rose Case) allowed to prescribe – but could only charge for medicine and not for advice • Also sold over the counter remedies or patent medicines • Bottom of hierarchy but busy practitioners

19. Rise of the surgeon-apothecary • The hierarchical structure did not reflect what was happening in practice, especially outside of London. • Practitioners opportunists – mixed activities. • Most significant blending – combination of occupations of surgeon and apothecary (MRCS/LSA) but also License in Midwifery (LM). • Surgeon-apothecaries evolved in 19th century into general practitioners, building good practices. ‘In many parts of [Great Britain] surgeons or apothecaries are the physicians in ordinary to most families, for which trust they are often well qualified by their education and knowledge’ (John Gregory, Letters on the Duties and Qualifications of a Physician, 1772).

20. 1783 Medical Register list of practitioners Total practitioners 3,120

21. Patient power. Goldsmith, the physician, leaves in a huff because the patient prefers to follow the advice of the apothecary.

22. ‘Medico-chirurgus’, A Letter addressed to the Medical Profession on the Encroachments on the Practice of the Surgeon-Apothecary by a New Set of Physicians (London, 1826).

23. The Doctor’, watching over a sick child 1891 painting by Luke Fildes

24. The marketplace of the 18th century • Expanding market – consumption and competition • Service to be paid for – doctors ‘petty capitalists’. • Advertised in newspapers, sold medicines, undertook a variety of medical tasks • Great variety in terms of earnings. Standard fee for a consultation 5s to 10s 6d but also ‘6d doctors’ in large towns, while some doctors commanded very large fees of several guineas e.g. Sir Hans Sloane, physician George II, President Royal College of Physicians; John Coakley Lettsom earned over £10,000 pa.

25. The marketplace of the 18th century Increase in number of practitioners: • 18th-century prosperity and consumption • Growth of middle class with surplus money to spend • Snobbery – affording the ‘best medicine’ e.g. of choice of accoucheur rather than traditional midwife • Purchasing more medicine and medical services e.g. spa visits • Less reliant on family practice (though household medicine still very important and can be seen as part of a medical marketplace, Leong and Pennell)

26. Humoral theory – heroic remedies

27. James Gillray, ‘Breathing a Vein’ (1804).

28. James Gillray A man standing by a fire place, pulling a peculiar face after taking some medicine. Coloured etching by J. Gillray, 1800.

29. The marketplace of the 18th century • Growth in medical services and opportunities to make a medical living • Medical charities, especially hospitals and dispensaries, set up in increasing numbers in 18th and 19th centuries • Also lunatic asylums, including private enterprises, lock hospitals (venereal diseases), maternity hospitals, fever hospitals • Offered posts (usually unpaid) but provided status and ‘foothold to practice’ • Poor Law medicine – offered lower status, but paid employment (often contracted)

30. Middlesex Hospital, London, early 19th Century.

31. - Westminster (1720) - Guy’s (1724) - St George’s (1733) - London (1740) - Middlesex (1745) - Edinburgh Royal Infirmary (1729) - Winchester (1736-7) - Bristol (1736-7) - York (1740) - Exeter (1741) - Bath (1742) - Northampton (1743) Eighteenth Century Hospitals

32. Doncaster Dispensary, 1792-1867. These images show the small, simple premises that housed the institution in the mid-nineteenth century.

33. The rise of quackery • Quacks, unqualified healers, irregulars, alternative practitioners, itinerants, empirics, charlatans, mountebanks, nostrum vendors Ben Johnson ‘Quackery was a bad thing’, the quack was a ‘wretch’ – a ‘turdy-facy, nasty pasty, lousy farcical rogue’. Yet popular!! • Hard to distinguish – no sharp lines between unqualified and qualified (e.g. all doctors advertised their skills, many sold medicines). No standardised training and until 1858 no single register of medical practitioners. • 18th century regarded as Golden Age of Quackery, included many famous quack doctors or doctresses, specialists (e.g. eye doctors, sexual diseases), sold remedies to cure ‘all known diseases’. • Print culture/advertising, medical consumption

34. Doctor Humbug, an itinerant medicine vendor selling his wares from a stage with the aid of an assistant. Coloured etching, 1799.

35. ‘Doctor Botherum’, perhaps based on Doctor Bossy, sells his ware to a raucous crowd with the aid of assistants. Coloured engraving by T. Rowlandson, 1800.

36. Quack doctor open for business. Coloured etching by G.M. Woodward, 1802

37. ‘Dr’ John Taylor Oculist, claimed to be doctor of physic and fellow of several colleges of physicians. ‘Chevalier and Ophthalmiater Royal’ Early specialist, appeared skilled Made fantastic claims, moved around from country to country

38. John Taylor • ‘He seems to understand the anatomy of the eye perfectly well; he has a fine hand and good instruments, and performs all his operations with great dexterity’ Dr William King, Tunbridge Wells, 1748 • An example of ‘how far impudence may carry ignorance’ Samuel Johnson

39. After the 18th century • Flourishing state of medical marketplace but also fierce competition to attract patients, who depending on their resources had choice of who to employ. ‘He who pays the piper calls the tune’. • The medical marketplace is referred to as ‘overstocked’ though still a great deal of medical consumption. • Qualified medical practitioners turn increasingly on unqualified in the 19th century. • New opportunities/new systems of medicine – rapid increase in chemists and druggists, spas, hydropathy, mesmerism, medical botany, homoeopathy – even more diversity in 19th century.

40. Conclusion • Breadth of 18th and 19thcentury medical practice • Rise in number of practitioners due to: • Consumer boom/marketplace opportunities NOT: • Advances in treatment • Professional reform • With boom came bust – not all practitioners were able to survive in such a competitive marketplace. Importantly, market was demand-led (Jewson on patronage)