Monday, 29 September 2014

Policing Medical Practice in the 17th Century



A brief note before jumping into the newest post: Apologies, I’ve been (mostly) AWOL from both the blog and  Twitter for just over a month now.  Regular updates/posts will resume shortly.  p.s. the thesis defense went well – I’m finally @medhistorian PhD.

On to more important things!  Like surgery!

Early modern surgery was painful with, often, unpredictable results.  Samuel Pepys’s lithotomist Thomas Hollier, for example, had a great run of 30 or 40 successful operations before cutting Pepys for the stone.  Hollier’s first four patients following the Pepys lithotomy were less fortunate and died as a consequence of their operations.

I’ve already written here on why anyone would be so desperate as to seek a surgeon and what that experience was like for Samuel Pepys.  This post looks at the unsuccessful medical/surgical experience.  What happened when practitioners failed to provide a suitable cure?

Legally practicing London-based medical practitioners were usually under the administrative umbrella of the Royal College of Physicians of London, the Company of Barbers and Surgeons, or the Company of Apothecaries while others practiced via the so-called Bishops Licenses.  There were, of course, a much larger number of practitioners who lacked any sort of institutional affiliation or license to practice.

As the formal administrative bodies, the College and Companies were the first line of defense against any sort of “medical malpractice.”  Indeed, both groups met frequently to hear patient complaints and adjudicate cases.  They had significant interest invested in the continued good name of their organizations and punished harshly those whose bad practice or dishonesty could cast the whole medical occupation in a poor light.  

The Company court minutes look like this & are a fun read.
The College - Policing Professional Boundaries

The College, especially, used these hearings to police the boundaries of medical practice; they sought to regulate all medical practitioners and enforce the restrictions on practicing physick to only their members.  This brought the College and Company into frequent conflict over the course of the long seventeenth century. 

In 1596, for example the College charged a surgeon named Roger Jenkins for practicing physick.  Jenkins insisted that as a surgeon, it was his right to use internal medicines when he deemed it necessary.  He was deemed an empirick and summarily imprisoned.[1]  Interestingly, the quality of Jenkins’ work was not under question – just his occupational status.

The College saw university education as a key part of the physician’s life.  It transformed “the student into a physician of good character, who could exercise good judgment and advice: a man of learning.”[2]  The learned physician, then, was a virtuous man whose practice was made legitimate by both his philosophical knowledge and his moral authority. 

Useful knowledge, quite frankly, wasn’t enough.

The censorial hearing of James Saul, a Dutchman, demonstrates this quite clearly  Upon examination at an earlier hearing, he was found to lack Latin and a proper understanding of Galenic theory.  Several years later, in 1604, the College once again questioned his involvement in medical cases.  While acknowledging that Saul possessed more knowledge than he did previously, the College questioned the manner in which it was gained, stating that it must have “been acquired ‘by infusion…or els by some extraordinary means.’” [3]  Saul’s medical knowledge and practice were not the issues at hand; indeed, his treatments’ efficacy was never questioned.

In 1596 the College sent surgeon Edward Messenger to prison, banned him from practice, and fined him £5 for giving medicines to his surgical patients.  The College Annals account noted incredulously that Messenger “spoke confidently and gave the impression that he considered that he had done well.”[4]  Indeed, there is no note that Messenger’s patients suffered in any way; he was merely punished for treating his patients successfully by trespassing on what the College saw as their monopoly. 

How Messenger came under College scrutiny is unknown.  Frequently, however, the Annals record instances where members of the public – that is patients – approach the College to punish a surgical practitioner.  In 1637 Mr. Thomas Man complained that Gervaise Nevel treated his wife “without Judgement or Skill” while Thomas Car, Susan Cran, and Widow Harvey complained that the unfortunately named surgeon Hogsflesh treated them all with harsh physick.[5] 

The Company – Policing Their Own

In keeping with the desire to have or keep a positive reputation, the Company required that each surgeon undertaking a difficult cure report to the masters.[6]  This by-law meant that difficult cases were presented to multiple senior surgeons so that the original practitioner could be advised about the course of treatment and have some support if the patient died.[7]  Consistent practice, in theory at least, would mean a lower rate of patient death and, perhaps, a higher rate of patient cures with both reflecting positively on surgeons and surgery. 

Unsurprisingly, surgeons not reporting difficult cases appear repeatedly in the Company court minutes; both a function of the Company prosecuting enthusiastically those surgeons failed to report and surgeons choosing not to report because the practice seemed unimportant or threatening to their autonomous practices. 

In May 1600 Peter Peerse and William Foster were fined for not presenting a patient they trepanned; the patient died, but the court minutes reveal that Foster’s fine was mitigated to only 5s.[8]  The next month, however, Oliver Peacock was both fined and forbidden to practice surgery for not presenting his cure to the Company masters.[9] 

The fines associated with this misdemeanor fluctuated significantly, but without apparent pattern.  It was clear, however, that a nonmember who treated a dangerously ill patient was prosecuted much more severely; in 1638 the unlicensed Thomas Bowden was first fined 40s, then a further £5, and then imprisoned.[10] 

Company efforts to create and reinforce a positive reputation for surgery mean that the very practice of surgery was policed closely and that patients – and other practitioners – had recourse to the Company court when they had complaints.  Patients knew, for example, that they could appeal to the Company if a practitioner was unskillful, defrauded the patient of money, or did not complete or effect a cure. 

The latter is especially present in the Court Minutes as patients and their family members seemed to expect a “no cure, no money” policy similar to that advertised in quack handbills.  In 1599, Edward Netmaker complained that Anthony Sparkman delayed the cure Netmaker’s apprentice – presumably to extract a higher fee.[11]  In 1647, Henry Ivatt approached the Company about Anthony Mold who failed to cure Ivatt’s wife of the King’s Evil (scrofula).  Mold, it seems had taken 30s in payment with a further 40s to be paid upon completion of the cure.  The Company decided that Mold should refund Ivatt 20s and keep only 10s for his attempted cure.[12] 

In 1713 the Company investigated the complaint lodged against a Mr. Ogilvy by William Bush; it concluded, likely through a physical examination, that the complaint was “false and scandalous” as “his [Bush’s] tendon was not prick’d.”[13] 

In addition to its role as an organizing body, the Company also acted as an advocate and adjudicator when its members’ practice was called into question.  Though unable to fully regulate all of surgical practice in London and the seven miles around, it sought actively to obtain and keep a positive reputation for surgery and surgeons by punishing unskillful or dishonest practitioners and ensuring patient safety and satisfaction.  Perhaps, in this fashion, the Company sought to set their members apart from the irregular medical practitioners that littered the medical marketplace.

Let me know what you think here or on Twitter - I'm @medhistorian.

[1] Charles Goodall, The Royal College of Physicians of London (London: printed by M. Flesher for Walter Kettilby, 1684), 341.
[2] Harold Cook “Good Advice and Little Medicine: The Professional Authority of Early Modern English Physicians,” The Journal of British Studies 33,1 (January 1994), 4.
[3]Sail, ?James or Jacob,” Physicians and Irregular Medical Practitioners in London 1550-1640: Database (2004). URL: http://www.british-history.ac.uk/report.aspx?compid=17781&strquery=james saul
[4] Annals, vol. 2, f. 124b.
[5] Annals, vol. 3, f. 187a.
[6] Sidney Young, Annals,  77.
[7] Once having served as Company master, you no longer had to present your cures to the current masters or governors.   With seniority came the assumption of advanced knowledge and wisdom. GL MS 5257/4/314.
[8] GL MS 5257/3/54 and 5257/3/58.
[9] GL MS 5257/3/59.
[10] GL MS 5257/5/248.
[11] GL MS 5257/3/47.
[12] GL MS 5257/5/413.
[13] GL MS 5257/7/103.