William Harvey’s experiments led him to realise that the blood was not used up by the organs, but continually circulated through the veins and arteries. Joseph Lister’s efforts to kill the germs which caused wound infection led to the development of antiseptic and aseptic surgery.
But until the 20th century, very few medical men were full-time researchers. The vast majority were also working practitioners, dependent on the fees they received from their patients. Their great moments of discovery were only a tiny part of their working lives – so what did they do in the rest of the time?
Medical Practice in the 17th and 18th Centuries
Until the 19th century, it was generally accepted that health depended on a balance of the body fluids, and that an imbalance of the humours produced disease. The experts in interpreting the internal state of the body were the physicians. Educated in universities in the theory of medicine, physicians diagnosed by analysing the patient’s pulse, observing their general appearance and mood, and the quantity and quality of their evacuations (especially the urine). To treat the conditions, they would prescribe a course of drugs and a regimen of diet, rest or exercise.
William Cullen (1710-1790), physicianCullen was one of the most distinguished practitioners of his day, teaching medicine in both Edinburgh and Glasgow.
Of course, there were no mass-produced pharmaceuticals at this time. The medicines prescribed by the physician would be made up by an apothecary. Trained through an apprenticeship of up to seven years, the apothecary knew the properties of a wide range of medicinal substances taken from plants, minerals and animals (for example, crab’s eyes).
He also understood to combine them into a wide range of medicines – from purges to remove humours to soothing syrups to stop a cough. Complaints that affected the surface of the body – skin diseases, boils and wounds – were the province of the surgeon. Also trained by apprenticeship, the surgeon had highly developed manual skills. He could set bones, apply plasters and ointments, remove cysts and perform bloodletting to remove corrupt humours.
David Teniers II, “Surgeon treating a peasant’s foot” 17th century
This is one of many images of surgeons at work among their lower class clientele. Here the surgeon applies a dressing, surrounded by his instruments.
In theory, then, the practice of medicine was neatly divided between three groups. Patients would call on a physician to diagnose their complaint, employ a surgeon to let blood and an apothecary to make up medicines. In fact, only the very rich could afford to consult the whole panoply of practitioners. The poorer would go direct to an apothecary and buy some medicine, or take their rashes and boils to the surgeon for treatment.
In practice, the neat divisions of medicine were rarely observed, and physicians, surgeons and apothecaries competed fiercely among themselves and with the other groups for patients’ fees. In the 17th and 18th centuries physicians (who were the best educated, and worked among the highest social classes) constantly complained that apothecaries were taking over their job by diagnosing and prescribing for patients who came to their shops. Surgeons too were muscling onto the physician’s well-paid territory, by prescribing drugs to help treat cancers or skin disease.
Alexander Monro primus (1697-1767)Alexander Monro was trained as a surgeon, but as this engraving shows, laid claim to high social and intellectual status.
And patients helped to blur the divisions of practice: no one wanted to pay over the odds for medical care, so rich and poor would go to whichever practitioner could help them for the least outlay. And to the disgust of all classes of practitioner, this included buying remedies from untrained “quacks”.
Medical Practice after the “Big Bang”
Around 1790, there was a massive shift in medical theory. The idea that health was governed by humours was replaced by the theory that disease affected the body’s organs and tissues. At the same time, the organisation of medical practice also went through a fundamental change: the three-way division into physicians, surgeons and apothecaries was replaced by the familiar two-tier hierarchy of consultant and general practitioner. Unlike the “big bang” which transformed medical theory, the change in medical practice occurred gradually, and was driven by economics. By the 18th century there was fierce competition between practitioners for patients and their fees. Physicians competed with surgeons and apothecaries, surgeons and apothecaries complained of unfair competition from untrained quacks. As one historian of medicine put it, it was as if medicine was a ladder, with every practitioner shouting “quack” at those standing on the rungs below.
William Salmon (1644-1713)
Untrained quacks often presented themselves as if they were trained practitioners. In this engraving, William Salmon claims to be a professor, but actually had no formal qualifications.
In this situation, every practitioner sought the knowledge that would best equip him to attract the maximum number of patients. As disease was seen to be located in organs, which could be detected with new diagnostic aids like the stethoscope, students training to be physicians began to study anatomy. As surgeons devised operations to deal with internal complaints, like cancers, they needed to understand the workings of the body. And practitioners setting up in the growing towns, aiming to earn their fees from the expanding middle class, realised if they could make up drugs they could keep the fees that would have gone to the apothecary.
Thus was born the general practitioner, the medical jack of all trades, able to deal with any type of medical complaint. However, there were always a few difficult cases, requiring highly specialist knowledge to arrive at a successful diagnosis and treatment. These patients were passed to practitioners working in hospitals, the consultants, who continued to specialise in medicine or surgery.
The re-organisation of medical practice did not bring an end to competition. Consultants fought for the most prestigious posts in hospitals and medical schools. General practitioners worked hard to build up their practice at the expense of rivals, satisfying patients not only by their medical skills, but by a soothing bedside manner, and generous donation of time to medical charities to treat the poor.
All practitioners were anxious to maintain the status of medicine as a skilled (and well-paid) profession. No wonder they were anxious to keep nurses in their place. Nurses were expected to carry out the doctor’s instructions: to give medicine, not prescribe it. Much of their work was confined to domestic tasks – keeping the sickroom or ward clean and fresh.
Nurse, Corstorphine Convalescent Home, Edinburgh c. 1900
Nurses were often photographed with children, affirming their status as carers. Male practitioners’ concern with status also explains the hostility of many doctors to female practitioners – if women were incapable of study, yet could obtain medical qualifications, then the public might start to believe that medicine was not a highly skilled occupation after all!
Scottish Women’s Hospital, Serbia
The services of women doctors were rejected by the British army, but the Scottish Women’s Hospitals, which were funded by charitable donations, went on to work in France and Serbia. Staffed entirely by women, they treated soldiers in France and Serbia, proving the competence of their female surgeons under difficult conditions.
Medical Practice in the 21st Century
The divisions of medical practice created in the 19th century – between general practitioners, consultants and nurses have proved to be very stable. But occupations are not set in stone. We may be at the beginning of another period of upheaval, with economic pressure for general practitioners to carry out simple surgery and for specialist clinics to be based in health centres. Practice nurses have taken on some of the routine aspects of the general practitioners’ work. Perhaps the boundaries are about to change again.