It is impossible and misleading to analyse a dyadic relationship, such as the interaction between a ‘doctor’ and a ‘patient’, in isolation from its context. In this case, the socio-economic pressures upon practitioner-patient interactions from the sixteenth to the eighteenth centuries include the formation of the Royal College of Physicians in 1518, the Reformation of the 1540s, subsequent Poor Laws passed by Parliament, dissolution of the Scottish parliament after 1707, the British agricultural revolution, and the French Revolution in 1789. Medicine is shaped by its society. Just as Venice ceased to be Europe’s leading medical centre when its commercial power declined in the seventeenth century, so medical care in doctor-patient relationships were stratified with the charters of the Royal College in London.
While contextualisation provides assistance in addressing this question, clarification of the terms is absolutely necessary. First, we need to establish what ‘doctor’ and ‘patient’ really mean. In the sixteenth century, the term ‘doctor’ would be applied to a learned physician, perhaps a graduate of Oxford or Cambridge, or even a medical scholar from the Continent. As medicine had yet to evolve the qualities that twentieth century social historians would use to characterise it as a ‘profession’, ‘doctors’ were yet to have ‘patients’, so to speak. Instead, there was much more an element of a trade within the occupation, and medical practitioners relied on their abilities to attract patrons, clients or customers.
Medical practitioners ‘depended for success upon their reputation and this was extremely vulnerable to attack by colleagues’ (Harley, 1990). With its combination of mental and manual skills, the practice of medicine reflected ‘changing or conflicting attitudes to hierarchy and class’ (Pelling, 1987). The learned physician of sixteenth century Europe belonged to a higher social class than unlearned ‘quacks’, midwives, apothecaries, surgeons and folk practitioners, but that is not to say he was the most common or popular form of medical care.
Second, it is necessary correlate the context with the type of medical practice available, and their combined effect in changing, modifying and enhancing various aspects of the doctor-patient dynamic, focussing especially on Britain. In this essay, I will explore the variety of practitioner available, and the assorted factors that led to a patient choosing one type of medical practice over another. Throughout this essay, it is important to remember that the societies from sixteenth to eighteenth century Europe were not homogeneous, neither across international borders, nor within social classes themselves. In what follows, I plan to discuss the concept of power within this ‘doctor-patient dynamic’ and the effect of institutionalisation within this framework.
The variety of practitioner available meant that, regardless of social class, an individual had the opportunity to choose the type of medical care they received. Obviously, this was also dependent on financial resources, and the completely destitute could rely only on ‘poor relief’ within their parish. The traditional view of practitioners during this period is a tripartite hierarchy, with learned physicians at the top of a pyramid, more manual surgeons (or barber-surgeons) below, and many obedient apothecaries at the bottom.
This model is useful in starting a discussion about power dynamics, but it seems to represent homogenous isolated groups, and omits far more practitioners than it includes. It also does not allow for any sort of complex interaction, nor does it blur the lines for most informal practitioners who either practiced part-time or straddled the boundaries in the practitioner-pyramid. With the rise of medical education in the Renaissance, practitioners could have a wide range of skills, and some were multidisciplinary. However, only one per cent of practitioners could be considered ‘learned’, having spent the best part of a decade at university, learning in Latin, and the more ambitious of whom had studied in the Continent.
These practitioners, the ‘physicians’, usually attended to aristocrats and the social elite, because anyone from a lower class simply could not afford their fees. They dressed as finely as they could afford to give the impression of success (and hence, competence) and were trained to give their educated opinion on various medical conditions (perhaps a prescription would also be written, but they certainly did not indulge in manual labour of any kind). Surgeons, in contrast, were ‘skilled artisans’, whose activities were generally restricted to the external body, although they would perform bloodletting and bone-setting where necessary. While surgeons may not have been taught in Latin (instead they would have learnt by apprenticeship), it is likely that some were literate, like apothecaries who had to be able to read in order to concoct a prescription’s recipe. With this being a free market, any medical practitioner had to ‘court’ his (or her) patients with skills and by reputation.
In a free market, ‘the loyalty of patients was unreliable’ (Harvey). The ‘conditional contract’ (Pelling, 1987) meant that a patient could pay for the opinion of several practitioners before agreeing on a treatment. Ill people, when they could afford it, would transfer from one kind of practitioner to another in search of relief according to their judgement of the condition. At the extreme, this led to some patients hiring practitioners to cure the form of disease that the patient had diagnosed. Private transactions were assumed to be integral to the face-to-face ‘patronage’ relations said to be characteristic of medicine before 1800 (W. Munk’s The Roll of the Royal College of Physicians of London, 1878) but, as Pelling claims, I believe a practitioner’s reputation was a more significant feature in his practice.
The patronage of patients was ‘property for which the disputants were actually competing’ (Harley, 1990). Ultimately, the occupation was rife with competition, and, while guilds and corporations existed in urban areas to control and monopolise the medical market, there was no state provision to counteract the rivalry. All practitioners had to earn a living through private practice. The variety of practitioner available, and the common choice for a pluralistic treatment, meant the business of being a successful medical practitioner was a ruthless one.
With the British Reformation in the 1540s – Henry VIII declaring the English church free from Rome – the institution of the hospital (previously a Catholic charity) was removed and many such buildings were sold. While these institutions had not been places of medical research per se, they had provided bodies (cadavers) upon which dissection, an important Renaissance activity, could be performed. Dissection is an interesting example of a posthumous doctor-patient dynamic. When Henry VIII sold all hospitals and their land (except for St. Thomas’ and St. Bartholomew’s in London), the medical occupation lost a significant teaching resource. No medical institutions as such were built until the eighteenth century. On top of this, the poor (who had received some ‘relief’ at these hospitals) were now obliged to go to workhouses for medical attention.
This ‘indoor relief’ was generous compared to later in the period, but probably less preferable to the attentions of the nuns at the Catholic hospitals. This change in circumstance also highlights an interesting aspect of the doctor-patient dynamic: location. Affluent society would pay for a doctor or physician to attend to them within their own household in the sixteenth century. Interaction with an apothecary would occur at his shop (sometimes affiliated with a grocer’s), but generally medical treatment occurred within the private sphere. This was to change by the end of the eighteenth century, when the exclusive rules of the Royal College of Physicians prompted the formation of the College of Licentiate Physicians in 1767. The latter group were a dynamic, research-orientated collection of talented medical practitioners (including William Hunter, who would later be midwife to the Queen), some of whom had been spurned by the Royal College.
They were as much surgeons as they were physicians because a majority of them had been educated in Scotland (Edinburgh’s university was based on the Boerhaave model in Leiden) and felt their skills were not being valued as they should. As they were skilled in both surgery and physic, they were the foundations of the ‘general practitioner’ (although this term only came into use in the nineteenth century) who practiced in their own ‘surgeries’, where they would attend to patients.
Alongside this idea came the dispensaries: local establishments (the first of which was in 1769 in London’s Red Lion Square) which would attend any member of the poorer classes, and diagnose, treat, and dispense medicines for the illness without charge. John Reid reported in 1802 that these dispensaries facilitated access so that the physician could observe disease from beginning to end, providing a more efficient and satisfactory service. Dispensaries worked much like Voluntary Hospitals, in relying on subscribers to fund them. So the medical interaction of doctor and patient had gone from the public arena of a hospital and domestic sphere to more informal and confidential dispensaries and surgeries.
As Britain began its steady climb to the first Industrial Revolution in Europe, there were improvements in agriculture, commerce and trade. The increase in wealth meant the beginnings of a ‘middle-class’ with a higher disposable income (in other words, a class that could afford to buy something other than bread). A retrospective estimate places London as the most populous city in the world (even more than Constantinople) by 1750. Meanwhile, the British Navy was building the Empire in Africa and India, gaining wealth from raw resources abroad and new trade markets. All of these global changes created a bigger market to be supplied by medical practitioners in Britain, especially in urban areas, such as towns and cities, where most of the money was available.
A larger and more demanding population can support a wider range of practitioners. While an estimate of the ratio of practitioners to people in sixteenth century London is 1:400, it is likely that even smaller rural centres were able to maintain a higher incidence of qualified and unqualified practitioners. Competition was probably even greater by the end of this period, but there was certainly a greater financial viability. The interaction between doctor and patient must have grown more sophisticated, and the power dynamics (having been in favour of the patient population) probably became more balanced.
Even though, in 1783, Samuel Foart Simmons made a medical register stating there were three thousand medical practitioners in England and Wales (outside London), this is probably a gross underestimate because most medical practitioners were part-time or invisible within the domestic setting (in other words, women). Women provided up to ninety per cent of all medical care during this period, attending to their family members, their masters and mistresses, or within an informal setting, and were not greatly changed by external pressures because of the invisibility of their care.
The creation of an upwardly mobile population and changing infrastructure within the classes certainly provided opportunity for more people to access more types of medical care from practitioners visible within the literature; however their individual interaction with women carers was not affected because it was not recognised as a service, merely assumed as a given. Outside the household, struggles between old and new institutions may have created more disputes between rival groups within medical practice, but even though male midwifery began to be accepted as a specialist route, the role of female midwives remained a constant within the home. If recognition was given to these women, it was only in the form of learned medical men condemning their ’empirical medicine’.
Establishing a lucrative medical practice was often extremely difficult amidst the medical marketplace of the sixteenth century. Competition was not removed by the eighteenth century; if anything, the rising income of successful practice ‘perpetuated rivalry between physicians’ (Harley, 1990). Socio-economic changes, such as the Reformation and the Industrial Revolution, meant a change in the way both practitioners and patients responded to each other. The interface between rival groups of practitioners blurred (with the roots of general practitioners in the form of the College of Licentiate Physicians) and also became more apparent (with the separation of the Company of Surgeons from the Guild of Barbers), and this in turn affected the services they could provide to their patients.
An aspect of change which I have not addressed is the conceptualization of health and disease; while there were no major revolutions in this area during this period, one can deduce that a blurring of services provided by medical practitioners meant a cross-over in medical knowledge. Foucault’s concept of power/knowledge (Foucault, 1980) would extend this idea to support my suggestion that the equilibrium of power between patient and practitioner became more balanced. The political divisions of all three centuries affected all aspects of medical theory and practice, and the changes in dynamics between patient and practitioner lay the foundation for the subsequent effect of the French Revolution.
Harley, D (1990) ‘Honour and Property: The Structure of Professional Disputes in 18th century English Medicine.’ The Medical Enlightenment of the Eighteenth Century, A Cunningham and R French (eds.) Cambridge University Press, pp. 138-64
Foucault, Michel. (1980) Power/knowledge: selected interviews and other writings, 1972-1977, Harlow: Longman, translated by Colin Gordon
Oxley, G. W. Poor Relief in England and Wales, 1601-1834.
Pelling, M (1987) ‘Medical Practice in Early Modern England.’ The Professions in Early Modern England, London, pp. 90-128
Waddington, I (1973) ‘The Struggle to Reform the Royal College of Physicians, 1761-1771’, Medical History, 17, pp.107-26
Anouska Bhattacharyya Paper 7 Essay for Patrick Boner