Monday, September 19, 2011

Regency Medical Men

This is my first post on Romancing the Past, and I'm so pleased to be joining the authors here! Since my first two regencies won't be coming out until 2012, I thought I might tackle a general topic today. Have you ever wondered why some medical men in historical romances (and during the regency, they were uniformly men) are referred to as "Doctor," and some are called just plain "Mister"? I'd like to discuss the differences between the three major medical practitioners working in nineteenth century England: physicians, surgeons, and apothecaries.

But first, a word about the state of medicine during the regency. Doctors had no sonograms, no X-rays, no MRIs; they didn't even have a germ theory of disease. Hippocrates had theorized centuries before that poor health stemmed from an imbalance of bodily humors, so doctors routinely bled or cupped their patients. Illness was also attributed to unhealthy vapors, leading medical practitioners to prescribe "a change of air." Because antibiotics were still unknown, compound fractures and other serious wounds usually meant either amputation or death, and frequently both. Childbirth, too, was often fatal, especially in maternity wards, where hospital-acquired infection drove the mortality rate as high as forty percent. Operations were performed only as a last resort, not only because of the high risk of sepsis, but also because the poor understanding of blood group compatibility made transfusions so risky they were not even attempted successfully until 1818. The use of modern anesthetics was still decades away. Want to read something harrowing? Try novelist Fanny Burney's letter to her older sister, in which she gives a first-hand account of her 1811 mastectomy. The operation required seven men and a nurse, most of whom were needed just to hold the patient down.

But if medicine was more art than science, the artists at the top of the professional ladder were physicians. Distinguished and expensive, they were socially respected figures who hailed from genteel backgrounds and obtained their educations at universities like Edinburgh, Oxford, and Cambridge.

Doctor examining an obstetric patient, 1831 (at least, that's his story and he's sticking to it).

As a percentage of medical practitioners, physicians were a minority, and until 1858 they weren't permitted to perform surgery or dispense medicines—not that they would have wished to stoop so low. They took a more cerebral approach, diagnosing internal ailments and perhaps deigning to write a prescription or two. Physicians' fees were charged in gentlemanly guineas, not pounds, and payment was a matter of some delicacy. Licensed by the Royal College of Physicians (such colleges existed in London, Edinburgh, Glasgow, and Dublin), they could trace the university degree they received back to the medieval church, and were the only medical professionals properly addressed as "Doctor."

Surgeons were not nearly so well regarded. Though respected today, in the early 1800s they had yet to live down their origins as medieval barbers. More numerous than doctors—in 1815, there were only 14 physicians attached to the Royal Navy, compared to 850 surgeons and 500 assistant surgeons—they were looked on not as true professionals but as technicians, sawbones who treated the distasteful aftermath of accident and infection.

Amputation without anesthesia, 1775. Compare the struggle here to the following picture.

Because blood loss was a major obstacle and modern anesthesia was unknown (Humphrey Davy discovered in 1799 that nitrous oxide could dull pain, but his discovery was never put to practical use), the primary skill to recommend a good surgeon was speed rather than finesse. Richard Hollingham notes in his book Blood and Guts: A History of Surgery how the famous surgeon Robert Liston could remove a limb in under thirty seconds—but once accidentally sawed off his assistant's fingers in the process. "The patient died of infection, as did the assistant, and an observer died of shock. It was the only operation in surgical history with a 300 percent mortality rate." In the face of such bold measures, cleanliness was considered an affectation; Liston reportedly operated in Wellington boots, and to free his hands when switching between the scalpel and the bone saw, he clamped the bloody knife between his teeth.

"The First Operation Under Ether" (detail), Massachusetts General Hospital, 1846.

(To Liston's credit, he also went on to pioneer the use of anesthesia in Europe, in 1846 amputating the leg of Frederick Churchill, a butler, while Churchill was under the influence of ether; Churchill subsequently survived.) To become a surgeon in 1800, a man had only to complete an apprenticeship and pass an examination, whereupon he obtained a diploma—though not a degree. Surgeons were (and in the U.K. still are, despite today's postgraduate requirements) properly addressed as "Mister."

So physicians were for the rich, and surgeons were for the desperate, but for most everyday medical complaints, patients consulted an apothecary. Apothecaries could trace their origins back to medieval grocers, who in turn grew out of the Guild of Pepperers. They were the nineteenth century equivalent of pharmacists (or chemists, if you're British), only they dispensed medical advice along with their pills. Up until 1704, apothecaries were supposed to know their place—namely, behind the counter of a shop, keeping their opinions to themselves and concocting remedies prescribed by a real physician. Then a disgruntled patient named John Seale sued his apothecary, William Rose, for "practicing physic"—that is, for charging the staggering sum of fifty pounds to sell Seale medicines that left him "never the better but much worse."

Apothecary's shop, 1752.

When Seale turned to the College of Physicians, they acted to shut Rose down, but Rose appealed and the House of Lords overturned the original judgment. The decision opened the door for apothecaries to practice medicine. Legally, an apothecary could not charge a fee, theoretically making his money only from the remedies he sold, though by the nineteenth century most apothecaries left a blank space on their bill for patients to write in the amount, if any, they wished to bestow as a courtesy in return for services rendered. Unlike physicians, surgeons could hold dual licensure as apothecaries; of the more than 6000 apothecaries' licenses issued between 1815 and 1834, more than half went to surgeons. Realizing the best way to expand the business was to bring new customers into the world, apothecaries quickly added midwifery to their repertoire. An 1815 act of Parliament required apothecaries to serve a five-year apprenticeship and pass an examination, and to have reached a minimum age of twenty-one. Perhaps the most famous of all English apothecaries was the Romantic poet John Keats, who was licensed but did not practice, choosing instead to compose odes and die tragically of tuberculosis.

Throughout the nineteenth century, the accelerating pace of scientific advances changed medicine profoundly. The social and legal distinctions between the professions evolved, until by 1900 they had assumed much the forms they have today. Sterile operating conditions and the advent of anesthesia reduced mortality rates considerably, raising the surgeon's prestige, while the apothecary's role narrowed to the more limited duties of the modern-day pharmacist. Physicians, meanwhile, remained as pleased with themselves as ever.

Alyssa Everett is married to a handsome doctor with an excellent sense of humor. Her debut regency, A Tryst With Trouble, is available now for pre-order from Amazon. She hopes you'll visit her website and follow her on Twitter, where she promises not to spam you relentlessly.

17 comments:

Claire Robyns said...

Very interesting.
Just colour me confused by the fact that my local GP is referred to as Dr while the specialist consultant (with about a hundred degrees behind his name) is a plain mister. I've been in the UK 8 years now and still can't wrap my head around it, but seeing the origins starts to make a little more sense out of it

Wendy Soliman said...

Welcome, Alyssa. Very interesting post but personally I can never get past the thought of those leeches literally sucking out my blood. Yuk!

Alyssa Everett said...

@Claire--Yes, it's odd, isn't it? UK surgeons go from Mister to Doctor when they finish medical school, then back to Mister again after their surgical training. (Or back to MIss or Mrs--thank heavens medicine is no longer an all-male domain.)

@Wendy--thanks for the welcome! Leeches completely creep me out, too. It's funny to think of doctors carrying around little jars of them inside their medical bags.

Karen Dobbins said...

This is great information, Alyssa. I am just astounded by the idea that no one immediately decided that nitrous oxide and its pain-dulling properties were important! I can't imagine how much our ancestors suffered when they were sick or injured.

Vonnie said...

Excellent blog, Alyssa. Thank goodness medicine has improved in leaps and bounds. I've often wondered why they bothered to operate, or rather amputate, when so many of their patients died anyway.

Tracey Devlyn said...

Thanks, Alyssa! I've long been fascinated with the history of medicine. I'll add this to my keeper file.

Gillian Layne said...

As Tracey, I will be adding this to my files. Excellent post, and I'm having fun looking over the other articles on this blog. Great job!

Cheryl Bolen said...

What a fabulously researched and fascinating post! I pity the poor blogger who must follow in your steps.

Alyssa Everett said...

@Karen--Wasn't that a huge missed opportunity? But nitrous oxide quickly got a bad rap, because young people started having nitrous oxide parties where they would get high and stumble around giggling and hurting themselves. The gas developed a reputation as an undignified recreational drug. Gillray did a cartoon showing nitrous oxide making the experimental subject fart, and other cartoons recommended giving the gas to "scolding wives" to make them be quiet. No one thought of it as an important or practical discovery.

@Vonnie--I'm certainly grateful for modern medicine! But I suppose they figured any chance was better than no chance at all, and untreated gangrene was always fatal. Thanks for the comment!

Alyssa Everett said...

@Tracey--Thanks so much, Tracey! I'm glad you found the post helpful.

@Gillian--Thanks to you, too, Gillian! It's a fun subject with lots of interesting sidelights.

@Cheryl--That's so sweet of you to say, but the blog posts here are always great reading!

Joanna Chambers aka Tumperkin said...

Great, informative post - thanks!

Alyssa Everett said...

Thanks, Joanna! I'm glad you found it informative.

Gerri Bowen said...

That was very interesting, Alyssa.

Rose Lerner said...

Coming late to the party, but what an awesome post! Also, now I want to write a nitrous oxide party in one of my books...

Alyssa Everett said...

@Gerri--Thanks!

@Rose--OMG, please write a nitrous oxide party scene! I would so love to read it.

Snigel 1962 said...

This is great - I'm the Antiseptics Global Training Manager for a large Medical Device company and I'm also an ex theatre nurse. With your permission, I'd like to include a link to your blog in my training material - would that be acceptable?

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