Medical Conflicts in Early Modern London: Patronage, Physicians, and Irregular Practitioners 1550-1640
Oxford, Clarendon Press, 2003, ISBN: 199257809X; 426pp.; Price: £65.00
University of North Florida
Date accessed: 24 April, 2014
Margaret Pelling, author ofThe Common Lot: Sickness, Medical Occupations and the Urban Poor in Early Modern England (London: Longman, 1998) and currently Reader in the Social History of Medicine at the University of Oxford, has produced a new volume in the Oxford Studies in Social History series, Medical Conflicts in Early Modern London. She continues to focus on those marginalized by the forces of history and by historians, in this case the 714 irregular practitioners referred to in the Annals of the Royal College of Physicians for the ninety years between 1550 and 1640. In her comprehensive examination of the Annals she finds a wealth of information about a city in flux, its neighbourhoods, and its denizens. She also relentlessly disparages the College for its collective suppression of medical rivals, a would-be domination of healing based not on a responsibility to safeguard the public good, but on economic, social, and sexual insecurities.
In its official capacity as the guardian of London’s health and regulator of the medical profession, the College, through the offices of President and Censor, prosecuted unlicensed practitioners whose activities were brought to its attention by outside complainants, including those at court, or by the Fellows themselves. While in the majority of cases no chief plaintiff can be identified, College members, patients, and other medical providers lead the list of identifiable petitioners. Londoners viewed the College as a ‘potential resource in the management of their own affairs’ (p. 84), ‘one recourse among many’ (p. 113), but the Fellows themselves never ‘claimed success in tracking down all irregulars within seven miles of the capital’.(p. 97) Despite concerns for its own legitimacy as an enforcement agency and for the professional status of its members, the College was overwhelmed by the circumstances ‘which made London a magnet for those providing and seeking medical care’.(p. 99) Pelling concludes that the College clearly failed to establish recognized hegemony over health-related issues among Londoners. Nonetheless, the College persisted in seeking out those who seemed to threaten its interests, particularly in those parishes where irregulars concentrated. Pelling points out, however, that a significant number of those pursued by the Fellows eventually gained entry to the College, ‘poachers-turned-gamekeepers’. (p. 140)
The College’s criteria for admission and licensing remained problematic and protectionist, ‘lagging behind a renewed tendency to study abroad’ (p. 142), and flexible only when powerful individuals intervened on a practitioner’s behalf. When the very English universities the Fellows considered essential for membership in the College incorporated holders with foreign degrees, trouble ensued, although Pelling insists that there is ‘little evidence of laxity on the part of the universities’.(p. 143n) Indeed, Pelling describes a Fellowship nearly identical to highly qualified irregulars and not discernibly superior to those with other kinds of occupational education. Barber-surgeons and apothecaries constitute the largest group, nearly 30 per cent, of those charged with the unlicensed practice of medicine, but ‘doctor’ appears as a significant category in the Annals.
Women and strangers were also among those accused of violating the law. Though women were underrepresented in the Annals and have been used by ‘College apologists’ as examples of ridiculous empirics (p. 189), Pelling goes to great lengths to examine female contributions to medicine in the capital, particularly during plague periods when distaff healers intruded onto the ‘homosocial’ Fellows’ turf.(p. 191) In Chapter 6, devoted entirely to women practitioners, she discusses the small number of cases involving females in the College sample, but concludes that women were more likely to be the ‘general practitioners of [their] day’ (p. 206) than their male counterparts. They were resourceful, too. While women often informed on one another to the College, she finds that they more easily deflected the Fellows’ summons. Additionally, Pelling assertively corrects the impression, ‘dating back to the pioneering work of Alice Clark’ (p. 203), that women who were paid to provide care outside the home lacked respectability. However, contemporary stereotypes about gender filled the College record and perpetuated erroneous negative attitudes about distaff healers.
Pelling lambasts the Fellows for pursuing strangers ‘disproportionately to their presence in the population, [yet] another way in which the College showed itself detached from London’s citizens’. (p. 336) The arrival of a Scottish contingent with James I necessitated some reconsideration of the College’s requirement that its Fellows be English, but despite the 1606 substitution of Britishness as essential to membership, Scots continued to be thought of as aliens by the Fellows. Although she briefly acknowledges that attitudes toward foreigners ‘fluctuated according to general economic as well as political conditions’ (p. 165), the word xenophobia does not appear in Pelling’s index.
Chapter 7 investigates the contractual nature of early modern medicine and, in spite of the Annals’ general depiction of submissive sufferers, Pelling finds active patients more characteristic of the patient-practitioner relationship outside of the College. Even within the Annals she uncovered named patients who initiated complaints against their doctors, confirmation that the role of contractual medicine appears ‘central rather than peripheral’.(p. 247) As a quasi-court, the College dealt not only with cases against unlicensed medicos but also with conflicts brought to it by hostile patients and practitioners. Pelling includes a chart illustrating the cost of medical contracts for most of her period, but argues that nothing in the College’s records precluded poorer patients and practitioners from making health contracts. Despite the apparent ubiquity of contractual medicine, English physicians ‘participated [in it] … [but] ultimately came to oppose it’.(p. 268) The College’s Fellows in particular found contractual medicine suggestive of the sort of commerce engaged in by tradesmen and therefore, according to Pelling, incompatible with what was expected of the professional elite.
Pelling also devotes considerable space to the influence of patronage on iatric matters. Chapter 8 recreates many of the confrontational scenes when the College attempted to emphasize its authority over irregulars, judging both their character and iatric conduct worthy of formal condemnation. However, although the Fellows imitated ‘the modes of authority closest to the crown’ (p. 276), nearly half of the actions they took were ‘inconclusive’.(p. 299) How did the irregulars fight back when they were charged? Sometimes they denied practising medicine and sometimes they brought in important patrons to intervene with the Fellows on their behest. Paradoxically, the College’s authority depended upon those titans ‘most likely, in practice to undermine it’ (p. 315), so the Fellows were careful to compliment the men of high rank who interceded for an irregular, all the while reiterating the requirements of the law they were charged with enforcing.
Though she primarily concentrates on those practitioners outside of the establishment, Pelling disparages the College or CPL (not ‘Royal’ for her period, she insists), and condemns its ‘self-conscious humanist intellectual’ Fellows. (p. 11) Chapters 1 and 2 are exclusively devoted to the anxious institution and its repressive activity under 53 different Censors. Pelling labels the Fellows inept in their ‘perversely’ intermittent exercise of authority (p. 42), parochial in outlook, and morally bankrupt for refusing to deal with plague and sexually transmitted diseases. She also finds them ‘parasitic’ (p. 55), routinely eschewing public offices, avoiding any meaningful philanthropy, and, despite their own ‘middling’ status, assiduous in their ‘disparagement of the lower middling sort and its institutions’.(pp.148, 336) In Chapter 8 she compares the College to Star Chamber, quite an incendiary indictment, given how publicly reviled that court became in its later years, a popular byword for unfair judicial proceedings. By frightening opponents into submission, then gaining ‘credit for clemency once submission was obtained, the College, as with Star Chamber’ exaggerated the pattern of authoritarian behaviour.(pp. 306, 311) Although she tempers her denunciation somewhat by claiming that this comparison also has to do with the failures that these courts shared (p. 299n), the implications of her judgment linger. The College must have been a fearsome institution indeed to warrant coupling to the dreaded Star Chamber, abolished for its excesses in 1641, unlike the College, which bumbled on through the centuries.
I wanted to enjoy this book, I really did. I wanted to revel in it, in part because Margaret Pelling is the doyenne of the social history of English medicine and in part because the completed tome was so long in coming, anticipated eagerly by specialists in the field. Pelling has devoted the better part of twenty years sifting through primary and secondary sources germane to various aspects of early modern medicine, struggling with the vicissitudes of diminishing funding and accelerating technologies, both of which threatened to derail her project. Attempting to fill the void in the evolution of medicine in the capital before 1640, Pelling has combed the College Annals so thoroughly that one cannot imagine there being any specific details left to consider. If the reporting of primary research can be said to be painstakingly meticulous, this is it. Furthermore, she has compiled a biographical index of medical practitioners in London and East Anglia for the period 1500-1640, not yet computerized, and a database of seventeen tables, attributed to Frances White, to be made available on the Internet. These contributions alone merit praise and thanks from future researchers.
And yet, reading Medical Conflicts in Early Modern London gave me little joy, certainly not in the way that one might expect to be thrilled by a most comprehensive examination in one’s own area of interest. It is not a book one could assign to a class because it lacks prudent balance and narrative style. In attempting to redress what she regards as the worshipful attitude of earlier authors writing about the College, Pelling goes too far in the other direction and produces a Manichean polemic that represents as good only those who practised medicine outside of that counterfeit institution. She upbraids Harold Cook for titling his 1986 work on the College The Decline of the Old Medical Regime in Stuart London (Ithaca: Cornell University Press), since that implies the institution and its Fellows had reached respected heights before 1630 from which to fall. Moreover, except for a pithy and focused concluding chapter, Pelling’s writing is dry, long-winded, and unengaging when it should be lively and magnetic, particularly since she has such an axe to grind with collegiate physicians. The tone is grimly sour, not just when barbs are directed at the College, but throughout the text and in its bibliographic asides. She also cavils at Cook for coining the term medical marketplace, a concept that has galvanized much historical research into English medicine but is too capitalistic and ‘now overdue for revision’.(p. 343) She disparages Andrew Wear for ‘leaving the core of socio-economic assumptions intact’ despite his demonstrating the importance of religious influences on early modern medicine. (p. 343) Even the late, exuberant Roy Porter comes in for criticism because she avers that he ‘maintained this tendency [to] see pre-modern physicians and quacks as one and the same’ (p. 13n), while for Pelling the quacks – antecedents of today’s general practitioners – clearly had it all over the collegiate physicians. The great irony of Pelling’s research is not lost on her – that she derives most of her exhaustive mountain of information on unlicensed practitioners from the records of their principal antagonist – but the conclusions of her research design perhaps prove inevitable. By drawing on the archive of an institution charged with prosecuting the very irregulars Pelling esteems, she discerns only adversarial repression and professional frailty on the part of the College.
Too many self-referential citations put me off as well. Apart from the Annals, Pelling is most likely to cite herself, mentioning her published and unpublished pieces on nearly every page. Having built an impressive oeuvre of articles written while compiling Medical Conflicts, Pelling feels the need to assure her readers that the book’s chapters are fresh and not recycled bits from the past two decades. There were few omissions in Pelling’s lengthy bibliography, which includes 22 of her own entries, but I found these noteworthy: Brian Nance’s 2001 study of Mayerne’s casebooks, Turquet de Mayerne as Baroque Physician (Amsterdam: Rodopi), published under the auspices of the Wellcome Library; and two early, influential articles in Ambix, Allen Debus’s piece on the Paracelsian compromise in Elizabethan England and Pyrali Rattansi’s seminal article on Paracelsus and the Puritan Revolution.(1) Pelling bemoans the absence of a thorough examination of Mayerne’s manuscripts and has so little to say, and that almost all in footnotes, about the theoretical split among the College Fellows. The internal rift between traditional Oxbridge Galenists and the growing number of Fellows continentally-trained in the curriculum of Paracelsus and van Helmont was surely as debilitating to the institution as the jurisdictional challenge presented externally by surgeons, apothecaries, and irregulars. And, happily, Kevin Siena’s forthcoming Venereal Disease, Hospitals and the Urban Poor (Woodbridge: Boydell Press/Rochester University Press, 2004) will fill the void in scholarship that Pelling laments about venereal disease in early modern England.
Acting like a defence attorney for the irregulars, Pelling has set out to prove them innocent of any charges of impropriety and has cast the College as the villainous, hypocritical prosecution, guilty itself of illegitimate shenanigans and cruel injustices. Courtroom dramas, past and present, usually compel our attention, but even though Pelling fashions an adversarial ambiance for her readers, the telling of her story remains one-sided, tiresome, and uninviting. Perhaps, given persistent assumptions about past learned physicians that nurture popular prejudices against research-oriented consultants today, or vice-versa, her challenge to the College’s hegemony over medicine will find an appreciative audience. But Pelling’s bleak view of the College is just one of many possible; we still await a complete and balanced institutional history. So, the challenge of retrieving an accurate picture of medicine in the Tudor and Stuart centuries goes on, with a new generation of historians eager to find fresh truths and test their own hypotheses.
- A. G. Debus, 'The Paracelsian compromise in Elizabethan England', Ambix, 8 (1960), 71-97; P. M. Rattansi, 'Paracelsus and the Puritan Revolution', Ambix, 11 (1963), 24-32.Back to (1)
I am grateful to Professor Furdell for devoting the major part of her review to giving some account of the contents of my book. This performs a useful service for readers. In this part of the review, Furdell makes it clear that Medical Conflicts deals with both collegiate physicians and irregular practitioners, but that the main purpose of the book is to gain access to the latter, while taking full account of the fact that we are seeing the irregulars through the eyes of their opponents.
The rest of the review is more attention-seeking than useful or revealing. It projects its own over-simplifications – and its own techniques of description ('lambast', 'upbraid', 'condemn', and so on) – onto its subject matter. Some readers may even be disappointed, on consulting Medical Conflicts, to find it lacking in the violent partisanship that Furdell’s epithets suggest. Similarly, my comments on the work of other authors are not as she represents them. For example, criticizing Cook for coining 'the medical marketplace' is precisely what I do not do.(Pelling, p. 342) Rather, I suggest that the concept is now in need of reassessment because it has been too automatically applied within the history of medicine without reference to economic content or geographical location. A candid reader might conclude that my style cannot be as Furdell represents it either, given her account of the book in the first part of the review. Overall, Furdell is presenting herself as an uncritical champion of the Royal College of Physicians (and some London historians of medicine), which she views without reference to historical context. The aim of Medical Conflicts with respect to the College was to redress the balance of historical comment, by assessing the strength of the College’s position in relation to the established structures of male authority.
In her own fashion, Furdell does raise the issue of seriousness. As its practitioners know only too well, the history of medicine can be done in two different ways. It can be light entertainment along predictable lines, or it can be more challenging. I chose to attempt the latter, and to accept the standards set for history as a whole – in this case, social and cultural history, defined in the most inclusive sense. It is for other readers to decide whether these standards have been met.
As this suggests, Furdell is unwilling or unable to engage with the substance of the book at the level either of its main arguments, or of the sources. Her summary aside, her own focus on the College leaves little room for the irregular practitioners. She accuses Medical Conflicts of lack of balance, but this is a fault on her side. Since she does not tackle the main issues, there are only a few matters of content in what she says which should perhaps be clarified.
First, she is likely to confuse the reader on the issue of stranger practitioners (and possibly also on the purpose of an index). My point here is that the College’s disproportionate pursuit of stranger irregulars, which was more or less constant, underlines both its isolation in London, and its focus on its own concerns. It did not follow the fluctuations in hostility and tolerance that have been noted for London as a whole, and which can be correlated with economic and political conditions.
I did not 'label the Fellows inept in their “perversely” intermittent exercise of authority'. The sentence on p. 42 to which Furdell presumably refers is: 'for the College, as a group of medical practitioners, the summer recess presents the apparent perversity of absence just when need among the general population was likely to be greatest'. One of the aims of this chapter was to prove, as directly and concretely as possible, that collegiate physicians did indeed flee the city during plague periods – a familiar contention, but one previously resting on anecdotal evidence or contemporary polemic. One of the concerns of the book is to balance the College against the needs of the population, and to estimate the irregular practitioners according to the value (negative as well as positive) likely to have been placed on them by Londoners as a whole, rather than by the College. As Furdell realises, it is the irregular practitioners who are the main focus of the book’s attention, but most of them are accessible only via the College’s account of them. Hence the need for analysis of the College’s forms of authority, and of the College’s Annals as a text. I was also concerned in this chapter to develop the concept of `monitoring’ of disease, that is, the service performed by physicians for their elite clients in deciding when it was safe for them to stay in the capital. Physicians themselves were inevitably caught up in this restless ebb and flow between London and the country, which helped to create the pattern of `seasonal’ living long familiar to those interested in the elite.
In her point about Star Chamber, Furdell again becomes simplistic. There are long-standing debates over the effectiveness of Star Chamber, and about the reasons for its abolition in terms of the bulk of its activities. Furdell also seems unaware of the literature that has established that the College, rather than merely bumbling, adapted itself quite dramatically to the changes of the civil war period.
With respect to what she calls 'the quacks', it is not clear what Furdell wants most: to imply that I think today’s GPs are descended from quacks, or to convict me once more of disrespect towards collegiate physicians. Either way, she seems unable to break free of the physicians-versus-quacks story that has persisted for so long. What the College’s Annals reveal is not only the overlap between the College and some of the irregulars, but also the 'excluded middle' of apothecaries, barber-surgeons, and other practitioners at the artisan level, with whom the College was so unwilling to identify, and whom it tried so hard to suppress. Medical Conflicts tries to provide a reconstruction of 'citizen' or contractual medicine, in which patient and practitioner arrived at a bargain (often conditional) based on an assessment by each side of the patient’s condition and of the likelihood of a cure. Such contracts were verbal, but forms of redress were available just as they were in cases of debt. It is this widespread, long-lived, and flexible urban system, rather than the patronage links dominating the College’s own affairs, which was the staple of early modern patient-practitioner relationships.
Similarly, Furdell misreads what I say about the literature on venereal disease. She brings forward Siena’s study, to be published by the same press as Furdell’s own work. I am sure this will be a valuable addition to the literature. However, my point (p. 341) was to deplore the fact that the contemporary preoccupation with this disease is still so routinely ignored, not by historians of medicine, but by generalists whose primary focus is on such subjects as poverty, manners, or gender relations.
Lastly, Furdell falls prey to the common vice of castigating a book for not doing what it explicitly states (for good reasons) it does not intend to do. I did not set out to provide an institutional history, not least because I regarded Furdell’s desideratum of 'a complete and balanced institutional history' as having been admirably fulfilled by Cook (I am surprised that Furdell apparently does not agree with me about this). Equally, I am fully aware of the importance of what she calls theoretical splits among the College Fellows. So important is the subject of the pluralistic medical philosophies of the period that it has already been handled by scholars over an extended period, primarily with reference to the published writings of the main protagonists. Partly for this reason, Medical Conflicts took a different approach.(See the Introduction, and especially p. 3) That said, the reader will find in the book a good deal of information about the educational, social and religious allegiances of College members, which is linked to the issue of how this might have affected their selective approach to irregular practice. Sources of intellectual authority are also dealt with as part of the content of confrontations between College and irregulars. At this point Furdell digs deep to find two early articles on Paracelsianism not mentioned in my bibliography; she seems unaware that these contributions, albeit pioneering, have been superseded, notably by Charles Webster. It is curious that she highlights Paracelsianism, given that the doctrines of Paracelsus constituted a reforming critique of established religious and medical institutions, which in the earlier part of the review she seems so concerned to defend.
The energy devoted by Furdell to issues of presentation is somewhat misplaced. The shape of the bibliography was determined by my decision to use only short titles in the footnotes, a decision which had disadvantages as well as advantages. However, Furdell’s contention about the footnotes is obviously absurd. As she admits, the bibliography is extensive (including multiple references to various authors). Because some of the themes of the book are complex or contentious, I wished to refer the reader to as wide a range of sources as possible, and also to further discussions where certain arguments, or information, were set out at greater length.(see p. viii) In accordance with normal scholarly practice, the preface to the book sets out what part of it has appeared in print before – in this case, different versions of sections of two of the nine chapters, one of them in Dutch.
No bibliography, however extensive, is without its oversights. Although the book does not set out to be comparative, I should like to take this opportunity of regretting that I made no reference to the work of Katherine Park, which I certainly should have done. I knew of Brian Nance’s work, but it was not available to me before my own book went to press. My comment about Mayerne referred rather to the project undertaken by Hugh Trevor-Roper, who died before he could complete it. There is some prospect that this work may be published posthumously.
I am naturally sorry that Furdell’s strenuous efforts to enjoy my book ended in such abject failure. Her own work is very different in its aims and techniques from my own, but all authors wish their work to reach as wide an audience as possible. Possibly she was over-hasty, both in her reading and in the writing of her review. She may also have underestimated the abilities of her students; certainly I can say that the book has been adopted for teaching in other universities. In any case, I would urge her students to retain an open mind, and to make their own comparisons between the works available to them.