Medicine and the Market in Ealry Modern England

Medicine and the Market in England and Its Colonies, c. 1450–c. 1850 Edited by

Mark S.R. Jenner and Patrick Wallis

Medicine and the Market in England and Its Colonies, c. 1450–c. 1850

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Medicine and the Market in England and Its Colonies, c. 1450–c. 1850 Edited by

Mark S. R. Jenner University of York

and

Patrick Wallis London School of Economics and Political Science

Editorial matter, selection and introduction © Mark S. R. Jenner and Patrick Wallis 2007. All remaining chapters © their respective authors 2007 All rights reserved. No reproduction, copy or transmission of this publication may be made without written permission. No paragraph of this publication may be reproduced, copied or transmitted save with written permission or in accordance with the provisions of the Copyright, Designs and Patents Act 1988, or under the terms of any licence permitting limited copying issued by the Copyright Licensing Agency, 90 Tottenham Court Road, London W1T 4LP. Any person who does any unauthorised act in relation to this publication may be liable to criminal prosecution and civil claims for damages. The authors have asserted their rights to be identified as the authors of this work in accordance with the Copyright, Designs and Patents Act 1988. First published 2007 by PALGRAVE MACMILLAN Houndmills, Basingstoke, Hampshire RG21 6XS and 175 Fifth Avenue, New York, N.Y. 10010 Companies and representatives throughout the world PALGRAVE MACMILLAN is the global academic imprint of the Palgrave Macmillan division of St. Martin’s Press, LLC and of Palgrave Macmillan Ltd. Macmillan® is a registered trademark in the United States, United Kingdom and other countries. Palgrave is a registered trademark in the European Union and other countries. ISBN-13: 978–0–230–50643–5 ISBN-10: 0–230–50643–7

hardback hardback

This book is printed on paper suitable for recycling and made from fully managed and sustained forest sources. Logging, pulping and manufacturing processes are expected to conform to the environmental regulations of the country of origin. A catalogue record for this book is available from the British Library. Library of Congress Cataloging-in-Publication Data Medicine and the market in England and its colonies, c.1450–c.1850/ edited by Mark S. R. Jenner and Patrick Wallis. p. ;cm. Includes bibliographical references and index. ISBN-13: 978-0-230-50643-5 (hardback: alk. paper) ISBN-10: 0-230-50643-7 (hardback: alk. paper) 1. Medical economics–Great Britain–History. 2. Medical care– Great Britain–History. 3. Medicine–Great Britain–History. 4. Medical economics–Great Britain–Colonies–History. 5. Medical care–Great Britain–Colonies–History. 6. Medicine–Great Britain–Colonies–History. I. Jenner, Mark S. R. II. Wallis, Patrick. [DNLM: 1. Economics, Medical–history–England. 2. Economics, Medical–history–India. 3. Economics, Medical–history–New England. 4. Delivery of Health Care–history–England. 5. Delivery of Health Care–history–India. 6. Delivery of Health Care–history–New England. 7. History, Early Modern 1451–1600— England. 8. History, Early Modern 1451–1600—India. 9. History, Early Modern 1451–1600—New England. 10. History, Modern 1601— England. 11. History, Modern 1601—India. 12. History, Modern 1601—New England. W 74 FE5 M489 2007] RA410.55.G7M46 2007 610.94109'024—dc22 10 16

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Printed and bound in Great Britain by Antony Rowe Ltd, Chippenham and Eastbourne

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Contents List of Tables, Figures and Illustrations

vii

Preface

ix

List of Abbreviations

x

Notes on Contributors

xi

1.

The Medical Marketplace Mark S. R. Jenner and Patrick Wallis

2.

Medical Economies in Fifteenth-Century England Robert Ralley

1 24

3. Competition and Cooperation in the Early Modern Medical Economy Patrick Wallis

47

4. The Rural Medical Marketplace in Southern England c. 1570–1720 Ian Mortimer

69

5. Magic, Alchemy and the Medical Economy in Early Modern England: The Case of Robert Fludd’s Magnetical Medicine Lauren Kassell 6.

The Marketplace of Print Mary E. Fissell

88 108

7. Recipe Collections and the Currency of Medical Knowledge in the Early Modern ‘Medical Marketplace’ Elaine Leong and Sara Pennell

133

8.

153

Midwifery in the ‘Medical Marketplace’ Adrian Wilson

9. Illness in the ‘Social Credit’ and ‘Money’ Economies of Eighteenth-Century New England Ben Mutschler

v

175

vi

Contents

10. Medical Marketplaces beyond the West: Bazaar Medicine, Trade and the English Establishment in Eighteenth-Century India Pratik Chakrabarti 11. Monopoly, Markets and Public Health: Pollution and Commerce in the History of London Water 1780–1830 Mark S. R. Jenner 12. Medicine, Quackery and the Free Market: The ‘War’ against Morison’s Pills and the Construction of the Medical Profession, c. 1830–c. 1850 Michael Brown Index

196

216

238 262

List of Tables, Figures and Illustrations Table 3.1 Table 4.1 Table 4.2

Household size and structure of medical practitioners (1692)

51

The proportion of higher-status males owing payments for medical care at death

80

The proportion of lower-status males owing payments for medical care at death

80

Table 6.1

Popular medical books in Robert Hooke’s Library

112

Table 6.2

Best-selling medical books (1641–1740)

115

Table 8.1

Locations of recorded Warwickshire apprenticeships (1710–60)

160

Premiums paid to medical masters (including barber-surgeons), Warwickshire (1710–60)

162

Premiums paid to medical masters (excluding barber-surgeons), Warwickshire (1710–60)

163

Premiums paid to non-medical masters in four periods, Warwickshire (1710–60)

163

Table 8.2 Table 8.3 Table 8.4

Table 10.1 Bazaar medicines used by the EEIC

Figure 6.1

202

Numbers of popular medical books published (1641–1740)

113

Figure 6.2

Genres of popular medical books

116

Figure 6.3

Genres over time

117

Figure 6.4

Percentage of books that claim royal authority

119

Figure 6.5

Books published for the ‘public good’ vs. ‘commercial’ ones

121

vii

viii List of Tables, Figures and Illustrations

Illustration 5.1

Illustration 11.1

Illustration 12.1

Robert Fludd, Medicina Catholica, Tract. II, Sect. 2, 344, reproduced by permission of the Wellcome Library, London

96

Robert Cruickshank, ‘Waterworks in Danger, or a Grand Cut at the MP for Westminster’, copyright Trustees of the British Museum

221

‘Fallacy of the Organic Theory’, reproduced by permission of the Wellcome Library, London

243

Illustration 12.2 ‘Extraordinary Effects of Morrisons Vegetable Pills’, reproduced by permission of the Wellcome Library, London

249

Preface This collection originated in a conversation between the two editors a number of years ago. It began to take shape at a workshop held at the Wellcome Trust Centre for the History of Medicine, University College London, in January 2005. We are grateful to all those who took part in what was a particularly fruitful occasion, and especially to Hal Cook who opened proceedings and to Colin Jones, Sandra Cavallo, Craig Muldrew and Willem de Blécourt who acted as respondents to the papers. We wish to acknowledge the financial support of the Centre and the Wellcome Trust, which made the workshop possible. The workshop took place just after the Centre had moved buildings and we are therefore especially grateful to Sally Bragg for her truly heroic work in organizing the event amid the chaos of the move. The chapter one benefited greatly from discussions both at that meeting and at a graduate workshop at the Centre. The editors would also like to acknowledge how much they individually or collectively learned from discussions on these themes with Hal Cook, Natasha Glaisyer, David Harley, Margaret Pelling, Adrian Wilson and the late Roy Porter. In addition they would like to thank Patricia Greene and Rosie Blau.

ix

List of Abbreviations Annals BHM BL Bodleian CLRO Cook, Decline Cook, ‘Good Advice’

EcHR GL JHM LMA MH ODNB OED Pelling, Conflicts Porter, Health Porter, Progress P&P SHM STC

TNA Wing

WMQ

Annals of the Royal College of Physicians of London Bulletin of the History of Medicine British Library, London Bodleian Library, Oxford Corporation of London Record Office, London Harold J. Cook, The Decline of the Old Medical Regime in Stuart London (Ithaca, 1986) Harold J. Cook, ‘Good Advice and Little Medicine: The Professional Advice of Early Modern English Physicians’, Journal of British Studies, 33 (1994) Economic History Review Guildhall Library, London Journal of the History of Medicine and Allied Sciences London Metropolitan Archives, London Medical History Oxford Dictionary of National Biography (Oxford, 2004) Oxford English Dictionary M. Pelling, Medical Conflicts in Early Modern London (Oxford, 2003) R. Porter, Health for Sale (Manchester, 1989) D. Porter and R. Porter, Patient’s Progress (Oxford, 1989) Past and Present Social History of Medicine A. W. Pollard and G. R. Redgrave, A Short-Title Catalogue of Books Printed in England, Scotland, & Ireland … 1475–1640, 2nd edn (1991) The National Archives (formerly the Public Record Office), London D. G. Wing, ed., Short-title Catalogue of Books Printed in England, Scotland, Ireland, Wales, and British America … 1641–1700, 2nd edn (New York, 1994) William and Mary Quarterly

Place of publication for works cited above and in the endnotes is London unless otherwise stated.

x

Notes on Contributors Michael Brown is Wellcome Research Fellow at the Centre for the History of Science, Technology and Medicine, University of Manchester. He received his Ph.D. from the University of York in 2004 with a thesis examining changes in medical culture, performance and self-representation from the late eighteenth to the mid-nineteenth centuries. He is currently researching the role of provincial medical and surgical associations in the ideological, rhetorical and imaginative construction of the medical profession in nineteenth-century England. He has published on a range of subjects within the cultural history of modern medicine, including medical sociability, asylum reform, public health and epidemiology, and is preparing a monograph based on his doctoral research. Pratik Chakrabarti is Wellcome Lecturer in the History of Modern Medicine, School of History, University of Kent. He is currently working on laboratory research in twentieth-century India. He was previously at the Wellcome Unit for the History of Modern Medicine, Oxford, where he worked with Mark Harrison on a project on medicine in eighteenth century British colonies. Their findings are currently being prepared for publication, provisionally entitled British Medicine in the Age of Empire: The East and West Indies, c. 1700–1830. He is also the author of Western Science in Modern India: Metropolitan Methods, Colonial Practices (New Delhi, 2004). Mary E. Fissell is Professor in the Department of the History of Medicine at the Johns Hopkins University. Her scholarly work focuses on the history of the patient, vernacular healing and gender relations. She is the author of Patients, Power and the Poor (Cambridge, 1991) and Vernacular Bodies (Oxford, 2004), and is currently working on a paper on gender jokes and a book about the best-selling early modern midwifery text/sex manual Aristotle’s Masterpiece. Mark S. R. Jenner is a Senior Lecturer in the Department of History, University of York. He has published extensively on the history of hygiene, health and on the history of London. He co-edited (with Paul Griffiths) Londinopolis: Essays in the Cultural and Social History of Early Modern London (Manchester, 2000) and is completing a study of early modern ideas of cleanliness and dirt. Lauren Kassell is a Lecturer in the Department of History and Philosophy of Science and a Fellow of Pembroke College, University of Cambridge. In 2003–4 she was a Member of the School of Historical xi

xii Notes on Contributors

Studies at the Institute for Advanced Study, Princeton. Her first book, Medicine and Magic in Elizabethan London: Simon Forman, Astrologer, Alchemist and Physician (2005), was shortlisted for the Royal Historical Society Whitfield Prize. She is now writing a book on magical ideas and practices in early modern England. Elaine Leong is a Leverhulme Early Career Research Fellow in the Department of History at the University of Warwick. Her current research project focuses on vernacular medical literature and ‘medical reading’ in early modern England. Ian Mortimer worked at the University of Reading (1993–4), the Historical Manuscripts Commission (1995–9) and the University of Exeter (1999–2003). In 2004 he completed a Ph.D. at Exeter, ‘Medical Assistance to the Dying, c.1570–1720’, and was awarded the Alexander Prize for an essay based on its conclusions. He is currently affiliated (as an Honorary Research Fellow) to Exeter, and working on an interconnected sequence of biographies of the rulers of England from 1327 to 1461, the first three volumes of which appeared in 2003, 2006 and 2007. Ben Mutschler is assistant professor of history at Oregon State University. His current book project, The Province of Affliction: Illness in EighteenthCentury New England, will be published by the Omohundro Institute of Early American History and Culture, where he was a postdoctoral fellow. Sara Pennell teaches early modern British History at Roehampton University. Her recent research has explored early modern manuscript recipe texts as an interface between prescription and practice, and a vehicle for knowledge transfer especially between women. She co-edited (with Natasha Glaisyer) Didactic Literature in England, 1500–1800 (2003) and is currently working on a monograph, The Uses of Food in Early Modern England. Robert Ralley is a Wellcome Research Fellow in the Department of History and Philosophy of Science at the University of Cambridge. He received his Ph.D. from the University of Cambridge for a study of ‘The Clerical Physician in Late Medieval England’. He is currently embarked on a project on ‘Medical Times in England, 1450–1550’. Patrick Wallis is a lecturer in the Department of Economic History at the London School of Economics. His current research focuses on the commercialization of health care in early modern England, the history of epidemic diseases and early modern social and economic history in general. He co-edited Guilds, Society and Economy in London (2002) and Quackery and Commerce in Early Modern London (2005).

Notes on Contributors xiii

Adrian Wilson completed a D.Phil. at Sussex and taught and researched at Cambridge and Leicester before taking up a Wellcome University Award at Leeds, in the History and Philosophy of Science Division of the Philosophy department, where he is now Senior Lecturer in History of Medicine. He is author of The Making of Man-Midwifery (1995) and editor of Rethinking Social History (Manchester, 1993). His main interests are history of childbirth and midwifery; the English voluntary hospitals in the eighteenth century; the history of pathology, especially the work of Morgagni; and historical theory.

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1 The Medical Marketplace Mark S. R. Jenner and Patrick Wallis

In the mid-1980s, a number of Anglophone historians began to describe health care in early modern England as a ‘medical marketplace’ or ‘medical market’. These terms were foregrounded by several scholars more or less simultaneously. The opening chapter of Lucinda Beier’s 1984 Ph.D. thesis (published in 1987) was entitled ‘The Medical Marketplace’.1 In 1985, Roy Porter wrote of the premodern ‘medical market place’ ‘where physicians, surgeons, and apothecaries . . . melted into each other along a spectrum that included thousands who dispensed medicine full- or parttime’,2 and Irvine Loudon observed that one of the most important unresolved areas of eighteenth-century medicine was ‘the extent of the market for medical care and how that market was satisfied’.3 The following year Harold Cook’s Decline of the Old Medical Regime began with a chapter entitled ‘The Medical Marketplace’.4 This terminology was not confined to scholars working on the United Kingdom. Katherine Park’s Doctors and Medicine in Early Modern Florence (1985) contained an identically entitled chapter.5 Most earlier accounts of early modern medical practice had either focused on the notional three-part occupational hierarchy of physicians who advised, surgeons who operated and apothecaries who prepared drugs, or else were simply dominated by a concern with learned, ‘professional’ practitioners. Other healers were either denigrated as ‘quackish’ or simply ignored. Developing pioneering work on the diversity of medical practitioners in early modern England,6 the medical marketplace literature was in the vanguard of a wave of scholarship that overturned all these assumptions and began to set out the characteristics of an emergent diverse, plural and commercial pre-professional system of health care. These studies stressed that the boundaries between physicians, surgeons and apothecaries were blurred to the point of irrelevance: regulation had 1

2 The Medical Marketplace

limited force, professionalization was anachronistic.7 Early modern practitioners, they argued, competed for custom in an open ‘medical marketplace where services were advertised and sold to those sufferers who cared to shop’. Patients had ‘relative freedom to choose the medical practitioners they liked’; they were ‘medically promiscuous’, selecting therapies and therapists according to their estimation of the practitioner’s effectiveness or manners, not to mention cost.8 For all their intellectual pretensions, learned physicians did not command any real degree of cultural authority until the nineteenth century. As the medical marketplace literature revealed, in any year a sick person might visit a wart-charmer, get a remedy from a neighbour or bookseller, pay for a surgeon and hire a horse leech.9 These works marked the coalescence of a new way of describing early modern medicine and were at the forefront of a revolution in the history of medicine.10 Medical market terminology has since been adopted to analyse contexts ranging from the Graeco-Roman world to nineteenth-century South Africa.11 Concurrently – and not accidentally – the marketplace has become ubiquitous in political, popular and academic discussions of contemporary health policy and provision. ‘Market’ mechanisms and terminology now play a far more prominent role in health care in most developed countries than they did in the 1980s.12 However, the success of the idea and language of the ‘medical marketplace’ has come at a price, for historians at least. As the concept has been applied to an ever-wider range of settings and employed by an ever-expanding variety of historians, its meaning has become vague to the point of confusion. Ironically, ‘marketplace’ language seems at times to have made it easier to avoid engaging in fuller studies of the market or the medical economy. Two decades after the medical marketplace became a commonplace, historians still know very little about the scale, scope, boundaries or internal dynamics of the market for medicine. Furthermore, the very idea of a ‘medical marketplace’ has also begun to attract criticism. As Margaret Pelling recently noted, the concept ‘is . . . overdue for revision’.13 This book undertakes a critical examination of the ‘medical marketplace’, its uses and abuses. The essays focus on the nature of medical provision and its economic, institutional, cultural and political contexts in order to develop and refine fundamental concepts and arguments associated with our understanding of medicine and the market in England and in Britain’s colonies between 1450 and 1850. Together, contributors demonstrate the importance of not only analysing the relationship between medicine and the marketplace, but also historicizing key terms such as medicine, the market and the economy.

Mark S. R. Jenner and Patrick Wallis 3

This clarification and re-examination is crucial. Social historians of medicine in early modern England took up this terminology with little discussion (and possibly little awareness) of how it had been employed in other fields, and have often used this language with little precision and sometimes in contradictory ways. Moreover, there has been little discussion of how far 1980s accounts of the ‘medical marketplace’ should be revised in the light of new research into the early modern economy that emphasizes the socially embedded nature of economic relationships.14 As we outline below, one theme that emerges clearly from this collection is the need for greater consideration of the nature of exchange and value in medicine that sensitively explores this and similar themes.

The medical marketplace and the history of medicine It is important to emphasize at the outset the achievements of the ‘medical marketplace’ literature. Previously, much (though by no means all) medical history concentrated on ‘great figures’ and on internalist intellectual history. The medical marketplace came as a breath of fresh air. It swiftly became part of the vernacular of early modern English history, a development likely facilitated by the wider spread of the language of the market since the 1980s.15 (The first time the term ‘medical marketplace’ appeared in The Times was in a 1985 editorial commending proposals to pay doctors by results.)16 Historians found that the term had appealing intellectual advantages. It helped demystify medical pretensions. It underlined the anachronism of standard categories and assumptions about professional boundaries, ethics and authority. It emphasized that medicine was a service that was purchased in a competitive arena at a time when contemporary medicine was largely isolated from commercial pressures. It encouraged research using a wider range of sources. It built bridges with developments in economic and cultural history, not least work describing eighteenth-century England as the first consumer society.17 For students, it made medicine ‘strange’ and encouraged critical thinking. Many consider that this analytical vocabulary helpfully conceptualizes the sick person as an active consumer of medical services.18 Above all, perhaps, scholars found that discussing medicine as a marketplace helped them undertake ‘Medical History from Below’, studies as concerned with laypeople as with practitioners or medical ideas.19 Yet the analysis of the early modern world as a medical marketplace has not swept all before it. Several recent studies of European medicine in this period have preferred different analytical frameworks. Reflecting

4 The Medical Marketplace

on early modern Italy, David Gentilcore has argued that the medical marketplace model unhelpfully obscures religious and magical explanations of, and remedies for, disease. He instead proposed a model of overlapping, but not homogeneous, healing communities.20 Lawrence Brockliss and Colin Jones, by contrast, have stressed the fundamentally corporatist nature of medicine in sixteenth- and seventeenth-century France, depicting a medical community surrounded by a ‘penumbra’ of informal and irregular healers rather than the unstructured free-for-all seemingly characteristic of England.21 Historians of English medicine have also expressed reservations. David Harley has noted that the marketplace model can lead historians to treat practitioners as ‘social equals, supplying an undifferentiated commodity’, obscuring social stratification and restrictions on the freedom to trade.22 Mark Jenner has argued that it obscures religious and political definitions of ‘quackery’.23 Andrew Wear has suggested that the marketplace is not the best way to address charitable or lay physic, and that cultural forces need to be placed alongside economic imperatives.24 Behind many of the problems that scholars have identified with the medical marketplace lies a broader confusion about this terminology. At present historians use the term ‘medical marketplace’ in at least three ways. Rather confusingly these include synchronic and diachronic applications. The opening chapter of Cook’s influential Decline of the Old Medical Regime is a case in point. An introductory survey, its key point is that there was a huge range of medical assistance available in the capital. Drawing on examples from across the seventeenth century,25 it showed that one might receive medical help from one’s friends, family or household; folk remedies; neighbours or charitable clerics; apothecaries and astrologers; and midwives and mountebanks, not to mention surgeons and sellers of simples. Other works sketched the early modern medical marketplace through colourful and capacious catalogues.26 This application of the term to convey an image of the pluralistic diversity of medical provision is perhaps the dominant usage. But Cook’s book also presented an argument about the emergence of a medical marketplace. By the end of the seventeenth century, he suggested, ‘the creation of a market for medical skills and services’, the diffusion of over-the-counter drugs and the growth of a monetarized economy had coalesced with political developments to transform medicine and to eclipse the College of Physicians’ dreams of regulation. In these sections of his book, therefore, the ‘medical marketplace’ appears to have a different meaning, standing for a particular stage in the process of commercialization of health care; now the pluralism described by the

Mark S. R. Jenner and Patrick Wallis 5

first meaning is presented as the product of the conjunction of social and economic forces specific to this period. Other works similarly intertwined such dynamic and descriptive uses of medical marketplace language,27 and Roy Porter’s discussions of quackery embedded it in a vivid (if static) account of Georgian England that stressed how, viewed within the longue durée, its medical marketplace reflected the nation’s development as ‘a commercial capitalist, spectacle-loving, consumer oriented society’.28 In such accounts, the ‘medical marketplace’ is shorthand for claims about the fundamental transformation of the medical economy during the early modern period. These studies developed long-established narratives of the development of ‘modernity’ and of capitalism, accounts which charted a decline in charitable, community and domestic health care in the face of emergent capitalism.29 And although Cook and Porter emphasized how the commercialized nature of early modern English medicine reflected the nation’s economic and social distinctiveness, this metanarrative is not peculiar to English or European history. There is, for instance, an extensive literature on the ‘market revolution’ in American society and American medicine which was expressed most influentially in the historiography of medicine in Paul Starr’s The Social Transformation of American Medicine.30 They also had affinities to older histories of medicine. In 1946 Henry Sigerist described how the sixteenth-century physician had to respond to a ‘new economic order’ of ‘free competition and free initiative’.31 In the 1960s R. S. Roberts concluded that seventeenth-century provincial practice ‘seems to be a natural example of supply and demand in which attempts to control the market, as it were, by legislation . . . completely failed’.32 However, some medical historians have developed a third variety of marketplace model which is not simply descriptive nor an aspect of early modern commercialization. They suggest that medicine can be analysed as a service provided through the workings of market mechanisms almost irrespective of period. Drawing heavily, although normally implicitly, on materialist models of culture and knowledge, scholars working in this vein have interpreted doctors’ behaviour and developments in the form and content of therapy or practice with reference to their entrepreneurial ambitions and economic circumstances. Such claims can be somewhat impressionistic, but some studies have constructed quantitative models of a medical marketplace, often relating medical changes to what Victorian commentators sometimes termed the medical labour market – fluctuations in the supply of, and demand for, medical practitioners.33 Irvine Loudon, for instance, argued that there was an ‘over-production

6 The Medical Marketplace

of general practitioners’ in the early nineteenth century. This encouraged doctors to form associations designed to fix fees and helped create new professional identities.34 However, such work is relatively rare except in the historiography of US medicine: changes in the supply, demand and price of medical care before the twentieth century remain poorly understood.35 This approach follows a path set out by social scientists in the 1970s.36 During that decade some sociologists of the professions developed Max Weber’s discussions of monopolization to explore how physicians established ‘domination over the market’.37 Sociologists of knowledge too employed this style of thinking. Among historians the most influential was Nicholas Jewson, who suggested that the changing styles and cognitive content of eighteenth- and nineteenthcentury medicine should be related to the changing social and economic basis of practice, what he called the source of patronage.38 Each of these ways of using the terminology of the ‘medical marketplace’ has had its attractions. However, they are of varying utility and have quite different implications. The first ‘pluralist’ medical marketplace is little more than a descriptive commonplace. It serves in the main as an underspecified counterpoint to domestic and professionalized medicine, which are seen as bracketing it in a loosely stated chronology. It gives little indication of how shifts between these different structures occurred, or what determines the spectrum of practitioners. And as various contributors emphasize, it is not always helpful to equate medical pluralism with the medical market.39 The second ‘commercializing’ medical marketplace provides the clearest chronological and empirical narrative, although the details remain uncertain. It has the strongest relationship to broader historical literatures in positing a role for medicine within a wider set of economic and social changes identified as occurring in early modern England. It also generally gestures to various external reasons for change, largely in terms of increasing wealth and urbanization, although as yet there has been no really satisfactory examination of the different factors in this process. The third ‘structural’ medical marketplace offers a more universalized emphasis on the connection between the content of medicine and the economic situation of health care. It thus highlights the relevance of sociological and economic approaches. However, in doing so it normally adopts rather than extends these disciplinary perspectives, and it carries with it some of the problems of its sister schools in assuming the priority of the material over the cultural or intellectual, understating the significance of external constraints and non-human actors and drawing unhelpfully sharp divisions between content and context.40

Mark S. R. Jenner and Patrick Wallis 7

The difficulties that these co-existing definitions present can be seen in how they draw different boundaries around the medical marketplace. If one conceptualizes the afflicted person as a consumer and presents every aspect of their search for relief or assistance as a kind of shopping, then including both commercial and non-commercial curers within it makes sense. Hence, scholars who use the term to describe medical pluralism often include domestic, charitable or other kinds of unpaid therapeutic assistance in surveys of the marketplace. Lucinda Beier, for instance, presented Lady Margaret Hoby’s charitable medical assistance as part of the medical marketplace. Others restrict the category to medical assistance for which the sick paid. Kevin Siena, for example, presented those selling remedies for venereal disease as part of the medical marketplace, but considers charitable treatment in hospitals and parish workhouses as outside it.41 These ambiguities are artificial, as is the debate about the position of commercial and domestic provision in the medical marketplace. Such arguments derive from the lack of a single clear definition of the ‘marketplace’, and are not necessarily indicators of any substantive conceptual or empirical divergence over the sources of health care or their relative importance. Given these divergent meanings and approaches, it might be argued that it would be best to abandon the terminology of the medical marketplace altogether. However, the resonance and familiarity of the language suggest that the chances of success for any such attempts at conceptual clear-cutting would be low. A more rigorous engagement with what is meant by the medical marketplace, while more modest, does seem an attainable ambition. In part, it is this we are urging here. More important, though, is that medical historians move beyond making linguistic nods to the economy of health and medicine, and engage seriously in the study of medicine, health and the market and reflect more explicitly on the ethical and political dimensions of using this kind of language. There is probably nowhere that this is more important than for the early modern period. For this reason, the essays gathered here concentrate on re-examining what we have described as the second of the approaches to the medical marketplace: that is the medical marketplace as a process and a period in the history of medicine.

An emerging medical marketplace? In presenting the sixteenth to eighteenth centuries as an era of commercialization and pluralism with at best ineffective regulation, historians overturned assumptions about the inevitability of the rise of

8 The Medical Marketplace

professional structures. Instead, they depicted a market for medicine that seemingly flourished independent of its therapeutic efficacy or access to authority. However, this historiography has thrown up further fundamental questions that are, as yet, unanswered. First, given the loose sense of period apparent in some discussions, when and where did the medical marketplace appear and disappear? Second, why did it do so? Drawing on the then standard accounts of the English economy, the earliest studies of the medical marketplace between the sixteenth and eighteenth centuries contrasted it with a largely non-market medieval medical system. Since that time, interpretations of the medieval economy have changed substantially. Scholars such as Britnell and Dyer emphasize that medieval England was strongly market-oriented, and that much production was for commercial ends.42 Robert Ralley’s chapter highlights the financial rewards of some medical work in the fifteenth century, demonstrating continuities with later periods. However, he also emphasizes that it was not a ‘medical marketplace’ avant la lettre: medical practice was far less commercialized than that depicted by Cook’s Decline. As his discussion of ‘medical economies’ makes clear, the boundary between the commercial and the non-commercial in medical matters is never straightforward, and while levels of commercialization clearly grew, there was no linear progression from altruistic and neighbourly assistance to the cash nexus, or from patronage relations to the capitalist marketplace and then to professional medicine. Ian Mortimer’s recent work has mapped parts of this transformation, providing the first plausible quantitative data on the growth in demand for medical services over the seventeenth century.43 In his chapter, he demonstrates both that specialist medical practitioners became more widely dispersed through rural Southern England over the sixteenth and seventeenth centuries and that an increasing percentage of probate accounts reveal payments for medical care over the same period. Between 1690 and 1719 half the number of higher-status males and one-third the number of lower-status ones leaving probate accounts owed payments for medical care before their death. Large parts of the English population, it seems, had been drawn into a medical marketplace; inhabitants of rural areas were only a couple of hours from specialist medical practitioners and increasingly paid for their assistance. Such indicators are only available for Southern England, for people with both worldly goods and an ultimately fatal condition. Even without these problems of sources, it is clear that the process of commercialization was far from simple. First, not all sections of medicine were

Mark S. R. Jenner and Patrick Wallis 9

drawn into such exchanges at the same rate. Venereal disease cures were particularly commercialized; the market in vernacular medical books expanded enormously from the mid-seventeenth century. Midwifery was, by contrast, far from straightforwardly commercial in character. Second, the growth of commercial supply did not simply supplant domestic medical provision. The informal exchange of medical recipes and remedies retained its vitality and importance throughout the eighteenth century. Third, the ‘unit of consumption’ is hard to define and changed over time. In seventeenth-century England, it is clear that the allocation of the costs of health care and decisions about consumption were made within the household. We should never assume that the consumer of medicine was an independent economic agent.44 Finally, commercialization did not simply trickle down the social hierarchy. Among the poor, reliance on commercially supplied health care might, counter-intuitively, occur in advance of their social superiors. In Colonial New England, the itinerant poor, those weakest in social bonds, were driven soonest to rely on paid health care, albeit often subsidized by community funds. Only those established within communities possessed the social capital sufficient to delay the unwelcome shift into reliance on commercially supplied health care. In England, while many of the labouring poor could not afford commercial medicine from their own purses, they quite often received medical assistance through poor law or parochial provision or through institutional and personal charity, and the Old Poor Law was therefore a major purchaser within the economy of health care.45 Given these complexities, it should be clear that we are still far from a convincing analysis of the economy of early modern health care. The ‘end’ of the medical marketplace is equally troubling. The early modern medical marketplace has generally been represented as being supplanted by the advent of professionalized medicine in the nineteenth century, notably the advent of medical registration in 1858. Yet the impact of these changes remains contested. Michael Brown’s chapter emphasizes that while there were significant changes in medical identity and organization in this period, this transition was complex and uneven: the ‘victory’ of the doctors was neither inevitable nor universally welcomed. Moreover, despite this notionally being the age of reform, the nineteenth-century proprietary medicine trade was much larger than that of the eighteenth.46 The emergence of new professional identities was a protracted and much-contested process. Much of what was captured by the idea of a medical marketplace remains relevant in the nineteenth century. Professional controls have

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The Medical Marketplace

never been unchallenged nor have they ever embraced anything like the full range of healing practices. At the most obvious level, it is clear that ‘irregular’ and community healing remained significant sources of medical assistance into the twentieth century, while domestic and religious cures and the supply of care retained a major role.47 Indeed, the nineteenth century was perhaps the heyday of thinking about medicine as a market. Whereas seventeenth- and eighteenth-century satirists presented practitioners as cynically maximizing profits, abstract discussions of medicine as a market seem to have developed in this later period.48 With the spread of the discourses of political economy, Regency and Victorian practitioners may have become more inclined to think in this way. Many early nineteenth-century discussions of health issues debated free trade and monopoly. Some letters to The Lancet during the nineteenth and early twentieth centuries analysed medical practice in starkly commercial and market-oriented language.49 It may be that such terminology was only felt to be inappropriate for discussions of British medicine between the late 1940s and late 1970s when the National Health Service was indeed agreed to be a national service.50 Certainly there remains a need for a longue durée analysis of the ways in which medicine has been conceptualized and imagined through the languages of trade, market and political economy.51 Why the ‘medical marketplace’ developed in the early modern period and in the way that it did is even less clear than its chronology. The initial studies of the ‘medical marketplace’ were rarely specific about the processes underlying its emergence and change. It is striking that few historians of Britain have discussed how far epidemiological factors, like the presence or absence of plague,52 or new medical techniques, instruments or goods, such as inoculation and the forceps, reshaped it.53 Cook’s discussion of practitioners in seventeenth-century London is unusual in even identifying a number of potential explanations, in particular the effect of urbanization and the general extension of the market economy.54 Some historians have suggested that competition between practitioners was the impetus for change and medical innovations such as man-midwifery and private madhouses. Others have presented the medical marketplace as growing because of the general expansion in the English economy, interpreting it as part of the rise of consumer society. Discussing the rise of proprietary medicines, Porter even resorted to assertions about a burgeoning bourgeois ‘fetishism of goods’, affluence and convenience to explain the growth in supply and consumption of drugs.55 What we have to date is more a cast of likely suspects than a convincing plot.

Mark S. R. Jenner and Patrick Wallis 11

The limits of our understanding of the causes of medical commercialization are well illustrated by the uncertainties that surround the effect of the growth of towns and cities on health care. Urbanization is, ironically, probably the best defined of all the wider factors cited in the literature. It is clear that urbanization increased dramatically in this period: between 1500 and 1700, the share of the population in England and Wales living in towns of over 5000 people increased from 7.9 per cent to 27.7 per cent.56 However, whether and how it drove demand for health care remains uncertain. Much history of medicine has long concerned itself with activities in urban settings, while Mortimer’s identification here of commercial medicine as initially urban-centred supports the suggestion that urban growth somehow induced commercialization. However, it is a large step from identifying such a spatial pattern to determining what it was about urban life – the density of demand, the concentration of wealth, higher morbidity, weaker communities, greater distance from ‘natural’ resources – that caused increasing reliance upon the marketplace for medicine, let alone to being sure that urbanization is not a proxy for other more fundamental changes in wealth or taste, or even simply an artefact of our sources. Nonetheless, while the increase in commercial health care still needs to be properly explained, it is now possible to make more refined judgements about at least some factors. First, assertions about a connection between general affluence and medical consumption seem increasingly implausible. While the real wages for labourers in London did rise slowly from the early seventeenth century, they did so following a fall in the late fifteenth and sixteenth centuries, begging the question of why there is little evidence of widespread demand for commercial medicine in the early fifteenth century. Interpretations of the medical marketplace as largely confined to the middling sort and the elite seem more plausible: their living standard rose faster than that of the poor during the seventeenth century.57 It is also worth highlighting the changing content and scale of commercially available drugs, particularly those imported from abroad. Only a minor theme in the earlier ‘medical marketplace’ historiography, where interest in commercialization overshadowed the material culture of medicine, some scholars now view this as potentially a key factor driving changes in the form and size of demand for medicine.58 Finally, as Fissell argues here, changes in the print trade, publicity and the public sphere seem to have contributed to the expansion of demand and supply.59 Like recent work on consumption and the world of goods, these approaches link consumer desires with ‘the social and economic

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The Medical Marketplace

processes . . . connected to particular commodities, their production [and] distribution’.60 Changes in medicine were complex cultural transformations.61 As Wilson notes, it is implausible to suggest that supply and demand can on their own explain the form of a medical innovation or specialization.62 More fundamentally other authors reformulate how we might understand ‘supply’ and ‘demand’, paralleling recent work in modern health economics on the nature of medicine as a commodity. In different ways Mutschler, Mortimer, Leong and Pennell suggest that an individual’s ‘demand’ for medical assistance was related to their household and neighbourhood resources.63 Wallis, Kassell, Fissell and Chakrabati demonstrate that we need to attend to the cultural and social construction of particular medical goods and services if we are to understand what was being supplied. Factors which might seem intangible to modern eyes – the practitioner’s ability to manipulate occult forces, their trustworthiness or ability to call upon other practitioners, the ‘exotic’ qualities of a good, the readability of a pamphlet – are all shown to be inherent to the value of goods and services supplied on the medical marketplace.

Medicine as a market or an economy This desire to historicize informs contributors’ approach to other categories fundamental to discussions of the ‘medical marketplace’. As Leong and Pennell observe, in the early modern period it is more accurate to write of the oeconomy of health care. This distinctive term, linking household management and commercial activity, better captures early modern mentalities and realities. Lauren Kassell is even more radical: fundamental to her account of magnetical medicine is a demonstration that the spiritual ‘economy’ flowed into the medical economy; such occult medicine was based on a bodily economy quite different from our own and quite different from the account of the economy propounded in the historiography.64 Such observations highlight two further questions running through this collection. How best should we characterize people’s conduct within this marketplace, and what was traded within it? Economic activity is embedded within all kinds of social conventions and legal norms; the very nature and units of exchange are historically contingent. Historians need, therefore, to be wary of making sweeping assumptions about the nature of ‘market activity’. Furthermore, the characteristics of exchange vary according to the kind of goods and services being traded.65 Markets

Mark S. R. Jenner and Patrick Wallis 13

for health care in particular appear very often to take on distinctive features related to the unusual characteristics of the products and services involved. This has been brought out most famously in the work of the economist Kenneth Arrow on the effects that pervasive uncertainty about levels of demand and the quality and efficacy of treatment have on consumers and suppliers of health care in later twentieth-century American medical markets.66 It is precisely not our point to suggest that uncertainty is somehow essential to all medical economies. Nonetheless, many of Arrow’s ideas do seem to echo some elements of the premodern medicine, and, as with Craig Muldrew’s work on trust,67 which is to an extent indebted to it, historians need to engage seriously with the particular historical construction of and response to uncertainty and related problems of information. It may well be that participants in the less regulated, more fluid and more fragmented medical economy of early modern England faced higher levels of uncertainty than modern consumers, despite the relatively narrower gap between lay and specialist medical knowledge. Certainly, the efficacy of drugs and the calibre of doctors were suspected more than celebrated in early modern England. The consequences of this are only now beginning to be explored.68 When thinking about the characteristics of exchange, it is obvious that one of the most distinctive elements that seemed to differentiate early modern and modern medical economies is regulation. In contemporary Western medicine the prevalence of licensing requirements for health care providers, restrictions on advertising and ethical norms that oppose direct competition all serve to limit consumers’ freedom of choice in the interest of ensuring the quality of the medical services they receive. By contrast, writers on the medical marketplace such as Roy and Dorothy Porter portrayed medicine in early modern England as a free market, stressing that there was little effective regulation of practice. Compared with much of mainland Europe, there was indeed relatively less state or ecclesiastical regulation of medicine.69 However, the language of the free market, with Friedmanite echoes, is misleading.70 Firstly, guild, ecclesiastical, civic and other regulations were far from a dead letter for much of this period, as Cook in fact argued in his original study of the College of Physicians. Charlatans and other nostrum sellers working in physical marketplaces were subject to extensive controls,71 while there were appreciable constraints on publishing up to 1695. More fundamentally, social pressures often curbed buccaneering forms of medical profiteering, as Ralley, Fissell and Mortimer highlight. Legal and contractual norms restricted practitioners’ behaviour,72 while

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The Medical Marketplace

any who wished to build up a geographically defined reputation and practice had to take cognizance of less formal, but equally tangible, expectations about fair conduct.73 Emphasizing how medical practice was embedded in social relations also qualifies the stress on competition found in the historiography. According to Anne Hardy, ‘It has become customary to speak of a medical marketplace when describing the range of treatment options available to eighteenth- and nineteenth-century patients, because of the number and variety of “practitioners” . . . competing for their custom.’74 Porter wrote that ‘medical men of all sorts were competing for custom, recognition, and reward. Each in his own way – top physician, humble general practitioner, empiric, folk healer – made his bid to seize the moral high ground in a medical arena in which the law was acknowledged to be dog-eat-dog’.75 In contrast, as Patrick Wallis demonstrates here, medical practice involved as much co-operation as competition; practitioners, particularly in urban areas, formed quasi-firms which facilitated their work, allowing the circulation of expertise and the effective transmission of information. A practitioner’s success depended on her or his integration into social networks rather than conflict with every potential rival.76 Similarly, Brown shows that in the early nineteenth century some ‘regular’ practitioners constructed alliances, despite the intensification of competition Irvine Loudon identified in this period. Furthermore, the languages of medical conflict expressed more than the self-interested pursuit of a greater share of the marketplace. The bitterly controversial world of magnetical medicine, Kassell reveals, was grounded on differing interpretations of spiritual and bodily economies; Nicholas Culpeper’s books, which, as Mary Fissell demonstrates, dominated the vernacular medical book market in the late seventeenth and early eighteenth centuries, denounced physicians as ‘unnatural Monopolizers’ of knowledge. But religious concerns were key to this analysis. Culpeper went on: ‘The truth is, throughout the whole World there are not such slaves to Doctors, as the poor English are; most of them profess themselves Protestants, but their Practices have been like those of the Papists, to hide the grounds of Physick from the vulgar’ who were thus driven to empty their purses or take dangerous drugs without care.77 And whereas many would assume that such religious concerns would have faded by the nineteenth century, Brown highlights not only the democratic epistemology but also the ecclesiological and spiritual language of advocates of Morison’s Pills. How we think about place is also fundamental to discussions of early modern medicine. Only regional analysis can take into account

Mark S. R. Jenner and Patrick Wallis 15

factors such as ecclesiastical licensing and varying economic structures, as Mortimer and Wilson demonstrate.78 Indeed, as Brown shows, it was only in the early nineteenth century that we can observe moves towards a national professional identity. The implications of this remain unclear. Unfortunately, we still know less about the social history of medicine of northern England,79 and, despite the rich literature on Edinburgh and on Scottish-trained medics in eighteenth-century practice,80 relatively little about the structure of practice in early modern Scotland,81 let alone Wales and Ireland.82 Early modern health care needs to be subjected to a global as well as a local analysis. The English and the continental European medical economies had a complex interrelationship that is still little understood. Work on the history of medical ideas has explored the movement of people and things across borders and language communities.83 But, written before the emergence of the new British and imperial histories, the original medical marketplace literature now looks rather Anglocentric. It contained little discussion of the impact of imperial and ‘exotic’ goods on medicine, even though Cook and Porter identified the rise of specific drugs as an important factor in its growth.84 Some commodities – tea, coffee, tobacco – moved from the medical marketplace into the wider world of goods;85 others – opium, quinine, guiacum – transformed therapeutics.86 The effect of the movement of people, both practitioners and laypersons, is also neglected. British subjects found themselves in revealingly different medical contexts in Asia, Africa and America, and these experiences marked the medicine of the metropole – discussions of public health, for instance, drew on imperial examples and experience.87 Conversely, ‘English’ medicine and health care practices were transformed by the process of transplantation into new environments. In New England, health care operated amid greater social and agricultural interdependency than in England and confronted acute shortages of specie. In eighteenth-century India, the East India Company relied on the bazaar to maintain the health of its personnel, while its employees also expended immense intellectual, economic and social energy on appropriating substances from their indigenous contexts into the Western pharmacopoeia. Such case studies remind us that, particularly in the seventeenth and eighteenth centuries, British, imperial and other transnational dimensions affected medicine more than many other areas of life. Finally, we need to move beyond the assumption made in most ‘medical marketplace’ literature that ‘medical’ self-evidently refers to therapeutics. In practice, care for the afflicted – nursing, washing and watching – was as essential and expensive a part of the economy of welfare as cure, as

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The Medical Marketplace

Mutschler emphasizes. This assistance and its superficially prosaic costs, particularly payments for food and drink, consumed time and labour and were central to the cost of ill health. These expenditures reflected not only the imprecise boundary between foodstuff, drink and drug, but also the importance of diet for health.88 This widening of focus needs to be applied at every level. For example, Jenner’s examination of water and public health in 1820s London argues that commercial relations were important factors in contemporary understandings of public health. Medical historians, he therefore suggests, should concern themselves with the allocation of resources broadly defined.

Conclusion The ‘medical marketplace’ was primarily introduced to describe and analyse the structure of therapeutic practice. This volume reveals that many more health-related matters and objects can be related to the market and market forces in historically specific situations. They range from medical books – which reveal medicine’s interaction with the print trade and how medical knowledge was commodified – to the networks which structured the production and distribution of drugs and the ways in which they moved from bazaar and factory to apothecaries and druggists, and on to patients and purchasers. The diversity of the social and economic networks apparent in these studies suggest that historians should in future think of the markets for medical goods and services rather than a generalized image of the medical market or marketplace. The market for bandages surely differed from that for bagnios; the woman in labour had little immediate call for an oculist. Furthermore, if we are to fully understand the economic workings of medicine in the early modern period we need to move away from a medical marketplace populated only by individual purchasers and individual practitioners. One of the distinctive contributions of Katherine Park’s discussion of the medical marketplace of fifteenth-century Florence is its emphasis on the power of institutional, ideological and social forces within the city’s medical marketplace.89 A full account of the English medical marketplace between the fifteenth and the early nineteenth century must similarly take account of the many other sources of medical demand, such as the state, hospitals, the military and naval establishments,90 and, above all perhaps, parochial and poor law provision, topics which we have only been able to touch on in this volume. Such a comprehensive account of the many kinds of economic exchange which paid for medical assistance would amplify the central messages

Mark S. R. Jenner and Patrick Wallis 17

of this collection: that the early modern medical marketplace must be understood as socially embedded, and that to understand how health care developed and changed over this period we must not look to the medical marketplace for an explanation but seek to explain the medical marketplace itself. This realization not only parallels recent work in cultural and economic history and economic anthropology, but also breaks down some of the excessively sharp distinctions drawn in the historiography between the English medical marketplace and European medical pluralism. For it recalls not only Park’s emphasis that the fifteenthcentury Florentine marketplace was ‘defined largely in personal and social terms’, but also Gianna Pomata’s work revealing how patients in Bologna sought recompense from medics if their treatment was not appropriate.91 More generally we must recognize that the marketplace is no more than a site where the broader forces of economy and society come together as people jostle to buy and sell. Yet what falls within the term ‘economy’ is not, in itself, stable. As historians of political economy have recently been arguing, it has to be understood in culturally specific ways. The oeconomy of the household was inseparable from the formal sector for much of this period, and medical supply and medical ideas flowed freely back and forth between the two. Even more dramatically, the economy of commodities flowed into an economy of spiritual and magical power that possessed equal or greater physical effects.92 The resonance of the medical marketplace was, as noted above, in part due to the rising prominence of market-language in late twentieth century society. What seemed surprising initially in the 1980s historiography, with its accounts of adverts for drugs and its emphasis on fees and competition, now seems disconcertingly familiar, as Mary Fissell notes in her chapter. But as this collection demonstrates, any early modern market of medicine should be thought of as socially embedded and historically specific – a social organization of health care and exchange that must be understood in its own terms.

Notes 1. L. M. Beier, ‘Sufferers and Healers: Health Choices in Seventeenth-Century England’ (Ph.D. thesis, University of Lancaster, 1984), ch. 2; idem, Sufferers and Healers (1987). 2. ‘The Patient’s View: Doing Medical History from Below’, Theory and Society, 14 (1985), 188. Porter also uses the terminology in R. Porter ed., Patients and Practitioners (Cambridge, 1985), 313 & 10; W. F. Bynum & R. Porter eds, William Hunter and the Eighteenth-Century Medical World (Cambridge, 1985), 21.

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3. I. Loudon, ‘The Nature of Provincial Medical Practice in Eighteenth-Century England’, MH, 29 (1985), 2. 4. Cook’s 1981 Ph.D. thesis did not use this terminology. Its equivalent chapter, entitled ‘The Medical Milieu: The Physicians and the Institutionalization of Physic in Early Modern England’, puts forward much the same arguments about how seventeenth-century medics adapted to the development of a market economy that his book advanced with this more resonant terminology: H. J. Cook, ‘The Regulation of Medical Practice in London under the Stuarts, 1607–1704’ (Ph.D. thesis, University of Michigan, 1981), 37, 372. 5. (Princeton, 1985), ch. 3. 6. M. Pelling & C. Webster, ‘Medical Practitioners’, in C. Webster ed., Health, Medicine and Mortality in the Sixteenth Century (Cambridge, 1979). 7. A few scholars working on pre-1750 medicine still foreground these categories: e.g., H. M. Dingwall, Physicians, Surgeons and Apothecaries (Edinburgh, 1995). Opinion on their relevance for the late eighteenth century is divided: M. Brown, ‘From the Doctors’ Club to the Medical Society: Medicine, Gentility and Social Space in York, 1780–1840’, in M. Hallett & J. Rendall eds, EighteenthCentury York (York, 2003); S. Lawrence, Charitable Knowledge (Cambridge, 1996); A. Digby, Making a Medical Living (Cambridge, 1994); I. Loudon, Medical Care and the General Practitioner 1750–1850 (Oxford, 1986); L. Jordanova, ‘Medical Men, 1780–1820’, in J. Woodall ed., Portraiture (Manchester, 1997). 8. Beier, Sufferers, 9; Cook, Decline, 29. 9. See also M. Ramsey, Professional and Popular Medicine in France 1770–1830 (Cambridge, 1988). 10. Many of these works cited each other as forthcoming publications. 11. V. Nutton, ‘Healers in the Medical Market Place: Towards a Social History of Graeco-Roman Medicine’, in A. Wear ed., Medicine in Society (Cambridge, 1992); H. Deacon, ‘The Cape Doctor and the Broader Medical Market, 1800–1850’, in H. Deacon, H. Phillips, E. Van Heyningen, eds, The Cape Doctor in the Nineteenth Century (Amsterdam, 2004). European historians have recently borrowed this approach and language, W. De Blécourt, F. Huisman & H. van der Velden, ‘De Medische Markt in Nederland, 1850–1950’, Tijdschrift voor Sociale Geschiedenis, 25 (1999); P. Rieder, ‘Médecins et Patients à Genève: offre et consummations thérapeutiques à l’époque moderne’, Revue d’Histoire Moderne et Contemporaire, 52 (2005). 12. D. Callahan & A. Wasunna, Medicine and the Market (Baltimore, 2006). 13. Pelling, Conflicts, 343. 14. One of the most influential examples of this, the work of Craig Muldrew, is directly relevant here: see Chapter 7. 15. For this explanation for the spread of the term: A. Wear, Knowledge & Practice in English Medicine, 1550–1680 (Cambridge, 2000), 28–29; D. Gentilcore, Healers and Healing in Early Modern Italy (Manchester, 1998), 2. 16. Based on a search of the Times Digital Archive 1785–1985; The Times (9 November 1985), 9. 17. N. McKendrick, J. Brewer and J. H. Plumb, The Birth of a Consumer Society (1982). 18. See e.g., W. De Blécourt & C. Usborne, ‘Medicine, Mediation and Meaning’, in W. De Blécourt & C. Usborne eds, Cultural Approaches to the History of Medicine (Basingstoke, 2004).

Mark S. R. Jenner and Patrick Wallis 19 19. Porter, ‘Patient’s View’. 20. Gentilcore, Healers, 2–3. 21. L. Brockliss & C. Jones, The Medical World of Early Modern France (Oxford, 1997). The critique of this by S. Broomhall, Women’s Medical Work in Early Modern France (Manchester, 2004) parallels the definitional debates described below. 22. D. Harley, ‘“Bred up in the Study of That Faculty”: Licensed Physicians in the North-West of England, 1660–1760’, MH, 38 (1994), 398. 23. M. Jenner, ‘Quackery and Enthusiasm, or Why Drinking Water Cured the Plague’, in O. P. Grell & A. Cunningham eds, Religio Medici (Aldershot, 1996). 24. Wear, Knowledge and Practice, 29. 25. It built on Pelling & Webster, ‘Medical Practitioners’. See also M. Pelling, The Common Lot (1998). 26. Cook, Decline, ch. 1. For such surveys, Beier, Sufferers, ch. 1; Porter, Progress, ch. 2. 27. E.g., M. E. Fissell, Patients, Power, and the Poor in Eighteenth-Century Bristol (Cambridge, 1991), 41 & ch. 3. 28. Porter, Health, 55. 29. There was a political historical dimension to this: Cook and Porter advanced accounts of the political and cultural development of Stuart and Georgian England which were strongly opposed to those of revisionist political historians such as Conrad Russell and Jonathan Clark, whose work was gaining much attention at the time. 30. See Chapter 9 and references contained therein. 31. ‘The Place of the Physician in Modern Society’, repr. in M. I. Roemer ed., Henry E. Sigerist on the Sociology of Medicine (New York, 1960), 65–66. 32. R. S. Roberts, ‘The Personnel and Practice of Medicine in Tudor and Stuart England. Part I. The Provinces’, MH, 6 (1962), 369. 33. The Times (29 October 1847), 4; (15 October 1901), 10. 34. Loudon, Medical Care, 208 and Part II passim. Also relevant here are histories which relate the construction of particular conditions to particular forms or understandings of market relations, e.g. A. Scull, The Most Solitary of Afflictions (New Haven, 1993), esp. 29–34, 105–10; T. Laqueur, Solitary Sex (New York, 2003), ch. 5. 35. The most systematic and sophisticated overview is Digby, Making a Medical Living. For the USA, the classic study which employs this model and language is P. Starr, The Social Transformation of American Medicine (New York, 1982). 36. Harold Cook recalls that the first time he consciously encountered the phrase ‘medical marketplace’ was in a commentary from the anthropologist, Michael Taussig, personal communication (2005). 37. J. L. Berlant, Profession and Monopoly (Berkeley, 1975), 49 and ch. 2; E. Freidson, Profession of Medicine (New York, 1970). 38. N. D. Jewson, ‘Medical Knowledge and the Patronage System in 18th Century England’, Sociology, 8 (1974); idem, ‘The Disappearance of the Sick-Man from Medical Cosmology, 1770–1870’, Sociology, 10 (1976). The frequency with which Jewson is cited in the medical marketplace literature is paradoxical. Although his approach was broadly materialist, Jewson never used market metaphors and presented eighteenth-century England as dominated by aristocratic patronage, not by commercial relations.

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The Medical Marketplace

39. On medical pluralism, S. De Renzi, ‘The Sick and their Healers’, in P. Elmer ed., The Healing Arts (Manchester, 2004); M. Lindemann, Medicine and Society in Early Modern Europe (Cambridge, 1999), ch. 7. 40. L. Jordanova, ‘The Social Construction of Medical Knowledge’, SHM, 8 (1995). 41. Beier, Sufferers, 28; K. Siena, Venereal Disease, Hospitals and the Urban Poor (Rochester, New York, 2004). 42. R. H. Britnell, The Commercialisation of English Society, 1000–1500, 2nd edn (Manchester, 1997); C. Dyer, Making a Living in the Middle Ages (New Haven, 2002). 43. I. Mortimer, ‘The Triumph of the Doctors: Medical Assistance to the Dying, c. 1570–1720’, Trans. Royal Historical Society, 15 (2005); idem, ‘Medical Assistance to the Dying in Provincial Southern England, c. 1570–1720’, (Ph.D. thesis, University of Exeter, 2004). 44. See L. W. Smith, ‘Reassessing the Role of the Family: Women’s Medical Care in Eighteenth-Century England’, SHM, 16 (2003). 45. E.g., E. G. Thomas, ‘The Old Poor Law and Medicine,’ MH, 24 (1980); J. Andrews, ‘“Hardly a Hospital, but a Charity for Pauper Lunatics?”: Therapeutics at Bethlem in the 17th and 18th Centuries’, in J. Barry & C. Jones eds, Medicine and Charity Before the Welfare State (1991); T. Hitchcock, P. King & P. Sharpe eds, Chronicling Poverty (Basingstoke, 1997); S. Williams, ‘Practitioners’ Income and Provision for the Poor: Parish Doctors in the Late Eighteenth and Early Nineteenth Centuries’, SHM, 18 (2005); Siena, Venereal Disease. 46. R. Porter and D. Porter, ‘Rise of the English Drugs Industry: The Role of Thomas Corbyn’, MH, 33 (1989); S. W. F. Holloway, ‘The Regulation of the Supply of Drugs in Britain before 1868’, in R. Porter & M. Teich eds, Drugs and Narcotics in History (Cambridge, 1995); ODNB, ‘Thomas Holloway’; M. Gijswijt, G. Van Heteren & E. Tansey eds, Biographies of Remedies (Amsterdam, 2002); L. Loeb, ‘Doctors and Patent Medicines in Modern Britain: Professionalism and Consumerism’, Albion, 33 (2001). 47. O. Davies, ‘Cunning-Folk in the Medical Market-Place during the Nineteenth Century’, MH, 43 (1999); ‘Healing Charms in use in England and Wales 1700–1950’, Folk-Lore, 107 (1996); J. Bradley and M. Dupree, ‘Opportunity on the Edge of Orthodoxy: Medically Qualified Hydropathists in the Era of Reform, 1840–1860’, SHM, 14 (2001); Digby, Medical Living, ch. 2. 48. Cf. Ruth Richardson’s discussion of the commodification of the cadaver, Death, Dissection and the Destitute (1988). The phrases ‘medical market’ and ‘medical marketplace’ are not to be found on the text database, EighteenthCentury Collections Online, but see L. F. Cody, ‘“No Cure, No Money,” or the Invisible Hand of Quackery: The Language of Commerce, Credit, and Cash in Eighteenth-Century British Medical Advertisements’, Studies in EighteenthCentury Culture, 28 (1999). 49. E.g., The Lancet, 60 (1852), 268; 72 (1858), 585; 121 (1883), 484; 128 (1886), 153; 179 (1912), 118–120. 50. In the 1960s and 1970s, for instance, The Lancet contrasted the British NHS with American ‘medicine of the market-place’, a contrast which was, of course, central to Richard Titmuss’s work on blood, The Lancet, 289 (25 Feb. 1967), 427–428; 306 (27 Dec. 1975), 1293; R. Titmuss, The Gift Relationship (1970). For a polemical overview of recent developments in the UK, A. M. Pollock, NHS PLC (2004).

Mark S. R. Jenner and Patrick Wallis 21 51. For a revealing analysis of the world of health economics, M. Ashmore et al., Health and Efficiency (Milton Keynes, 1989). 52. Studies which highlight this include Brockliss and Jones, Medical World; Park, Doctors. 53. On the former, D. Van Zwanenberg, ‘The Suttons and the Business of Inoculation’, MH, 22 (1978); on the latter, A. Wilson, The Making of Man-midwifery (1995). John Styles, ‘Product Innovation in Early Modern London,’ P&P, 128 (2000) offers a model which could be extended to other medical innovations. 54. Cook, Decline, 33–35. 55. Porter, Health, 41. 56. S. Epstein, ‘Europe, 1300–1800’, in S. R. Epstein ed., Town and Country in Europe, 1300–1800 (Cambridge, 2001), 10. 57. R. C. Allen, ‘The Great Divergence in European Wages and Prices from the Middle Ages to the First World War’, Explorations in Economic History, 38 (2001), 427–428; P. T. Hoffman, D. Jacks, P. A. Levin and P. H. Lindert, ‘Real Inequality in Europe since 1500’, Journal of Economic History, 62 (2002). 58. Mortimer, ‘Triumph’, 110–111; D. B. Haycock and P. Wallis eds, Quackery and Commerce in Seventeenth-Century London, MH, suppl. 25 (2005); Renate Wilson, Pious Traders in Medicine (Pennsylvania, 2000); P. Wallis, ‘Drugs and the Commercialization of Healthcare in England, 1550–1750’ (unpublished paper, 2006). 59. Cf. C. Jones, ‘The Great Chain of Buying: Medical Advertisement, the Bourgeois Public Sphere, and the Origins of the French Revolution’, American Historical Review, 101 (1996). 60. F. Trentmann and M. Daunton, ‘Worlds of Political Economy: Knowledge, Practices and Contestation’, in M. Daunton & F. Trentmann eds, Worlds of Political Economy (Basingstoke, 2004), 15. See also, M. Berg, ‘In Pursuit of Luxury’: Global History and British Consumer Goods in the Eighteenth Century’, P&P, 182 (2004). 61. Cf. Mortimer, ‘Triumph’. 62. On specialism, K. Buckle, ‘The Culture of Oculists in England 1660–1740’ (MA thesis, University of York, 2005). 63. Their analyses parallel David Wright’s arguments that nineteenth-century asylum admissions should be interpreted with reference to the economic and demographic circumstances of a region, Mental Disability in Victorian England (Oxford, 2001). 64. See her ‘The Economy of Magic in Early Modern England’, in M. Pelling and S. Mandelbrote eds, The Practice of Reform in Health, Medicine, and Science, 1500–2000 (Aldershot, 2005), esp. 46–48. 65. Cf. P. Warde, ‘Subsistence and Sales: The Peasant Economy of Württemberg in the Early Seventeenth Century’, EcHR, 59 (2006). 66. K. J. Arrow, ‘Uncertainty and the Welfare Economics of Medical Care’, American Economic Review, 53 (1963). 67. C. Muldrew, The Economy of Obligation (Basingstoke, 1998). 68. On one aspect of this, see P. Wallis, ‘Consumption, Retailing and Medicine in Early Modern London’, EcHR, 60 (2007). 69. E.g., D. Gentilcore, ‘Figurations and State Authority in Early Modern Italy: The Case of the Sienese Protomedicato’, Canadian Journal of History, 34

22

70.

71.

72. 73.

74. 75. 76. 77.

78.

79.

80.

81.

82.

The Medical Marketplace (1999); M. Lindemann, Health and Healing in Eighteenth-Century Germany (Baltimore, 1996); Brockliss & Jones, Medical World. Interestingly, some of Friedman’s early work was on the economic effects of medical regulation: M. Friedman & S. Kuznets, Income from Independent Professional Practice (New York, 1945). See, for example, the civic licenses to mountebanks in late seventeenthcentury Norwich, http://virtualnorfolk.uea.ac.uk/long18thcent/introduction/ norwichcorporation/mcbshows.html (10 July 2006). On market culture, A. Randall & A. Charlesworth eds, Markets, Market Culture and Popular Protest in Eighteenth-Century Britain and Ireland (Liverpool, 1996); C.S. Smith, ‘The Wholesale and Retail Markets of London, 1660–1840’, EcHR, 55 (2002). C. Crawford, ‘Patients’ Rights and the Law of Contract in Eighteenth-Century England’, SHM, 13 (2000); Pelling, Conflicts. Jonathan Barry, ‘Publicity and the Public Good: Presenting Medicine in Eighteenth-Century Bristol’, in W. F. Bynum & R. Porter eds, Medical Fringe and Medical Orthodoxy 1750–1850 (1987). A. Hardy, Health and Medicine in Britain since 1860 (Basingstoke, 2001), 14. [Our emphasis.] Porter, Health, 16–17. Cf. L. Leneman, ‘Smith v. Clark and Clark v. Smith: Eighteenth-Century Scottish Doctors in Dispute’, MH, 46 (2002). N. Culpeper, Culpeper’s School of Physick (1659), Sig. A8v. (This was a posthumous work.) On Culpeper’s epistemology, see M. E. Fissell, Vernacular Bodies (Oxford, 2004), ch. 5. See also Anne Digby’s mapping of the 1783 Medical Directory, which reveals striking variations in the ratio of practitioners to population, Medical Living, ch. 1. Exceptions include D. Harley, ‘The Scope of Legal Medicine in Lancashire and Cheshire, 1660–1760’, in M. Clark and C. Crawford eds, Legal Medicine in History (Cambridge, 1994); idem, ‘Bred up in the Faculty’; idem, ‘Provincial Midwives in England: Lancashire and Cheshire, 1600–1760’, in H. Marland ed., The Art of Midwifery (1994); S. S. Thomas, ‘Midwifery and Society in Restoration York’, SHM, 16 (2003). Rather more has been written on the late eighteenth and early nineteenth centuries: e.g. H. Marland, Medicine and Society in Wakefield and Huddersfield 1780–1870 (Cambridge, 1987); S. King, A Fylde Country Practice (Lancaster, 2001); I. Loudon, ‘“The Vile Race of Quacks with which this Country is Infested”’, in Bynum & Porter, Medical Fringe. These include H. M. Dingwall, ‘To be Insert in the Mercury: Medical Practitioners and the Press in Eighteenth-Century Edinburgh’, SHM, 13 (2000); G. B. Risse, Hospital Life in Enlightenment Scotland (Cambridge, 1986); L. Rosner, Medical Education in the Age of Improvement (Edinburgh, 1991); S. Jacyna, Philosophic Whigs (1994). See, however, C. W. J. Withers & P. Wood eds, Science and Medicine in the Scottish Enlightenment (Edinburgh, 2002); R. A. Houston, Madness and Society in Eighteenth-Century Scotland (Oxford, 2000) and his numerous articles. A. Borsay ed., Medicine in Wales 1800–2000 (Cardiff, 2003); G. Jones & E. Malcolm eds, Medicine, Disease and the State in Ireland, 1650–1940 (Cork, 1999); I. Campbell Ross, Public Virtue, Public Love (Dublin, 1986).

Mark S. R. Jenner and Patrick Wallis 23 83. E.g., J. Woolfson, Padua and the Tudors (Cambridge, 1998); H. J. Cook, Trials of an Ordinary Doctor (Baltimore, 1994); E. A. Underwood, Boerhaave’s Men at Leyden and After (Edinburgh, 1977); W. F. Bynum, Science and the Practice of Medicine in the Nineteenth Century (Cambridge, 1994), 46–54. 84. L. Schiebinger, Plants and Empire (Cambridge, Mass., 2004); L. Schiebinger and C. Swan eds, Colonial Botany (Philadelphia, 2004). 85. J. Goodman ed., Consuming Habits (1995); R. Porter and M. Teich eds, Drugs and Narcotics in History (Cambridge, 1997); B. Cowan, The Social Life of Coffee (New Haven, 2005). 86. R. S. Roberts, ‘The Early History of the Import of Drugs into Britain’, in F. N. L. Poynter ed., The Evolution of Pharmacy in Britain (1965); S. Jarcho, Quinine’s Predecessor (Baltimore, 1993); A. Barrera, ‘Local Herbs, Global Medicines: Commerce, Knowledge, and Commodities in Spanish America’, in P. H. Smith and P. Findlen eds, Merchants & Marvels (2002). H. Cook, Matters of Exchange: Commerce, Medicine and Science in the Dutch Golden Age (New Haven, 2007). 87. More generally, R. H. Grove, Green Imperialism (Cambridge, 1995). 88. See Pelling, Common Lot, ch. 2; J. O’Hara May, The Elizabethan Dyetary of Health (Lawrence, Kansas, 1977). 89. Park, Doctors, ch. 3. 90. E.g., H. J. Cook, ‘Practical Medicine and the British Armed Forces after the “Glorious Revolution”’, MH, 34 (1990); C. Lawrence, ‘Disciplining Disease: Scurvy, the Navy, and Imperial Expansion, 1750–1825’, in D. P. Miller & H. P. Reill eds, Visions of Empire (Cambridge, 1996); L. Brockliss, J. Cardwell & M. Moss, Nelson’s Surgeon (Oxford, 2005). 91. Park, Doctors, 85; G. Pomata, Contracting a Cure (Baltimore, 1998). 92. This was true not just of the sixteenth and seventeenth centuries. Many eighteenth- and nineteenth-century regimens and therapies drew upon a spiritual economy or attributed particular power and cosmological significance to particular practices or substances, e.g., M. S. R. Jenner, ‘Bathing and Baptism: Sir John Floyer and the Politics of Cold Bathing’, in K. M. Sharpe & S. N. Zwicker eds, Refiguring Revolutions (Berkeley, 1998); D. Madden, ‘Contemporary Reaction to John Wesley’s Primitive Physic: Or, the Case of Dr. William Hawes Examined’, SHM, 17 (2004); L. Barrow, Independent Spirits (1986).

2 Medical Economies in FifteenthCentury England Robert Ralley

John of Arderne, in an early fifteenth-century English translation, implored medical practitioners to charge as much as possible: ‘euer be he warre of scarse askyngis’, he argued, ‘ffor ouer scarse askyngis setteþ at not both þe markette and the thing’.1 The accounts that introduced the ‘medical marketplace’ to the history of medicine contrasted the new capitalist structures of early modern Europe with the ‘traditional’ healing of the Middle Ages. Subsequently, scholars have diverged over whether to extend the notion into this earlier period.2 How far can we read Arderne’s comments as reflecting a market in medieval medicine? This chapter sets out to reassess this contested territory: to look at the ‘medical economies’ of fifteenth-century England, the systems of social encounter and exchange within which responses to illness were sought and provided, and compare them against the influential models of Harold Cook and Katharine Park. Harold Cook employed the term ‘medical marketplace’ in discussing the conditions in early modern London.3 The market economy’s rapid growth in the seventeenth century was reflected in an increasing prevalence of medicine for payment. Most significantly, London attracted a range of people seeking a living from medicine. Cook’s view dethroned physicians, who were shown to be competing with myriad other practitioners, their attempts to control and stratify the London medical trades as much a response to commercial rivalry as a principled stand against medical incompetence. The status advantage wealthy patients enjoyed routinely forced healers to defer to their wishes, a situation that Cook suggested was responsible for innovations in healing, not least in promoting public quarrels over the various therapeutic options. In particular, he argued, it shifted medicine from maintenance of health towards a more ad hoc response to disease. Cook contrasted ‘traditional’ medicine 24

Robert Ralley 25

to this ‘marketplace’. Most activity had been at home; and at this prior stage, healers were simply members of the community with a reputation for facility in healing; local clergy also provided medical help. Much traditional medicine was practised charitably, or exchanged for favours as part of the barter economy. Subsequent research on the economic circumstances of fifteenthcentury England has altered the picture somewhat.4 One can find both the persistence of older social forms and signs of the shift towards the capitalist economy. On the one hand there is bastard feudalism, the primary social structure in late medieval England, though difficult precisely to characterize: it emerged from the feudal economy, and is traditionally regarded as having centred on a shift from the use of land as a reward for service to the payment of money – an allegedly more temporary expedient.5 On the other hand, the market’s importance at this point is undeniable, both in terms of the lively exchange of money and goods in and outside marketplaces and fairs throughout the country, and of rising wages, as the Black Death and declining population left estates bereft of labour and encouraged mobility among the more enterprising workers.6 While this was not yet the ‘culture of credit’ that Craig Muldrew has identified in sixteenth-century England, capitalist activity is discernible.7 Whether medicine was one of those spheres is uncertain; healing in fifteenth-century England remains comparatively unexplored. There is help from important work by Carole Rawcliffe and Faye Getz. Rawcliffe does not directly confront the medical marketplace as a concept, and while adopting one aspect of the model she rejects another: practitioners in her account earn their living from medicine, but do not have the freedom of the marketplace.8 Competition between practitioners is circumscribed by the categories they inhabit. Physicians are physicians; they do not do surgery and compete with surgeons. Getz, in contrast, emphasizes the plurality of healers and practices.9 Her account demonstrates the prevalence of practitioners whose primary income was not from medicine and who combined healing with other occupations. However, there is no suggestion that this variety of practitioners can be equated to breadth of choice for sufferers, as in Cook’s model; so this account stops short of being a medical marketplace. Harold Cook’s is not the only view of the medical marketplace. Katharine Park discussed the ‘medical marketplace’ in fifteenth-century Catholic Florence; this marketplace was not large, monolithic and impersonal, but a cluster of smaller ones, influenced by ‘noneconomic’ factors such as social and political ties of patronage, friendship and kinship, and notions of honour, loyalty and religious obligation.10

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She divided the paymasters of Florentine healers into three groups: the state, religious institutions and private employers. The state and religious institutions often funded treatment of the poor, but practitioners also worked charitably. Private employers included patients and other practitioners; collaboration was more typical than competition, and practitioners’ participation in communities such as the medical guild was important to their practices. Park’s medical marketplace consisted of the interactions between patients and a guild of practitioners who earned their livelihoods from medicine; it was a marketplace because making money was the central concern. These, then, are two pertinent notions of the medical marketplace to bear in mind when looking at fifteenth-century England. Cook’s model gives primary importance to market forces – patients’ needs and desires support variety and drive change. It is largely secular. Park’s medical marketplace, in contrast, is a cluster of smaller encounters centred on social bonds and shaped by perceptions of appropriate action. She emphasizes its institutional and social characteristics: its dependence on institutions, the prevalence of charity and the centrality of collaboration. Both models focus on those practitioners who earned money by practising medicine. Is this a useful way of understanding medical practice in our period? Since we are now better placed to judge the extent of commercial activity in fifteenth-century England, a re-examination of the evidence is due. This chapter does that. It consists of three parts. In the first I discuss medicine for money, medicine as charity and points in between. My examples are courtly and clerical, useful for their wealth of evidence and not the pre-eminence of their subjects. Their lessons, taken carefully, are broadly applicable; and for fifteenth-century England, where details of practice can be hard to find, such opportunities must be seized. In the second I examine the practitioner–patient relationship, central to the medical marketplace model; reliability could be developed as a commodity but was also bound up in the strength and character of social ties. In the final part I set healing in late medieval England within the context of patients’ understandings and possible responses to illness, encompassing prayer and pilgrimage, charms and exorcisms; such decisions had moral and spiritual, as well as physical, import.

Medical options Priests were probably a major source of medical care in late medieval England. We can tell something of the extent of medical practice of clergymen from their wills.11 Edmund Arnold, rector of St. Clement Danes,

Robert Ralley 27

London, bequeathed several medical works to his alma mater King’s College, Cambridge, and Mondino’s Anatomia to fellow practitioner William Hatcliffe. Robert Thurbarn, a priest from 1414, left New College a book on medicine, to be used first for life by Thomas Edmonds. Edmonds was himself a clergyman, from the same college, who became canon of Lichfield and prebend of Bishopshull in 1450, and rector of Amersham in Buckinghamshire in 1454. Thomas Bloxham, MD and rector of churches in Somerset, Oxfordshire and Gloucestershire, left his nephew medical books. Occasionally there are other glimpses of clerical medical practice. When William Wodecock, the rector of St. Edmund’s, Lombard St., London, was granted dispensation by the Pope in 1472 to keep that church for life, together with any other benefice, it was despite being a practising MD from Cambridge. Though neither medicine nor the priesthood demanded graduate expertise, and hence these are unusual cases, it tells us something about medical practice by the clergy – who, like scholars, emphasized their literacy and claimed superior wisdom. Above all, medical practice by beneficed clergy was in theory chiefly about offering help, not accumulating money. As a result, we see many discussions about whether payment could legitimately be claimed at all. John of Mirfield wrote in his religious encyclopaedia that ‘if the patient is rich and wishes to give nothing to him, the healer is still bound to cure him’.12 Since, as Solomon had remarked, God made the patient better, not the healer, Mirfield justified a healer’s payment by asserting that any money was ‘for his work and honour’, not for the result (this also meant that practitioners were owed even when patients died).13 He emphasized this point by stressing the metaphor of ‘spiritual healer’ for priests, and ‘spiritual medicine’ for their work. Priests healed, like medical practitioners, but they did so by helping sufferers receive spiritual health as a gift from God. Therefore they could not seek gold for this, only accept what was needed to live, as a gift. Just as priesthood was described as healing, so the late medieval conception of the healer owed much to the strictures of the priesthood. Of all the medicine practised in fifteenth-century England, we know most about that paid for by wealthy patrons. This took various forms. Some healers were employed to be constantly available: Humphrey Stafford, Duke of Buckingham, retained Thomas Edmond for £10 a year to visit whenever needed, with three horses, a yeoman and a page. For this, Edmond (who graduated MD at Oxford the following year) would serve the duke for life, at home and abroad, placing his patron’s needs first.14 In addition to the money, retained practitioners often claimed clothing, sometimes liveried, and bed and board; the potential rewards were

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substantial. Thomas Edmond gained in addition to his £10 annuity at least two benefices from the duke, and before long was awarded the position of secretary to the archbishop.15 Gilbert Kymer’s connection with Duke Humfrey helped him embark on his distinguished ecclesiastical career, and his chancellorship of the University of Oxford was due to his patron’s power.16 Humfrey used his role as the head of Henry VI’s council to provide Kymer with benefices and preferments in the king’s gift.17 Benefices were interchangeable with the financial rewards received by those not in holy orders. In 1395 Richard II gave his ‘clerk and leech’ John Middleton an annuity of £40 from the Exchequer until he could be given benefices worth £100 a year; in 1399 he gave another healer 40 marks a year until he could find a benefice without cure of souls worth £40, or with cure of souls but worth 100 marks.18 Royal physicians and surgeons in particular benefited from their patrons’ beneficence; several kings in the later Middle Ages rewarded medical servants with estates.19 In return for such generosity, advisors often provided additional services; Henry VI’s physician John Somerset, for example, was also his tutor and subsequently became Chancellor of the Exchequer and Warden of the Mint.20 This was a gift from the patron as much as reward for the advisor’s service, however. Like the annuities, benefices granted to medical practitioners, these positions were more than a pecuniary reward; they were a reflection of the honour due to a practitioner. Wealthy patrons could afford to employ a combination of the available healers. Edward IV’s surgeons probably worked on a rota: a master surgeon at the rank of esquire was resident, but two or three were on the payroll at any one time.21 When Richard Mitford, Bishop of Salisbury, fell ill late in 1406, he called a ‘certain priest physician’ to inspect his urine and give him medicines.22 For this he paid 49s. 4d. At least twice his servants called on a nearby leech. By December the bishop was worse and Thomas Thirlwall visited at Potterne manor in Wiltshire, with two attendants, to treat him, before heading to Oxford for supplies. Early next year Mitford’s friend gave him a silver catheter, and Mitford took medicines throughout March, sending for Thirlwall again in April. From the 2nd, Thirlwall was either at Potterne or ordering medical supplies in Oxford or Salisbury, borrowing a horse from the Abbot of Sherborne for speed. John Malverne joined him in the bishop’s chamber with a retinue of six servants, staying at the manor for a week before returning to Oxford. When the bishop died days later Thirlwall was still in attendance. Courtly healers were classified according to courtly categories. The duties of particular practitioners related to status and position, as the

Robert Ralley 29

household ordinances of Edward IV demonstrate. The job of the Doctor of Physic, they explained, was primarily to advise on diet, both ‘by the councelying or awnswering to the kinges grace wich dyet is best according, and to the nature and operacion of all the metes’, and conferring with the chamberlain, sewer and master cook to ensure that the right foods were served.23 He wore the livery of a squire of the household, a group of men ‘chosen . . . of theyre possession, worship, and wisdom’, of whom twenty were to be attendant on the king at all times for discussion and companionship, keeping ‘honest company aftyr theyre cunyng’.24 A parliamentary petition in 1421 described physic as the government of the body; and the primary role of the courtly physician was to advise on such matters as the proper food and exercise to avoid illness.25 Surgeons and barbers carried out prophylactic procedures such as regular bloodletting, and were available should the physician recommend surgical intervention to counter sickness. The Master Surgeon was to be liveried as a squire for the body; these men were ‘attendaunt vppon the kinges person to aray and unray hym, to wache day and ny3t, to dresse hym in his clothes’.26 Closeness to the king, even in apparently menial tasks, implied high status. The royal barber must be at least a gentleman, yeoman or groom, and needed supervision by a knight of the chamber or squire for the body.27 Moreover, while a lord would be healed by someone of sufficient standing to be granted access to his person, lowlier members of the household were seen by practitioners of lower status. While Bishop Mitford was consulting clerical physicians including one Oxford graduate in theology, his kitchen boy was being treated for a head injury by a local leech.28 Elite practitioners expected to attend patients of various kinds; Henri de Mondeville listed some broad classes according to status and ability to pay: The first class are paupers who must be treated for nothing; the second class are a little better off and may send presents of fowls and ducks; they pay in kind. The third class are friends or relatives who pay no fixed fee, but send victuals or presents in token of gratitude but no money . . . Then there is a class embracing those who are notoriously bad payers, such as our nobility and their households, government officials, judges, baillies, and lawyers whom we are obliged to treat because we dare not offend them. (In fact the longer we treat these people the more we lose. It is best to cure them as quickly as possible and to give them the best medicines.) Lastly there is a class who pay in full, and in advance, and they should be prevented from getting ill at all, because we are paid a salary to keep them in health.29

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The healer should ‘charge the rich man as much as possible’, Henri suggested, ‘provided that he does all that he can to cure the poor’.30 The penultimate group was larger than the last, paying for healers’ services when the need arose. In 1383, for example, Thomas Arundel, Bishop of Ely, paid a barber for medicines and a surgeon 40s. for his services; it cost him a further 2d. to have his urine examined in September of the next year.31 John Clerke, a healer in Suffolk, was paid 4 marks and an additional 16s. 8d. for treating the wife of Sir John Howard.32 Mondeville’s complaint about the ‘notoriously bad payers’ in this class is backed up anecdotally by such remarks as William Goldwyn’s request of his patron Lady Stonor that she ‘speck to my Master for þe xvj. li. [£16] þat ys dew unto me’.33 However, this straightforward cash-for-treatment relationship was one of mutual mistrust, and also earned physicians their reputation for greed. Medicines for wealthy patrons frequently contained more expensive ingredients than their equivalents for poor patients. While this was justifiable on the grounds that finer substances better suited nobler bodies, and better met patient expectations, it did nothing to mitigate portrayals of practitioners by satirists.34 The Italian practitioner Gabriele Zerbi justified setting a high fee by claiming that it bestowed more authority on the healer, and that everyone involved ‘will make an effort to obey him in order not to waste the money paid, and the patient will heal more quickly’. He recalled a saying: ‘Medicine bought dear is of great efficacy; given free it is of little use.’35 Working backwards through Mondeville’s list we reach less affluent groups of patients. One was friends or relatives, for whom a sort of generalized reciprocity sufficed. I will return below to healing within families. Another was the somewhat poor, who could afford to pay in kind for treatment. This kind of exchange was common. A medicus in Nottingham, having in 1360 treated a Master Tankardmaker, was paid with three tankards for the cure.36 Another in London, called John Luter, was prosecuted after failing to provide a cure for the skin complaint of John Clotes in 1408, despite having taken from Clotes fifteen ‘serpentyns’ worth 9 marks, a 60s. gold tablet and a 6s. 8d. sword for providing the service.37 The values of items offered clearly varied greatly, and wealthy patients also sometimes paid in kind. William Goldwyn, a physician attending Lady Agnes Stonor, asked her in July 1480 to ‘sende me a buck a Wedynsday next commyng acordyng to þe promyse that my Master and ye made at my laste beyng with yow’, since he had promised it for a friend’s wedding.38 The first item on Mondeville’s list, essential to courtly medicine, was charity. The standing (and image) of elite practitioners demanded that

Robert Ralley 31

he tend to those unable to pay him; his generosity ought to increase with his status, and was both sign and constituent of that status.39 The healer’s role, in other words, was to treat members of society regardless of rank and means.40 John Somerset, royal physician, boasted in verse: ‘Like Cosmas and his brother giving all things free/To patients, thus I gave everything’. Although I was overwhelmed by cases without rewards, deserving but Taking nothing for free, and making no profit . . . . There was no one more persistent in seeking money Or sustenance than I was in denying it.41 The author of a mid-century chronicle of Henry V’s reign ended by directing his ‘foolish, rude, poor and ragged little book’ to seek Somerset’s patronage, depicting the route to his house as covered with ‘the footprints of barefoot paupers pouring into his house, and of their shod feet returning’.42 Translating medical works into English could also be a charitable act.43 Charity was central to medieval conceptions of the individual’s role in society.44 Despite historians’ traditional scepticism about the scale and effectiveness of charity in late medieval England, recent studies suggest that it may have approached the rhetoric.45 Recipients owed their benefactors a debt which they were urged to repay in prayer. Thus, Mondeville wrote, if you operate conscientiously upon the rich for a sufficient fee and upon the poor for charity, you ought not to fear the ravages of fire, nor of rain nor of wind; you need not take holy orders or make pilgrimages nor undertake any work of that kind, because by your science you can save your souls alive, live without poverty, and die in your houses.46 Charitable acts, and the prayers of the poor, should be enough to ensure a healer’s place in heaven. A key vehicle for charitable healing was the hospital.47 Hospitals were institutions established for the poor, often the sick poor, and many paid medical practitioners to administer to their charges. Typically a hospital was founded for the good of the founder’s soul, institutionalizing and enforcing the hope that recipients of charity would pray for their benefactors. Beds afforded an unbroken view of the altar, where masses were performed, and regulations often stipulated a number of prayers

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per day for each patient. A foundation’s money also paid for healers to visit and attend patients. Since in this case the practitioner received payment, the benefit of the charitable action reverted to the donor. Patrons were not alone in employing institutions. Following the failure of a parliamentary petition in 1421 to control the practice of English physic through the universities, a group of courtly healers petitioned once more to enforce their medical economy, this time in London.48 On 15 May 1423, the physicians Gilbert Kymer, John Somerset and Thomas Southwell, and the surgeons Thomas Morstede and John Harowe, ‘with alle þe Cirurgeans wirkyng in þe Crafte of Cirurgy withinne London’, presented a petition to the Mayor and Aldermen of London seeking permission to establish a new guild, or ‘Comminalte’, of physicians and surgeons.49 The petition, which was approved, specified ten ordinances: no one might practise physic or surgery in the City of London without passing an examination set by the guild officers, and paying 100s. to the Chamber of the Guildhall; the Comminalte’s head would be an English medical graduate (Kymer himself was the first). The Comminalte would oversee the preparation of medicines, appointing two apothecaries to take this task from the Grocers’ guild. While the petitioners wanted to remove from practice those healers who could not afford the guild’s extremely high entry fee, limiting medical practice to the prosperous elite, they balanced this claim by trying to institutionalize the free treatment of the poor.50 If sick people ‘nedynge þe practyk of Phisyk or þe workyng of Cirurgy, [had] fallen in such pouerte’ that they were unable to pay for treatment, the guild officers would assign a good physician or surgeon free of charge. The practitioner would receive payment as determined by the guild. Most subtly, the organization set out in the petition would effectively divide London practitioners into physicians and surgeons, by physically and institutionally separating them in their government of their respective pursuits. As courtiers, the founders expected the Comminalte to increase their prestige. The stipulation that guild officers should be English was particularly important given the predominance of healers from abroad at the bedsides of English nobles.51 In claiming the right to control medicine in the city, the petitioners sought to place themselves (and by extension their noble patrons, Humfrey of Gloucester and Thomas Beaufort, duke of Exeter) at the top of a social hierarchy; granting a healer permission to practise was an act of patronage.52 Other issues were at stake, however. Surgical practice and the production of medicines were crafts governed through the guild structure of England’s urban centres.53 There was no equivalent organization for physic, and courtly physicians, whose

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self-identity forbade physical interaction with patients, were ipso facto excluded from claiming allegiance with surgical groups. This meant little interference in their practice but also left them politically weak. The 1423 petition was an attempt to rectify this. To the surgeons involved, already part of a fellowship before 1423, the Comminalte offered a chance to succeed in their long-standing political battle with the guild of barbers over control of surgical practices.54 Their success was short-lived. The outcome of a hearing in 1424, concerning an allegation that two senior members of the barbers’ guild had botched a procedure, was decided by senior members of the Comminalte.55 Afterwards the barbers complained to a new Mayor about interference in their affairs and won back the right to oversee their members in surgical practice.56 At around the same time, the relationship between Humfrey of Gloucester and the Beaufort family erupted into open hostilities, when Thomas’s brother Henry fortified London against Humfrey.57 What had been a powerful alliance of patrons ultimately became a source of division. While the founders went on to prestigious careers as courtiers, the organization itself had disappeared by 1425. English medicine flourished outside such slight mechanisms of institutional control, a situation that allowed diversity to a degree unthinkable elsewhere. While barbers’ guilds attempted within a civic context to curb the worst problems associated with unskilled surgical practice, other types of therapy fell outside their jurisdiction, and in the countryside even surgery was more or less unregulated. As a result, practitioners could adopt remedies freely according to their skills and experience. Thomas Fayreford, practising in mid-century Somerset and Devon, employed charms, prescriptions and bloodletting.58 Others, such as tooth-drawers and bone-setters, performed one procedure repeatedly.59 Nor, despite the complaints and injunctions of learned physicians, was medical practice restricted to men. Joanna Lee, who petitioned Henry IV early in the century after her husband’s death, claimed to be supporting herself by travelling the countryside practising physic; the apprentice of Nicholas Bradmore, a surgeon in London at around the same time, was a woman called Agnes Woodcock.60 The 1421 parliamentary petition for regulation of physic requested legislation that would have forbidden women from healing, along with other ‘unlearned’ (i.e. non-graduate) practitioners. It was approved by the Lords and then never mentioned again. The plurality of healing practices in late medieval England certainly matches that of any ‘medical marketplace’ identified elsewhere. The variety of practitioners and practices meant that there was no particular social status associated with being a healer. When John Russell,

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servant of Humfrey, duke of Gloucester, listed the social ranks from the highest (the Pope) to the lowest who might ‘sit at a table of good squyeris’, he included graduates in arts, law and theology, as well as merchants, pastors and judges, but there was no medical practitioner, graduate or not.61 During the fourteenth and fifteenth centuries the physicians working in Westminster Abbey’s infirmary had (judging by their robes) a variety of ranks.62 As with the clerics and courtiers already discussed, an individual’s status was put down to income, or linked to other positions and roles. Accordingly, attending to the sick was often only one activity among several undertaken by a member of the community.63 From 1455 a bailiff called John Crophill supplemented his substantial income by providing cures for those he encountered.64 For over two decades, Crophill collected rents for Wix Priory, probably earning about 3s. 4d. a month; he was also ale-taster. The patients he recorded ranged from carpenters, a cordwainer, a herdsman and a tailor, any of whom might earn 6d. a day, to the clothmaker, John Rote, whose estate at his death included more than 140s. and land worth over £20. They were, largely, inhabitants of local villages where the Priory owned land, or places on Crophill’s route through the countryside. For people like him, providing medical care was part of an array of different roles that together defined place and standing in the community. Just as we have seen Mondeville discussing the economic relationships important to an elite practitioner, so too these other healers combined such elements as charitable practice and healing for money to establish particular social roles. Those determined to claim payment could find ample justification in Gabriele Zerbi’s reasoning, linking a treatment’s efficacy to the attitudes and diligence of patient and household. Others might heed John of Mirfield’s advice that healing was by the grace of God and the healer worked for honour, not riches, so payment must be voluntary. Healers did not always ask for money, and would not even always accept it. Successful medical practice could be a way to greater standing in the community, or a path to divine reward; its efficacy, in that case, might even be dependent on not accepting anything in return. As one seventeenth-century writer on ‘healing Witches’ put it: ‘Their reward is for their curing, what people commonly wil giue them; some take more, some take but a little, often nothing, and some may not take anything at all, as some haue professed, that if they should take any thing they coud doe no good.’65 While most agreed on the importance of offering treatment for free, practitioners differed over their precise obligations.

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Though the cases I have outlined shared the same ingredients, combining (for example) medicine for payment and medicine as charity, they did so in different ways. Park’s account provides a closer model than Cook’s for what I have described, in its focus on institutions and emphasis on charitable medicine. Neither is totally sufficient, however, for dealing with the range of economic relationships described. If we think in terms of ‘medical economy’ rather than ‘medical marketplace’ we can see that healing could be offered in exchange for things other than money, and as part of relationships not easily reducible to discrete transactions. Individuals often practised medicine as only one activity among several; they structured their medical practice around the available social and economic relationships; and the nature of the attention offered often depended on the relationship. This does resemble Cook’s description of ‘traditional medicine’. In the next section I shift focus to the patient.

Choosing healers Medical practitioners had to convince potential patients of their skill and reliability. As a marketplace model implies, advertising played a role: Thomas Forestier, a French practitioner living in London, warned in 1485 of notices ‘placed upon gates and churche dores’ by people he called ‘false lechys’.66 They could be convincing salesmen, as Alice of Stocking on Fleet Street in London discovered to her cost in 1320. Trusting the surgeon John of Cornhill, she allowed him to treat her feet, but while she was bedridden he made off with several items from her house.67 Reliability was an attribute to be obtained or developed by practitioners keen to sell their services. Patients seeking trustworthy practitioners looked for particular characteristics, and practitioners tailored their behaviour to meet those expectations – as we see from their treatises describing how to act in front of sufferers and their families. John Arderne warned the ambitious healer that he should ‘be no3t y-founden temerarie or bosteful in his seyingis or in his dedes; and abstene he hym fro moche speche’; he should read books, because ‘the exercyse of bokes worshippeþ a leche’; he should avoid drunkenness for that ‘destroyeth al vertu an bringith it to not’; he should wear the clothes of clerks not of minstrels, and keep clean hands and ‘wele shapen naile3 & clense fro all blaknes and filthe’.68 Extricable from such documents are the characteristics expected of a good healer – in this case, ‘in gret mennes houses’.69 Steven Shapin has shown how, in the seventeenth century,

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gentility was taken as a marker of trustworthiness.70 To be a gentleman was to occupy a particular social and economic position, but it was also to embrace a mode of behaviour. Arderne’s text demonstrates that in our period assessments of reliability by patients and their families were based, among other things, on appearance and behaviour, and it implies the existence of established norms for courtly practitioners.71 Similar norms probably existed for non-courtly healers, though sources seldom give us access to them; there is a rare glimpse in Thomas Forestier’s remark that some of London’s dangerous healers ‘ar carpenters and some mylwardes’ – their respectability in these other trades enhancing their medical credibility.72 In urban contexts, guilds (in theory) guaranteed their members’ ability and trustworthiness.73 They checked tools and advised civic authorities in cases concerning their trades. More importantly, they also regulated training and tested skills: the 1435 ordinances for the Fellowship of Surgeons in London demanded that ‘no persoone be made maistir of the craft withinne vij yeere after his entrynge neither ony tyme but that he bi proued good & honest of gouernaunce & secret at the seid teerme of vij yeer’, and that every apprentice, on being made free, would be called to the masters of the craft ‘ther to yeue him his charge to be rulid & gouerned bi the seid craft’.74 However, London was also home to Alice Stocking’s duplicitous surgeon and Forestier’s ‘false lechys’; it provided choice and danger. Pursuing medical care through more distant networks could signal increasing desperation. Catherine, the wife of John Howard, later Duke of Norfolk, died in 1465: during her last illness she was attended initially by a local friar, who gave her medicines, but as her condition worsened she summoned physicians from London.75 As we have seen Bishop Mitford called on a succession of healers during his ultimately fatal sickness in 1407.76 Patients tended to confront the difficult and important task of selecting reliable medical practitioners by seeking help, at least initially, from those around them and through existing social ties. Close relatives’ attention and advice were more reliable not only because of the moral bond between family members, but also because their proximity and familiarity made assessment easier.77 In 1452, when the Norfolk gentlewoman Margaret Paston told her husband that her uncle was ill, she added that to get the medicine he needed he was going ‘into Suffolk this next weke to myn aunt, for there is a good fesician and he shal loke to hym’.78 The reputations of healers were derived from the experiences of those who had encountered them, and Margaret warned her husband years later ‘fore Goddys sake be ware what medesynys ye take of any

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fysissyanys of London. I schal neuer trust to hem be-cause of yowre fadre and myn onkyl, whoys sowlys God assoyle’.79 So while reliability could be an attribute to be acquired and lost by practitioners, it could also be structural: healers, or even informants, with strong ties to the sufferer were more clearly dependable; those connected by weaker ties, perhaps from different social groups or communities, might bring fresh information but were less obviously reliable.80 Accordingly, we find patients beginning with local practitioners and seeking help from more distant (and eminent) ones when things did not improve. Here, reliability was not an individual characteristic but an aspect of the healer’s relationship to the sufferer – a situation not explicable in terms of the marketplace. Next I set this relationship in the context of possible responses to illness.

Responding to illness Anyone suffering illness in fifteenth-century England faced a quandary. The position of disease in moral and spiritual discourse was important and ambivalent, and the claims and suggestions made by interested parties could be correspondingly varied. If illness was heaven-sent, it might be punishment or test, reprehending misbehaviour or rewarding saintliness with a spiritual purge. Otherwise an individual’s actions might be the cause: the sufferer’s intemperance or a foe’s malice. Each possibility suggested a response. Sometimes for members of a family, the primary forum for confronting these issues, the situation was sufficiently clear to decide for themselves and act accordingly. Late in the century Margaret Paston’s son, Sir John, asked his wife in all hast possybyll to send me by the next swer [sure] messenger that ye can gete a large playster of your flose ungwentorum for the Kynges Attorney James Hobart; for all hys dysease is but in hys knee. He is the man that brought yow and me togedyrs, and I had lever then a xl li. [£40] ye kond with your playster depart hym and hys peyne. But when ye send me the playster ye must send me wryghtyng hough it shold be leyd to and taken fro hys kne, and hough longe it shold abyd on hys kne vnremevyd, and hough longe the playster wyll laste good, and whethyr he must lape eny more clothys a-bowte the playster to kepe it warme or nought.81 Probably another example is Elizabeth Stonor’s request of William Stonor in August 1476 that he send her daughter Katherine, who was ‘craysed and hath a desese on hir neke’, to meet her in London, ‘to the intent

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she may be holpyn þeroff’.82 Self-help, however, was a risky option, and experts built their authority on the difficulty of safely navigating the dangers of disease and treatment. A contemporary proclaimed: ‘a gode ffesicyan nedes to loke well a bowte and be full well warra, and full well avysed’. He must know about the ‘complexions of men, composicions, myxtyous and medlynke, bouthe of members and of humours, and disposicyons of tymes and condiconse of male and female and age’, the ‘causes and occasyons of evylse’ and the ‘complexions, vertues and wyrkynges of medcynable thynges’.83 University physicians played on this view of their expertise, complaining, in their 1421 petition for regulation, about the ‘many unconnyng an unapproved’ practitioners putting lives at risk.84 A late-fourteenth-century judge ruled that a physician must visit his patient when asked, ‘since the patient himself cannot diagnose in order to notify the physician’, nor (because of illness) travel to see him.85 Treatment also brought worries. Was the response appropriate to the problem? Magically caused illness, it was commonly said, must be undone by magic; but magic could be natural or demonic, so the counter-magic varied too. Arnold of Villanova suggested manipulating natural items in some cases, while in others exorcism might be necessary.86 Sometimes the best remedy was dealing with the perpetrator.87 A royal commission established in 1426 agreed with the assessment by William, Lord Botreaux, that he was under magical attack from his uncle, and had the miscreant imprisoned in the Tower of London until he pledged to stop.88 Even graver was the suggestion that ‘secular’ healing risked impiety by undoing what might be God’s handiwork. Miracle accounts supported this conclusion, documenting in several cases the reversal of a miraculous cure when the recipient subsequently sought medical help.89 The Parisian medical faculty, conscious of this attitude, pointed out in 1348 that although God alone cures the sick: He does so through the medicine which in His generosity He provided. Blessed be the glorious and high God, who does not refuse His help, but has clearly set out a way of being cured for those who fear Him.90 Prayer remained advisable, since God could heal an illness regardless of its cause. Furthermore, prayer allowed people geographically separated to aid a sufferer. Margaret Paston wrote to her husband John in London in 1443 on hearing of his recovery, describing how she had ‘be-hestyd to

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gon on pylgreymmays’ on his behalf, and her mother had sent money ‘to þe iiij orderys of frerys at Norweche to pray for yow’ while he was ill.91 Another concern was whether the treatment was licit at all. Despite theologians’ fulminations against using the devil’s power – or perhaps because of them – it remained unclear which processes were natural and which not.92 Many used charms and blessings to prevent disease or combat evil spirits; one late medieval codex described in detail a ‘New remedy for evil or witchcraft and driving away demons’, and many sets of instructions for protective formulae or rituals survive.93 Aquinas provided a nice distinction to determine whether demonic forces were involved, but people applied their own principles in individual cases.94 Widespread practice of charms and spells occasionally prompted investigations: in 1406 Henry IV ordered an episcopal enquiry into the magicians, charmers and other unsavoury characters causing trouble in the diocese of Lincoln.95 Members of the laity, we should remember, had their own ideas about spirituality and the legitimacy of actions, and were not simply passive receptacles for clerical teaching.96 Consulting spirits could even be considered defensible in Christian terms, though few made the argument as explicitly as John the Monk, a Benedictine in fourteenth-century France.97 Magical procedures were neither psychological crutches for the fearful and superstitious, nor desperate acts by those denied access to humoral medicine; for most they were powerful ways of drawing on spirits or the hidden powers of the cosmos. They remained sources of spiritual danger for the unwary patient.98 It was a chance many were prepared to take. Above all, serious illness threatened patients with sudden death, mors improvisa.99 Treatises abounded on signs of impending death; one example informing readers that when the fingernails are dark and pallid in colour, and a bloodcoloured blister appears on the forehead, then know that the patient will die on the fourth day: and an indication is the occurrence of considerable sneezing and yawning.100 Prayers in books of hours promised readers safety from sudden death, or at least prior warning.101 That time was needed for making a will, a religious imperative and deathbed duty, and for a Church minister to perform the final Sacraments. The soul’s fate depended on these last rites, as the laity were only too aware.102 The importance of forewarning, and knowing how long remained, was reflected in demands placed on medical practitioners. London courts

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employed surgeons to determine whether people who were badly ill would survive.103 Richard Bryan’s remark to Sir William Stonor in 1479 reveals a similar sentiment: ‘I trust to Jhesu he shall endure till the messenger come ayene’, Bryan wrote of the ailing Thomas Betson: ‘lenger the ffysicians have not determined’. He added later from Betson’s bedside that the practitioner Master Brinkley ‘will not determyne him whether he shall live or dye as yet, but and [i.e. if] he may kepe him alive till Tuesday none he will undertake him’.104 A thirteenth-century chronicler praised the healer Gilbert Eagle for his actions before the death of Hubert Walter, the Archbishop of Canterbury. He had administered no medicines, but had recognized Hubert’s illness was terminal and advised him to take the last rites. Another physician disagreed, suggesting there was still time, but Hubert was soon delirious and needed reviving with ‘physical remedies’ before following Gilbert’s advice. Gilbert was praiseworthy for not attempting to cure the archbishop; he had judged that recovery was impossible, and recommended the act accordingly.105 Patients sought reliable healers who would treat them if recovery was feasible, and tell them in good time if it was not. Illness demanded a physically and spiritually appropriate response from the sufferer and his or her family. Doing the right thing was often more important than surviving. The issue might be as straightforward, and as difficult, as selecting the right medical practitioner. Patients, especially those of higher status, were bound by strict codes of behaviour, in whose violation lay considerable social and political risk. In selecting a course of action, and possibly someone to help, the patient and family were establishing their moral character.106 Deciding what kind of action was appropriate meant determining the nature of the situation. Sufferers could reject sin as the cause of illness by seeking a physician, or embrace the suggestion and repent. Misfortune ascribed to evil spirits was remediable using charms, but such acts risked at the least displeasing Church authorities. The route chosen to deal with illness might involve the patient in official or alternative forms of devotion – sometimes unwittingly. John Blumston, alias Phisicion, of Coventry, abjured in 1486 his claim ‘that there was as much virtue in one plant, as in Mary the Blessed Virgin and mother of God’ but continued expounding Lollard doctrines to those he met.107 Such considerations placed moral and spiritual concerns at the heart of decisions about illness. It contrasts with Cook’s account of the seventeenth-century medical marketplace, dominated by secular medicine secured by financial transaction. Park’s description of fifteenthcentury Florence is closer, allowing for the influence of religious factors

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in medical provision, prompting charitable practice by healers or charitable funding of practice by institutions. Nevertheless, in its primary concern with paid medical practitioners, it is insufficient for placing medical activity within the full spectrum of responses and concerns identified here. Another account is worth considering for its similarity to the discussion above: an alternative to the marketplace model for early modern Italy presented by David Gentilcore, tying sufferers’ views on causes of illness to choices of practitioner.108 Visually, the ‘medical pluralism model’ is a Venn diagram comprising three mutually overlapping circles, labelled respectively ‘popular’ (i.e. magical), ‘ecclesiastical’ and ‘medical’, each representing a type of healer, source of healing and aetiological category. Each practitioner falls within one or more categories. This schematic, helpful for emphasizing the relationship between perceived cause and chosen response, is nonetheless too restrictive for my purposes. A healer’s warning of impending death had spiritual import, yet neither the aetiology nor the healer in question needed to be ‘ecclesiastical’. I began with medical practitioners, who healed for profit or for charity, out of familial love or for the promise of gifts; they offered their medicine within a variety of economic relationships, which the marketplace models do not capture. Next I examined the problem of finding a reliable practitioner, arguing that reliability was a function of social networks, and only sometimes the attribute of an individual. In the last part I situated medical practice within its moral and spiritual context, outlining how an understanding of patients’ religious convictions and social mores is important for judging medicine’s place among the available responses to illness – and thus of understanding the roles of healers in this society. In these respects Katharine Park’s account of Florence’s medical marketplace suits fifteenth-century England much better than Harold Cook’s depiction of seventeenth-century London: in its attention to the importance of social and religious factors in shaping medical practice, and its emphasis on individual and institutional charity. In the end, though, neither model captures the full range of economic relationships within which medicine was practised in this period, nor the significance of cultures of illness and healing for understanding that practice. I have tried to demonstrate an alternative way of approaching fifteenthcentury English medicine. This has emphasized medical economies rather than medical marketplaces: systems of exchange that need not be monetary. Rather than assume a buyer–seller tie between practitioner and patient, I have examined the social implications of providing

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medical treatment, whether as a commodity that could be exchanged for cash or some other service or item, or as an integral part of the provider’s social role or relationship with the recipient. I have studied how patients sought out help and healers; and I have suggested that responding to illness involved moral decisions, bound up in the medical, magical and spiritual economies of fifteenth-century England.

Notes I would like to thank the editors of this volume, Jill Whitelock, Lauren Kassell, Peter Murray Jones and the participants of the ‘Rethinking the Medical Marketplace’ symposium. 1. D’A. Power ed., Treatises of Fistula in Ano, Haemorrhoids, and Clysters by John Arderne, Early English Text Society, o.s., 139 (1910), 5–6. 2. Roger French does: R. French, Medicine Before Science (Cambridge, 2003); others do not (see below). 3. Cook, Decline. 4. C. Dyer, ‘Were There Any Capitalists in Fifteenth-Century England?’, in C. Dyer, Everyday Life in Medieval England (1994). 5. M. Hicks, Bastard Feudalism (Harlow, 1995). 6. Dyer, Everyday Life; idem, Making a Living in the Middle Ages (New Haven, 2002); R. H. Britnell, The Commercialisation of English Society 1000–1500 (Manchester, 1996). 7. C. Muldrew, The Economy of Obligation (Basingstoke, 1998). 8. C. Rawcliffe, ‘The Profits of Practice’, SHM, 1 (1988); C. Rawcliffe, Medicine and Society in Later Medieval England (Stroud, 1995); C. Rawcliffe, ‘More Than a Bedside Manner’, in C. Richmond and E. Scarff eds, St. George’s Chapel, Windsor, in the Late Middle Ages (Windsor, 2001). 9. F. M. Getz, Medicine in the English Middle Ages (Princeton, 1998). 10. K. Park, Doctors and Medicine in Early Renaissance Florence (Princeton, 1985), 85–117. 11. Surgery as well as physic. See D. W. Amundsen, ‘Medieval Canon Law on Medical and Surgical Practice by the Clergy’, BHM, 52 (1978); R. Ralley, ‘The Clerical Physician in Late Medieval England’ (Ph.D. thesis, University of Cambridge, 2005). For Arnold, Thurbarn, Edmonds, Bloxham and Wodecock, see their entries in C. H. Talbot and E. A. Hammond, The Medical Practitioners in Medieval England (1965). 12. BL MS Sloane 59, f. 191r. See also P. H.-S. Hartley and H. R. Aldridge eds, Johannes de Mirfeld of St Bartholomew’s, Smithfield (Cambridge, 1936), 132–3. 13. BL MS Sloane 59, f. 191v. Cf. Hartley and Aldridge, Johannes de Mirfeld, 134–5. The reference is to the apocryphal Wisdom of Solomon xvi.12. 14. A. C. Reeves, ‘Some of Humphrey Stafford’s Military Indentures’, Nottingham Medieval Studies, 16 (1972), 91. 15. Rawcliffe, Medicine and Society, 114. 16. Epistolae academicae, 256. On Kymer, ODNB, s.n. 17. Calendar of Patent Rolls 1422–29, 140, 410.

Robert Ralley 43 18. Rawcliffe, Medicine and Society, 110 and n. 31 on 123. 19. E.g., the examples discussed in Rawcliffe, ‘Profits of Practice’, 69. 20. See his entries in Talbot and Hammond, Medical Practitioners; A. B. Emden, A Biographical Register of the University of Cambridge; and ODNB. Medical practitioners often provided astrological services for patrons: see H. M. Carey, Courting Disaster (1992). 21. A. R. Myers ed., The Household of Edward IV (Manchester, 1959), 124–5. 22. Rawcliffe, Medicine and Society, 105–6. 23. Myers, Household, 123–4. 24. Ibid., 127–9. 25. Rotuli parliamentorum (1783), iv, 158. 26. Myers, Household, 111–12, 124–5. 27. Ibid., 126–7. 28. C. M. Woolgar ed., Household Accounts from Medieval England (Oxford, 1992) 428. 29. E. A. Hammond, ‘Incomes of Medieval English Doctors’, JHM, 15 (1960), 155. 30. Ibid., 156. 31. C. M. Woolgar, The Great Household in Late Medieval England (New Haven, 1999), 105. 32. J. K. Mustain, ‘A Rural Medical Practitioner in Fifteenth-Century England’, BHM, 46 (1972), 469–70 and n. 6. 33. C. Carpenter ed., Kingsford’s Stonor Letters and Papers (Cambridge, 1996), no. 274, p. 366. 34. See, for example, Rawcliffe, Medicine and Society, 116. 35. Quoted in Park, Doctors and Medicine, 112. 36. Rawcliffe, ‘Profits of Practice’, 67, n. 25. 37. Talbot and Hammond, Medical Practitioners, 164. 38. Carpenter, Stonor Letters, no. 274, p. 366. 39. H. Kaminsky, ‘Estate, Nobility, and the Exhibition of Estate in the Later Middle Ages’, Speculum, 68 (1993); F. Heal, ‘The Idea of Hospitality in Early Modern England’, P&P, 101 (1984). 40. Surgeons as well as physicians: see the case of Thomas Thornton in Rawcliffe, Medicine and Society, 144. 41. BL MS Cotton Tiberius B ix, ff. 201r-v; Cf. T. Hearne, Elmham (1727), 349; I have followed Hearne’s corrections in the translation. 42. Hearne, Elmham, 338, 340. 43. F. M. Getz, ‘Charity, Translation and the Language of Medical Learning in Medieval England’, BHM, 64 (1990). 44. M. Rubin, Charity and Community in Medieval Cambridge (Cambridge, 1987). 45. N. S. Rushton, ‘Monastic Charitable Provision in Tudor England’, Continuity and Change, 16 (2001); B. Harvey, Living and Dying in England 1100–1540 (Oxford, 1993), 7–33. 46. Hammond, ‘Incomes’, 156. 47. C. Rawcliffe, ‘The Hospitals of Later Medieval London’, MH, 28 (1984); C. Rawcliffe, Medicine for the Soul (Stroud, 1999); Rubin, Charity and Community, 148–236. 48. Rotuli parliamentorum, iv, 130, 158.

44 Medical Economies 49. CLRO, Letter Book K, ff. 6v–7v; R. W. Chambers and M. Daunt eds, A Book of London English 1384–1425 (Oxford, 1967), 92–115; R. T. Beck, The Cutting Edge (1974), 63–70. Cf. P. Kibre, ‘The Faculty of Medicine at Paris, Charlatanism, and Unlicensed Medical Practice in the Later Middle Ages’, BHM, 27 (1953). 50. For comparison, late in the fourteenth century the mercers’ and drapers’ guilds each charged 20s. for entry. G. Unwin, The Gilds and Companies of London (1908), 122. 51. Ralley, ‘Clerical Physician’, 61–2. 52. Cf. H. J. Cook, ‘The Regulation of Medical Practice in London under the Stuarts, 1607–1704’ (Ph.D. thesis, University of Michigan, 1981), 55–6. 53. M. T. Walton, ‘Fifteenth-Century London Medical Men in their Social Context’ (Ph.D. thesis, University of Chicago, 1979). 54. Ibid.; Ralley, ‘Clerical Physician’, 174–7. 55. CLRO, Plea and Memoranda Rolls, A52, membrane 5; A. H. Thomas ed., Calendar of Plea and Memoranda Rolls . . . at the Guildhall, A.D. 1413–37 (Cambridge, 1943), 174–5; M. T. Walton, ‘The Advisory Jury and Malpractice in 15th Century London’, JHM, 40 (1985), 478–82. 56. S. Young, Annals of the Barber-Surgeons of London (New York, 1978), 43. 57. B. Wolffe, Henry VI (1981), 39–42. 58. P. M. Jones, ‘Thomas Fayreford’, in R. French, J. Arrizabalaga, A. Cunningham and L. Garcia-Ballester eds, Medicine from the Black Death to the French Disease (Aldershot, 1998). See also P. M. Jones, ‘Harley MS 2558’, in M. R. Schleissner ed., Manuscript Sources of Medieval Medicine (New York, 1995). 59. N. G. Siraisi, Medieval and Early Renaissance Medicine (Chicago, 1990), 177. 60. Rawcliffe, Medicine and Society, 186, 188. 61. F. J. Furnivall ed., Manners and Meals in Olden Times, Early English Text Society, os, 32 (1868), 186–7. 62. Harvey, Living and Dying in England, 82. 63. M. Pelling, The Common Lot (1998), ch. 9. 64. Mustain, ‘Rural Medical Practitioner’, 469–76, esp. 471–2, 475. 65. R. Bernard, A Guide to Grand Iury-Men (1627), 131–2; cf. K. Thomas, Religion and the Decline of Magic (1973), 244–5. 66. M. T. Walton, ‘Thomas Forestier and the “False Lechys” of London’, JHM, 37 (1982), 72. 67. Getz, Medicine, 7: ‘John was attached for trespass on 29 August 1320’; Talbot and Hammond, Medical Practitioners, 137. 68. Power, Fistula, 4–6. 69. Ibid., 6. 70. S. Shapin, A Social History of Truth (Chicago, 1994). 71. On courtly manners see N. Elias, The Civilizing Process, trans. E. Jephcott (Oxford, 1994). 72. M. T. Walton, ‘Thomas Forestier’, 72. Cf. also the case of attributions of sanctity, which were based at least partially on stereotyped images of the ascetic. See R. N. Swanson, Religion and Devotion c. 1215–1515 (Cambridge, 1995), 152–3. 73. On the medieval guilds see S. L. Thrupp, The Merchant Class of Medieval London (1300–1500) (Chicago, 1948); Unwin, Gilds.

Robert Ralley 45 74. 75. 76. 77.

78. 79. 80.

81. 82. 83. 84. 85. 86. 87.

88. 89. 90.

91. 92. 93.

94. 95. 96. 97. 98.

99. 100.

Beck, Cutting Edge, 132. Woolgar, Great Household, 104–5. ODNB, s.n. On family sentiments see D. Herlihy, Medieval Households (Cambridge, MA, 1985), 112–30; idem, ‘The Making of the Medieval Family’, Journal of Family History, 8 (1983). Margaret Paston to John Paston I, 5 November 1452, in N. Davis ed., Paston Letters and Papers of the Fifteenth Century, 1 (Oxford, 1971), Letter 144, p. 246. Margaret Paston to John Paston I, 8 June 1464, ibid., Letter 177, p. 292. M. Granovetter, ‘The Strength of Weak Ties’, American Journal of Sociology, 78 (1973); cf. M. Granovetter, ‘Economic Action and Social Structure’, Ibid., 91 (1985), 490, on the trustworthiness of close ties. John Paston III to Margary Paston, undated (but between 1487 and 1495), in Paston Letters, Letter 389, p. 628. Carpenter, Stonor Letters, no. 68, p. 266. Rawcliffe, Medicine and Society, 53. Rotuli parliamentorum, iv, 158. J. B. Post, ‘Doctor Versus Patient’, MH, 16 (1972), 299. R. Kieckhefer, Magic in the Middle Ages (Cambridge, 1989), 85. On witchcraft see, N. Cohn, Europe’s Inner Demons, rev. edn (1993); J. B. Russell, Witchcraft in the Middle Ages (Ithaca, 1972); S. Clark, ‘Demons and Disease’, in M. Gijswijt-Hofstra, H. Marland and H. de Waardt eds, Illness and Healing Alternatives in Western Europe (1997), 38–58; on necromancy see R. Kieckhefer ed., Forbidden Rites (Stroud, 1997). Rawcliffe, Medicine and Society, 92. R. C. Finucane, Miracles and Pilgrims (1977), 64, 77. Horrox, The Black Death (Manchester, 1994), 163. Cf. D. Harley, ‘Spiritual Physic, Providence and English Medicine, 1560–1640’, in O. P. Grell and A. Cunningham eds, Medicine and the Reformation (1993), 101–2. Margaret Paston to John Paston I, 28 September 1443. Paston Letters, 1, Letter 126, p. 218. On distinguishing these see R. Kieckhefer, ‘The Specific Rationality of Medieval Magic’, Speculum, 99 (1994). Sloane 3132, ff. 29v–32r; E. Duffy, The Stripping of the Altars (1992), 266–87; C. F. Bühler, ‘Prayers and Charms in Certain Middle English Scrolls’, Speculum, 39 (1964), 270–8. T. Aquinas, Summa contra gentiles, lib. iii, cap. 104–7; L. T. Olsan, ‘Charms and Prayers in Medieval Medical Theory and Practice’, SHM, 16 (2003). Rawcliffe, Medicine and Society, 92. Duffy, Altars. C. Fanger, ‘Plundering the Egyptian Treasure’, in C. Fanger ed., Conjuring Spirits (Stroud, 1998). For the possible ambivalence and ambiguity of the categories of saint, witch and necromancer, see R. Kieckhefer, ‘The Holy and the Unholy’, Journal of Medieval and Renaissance Studies, 24 (1994). Rawcliffe, Medicine and Society, 100; Duffy, Altars, 301–37, esp. 315; Rawcliffe, ‘More Than a Bedside Manner’, 77. Hartley and Aldridge, Johannes de Mirfeld, 65.

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101. Duffy, Altars, 209–98. 102. See, for example, Duffy, Altars, 310–12, 322. 103. See, for example, the entries for Adam Rous, David, the surgeon, Henry de Wotton and William Taunton in Talbot and Hammond, Medical Practitioners. 104. Carpenter, Stonor Letters, nos. 249 and 250, p. 344. 105. Getz, Medicine in the English Middle Ages, 4–5; Ralph of Coggeshall, Chronicon Anglicanum, Rerum britannicarum medii aevi scriptores, 66 (1875), 156–9. 106. Cf. P. Brodwin, Medicine and Morality in Haiti (Cambridge, 1996), 200–1. 107. S. McSheffrey and N. Tanner eds, Lollards of Coventry 1486–1522, Camden Soc., 5th ser., 23 (2003), 63–87, esp. 64–5, 195–6 and 200–1. 108. D. Gentilcore, Healers and Healing in Early Modern Italy (Manchester, 1998), esp. 2–3.

3 Competition and Cooperation in the Early Modern Medical Economy Patrick Wallis

What was it like to work in the ‘medical marketplace’ of early modern London? How did medical practitioners interact with each other? How did they obtain, treat and cure patients? Studies of early modern medical marketplaces over the last three decades have shattered old accounts that emphasized the small scale of the medical sector, its dominance by an elite of learned physicians, and the importance of institutional, professional and theoretical boundaries between groups of medical practitioners. In their place, historians of English medicine have described a situation in which professional controls were either absent or contested, and where ‘occupational diversity’ was the norm. Above all, they have shown medical practitioners competing with each other in a ‘marketplace’ that was influenced but not defined by institutions, patronage and law.1 Arguably, it is competition that most clearly distinguishes the medical marketplace from other systems of health care, such as domestic provision, socialized medicine, and, particularly, professionalized medicine – in which competition is normally constrained by entry controls and prohibitions on advertising, poaching patients and discounting. Where competition was limited, as in those parts of early modern Europe where occupational and regulatory institutions were stronger, historians have developed alternatives to the medical marketplace that reflect the more constrained form of practice they observe.2 Given the prominence of competition in accounts of medical marketplaces, the subject of this chapter – cooperation between medical practitioners – may seem perverse. Nonetheless, I want to suggest that we can gain a better understanding of the internal dynamics of the medical economy if we consider when and why medical practitioners worked together. As I show, medical practitioners cooperated both by creating firms and, more often, by developing less concrete kinds of 47

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commercial relationships. The small-scale, personalized and fluid informal institutions – commercial networks – that medical practitioners established enabled them to address basic practical problems: how to gain patients; how to provide them with the services and commodities they needed; and how to secure fees and profits from their knowledge. This is not to deny the presence of competition. In fact, competition, diversity and pluralism actually tended to produce a certain level of collaboration, as did the functional specialization of most participants in medicine, and the relationships fostered within guilds, the College of Physicians, other institutions, neighbourhoods and social networks. Even if they eschewed the theoretical boundaries of tripartition, the division into physic, surgery and pharmacy, few practitioners sought to offer every aspect of medicine. Fulfilling the diverse needs of patients, therefore, necessitated interaction. Even those practitioners who did agree to provide the entirety of a cure would often need to tap external resources, whether for drugs, advice or assistance.3 Aside from studies of medical practitioners’ participation in the College, medical guilds, or collective intellectual endeavours such as the Royal Society, historians have paid little attention to how English medical practitioners interacted with each other.4 Most have assumed that regular and irregular practitioners worked as autonomous, solitary individuals. The College and guilds provided their members with institutional ties that had uncertain implications for their everyday activities; those outside these bodies had nothing. It is an impression reinforced by the prominence of disputes in the historiography; the supposed ‘atomism’ of these market relationships is in many ways a product of historians’ reliance on print sources, particularly advertising and the fodder of pamphlet wars. As Roy and Dorothy Porter put it, in ‘what was tantamount to a free market ... Doctors would sink or swim as individuals’.5 This emphasis on individualism, particularly for higher status practitioners, is one of the marked continuities between medical marketplace and professional models of practice. Freedom from commercial entanglements that could bias judgments is a defining characteristic of all traditional professions. However, this ‘consultant’ interpretation has helped obscure the varieties of association and interdependence between medical practitioners. Indeed, it is ironic that as medical historians have become used to discussing a pluralistic, competitive and atomized medical marketplace, historians of other areas of early modern work have been emphasizing the role of networks and informal structures in the economy, echoing wider academic interest in the social embeddedness of economies; one of my concerns here is to begin to reconcile these two literatures.6

Patrick Wallis 49

Association was not a neutral act. Many early modern medical practitioners did take pains to present themselves as operating autonomously. Apart from the few large hospitals, military service and the East India Company, medical practitioners were rarely employed by large organizations. Indeed, physicians who did have hospital appointments generally emphasized their independence, although surgeons and apothecaries might be employed for wages. These displays of autonomy were rooted in traditions about the organization of medical work, but they were also closely related to general assumptions about masculinity and the proper organization of work. As Alex Shepard has emphasized, independent mastery was important to understandings of manhood among the middling sorts.7 The attractions of involvement in patronage networks and royal or aristocratic household positions complicated matters for some practitioners, but concepts of artisan honour and gentility both reinforced the significance of appearing to stand free from compromising ties. Contemporary views on the organization of the economy also affected the public acceptability of association. Some forms of relationship, surgical partnerships and apprentice–master contracts, in particular, were wholly proper. Others were more suspect. That the market should by rights be based on small specialist producers and retailers was a frequent assumption in early modern commentaries on trade and production.8 For consumers, anxiety about price fixing and monopolies similarly reinforced the importance of clear divisions between different segments of production. As we will see, medical networks were affected by these expectations. The discussion below focuses on medicine within sixteenth- and seventeenth-century London. Tracking informal ties and networks between medical practitioners is inherently difficult. One fortunate side effect of the organizational disputes that afflicted early modern London’s medical institutions is the survival of extensive evidence about medical practice, particularly in the College of Physicians’ records.9 It is hard to assess how far London diverged from the rest of the country. The city was expanding dramatically and patterns of consumption, particularly among the middling sort, were changing: as part of this shift, the level of demand for medicine appears to have grown. Moreover, metropolitan medicine was organized differently. One result was the institutional conflicts just mentioned. Another was the existence of a set of corporate loyalties alongside – and sometimes opposing – the social and business interests of practitioners. Such local conditions affected the way in which markets for medical goods and services operated. That said, London medicine was not separate from the rest of the country, and differences in practice probably should not be overstated.

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Competition and Cooperation

Medical ‘firms’ and workshops Before discussing loose and informal ties between medical practitioners, we need to be clear about the normal ‘units of production’ in early modern medicine. Like natural philosophers, even the most learned of medical practitioners might rely on the presence of wives, servants, assistants and partners without whom their enterprises would falter.10 In most sectors, premodern production was dominated by small workshops, while service professionals – lawyers, clergy, bankers – tended to work as individuals or in small partnerships. Medicine followed, even exaggerated, this pattern. Medical practitioners’ ‘firms’ and workshops were small. Apothecaries and barber-surgeons took relatively few apprentices and journeymen.11 Physicians rarely took any, but might employ servants (some of whom they apparently trained) and did instruct others on occasion.12 In the 1690s, when household data survive, apprentices remained relatively rare, as Table 3.1 shows. Servants were significantly more common. There is no easy way to determine servants’ role, but some at least were involved in their employers’ work, for example, letting blood or preparing medicines.13 Families could of course play a significant part in businesses. Wives were not inevitably less skilled than their husbands, as the activities of widows show, while those practitioners who accommodated patients doubtless relied on their kin and servants’ help. However, close family could almost never produce a large enterprise on its own, and medical practitioners’ family sizes were not particularly large. Indeed, many, particularly physicians, were unmarried.14 Partnerships were also rare. A number of examples are found among apothecaries and surgeons, some involving explicit profit-sharing agreements.15 As well as offering a way to combine scarce credit and capital, such partnerships were used to transfer businesses between owners; as such they were a practice shared with other wholesaling and retailing occupations, particularly grocers. Fewer physicians worked together.16 Within London, Hal Cook has described how in the late 1680s several licentiates of the College of Physicians established a unique and shortlived joint practice called the ‘repository’.17 To the extent that we can discern the functions of different individuals, partnerships seem to have mostly occurred between those engaged in the same specialty. Where practitioners employed other medical practitioners the pattern was reversed. For example, we have several descriptions of London physicians employing private apothecaries, transgressing the theoretical and institutional boundaries of medicine.18

Table 3.1 Household size and structure of medical practitioners (1692)∗ Kin

Servants and Apprentices Percentage with

Physicians Surgeons Apothecaries Druggists Chemists

Average number (where present)

Percentage with

Average number (where present)

N

Servants

Apprentices

Servants

Apprentices

Wives

Children

Children

37 76 160 55 11

75.68 81.58 85 87.27 72.73

2.7 25 26.25 18.18 18.18

2 1.79 2.14 2.44 2.25

1 1.26 1.36 1.5 1

51.35 69.74 70 56.36 54.55

8.11 46.05 50 49.09 27.27

4.33 1.77 2.26 2.22 2.33

∗ The figures represent minima and the degree of undercounting is uncertain. The relative size of households should be reasonably accurately represented. Source: The 1692 Poll Tax database created by James Alexander and held by the Centre for Metropolitan History, University of London. See: J. M. B. Alexander, ‘The Economic and Social Structure of the City of London, c. 1700’ (Ph.D. thesis, University of London, 1989).

Patrick Wallis 51

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The explanation for the small size of these enterprises is straightforward. Providing medical services such as surgery and physic offered few opportunities for economies of scale or scope. Even retail pharmacy largely remained small-scale and personalized, although there were the beginnings of larger scale pharmaceutical production at this time. Moreover, larger businesses involved risks as well as opportunities. Partners and employees might benefit from each other’s reputations and earnings, but they also shared vulnerability to any downturn in business and faced problems in monitoring each other’s output. These arguments against functional integration held even more strongly for arrangements between general medical practitioners and those who supplied other parts of medical care, such as midwifery, or specialized surgical procedures like lithotomy or optical operations. As the occasional attempts by the College of Physicians and Society of Apothecaries to limit such relationships suggest, integration was also politically and economically suspect, running against traditions of craft autonomy and raising concerns about conspiracy and price gouging. These institutional boundaries and conflicts stand in stark contrast to Renaissance Florence where contractual arrangements between physicians and apothecaries were the norm.19 More common in London was the development of close but informal ties between practitioners with complementary functional specialties who engaged in repeated transactions, as will be discussed below. Many of the difficulties involved in expanding medical businesses can be seen in the relationship between the physician Helkiah Crooke and the apothecary Thomas Lord. In the 1610s, Crooke, then a candidate for membership of the College, employed Lord as his servant and later as his ‘private Apothecarie’.20 Some time later, Lord inherited some money and decided to set up his own shop. He hoped to continue making medicines for Crooke ‘because he had beene his auncient servaunt’. However, Crooke refused, because, Lord later recalled, he would not be ‘sufficiently advantaged’. Instead, Crooke proposed a partnership – using Lord’s capital and labour: Lord would get two shillings in the pound for all medicines sold, as well as £10 in the £100 for the money spent furnishing the shop. The loss of Crooke’s practice would have, presumably, been devastating, and so Lord agreed. The arrangement worked for two years before Crooke, who was experiencing money problems, decided that the shop was not sufficiently profitable and apparently turned it over to Lord. At around the same time, Crooke’s debts led him to be ejected from his house and the shop. Lord therefore removed the stock to his own house. The evidence is contradictory about these and subsequent events, with both Crooke and Lord claiming in the lawsuit that followed that each

Patrick Wallis 53

was indebted to the other. Yet, despite these uncertainties, their dealings clearly illustrate some of the ways in which arrangements could shift as age, experience and wealth changed. Ironically, Crooke’s eviction coincided with his election as a fellow of the College after a series of unsuccessful attempts, while Lord seems to have been relatively successful on his own behalf for the short period in which he appears to have remained active in London. The collapse of Crooke and Lord’s partnership illustrates some of the difficulties that constrained any practitioner’s desire for expansion: the weaknesses of contracts, the problems of monitoring each other’s work and the awkwardness in securing a sufficient flow of business between partners. Most medical practitioners, therefore, remained formally independent of others, masters of what were, at most, small household workshops. Instead of employees or partners, they relied on their ability to form informal relationships. It is these associations that we turn to next.

Associations, ties and consultations While medical firms were rare, briefer case-by-case associations were common in all areas of medicine. Of course, calling in another practitioner for advice on a particular case – consultation – might be a response to a patient’s demand for a second opinion, and the selection of practitioner was sometimes their prerogative. The efforts of the College of Physicians to set rules about behaviour in these situations suggest that consultations might easily become hostile encounters.21 However, consultation could also be driven by practitioners’ need for specialist support or assistance. In this form it might be closer to collaboration. It was an inevitable result of specialization and differing levels of skill and experience. It also allowed practitioners to keep hold of cases that tested the bounds of their own abilities. For example, one irregular empiric, Butler, was, according to Dr Gulston, in league with an apothecary Mr Thomas who instructed him ‘when he knowes not what to doe’.22 Although Thomas denied this charge, it is clear that many practitioners consulted people with whom they had ongoing informal relationships. Brief combinations between practising apothecaries and surgeons seem to have been a particularly common way of treating patients. Typically, in 1600 when an apothecary called Besse treated a patient in his house he did so in association with a surgeon Moore.23 Immigrant practitioners can be found working together in this way in their own communities, as can be midwives.24 The extent of these relationships is uncertain. When one Bowden, a surgeon, assisted the apothecary Fludd in treating

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Competition and Cooperation

Henry Leach’s syphilis, he gave his prescription verbally in Fludd’s shop, perhaps suggesting a shared workplace, as occurred in some Italian cities.25 The possibility of consultation or case-specific partnerships might also allay a patient’s concerns. When asked by the patient he was bleeding ‘how he durst do this without a doctors advise’, the apothecary Valentine Figge’s response was apparently that ‘if he were not trusted he would bring a doctor to him’. Figge’s nonchalance about summoning assistance suggests the ease with which irregular medical practitioners called upon each other as necessary, ignoring institutional boundaries.26 Surgeons were particularly prone to forming temporary partnerships for specific cases, as their frequent disputes over the division of fees indicate. In January 1604, to give but one example, the company ordered Edward Wood to pay 40s. to Henry Ulster’s wife, now presumably his widow, for ‘a Cure in partnership betwixt him and Henry Ulster’.27 In dangerous cases, this was, in theory, obligatory: the Barber-Surgeons’ Company had a rule that surgeons were to consult on risky operations. Some patients also seem to have sought joint treatment.28 This could lead to clusters of practitioners developing around particular cases. This can be seen in the treatment of Simon Hamond’s son in 1646, who had fallen out of a first-story window and landed on his head. Hamond sent for a surgeon, Browne. However, when Browne arrived, he found Doctor Spicer and another surgeon, Thomas Bowden, already there. The treatment proceeded ‘by general consent’, and when it later became necessary to open the boy’s head, Browne carried out the trepanation ‘in the presence and with the advice and approval of Serjeant Clowes, then master, and George Dunn, then warden, of William King, Mr Eaton, approved surgeon, and Bowden’.29 Here, the relationship between the six different practitioners appears to have been initiated by the patient’s family, much as they might consult several physicians. The legitimacy of partnerships between surgeons was beyond doubt. We find a more mixed picture if we turn to associations between irregular practitioners and physicians. Here, a practitioner’s desire for specialist advice on a case often overlapped with a strategy to evade prosecution for illegal practice by the College of Physicians. Several College members seem to have been involved in arrangements with apothecaries who illicitly practised medicine, and defended them against College actions.30 The most active of these was the Scottish physician Alexander Read. When the apothecary George Haughton was accused in 1622 of poisoning one of his patients, he asserted that Read – with whom Haughton was still associated in 1634 – had ‘afterwards’ approved the pills.31 Similarly, in

Patrick Wallis 55

1634, the College heard how Read helped a surgeon, Cotton, convince a patient of his skill. Cotton had reportedly told his patient ‘hee made as good a water as any in England, but if hee would [not] believe him, hee should have the opinion of a Dr., [and] so Dr. Read was called’.32 It is hard to know if Read was supplying excuses or if these consultations actually occurred. He certainly claimed to have been paid for his prescriptions when examined by the College, although he admitted that ‘for whom they weare he knewe not’.33 Read, who was also a freeman of the Company of Barber-Surgeons and received £20 a year to lecture to them, may have been unusually willing and safe to consult: one surgeon later commented that ‘out of his love to the Chirurgions [Read] will not take their patients out of their hands’.34 Two characteristics of Read’s purported interactions with other practitioners are worth highlighting: he appears to have been selected by the practitioner not the patient; and he was kept at a distance, rarely if ever seeing the patient. Similar patterns can be found in other cases. When the apothecary William Clapham was summoned before the College in 1631 for the treatment of William Turner, the nurse, Margaret Woodmen, claimed that in the ten weeks she had cared for Turner no doctor had visited. Clapham had even examined the patient’s urine, which was a physician’s role. Clapham, however, denied practising physic. He claimed to have followed the directions of Dr Peter Maden, an unlicensed physician.35 No one had seen Maden, Clapham argued, because he examined Turner’s urine in Clapham’s shop. Two other witnesses confirmed that Turner had paid Clapham for an unnamed doctor. Clapham therefore entirely controlled Maden’s involvement and the extent of his own practising remained ambiguous.36 A more convoluted example of this kind of informal relationship can be seen in Henry Dickman’s treatment of Frederick Porter early in 1630.37 After having been treated by Dr Meverall for a month, Porter resorted to Dickman, an apothecary, on the advice of a friend. Dickman diagnosed the pox and began salivation. While Dickman made the diagnosis and organized treatment, he apparently did not work alone. He claimed that the pills he administered came from Edward Harris, a surgeon, who had seen Porter twice, although Porter and Dickman disagreed on whether this was before or after Porter took the pills. (Harris admitted supplying the pills, but denied prescribing or being paid for them, thus sidestepping the issue of whether he had practised illegally.) Dickman did admit giving Porter a dietetic potion, but claimed he stopped this on the advice of one Butler, to whom he had taken Porter. Dickman then exculpated himself totally by producing a statement from Butler undertaking

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Porter’s case. Porter’s treatment thus involved several interlinked practitioners orchestrated by Dickman; the responsibility of each, even their pay, was unclear to the patient. Dickman appears to have encouraged Porter’s reliance upon him, suggesting that the physicians would abandon him when they realized he had the pox.38 Dickman was pursued by the College for illegal practice three times between 1607 (when still an apprentice) and 1639. The last complaint suggests that his treatment of Porter had followed a standard pattern. Again recommended by a friend, Dickman seemingly diagnosed John Willis’s diseases, contracted for his cure, treated him and even arranged his lodgings single-handed. Yet, when summoned, he could produce prescriptions for the medicines he had supplied, this time from Dr Hinton.39 Dickman and Clapham were both acting as portals to other practitioners’ expertise, as well as, it seems, practising themselves.40 Both were apothecaries, and their activities in filling prescriptions supplied by other practitioners may have helped them to build up such ties. Selling medicines could also bring apothecaries patients: as Nathaniel Hodges complained, ‘under pretext of selling their Medicines to all who come to their Shops they also take upon them to advise what they think most agreeable to their conditions who are sick’.41 In these two cases, the patients seem to have known of the consultation, although they did not control it. Other apothecaries accused of illicit practice were able to supply prescriptions from physicians of whom their patients were apparently unaware. William Tole, a patient of John Sotherton, explicitly acknowledged this to the College in 1630. Sotherton had given him physic, a purge and let his blood, but ‘whether hee had the Counsel of a Doctor or no hee cannot saye’.42 Tole was probably pressed on this point by the College, because earlier that year Sotherton had avoided another charge by producing a physician, Dr Tomand, who stated that he had prescribed medicines without the patient’s knowledge. Surgeons and other irregulars used similar strategies.43 Given that most of our evidence comes from the records of the College of Physicians’ prosecutions, it is possible that physicians like Tomand actually became involved after the fact; but if so their willingness to perjure themselves only reinforces the importance of such relationships to them. Arrangements that were apparently discrete from the patients can be found elsewhere, suggesting that these were not just devices to confound the College. For example, when Andrew Faye, an irregular practitioner in Whitefriars, was sued by George Butler, a ‘practiser in physic’ (and perhaps the irregular involved in Dickman’s treatment of Porter), over payment for the treatment of Richard Godfrey and Anne Crewe, the patients themselves denied all knowledge of Butler’s involvement.44

Patrick Wallis 57

Consultations between practitioners clearly helped provide assistance, advice and – when a practitioner was dragged before the College – alibis. Practitioners’ willingness to consult others suggests confidence about access, reliability and a disregard for institutional boundaries, although the emphasis on secrecy indicates a persistent fear of poaching.45 Moreover, the opaqueness of some of the relationships just outlined relates at least in part to the forms of contractual citizen medicine. When contracts for a ‘cure’ were drawn up, it was hard for a practitioner to know how long treatment would take, how an illness might develop and whether their own abilities would be sufficient. For the patient, contracts that specified payment on ‘cure’, might serve to insulate them from such uncertainties, but in doing so they simply transferred them to the practitioner. Ties offered practitioners one mechanism to manage such uncertainties while limiting the risks of involving a third party in such a relationship. It is unsurprising that, as Ronald Sawyer noted, ‘cooperation ... was part of the everyday routine of most healers’.46 However, such informal links formed only one aspect of association in early modern medicine. Ties between practitioners supplying advice and those supplying medical commodities, particularly drugs, appear to have differed from these consultative associations. In this area, prescriptions provide us with the best chance to observe the organization of networks of supply and demand. The prescription or ‘bill’ that conveyed doctors’ instructions about what medicines were to be used lay at the heart of the orthodox interaction between patient, physician and apothecary. Prescriptions could range from standard remedies to highly personalized or new recipes, devised as required. Old prescriptions could become valuable, particularly if they contained ‘secrets’ or were linked to noted practitioners, and they circulated widely in manuscript networks.47 The distribution of prescriptions was an important element in the relationship between physician, patient and apothecary. It was often the prescribing practitioner, not the patient, who decided who would make up a prescription. Practitioners generally sent them to apothecaries with whom they had links, as surviving records of prescriptions kept by apothecaries show. The majority of the 251 prescriptions which the London apothecary Edward Barlow recorded between 1588 and 1590 came from four physicians.48 A book of prescriptions kept by an anonymous apothecary in the mid-1620s shows a similar pattern: 18 of its 83 prescriptions were from one Dr More.49 It is clear that many physicians established such bonds. The famous physician Theodore de Mayerne, for example, relied on a series of Huguenot apothecaries including Gideon de Laune, Edward de Plures, Lewis de Lyfte (who received the

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freedom of the Society of Apothecaries at his request), Paul de la Belle [L’Obel] and Didier Foucaunt.50 Immigrants’ marginality may have encouraged collaboration, but Mayerne was not unusual. English physicians, such as Charles Goodall, Thomas Moffett and Thomas Winston, kept apothecaries.51 Even the orthodox William Harvey had ‘his apothecary’, Peter Shambrooke, who let his blood on his deathbed.52 The significance and vulnerability of such links is underlined by a complaint the College heard against the apothecary Smith for ‘trickery’ in 1608. Smith’s offence was to disregard these connections: if messengers with prescriptions written by physicians to other apothecaries in error found their way into his shop, he would treat them as if they were sent to him and sell the medicaments piecemeal.53 The College occasionally acknowledged these arrangements. In 1635, fellows were ordered to ‘searche their owne Apothecaryes 4 tymes a yeare’, while in 1637 several physicians offered the troublesome apothecary and physician John Buggs ‘halfe their practise’ if he would stick to working as an apothecary – a proposal Buggs rejected as ‘too great [a] dishonor unto him’.54 Perhaps the best measure of the strength, importance and ubiquity of such relationships was their targeting by the College of Physicians in its campaign against irregular practitioners in the 1630s. This relied on prohibiting College members from using any apothecaries (‘discommuning’ them) who practised physic or filled irregular practitioners’ prescriptions.55 The College plan derived from its regulatory experiences of identifying apothecaries supplying irregulars with drugs or filling their prescriptions.56

The uses of association It is worth exploring the benefits of the different relationships discussed above to medical practitioners in some detail. They served as an axis along which three kinds of object – profit, patients and medical products – could be passed. Prescriptions suggest the most obvious potential benefit, in the form of a share in the profits from the medicines supplied, something also possible in agreements with specialist surgeons and the like. For physicians in particular, this may have helped overcome the difficulty of valuing – and extracting payment for – intangible learned advice.57 However, it was the possibility for profiteering that was more often identified by contemporary critics.58 The College of Physicians

Patrick Wallis 59

occasionally acted against such behaviour. In the mid-sixteenth century, it expelled the physician John Howell, only readmitting him on the condition ‘that he would agree not to increase the price of drugs with the apothecaries’.59 Practitioners’ ability to shape their patients’ decisions about who else to employ could, it seems, have been equally beneficial. In consultancy arrangements and partnerships this was most explicit. The ability to involve practitioners with differing degrees of skill or specialty in particular cases facilitated the distribution of work and allowed for the fluctuating and uncertain nature of illness. Their ability to offer informed advice on this question was also very important. For sick people seeking medical care, the evaluation of the quality, reliability and cost of practitioners was difficult.60 Advice from relations, friends and associates could only go so far. Apothecaries were particularly important in acting as clearing houses for information and advice, providing ‘contextual knowledge’ about the quality and price of provision. In parts of Italy, lists of licensed physicians were even posted in apothecaries’ shops.61 This never occurred in London. Nonetheless, as the London physician Jonathan Goddard complained, apothecaries were ‘generally entertained in the beginning of sickness, and are made judges of whether or no, and when any, and what Physician shall be sent for’.62 Midwives had a similar role.63 As indeed did successful physicians: some of the best evidence of this is in the letters of the provincial clergyman and physician Richard Napier. For example, Richard Spicer wrote to him ‘specifically requesting that he be recommended to administer physic to Lord Purbeck’ when he next came to London; similarly, Napier recorded that ‘an honest Apothecary ... new come to Bedforde [had] requesteth yt if any come from Bedford he may have my bils’.64 A well-placed connection could help establish a practice, overcoming the conundrum of needing a reputation to get patients, and patients to get a reputation. As in fifteenth-century Florence, ‘the new doctor’s fortunes depended heavily on connections’.65 Alliances with those who would ‘cry up’ their reputation were attractive in the long term also.66 Demand was uncertain and unpredictable: dissatisfied patients freely dismissed practitioners, and contracts generally lasted for a single illness. Practitioners allied in networks of mutual recommendation and patronage thus helped advance each other while resolving patients’ uncertainties about whom to employ. Associations served a further important purpose where medical practitioners contracted to supply both medicines and advice, or when they wished to prescribe medicines they had invented. The nature of medical

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production accentuated the importance of finding a trustworthy supplier. The College and medical guilds provided only limited assurances about the quality of medicines. The fragmentation and diffusion of production, limitations of assaying techniques and the legitimacy of substitutions and variation in some recipes meant that fraud was widely suspected.67 Yet, as the College of Physicians repeatedly argued, practitioners faced severe consequences if medicines were falsified: their treatments would fail and with them their reputations; they would reach false conclusions about efficacy; and, most concerning of all, they might be blamed – even prosecuted – if the patient died. Patients’ identical concerns about quality further strengthened the demand for the reassurance that reliable suppliers, proved by repeated use, might provide. Medical practitioners engaged in practice also had a further motive for building a reliable relationship with whoever supplied their medicines: they needed to ensure the security of these personal ‘secrets’, otherwise a rival might ‘injuriously reap the fruit’ of their labours, as one physician warned.68 Such worries are behind some unusual tactics, such as Dr Brouvaert’s ‘enigmatically’ written prescriptions – probably a basic cipher that he later justified on the grounds that ‘the apothecaries dealt very unfairly’ with physicians. Brouvaert intended to prevent apothecaries reproducing his medicines for their own profit.69 Ties built through repeated interactions provided another means to operate in the face of these high levels of uncertainty and asymmetric information, as has been observed in other contexts.70 Repeated transactions reduced the ‘search costs’ faced by patients and medical practitioners, and gave apothecaries an incentive to be accurate.71 Thus, even without a profitsharing deal, practitioners would probably direct prescriptions only to apothecaries they knew and trusted. Associations between practitioners in different fields thus reduced transaction costs and strengthened incentives against poaching patients or shirking quality requirements.72 These arrangements might be more or less public. This interplay of expectations, functions and norms, and the fluidity of informal associations, meant that ties took a wide variety of forms, some more open than others; no single mode of relationship dominated within the medical economy. While the formation of ties can be linked in this way to the circumstances of early modern medical practitioners, these were not, it must be emphasized, simply functional associations. They were formed through and reinforced by social relationships and norms. They could be fostered by systems of training, with their emphasis on apprenticeship and observation.73 Ties also emerged from other connections, through family, faith, institutional membership

Patrick Wallis 61

and shared sociability.74 They might develop into stronger social bonds. When the apothecary George Sheeres described his relationship with Dr Elwyes, he spoke of the ‘great kindness and familiarity’ and the ‘diverse matters of trust’ which had passed between him and Elwyes.75 The Paracelsian physician William Butler not only lived out his old age in the home of the Wisbech apothecary John Crane, who had worked for him when younger, but bequeathed him his estate.76 Medical practitioners’ wills hint at similar sentiments: in 1663, the apothecary Benjamin Banister left rings worth 20s. to three physicians, Wharton, Welby and Burnett, alongside a number of apothecaries.77 Associations, partnerships and repeated consultations were a useful and important part of early modern medicine. However, they had their limitations. First, alliances did not preclude competition and conflict; indeed the persistence of competition, particularly the poaching of patients and ideas, helped make them necessary. Second, that ties might cross-institutional boundaries did not mean that the institutions had no meaning. As we have seen, the College and medical guilds were at times discomforted by the existence of associations, while the many institutional conflicts that afflicted seventeenth-century London medicine underlines the significance of corporate loyalties. This institutional antagonism shaped and limited connections. Several apothecaries in the 1630s rejected any submission to physicians. According to Dr Clement, Reeve frequently asserted that ‘he would not [be] beholding to Skurvy Physitians nor give forty pounds to any of them’; in a similar vein, Nicholas Aylet boasted that when he finished his apprenticeship ‘he should not be such a Jack dandy as other Apothecaries were to waite upon the doctors’.78 At the other end of the spectrum, many of those who only occasionally engaged in medical practice, or who operated just within their own neighbourhood, were unlikely to become embedded in commercial bonds, and a great deal of medical care continued to operate on this scale.

Conclusion What did the existence of ties that cut across institutional boundaries and counterbalanced raw competition mean for the sick? The medical marketplace has been seen as a ‘buyer’s market’ in which patients were ‘discerning’ judges of a largely undifferentiated mass of regular and irregular practitioners; one result of this was that patients often ‘controlled the medical relationship’.79 This seems to run the risk of exaggerating patients’ autonomy. Certainly, a significant degree of bargaining emerged

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from patients’ involvement in determining symptoms, diagnosis and therapies; some did shop around, particularly for long-running conditions. The diffusion of medical knowledge and practitioners’ diagnostic reliance on patients’ narratives reinforced this.80 Yet choice was not necessarily exercised easily. On the one hand, personal and social status, and religious and institutional affiliations still influenced decisions, as did the physical and emotional constraints of illness.81 On the other, various factors complicated choice: the problem that patients faced in discriminating between practitioners; the need for reliable recommendations; the problem of controlling costs; and the urgency of emergencies. The dynamic of ongoing patient–practitioner relationships under the stress of sickness could further circumscribe the patient’s freedom: not all patients were ‘medically promiscuous’, while a practitioner’s understanding of their patient’s temperament took time to develop.82 In one of the cases discussed earlier, Clapham’s patient Turner had described him as ‘his antient Apothecarye whose councell he used, and one that knew his bodye well’. The web of connections between practitioners facilitated treatment and resolved such uncertainties for patients and practitioners alike. In the process, they also bounded competition and served to counter-balance the power of the patient-purchaser. To some extent, then, networks provided premodern medical practitioners with some of the power to take choice out of the hands of the patient that Eliot Friedson identified in the professional ‘referral system’ of modern medicine.83 That said, networks between practitioners paralleled and overlapped lay networks, and the interaction between these systems needs to be further explored. I have suggested here that medical practitioners in seventeenthcentury London commonly operated within and through commercial networks that linked them in diverse mutually beneficial relationships. A crucial aspect of this was the establishment of ties of varying strength and durability. These networks helped practitioners reach prospective patients, smooth irregularities in the rate of business and access reliable resources. Relationships allowed medical practitioners to manage the uncertainties involved in judging the quality of drugs and estimating the skills, knowledge and time required for a case. Although the medical treatments employed by practitioners were not complex or resource-intensive by comparison with subsequent developments, most still relied on some division of labour in order to supply different elements, such as drugs, knowledge, bleeding and nursing. Without such connections, practitioners would have found it much harder to practice, and faced greater reputational risks and vulnerability to poaching. Associations were formed both between practitioners of different status

Patrick Wallis 63

and those who were more equal, although it is hard to discern what impact this had on them. Some were also more open than others. It seems likely that many patients knew of the relationships that existed between some of the practitioners they encountered, and some might be cultivated to enhance a practitioner’s reputation through a positive association – as the entreaties Napier received indicate. Yet, it is also clear that other connections were kept from patients for varying reasons including the need for alibis against institutional policing, preserving the secrecy of a remedy and the suspicion that some connections – between apothecaries and physicians, for example – could occasion. Connections between ostensibly independent operators seem to be characteristic of a number of areas of early modern manufacturing and trade, suggesting the importance and ubiquity of embedded networks within early modern markets. Although I have focused on sixteenthand seventeenth-century London, it seems likely that the medical economy continued to possess many of these characteristics for a longer period. London, with its high levels of mobility, disproportionate number of immigrant practitioners and sheer size, intensified some of the specific difficulties that ties emerged to overcome, but similar networks can be observed for practitioners who worked in provincial England. What little we know of medicine in fourteenth- and fifteenth-century England, and the significantly richer picture we have for Europe, suggests similarities, although the force of London’s collective institutions was weaker and tended to divide rather than unite.84 Certainly, Tobias Smollett’s 1753 description of knots of practitioners who ‘tossed the ball from one to another’ while continually advising additional questionable treatments would have rung true a century earlier or later.85 It was only with the shift during the twentieth century towards provision of health care by the state or insurance companies that health care providers – like many other parts of the economy – commonly became involved in large-scale organizations, in part as a device to ration access and contain costs. Of course, not all early modern practitioners formed such associations. Some operated outside them, pinning their hopes on their own skill and, frequently, a valorized image of their institutional and intellectual authority. For Christopher Merrett and his allies in the pamphlet war against practising apothecaries in the 1660s and 1670s manufacturing their own medicines became a point of principle. Making medicines was, they argued, necessary if the physician was to emulate the observational practices of the natural philosopher.86 Merrett’s own career ended in virtual paupery, with him offering his services at discount to his parish. That perhaps reveals the price of spurning association.87

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Notes I would like to thank the Wellcome Trust for generously funding the research on which this paper is based. I am very grateful for incisive and helpful comments from Hal Cook, Margaret Pelling, Rosie Blau, Sandra Cavallo, Mark Jenner and Lauren Kassell among others. A much earlier version of this paper was given in 2002 at a seminar at the Department for the History and Philosophy of Science, University of Cambridge. 1. Notable examples include: Cook, Decline; M. Pelling, The Common Lot (1998); idem, Conflicts; Porter, Progress; Porter, Health. On the legal constraints to the marketplace: C. Crawford, ‘Patients’ Rights and the Law of Contract in Eighteenth-Century England,’ SHM, 13 (2000), 381–410. On problems with interpretations of the effects of competition, see Wilson in this volume. 2. Park’s more corporatist ‘medical marketplace’ was the first instance of this: K. Park, Doctors and Medicine in Early Renaissance Florence (Princeton, 1985). See also: D. Gentilcore, Healers and Healing in Early Modern Italy (Manchester, 1998); L. Brockliss and C. Jones, The Medical World of Early Modern France (Oxford, 1997). 3. On contracts: G. Pomata, Contracting a Cure (Baltimore, 1998); Pelling, Conflicts. 4. Associations have been discussed by a small number of historians: M. Pelling, ‘Defensive Tactics: Networking by Female Medical Practitioners in Early Modern London’, in A. Shepard and P. Withington eds, Communities in Early Modern England (Manchester, 2000); R. C. Sawyer, ‘Patients, Healers, and Disease in the Southeast Midlands, 1597–1634’ (Ph.D. thesis, University of Wisconsin-Madison, 1986); R. G. Frank, ‘Medicine’, in N. Tyacke ed., The History of the University of Oxford. Vol IV (Oxford, 1997), 540. See also: Park, Doctors, 109–117. 5. Porter, Progress, 208. 6. C. Muldrew, The Economy of Obligation (Basingstoke, 1998); M. Sonenscher, Work and Wages (Cambridge, 1991), 138, 140; J. R. Farr, ‘On the Shop Floor: Guilds, Artisans and the European Market Economy’, Journal of Early Modern History, 1 (1997); M. P. Davies, ‘The Tailors of London and Their Guild, c.1300–1500’ (D.Phil. thesis, University of Oxford, 1994), ch. 6. 7. A. Shepard, ‘Manhood, Credit and Patriarchy in Early Modern England c.1580–1640’, P&P, 167 (2000). 8. J. O. Appleby, Economic Thought and Ideology in Seventeenth-Century England (Princeton, 1978); R. S. DuPlessis and M.C. Howell, ‘Reconsidering the Early Modern Urban Economy: The Cases of Leiden and Lille’, P&P, 94 (1982), 49–84. 9. For the fullest discussion of this material, see: Pelling, Conflicts. 10. S. Shapin, A Social History of Truth (Chicago, 1994), 355–407. 11. On apothecaries: P. Wallis, ‘Medicines for London: The Trade, Regulation and Lifecycle of London Apothecaries, c. 1610–c. 1670’. (D.Phil. thesis, University of Oxford, 2002), 164, 170. On barber-surgeons: Pelling, Common Lot, 217. 12. H. J. Cook, Trials of an Ordinary Doctor (Baltimore, 1994), 133–4; M. Pelling, ‘Knowledge Common and Acquired: The Education of Unlicensed Medical Practitioners in Early Modern London’, in V. Nutton and R. Porter eds, The History of Medical Education in Britain (1995), 250–79.

Patrick Wallis 65 13. For various examples, see: GL, MS 5057/5, f. 31; L. M. Beier. ‘SeventeenthCentury English Surgery: The Casebook of Joseph Binns’, in C. Lawrence ed., Medical Theory, Surgical Practice (1992), 48–84; Sawyer, ‘Patients, Healers, and Disease’, 100, 110. See also: Annals, iii, 328. 14. Rates of marriage for physicians were very similar to those for clergy and attorneys. 15. For example: TNA, PROB 11/191, f. 153r; GL, MS 5257/5, f. 29. Sandra Cavallo’s ongoing research of Italian surgeons in this period suggests that we would expect to find more, if we had the records. 16. One rare example is John Symcotts and Gervase Fullwood: F. N. L. Poynter and W. J. Bishop, A Seventeenth Century Doctor and His Patients (Streatley, 1951), xxvi. 17. Cook, Trials of an Ordinary Doctor, 137–43. 18. GL, MS 8200/1, 390v. The College had worried about such agreements seven years before: Annals, iii, 409. 19. Park, Doctors, 109–110. 20. Bill of Complaint (22 Nov 1620) and Answer (4 Dec 1620): TNA, REQ 2/296/ 113. On Crooke: C. D. O’Malley, ‘Helkiah Crooke, M.D., F.R.C.P., 1576–1648’, BHM, 42 (1968); Pelling, Conflicts, 126–7. 21. Cook, Decline, 55–6. 22. Annals, iii, 226, 312. 23. Annals, ii, 128, 172. 24. Annals, iii, 443: D. Evenden, The Midwives of Seventeenth-Century London (Cambridge, 2000), 95. 25. Annals, iii, 314–15; R. Palmer, ‘Pharmacy in the Republic of Venice in the Sixteenth Century’, in A. Wear, R. French and I. M. Lonie eds, The Medical Renaissance of the Sixteenth Century (Cambridge, 1985), 105–106. 26. Annals, iii, 525. 27. GL, MS 5257/3, f. 182 . Similar complaints include: GL, MS 5257/4, ff. 19, 21, 316; MS 5257/3 f. 57; MS 5257/5, f. 99. 28. GL, MS 5257/4, f. 284. 29. GL, MS 5257/5, ff. 365–6. 30. On this grey area: Pelling, ‘Defensive Tactics’, 47. 31. Annals, iii, 157, 163. On Read: W. Munk, The Roll of the Royal College of Physicians of London, 5 vols (1878–1965), i, 183–4. 32. Annals, iii, 359. For another surgeon asserting he had Read’s directions: ibid, iii, 358. 33. Annals, iii, 377. 34. Annals, iii, 359; GL, MS 5257/5, f. 150. 35. Maden or Muden apparently had taken an MD abroad. He later moved to Devon: R. S. Roberts, ‘The London Apothecaries and Medical Practice in Tudor and Stuart England’ (Ph.D. thesis, University of London, 1964), 271; R. S. Roberts, ‘The Personnel and Practice of Medicine in Tudor and Stuart England: Part II London’ MH, 8 (1964), 375. 36. Annals, iii, 320–22. 37. Annals, iii, 273–77. 38. Annals, iii, 313–14. For similar examples from France: M. Ramsey, Professional and Popular Medicine in France, 1770–1830 (Cambridge, 1988), 282. 39. Annals, iii, 488–89.

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40. 41. 42. 43.

Annals, iii, 419. N. Hodges, Vindicae Medicinae & Medicorum (1665), 53. Annals, iii, 294. M. Pelling. ‘Thoroughly Resented? Older Women and the Medical Role in Early Modern London’, in L. Hunter and S. Hutton eds, Women, Science and Medicine 1500–1700 (Stroud, 1997), 74–5; Pelling, ‘Defensive Tactics’, 50. TNA, REQ 2/295/44. Poaching was a complaint pursued before the Barber-Surgeons’ Company, for example: GL, MS 5257/3, ff. 13v, 22, 50, MS 5257/4, f. 53 (23 May 1609) MS 5257/5, f. 38. Sawyer, ‘Patients, Healers, and Disease’, 123. See Chapter 7 in this volume. Bodleian, MS Ashmole 1487, ff. 7–27. Cambridge University Library, MS Add. 3071, ff. 1–28r. See also: BL Sloane MS 564, ff. 18b, 45b, 47, 51, 52, 53, 54, 56. GL, MS 8200/1, f. 337r. B. Nance, Turquet De Mayerne as Baroque Physician (Amsterdam, 2001), 37, 156; F. N. L. Poynter, Gideon Delaune and His Family Circle (London, 1965); M. Barber, Directory of Medical Licenses Issued by the Archbishop of Canterbury, 2 vols (Lambeth Palace Library, typescript, 1997–2000), ii, no. 992. Pelling, Conflicts, 182; F. Dawbarn, ‘New Light on Dr Thomas Moffet’, MH, 47 (2003), 11–12. See also: A. Wear, Knowledge and Practice in English Medicine, 1550–1680 (Cambridge, 2000), 47, n. 6. J. Aubrey, Aubrey’s Brief Lives, ed. O. L. Dick (1949), 132. Annals, ii, 190. Annals, iii, 324, 418, 442–43. Annals, iii, 159. For some examples: Annals, iii, 120, 125, 203–4, 294, 468; iv, 38. Magali Larson, in particular, has argued that the difficulty of commodifying learning and advice was a problem which beset pre-professional medicine: M. S. Larson, The Rise of Professionalism (Berkeley, 1977), 14–15. See, G. Chaucer, The Riverside Chaucer, ed. L. D. Benson and F. N. Robinson, 3rd edn (Oxford, 1987), 30; C. Rawcliffe, Medicine & Society in Later Medieval England (Stroud, 1995), 162–64. Later examples include: W. Bullein, A Dialogue against the Fever Pestilence (1888 [1578]), 19, 27, 41. For Molière’s comparable satire: Brockliss and Jones, Medical World, 338–9. Annals, i, 26. These issues are highlighted in a different context in: C. Geertz, ‘Suq: The Bazaar Economy of Sefrou’, in C. Geertz, H. Geertz and L. Rosen eds, Meaning and Order in Moroccan Society (Cambridge, 1979), 123–244; C. Geertz, Peddlers and Princes (Chicago, 1963), 30–46. Pomata, Contracting a Cure, 2. J. Goddard, A Discourse Setting Forth the Unhappy Condition of the Practice of Physick in London (1670), 19. For a similar complaint, see: BL Sloane 2563, quoted in Cook, Decline, 67. A. Wilson, The Making of Man-Midwifery (1995), 37–8. Sawyer, ‘Patients, Healers, and Disease’, 83, 121, 123. Park, Doctors, 135.

44. 45.

46. 47. 48. 49. 50.

51.

52. 53. 54. 55. 56. 57.

58.

59. 60.

61. 62.

63. 64. 65.

Patrick Wallis 67 66. An Essay for the Regulation of the Practice of Physick (London, 1673), 9. 67. P. Wallis, ‘Controlling Commodities: Search and Reconciliation in the Early Modern Livery Companies’, in I. A. Gadd and P. Wallis eds, Guilds, Society and Economy in London, 1450–1800 (2002); M. Berlin. ‘“Broken All in Pieces”: Artisans and the Regulation of Workmanship in Early Modern London’, in G. Crossick ed., The Artisan and the European Town (Aldershot, 1997). 68. Essay for the Regulation of Physick (London, 1673), 13. 69. Annals, iv, 286, 287. A cipher was also used by de Mayerne in his recipes for the London Distillers’ Company: The Distiller of London (London, 1639). 70. Significant studies include: A. Oberschall and E. M. Leifer, ‘Efficiency and Social Institutions: Uses and Misuses of Economic Reasoning in Sociology’, Annual Review of Sociology, 12 (1986); J.-F. Hennart, ‘Upstream Vertical Integration in the Aluminium and Tin Industries’, Journal of Economic Behavior and Organization, 9 (1988); A. Darr and I. Talmud, ‘The Structure of Knowledge and Seller–Buyer Networks in Markets for Emergent Technologies’, Organization Studies, 24 (2003). 71. An example of physicians penalizing their apothecary is: Annals, iii, 421. Parallel processes are explored in: M. Granovetter, ‘Weak Ties’, Sociological Theory, 1 (1983); Geertz, ‘Bazaar’. 72. This discussion of ties is obviously indebted to: R. G. Eccles, ‘The Quasifirm in the Construction Industry’, Journal of Economic Behaviour and Organization, 2 (1981); M. S. Granovetter and R. Swedberg, The Sociology of Economic Life (Boulder, 1992), especially 9–13; B. Uzzi, ‘Social Structure and Competition in Interfirm Networks: The Paradox of Embeddedness’, Administrative Science Quarterly, 42 (1997). 73. Examples of this include: Lex Talionis; Sive Vindiciæ Pharmacoporum (1670), 7; Essay for the Regulation of Physick, 26; Thomson, Loimotomia: Or the Pest Anatomised (1666), 158; Cook, Decline, 42, 65; Palmer, ‘Pharmacy in Venice’, 104–5. Annals, iii, 81. On lodging, see also; TNA, PROB 5/1586; T. D. Whittet, ‘Apothecaries and Their Lodgers’, Journal of the Royal Society of Medicine, 76, suppl. 2 (1983), 1–22. 74. For more on kin-relations between apothecaries and physicians, see: Wallis, ‘Medicines’, ch. 5. 75. TNA, REQ 2/399/33, f. 2. 76. ODNB, s.n. 77. TNA, PROB 11/319, f. 2r. Similar examples, include: PROB 11/300, f. 179v; PROB 11/331, f. 120r; J. H. Appleby, ‘Dr Arthur Dee: Merchant and Litigant’, Slavonic and East European Review, 57 (1979), 32–55 ; C. Fiennes, Journeys (1949), 152. 78. Annals, iii, 255; GL, MS 8286, f. 13. 79. Cook, Decline, 28, 60. See, similarly, K. P. Siena, ‘The “Foul Disease” and Privacy: The Effects of Venereal Disease and Patient Demand on the Medical Marketplace in Early Modern London’. BHM, 75 (2001), 200. 80. N. D. Jewson, ‘Medical Knowledge and the Patronage System in 18th Century England’, Sociology, 8 (1974), 369–85; Porter, Progress, passim. 81. D. Harley, ‘“Bred up in the Study of That Faculty”: Licensed Physicians in the North-West of England, 1660–1760’, MH, 38 (1994); M. Jenner, ‘Quackery and Enthusiasm, or Why Drinking Water Cured the Plague’, in O. P. Grell and

68

82. 83. 84. 85. 86. 87.

Competition and Cooperation A. Cunningham eds., Religio Medici (Aldershot, 1996); Crawford, ‘Patient’s Rights’. M. Lindemann, Medicine and Society in Early Modern Europe (Cambridge, 1999), 199. E. Friedson, ‘Client Control and Medical Practice’, American Journal of Sociology, 65 (1960). See, especially: Park, Doctors; M. R. McVaugh, Medicine before the Plague (Cambridge, 1993); Palmer, ‘Pharmacy in Venice’. T. Smollett, The Adventures of Ferdinand Count Fathom (London, 1971 [1753]), 258–59. See: Cook, Decline. Similar assertions occur earlier: Annals, iii, 125, 191; iv, 373. Christopher Merrett, Dr Merrett . . . Makes to His Parish of St Andrews Holbourn This Proposition [1695].

4 The Rural Medical Marketplace in Southern England c. 1570–1720 Ian Mortimer

Most recent work on the relationship between medicine and the market in early modern England has focused on patients and practitioners in towns and cities, particularly London. Indeed, the idea of a ‘medical marketplace’ was developed for London and Florence, two of Europe’s most important metropolises. By contrast, little is known about healthcare in rural areas. Most studies of urban medicine have assumed that town-based medical practitioners primarily concentrated on serving their immediate market and did not reach out into the countryside to any significant extent. As a consequence, it has often been assumed that people living outside towns – the majority of the population of England at this time – were largely reliant on informal, irregular and charitable provision, particularly parish clergy or benevolent gentlewomen, an assumption reinforced by the appearance of case studies of the few such individuals for whom significant bodies of evidence have survived. In this chapter, an alternative model of rural medical provision is outlined, based upon extensive research into the consumption of medical services in Southern England between the late sixteenth and early eighteenth centuries. As shown below, town and country were medically interdependent, not distinctive arenas. Moreover, by tracking the location and usage of medical practitioners who sold their services to rural patients – essentially the supply side of the medical economy – we can observe how the shape and structure of this rural ‘medical marketplace’ shifted over time as rural-based practitioners begin to dominate provision in the early eighteenth century. One of the fundamental reasons for our current state of knowledge about rural medicine is the serious problem of defining both the bounds of town and country, and what we mean by medical practice. The difference between ‘a town’ and ‘the country’ is an easy one even for a 69

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The Rural Medical Marketplace

child to grasp; but whether a settlement at which a livestock market was regularly held constituted a ‘town’ in the early seventeenth century, or whether a wider range of goods and services, or a charter of incorporation or a certain population was necessary, are questions arising from the methodological complexity and multiple viewpoints of contemporary scholarship. We therefore operate in a constant tension between the desire for precision and the desire to make statements which are generally true and widely relevant. This is worth stating at the outset, for in many respects the confusion about rural medical services is a consequence of such failures of definition, or, rather, the conflict of precision and generalization. Too loose or too rigid definitions of ‘medical services’ create problems; so too do hard-and-fast definitions of ‘rural’ and over-simplistic understandings of the relationships between the purveyors of medical services, the beneficiaries of those services, and those who paid for them on behalf of the patient. The result is that we have a number of conflicting and unsubstantiated statements about early modern medical practice in the country, and the reader remains ignorant of both the range and variety of socio-medical encounters, as well as whether one sort of encounter was inherently more unlikely than another. The heart of the problem becomes clear if we consider one of the earliest propositions advanced by R. M. S. McConaghey in 1961 about the availability of medical practitioners in the south west of the country: The place of residence of recipients of licences in Devon and Cornwall is not always mentioned in the registers, especially during the early years, but in the list of 288 licences recorded, 127 different places, parishes and boroughs outside Exeter are mentioned, and we may assume from this that it was not unusual for licensed surgeons to be in practice even in small villages.1 First, McConaghey’s concise argument clearly assumes that the place of residence of an applicant or licentiate indicated the place of practice. Underlying this, is a more subtle preconception: that practitioners needed to live in proximity to their patients in order to serve them. There is no reference to practitioners from Exeter or other towns, for example, serving their rural hinterlands.2 Behind this seems to be an older assumption that people tended not to travel very far from their homes in the pre-industrial age, and therefore only took advantage of those goods and services which were available in the immediate vicinity.

Ian Mortimer 71

Next, it may be observed that McConaghey is talking simply about licensed surgeons. Although it would be wrong to accuse him of regarding licentiates as the sole form of medical practitioner available, his statement does beg the question of what other practitioners were present in ‘rural areas’ and whether they were ubiquitous, or whether, like the licensed surgeons he mentions, they were resident in just 20 per cent of the more than 650 parishes in Devon and Cornwall. However, probably the most important problem here is the most basic definition, what is ‘rural’? On a straightforward level, it is those areas which lie outside a town, obviously. But to speak of the ‘rural medical marketplace’ as being a series of medical interactions entirely outside towns is not sensible; one might as well speak of the urban corn supply without reference to the hinterland around a town. Clearly, the idea of what is ‘rural’ must incorporate references to the urban supply of commodities which did not originate in the countryside but which were consumed there. Nor can these only be references to ‘rural’ areas adjacent to small towns. For example, the Devon parish of Holcombe Burnell has never been anything other than rural, but to investigate its sociomedical history with no reference to the city of Exeter, just two miles away – especially when we can reasonably expect the demand for medical supplies regularly to have been predicated on matters of life and death – would be ludicrous. Clearly, it is artificial to exclude urban supply in any consideration of rural medical assistance. The Holcombe Burnell example draws attention to the next major problem of definition: what is ‘medical’? While it is reasonable to consider that Holcombe’s residents looked to Exeter for medical advice and medicines in order to treat the majority of its grave cases, it would be unwise to assume that they did this for all conditions. A cut finger, a minor fracture of a bone, a common cold: one may draw up a list of minor ailments and make a reasonable case that these were not normally brought to the attention of practitioners from further afield but dealt with in the home by family members, friends and servants, or the sufferer themselves. In contrast, the urban sufferer of a minor ailment who lived in the same street as a medical practitioner may have been far less reluctant to seek advice. Nor can the contrast of fatal conditions and cut fingers in rural areas be dismissed as absurd: over two centuries both were surely common. Similarly, we need to consider the different prospective purchasers in the rural medical marketplace; one might contrast those residents of Holcombe Burnell who did send to Exeter for certain remedies with those who did not – a distinction which may

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have arisen from wealth, social connections, age, regular business or physical infirmity. The key point is that there is no strict line of demarcation between urban and rural responses. Faced with so many methodological and empirical complications, it is tempting to say simply that one cannot generalize about rural medical supply. However, that too would be wrong. If we start by considering the quantitative elements which informed the earliest writers on early modern provincial medicine, we find that there was sound reckoning behind their methods. They advanced their arguments not by putting forward comprehensive models of rural socio-economic behaviour but by producing evidence to disprove previous assumptions about the lack of medical supply. In 1962 John Raach drew up a ‘directory’ of more than 800 provincial physicians with really only one point in mind: to show that early seventeenth-century provincial society was not wholly dependent on London practitioners for their medical services.3 As a directory, it leaves a lot to be desired: it employs a very narrow definition of ‘physician’, and the locations given by Raach did not necessarily correspond with the places of practice of these physicians (often being merely their hometown or place of retirement). However, as an argument that qualified medical practitioners existed outside the capital in the early seventeenth century, it was a complete success. Much the same can be said for the places in Devon and Cornwall mentioned by McConaghey. Some of these locations would simply have been the licentiates’ parishes of upbringing, the practitioners themselves being licensed to practise throughout the county or diocese.4 Nevertheless, a close examination of the licences which McConaghey used, or the extant post-1660 applications and petitions for licences in the diocese of Exeter reveals that, by their own admission, some of these physicians and surgeons were practising in rural areas, and some had served apprenticeships in small towns and rural communities. It is therefore safe to assume that there was a ‘medical marketplace’ in seventeenthcentury rural Southern England, and it included licensed practitioners and degree-holders alongside the variously experienced amateur rural helpers who in the normal course of things would have been the first source of advice and help to many of those in their vicinity. This last-mentioned category brings us to an important question: how extensive were the medical roles of clergy and gentlewomen in rural areas? Although historians often emphasize the importance of these amateur groups, their significance has never been quantified. The idea that large numbers of well-meaning clerics and gentlefolk contributed significantly to rural medical services and therefore should be included

Ian Mortimer 73

in the category of ‘rural medical practitioner’ emerged in the 1970s and early 1980s. When R. S. Roberts published his perceptive article on provincial medicine in 1962, he hardly mentioned this element of provincial help, concentrating on occupationally defined physicians and surgeons.5 The only non-occupational part-time medical practitioners he mentioned were ‘Rawe Clyes, the blacksmith, and Mr Atwell, the parson’ quoting from Carew’s survey of Cornwall (1602).6 By the time Ronald Sawyer came to study the papers of the early seventeenth century clergyman and medical practitioner, Richard Napier, it had become accepted that ‘clergymen doctors were among the most common healers in early modern England’.7 Many diaries and similar anecdotes link medical help with a clergyman’s ministrations. Yet the available evidence does not support the claim that the clergy formed a significant part of the medical provision of rural areas. This view of the ubiquity of ‘clerical medical’ practice is based largely on diaries (including those of a few gentlewomen, like Lady Mildmay, as well as clergymen) and theological works stressing the medical responsibilities of those with a divine vocation.8 But diarists did not constitute a majority of the population, and to presume that they are representative of rural people as a whole is to fall into the trap of allowing ourselves to believe that the literary few were the spokesmen and spokeswomen of the masses. As for theological teaching, somewhat idealistic contemporary discussions of the duties of parish clergy are not evidence of the widespread practical application of medical knowledge by clergymen.9 In fact, the theory that clerical medical interventions were common seems to have arisen not as a result of hard evidence for suffering parishioners consulting clergymen but as a result of negative evidence: the apparent dearth of medical practitioners in rural parishes. For example, Doreen Evenden Nagy used this ‘negative evidence’ argument in her book on popular medicine in England. Using Raach’s Directory she claimed that, because his list included medical practitioners for only 415 of the approximately 9000 parishes in the country, most of the country was medically remote.10 Such an argument is mathematically correct but otherwise deeply flawed, as it totally discounts the mobility of the population, thus making proximity the determining factor, and assumes that Raach had succeeded in uncovering and mapping the majority of medical practitioners in this period.11 Herein lies the crux of the debate. Was the rural medical marketplace populated by local gentlewomen and well-meaning clergymen-doctors, forced to act in a dearth of more expert practitioners? Or was it populated by predominantly urban-based physicians and surgeons serving the hinterlands of their towns? Presented as starkly as this, the issue

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becomes one not of medical knowledge but transport. We know that most large towns in seventeenth-century England had strong contingents of resident medical practitioners: records of freeman admissions, licences, probate records, accounts of medical purchases, diaries, parish poor law papers, disputes over qualifications, medical degrees and practitioners’ own papers leave us in no doubt about this. Analysis of such records for the diocese of Canterbury in the years 1570–1720 has identified approximately 800 apothecaries, physicians and surgeons in that diocese alone.12 Moreover, there was probably no time after 1620 when fewer than 180 practitioners were alive and working in East Kent.13 This gives practitioner-to-population ratios of approximately 1:400, comparable with those claimed for London in 1600.14 Practitioners in East Kent were spread across the whole region, residing predominantly in towns. If rural people travelled to these widely distributed urban practitioners, or if the practitioners regularly travelled to their clientele, then it is not possible to state that a parish was ‘medically remote’ simply because it did not have a resident medical practitioner. Almost no part of the diocese of Canterbury is more than seven miles from a town in which medical practitioners were resident by 1640 and are practising (according to records of payments made in respect of the dying).15 This accords with Hoskins’ argument that people regularly travelled up to seven miles to reach their nearest market.16 If they were prepared to travel so far to buy utensils and similar household requisites, why would they not have travelled just as far – or sent a representative, relation or friend – to ask for medical help? Thus existing models of rural medicine may be seen to be based too heavily on assumptions about a static population which could not transport its resources, even though the resources in question – medical practitioners – were quite able to transport themselves. Understanding this allows us to remodel rural medical services by considering both the accessibility of the nearest ‘medical town’ (the medical equivalent of a ‘market town’, discussed fully below) and the availability of practitioners there as the key variables determining the density of medical provision in the countryside. It also allows us partially to test that model, using records relating to one set of medical situations: medical help sought by the seriously ill and dying noted in probate accounts. An analysis of the probate accounts for East Kent – by far the largest collection of such documents in the country, relating to some 13,423 estates – reveals that of the 2042 payments for medical services (excluding nursing and similar caring roles), a maximum of four (0.2 per cent) were made to clergymen.17 This does not equate to a

Ian Mortimer 75

huge role for clergymen-doctors. Similarly the number of medical interventions by gentlewomen is very small. Although it is not possible to segregate payments to gentlewomen from those to women generally, the total number of medical (as opposed to nursing) interventions by all women recorded in the East Kent probate accounts is 36 (1.8 per cent).18 Of course, low figures for payments to gentlewomen would be expected offered that care given charitably would not be recorded in an account. Nevertheless one might argue that those who have taken the spiritual theorists at their word, and presumed that the good intents of clergymen and gentlewomen provided a significant contribution to rural medical care, have unwittingly distorted our picture of the rural medical marketplace, at least insofar as we are considering commercial medical provision, and that the scale and availability of commercial providers renders the argument from absence less convincing. From this perspective, the clergyman-physician about whom we know the most, Richard Napier, appears rather exceptional. It was, it seems likely, Napier’s identity as a licensed physician which gave him his extensive medical clientele in early seventeenth-century Buckinghamshire, not his clerical status. As a clergyman-doctor who took an income from both sides of his very active career, he was more unusual than is often realized. In East Kent probably no more than nine of the 800 practitioners of medicine identified were ordained; very few of the medical licentiates in Devon and Cornwall were clergymen (even though it behoved them to apply for a licence as they were particularly vulnerable at the triennial episcopal visitation), and the proportion of active clergymen-doctors in Southern England was almost certainly never more than 2 per cent of the total number of practitioners. If we consider Napier as primarily a licensed practitioner whose clerical income, idiosyncratic character and unique style of business required and permitted him to live at the rectory of his parish of Great Linford, he appears as one of a tiny minority of clergymen who served the dying and charged for his medical expertise in the same way that urban practitioners did. Certainly he should not be regarded as typical even of clergymen-doctors: few others were still remembered by the general public two centuries later, being ‘held in superstitious reverence for his skill in the sciences of physic and astrology’.19 That said, in East Kent we are only dealing with the seriously ill and dying, comparable with the minority of Napier’s – and presumably other clergymen-physicians’ – clientele. Moreover we are only dealing with those for whom medical help was purchased, as opposed to given. For this reason, the clergy may have had an importance that is not

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captured by this data. Clergymen-doctors like Napier might have been expected not to charge a fee to those who later died; in some circumstances Napier himself waived his fee. If an East Kent clergyman-doctor did not levy a charge, his medical intervention would not appear in the accounts. This could allow us to reconcile a limited clerical medical role in East Kent with the absence of payments to clergymen in the probate accounts. Medical interventions by men like Napier do not appear in the East Kent accounts because they either administered to those with less serious complaints – in short, those who were not about to die – or because the practitioner did not charge out of charitable instincts. Moreover, if the ailment was perceived to be grave at the outset, then the majority of clergymen and gentlewomen could have done little, a more experienced and proficient medical practitioner would be needed. In such cases, it is highly unlikely that an amateur would have been consulted beyond the first initial appraisal of the ailment by those close at hand. In this way the entire cadre of well-meaning amateurs would have been bypassed. We can thus begin to reconstruct the rural medical marketplace with much greater confidence than has previously been possible. The majority of the population – certainly all those living in south-east England – were within two hours’ walk or one hour’s horse ride of a town where medical practitioners could be found. Taking into consideration the widespread distribution of these towns and their resident practitioners, throughout the seventeenth century the availability of medical care expressed as a ratio of practitioners to patients was no less than in London, 1:400. Those in rural communities, if afflicted by a minor ailment, would have turned first to their kin and other members of the household to administer what we today call ‘first aid’. Those in these communities who were struck by a disease for which they did not have a remedy within their household might have asked for advice from womenfolk in the community, or perhaps a knowledgeable fellow parishioner or clergyman, but might equally well have travelled to the nearest town to seek advice. If the situation was perceived to be grave, then the strategy would certainly have been to send a representative or messenger to the nearest medical town seeking an appropriate medical practitioner. Of course, the severity of the ailment necessary to occasion a trip to a town on behalf of the rural sick varied with respect to how far the patient was situated from the best-provisioned medical towns, while the likelihood of consulting a medical practitioner itself increased significantly over the seventeenth century. This also applies for those who were afflicted when not at home. If a man was staying away from home on business or for labour, for example, and was suddenly struck with a

Ian Mortimer 77

disease, his advice would not always have come from his own home community but often from the appropriate practitioners most accessible to his location. This model, which is much more inclusive of variable situations than previous understandings, nevertheless presents us with a new range of questions relevant to the rural medical marketplace. What actually constituted a ‘medical town’? Who were the provincial physicians and surgeons, and what was their training? Were they unregulated, as is normally supposed? How far did they travel to assist the ill and injured? Was there a noticeable difference in the regions? And most important of all, did the early modern medical marketplace as modelled above remain a static, unchanging series of urban-based services and widespread urban–rural interactions? These questions provide the focus for the remainder of this discussion. The term ‘medical town’ was coined as a way to address the age-old problem with which this chapter began: it is neither useful nor appropriate for our purposes to bundle all ‘towns’ together and regard them as one homogenous type of settlement. The division of small and large towns is hardly any more satisfactory. The existence of a market – an agricultural economic marker – cannot be considered a satisfactory measure of the availability of a range of medical services. John Norden’s list of towns in 1625, for example, includes Lenham – with which only five practitioners can be associated in the ‘Directory of East Kent medical practitioners’ – and excludes Tenterden, with which 17 practitioners can be associated.20 While all large towns may be safely assumed to be ‘medical towns’, smaller settlements had special functions (for example: ports, livestock markets, horse fairs, stannary towns and other places of assaying, and wool towns) which set them apart from villages, and these functions sometimes included the provision of medical services. In defining which smaller towns should be considered ‘medical’, two criteria are useful. First, the recorded presence of a significant number of medical practitioners; for East Kent, at least nine medical practitioners over the period 1560–1730 was taken as a minimum. On its own, this is not entirely satisfactory, for we cannot assume that licentiates always practised in their home parishes. Therefore, a second criterion is necessary: the propensity with which people living in the hinterland of a town sought medical help from that same town for their seriously ill and dying dependants. When we apply these two criteria together, they reveal that even some quite well-provisioned towns in Kent, such as Deal and Cranbrook, did not always cater for the seriously ill people within six miles. But for the most important medical towns there was a

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very high level of rural dependence on their medical resources. This is broadly consistent with the towns which had the highest numbers of recorded practitioners. Thus Faversham (for which 26 practitioners were noted in the ‘Directory’) catered to 71 per cent of the seriously ill and dying within six miles of the town (including inhabitants of the town itself). Ashford (22 practitioners) also catered to 71 per cent of the population within six miles. Dover (40 practitioners) catered to 78 per cent, Sandwich (33 practitioners) catered to 81 per cent, Maidstone (44 practitioners) catered to 83 per cent and Canterbury (more than one hundred practitioners) catered to 91 per cent.21 Deal and Cranbook, by contrast, catered to only 40 per cent, and 35 per cent respectively. Considering the additional services available in the lesser medical towns – Milton and Sittingbourne, Hythe, Elham, Deal, Cranbrook and New Romney – it is clear that there was a high level of rural medical provision available to those who could afford to pay. It needs to be remembered that this analysis of medical towns is based specifically on the needs of the seriously ill and dying – one cannot presume that the same applied to minor injuries and common ailments, nor necessarily diseases specific to children – but as far as it goes, the implications are of great importance. If 91 per cent of the population living within six miles of the city looked to Canterbury to provide them with medical relief in the advent of serious illness, then the medical practitioners living within the city cannot be considered as serving only their fellow citizens, any more than the rest of the city’s service sector, its lawyers, entertainers, booksellers and the like, attended only to their neighbours. This has significant implications for the work on the practitioner-to-population ratios of any city or town. London practitioners cannot be considered as only catering to London patients. Norwich practitioners, each one of whom (according to Pelling and Webster’s well-known survey) catered for about 200–250 of the urban population, also catered for a large hinterland, something not taken into consideration by Pelling and Webster in the calculation of their ratios.22 In the case of Canterbury, 77 per cent of the hinterland population (living within six miles) sought their medical services from the city. Thirty-five non-urban parishes fall within this radius, with a population (if each parish was the average size at the time of Compton Census) of about 8750. Seventy-seven per cent of this figure means that the practitioners of Canterbury were catering to about the same number of people in the six-mile hinterland as they were within the city itself. By implication one should assume that the Norwich practitioner-topopulation ratios need to be revised to reflect the fact that the city’s

Ian Mortimer 79

practitioners also served its hinterland. Whether one can say the same for London is a moot point; the population in the seventeenth century expanded so rapidly that its resources may well have been fully employed with tending to its own, and the numbers of unofficial, unqualified and semi-skilled practitioners are far harder to estimate. But it is not unreasonable to think in terms of the whole of the south-east of England, including East Anglia, being covered at a similar level in the seventeenth century, with an average of one practitioner for every 400 individuals, whether they were all situated in one parish or spread across an urban hinterland. On the above basis it would appear that as far as serious illnesses and ailments went, the rural medical marketplace was almost synonymous with the urban one. There was one notable difference, however: the need to travel. Although in theory a man seeking medical help from a rural area could find the same practitioner and receive the same service as the denizen of a medical town, he was at an economic disadvantage in a number of respects. First he needed to get to the town, or for a representative to travel to the town on his behalf, entailing a journey of perhaps two hours each way. Then he needed to contact the practitioner – who might have been absent seeing to other patients in other localities – and his representative may have had to persuade the practitioner to travel back to his parish (in the case of serious injuries and illnesses). The East Kent accounts contain many references to horse hire on behalf of messengers helping dying people, especially in the latter part of the seventeenth century, and a number also refer to practitioners’ costs in travelling to the patient.23 Travel, combined with a physician’s prolonged absence from town, required further expenses in sustenance, and sometimes accommodation, to be met. If more than one practitioner was sought – and often several were asked for, sometimes from different towns – then such costs rapidly escalated. If the situation was grave, there may have been an apprehension that a practitioner would simply not be able to come quickly enough. Finally, as most expenditure on medical services was settled in arrears, the agent or the sufferer himself had to convince the practitioner that he or his kin would be able to meet the likely total expenditure. As a result, patients outside towns suffered a ‘rural disadvantage’ arising from the difficulties of transportation and communications. Using the East Kent accounts it is possible to quantify this ‘rural disadvantage’, because one can compare the proportions of dying people of a similar status who purchased medical relief at different distances from a ‘medical town’. The results reveal how the rural medical marketplace was affected by distance and transport problems. As Tables 4.1 and 4.2

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Table 4.1 The proportion of higher-status males owing payments for medical care at death ⬍1 mile

Distance from town

1570–99 1600–29 1630–49 1660–89 1690–1719

⬎3 miles

1–3 miles

%

(N)

%

(N)

%

(N)

9 18 48 34 49

(111) (299) (194) (447) (80)

6 8 19 37 53

(67) (225) (178) (265) (83)

9 10 16 28 53

(160) (418) (330) (643) (163)

Note: Higher-status males are defined as having inventoried wealth £100 or more, or highstatus descriptors.

Table 4.2 The proportion of lower-status males owing payments for medical care at death ⬍1 mile

Distance from town

1570–99 1600–29 1630–49 1660–89 1690–1719

⬎3 miles

1–3 miles

%

(N)

%

(N)

%

(N)

6 10 17 26 29

(481) (991) (418) (578) (56)

2 6 13 26 52

(408) (724) (272) (362) (29)

4 4 10 20 31

(791) (1456) (585) (700) (72)

Note: Lower-status males are those with inventoried wealth under £100. See Mortimer, ‘Medical Assistance’, I,116, for a more detailed discussion and breakdown of these figures.

show, there seems to have been a slightly greater propensity for medical services to be obtained on behalf of the urban dying rather than their rural counterparts. This is most clearly marked in the first half of the seventeenth century. Interestingly, even as the shift towards physic took hold, with a commensurate rapid increase in the levels of medical consumption, the rural areas kept pace with the urban. The conclusion is obvious and unavoidable. There was a slight rural disadvantage with regard to obtaining medicine. The wealthy sought their medical services in the towns, as did the less wealthy, with a discrepancy in medical uptake amounting to very roughly a fifth less in rural areas in both sectors. But these differences were not dramatic. As people in towns took advantage of seventeenth-century medical innovations, so too did their country cousins, both rich and poor. This is not surprising considering

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that the rural and urban medical marketplaces were essentially the same, differentiated mainly by distance. Thus far, we have been concentrating on the activities of town-based medical practitioners in the countryside. But what about resident rural medical practitioners? How do they fit into this model? Did they solely cater for their fellow parishioners? Or did their rural role reflect that of urban practitioners? How did rural practitioners differ from their urban colleagues in qualifications and the geography of their practices? The first thing to note is that there seem to have been very few occupationally defined medical practitioners resident in rural parishes prior to the second half of the seventeenth century. This is another respect in which Napier was unusual. In East Kent only 36 rural-based practitioners have been positively identified as practising.24 In Devon and Cornwall, although individuals like Humphrey Greinville of the small village of North Petherwin appear in the Act Books as receiving a licence to practise surgery throughout the diocese, most licentiates from this period resided in the medium and larger towns. In addition, there is no guarantee that men such as Greinville continued to practise from their rural abode, as implicit in the wide area of the licence.25 In East Kent, where it is possible at least partially to track some of these early rural practitioners’ activities, they tended to cater not just to their local communities but to a wider spread of clients (and mostly better-off clients at that), thus mirroring the practices of physicians and surgeons in medical towns.26 It was the post-Civil Wars period which saw a significant spread of practitioners into rural areas. Let us take the small town of Moretonhampstead in Devon as an example. Twelve miles from Exeter, this place had a longestablished market and a population which increased with the growth of the serge industry from about 1000 in 1605 to about 1520 individuals in 1670.27 No practitioner was recorded as resident or practising there prior to 1660. Then in 1662 Joshua Smith received his licence to practise surgery.28 That he was already practising locally, and intended to carry on doing so, is demonstrated by the signatures of 20 local people who wished to attest to his skill. In 1700 two licences were granted: one to another Joshua Smith and one to Christopher Harrison. As with Joshua Smith the elder, Harrison presented a petition signed by a number of local figures attesting to his excellence, among whom were the rectors of Manaton, Drewsteignton and North Bovey (besides the rector of Moretonhampstead itself). These three parishes all adjoin the parish of Moretonhampstead and are directly connected by road and bridge to it. It would appear that by 1700 the small town had acquired

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an identity as a minor medical centre. It acted as an intermediate source of medical provision between the absence of any practitioners in its neighbouring parishes and the wide array of practitioners and apothecaries in the city of Exeter, between 10 and 18 miles distant from the boundaries of these parishes. In East Kent this process of medical rustification is easier to chart. It began with the distribution of medical services from the larger urban centres in the sixteenth century, those in need travelling to the towns to consult their physicians or request a surgeon’s attendance. By 1620 – the earliest date for which we can establish reliable estimates of the number of practitioners for the whole diocese – there were about 190 practitioners distributed through East Kent, mostly in the major medical towns but with a presence in all the lesser towns too. This diffusion of skills from the larger towns to the smaller, and ultimately to rural parishes, continued throughout the seventeenth century, all the time diminishing the ‘rural disadvantage’. By the end of the seventeenth century so many practitioners had settled in the rural outposts of East Kent that few areas suffered from a ‘rural disadvantage’. Indeed, many of the most remote areas, for example, the Isle of Sheppey, Thanet and Romney Marsh, included very of prosperous parishes. This did not mean that these areas were medically self-sufficient – in order to obtain the services of an apothecary or a doctor of medicine, patients and their representatives still had to travel into a major medical town – but licensed medical practitioners had completed a logical cycle. This may be described in three stages: from their being sought out in the towns by rural patients in the sixteenth century (an ‘urban-centred’ period) to the practitioners themselves making regular forays into rural areas in the early seventeenth century (an ‘urban-distributed’ period), and finally the settlement of significant numbers in small communities in rural areas (a ‘rural-development’ period).29 More locally settled practitioners, of course, meant that fewer practitioners were required to be resident within the medical towns. Popular demand for medical assistance thus may be seen to have shifted from towns to the entire rural community by the first decades of the early eighteenth century. In all this development, it is striking that, in East Kent at least, the character of small town and rural practices remained very much like those within large towns. Medical degree holders – the best qualified practitioners – tended to settle only in the major medical towns, and the descriptor ‘apothecary’ was one which was exclusively applied to urban purveyors of medicines. So in some respects the medical towns remained the conduits of specialist medical services. But otherwise the

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nature of rural practitioners’ identities and qualifications was similar to those in urban areas. In East Kent the proportion of those who were licensed or otherwise officially recognized in rural areas and small towns was comparable with the proportion in major medical towns throughout the seventeenth century: about two-thirds of the practitioners, serving the seriously ill and dying, in the early part of the century and about three-quarters in the later decades were officially recognized.30 How far this pattern was repeated across England is not easy to say, for a far higher proportion of practitioners was licensed by the ecclesiastical authorities in Kent than elsewhere; many fewer practitioners in the south west were officially recognized, for example. However, there is every reason to believe that the role played by the pioneering rural practitioners in Devon and Cornwall in the seventeenth century was comparable to that of their counterparts in the larger towns. The hilly nature of the diocese, which itself was responsible for the large number of small towns there, encouraged practitioners to settle in rural areas, and such inclinations were amplified by personal ties, parochial responsibilities, the positive economic benefits to be gained from serving a rural population at first hand compared with the pressure of competition in the major medical towns. This phase of the medicalization of rural areas – the ‘rural-development’ period – secured the link between a community and ‘its’ practitioner. A notable side effect of this was the strategic implementation of licensing laws which had previously proved almost impossible to police. It is not difficult to understand the process by which this came about. When a practitioner had found his rural niche, and secured the trust of key members of the community, his position and livelihood were at risk if a rival practitioner sought to muscle in on the same territory. As a result, in the latter half of the seventeenth century, there were good reasons to acquire a licence where it might help to secure a practitioner threatened by competition. Although medical practitioners should not have charged for their services without obtaining a licence, the requirement was widely ignored. Nevertheless, the medical licence was for many a ‘kite mark’, an indicator of proficiency and orthodoxy.31 But in certain situations it allowed a form of protectionism too, which of course has its implications for understanding the rural medical marketplace. If a rival practitioner who had no licence sought to win the custom of members of the community, he could be reported to the authorities and taken before the church courts. Such letters occasionally survive in the Exeter diocesan papers, attesting both to the willingness of the authorities to take action against an unlicensed practitioner and the

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readiness of a practitioner’s enemies to report him for practising without a licence.32 In such dealings what is particularly striking is the frequency with which communities wrote on behalf of an applicant, trying to secure his services for their members and at the same time preserve his medical demesne from interlopers. The petition of Abraham Quick of Tiverton is a good example. Quick’s petition and affidavit of good service (dated 1689) was signed by a number of officers of the town, including the mayor, a JP and the town clerk.33 The emphasis both on his successful cures and the way he deserved a licence to practise reflects the wishes of smaller communities trying to secure ‘their’ practitioner. Finally it may be remarked that even in those places where there was no rival physician or surgeon, there was every reason for a community to secure the services of a practitioner through an expression of approbation. As late as 1675 the small town of Colyton was apparently without an officially licensed surgeon, for when trying to find the support of a practitioner to sign his own application for a licence to practise there, John Abbot could only find a physician, ‘as for chirurgions we have never a one in our parts noe nearer than Exeter’.34 In conclusion, historians have traditionally but erroneously considered the rural medical marketplace as distinct from that of urban centres. However, this view depends heavily on two assumptions: first, that people did not travel far, and second, that before general practitioners were employed to serve specific communities, the needs of those communities met by amateur practitioners already living in the locality – gentlewomen and clergymen in particular – who served their neighbours in much the same way. Both these assumptions are wrong. This is not to say that gentlewomen and clergymen did not help their fellow parishioners: there is every likelihood that all those in the community with medical skills did what they could to assist their suffering neighbours. In particular, poor women’s experience of nursing the sick would have given them plenty of practical experience about illnesses. But it is wrong to suppose that the general practitioner’s role was ever regularly performed by the local vicar and the lady of the manor, or even the cadre of amateur nurses. Charitable care was undoubtedly of importance to early modern medical provision, but given the material we have now available on rural commercial provision we need to recognise that it was not the only option. Instead we should consider the following model. When an individual fell ill in a rural community, he or she would first have had the benefit of the household’s own medical knowledge. If this had proved insufficient to remedy the problem, then the services of the wider community would have been called upon. If no

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one in the community could help, then practitioners with expertise from further afield would have been brought in. In the late middle ages it is unlikely that any occupational physician was available in rural areas, and it is doubtful that specialist surgeons were resident in any but the largest towns prior to 1500; but by 1560 most large towns would have been able to boast of a physician and a surgeon, perhaps even several surgeons. By 1590 the majority of towns with a population of 2500 or more had resident practitioners, and by 1600 such men were regularly being sought out by those living in the hinterlands of those towns. Hence the options open to the rural patient increased. Thereafter the numbers of occupationally defined practitioners in the provinces grew rapidly until they reached a level of about one practitioner for 400 of the total regional population (both urban and rural). Still they were almost entirely based in towns, but they were prepared to travel out from those towns to serve those who needed their skills. It follows that, as the availability of such practitioners grew, those who had provided amateur help at a local level became less important in the treatment of the sick. This dispersal of medical resources carried on until practitioners began settling themselves in rural areas. By 1720 there were some rural practitioners who (to all intents and purposes) were general practitioners to their communities. For some specialist medical treatments, the rural community still relied upon the nearby urban centres, and of course not all rural areas had their proto-general practitioner by this date, but the pattern was in place, if not yet formalized. Those practitioners who had been resident in rural areas a century earlier – like Richard Napier – may have been precursors of the pattern, finding an economic or social advantage in rural living (such as a clergyman’s income to add to the medical earnings), but on the whole it was not until the third quarter of the seventeenth century that practitioners regularly began to settle in rural areas in the south east. Only at this point does the rural medical marketplace start to acquire those features of constituency, loyalty, exclusivity of service and experience which so many writers have taken for granted for so many years to be the identifying features of the rural practitioner.

Notes 1. R. M. S. McConaghey, ‘The History of Rural Medical Practice’, in F. N. L. Poynter, ed., The Evolution of Medical Practice in Britain (1961), 125. 2. Although this is arguably not directly connected to the point which McConaghey was trying to make, it is clear from elsewhere in this piece that he did not believe towns acted as medical foci in this period. As he states

86

3. 4.

5. 6. 7. 8. 9. 10. 11.

12.

13. 14.

15. 16. 17.

18.

19. 20. 21. 22.

The Rural Medical Marketplace on p. 122, ‘Barber-surgeons were probably the only orthodox practitioners commonly found in the smaller towns, but it is unlikely that they practised regularly in the towns and villages.’ J. H. Raach, A Directory of English Country Physicians 1603–1643 (1962). A good example of this comes from the East Kent parish of Wye, whose seriously ill patients did not employ local practitioners even though ten Wye men were licensed to practise physic or surgery in the seventeenth century. See I. Mortimer, ‘Medical Assistance to the Dying in Provincial Southern England, c.1570–1720’ (Ph.D. thesis, University of Exeter, 2004), 123. R. S. Roberts, ‘The Personnel and Practice of Medicine in Tudor and Stuart England. Part One: The Provinces’, MH, 4 (1962). Roberts, ‘Personnel’, 369. R. Sawyer, ‘Patients, Healers and Disease in the South East Midlands, 1597–1634’ (Ph.D. thesis, University of Wisconsin-Madison, 1986), 126. L. Pollock, With Faith and Physic (1993); L. Beier, Sufferers and Healers (1987), 211–241. Sawyer, ‘Patients, Healers’, 127. D. Nagy, Popular Medicine in Seventeenth Century England (Ohio, 1988), 18. Measuring proximity and determining what counted as ‘local’ have often been left ambiguous in these analyses. Alternatively, the ‘local’ might be on a quite large scale. Contrast, for example, Sawyer’s suggestion that patients ten miles from Napier were local with the finding below of medical towns having a seven-mile radius (Sawyer, ‘Patients, Healers’, p. 196). In fact, ten miles is approximately three times the average distance between an individual selected at random and the nearest ‘medical town’ (Mortimer, ‘Medical Assistance’, I, 163, 193–4). Mortimer, ‘Medical Assistance’, II, 158–317. This section, Appendix Two of the thesis, is published in an abbreviated form as ‘Directory of Medical Personnel Qualified and Practising in the Diocese of Canterbury, circa 1570–1730’, Archeologia Cantiana (2006). A fuller version is available on the Kent Archaeological Society’s website. Mortimer, ‘Medical Assistance’, I, 156–160. Before 1620 the figures are less reliable. M. Pelling and C. Webster, ‘Medical practitioners’, in C. Webster ed., Health, Medicine and Mortality in the Sixteenth Century (Cambridge, 1979), 165–236, esp. 188, 224–5. Mortimer, ‘Medical Assistance’, I, 115. Quoted in Sawyer, ‘Patients, Healers’, 196. Mortimer, ‘Medical Assistance’, I, 238. It is more likely that the actual number was zero or two, two of the clergymen probably not being in a post at the time they were paid. Mortimer, ‘Medical Assistance’, I, 241–3. This includes two instances of medical advice given by women, Mrs Wright and Mrs Jacob (p. 241), 13 instances of minor ailments being attended to by women and 21 for surgery and/or providing physic (p. 243). S. Lewis, A Topographical Dictionary of England, 7th edn (1849), III, 95. Mortimer, ‘Medical Assistance’, I, 112. Mortimer, ‘Medical Assistance’, I, 123. Pelling and Webster, ‘Medical Practitioners’, 223–5. See also Margaret Pelling’s revision of these figures in ‘Tradition and Diversity: Medical Practice in

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23.

24. 25.

26. 27.

28. 29. 30. 31. 32. 33. 34.

Norwich 1550–1640’, in Instituto Nazionale de Studi sul Rinascimento, Scienze Credenze Occulte Livelli di Cultura (Florence, 1982). This was no less the case in Berkshire. See under ‘Horses, hire of’ in the index to Ian Mortimer ed., Berkshire Probate Accounts 1583–1712, Berkshire Record Society, 4 (Reading, 1999). Mortimer, ‘Medical Assistance’, I, 217, Table 4.9. I. Mortimer, ‘Index of Medical Licentiates, Applicants, Referees and Examiners in the Diocese of Exeter, 1568–1783’, Transactions of the Devonshire Association, 136 (2004), 114. As regards the area of the licence, see I. Mortimer, ‘Diocesan Licensing and Medical Practitioners in South West England, 1660–1780’, MH, 48 (2004), 55. Mortimer, ‘Medical Assistance’, I, 235. These figures are based on a reconstitution of the population based on the parish registers, taking ten-year rolling averages and extrapolating likely baptism- and burial-related populations in conjunction with the crude baptism and burial rates given in E. A. Wrigley and R. S. Schofield, The Population History of England 1541–1871 (1981), 532. The 1670 figure of 1520 individuals is regarded as most reliable as at that date the baptism- and burial-based population estimates tally. Details of the specific licentiates are from Mortimer, ‘Index of Medical Licentiates’. These terms, ‘urban-centred’, ‘urban-distributed’ and ‘rural-development’ are from Mortimer, ‘Medical Assistance’, I, 247–8. Mortimer, ‘Medical Assistance’, I, 247–8. Mortimer, ‘Diocesan Licensing’, 61–2. For example, see Mortimer, ‘Diocesan Licensing’, 64. Mortimer, ‘Index of Medical Licentiates’, 115, 124–5, 128. Quoted in Mortimer, ‘Diocesan Licensing’, 58. See also: P. Sharpe, Population and Society in an East Devon Parish (Exeter, 2002), 77–78.

5 Magic, Alchemy and the Medical Economy in Early Modern England: The Case of Robert Fludd’s Magnetical Medicine Lauren Kassell This chapter is about the commerce between physicians and patients, angels and demons, and the living and the dead. In 1656 Nicholas Culpeper, the prolific medical author and audacious critic of the College of Physicians, spoke from the grave. He had been dead for two years, and his voice issued from a brief, satirical pamphlet called Mr Culpeper’s Ghost.1 His ghost affirms that alchemy provides a key to understanding natural philosophy and to preparing medicaments. He also wonders whether chymical remedies are appropriate for all cases, or whether conventional Galenic and Hippocratic ones are more reliable.2 He began to have these doubts when on a walk through heaven he bumped into Robert Wright, former apothecary to Robert Fludd. Fludd was an eminent London physician and prolific philosophical author who had died in 1637. ‘[T]hough a Trismegistian-Platonick-Rosy-crucian Doctor’, Wright reported of his employer, he ‘gave his Patients the same kind of Galenical Medicaments, which other Physitians in the Town ordinarily appointed’. Even when he himself was ill, Wright insisted to the ghost, Fludd only used Galenic therapeutics.3 Culpeper’s ghost continued his stroll and bumped into Dr Fludd, who was engaged in heated debate with Raymond Lull, the thirteenthcentury Spanish philosopher to whom numerous alchemical treatises were attributed, and Johann Baptista Van Helmont, an alchemical reformer who had lived in the Spanish Netherlands until his death in 1644. These three great men were talking about the weapon salve and ‘plotting’ to invent a ‘universal magnetic medicine’ for fevers. As the weapon salve could be used to cure a wound by anointing a bloodstained weapon with a sympathetic unguent, so the ‘universal magnetic medicine’ would cure a fever by being placed in a chamber pot. As the blood conveyed the virtues of the unguent to the wounded body, 88

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however great the distances between them, so the urine conveyed the virtues of the ‘magnet’ to the fevered body.4 Culpeper’s ghost interrupted this vital discussion to ask Fludd whether Wright’s report was true. Yes, the dead theosopher-physician confided to the dead medical reformer, Galenical medicaments were indeed best. This chapter makes sense of this scenario. In 1656 a printed pamphlet reported conversations between dead people, conversations in which Robert Fludd confirmed that whatever his philosophy, he practised Galenic medicine; and in which he plotted the invention of a ‘universal magnetic medicine’ to cure illnesses through action at a distance. Printed books feature throughout this account, but I will leave the concern for their place in the medical marketplace to others.5 My project is to present the history of ‘magnetical medicine’ in seventeenth-century England as a case study with which to consider the complexities of the early modern medical economy. I will suggest that a more inclusive model is needed, one that encompasses exchanges both between physicians and their clients and between these people and the spiritual realms. Conventional physic depended on a medical economy in which the dynamic between the patient and the practitioner was defined according to the four humors and their correspondences. Chymical philosophies, whether Paracelsian, Helmontian, Platonic and otherwise magical, often foregrounded the analogy between the microcosm (man’s body) and the macrocosm (the cosmos), spelling out an elaborate ‘œconomy’ of health and healing. Magnetical medicine did this in the extreme. As one contemporary proponent noted, it ‘depends [on] the whole œconomie, and every change in sublunary things’.6 Magnetical medicines worked by sympathy, drawing the powers of the cosmos into the human body, sometimes through chymical, sometimes through human ingredients. In this system, the human body was located within a domestic economy of production and consumption, and a spiritual economy of good and evil. The physician had the power to mediate between the living and the dead.7 Debates about humoral and chymical medicine had occupied the medical community since the 1570s. From its foundation in 1518, the College of Physicians had defined itself through the enforcement of its privilege to regulate the practice of medicine within a seven-mile radius of London. It consolidated its powers in the 1580s, faced an initial crisis following the ascension of James VI and I in 1603, joined forces with him, and against the City guilds, to establish the Society of Apothecaries in 1618, saw attempts by Parliament to curtail its authority in the 1620s, and reached the height of its powers under Charles I in the 1630s.

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Prudently, with the turmoil of the 1640s and 1650s, the College ceased to enforce its privileges and instead sought to strengthen its identity as a society of learned medicine.8 Throughout this period the use of chymical remedies by unlicensed practitioners was a persistent problem.9 In the revolutionary decades an influx of chymical, hermetical and Paracelsian philosophies combined with the increasing availability of vernacular books to make irregular practitioners more visible, if not more numerous. Chymical physicians and astrologers, like Culpeper, railed against the College. In 1655 the College allied itself with Oliver Cromwell in a new bid for power, and in the spring of 1656 they began to crack down on the ‘empirics’.10 While commenting on long-term disputes, Culpeper’s ghost was protesting against the College’s efforts to reinstate its authority over print and practice.11 The chymical remedies that feature in these power-struggles are often seen as a major contributing factor to the emerging medical marketplace in seventeenth-century England.12 Some members of the College endorsed chymical remedies, while others did not; but, however varied the philosophical positions of its individual members, the College was unequivocal in its objections to breaches of its privileges. Throughout the century, pills, powders and waters promising universal, immediate and gentle effects became increasingly available on the streets of London. These products fit neatly within a marketplace model.13 They are commodities, bought and sold in a monetary transaction between a medical practitioner and his or her client. These practitioners often called themselves ‘chymical physicians’; their critics, especially the College of Physicians, labelled them ‘empirics’. Though many of them lacked university credentials, as their self-designation suggests, they adopted the demeanour of learned physicians, proffering advice and expounding philosophies of medicine.14 Historians have often considered the trade in chymical remedies and the exposition of chymical philosophies separately.15 It is a premise of this study that the medical economy was defined both through disputed medical practices and through contested ideas. In what follows I will argue that Fludd’s careers as an established London physician and internationally renowned author of theosophical books need to be understood as parts of the same project. His practices were consonant with his philosophy. This is clear from his involvement in printed disputes about the weapon salve, books well-thumbed by historians for their natural philosophical and theological content but untouched for their practical and medical import. While arguing about the powers of nature and the devil, Fludd also presented evidence

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about his practice of magnetical medicine.16 This system was fully, and lucidly expounded in a text by one of his followers, probably William Maxwell.17 In Maxwell’s work we find instructions for how to make the ‘universal magnetic medicine’ that Fludd, Lully and Van Helmont discussed from the world beyond in 1656. To practise magnetical medicine was to control an economy of bodily products and spiritual forces. *** Late one night in early 1631 a pair of title pages of a pamphlet were posted on either side of the door of Robert Fludd’s house in London.18 To post a printed page was to advertise. Playbills, plague regulations, title pages of newly printed books and posters describing the powers of universal medicines, and where they could be purchased, were tacked up throughout London.19 The text flanking Fludd’s door was Hoplocrisma-spongvs: Or, a Sponge to Wipe Away the Weapon-Salve, by William Foster, a Buckinghamshire divine. Foster had been set to the task, he says, by a pair of surgeons, John Scott and Edward Charley.20 Rivalry between physicians and surgeons may have occasioned Foster’s pamphlet, though it seems not to have been a response to a specific conflict between Fludd, the College or the Company of Barber-Surgeons.21 Foster complained that the practice of using the weapon salve was taking over the country. He decried its advocates as practising superstitious, demonic magic, and singled out Fludd for particular recriminations. Fludd had defended the weapon salve in a three-page digression on the mystical properties of blood in a Latin work of 1623, Anatomiæ amphitheatrum.22 This, and his other writings, sparked a literary feud abroad, beginning with Marin Mersenne, the Parisian mathematician and physicist, objecting to Fludd’s defense of Rosicrucianism and calling him a ‘cacomagus’, or evil magician. Fludd replied in 1629, then Pierre Gassendi, another French natural philosopher, took up Mersenne’s position, and Fludd again countered.23 Foster’s book appeared in the midst of this feud, drawing on Mersenne’s and Gassendi’s texts, and Fludd swiftly responded with Doctor Flvdds Answer vnto M. Foster Or, The Sqvesing of Parson Fosters Sponge (1631). Fludd argued, in short, that the weapon salve worked by natural, not demonic powers.24 The Foster–Fludd dispute and the larger debates about the weapon salve that occupied some major theologians and natural philosophers in seventeenth-century Europe are well known. The properties of the weapon salve were first promoted in the Pseudo-Paracelsian Archidoxes (1570), then received broader circulation in Giovanni Battista Della

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Porta’s Magia Naturalis (1589) and Oswald Croll’s Basilica Chymica (1608); in 1594 Andreas Libavius, a German physician, condemned the salve as demonic. In a 1608 treatise Rudolf Goclenius the Younger, a Calvinist professor from Marburg, dedicated an entire work to the salve, arguing that it worked through the sympathetic and antipathetic principles of natural magic. Goclenius’s work was expanded in a 1613 edition, to which Jean Roberti, a Flemish Jesuit theologian, replied in 1616, arguing that the weapon salve worked through demonic powers. They continued this dispute, exchanging seven tracts, and eventually drawing Johann Baptista van Helmont, the Belgian physician who would become famous for his interpretation of Paracelsianism and would converse with Fludd and Lull in heaven, into the controversy.25 Previous studies of these debates have focused on their concern for defining the limits of what was natural and what was demonic, not on the definitions of medicine that they entailed. The weapon salve was rich fodder for proponents of Jesuit physics, Platonic correspondences, Paracelsian sympathies, and, later, experimental philosophers. When the title page of Foster’s pamphlet was posted on the front door of Fludd’s house, the force of these learned debates was brought to bear on the local politics of medical practice in London. Someone was signalling Fludd’s participation in the metropolitan medical marketplace, advertising that he was a proponent, and perhaps also a practitioner, of demonic magic and challenging him to defend himself. Fludd was an eminent London physician with a reputation for strange ideas. He was born to a gentry family in Kent in 1574, studied in Oxford in the 1590s, then travelled throughout Europe from 1598 to 1604 or 1605. He visited Rome in 1602, where he met a Swiss humanist engineer called Master Greuter who taught him the secrets of ‘magnetical experiments’.26 In 1605, at the age of 29, he settled in London and petitioned the College of Physicians for a licence to practise physic. In November 1605 they examined him ‘in both galenical and spagyrical [alchemical] medicines’ but found him ‘not satisfactory enough in either’. It was typical for the College to send people away with a reading list; it was unprecedented for them to examine someone in alchemical medicine, a decision that reveals that complex attitude of the College and its members to alchemy. In February 1606 the College deemed Fludd ‘not uneducated’, but by May the Censors had received a report that he ‘had boasted much about himself and his chemical medicaments and looked down with contempt on galenical medicines’. He denied the charges ‘with the utmost confidence’, and was warned ‘to think and speak modestly about himself, and respect the Fellows of

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the College’. Eventually, in 1608, Fludd would become a Fellow of the College.27 Foster’s pamphlet would provide an occasion for his colleagues to ‘jeer’ and ‘scoff’ at him, but, for the most part, he played the part expected of a Fellow of the College of Physicians: in 1616 he assisted in inspecting the wares of apothecaries, in 1618 he endorsed the publication of the Pharmacopoeia Londoniensis, in 1620 he gave the annual anatomy lecture, and he held the office of Censor in 1618–19, 1627–8 and 1633–5.28 Fludd’s early encounters with the College reveal his chymical pursuits and his arrogant demeanour. These characteristics are also evident in the many books that he published abroad.29 These are lavishly illustrated with the famous engravings that have made Fludd the poster-boy of Renaissance Platonism. A 1636 account describes him as ‘a learned Doctor, well esteemed at home for his practicall skill in Physick, and much honoured abroad for his learned Bookes in Print’.30 Baldwyn Hamey the Younger, a contemporary physician, similarly describes Fludd’s dual talents. He continually supported, outside the custom of his colleagues, an amanuensis and apothecary at his house; the latter mixed and distributed medicines by day, the former received ideas that he had at night; in both of [these endeavours] he kindled not a little envy of himself; moreover, by his night studies, which was his custom to profusely produce, he seemed to undertake more work than our common people wished to enjoy; they mostly overlooked him because of the tediousness of reading him, and their prejudice against wasting time and oil, and because of the Cabalistic, rather than Peripatetic nature his writings are said to smack of, and because of the rather fervent character of the man, in whom many failed to find judiciousness.31 By day he worked as an eminent, and unconventional, London physician, by night he wrote weighty Latin philosophical books. Thomas Fuller, the seventeenth-century clergyman and historian, identified a consonance between Fludd’s writings and practices, and suggested that his arcane language had a therapeutic impact: His Books written in Latine are great, many and mystical. The last some impute to his Charity, clouding his high matter with dark language, lest otherwise the lustre thereof should dazle the understanding of the Reader. The same phrases he used to his Patients;

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and, seeing conceit is very contributive to the working of Physick, their Fancy, or Faith natural, was much advanced by his elevated expressions.32 Remember, though, that in 1656 Culpeper’s ghost insisted that Fludd’s practices were Galenic, not chymical, a proposition that drives a wedge between his ideas and practices. Many historians have concurred with the ghost, portraying Fludd as leading a double life in which he maintained the semblance of philosophical and medical conformism at home while parading in print as a prolific and controversial philosopher abroad.33 However, a careful reading of Fludd’s works demonstrates that by night he wrote about magnetical medicine, and by day he practised it. In theory, and in practice, he located himself at the centre of a medical economy in which the physician managed the domestic products and spiritual forces necessary to heal his patients. The weapon salve is the key to understanding how magnetical medicine works. The standard recipe, following the pseudo-Paracelsian Archidoxes, goes like this. Take two ounces of skull moss (the moss growing on the skull of man who had died violently; hanging is good), an ounce and a half of mummy (human flesh; more about this later), two ounces of man’s fat, half an ounce of man’s blood, two drams of linseed oil, an ounce of oil of roses, an ounce of bole armeniac, and an optional ounce of honey and a dram of bull’s fat. Mix these together into an ointment. As the name suggests, this salve is used to heal wounds. Once a day anoint the bloodstained weapon or, if it is not available, a stick dipped in the blood of the wound. Keep the wound clean and bind it with a dressing dipped in the wounded person’s urine. The ointment works, Croll, an expounder of Paracelsian doctrine, explains, ‘by the magnetique attractive power of the Salve, caused by the Starres, which by the mediation of the ayre, is carried and adjoyned to the Wound, that so the Spirituall operation thereof my be effected’. It does this according to the sympathy of nature, influence of the celestial bodies and a natural balsam in every man that has a healing power.34 Like a magnet, magnetical medicine, of which the weapon salve is one example, works at a distance; this is why it is also called sympathetic or magical medicine.35 Critics of the salve objected, to generalize, that its powers could be explained neither by the strength of nature nor the art of medicine; rather, knowingly or not, a practitioner who used the salve entered into a pact with the devil. This pact was signalled by the human ingredients – mummy, fat, blood – contained in the salve.36 ‘Magicall and divelish

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actions’, concludes Daniel Sennert, a Wurttemberg professor of medicine, ‘are covered, and shifted in under the vaile of Magnetique actions’.37 Human ingredients, however, were typically bought and sold alongside herbal, chymical and animal products. Whether exotic or local, preserved or fresh, seldom did these goods carry a magical or demonic value. Alchemical and Paracelsian medicine was usually chemical. Preparations of mercury, antimony (what we call stibium) and lac sulphuris (milk of sulphur) were sold by apothecaries and administered by surgeons throughout London. Alchemical and Paracelsian remedies also included herbs purified through distillation, and, as is less often noted, animal or human ingredients.38 Mummy, or ‘mummia’, was the most common of these, though it was also employed within humanist therapeutics. By the sixteenth century, mummy was for sale in apothecary’s shops throughout Europe. Whether this substance was human flesh or the bitumen that exuded from preserved bodies, what virtues this substance held, and how it had been sourced had been debated since at least the tenth century. Paracelsus defined two sorts of mummy. Corporeal mummy was human flesh; spiritual mummy was the vital force within all beings. He also, as an early advocate of local produce, preferred mummy from his native land. This was to be sourced from the body of a person who had died violently, thereby ensuring that the corporeal mummy retained the healing power of the spiritual mummy.39 This is the sort of mummy used to make the weapon salve. While opponents of the salve objected that the use of human ingredients signalled a pact with the devil, proponents of sympathetic remedies, at least from the 1620s, were divided about whether human ingredients should be used, and if so, of what sorts. Some practitioners reported the healing virtues of a salve made without any human ingredients at all.40 A sympathetic powder, with vitriol as its crucial ingredient, was in use throughout Europe. Kenelm Digby, the experimental philosopher, claimed to have acquired the secret of such a powder in Florence in the early 1620s, and soon after to have introduced it into England.41 Others, such as Andreas Tentzel (fl. 1625) and Fludd, as we will see, pursued the Paracelsian virtues of mummy while stressing that ingredients from a healthy, living human body could also be put to good use.42 'Blood was key. It contained the principle of salt, and, according to the Paracelsian doctrine of the tria prima, all things were made from salt, sulphur and mercury. Fludd’s 1623 digression on the weapon salve in Anatomiæ amphitheatrum was about the powers of blood, and the virtues of blood and other human ingredients remained a major concern in his subsequent writings.

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Famously Fludd drew extensively on the analogy between the heart and the sun, and was the first author to make favourable reference to William Harvey’s account of pulmonary circulation.43 Blood, Fludd explains throughout his writings, is the animating principle. When God breathes his spirit into man, the spirit moves in the blood, feeding man’s fat, flesh and bones. The essence of blood is the ‘glew of life’. It is a mystical, balsamic, volatile salt. This salt is also present in flesh, fat, bones and the excretions of the body, substances carrying a value by virtue of their vital properties.44 Fludd depicts his medical cosmology in a pair of engravings from Medicina Catholica (1629–31). In ‘The Fortress of Health’ man is healthy; in ‘The Invasion of the Fortress of Health’ (Illustration 5.1), he is ill.45 The images follow the same scheme. In ‘The Fortress’ a man kneels at the centre of the image, four angels (Michael, Gabriel, Raphael and Uriel)

Illustration 5.1 Robert Fludd, Medicina Catholica, Tract. II, Sect. 2, 344, reproduced by permission of the Wellcome Library, London.

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guard the four turrets, and all of the walls are intact. The man prays to God and God responds, speaking in Biblical verses. Each of the angels repels a demon, blown in from the four corners of the globe. The winds, Fludd explains, embody the occult forces emanating from the celestial bodies. These forces are governed by angels and demons, and each has specific properties: the northern wind is cold and dry, causing things to contract; it is countered by the warm and moist winds of the south that dilate and dissipate. With every breath, man inhales air infused with these spirits, and so long as the forces of good and evil are evenly matched, so long as the walls of the fortress are not breached, he remains healthy.46 If there is an invasion, as depicted in Illustration 5.1, man takes to his bed and calls his physician. The physician adopts the pose in which he was trained. He takes the pulse and inspects the urine. By identifying the humoral imbalance within the body, he can measure which evil forces are at work. In this case the southern wall has fallen, the demon Azazael has slipped past Uriel, and the western corner is also under threat. Once he has identified the nature of the forces at work, the physician’s task is to rebuild the walls and ensure that the angels return to their stations. He does this, Fludd explains, by restoring the vital spirits, or beams, to man’s body. This is possible with the use of a microcosmical magnet, of which the weapon salve is one example. Just as William Gilbert’s De Magnete (1600) had demonstrated that the Earth was a giant, macrocosmical lodestone, so Fludd’s Mosaical Philosophy (1638) presented practical proofs and experimental conclusions to demonstrate the principles of the microcosmical, living magnet.47 Gilbert showed the hidden virtues of the lodestone; Fludd the invisible beams linking man and the cosmos. The engravings of ‘The Fortress of Health’ and ‘The Invasion of the Fortress of Health’ are emblems of the bodily and medical economies. The physician judges which cosmic forces are affecting the body of man, and prescribes therapies to rectify the imbalance of good and evil, hot and cold, moist and dry. How did he do this? What did it mean to practise magnetical medicine, to use a microcosmical magnet? Remember that Foster had complained that the use of the salve was ‘growing every day more common (so that I have seene the Salve in the very hands of women)’.48 Fludd confirms Foster’s worries, assuring his readers that Sir Nicholas Gilbourne (his brother-in-law), Captain Styles, Sir Bevis Thewell, a Mr Deptford and other notable gentlemen had cured more than a thousand cases with the salve and other magnetical medicines.49 Fludd reported these cases not as evidence of the popularity of the cure, but to ‘prove’ that it worked by natural and angelic

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principles; the salve was made without superstitious ceremonies or magical ingredients.50 While defending the principles of magnetical medicine, Fludd also upheld the medical hierarchy. Just as he specifies that the cases noted above concerned gentlemen practising, for the most part, in the country, so Fludd endorsed John Evans’ antimonial cup while specifying that it was to be used by people who did not have access to a physician. This vessel was to be filled with wine, left by the fire over night and drunk in the morning. The effect was a gentle purge. Evans advertised his cup in a 1634 book that was destroyed on order of the College of Physicians. Fludd, holding office as a Censor, was instrumental in this.51 A couple of years later, Fludd informed the College that these cups were for sale at the sign of the magpie in Gunpowder Alley.52 Evans published this work again in 1642, now with endorsements by numerous learned gentlemen, including Fludd. Fludd’s comments are suitably diffident. He states that the heat causes the liquor to imbue the virtues of the cup; that when drunk this liquor purges noxious humors; and, he concludes, that this cup will prove beneficial to people who cannot consult a physician or apothecary, either because they live in the country or they lack funds.53 Thus speaks an elite physician, coyly distancing the use of Evans’s antimonial cup from the therapies available to his own patients. What then, if anything, do we know about Fludd’s medical practices? As already noted, Fludd acknowledges an intellectual debt to one Master Greuter, the humanist engineer whom he met in Rome in 1602 and who taught him ‘the best of my skill in those practices: … hee delivered this magneticall experiment unto me, as a great secret, assuring me that it was tried in his Country’.54 Usually he distances himself from the cases he reports, perhaps because of his standing as a London physician. He credited John Kellet, a freeman-apothecary, with curing a gentlewoman with an abdominal tumor by stroking it with the hand of a corpse. Fludd simply allowed the woman and Kellet access to a body that he had stored in his house in preparation for his delivery of a public anatomy lesson.55 Similarly, a wise, religious, and aged gentleman in the country had perfected a sympathetic cure for jaundice. He would mix the patient’s urine with ashes, roll the paste into balls, insert strands of saffron into them, and put them some place safe. In two cases, Fludd reports, he had his patient’s urine sent to this man, who accordingly cured them.56 In the rare instances where Fludd draws on his own use of magnetical medicine, he reports experiments that he conducted on his own body.

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One of these, in Mosaical Philosophy, describes the magnetical properties of different sorts of mummy. ‘I collected a portion of this Northern mummy’, he begins, meaning mummy imbued with airy, cold properties of the north pole, ‘namely of the flesh of a man strangled in the aire, in which the spiritual Mummy, was Centrally contracted by cold, and I applied it typically unto the part of my body, which was nearest unto its natural position’. That is, if the flesh came from the inner thigh of the corpse, so Fludd applied it to his own inner thigh. It felt cold, and gradually sapped the heat and vivifying spirit from his body. He removed it, noting its change in ‘smell and view’, then prepared more pieces of mummy in the same manner, ‘for the use of mine own body’. These were virtuous patches, possessing a magnetical power that could be used to prepare ‘a singular medicine for mans health and conservation’. Were he to become ill, he could apply a previously prepared patch to the afflicted area.57 Earlier in the treatise Fludd had noted the powers of mummy, stating ‘that by a right application of the fleshy parts of a dead man’s carcass unto a live man, (if the application be long) it will make the live man faint and feeble . . . [I]t will suck or draw forth of the live man the spirituall Mummy in a visible manner’. This substance can be gathered, as he gathered his own vital spirit into the patches of mummy, into ‘a very pretious and wholsome Panacea or generall medicine’.58 If, however, the person out of whom this spirit is extracted is not healthy, the result will be a microcosmical magnet that conveys harm and ill health. Whatever Fludd told Culpeper in heaven, this was not Galenic medicine. This was magnetical medicine, harnessing vital beams and redirecting them to alter, for good or ill, the health of the body. *** For evidence of how the practice of magnetical medicine fitted within the medical economy of seventeenth-century London, we need to return to Fludd’s house in Coleman Street. Last time we were there it was in the early months of 1631, when Foster’s title page was posted on either side of Fludd’s front door. Now it is sometime after that date but before Fludd’s death in 1637. This time we go through the front door and into one of the parlours. Here we find, perhaps not coincidentally, a scene similar to the one that Culpeper’s ghost portrayed in 1656.59 Fludd and two other men are debating how to make a magnet with medicinal virtues, that is, a microcosmical, living magnet. There were four methods to make such a magnet, attributed to Paracelsus

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and Tentzel.60 First, take the dung of a sound man, dry it in a shady place until it no longer stinks. Second, cut a piece of warm flesh from a man who has died violently, and dry it. Third, obtain as much blood from healthy, living men as you can, let it congeal, pour off the liquid (setting it aside for later), dry it in the shade, moisten it with the liquid, dry it again and repeat until all of the liquid has been used. The ingredients of a fourth method are a great quantity of dung and some urine from a healthy man, as much sweat as you can obtain, taken from healthy bodies using linen cloths or a sponge, and some fresh blood. This concoction, like the previous one, is to be subjected to a process of wetting and drying. All of these methods to make a medicinal magnet involve the use of human matter, but while the first, third and fourth drew material from healthy men, the second required that the source had died violently. One might object that this was not only cruel but also difficult to obtain. It was this second magnet that these three men were discussing. Fludd said that if it were placed near a man’s heart, ‘he could not suffer it longe’. He similarly warned the readers of Mosaical Philosophy, we should recall, about the dangers of a sustained application of mummy. On this occasion, when asked to explain the uses for such a magnet, Fludd would not answer, regretting having said so much. This information – about how to make a microcosmical magnet and about the discussion with Fludd – was reported by one of the men sitting in Fludd’s parlour. His name might have been William Maxwell.61 The other man was Sir Edmond Stafford, a gentleman with some alchemical expertise who lived in London and summered in the country, about whom almost nothing else is known.62 Maxwell is similarly obscure. He was probably Scottish and he probably wrote the treatise on magnetical medicine in which the above conversation is described. The work almost certainly dates from 1631 to 1639.63 It circulated without an author, title or date, was printed twice in 1656 under different names and titles.64 In one of these it was attributed to Dr John Everard (1584?–1640/41), the Protestant preacher known for his alchemical expertise.65 In the Latin edition, printed in Frankfurt in 1679, it was attributed to Maxwell, and for convenience I will consider him the author.66 This work provides the clear and systematic account of how to practise magnetical medicine that is lacking in Fludd’s writings. Here is what Maxwell’s treatise says.67 Book 1 contains ‘An hundred Aphorisms: containing all the whole body of Natural-Magic: being the Key to open that which followeth in Sympathetick-Medicine’. Book 2 consists of twelve ‘conclusions’, like ‘columns, to support the Noble frame of

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Magical-Medicine’. These explain how the soul produces corporeal beams that flow within and beyond every living body. Book 2, Conclusion 5 contains the central premise of the work: ‘That the excrements of the bodies of living creatures retain a portion of the vital spirit; and therefore we cannot deny them life, and this life is the same species that the life of the creature is of, and propagated from the same soul.’ Book 3, the bulk of the work, is about ‘The Method of Curing by Sympathy’, beginning with ‘Of the things necessary for a Physitian before he undertake the Practice of Magical-Physick.’68 In some versions ‘the practice of magical physic’ reads ‘the practice of magnetic cures’, suggesting that some scribes wished to stress the natural basis of the art.69 The conversation between Fludd, Stafford and Maxwell about the different ways to make microcosmical magnets occurs in Book 3, Chapter 11, ‘Of the Magnet necessary in this Art’. This is a transitional chapter. Chapters 1–5 describe how magnetical medicines might be used within the framework of conventional remedies. For instance, Maxwell notes that, with the exception of some ointments, magnetical purges have not yet been discovered. There are also chapters on blood-letting, cauteries (largely dismissive) and comfortative medicines, all of which are encoded in alchemical terms. Chapter 6 focuses on the art of magnetical medicine itself, concluding ‘This one thing I would especially commend unto thee, as the greatest secret in this whole Art, (viz.) That medicines from mens bodies, if they be rightly used, can do the greatest matters in this Art; and therefore with great diligence, enquire what parts or excrements of the body conduce to what disease . . . . ’ These are known through a system of signatures, as catalogued by Croll in a work on ‘sagacious herbs’.70 Chapter 7 specifies the astrological timing for gathering herbal and human ingredients. Chapters 8, 9 and 10 describe ‘transplantation’ and ‘naked application’, procedures to move malevolent spirits from a diseased body into another object. Chapter 11, which is where we began, describes how to make the microcosmical magnet, Chapter 12 describes how to impregnate it with the vital spirit (strap it to your chest and play a vigorous game of tennis) and Chapter 13 describes how to manipulate the naked spirit without a magnet. Chapters 14–20 each consider bodily products: shit, piss, sweat, hair, nail pairings and teeth, spittle and snot, and blood and other such things (such as vomit, which has little merit). Throughout Maxwell describes the healing virtues of these products, as well as the dangers of allowing them to fall into the hands of a dangerous person or come into contact with foul spirits. Do not relieve yourself, he warns, in the same place that an unhealthy person has.

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Maxwell’s work instructs its readers in the complexities of magnetical medicine. It also contains a possible explanation for why Culpeper’s ghost suggested that Fludd’s practices were Galenic. If he read Maxwell’s work,71 he recognized that though it promised a mild panacea like so many chymical remedies, it also upheld the conventional authority of the physician to maintain and restore his patient’s health. And it extended the physician’s role to that of master of the cosmic economy of vital beams. The physician who practised magnetical medicine judged the balance between angels and demons, redirected vital powers from dead bodies into living ones, and managed the production and disposal of bodily waste. Culpeper’s ghost, I suspect, found the premises of magnetical medicine intellectually outlandish and the enhanced authority with which it invested the physician ideologically offensive. Fludd’s magnetical medicine provides a model for an expansive medical economy, but rather than investing the patient, as client, with the ability to choose her therapy, it endows the physician with the power to control the cosmic forces that govern health and disease. Just as Fludd depicted the ‘Fortress of Health’ and its ‘Invasion’, his friend Maxwell provided a systematic account of how the invisible beams that constitute the vital spirits work, and explained how to make and apply microcosmical magnets. This was magnetical medicine in theory and in practice. In Fludd and Maxwell’s accounts, the physician is at the centre of the system, surrounded by angels and demons, managing an economy of bodily excretions and cosmic forces. If the patient is the primary agent within the model of the medical marketplace, choosing which remedies to buy and practitioners to consult, in the practice of magnetical medicine, the physician is central. With medicines sourced from the bodies of executed criminals or human waste, he manages the cosmic commerce necessary to preserve, or restore his patient’s health.

Notes I thank Nick Popper and Joad Raymond for their detailed comments on this chapter, and the editors of the volume for many constructive readings and brutal excisions. Its argument was developed through talks at the Centre for the History of Medicine, University of Warwick, the Seminar in Early Modern Economic and Social History, University of Cambridge, and the American Association for the History of Medicine Meeting in Halifax, Nova Scotia, 2006. 1. Mr Culpeper’s Ghost may have been written by Culpeper’s publisher, Peter Cole. It seems to have been issued on its own (Wing C7523), to have been appended to several of Cole’s productions (Wing P3328, C7549), and to

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2.

3. 4. 5. 6. 7.

8. 9.

10. 11. 12. 13. 14. 15. 16.

17. 18. 19. 20.

have been re-set at least once (compare Wing P3328 and C7549). On ghost pamphlets, see J. Raymond, Pamphlets and Pamphleteering in Early Modern Britain (Cambridge, 2003). Culpeper’s Ghost, 6. On the work, see: A. Debus, The Chemical Philosophy (Mineola, NY, 1977), 249–50; W. Huffman, Robert Fludd and the End of the Renaissance (1988), 19–20. Culpeper’s Ghost, 6–7. Culpeper’s Ghost, 8. See Mary Fissell’s essay in this volume and C. Webster, The Great Instauration, (1975), 264–73. C. Irvine, Medicia Magnetica: Or, The Rare and Wonderful Art of Curing by Sympathy (Edinburgh, 1656), 23. On this text see Note 63 below. L. Kassell, ‘The Economy of Magic in Early Modern England’, in M. Pelling and S. Mandelbrote eds, The Practice of Reform in Health, Medicine, and Science, 1500–2000 (Aldershot, 2005). Cook, Decline; Pelling, Medical Conflicts. A. Debus, The English Paracelsians (1965), 142–5; C. Webster, ‘Alchemical and Paracelsian Medicine’, in C. Webster ed., Health, Medicine and Mortality in the Sixteenth Century (Cambridge, 1979). Cook, Decline, 121ff.; Webster, Great Instauration, 275–82. Culpeper’s Ghost, 2–5. Cook, Decline; Porter, Health. Debus, English Paracelsians, 142–5; C. Webster, ‘Alchemical and Paracelsian Medicine’. Cook, Decline, 121–6; Cook, ‘Good Advice’. E.g. Cook, Decline; Debus, English Paracelsians. On Fludd, see Huffman, Fludd; Debus, English Paracelsians (1965); Debus, The Chemical Philosophy (Mineola, NY, 1977); F. Yates, Giordano Bruno and the Hermetic Tradition (Chicago, 1964); idem, The Art of Memory (1966); P. Gouk, Music, Science and Natural Magic in Seventeenth Century England (New Haven, 1999); R. Westman, ‘Nature, Art, and Psyche: Jung, Pauli, and the Kepler–Fludd Polemic’, in B. Vickers ed., Occult and Scientific Mentalities in the Renaissance (Cambridge, 1984). On the weapon salve, Stuart Clark concludes that it attracted so much attention because scholars wanted to know ‘On which philosophy is this remedy based?’: Thinking with Demons (Oxford, 1997), 269–70. See Note 63 below. Fludd, Doctor Flvdds Answer vnto M. Foster Or, The Sqvesing of Parson Fosters Sponge (1631), sig. [A3v]. See L. Kassell, Medicine and Magic in Elizabethan London (Oxford, 2005), 152; Pelling, Conflicts, 97–8 and passim. Foster, Sponge, sigs. A2v, B1. Foster dedicated the work to Robert Dormer, first Earl of Carnarvon, a rising courtier with substantial holdings in Buckinghamshire (ODNB) and to the prominent surgeons Richard Wateson, Joseph Fenton, William Clowes Jr. and James Molines, all officers in the Barber-Surgeons’ Company in the 1620s and 1630s, with Wateson and Clowes also holding royal offices, as well as Scott and Charley: S. Young, The Annals of the Barber-Surgeons of London (1890), 8. Thanks to Margaret Pelling for help in identifying Charley.

104 Magic, Alchemy and the Medical Economy 21. Fludd suggests that Foster, because he was the son of a barber-surgeon, wished to ‘curry fauour’ with the Barber-Surgeons’ Company: Flvdds Answer, 120–2; his full discussion of Foster’s motives runs on pp. 115–31, where he insinuates that Scott and Charley were not wholly invested in Foster’s project. Fludd had encountered Scott in 1618, at the first meeting in which Fludd was a Censor: Annals, 117. This, and many other cases that I cite from the Annals, are also noted in Pelling, Conflicts. Fludd had several conflicts with surgeons in the College, e.g. Annals, 246; 314; 316–17. I have not explored the possibility of rancour or jealousy following an unspecified service that Fludd provided for the crown in 1629, for which Charles I granted him a house and some land in Suffolk: Calendar of State Papers Domestic, Charles I, 1628–9, 570, cited in Huffman, Fludd, 34. For tensions between the physicians and surgeons in the 1620s, see Cook, Decline, 98. 22. Fludd, Anatomiæ amphitheatrum (Frankfurt, 1623), 236–9; see also Debus, ‘Robert Fludd and the Use of William Gilbert’s De Magnete in the Weapon Salve Controversy’, JHM, 19 (1964) 392, 394. 23. Debus, Chemical Philosophy, 266–76; Huffman, Fludd, 62ff. 24. On Fludd and the weapon salve controversy, see esp. Debus, Chemical Philosophy, 279–90 and Debus, ‘Fludd’. See also W. F. Bynum, ‘The Weapon Salve in Seventeenth Century English Drama’, JHM, 21 (1966); Daniel Stolzenberg, ‘The Sympathetic Cure of Wounds’ (M.A. thesis, Stanford University, 1999) (which the author kindly sent me along with further references). 25. C. Z. Camenietzki, ‘Jesuits and Alchemy in the Early Seventeenth Century’, Ambix, 48 (2001). See also Debus, ‘Fludd’, 390–2; Debus, Chemical Philosophy, 246, 303ff.; W. Pagel, Joan Baptista Van Helmont (Cambridge, 1982), 8–13; Stolzenberg, ‘Sympathetic Cure of Wounds’; L. Thorndike, A History of Magic and Experimental Science (New York, 1923–41), vols. 6–8, passim. 26. Flvdds Answer, 133; Fludd, Mosaicall Philosophy, 257. On Greuter see C. H. Josten, ‘Robert Fludd’s Theory of Geomancy and his Experiences at Avignon in the Winter 1601 and 1602’, Journal of the Warburg and Courtauld Institutes, 27 (1964); Westman, ‘Nature, Art and Psyche’, 178. 27. Annals, 175, 181, 183, 211. On Fludd, see also Annals, 198, 201, 206, 210. 28. Flvdds Answer, 122–3; ODNB; Pelling, Medical Conflicts, 28. 29. Fludd’s major works include: Utriusque cosmic . . . historia (Oppenheim, 1617–26); Medicina Catholica, (Frankfurt, 1629–31); and Philosophia Moysaica (Goudae, 1638). An English translation, Mosaicall Philosophy, was printed in 1658. He was also embroiled in several print disputes. 30. Baker, ‘To the Reader’, in Sennert, Weapon–Salves Maladie, sig. [A3v]. 31. ‘Bustorum aliquot Reliquae’, Royal College of Physicians, London, MS 149; BL, Sloane MS 2149, cited in Huffman, Fludd, 174. 32. Thomas Fuller, The History of the Worthies of England (1811), vol. 1, 503–4, cited in Huffman, Fludd, 174–5; cf. Flvdds Answer, 47. 33. E.g. Debus, Chemical Philosophy, 246, 249–50; Huffman, Fludd, 18, 22, 24, 29. 34. These details are drawn from Sennert, Weapon-Salves Maladie, 2–11 (quotation 4). 35. For magnetical medicine that predates the Paracelsian weapon salve, see Pliny, Natural History, bk. 36, chs. 16–17; William Gilbert, De Magnete (1600), bk. 1, chs. 1, 14, 15. For broader discussions about magnetical

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36. 37. 38.

39. 40. 41.

42.

43. 44. 45. 46. 47. 48. 49.

50. 51. 52. 53. 54. 55. 56.

medicine, see: Debus, ‘Fludd’, 389n; H. Schott, ‘Paracelsus and van Helmont on Imagination’, in G. William and C. Gunnoe eds, Paracelsian Moments (Kirksville, MO, 2002). Foster, Sponge, 7–8, 18–19; Sennert, Weapon-Salves Maladie, 13–14, 17, 26. Sennert, Weapon-Salves Maladie, 29; see also Foster, Sponge, 32; cf. Flvdds Answer, 116. On remedies and ingredients: C. Webster, ‘William Harvey and the Crisis of Medicine in the Jacobean Age’, in J. Bylebyl ed., William Harvey and His Age (Baltimore, 1979), 11–14; Stolzenberg, ‘Sympathetic Cure of Wounds’; Thorndike, Magic, vol. 8, 413–20; A. Wear, Knowledge and Practice in English Medicine, 1550–1680 (Cambridge, 2000), ch. 2. K. Dannenfeldt, ‘Egyptian Mumia: The Sixteenth Century Experience and Debate’, Sixteenth Century Journal, 16 (1985). Foster, Sponge, 54–5; Sennert, Weapon-Salves Maladie, 8–9. Kenelm Digby, A Late Discourse . . . Touching the Cure of Wounds by the Powder of Sympathy, trans. R. White (1658), 11–14, 5–6; ODNB. See also Nathaniel Highmore, A Discourse of the Cure of Wounds by Sympathy, appended to The History of Generation (1651), 134. See also Stolzenberg, ‘Sympathetic Cure of Wounds’; Thorndike, Magic, vol. 7, 503–8. Andreas Tentzel, Medicina Diastatica (Jena, 1629); trans. Ferdinando Parkhurst, Medicina Diastatica or Sympatheticall Mumie (1653). On Tentzel, see Thorndike, Magic, vol. 8, 414–15. Tentzel abstracts Paracelsus’s teachings on mummy, and I suspect that he is borrowing Petrus Severinus’s notion of transplantation as a theory of morbidity and applying it to the production of remedies, on which see J. Shackelford, A Philosophical Path for Paracelsian Medicine (Copenhagen, 2004), 177, 183–5 and passim. Perhaps there is a longer-term history to be written about a shift from exotic to local to domestic ingredients. Webster, ‘Alchemical and Paracelsian Medicine’, 18–19. Flvdds Answer, 102; Memb. 3, 6–16. Fludd, Medicina Catholica, Tract. II, Sect. 2, 308, 344. Fludd, Mosaicall Philosophy, 90–97, 160ff. See Debus, ‘Fludd’; S. Pumfrey, Latitude and the Magnetic Earth (Cambridge, 2002). Foster, Sponge, sig. A3. On the popularity of the weapon salve, see K. Thomas, Religion and the Decline of Magic (Harmondsworth, 1973 [1971]), 225. Flvdds Answer, 108–44, passim. I have not been able to identify any of these men. Digby famously claimed that every country barber in Europe knew the formula for the weapon salve: Late Discourse, 14. Flvdds Answer, 108–9, 114. John Evans, The Vniversal Medicine: Or the Vertues of the Antimoniall Cup (1634); Annals, 420, 421. Annals, 444, cited in Webster, ‘Harvey and the Crisis of Medicine’, 12. John Evans, The Universall Medicine: Or, the Virtues of the Magneticall, or Antimoniall Cup (1642), sig. C3v. Flvdds Answer, 133; Mosaicall Philosophy, 257. Fludd, Mosaicall Philosophy, 255. Thanks to Patrick Wallis for identifying Kellet. Fludd, Mosaicall Philosophy, 287; cf. Flvdds Answer, 141.

106 Magic, Alchemy and the Medical Economy 57. Fludd, Mosaicall Philosophy, 248. Earlier Fludd reported that he had cured himself of a persistent ache in the back of his hand by anointing it with the ‘crude quintessential balme of wheat’, though he regretted not pursuing the virtues of this substance with further experiments: Fludd, ‘A Philosophical Key’, in A. Debus ed., Robert Fludd and his Philosophical Key (New York, 1979), f. 56v, cited in Huffman, Fludd, 23. 58. Fludd, Mosaicall Philosophy, 219. 59. For another echo in Culpeper’s Ghost, see Tentzel, Medicina Diastatica, 116. 60. For one, see: Tentzel, Medicina Diastatica, chs 5 and 6, 58–60. 61. For some unconvincing suggestions about Maxwell, see Ron Heisler, ‘Robert Fludd: A Picture in Need of Expansion’, Hermetic Journal (1989). I have not pursued Maxwell in the Scottish medical records. 62. Most of what we know about Stafford comes from: Bodleian, MS Ashmole (hereafter Ashm.), 358.7, p. 66. Compare the versions in Irvine, Medicina Magnetica, 60, and Boulton, Medicina Magica, 106, which do not mention Stafford. 63. It includes a reference to the Foster–Fludd exchange of 1631, while the conversation must have taken place before Fludd’s death in 1637, and the author specifies that he wrote the treatise within two years of it. If, however, the conversation is fictional, then the work could date from as late as 1648, when Ashmole made his copy. 64. Ashm. 358.7, pp. 88–91 (quotation p. 89). The two 1656 editions are Boulton, Medicina Magica (Wing 3833A) and Irvine, Medicina Magnetica (Wing I1053). A variant of Boulton mistakenly records ‘1665’ on the title page (Wing B3833B). These are variants of the same text. Ashm. 358.7, pp. 1–108 is at least partially in Ashmole’s hand, with corrections by him. He completed his transcription in July 1648 (C. H. Josten ed., Elias Ashmole, Autobiographical and Historical Notes, Correspondence, and Other Sources (Oxford, 1966), vol. 2, 490). Authorship of the work has been erroneously attributed to him: W. Black, A Descriptive, Analytical and Critical Catalogue of the Manuscripts Bequeathed unto the University of Oxford by Elias Ashmole (Oxford, 1845), 270. BL, MS Sloane 1321 is similar to Ashm. 358.7, and lacks date, title and author; BL, Sloane 2220, ff. 251v–65 contains only the aphorisms and conclusions (cf. Thorndike, Magic, vol. 7, 320, n. 219). BL, Sloane 643 ff. 1–17b contains Dr S. Bellingham’s extracts from Boulton’s edition. These texts are discussed in: Thorndike, Magic, vol. 8, 418–21 and ODNB, s.n. 65. Boulton, ‘To the Reader’, sig. [A4v], states that he obtained the work from a friend, Mr M. B., a gentleman of Kent. Similar themes run throughout Magnetical Medicine and a hermetical treatise annotated by Everard and published by Ashmole, The Way to Bliss (1658). 66. De Medicina Magnetica libri III (Frankfurt, 1679). Its publisher corresponded with Henry Oldenburg about the text in 1677 (A. R. Hall and M. B. Hall eds, The Correspondence of Henry Oldenburg (1986), vol. 13, 339–40). On this edition, see: Thorndike, Magic, vol. 8, 419–20. For evidence of the confusion about the authorship of the various versions of this text, see: BL, Sloane 696, ff. 2, 18v, 20. 67. The three books appear in different sequences in the different versions. Here I follow Irvine.

Lauren Kassell 107 68. 69. 70. 71.

Irvine, 42ff; Ashm. 358.7, pp. 49ff. Boulton, 71. Irvine, 64–5; Ashm. 358.7, p. 71. See also Boulton, 185–95. The evidence is circumstantial. As noted above, the scene in which Fludd converses with Lull and Van Helmont in Culpeper’s Ghost seems to parody the scene in Magnetical Medicine, and the works were both printed in the late spring or early summer of 1656.

6 The Marketplace of Print Mary E. Fissell

The cluster of ideas we now call ‘the medical marketplace’ comes from the intersection of three different historiographic strands in the mid1980s and the 1990s. First, the medical marketplace became a kind of shorthand for a critique of older ideas about the structures and regulation of the medical profession. The old narrative was of a tripartite London-centred hierarchy of rank and value: physicians, surgeons and apothecaries, each assigned specific healing functions that minimized competition between them. The work of Harold Cook and Margaret Pelling demolished this older view.1 Taken together, these two painted a picture of a College of Physicians that was neither particularly powerful nor controlled medical practice. In the 1970s, medical sociologists such as Nicholas Jewson and Ivan Waddington had reminded us that doctors competed with each other for patients, often in crowded markets, and Pelling in particular emphasized the variable nature of medical work and underlined its economic aspects.2 Second, the post-1985 boom in the history of the patient, spearheaded by Roy Porter, animated the medical marketplace and made it much more than a tale of failed regulation.3 Pelling and Cook both alluded to the power of the patient, but Porter’s work made it possible to discuss the patient as the centre point of a historical narrative. Once patients became active agents, the medical marketplace came to life as a heuristic device that explicated the behaviours of both patients and practitioners. The third strand was the larger history of consuming and consumption. Roy Porter’s English Society in the Eighteenth Century sketched out an eighteenth century that the getting-and-spending 1990s recognized as its own.4 The English became, in Paul Langford’s phrase, ‘a polite and commercial people’. Similarly, John Brewer’s work emphasized relationships between larger economic structures and individual experiences.5 108

Mary E. Fissell 109

The construct of ‘the medical marketplace’ accorded well with this historiographic shift, especially in terms of re-thinking the category of quackery,6 but there has been little cross-fertilization of ideas and techniques between histories of medicine and of consumption.7 These three themes have helped to make ‘the medical marketplace’ a robust concept, especially in the classroom. Instead of focusing on William Harvey as a pinnacle of scientific discovery, social historians of seventeenth-century medicine could talk about patients and practitioners, using the marketplace to organize what might otherwise remain somewhat anecdotal information. Pedagogically, the concept helped to make early modern medical practice suitably strange when compared with the staid AMA-regulated medical profession that most of my students have aspired to join. Think of it – advertising medical wares in a newspaper! practising in coffee houses! competing medical theories on offer by different practitioners! Over the years that I have taught, however, American medicine has become a highly commercialized world quite unlike that of two decades ago when historians adopted the ‘medical marketplace’. These changes do not make the medical marketplace less useful; on the contrary, the emerging similarities of past and present medicine make the concept all the more thought-provoking. However, the medical marketplace concept needs refining. First, the seventeenth- (and now the later sixteenth-) century version of the story focuses on the College of Physicians and its struggle for authority, while eighteenth-century accounts are absorbed with consumer behaviours with little regard to regulation or the construction of authority.8 Second, in its simplest versions, all early modern medicine gets condensed into a single marketplace lacking chronological change. Fundamental economic changes that transformed England into a mercantile power are not addressed because the medical marketplace is portrayed as a relatively static set of social and economic relations. In this paper I want to add a fourth element to the three themes discussed above: the marketplace of print. In so doing, I seek to add a layer of specificity to our account of the later seventeenth- and early eighteenth-century metropolitan medical marketplace. My claim is that the world of popular medical books both reflects and embodies some larger aspects of the market for medicine and thus helps us to identify certain aspects of change within that market. Over the longer early modern period, I suggest, print became a significant component of the medical marketplace in large cities such as London, and perhaps even in provincial towns.9 Undoubtedly, face-to-face relationships remained

110 The Marketplace of Print

an important structuring feature of early modern medical markets, even in the capital, but print assumed an almost catalytic function in the later seventeenth century, permitting a range of practitioners to advertise and practice much more intensively than they had done a century before.10 The chapter describes the overall shape of the market for what are generally described as popular medical books and then focuses on a few specific practitioners. The category ‘popular medical books’ is a vexed one. The word ‘popular’ has multiple and often fuzzy meanings – ‘of the people’ or ‘folk’; ‘reprinted often’; ‘non-professional’ and so on. As Roger Chartier reminds us, ‘the popular’ is always constructed by the learned, and ‘popular’ often exists in some uneasy binary relationship with categories such as ‘learned’ or ‘elite’.11 The core of my interest here is to understand what kinds of knowledge about health and healing were available to ordinary people through this medium, and how those knowledges were or were not related to those held by full-time practitioners. As a result, I prefer the term ‘vernacular’ to ‘popular’, for two reasons. First, the books I examine are in the vernacular, that is to say, English, not Latin. Second, ‘vernacular’ alludes to the kinds of not-fully formalized knowledges used and reproduced by ordinary people, as in the term ‘vernacular architecture’.12 Obviously not every medical book in English was intended for a lay audience; I have therefore focused on medical books that state they are for readers who were not primarily health care practitioners. This category ‘vernacular medical books’ is thus a double proxy: first, I am using medical information in books intended for non-practitioners as a way into ordinary people’s medical knowledge, and second, I am using the intended audience for a book as a kind of proxy for its actual readership. Neither is perfect. This account is based on a database of all medical works intended for non-practitioners published in English from 1641 to 1800, although this paper focuses on the first century 1641 to 1740. It begins with the 1640s when medical publishing, like all other publishing, took off.13 The end date of 1800 reflects the endpoint of the ESTC.14 The database contains records of about 2700 editions of vernacular medical books. To compile it, I searched titles for 30 or 40 medical or health-related words. After discarding metaphorical uses of medical language, I looked at each work. I define ‘medical’ very broadly. Anything to do with health, illness or bodily function is included as long as the book describes some kind of practice: I am interested in books that tell the reader how to do something, whether that is to gather herbs, choose a diet, make a remedy or figure out what ails a person. I focus on health

Mary E. Fissell 111

care in the home, so I have not included books about spas that tend to blend into guide books, but I have included manuals of shipboard medicine intended for non-surgeons. The only really ambiguous category, not surprisingly, is cookery books, where I decided that a book with about 25 per cent or greater medical content (measured in pages) qualified for inclusion. I have also focused on books and pamphlets rather than single sheets, poems, records of institutions, songs, controversies, commentaries, satires or periodicals. Nor have I included almanacs, which are complex works with quite variable amounts of health information.15 Surprisingly few books are completely mute about their intended audiences. This is a period before book jackets and blurbs, so the title page and sometimes the preface had a crucial advertising function. Titles such as Every Man His Own Rupture-Curer or Every Woman her Own Midwife can be good indicators of intended readership. Many books state on their title pages that they are intended ‘for the use of all families’, or ‘for all married women’, or ‘for the meanest capacity’. Again and again, books claim to be ‘published for the general good of mankind, especially the meaner sort’ or so that ‘women and maids of the meanest capacity may perfectly understand the symptoms, nature and true cause of their own illnesses’. These descriptions of audience cannot be taken literally. Literacy was not so extensive that many agricultural day labourers or others of ‘the meanest capacity’ were likely to be reading them. Rather, such claims were rhetorical, perhaps signalling that not much knowledge nor deep literacy skills were required to use the book. This ‘lowest common denominator’ claim about readership was common to many early modern didactic books. Nevertheless, early modern printers and publishers were highly effective at marketing their product, and we should take their designation of intended readership seriously. Indeed, three-quarters of the vernacular medical books published between 1641 and 1740 appeared in multiple editions, underlining how accurately publishers knew what would sell. Another way to think about readership is to track the bottom end of the potential market, in terms of literacy and in terms of cost. Reading was often a silent and solitary activity, practised at a wide range of proficiencies, that left few traces in the historical record. The best current estimates are that around 1700, roughly 50 per cent of men and 25 per cent of women could read, but these may be underestimates.16 The ability to read was very strongly related to location and occupation; in 1700 about half of all London women could read.17 However, England was still a profoundly oral culture: long sermons were preached and discussed, proclamations read aloud, ballads hawked in the streets,

112 The Marketplace of Print

their sellers singing or declaiming them.18 The median price of a vernacular medical book was about 1s 6d.19 This sum represents (very) roughly a twentieth of the weekly income for those on the lower rungs of the middle class, a quarter of a labourer’s weekly income, or six meals at the cheapest London cookshops. Hence, these books were probably neither bought nor read by the ‘the meanest capacity’. However, prices provide only the roughest indicator of readership. Vernacular medical books circulated widely. One eighteenth-century Somerset shoemaker, for example, owned seven books, including two vernacular health texts, one by Nicholas Culpeper.20 An early eighteenthcentury pamphlet about venereal disease is inscribed ‘for John Coppin Esq’s gard’ner’.21 Nor were gardeners and shoemakers the only readers.22 The posthumous auction of Robert Hooke’s books gives us some indication of the reading of a middling man.23 Hooke’s library included many rare books, lots in Latin, and many costly folios and quartos.24 But the octavos and duodecimos include some of the more successful vernacular medical texts (see Table 6.1). Some of the prices at auction, such as Sadler for 10d or the Compleat Midwife’s Practice for 4d, are far below their likely cost new. This auction catalogue indicates the potential social range of vernacular health texts. Hooke, moving in elite circles, owned such books, but they sold at auction at low prices, suggesting that the broader second-hand book market may have made such books available to artisans and above. Vernacular medical books were a fairly stable category of publication after the initial boom of the 1650s. As other historians have observed,

Table 6.1 Popular medical books in Robert Hooke’s Library Title

Price at Auction

R. Bacon, Cure of Old Age (1683) The Regimen of Health (1575) The Compleat Midwifes Practice (1656) Secrets of Physick and Surgery (1651) K. Digby, Receipts in Physick and Chemistry (1675) J. Sadler, Art of Physick (1657) The Accomplished Lady’s Delight (1685) Lovell, Herbal (1659) Right Course of Preserving Health (1636) G. Harvey, Family Physician (1676) The Cure of Diseases by Signature (no date) [R. Bunworth], Dunworth’s Doctress, or Curing of Women’s Diseases (1656) Source: L. Rostenberg, The Library of Robert Hooke (Santa Monica, 1989).

1s 3d no price 4d no price 7d 6d 7d 1s 2d 1s 2d 1s 1s 6d 10d

Mary E. Fissell 113

200 180 160 Number

140 120 100 80 60 40 20 0 1640

1650

1660

1670

1680

1690

1700

1710

1720

1730

Decades Figure 6.1

Numbers of popular medical books published (1641–1740).

the 1650s represented an extraordinary flowering of vernacular medical publishing (see Figure 6.1).25 While some of this publishing can be related to the ideological currents of the 1640s and 50s, some of it was also due to a lag in the medical book market in relation to other forms of more ephemeral print. The print trade was totally altered in July 1641 with the closure of the Court of Star Chamber, where violations of censorship had been prosecuted.26 With it gone, cheap print exploded. In the late 1630s, about 600 titles were produced in England per year. In 1641, that number tripled to almost 2000, and in 1642, more than 4000 titles were published. For the rest of the decade, anywhere from 1200 to 2000 items were produced every year, a pattern that continued into the 1650s.27 However, as Donald McKenzie observed, in 1641 England did not suddenly have many more reams of paper (all the paper for books was imported from France) nor many more compositors. What changed were the kinds of items published. The boom in print was initially in sensational 8- or 16-page pamphlets telling readers about current events and politics.28 By the 1650s, however, the print trade had expanded and consolidated into a new form. Pamphlet literature had partly morphed into newsbooks, which provided raucous twice-weekly accounts of current events in different ideological flavours; some older forms of cheap print like ballads were in remission; and vernacular medical publishing took off.29 In the 1650s, 1660s and 1670s, vernacular medical books amounted to about 1 or 1.5 per cent

114 The Marketplace of Print

of all items published; from the 1680s onwards, they fell back to about 0.5 per cent of all titles. Between 150 and 180 vernacular medical books were published every decade from the Restoration onwards. The 1660s and 1720s saw surges in numbers of books that were due largely to publications on plague: 23 in the 1660s and 21 in the 1720s. Booksellers were quick to respond to public anxiety (perhaps fuelling it), rushing four books on the plague into print in 1664, and another nineteen the following year. The dreaded Marseilles plague never reached England, but many works on the plague were reprinted in the 1720s.30 Fifteen or eighteen books a year may seem trivial. However, these works were not ephemeral. Nor was medical knowledge valued because it was new; quite the contrary. The longevity of some vernacular medical works is striking: in one copy of Castore Durante’s 1686 A Family-Herbal or Treasure of Health, one E. J. Bridges inscribed his name in 1772. In the Folger Library’s copy of the same book, one William Davis inscribed his name in 1798.31 We can track another book in use for over a century and a half: the Folger’s copy of the 1640 first edition of Thomas Brugis’s The Marrow of Physick was signed by Richard Goodwin in 1712. By the 1780s, the book was in the possession of one John Hughes, who signed and dated it repeatedly in 1786, 1787 and 1789. One Williams later inscribed it in 1802 as the gift of James Hughes, perhaps the heir of John.32 Books therefore need to be thought of in terms of the number circulating at any given time. If we assume that vernacular medical books had an average life of 30 years, then in 1700 and in 1750 there would have been one work in circulation in England for every four households. Such a crude calculation offers us only an order of magnitude.33 However, this estimate suggests a fair degree of market penetration, and fits with the limited evidence we have of vernacular medical book ownership.34 In other words, these books were not just in the libraries of bibliophiles like Hooke, but were a common item of print for those who owned more than just an almanac and a religious work. In early modern contexts, authorship is not straightforward. Seventeen per cent of vernacular medical texts were anonymous. In other cases, we have an author’s name, but know almost nothing else about him or her. For example, Jane Sharp is the name on the title page of the first female-authored English midwifery book (1671), yet despite impressive recent detective work by Ornella Moscucci and Elaine Hobby, we still know virtually nothing about Sharp.35 Many other texts are translations, some acknowledged, some not; at a minimum, between 10 and 17 per cent of these texts are translations, with the proportion declining

Mary E. Fissell 115

slightly over time.36 Even texts apparently authored by an individual may be more complex than they initially appear. For example, The Compleat Midwifes Practice (1656) is often described as being by Thomas Chamberlayne, because the title page lists a series of initials, beginning with ‘T.C.’. The text actually consists, in part, of translations of midwifery books by Louise Bourgeois and Jakob Rueff.37 By 1659 the text had grown to The Compleat Midwife’s Practice Enlarged, and claimed to offer Nicholas Culpeper’s best secrets.38 But the additional section is not Culpeper – it is more Rueff. In short, the material object of a single book that you hold in your hands is often made up of many texts written by acknowledged and unacknowledged authors. Thus our modern notion of authorship – one person sitting down and composing a book – is close to meaningless in this context. Instead, an author’s name on a title page is significant as a sign or symbol, an attribute of the book, rather than a pointer to its originator in some biographical sense. As Table 6.2 suggests, some authors produced outstanding best-sellers, measured by the number of editions. Nicholas Culpeper leads the pack.39 His name is associated with an astounding 8.5 per cent of all the editions of vernacular medical books produced 1641–1740. Of the top five most-produced books, Culpeper produced the first, third and fourth. However, the curious thing about this list of best-selling books is that for at least three of them the notional authors were vaguely specified and probably marginal to the text’s popularity. Aristotle’s Masterpiece

Table 6.2 Best-selling medical books (1641–1740) Title

Author

A Physicall Directory The English Physician Aristotle’s Masterpiece A Directory for Midvvives A Choice Manual of Rare and Select Secrets The Practical Scheme of the Secret Disease The Curiosities of Common Water The Queen’s Closet Opened The Diseases of Women with Child Culpeper’s Last Legacy An Essay of Health and Long Life

Nicholas Culpeper Nicholas Culpeper Nicholas Culpeper Elizabeth Grey, Countess of Kent [Anodyne necklace series] John Smith F. Mauriceau Nicholas Culpeper George Cheyne

Number of editions 33 33 31 22 21 14 13 13 12 11 11

116 The Marketplace of Print

was in some distant way imagined to have something to do with Aristotle, but the link was loose.40 I would suggest that an individual bought a copy of The Queen’s Closet Opened or A Choice Manual of Rare and Select Secrets, rather than a book by W.M., known only by his initials, and purveying what were supposed to be Queen Henrietta Maria’s recipes, or by Elizabeth Grey, Countess of Kent, a posthumous author whose relation to the text that bears her name remains uncertain.41 A Practical and Philosophical Scheme of the Secret Disease is part of a series of early modern advertising pamphlets, centred around a product (the Anodyne Necklace), rather than an author. In this case the textual sign of the product, especially the little woodcut of the necklace, provided an easily recognizable identity similar to that of a name like Culpeper. Only after 1730 did other authors approach Nicholas Culpeper’s name recognition and best-selling status – and even here, most of the stars were one-book men. John Wesley’s Primitive Physick or William Buchan’s Domestic Medicine appeared in myriad editions in the later eighteenth century, but each had only one best-seller. George Cheyne is the exception, producing two.42 The overall distribution of types of book published is shown in Figures 6.2 and 6.3. Recipe books, such as the The Queen’s Closet Opened, boomed in the 1650s and remained popular throughout the period. They were clearly related to manuscript recipe and cookery books, being compilations of recipes, often in seemingly random order, usually

Recipe Books 22%

Surgery 3%

Plague 4% Herbal 6% Venereal 7%

General work 13%

Regimen 8% Proprietary Med. 11% Midwifery 9% Figure 6.2

Misc. 8% Specific Disease 9%

Genres of popular medical books.

Mary E. Fissell 117 100 90

% of Books per Decade

80 70 60 50 40 30 20 10 0 1640

1650

1660

1670

1680

1690

1700

710

1720

1730

Decade Recipe Books General Work Proprietary Med. Midwifery Specific Disease Misc.

Figure 6.3

Regimen Venereal Herbal Plague Surgery

Genres over time.

without diagnostic information.43 The category labelled ‘Proprietary Med.’ refers to commercially available preparations – small pamphlets that were extended advertisements. ‘General Work’ refers to works that offer a kind of general guide to medicine overall, such as John Tanner’s 1659 The Hidden Treasures of the Art of Physick; Fully Discovered: in Four Books. 1. Containing a Physical Description of Man. 2. The Causes, Signes, and Cures of All Diseases, Incident to the Body. 3. The General Cure of Wounds, Tumours, and Ulcers. 4. A General Rule, for Making All Kind of Medicines; with the Use and Nature of Distilled Waters, Juyces, Decoctions, Conserves, Powders, Elestuaries, Plaisters, & c. Midwifery books also took off in the 1650s and never ceased to be popular. The category ‘Disease’ refers to works that focus upon one specific disease, with the exception of books on venereal diseases and plague, which warranted their own categories. The stone, gout, scurvy and smallpox were all common topics for such books.44

118 The Marketplace of Print

Figure 6.3 allows us to observe the relative popularity of genres decade by decade. As mentioned before, plague tracts echoed actual or threatened epidemics. Unsurprisingly, given the Civil War, surgery books were more prominent in the 1640s than in other decades. The market for general works on medicine seems to have become relatively saturated by c. 1700, but works on specific diseases increased in number. One striking feature is the boom in venereal disease books from the 1700s onwards. In part, this is due to the popularity of ‘Anodyne Necklace’ works, many of which were about venereal disease, and a general increase in books that were advertisements of one sort or another. Nonetheless, this change also suggests a shift in writing about sexual topics more generally, which may be related to the demise of the print licensing system in 1695. The number of editions of Aristotle’s Masterpiece and of venereal disease books expanded at the turn of the century, suggesting that printers and booksellers discovered or created new kinds of markets in books with sexual themes – a trend amplified by the publication of Onania in 1716. If we look more specifically at how the authors of vernacular medical books presented themselves on title pages, we see an extraordinary array of claims to legitimacy. Writers were identified as doctors (MD, Doctor, Dr or physician) fairly steadily and readily over the course of the seventeenth and early eighteenth centuries. On average, 22 per cent of books had authors described as medically qualified. In the 1670s, almost a third of writers claimed such qualifications. At least a quarter of those were openly selling their skills through their publications, urging their readers to consult them, so we should not read this claim as in any way insulating these practitioners from the market. Somewhat fewer (11 per cent) of books modestly claimed to be by ‘students’, but the popularity of this category is largely due to Nicholas Culpeper, who habitually identified himself as ‘gentleman student of physick and astrology’. In general, it seems that those who called themselves students often had links to astrology or to chemical medicine. A mere 3 per cent of books were authored by ‘professors’. There is one clear trend in claims to legitimacy: the rise and fall in appeals to aristocratic or royal connections, which can be seen in Figure 6.4. There is a striking ideological divide in the 1650s that lives on into the next few decades and then disappears. In the 1650s a radical Puritan-oriented group of men sought to reshape natural knowledge.45 In vernacular medicine, Nicholas Culpeper lambasted all kinds of hierarchical authority, monarchical, aristocratic, episcopal or medical.46 He virtually reinvented vernacular medical publishing in the few short

Mary E. Fissell 119

% Books per Decade

25 20 15 10 5 0 1640

1650

1660

1670

1680

1690

1700

Decade Figure 6.4

Percentage of books that claim royal authority.

years before his death in 1654. However, at the same time, books with a very different appeal (and a very different epistemology) appeared with titles such as The Ladies Cabinet; The Queen-Like Closet and The Accomplished Ladies Rich Closet.47 The royal or aristocratic flavour to these texts is quite personal. The Queen’s Closet proclaims that these recipes were given to the Queen ‘many whereof were honoured with her own practice, when she pleased to descend to these more private recreations’. The Rich Closet of Physical Secrets told the reader that one section of the book had been collected by a great navigator and presented ‘with his own hands, to our late Queen Elizabeth’.48 The preface to Kenelm Digby’s Closet specifies that Digby was a knight, a member of the Royal Society and chancellor to the Queen Mother, and adds ‘His name does sufficiently auspicate the Work’.49 An antimonopoly stance did not always imply scorn for royal authority. John Archer, in his democratically titled Every Man His Own Physician, styled himself ‘Chymical Physitian in ordinary to the King’.50 This boom in royal or aristocratic allusion, which started somewhat improbably in the 1650s, waned after the Glorious Revolution, and such allusions were rare in the eighteenth century. In general, however, for every John Pechey, ‘Fellow of the College of Physicians, London’ or Thomas Mouffet, ‘that ever famous Thomas Muffett, Doctor in Physick’, whose book was, for good measure, ‘corrected and enlarged by Christopher Bennet, Doctor in Physick, and fellow of the Colledg of Physitians’, there was a Michael Bromfield, ‘approved

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physician’, promoting his own pills for the scurvy, or Charles Peter, ‘Cyrurgeon, and Practitioner in Physick’, ‘at his House in St. Martins-lane, near Long-acre, over against the sign of the castle’ where readers could obtain his special antivenereal pills.51 Claims to what we might think of as a certain measure of training or corporate belonging – terms like ‘physician’ or ‘chirurgeon’ or perhaps even ‘College of Physicians’ – seem to have been freely adopted rather than necessarily attesting to an occupational status that anyone other than the author and (perhaps) his patients recognized. Indeed, authors were described through a plethora of polymorphous qualifications: ‘an eminent practitioner in physick, surgery and chymistry’; ‘King of Persia’; ‘a Franciscan frier’; ‘sometimes Fellow of New-Colledge in Oxford, Doctor of Physick, Regius Professor in that faculty, and physitian to Queen Elizabeth’; ‘physician ordinary of Oshatin’; ‘residing at Batavia in the East-Indies, in the service of the Dutch East-India Company’; ‘Baronet’; ‘chymist, living at the Golden Ball in Devonshire-street, without Bishopsgate’; ‘lover of Physick and Chyrurgery’; ‘citizen [of London] and student in physick’; ‘an expert operator, and presumed to as good as any the best in all Europe’; ‘a Jew, borne in Jewry, Doctor in Astronomie and Physick’; ‘a lover of truth’; ‘a servant of God, and secretary of nature’; ‘a noble gentleman of Venice’; ‘gent and traveller’; ‘doctor in the faculty of Chyrurgerie at Paris’; ‘a strict examiner of medical art’; ‘Dr. in physick and hermetick philosophy’; ‘practitioner in the art of midwifry above thirty years’; ‘spagirick physician in both medicines, and philosopher by fire’. To summarize or generalize from this rich array is perhaps foolhardy, but it is noticeable that there are few claims about experience (save for Jane Sharp, the midwife); a lot of claims about institutional recognition, often in foreign places (in part this is because of the many translations from foreign works); a weakness for the exotic; and an enthusiasm on the part of chemical or hermetic practitioners to label themselves as such. Finally, I want to look more closely at arguably the most marketoriented group of vernacular medical books: those that promoted the author or his (rarely her) remedies. It is impossible to draw hard-and-fast distinctions between books or pamphlets that we would consider ‘advertisements’ and those that we would consider to be purely conveying medical knowledge. I have categorized many books as ‘commercial’, meaning that they seem to have been produced to promote an author’s remedies or practice, but many items seem more like early modern infomercials (to be anachronistic), than advertisements per se. Figure 6.5 tracks the number of commercial books against those that claimed to be ‘for the public good’ or ‘for public benefit’ or other similar language.

Mary E. Fissell 121 30 Commercial Public good

% of Books per Decade

25 20 15 10 5 0 1640

1650

1660

1670

1680

1690

1700

1710

1720

1730

Decade

Figure 6.5

Books published for the ‘public good’ vs. ‘commercial’ ones.

As it shows, as fewer books claimed to be for the public good, more served to promote their authors. In part, I suspect, this opposition reflects a much larger shift: the gradual acceptance of print as a polite medium and the corresponding withering-away of manuscript or scribal culture.52 More specifically, as vernacular medical books increased in number, authors may have felt less need to justify their publications. Here I want to focus on an additional feature of this trend: its relationship to London’s robust culture of proprietary medical practice (by which I mean both drugs and other therapeutic interventions) in the late seventeenth and early eighteenth centuries. Proprietary medicine was fully enmeshed in the world of print.53 Indeed, it could not have flourished as it did without print because it was print that brought the patients to the practitioners. In what follows, I explore three such practitioners ( John Archer, Joseph Cam and John Marten) as examples of the ways in which the medical and print marketplaces were thoroughly intertwined in London by the turn of the eighteenth century. I have not included John Archer’s books in my ‘commercial’ category although others might well do so. He first appears as the author of Every Man His Own Doctor in 1671. The title page promised the kinds of advice about regimen that had sold many a previous vernacular medical book: ‘How every one shall know his own Constitution and Complections … the Nature and Faculties of all Foods … Treating also of Air, passions of Mind, Exercise of Body, Sleep, Venery & Tobacco, &c.’54

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With the exception of tobacco, it is a pretty typical list of the nonnaturals. It also promises advice about an interesting list of sexual and non-sexual complaints: pox, running of the reins, gout, dropsy, consumptions and obstructions, and agues. It promises the knowledge of cures at little cost ‘and no danger of Reputation’ (an obvious allusion to VD). The preface and table of contents emphasize the regimen aspect of the book, noting the old saw that ‘many Dig their Graves with their Teeth’. In the British Library’s copy, there is a handwritten inscription (perhaps in Archer’s own hand?) that makes this copy of the book into a more ‘commercial’ item: ‘The Author is to be spoke with at his Chamber in a sadlers house overagainst the mewes Gate next the Black Horse nigh Charing cross his howers there are from 11 to 5 in the Evening at other times at his howse in knights-bridge.’55 By 1684, Archer had a speciality in venereal disease, publishing Secrets Disclosed of Consumptions which, among other things, promised to teach the reader how to distinguish between scurvy and venereal disease.56 Now his address, which was still the same, was on the title page. Nine years later, Archer republished Secrets Disclosed without his address but with a splendid frontispiece that portrays him as a man of learning. Throughout this period, Archer also had printed single-sheet handbills advertising his medical practices.57 He illustrates how a single practitioner could present himself in various ways in print, appearing more or less removed from the market in different publications. The mix of handbills and vernacular medical guides suggests the way that the relationship between print and the London medical marketplace had some symbiotic aspects by the late seventeenth century. Where Archer suggests the density of print a single practitioner could produce, Joseph Cam’s Short Account of the Venereal Disease (1717) offers us a wonderful image of the geography of the medical marketplace in early eighteenth-century London. Cam was a surgeon who specialized in venereal diseases; as Philip Wilson has discussed, he and Daniel Turner fought something of a rearguard action against using mercurials to promote salivation.58 In his book, he details how he had been bound an apprentice to a Mr. Ballard, an apothecary in Worcester, and then came to London to study medicine further, before family troubles forced him to begin advertising and selling remedies. He then made enough money to complete his studies and gain an MD. He relates in almost picaresque style his changes of fortune, before admitting somewhat apologetically that his line of business does not sit well with the dignity of his degree. Yet, he consoles himself, it is better to have reached the top of one’s chosen field than remain at the bottom of another. In a striking

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and revealing passage, Cam rails against the author of the so-called Practical Scheme, supposedly Paul Chamberlain, who marketed the well-known Anodyne Necklace, and as we shall see, much much more. It is worth quoting at length because it conveys the geographic quality of the London market so clearly, at the Seneca’s-Head you have his Onania, with his Sugar Plums, which he first began with; at the Wheat-Sheaf you have his Blisters, and his low-priced Electuary, or rather his Guinea Specific here for a Crown; at Garway’s you have his Necklace, and his most Excellent Philosophical Essay, at Mr. Cooper’s in the Strand you have his most Excellent new System; at the Rose Tavern you have his most Excellent Lip Salve, and Saffron Drops; in Kingstreet, Westminster, you have his most Excellent Beautifying Cream; now three or four Distempers more, may perhaps build him up a most excellent Purse; and I desire he will not fail to give the World to understand, that they are enter’d in the Hall Book; and one Word of Advice I shall give him for his Favours towards me, that is, let him stick to his Function, or let him teach Short-Hand and breed up Canary-Birds, which are innocent Diversions, and will do no harm, (as may be perceived by his most excellent Treatises on Short-Hand and Canary-Birds,) but Physick is an edge Tool.59 Even I, who thought she was something of a connoisseur of the Anodyne Necklace pamphlets, have never seen the canary bird ones, nor did I appreciate the geographic spread of his marketing.60 Cam treats Chamberlain’s pamphlets and his actual remedies (the necklace, the sugarplums) as interchangeable, scattered intensively over a relatively small area of London. The world of print and the world of remedies are utterly tangled up in the Anodyne Necklace series so disliked by Joseph Cam. There is a kind of exuberant and pleasurable superfluity of prose, seemingly far beyond what might be necessary to sell any individual item. As Francis Doherty showed, the author of these pamphlets borrowed chunks of prose and contemporary news events with abandon, fashioning new pamphlets from a melange of unlikely sources. For example, the 1715 edition of A Philosophical Essay upon Actions on a Distant Subject, cheekily dedicated to the Royal Society, offers an extended parody of Newtonian theory about action at a distance.61 Why do people yawn when they see someone else yawn? Why do dogs bark at beggars? How do hunting dogs pursue game? Of course, the Anodyne Necklace, a teething remedy

124 The Marketplace of Print

worn around the neck, itself functioned through action at a (short) distance, but this 24-page pamphlet, with its borrowings from various scientific and medical writers, seems to have a life of its own quite beyond salesmanship. There is an excess of narrative pleasure that makes these small pamphlets into a kind of game or (sub)literary series of jokes. Just as Cam had a minute knowledge of the marketing practices and geographic range of his competition in the Anodyne Necklace pamphlets, so too John Marten, who also specialized in venereal disease, gives us a micro-appreciation of the marketplace of print.62 In his Gonosologium Novum (1709) Marten fine-tunes the cost of print. He explains that he is printing his book so that it can be bound with the sixth edition of his other venereal disease book, and, tho’ it contains full twelve sheets, which by rate makes a half crown book or more, it is charg’d but at eighteen pence, which is the same or less than it would have swell’d the other book to, had it been printed with it, so that both for matter and price, tis presumed ‘twill not be found unacceptable.63 Roy Porter identified two other examples of this same tactic, where Marten talks about his books swelling with detail until they threaten to burst out of their price point – but are reined in by their author.64 Marten perceives his wares both as printed books and as the venereal remedies and consultations he sells, and suggests that both he and his readers were familiar with the economics of the print trade. Porter also highlighted another crucial aspect of Marten’s writing: the way he disingenuously claims to abhor even the mention of certain sexual practices while providing readers with juicy details about them, a tactic employed well into the nineteenth century by writers of sexual advice books.65 Indeed, the indecencies of Gonosologium Novum led Marten to court in 1709, accused – and acquitted – of attempting to corrupt his Majesty’s subjects by publishing an indecent book.66 Marten’s invocations about quacks are similar in structure to his paradoxical stance about sexual matters. Like Cam, Marten vigorously criticized other venereal disease practitioners in London, sometimes with the same disingenuous use of the ellipsis employed in matters sexual. Thus his description of the specifics of ‘B———-ry’ (buggery) is paralleled by his account of the quackery of another venereal disease specialist ‘C———s T———g’ of Lincoln’s Inn Fields.67 It seems that many an early eighteenth-century Londoner could have filled in the

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blanks of both phrases. Marten’s writings, which I have only touched upon here, underline how central print was to the practices and the fierce competition among specialists in venereal disease. Indeed, Marten says that another practitioner, who styles himself ‘Your Old Friend’, ‘desires you not to forget him, tho; he has left off the common way of Publishing’, suggesting again the interdependency of print and VD practice (this is presumably a reference to Dr John Case, who described himself as ‘your old friend’ and who published several bills that threatened ‘This is my last time of publishing of Bills in this Nature; therefore be still mindful of the House and Place above mention’d’).68 All of these examples – Archer’s careful marketing of himself; Cam’s complaints about the market penetration of the Anodyne Necklace and Marten’s careful calculation about pricing and books to be bound together – illustrate how intertwined some aspects of medical practice and print culture had come to be in early eighteenth-century London. Of course, all three examples are related to the venereal disease trade, one of the most commercialized aspects of medical practice.69 They offer us striking counterpoints to the Rose Case, in which the right of London apothecaries to offer medical advice was established by the defeat of a College prosecution, at just this moment.70 I say counterpoint because in these examples of cheap print and practice, there is no doubt that advice, remedies and entertainment are all for sale. Indeed, in texts like Marten’s or the Anodyne Necklace series, they are intermingled completely. Marten spins tales of patients wronged by colourful quackish practitioners, and saved only by his sober and careful treatment – but he provides a glorious riot of detail, not just as ‘matters of fact’ that lend verisimilitude, but as a curious blend of entertainment, titillation and information made possible only in print. I conclude with two reflections on the larger idea of the medical marketplace. First, the market for vernacular medical manuals offers us a sideways perspective on the larger market for medical practice. Many of the aspects that other scholars have explored reappear here in slightly different form. In their various ways, both Margaret Pelling and Harold Cook have shown just how hopeless was the College of Physicians’ fantasy that it governed medical practice in the capital.71 Similarly, in the print marketplace, the kinds of emblems of learning and accomplishment valued by the College were often irrelevant or appropriated to other uses. Thus one writer might quite accurately style himself a member of the College, but others, equally or more successful, loudly proclaimed their own less-conventional credentials. Pelling’s suggestion that members of the College in the later sixteenth and early

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seventeenth centuries produced their identities in opposition to their all-too-similar competition might, I think, be even more pronounced in the hurly-burly of the print marketplace of medicine in the early eighteenth century. Men who thought of themselves as medicine’s elite in the later seventeenth and eighteenth centuries walked through a London saturated with Anodyne Necklace pamphlets, John Archer’s handbills and the like. Indeed, their claims to authority, such as membership in the College of Physicians, seem tame and undistinguished in this market. The vigour with which various venereal specialists attacked each other in print speaks in part to their needs to distinguish themselves in a crowded market of print and practice. As with Pelling’s earlier College physicians, it was nearness, not distance, that burned brightest. Focusing on the kinds of cheap print associated with the venereal disease trade emphasizes change over time. Beyond their engaging prose styles, the works of Nicholas Culpeper and the Anodyne Necklace pamphlets have little in common. Culpeper dominated the print marketplace of the 1650s and the Restoration with his antimonopoly levelling ideology of medicine for all. By the turn of the century Culpeper was still a best-seller, but the market had expanded and developed a different kind of promotional literature that endured throughout the eighteenth century. These books and pamphlets, as I have suggested, were neither purely informational nor purely promotional but an extremely successful hybrid of the two. They are part of a larger move towards a more fully commercialized economy that became increasingly driven by consumption and commodification. I argue here that print did not just reflect these changes, but was an actor in them – that both practitioners and printers flourished in new ways in the ever-morecommercial London medical marketplace. These cheap-print venereal disease pamphlets and books were the most commercial and market-like aspects of medical print.72 They were not representative of the whole, and the risk that we should assume that they were points to one of the recognized hazards of the phrase ‘medical marketplace’. Often we act as if early modern medical workers operated in a completely open and free market, a concept alien to contemporaries. Markets – actual physical spaces containing stalls or tables – were highly regulated, with price and quality controls for the most important commodities. After 1695, the print marketplace was far more open than most physical markets. And, just as people regulated the grain market through rioting, so too informal yet highly scripted means to address problems in relationships between practitioners

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and patients existed. Pelling’s work on an earlier period shows that ordinary people had very strong ideas about what was acceptable and unacceptable in medical practice, and acted upon those ideas in a wide array of ways.73 Neighbourhood gossip could be a powerful force shaping both the perceptions of and the economic success of individual practitioners.74 In other words, the extremely valuable work that the concept ‘medical marketplace’ has helped to accomplish – demolishing the old tripartite idea, emphasizing the role of the patient, underlining the economic significance of medical work – should not lead us to use the term a historically to convey a near-complete lack of regulation. And, as recent studies have underlined, medicine in England does seem to be peculiarly underregulated in relation to Continental Europe.75 That lack, I suggest, fostered a medical world characterized by a high degree of commercialized and commodified relations between healers and patients, a world increasingly interconnected with that of the print trade and the market for books and pamphlets.

Notes It is a pleasure to thank Charles E. Rosenberg and the editors for their advice on this piece, and Susan Ferry and Olivia Weisser for their scrupulous and invaluable research assistance without which this paper could not have been written. 1. Cook, Decline; M. Pelling, ‘Medical Practice in Early Modern England: Trade or Profession?’ in W. Prest ed., The Professions in Early Modern England (1987). 2. I. Inkster, ‘Marginal Men: Aspects of the Social Role of the Medical Community in Sheffield 1790–1850’, in J. Woodward ed., Health Care and Popular Medicine in Nineteenth-Century England (1977); I. Waddington, ‘General Practitioners and Consultants in Early Nineteenth-Century England: The Sociology of an Intra-Professional Conflict’, in ibid.; idem, The Medical Profession in the Industrial Revolution (Dublin, 1984); N. D. Jewson, ‘Medical Knowledge and the Patronage System in Eighteenth Century England’, Sociology, 8 (1974). 3. R. Porter ed., Patients and Practitioners (Cambridge, 1985); Beier, Sufferers; R. & D. Porter, In Sickness and in Health (1988); Porter, Progress. 4. R. Porter, English Society in the Eighteenth Century (Harmondsworth, 1982). 5. P. Langford, A Polite and Commercial People (Oxford, 1989); J. Brewer, The Sinews of Power, (New York, 1989); J. Brewer & R. Porter eds, Consumption and the World of Goods (1994). A. Bermingham & J. Brewer eds, The Consumption of Culture, 1600–1800 (1995); N. McKendrick, J. Brewer & J.H. Plumb, The Birth of a Consumer Society (Bloomington, 1982). 6. Porter, Health; W. F. Bynum & R. Porter eds, Medical Fringe and Medical Orthodoxy (1987). 7. Significant exceptions include: J. Styles, ‘Product Innovation in Early Modern London’, P&P, 168 (2000); S. Pennell, ‘“Pots and Pan History”: The Material

128 The Marketplace of Print

8.

9. 10.

11.

12. 13. 14.

15.

16.

17. 18.

Culture of the Kitchen in Early Modern England’, Journal of Design History, 11 (1998). Two exceptions are: C. Crawford, ‘Patients’ Rights and the Law of Contract in Eighteenth-Century London’, SHM, 13 (2000); S. Shapin, ‘Trusting George Cheyne: Scientific Expertise, Common Sense, and Moral Authority in Early Eighteenth-Century Dietetic Medicine’, BHM, 77 (2003). On the later sixteenth century, see Pelling, Conflicts. P. Borsay, The English Urban Renaissance (Oxford, 1989). Face-to-face relations are emphasized in D. Evenden, The Midwives of Seventeenth-Century London (Cambridge, 1999). On earlier uses of print: Pelling, Conflicts, 97–8. R. Chartier, ‘Culture as Appropriation: Popular Cultural Uses in Early Modern France’, in S. L. Kaplan ed., Understanding Popular Culture (Berlin, 1984). See also: R. Scribner, ‘Is a History of Popular Culture Possible?’, History of European Ideas, 10 (1989). D. Upton & J. M. Vlach eds, Common Places (Athens, GA, 1986); H. Glassie, Folk Housing in Middle Virginia (Knoxville, 1975). I hope in future, perhaps in collaboration with another scholar, to extend the database backwards to the dawn of print in England. The ESTC was originally the Eighteenth-Century Short-Title Catalogue, and now encompasses Wing and the STC as the English Short-Title Catalogue. Pioneering scholarship on popular medical works includes: C. Webster, The Great Instauration (1975), esp. 265–74; P. Slack, ‘Mirrors of Health and Treasures of Poor Men: The Uses of the Vernacular Medical Literature of Tudor England’, in C. Webster ed., Health, Medicine, and Mortality in the Sixteenth Century (Cambridge, 1979); G. Smith, ‘Prescribing the Rules of Health: Self-Help and Advice in the Late Eighteenth Century’, in Porter ed., Patients and Practitioners; C. E. Rosenberg, ‘Medical Text and Social Context: William Buchan’s Domestic Medicine’, BHM, 57 (1983); R. Porter, ‘“The Secrets of Generation Display’d”: Aristotle’s Master-Piece in Eighteenth-Century England’, in R. P. Maccubbin ed., ‘Tis Nature’s Fault (Cambridge, 1987). On almanacs, see L. Curth, ‘The Commercialisation of Medicine in the Popular Press: English Almanacs 1640–1700’, Seventeenth Century, 17 (2002); idem., ‘The Medical Content of English Almanacs 1640–1700’ (Ph.D. thesis, University of London, 2001); B. Capp, Astrology and the Popular Press, 1500–1800 (1979); T. Horrocks, ‘Rules, Remedies, and Regimens: Almanacs and Popular Medicine in Early America’ (Ph.D. thesis, University of Pennsylvania, 2003); D. McCarter, ‘Of Physick and Astronomy’: Almanacs and Popular Medicine in Massachusetts, 1700–1764 (Ph.D. thesis, University of Iowa, 2000). D. Cressy, Literacy and the Social Order (Cambridge, 1980); T. Laqueur, ‘The Cultural Origins of Popular Literacy in England, 1500–1850’, Oxford Review of Education, 2 (1976); M. Spufford, ‘First Steps in Literacy: The Reading and Writing Experiences of the Humblest Seventeenth-Century Spiritual Autobiographers’, Social History, 4 (1979). P. Earle, A City Full of People (1994), 36–8, 119–121. See A. Fox, Oral and Literate Culture in England, 1500–1700 (Oxford, 2000); B. R. Smith, The Acoustic World of Early Modern England (Chicago, 1999).

Mary E. Fissell 129 19. This calculation is from publishers’ advertisements, and increasingly in the eighteenth century, prices on title pages. With a lot of patience one could calculate the relative costs of books since about 70 per cent of the cost of producing a book of this period was for the paper. 20. J. Lackington, Memoirs of the First Forty-Five Years of the Life of James Lackington (1792), 91. 21. A Practical and Philosophical Scheme of the Secret Disease [c.1718], BL: 1405.c.25 (3). 22. M. Spufford, Small Books and Pleasant Histories (Cambridge, 1981); T. Watt, Cheap Print and Popular Piety 1550–1640 (Cambridge, 1991); Chartier, ‘Culture as Appropriation’. 23. On Hooke, see: S. Shapin, ‘The Invisible Technician’, American Scientist, 77 (1989). 24. On Hooke’s library, see L. Rostenberg, The Library of Robert Hooke (Santa Monica, 1989). 25. Slack, ‘Mirrors of Health’; Webster, Great Instauration. 26. On the book trade, see A. Johns, The Nature of the Book (Chicago, 1998); D. F. McKenzie, The London Book Trade in the Later Seventeenth Century (Cambridge, 1976); A. Halasz, The Marketplace of Print (Cambridge, 1997). More generally, see: The Cambridge History of the Book in Britain (Cambridge, 1998–2005), vols 3–5. 27. These numbers were generated from a search of the online ESTC on 30 January 2001. As the ESTC adds new entries, the totals will change, but the overall picture has long been known. See, for example, N. Smith, Literature and Revolution (New Haven, 1994), 23–31; F. S. Siebert, Freedom of the Press in England 1476–1776 (Urbana, 1952), 165–263; J. Barnard, ‘London Publishing, 1640–1660: Crisis, Continuity, and Innovation’, Book History, 4 (2001). Many thanks to Yvonne Noble for this reference. For a broader time span, see: Cambridge History of the Book in Britain, vol. 4, esp. 779–785. 28. J. Raymond, Pamphlets and Pamphleteering in Early Modern Britain (Cambridge, 2003); D. Freist, Governed by Opinion (1997); D. F. McKenzie, Bibliography and History (Oxford, 1988). 29. On newsbooks, see J. Raymond, The Invention of the Newspaper (Oxford, 1996); idem., ed., News, Newspapers, and Society in Early Modern Britain (1999). 30. C. F. Mullett, ‘The English Plague Scare of 1720–23’, Osiris, 2 (1936). 31. Castore Durante, A Family-Herbal or Treasure of Health (1686), Wing D2682B, Huntington Library, San Marino, 379990; Folger Shakespeare Library, Washington (hereafter Folger), G2165. 32. T. Brugis, The Marrow of Physick (1640), STC 3931; Folger, STC 3931. Hughes’s seemingly compulsive reinscribing of his name in the book is not unusual – see, for example, the Folger’s copy of Kenelm Digby’s Choice and Experimented Receipts in Physick and Chirurgery (1668), Wing D1423A, Folger, 151–446q. 33. This estimate does not take into account circulation beyond England and Wales (those being the population figures I employed) – obviously an underestimate given emigration to North America – nor does it account for huge regional variation in literacy, nor in Scottish or Irish consumption of books printed in London. Unfortunately, vernacular medical books were rarely enumerated in probate inventories (they were too low in value), so we cannot use such inventories as a basis for ownership.

130 The Marketplace of Print 34. B. Capp estimates one almanac printed annually per three households in the later seventeenth century: Capp, Astrology, 23. 35. Jane Sharp, The Midwives Book (1671), Wing S2969B. See ODNB, s.n., and Hobby’s edition of Sharp (Oxford, 1999). 36. This figure represents an absolute minimum – I have counted a book as a translation if either it says so in the title (i.e., ‘Englished by …’ or uses the word translation) or if ESTC’s notes say it is so – but of course many additional works are unacknowledged or unrecognized borrowings/translations of other texts. 37. T.C., I.D., M.S., T.B., The Compleat Midwife’s Practice (1656), Thomason E.1588[3], sig. A2r. I have not been able to identify these practitioners, although T.C. is often considered to be Thomas Chamberlayne. The book claims to be ‘published with the approbation and good liking of sundry of the most knowing Professors of Midwifery now living in the City of London, and other places’. Doreen Evenden argues that the authors were midwives, Evenden, Midwives, 8–9. I see no evidence for this assertion. 38. The Compleat Midvvife’s Practice Enlarged (1659), Wing C1817D. 39. On Culpeper, see F. N. L. Poynter, ‘Nicholas Culpeper and His Books’, JHM, 17 (1962); idem., ‘Nicholas Culpeper and the Paracelsians’, in Poynter ed., Science, Medicine and Society in the Renaissance (New York, 1972), 201–220; Webster, Great Instauration, 268–73. M. R. McCarl, ‘Publishing the Works of Nicholas Culpeper, Astrological Herbalist and Translator of Latin Medical Works in Seventeenth-Century London’, Canadian Bulletin of the History of Medicine, 13 (1996). Unfortunately, I have not been able to consult J. Sanderson, ‘Nicholas Culpeper and the Book Trade’, (Ph.D. thesis, University of Leeds, 1999). Many thanks to Yvonne Noble for this reference. See also B. Woolley, Heal Thyself (New York, 2004). 40. On the Masterpiece, see Porter, ‘Secrets of Generation’; M. E. Fissell, ‘Hairy Women and Naked Truths: Gender and the Politics of Knowledge in Aristotle’s Masterpiece’, WMQ, 60 (2003); idem, ‘Making a Masterpiece: The Aristotle Texts in Vernacular Medical Culture’, in Charles E. Rosenberg ed., Right Living (Baltimore, 2003). 41. W. M., The Queen’s Closet Opened. Incomparable Secrets in Physick, Chirurgery, Preserving, Candying, and Cookery; as They were Presented to the Qveen by the Most Experienced Persons of Our Times (1655), Wing M96; Thomason E.1519[1]; Elizabeth Grey, Countess of Kent, A Choice Manual of Rare and Select Secrets in Physick and Chyrurgery (1653), Wing K310B. On these texts, see L. Hunter, ‘Women and Domestic Medicine: Lady Experimenters, 1570–1620’, in L. Hunter and S. Hutton eds, Women, Science and Medicine 1500–1700 (Stroud, 1997). 42. George Cheyne’s best-sellers were, Essay on Health and Long Life (1724), and The English Malady (1733). On Cheyne see, Shapin, ‘Trusting George Cheyne’, and, A. Guerrini, Obesity and Depression in the Enlightenment (Norman, 2000). On Wesley’s Primitive Physick (1747), see D. Madden, ‘Contemporary Reaction to John Wesley’s Primitive Physic’, SHM, 17 (2004); idem, ‘Medicine and Moral Reform: The Place of Practical Piety in John Wesley’s Art of Physic’, Church History, 73 (2004); A. Wesley Hill, John Wesley among the Physicians (1958). On Buchan, see Rosenberg, ‘Medical Text and Social Context’; C. J. Lawrence, ‘William Buchan: Medicine Laid Open’, MH (1975).

Mary E. Fissell 131 43. On such works, see, J. K. Stine, ‘Opening Closets: The Discovery of Household Medicine in Early Modern England’ (Ph.D. thesis, Stanford University, 1996); E. Leong, ‘Medical Recipe Collections in Seventeenth-Century England: Knowledge, Text and Gender’ (D. Phil. thesis, University of Oxford, 2005); A. Rankin, ‘Medicine for the Uncommon Woman: Experience, Experiment, and Exchange in Early Modern Germany’ (Ph.D. thesis, Harvard University, 2005); S. Pennell, ‘The Material Culture of Food in Early Modern England, circa 1650–1750’ (D.Phil. thesis, University of Oxford, 1997). 44. Some of these categories include a number of subcategories. ‘General work’ includes books of medicine targeted to families, to women (but not midwifery books) and books about children’s health. ‘Surgery’ includes a couple of books on accidents, military medicine and medicine for ships sailing without surgeons. ‘Recipe Books’ includes books that were partly cookery or cosmetics. ‘Regimen’ includes books about longevity. ‘Misc.’ includes the categories: chemical, magic, masturbation, method [i.e. a particular method of healing]; mineral; poisons; Rosicrucian healing and dentistry. 45. The germinal work on the reformers who sought to make knowledge useful is Webster, Great Instauration. 46. See M. E. Fissell, Vernacular Bodies (Oxford, 2004) for more on Culpeper’s epistemology and politics. 47. The Ladies Cabinet Enlarged and Opened (1654), Wing B135, Thomason, E.1528[1]; Hannah Woolley, The Queen-Like Closet (1670), Wing W3282; J. S. [ John Shirley], The Accomplished Ladies Rich Closet of Rarities (1687), Wing S3498A. These books all echo the original success of The Queen’s Closet Opened. 48. W. M., Queen’s Closet Opened, sig. A2r; A. M., A Rich Closet of Physical Secrets (1652), Wing M7, A2r. 49. Kenelm Digby, The Closet of the Eminently Learned Sir Kenelme Digbie Kt. (1669), Wing D1427, ‘To the Reader’. 50. John Archer, Every Man His Own Physician (1671), Wing A3608. Archer had trouble with the College of Physicians repeatedly in the 1680s. While he claims to have treated Charles II, he was not a royal physician or surgeon in the sense of any regular appointment. A number of other authors had their royal service highlighted (often by translators or printers) including François Mauriceau, William Sermon and Theodore Turquet de Mayerne. 51. John Pechey, The Compleat Midwife’s Practice Enlarged (1697), Wing P1022; Thomas Muffet, Healths Improvement (1655), Wing M2382, Thomason E.835[16]; M. Bromfield, A Brief Discovery of the True Causes, Symptoms and Effects of That Most Reigning Disease the Scurvie (1672), Wing B4884H; Charles Peter, A Description of the Venereal Disease (1678), Wing P1682. 52. On the continued vitality of manuscript circulation, see H. Love, Scribal Publication in Seventeenth-Century England (Oxford, 1993). 53. Curth’s finding of increased medical advertising in almanacs may be another instantiation of the connection between health care and print: Curth, ‘Commercialisation of Medicine’, 49. 54. Archer, Every Man His Own Physician. 55. BL, 1039.c.9 56. John Archer, Secrets Disclosed of Consumptions (1684), Wing A3610. On the London market for cures for VD, see K. Siena, Venereal Disease, Hospitals, and the Urban Poor (Rochester, 2004), 30–61.

132 The Marketplace of Print 57. See, for example, the single sheet Catalogue of Medicines Prepared by J.A. Authour of Every Man His Own Doctor (np, nd), Wing A3609B, BL, 551.a.32.(117). 58. P. K. Wilson, Surgery, Skin, and Syphilis (Amsterdam, 1999), 174–6. 59. Joseph Cam, A Short Account of the Venereal Disease (1717), sig. A3r-v. 60. On the Anodyne Necklace, see F. Doherty, A Study in Eighteenth-Century Advertising Methods (Lewiston, 1992). 61. A Philosophical Essay upon Actions on a Distant Subject, 3rd edn (1715). 62. R. Porter, ‘“Laying Aside Any Private Advantage”: John Marten and Venereal Disease’, in L. Merians ed., The Secret Malady: Venereal Disease in EighteenthCentury Britain and France (Lexington, 1996). 63. John Marten, Gonosologium Novum (1709). The 6th edition to which he refers is A Treatise of All the Degrees and Symptoms of the Venereal Disease, in Both Sexes (1708). 64. Porter, ‘Laying Aside’, 54. Porter says that both Gonosologium and the Treatise are largely plagiarized versions of Nicholas Venette’s Le Tableau d’Amour Conjugal. 65. See, for example, the works of F. C. Hollick, as discussed by C. E. Rosenberg. ‘At the Boundaries of Transgression: F. C. Hollick, Invisible Best Seller’ (unpublished paper given at the Johns Hopkins University, September 2003). Thanks to Charles Rosenberg for sharing this paper with me. Hollick employed just the titillating mix of abhorrence and prurience that Marten might be said to have pioneered. 66. Porter, ‘Laying Aside’, 66 n31; D. Foxon, Libertine Literature in England, 1660–1745 (New Hyde Park, 1965), 31. 67. Marten, Treatise, 68; 251. Historians have been able to work out who was meant by the blanks, so some early modern Londoners would have been able to do likewise. 68. Marten, Treatise, 260. For Case, see BL, 551.a.32, f. 192. Many thanks to Patrick Wallis for this information. 69. On this trade, see W. F. Bynum, ‘Treating the Wages of Sin: Venereal Disease and Specialism in Eighteenth-Century Britain’, in Bynum and Porter, Medical Fringe. 70. On this case, see H. J. Cook, ‘The Rose Case Reconsidered: Physicians, Apothecaries, and the Law in Augustan England’, JHM, l 45 (1990). 71. Cook, Decline; idem, Trials of an Ordinary Doctor (Baltimore, 1994); Pelling, Conflicts. 72. See Chapter 3 in this volume for a helpful counterpoint to my portrayal of the rather dog-eat-dog world of VD doctors. 73. Pelling describes how ordinary Londoners had coherent and relatively clear norms for what they saw as acceptable behaviour by medical practitioners of all kind: Conflicts, passim. 74. See L. Gowing, Common Bodies (New Haven, 2004); Y. Bar-On, ‘Neighbours and Gossip in Early Modern Gynaecology’, in W. de Blécourt and C. Usborne eds, Cultural Approaches to the History of Medicine (2004). 75. L. Brockliss and C. Jones, The Medical World of Early Modern France (Oxford, 1997); G. Pomata, Contracting a Cure (Baltimore, 1998); D. Gentilcore, Healers and Healing in Early Modern Italy (Manchester, 1998).

7 Recipe Collections and the Currency of Medical Knowledge in the Early Modern ‘Medical Marketplace’ Elaine Leong and Sara Pennell Conventionally, the relationships which have loomed largest in the historiographical terrain of the early modern ‘medical marketplace’ have been between paid practitioners and patients. In this chapter, we want to bring into clearer view another relationship which frequently mediated any association between patient and practitioner: the relationships between lay people as cultivators and communicators of medical information. As we show, by studying how people communicated information about treatments, particularly recipes for remedies, some of the processes of constructing personalized medical knowledge can be recovered. One crucial factor in these exchange relationships was the degree of trust placed in the supplier of a recipe. Our analysis of recipe transmission therefore also allows us to examine from the lay perspective one of the central issues of discussions of the medical marketplace. While trust has been explored as a factor in patient/practitioner interactions in early modern medical encounters in England by Lucinda Beier, Roy and Dorothy Porter and more recently Steven Shapin, the same cannot be said of the operation of trust and trustworthiness in the sphere of domestic medicine.1 One of the emerging sources for considering relationships within the lay medical culture of early modern England is the manuscript recipe collection. These collections contain a wealth of evidence regarding the exchange, acquisition and evaluation of medical information. This essay analyses a number of such collections and the circumstances of the exchanges that lay behind their construction and subsequent material histories. Beyond this it will show how medicinal recipes constituted a part of the social capital of their possessors.2 Therapeutic and pharmacological information and the ways in which it was disseminated, judged and validated can be seen as sharing some of the characteristics 133

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of currency, as it was understood by contemporaries: a commodity which flowed between people, and the authority and reliability of which was inflected by the circumstances of that movement. We can also look at the evaluation of recipes by recipients (recorded in annotations) as relating to another meaning of currency: that is, the immediate appropriateness of the information it contained for the potential user. In both these senses, recipes can be seen as analogous to particular forms of early modern financial transaction, notably bills of exchange, in that their realizable value was tied up with the trustworthiness of the relationship on which the exchange was based. But recipe exchanges also at times involved recipes as a variety of gift, where the values placed on the texts donated and received were framed by social relations, as much as any inherent ‘value’ in the recipe itself.3 The networks in which such information transfers and knowledge ‘banks’ functioned were not dominated by ‘commercial’, ‘professional’ or even hierarchic relationships, and this has consequences for how recipes circulated and were used, as a commodity sometimes carrying ‘currency’ meanings and sometimes gift exchange meanings. It has long been acknowledged that the primary arena for medical treatment in the premodern era was the household.4 ‘Kitchen physick’ – both prophylactic, in the construction of good eating habits and a healthy environment, and curative, in the making and administering of remedies – almost always preceded the intervention of any external practitioner, except in the most extreme situations, such as emergency surgery or an identifiably fatal illness.5 The decision to call on the services of a physician, surgeon, apothecary or other forms of paid medical practice, usually followed the failure of domestic treatment to cure or alleviate conditions; domestic treatment also continued alongside any formal medical intervention – unsurprisingly as the physical locus of care was normally the patient’s home. This hierarchy of resort conspired to make commercial medical treatment an occasional, rather than a regular, event. Individuals mostly saw their own corporeal care as a domestic matter, rather than a cause for outside intervention.6 There is certainly no lack of evidence for the scope and scale of domestic medical practice. Using a combination of personal writings such as letters and diaries, and manuscript recipe collections, researchers such as Beier, Linda Pollock and Lynette Hunter have produced informative case studies of early modern women conducting a range of medical activities within the domestic sphere.7 In particular, Pollock’s study of Lady Grace Mildmay has provided us with an example of a landed gentlewoman who was making medicines on a vast scale both for the use of her household and for philanthropic ends. Our own research attests

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that the subjects of Beier’s and Pollock’s case studies were by no means exceptional. The large number of manuscript and printed collections compiled by both early modern men and women suggest that interest in maintaining one’s health through good regimen and curative strategies when health failed was fairly universal. Surviving manuscript collections frequently contain both culinary and medicinal recipes, either within the same volume, or collected into separate, but companion, volumes. Likewise, printed household manuals, especially those attributed to female ‘authors’ of the late seventeenth century through to the middle of the eighteenth century, commonly contained sections on ‘chirurgery’ and ‘physick’, rather than simply being cookery books.8 While making medicines at home was a common pastime for both men and women, for the latter it was invoked as one of their Christian duties: salving the sick at home and in the locality loomed large in early modern moral idealizations of the ‘good housewife’.9 Domestic medical activities were focused on dealing with a range of non-life-threatening ailments, although recipe collections do also include treatments for conditions which usually proved fatal, such as plague, the ‘sweating sickness’ and rabies. Contemporary recipe collections contain information to deal with external ailments such as cuts, bruises and burns, chronical conditions like rashes and spots, warts and dandruff, and common internal chronic ailments such as colds, coughs, digestive disorders and headaches. Looking into the medicinal closet of Elizabeth Freke, a Norfolk gentlewoman, recreated from her inventories taken in the 1710s, suggests that such elite households often kept a range of strengthening cordial waters on hand to deal with everyday overindulgence in food and drink, headaches and perhaps to act as ‘pick-me-ups’ for when someone was feeling under the weather.10 Few women engaged in Mildmay’s scale of production, and it is likely that most lacked the dedicated physical space for a distilling closet like Freke’s. Nonetheless, most medicines kept on hand domestically could easily be produced using common cooking methods and equipment. Many liquid medicines relied on boiling or steeping as the main method of production, and solid medicaments were often made by mixing crushed herbs into melted wax or animal fat. The utensils used, aside from the more specialized glass still and limbeck required for distilling, were the common earthen or copper pots, frying pans and skillets which populated the early modern non-elite kitchen.11 Indeed, it is the multifunctionality of such utensils which has made it easy to overlook the domestic manufacture of medicines within the spectrum of household productive activities.12 Likewise, the majority of the ingredients used were herbs commonly found in kitchen gardens or spices increasingly

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common to kitchen spiceboxes. A survey of over 9000 recipes in 28 collections (15 manuscript and 13 printed) reveals that rose, wine, sugar, honey, egg and a number of herbs and spices such as rosemary, nutmeg, aniseed, liquorice and cinnamon were among the most common ingredients used.13 Thus, inventory evidence and the contents of manuscript recipe collections point to much domestic medicine production being undertaken on a far less ambitious scale than that of Lady Grace Mildmay. Domestic medicine was reliant upon easily accessible ingredients rather than newly introduced exotics, such as Peruvian bark, or the metallic and mineral components advanced in Paracelsian and Helmontian pharmacopoeia.14 But this is not to suggest domestic medicine was mostly mundane, or that it was minor in its impact. Far from it: to reiterate, domestic medicine was by far the most important form of health care throughout the early modern period. The ubiquity of domestic medicine and its association with female ‘household’ skills that are largely seen as intellectually static, tacitly transmitted and either resistant to, or uninteresting for, historical enquiry has meant that little attention has been given to the knowledge economy underpinning household medical production. The process of acquiring, compiling and circulating medical information has been mostly ignored in historians’ accounts, except where the domestic producer is deemed exceptional, as is the case with Mildmay. The illogicality of this is obvious if we were to imagine omitting discussion of the medical education of formal medical practitioners from evaluations of their expertise. Such information was a necessary precursor of medical production. Considering the ways in which medical information was acquired, and how it was evaluated as knowledge, in the domestic environment is a necessary step in the task of reinscribing the central role played by the household in the early modern medical market. This is particularly important for a number of reasons. Firstly, once we understand more about the extent and expertise of domestic medicine, we will be able to gauge far better the nature of patients’ ‘demand’ for medical services in the early modern era, a demand which is generally naturalized and ahistorically explained by reference to the high levels of morbidity and low levels of expertise in the period.15 Secondly, this analysis breaks down the inappropriate and artificial distinction between private (understood as non-commercial) and public (equated with commercial) which underpins much of the discussion of the commerialization of early modern English medicine. Instead of this divide, we wish to stress the significance of the household, and thus of domestic medicine within the household, in the early modern œconomy, a

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system which, as John Walter, Craig Muldrew and others have contended, was structurally and morally quite different from modern formulations of ‘economy’.16 We also see aspects of domestic medicine as belonging within the sphere of exchanges, not wholly monetarized, that Beverley Lemire calls ‘alternative economies’, and which are only now beginning to emerge from the historical periphery as significant in the maintenance of early modern social and economic relations.17

Recipes: Collection, circulation, dissemination The utility of manuscript recipe collections for evaluating the nature and extent of lay medical knowledge has not gone unnoticed by historians of medicine and historians of gender in the past two decades.18 Nevertheless, it is only now, through concerted research on single compilations and groups of manuscripts, that we are beginning to illuminate the myriad methods and motives of compilation, the sources, uses (prescribed and actual), as well as something of the people who brought the recipes together.19 Shapin has identified manuscript recipe books as one of the ‘informal’ channels by which patients gathered and evaluated medical information and expertise; but this trivializes their significance in the seemingly ceaseless project of therapeutic and pharmacological ‘data retrieval’ (to use Andrew Wear’s phrase) which sustained domestic medical care.20 Gideon Harvey, in his 1669 The Vanities of Philosophy and Physic, observed ‘that most of men do very readily take upon trust any Remedy or recipe, that is confidently recommended to them, can scarce be contradicted . . . without loss of time, they are to be registred in their book of Recipes, handed to them possibly by their Grannam, and Archive like to be lock’d up in their Desks’.21 Harvey’s mockery of what he saw as uncritical recipe collection and dissemination is unsurprising, given his interests in promoting medical knowledge based on experience, but his criticism highlights the prevalence of these activities in Restoration England. Of particular interest in this chapter are manuscripts which date roughly from the mid-seventeenth through to the mid-eighteenth century. The survival in sizeable numbers of compilations begun or continued with vigour in this period is in itself telling; ‘kitchen physick’ did not wither away in the face of commoditized medicaments and professionalizing medical interventions, but rather adapted itself to a more kaleidoscopic range of inputs.22 As with all manuscript sources, recipe collections have their shortcomings, not least in the relatively narrow and elevated social status of their compilers (where known: anonymity of production is also an

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issue), and the motives of compilation, alongside other problems of timescale of production, degrees of practical usage and so forth.23 But negotiating these problems plays its part in investigating the workings of, and values placed on, recipe exchange and circulation. In turn, these practices help reveal ideas about the utility of the information itself. Even if a collection is ‘anonymous’, with little more than the occasional signature to suggest ownership, compilation or even just consultation, its contents can still help us to assess the role of recipe providers (who were also sometimes ‘authors’) in shaping the ‘currency’ of the medicinal recipe. Even a cursory look into these collections highlights the immense number of seemingly different recipes available for collection, exchange and use. Recipes – not simply medicinal, but also culinary and veterinary – were ubiquitous in early modern England. Oral exchange was still the primary vehicle for communication of medicinal advice in early modern England. However, the setting down of advice to preserve that exchange (but by no means to fix the information transmitted during it) was not the sole preserve of the prescribing physician or apothecary. Instructions to make medicaments for all sorts of ailments and illnesses were exchanged during social visits, circulated in letters, and were recorded into bound notebooks. Sometimes they were even merely bundled together as batches of paper. The onward circulation of individually inscribed recipes and prescriptions, indeed of entire manuscripts, provided other compilers with an important source for their own collections. Manuscript recipe collections, with their frequently heterogenous compilers, origins, sources and applications, are not easily accommodated within the prevalent idioms of early modern women’s ‘kitchen physick’. They are not the privatized, ‘closeted’ practices of elite women, but nor are they the vernacular ‘vulgar’ medical ministrations of ‘wise women’ and the like which so incensed contemporaries such as James Primrose. Rather these texts reflect a more complex and by no means gender-specific terrain of medical information and encounters.24 How did a compiler pick and choose recipes from the myriad examples in circulation in oral form or in manuscript and print? An answer to this question lies in a common feature of the recipe text: the inclusion of a name tag with recipes. In a study of 15 seventeenth-century manuscript recipe collections, comprising 6554 individual recipes, over one-third of recipes (2402) came with the name of a donor or ‘author’.25 The importance of source citation in single recipes suggests that the practice of citation and the sorts of donors/authors cited served a particular role within compilation practices and recipe exchange.

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The sources compilers recorded allows us to recover the selection criteria they used when collecting recipes. Compilers most commonly collected recipes from their extended family or from medical practitioners.26 These are, of course, both logical avenues for collecting medical recipes, but they also reflect contemporary patterns of kin-based sociability, and the familial and communal relationships through which credibility was maintained and reinforced. Many recipes were exchanged either through correspondence or during various types of visit. The collection of Leicestershire gentleman Archdale Palmer (d. 1673), compiled for the most part during the 1660s, provides us with information about the social occasions when recipes might be exchanged. He cited the place where he exchanged recipes in 34 cases in most instances, only noting a place name. A total of 12 recipes, from a number of occasions, were collected at Palmer’s own residence in Wanlip. Some of the donors were labelled as ‘cousins’, while William D’Anvers of Swithland, the father of Palmer’s daughter-in-law, is typical of the extended family who exchanged recipes with him during social visits. Palmer also collected recipes when visiting friends and family. On 16 April 1659, Palmer visited a Dr Bowles and his wife in Oundle and collected recipes for a cordial and two recipes dealing with sore teeth and mouth cankers in children. While on a visit to a Mrs Palmer at Aston, Palmer collected two recipes which Mrs Palmer had received from Dr Wright of London. Certain entries document that dinner guests might contribute to the collection after the meal. Mr Hollid, described as a minister in Northamptonshire, dined with the Palmers on 13 May 1663 and gave Palmer a recipe ‘For a bone of pinne in ye throate’ and another ‘for the ricketts’ while he was there and Palmer similarly accumulated recipes when dining at other people’s houses.27 Much of the credibility that compilers gave to recipes seems to have depended on their view of the trustworthiness of the donor and his/her experience. It was an evaluation in which the nature of the relationship between the donor and compiler also played a part. The location and social circumstances in which exchanges of recipes took place suggests that familial or social ties between the recipe donor and the compiler placed the exchange within ‘safe’ parameters. Sir Peter Temple’s mid-seventeenth-century manuscript collection illustrates how these factors functioned in his judgment of the trustworthiness of each recipe. For example, he writes of Sir Alexander Hambleton’s recipe ‘to bring away the afterbirth’ that ‘I have found [the author] a man of truth in other matters’.28 This suggests that Temple judged the authority of a particular recipe by the credibility of the donor in matters social, economical

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and political. Temple also collected recipes that came with personalized testimonials to their efficacy. Annotations that record success, or at least a positive impact, appear to have been deployed as an additional level of assurance of the value of the recipe. These were amplified when the patient was linked by familial or social ties to the compiler. Thus Temple inscribed a recipe for ‘an excellent Pomatum for the face’ from Lady Forster which he further subscribed, ‘this was tried by a friend of mine who sayes tis ye one yt ever she saw yt did not yellow ye skin and yt tis as good as [it is] costly’.29 Such experiential detail was especially important in the transmission of recipes via a third party. In the earlyto-mid-eighteenth century collection descending within the Malet family, a recipe for ‘lady Moore drops for a cough’ is annotated in just such detail: ‘This recipe was given me by Watkin Williams Esqr March 19 1735/6 who had it from L[or]d Nowel Somerset[.] Mr Williams assured me he had tryed it with great success.’30 Compilers also ventured beyond their extended familial and social circles in search for recipes; again, in such cases compilers often appended information concerning the geographical location and occupation of the recipe donor. Archdale Palmer, for example, collected eight recipes from donors described as ‘ministers’, and several more from servants and tradesmen.31 On 17 October 1666, while visiting his brother John Palmer at his residence Temple Hall, he took a recipe ‘for a bone spaven’ [a bony tumour of the leg in horses] from a farrier.32 On another occasion, he took a recipe for tobacco from ‘Mr Clark an Apothecary at Lugborrow’.33 Palmer also collected recipes from wandering travellers and during stops at public houses. On 16 January 1659/60, Palmer entered a recipe for the ‘horse plague’ which was ‘given to me by a soldiar whose name was Thorpe livinge att Spalden [Spalding] in Lincolnshire, given in my house at Oneleppe’.34 He recorded two recipes to sweeten stone bottles from ‘Fran Pochyn of ye Mitre Taverne in Cheapside’ on 14 November 1659, and took three recipes from Captain Evenson (one for the plague in horses, and two for the stone) at the Red Lion in Leicester.35 In all of these cases, it is clear that evidence of hands-on experience was necessary for a recipe to be valued by Palmer. Historians have long suggested that early modern clergymen often subsumed medical service into their pastoral role, and other collections are peppered with contributions from ministers.36 Understandably farriers and soldiers were deemed reliable sources for veterinary information and a tavern worker would certainly be a plausible informant for a recipe for sweetening beer bottles. Domestic servants could also be invaluable sources. In 1718 the Bennett family from Somerset collected two recipes from Hannah Draper, described as

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‘the Doctors old servant’; presumably Hannah’s first-hand experience with these cures and her role within a doctor’s household gave her credibility in matters medical.37

Exchange and gifts Another mode of circulation in evidence for recipes, is the way in which their donation and collection functioned as a variety of gift exchange, not unlike those discussed by Paula Findlen as operating between early modern Italian collectors of natural history specimens.38 Presentation collections of recipes, drawn up as part of a dowry or a wedding gift, are not uncommon. One notable example is the large quarto volume, beautifully inscribed and gilt-stamped with the ‘AA’ monogram of Alatheia Talbot (d. 1654), countess of Arundel. This is believed to have been a wedding gift from her mother-in-law, Anne Dacre, on the occasion of her daughter’s marriage to Thomas Howard, 24th earl of Arundel, in 1606.39 Intergenerational bequests of collections – not simply mother to daughter, but in the case of Sir Peter Temple’s collection, from father to daughter, and across other non-kin ties – can be traced not only in internal inscriptions, but also in wills. In 1740 Rebecca Brandreth left her two folio volumes, ‘one being for Surgery and physick and the other for Cookery and preserves’, firstly to her daughter Alice, but only in trust until her grandson Henry came of age.40 The value placed upon recipes and recipe collections is illustrated by the inscription on the first folio of Lady Frances Catchmay’s collection: this booke with the others of medicins, preserves and cookerye, my lady Catchmay lefte with me to be delivered to her sonne Sir William Catchmay, earnestly desiringe and charginge him to lett every one of his brothers and sisters to have true copyes of the sayd bookes, or such parte thereof as any of them doth desire. In witness that this was her request, I have thereunto sett my hand at the delivery of the sayd bookes. Ed. Bett.41 The gift of these books to William Catchmay came with the responsibility to disseminate the knowledge contained within. Frances Catchmay intended to pass her collection on to all her children, hinting at the value she placed upon it. The significance of recipe collections as gift objects is apparent in the fortunes of a compilation owned by the Johnson family of Spalding, Lincolnshire. Here we can also see a collection being appropriated by a

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male member of the family. One page of the book carries two slightly cryptic inscriptions. The first is simply ‘Elizabeth Philips Nov 1694’. Underneath, we find: ‘Eliz Johnson ye gift from her Mother Johnson/ Maurice Johnson of Spalding in Lincolnshire claims this family book as of right it belongs to him’.42 Relating this to the family’s genealogy, we find that the book first belonged to Elizabeth Oldfield Philips who most probably began the work in 1694 during her first marriage to Andrew Philips of Leominister, Herefordshire. Elizabeth must have brought the book with her to Spalding following her marriage to Maurice Johnson the elder (1661–1748).43 She then gave the book to Elizabeth Johnson (nee Ambler), who had married Maurice’s eldest son from his first marriage, Maurice Johnson the younger (1688–1755), an antiquary and barrister. It would appear that it was Maurice Johnson the younger who wrote that the book by rights belonged to him.44 The assertive note written by him is revealing of the importance that men placed upon recipe collections (although Johnson’s antiquarian interests in the book cannot be discounted), as well as of the value placed on such documents within early modern families. Although some historians have suggested the ‘heirloom’ status of manuscript recipe collections once they moved beyond the ownership of original compiler(s) became more significant to later owners than the practicality of the contents, contemporaries appear to have viewed their utility as the key reason for passing them on, as much as their carriage of any symbolic value.45 Beyond such domestic gifting, recipe collections also appear to have been a commodity in more freighted gift exchanges, where patronage and service were implied. A collection in the British Library has two curious inscriptions on the first folio.46 The first, which was crossed out, reads ‘Hester Gullyford her book, Feb 16th 1679’. The second inscription, written below, states ‘This book humbly begs Madam Elizabeth Butler her acceptance from her faithfull servant, March the last 1679, Poore Colly’. The collection bears all the signs of a presentation copy – the entire collection was written in a single uniform hand and the notebook was meticulously ordered and planned out with distinct section headings. This suggests that the collection of Hester Gullyford was first copied out, perhaps by a professional scribe, on 16 February 1679, and then presented as a gift to Elizabeth Butler a month later. Alisha Rankin, who has examined the offering of collections and single recipes as gifts to the sixteenth-century German nobles, August and Anna of Saxony, argues that ‘presenting a prince or other patron with an efficacious remedy was an effective method of garnering favour’.47 While the evidence for the English context is not as rich or (as yet) as copious as Rankin’s

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case study, the example of Poor Colly’s gift hints at a not dissimilar motive in operation. If we turn to the donation of individual recipes or groups of recipes, the ways in which the obligations created in the process of donation were played out remain obscured. Recipe texts have an ambiguous status as gifts in this sense. Even when recipes were exchanged within social situations such as those outlined above – dinners, visits and so on – this act of exchange did not necessarily oblige the recipient to make up the recipe. The gift value of recipes at this stage is provisional and the degree of obligation deriving from the receipt of recipes depends on the successful making-up of the recipe and, more crucially still, its successful application. This differential valuation is illustrated in the index of a late seventeenth-century manuscript with links to the Okeover and Adderley families; Mrs Addison’s and Mrs Armsted’s recipes for the ‘Red Powder’ are both indexed but only Mrs Addison’s carries the annotation, in the indexer’s hand, ‘This one I make’. One can envisage that this approbation might in turn have led the compiler to supply Mrs Addison with trusted recipes, as well as establish a basis for relying upon other remedies Mrs Addison might recommend. Even if a personal relationship did not underpin the recipe exchange in the first place, the foundations for such a relationship are laid in this process and what ensues from it. The exchange and, as importantly, use of medicinal recipes thus becomes not so much a straightforward phenomenon of ‘swapping’ information, but a much more reflexive practice, drawing on concerns beyond the purely medical.

Recipe collectors as ‘smart consumers’ What do recipe collections tell us about lay engagement with the market for medicine? Market ‘participation’ has often been seen as leading to a decline in the role of domestically prepared pharmacy in later seventeenth- and eighteenth-century ‘kitchen physick’. As yet the evidence put forward to support this argument has tended to be the commercialization of ready-made medicines and the exhortations of didactic publications like John Wesley’s Primitive Physick (1747) to shake off dependence upon the apothecary, rather than material documenting any actual retreat of domestic medicine. The role played by manuscript collections needs evaluation in this context. As we have observed, they did not dwindle in number across the eighteenth century. Indeed, they played an important role in structuring patients’ encounters with commercial medicine provision. Collecting and collating medicinal recipes

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could educate the prospective patient in how to participate in such a mixed medical economy, as well as providing her with the necessary gamut of medical treatments to accommodate different physical constitutions. It is important to recognize that recipe and prescription circulation took place in the full knowledge of, as well as with the frequent participation of, practitioners operating on a commercial basis. Doctors, surgeons and apothecaries are all identified as the sources or ‘authors’ of prescriptions, recipes and advice. The recipes authored by physicians or medical practitioners came into lay medical collections via a variety of paths. Some of them were the direct results of particular consultations. For example, the recipe collection of the Carey family includes recipes given by Dr Theodore de Mayerne (1573–1655) to different family members: ‘1654 May, Dr Mayernes method for Lady Theophilia Cary’s Cold’ or ‘Dr Mayerne’s method for the Lady Mary Cary’s cold May 17th 1653’.48 The annotations noted both the author and the important information about when the prescription had been given, as treatment varied according to the seasons. These entries do not take the form of a single recipe. Rather, they are a set of instructions detailing several different medicines and ‘diet’ drinks to be taken by the patient. For example, the entry for Lady Mary Cary’s cold included a ‘pectorall decoction’, a purge, a recipe to make a china broth and a recipe for cough lozenges. The recipes come with detailed instructions of how and when to take the medicaments.49 Supplementing, and at times supplanting, the face-to-face meeting of practitioner and patient was the epistolatory consultation. Many prescriptions were copied into recipe compilations from such letters. One such example clearly illustrates the blurring of commercial and lay medicine in recipes copied into manuscript collections. In May 1701 Dr John Powell wrote to a patient advising them to obtain from the apothecary some ‘antiscorbutick electuary’ and to take it with a large quantity of nutmeg every morning. In addition, he told her to take posset drink with white wine and scurvy grass, brooklime and horse-radish root. Finally, he recommended that she take ‘Bath’ water and gave advice as to which apothecaries she should go to have her medicines made up.50 Strikingly, all of his recommendations were recorded for future use, even though the majority relied upon her using commercial practitioners. The recipes which patients received from physicians or medical practitioners were exchanged and passed around to friends and family as part of the wider circulation of medical information discussed above.

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In this way they were transmitted into other recipe collections. For example, the Bennett family received a recipe for scurvy from Mr Sam Boord of Batecombe in Somerset on 22 April 1710. Boord was himself taking the medicine at the time following advice ‘from his Doctor Warmister’.51 In the medical recipe collection commenced by Letitia Mytton in 1720, a number of cures come from a Mrs Griffith, including one for ‘the Chinkcough’, which had originally come from ‘Robt Gay, surgeon’.52 Certainly there was no means by which practitioners could prevent their clients from passing on the information they supplied to them; once supplied, a prescription or piece of advice from a consultation became the patient’s property, to do with as they wished. It is plausible that this circulation of information was not always condemned by practitioners. In an environment in which the supply of ‘expert’ knowledge was limited, the redistribution of prescriptions and advice disseminated that knowledge more widely, as well as providing a means of amplifying repute and expertise. Popular prescriptions might even bring future business, which could be conducted via letter if necessary. Of course, given that the expertise professed by most early modern physicians was rooted in their ability to tailor diagnosis and treatment to the individual by skilled reading of the particular symptoms, the circulation of specific prescriptions was in some lights pointless or even dangerous. But recipe collectors were not ignorant of the intellectual bases of Galenic medicine, and conceiving manuscript recipe collections as textual medicine chests takes us some way towards an explanation of why so many different remedies for the same condition were collected by compilers. However, the need to formulate remedies for particular individuals with varied temperaments and a range of specific environmental circumstances takes us further: compilers’ collecting strategies were informed by their sensitivity to corporeal and humoral differences.53 Shifting individual, familial and household requirements meant that no one recipe or prescription would suffice to cope with any single condition. Variables of sex, age and constitution had to be taken into account. In the late seventeenth- and early eighteenth-century Okeover/Adderley compilation, a paragraph attached to a recipe for the ‘Cordiall tincture good for Rheumatism’ makes clear compilers’ recognition of the need to consider the patient’s medical history: If cosen Bettey make use of these things she should bleed twise or thrise but but [sic] a little at a time. Cos. Thornbery had bled too much ere he had these remedis so had we occastion [sic], but others

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yt have used it & found greate benefit by it did blood a little and so ye Doctr tould Cos. Thornbery he must have done had he not bin blooded soe much before. If cos. Bettey would be perswaded to make tryal of these things I hope [they] would do her a great deal of good ... When she begins to take of the tincture she should continue taking it till the whole quantity be done.54 A similar counsel to the prospective user is appended to a ‘purge for the Gout’, attributed to Dr Hollings in the medical collection begun by Letitia Mytton in about 1720: ‘this is too great a quantity for one that Physick easily works with so they must proportion it to their constitution’.55 This set of conditions put bounds on the value of medicinal recipes that explain the need to ‘overstock’ a collection, just as it reiterates the importance of processes of trial, adaptation and approval, all of which were later recorded in annotations. Being a ‘smart consumer’ in the mixed medical economy of the period also meant being prepared to engage in an informed fashion in that economy, and protect oneself from exploitation. Arming yourself with a prescription, validated by exchange within one’s own domestic/familial network, might help you avoid the predations of an overenthusiastic apothecary and his medicating suggestions. Some contemporary printed recipe collections, such as Gideon Harvey’s The Family-Physician and the House Apothecary (1678), offer not only recipes for all sorts of ailments but indicate the prices of simple and compound drugs. In his preface to the collection, Harvey explained that patients were often ‘exposed to be defrauded by some little apothecaries of the Country and the skirts of the City, not onely through their ill preparation of Medicines, but also through their unjust and avaricious Prices’.56 By instead preparing their own medicines, patients could assure themselves of the quality of the drugs and make substantial financial savings. Throughout the book, Harvey carefully provides information on how much the medicament would cost if one prepared it at home and sets this against the current prices charged by apothecaries so that patients could ‘easily compute, what the Medicine is to be valued at, and what the apothecary deserveth for his pains’.57 These concerns were still being rehearsed nearly a century later: for example, William Ellis, the Hertfordshire author of The Country Housewife’s Family Companion (1750), recommended the home preparation of salves to his readers, since ‘These and other remedies being ready at hand, may probably save the expense of large doctor’s bills, and perhaps lives.’58

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The existence of recipes in collections for some of the proprietary medications which became prominent towards the end of the seventeenth century suggests that this advice was taken. Anne de Lisle’s and Letitia Mytton’s collections both contain recipes for making Daffy’s Elixir.59 The recipe for Lucatello’s Balsam recorded in the late seventeenth/early eighteenth-century recipe book of the Browne family of Troutbeck in Cumbria seems to have been used, if we can judge from entries noting purchases of the necessary ingredients in the household accounts.60 Geographical isolation and the expense of compound medicaments might provide a reason for such self-sufficiency earlier in the seventeenth century. Yet by the time these manuscripts were compiled, the widescale marketing and retailing of proprietary remedies by a range of outlets – from peddlars to booksellers – meant that even the Lake District could obtain its dose of such universal medications.61 The ways in which manuscript compilers collected and dealt with medical information about certain extreme, usually, fatal conditions for which little or no authoritative cure or prophylactic was yet known, can supply further insights into the practices of ‘smart consumers’. One of the more vivid afflictions for which compilers enthusiastically gathered recipes across this period was ‘the bite of a mad dog’ (the contemporary term for hydrophobia/rabies). The prevalence of cures for this usually fatal condition is certainly a measure of the level of contemporary fear about it. Notwithstanding the rarity of cases of fullblown rabies, it is unusual to find a recipe collection of this period without at least one recipe for curing or alleviating the condition.62 The inscription of treatments for rabies in these manuscripts reveals the spectrum of sources compilers employed in gathering cures. As Porter noted, published and commercial sources, such as the Gentleman’s Magazine and printed advertisements, were widely used. For example, a single-sheet flyer for the so-called Tonquin cure (itself first published in the Gentleman’s Magazine in 1738) is pasted into the mid-eighteenth century Pickard family recipe book.63 But alongside such commercial treatments, compilers also recorded those from domestic sources: Anne de Lisle’s mid-eighteenth century collection includes two folio pages of cures for ‘the bite of a mad dog’ including one for Dr Mead’s powder, but also one attributed to ‘Lady Lisle’ based on herbs and Venice treacle. The detailed recipes are also accompanied by comments on efficacy: ‘Some people eat a piece of the Liver of the Dog that was mad dried to a powder and think themselves secure. But I advise not to trust to it.’64 Is this the uncritical absorption of whatever might be deemed possibly useful

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in the event of being bitten, or a critical approach to sifting through what was a plethora of information, often contradictory, seldom truly authoritative, in search of useful knowledge? In the case of the de Lisle manuscript at least, the latter assessment emerges as more convincing. Responses to hydrophobia and searches for an effective cure also illuminate the transformation of domestic recipes into profitable commercial property. The cross-fertilization between manuscript ‘books of secrets’ and published medical texts from the mid-seventeenth century onwards has been discussed as part of the process of early modern medical vernacularization, and the development of early modern commercial pharmaceuticals is currently the focus of long overdue research.65 But alongside these processes, there is a smaller scale, more localized and more mundane commercialization and popularization of materia medica to uncover: one which was fuelled through the medium of recipe exchange and circulation in provincial social networks. The so-called Ormskirk or Colne cure for rabies probably began life as a treatment circulated between families in this corner of Lancashire, but by the 1740s was being sold and marketed by William Hill and Robert Parker in the area.66 On Parker’s death, the recipe passed to his widow Elizabeth Parker (later Shackleton) who continued to make and sell the cure across north-west England and the Midlands until her death in 1781. Significantly, the preparation remained a ‘secret’ of the Parker/Shackleton family. Elizabeth Parker’s manufacture of it was, in Vickery’s words, ‘a curious hybrid of ancient responsibilities and new commercial practices’.67 The recipe did not fully leave the domestic medical sphere, and the connotations of charity and care attached to that locus, to become the object of fullblown commercial exploitation. More significant still to our reading of the importance of domestic medical practice and recipe circulation to this practice, is Vickery’s further suggestion that it was ‘reputation, not profit’ which was Shackleton’s goal in the making and marketing of the Colne cure: a reputation which brought ‘social credit at home’, as much as repeated custom from a wide social spectrum of clients.68

Conclusion In this essay we have tried to map the territory occupied by manuscript recipe collections, and the process of recipe collection, exchange and circulation, in the wider moral and human geography of the early modern ‘medical marketplace’. The evidence of manuscript recipes for ‘the bite of a mad dog’, to take but one condition, bears witness not so

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much to the ‘demand-driven’ character of medical responses to disease, as to the immense fluidity and heterogeneity of medical knowledge about them, and thus the inability of any one player – physician, apothecary, quack, ‘wise-woman’ or gentlewoman – to assume preeminence in its treatment. In the diversity of their contents, the annotations and attributions of recipes, and the values assigned to them, manuscript collections suggest that at least some compilers were constructing collections in order to be an able participant in the activities of this decidedly mixed medical ‘economy’. Whether ‘buyer’ or ‘seller’, concerns about trust and reputation were crucial in the effective circulation and authorization – the currency – of medical information. Realizing the value of that information – that is, converting it into medical knowledge – was not simply about knowing how to construct and operate a still, but about knowing what and who was trustworthy in provision of the raw data of recipes. In offering one of the few sources that allows us to consider the contours of the potential knowledge of the laity in pharmacy and therapeutics, manuscript recipe compilations repay close reading. Moreover, they are texts which suggest that the acquisition of medical information by the laity was not so much a prerequisite for driving demand in the commercial arena, but a means by which medical needs were clarified. This gave the sick the ability to ask the right questions and obtain the best treatments from practitioners and, just as importantly, from other lay medical consumers.

Notes 1. Beier, Sufferers; Porter, Progress; S. Shapin, ‘Trusting George Cheyne: Scientific Expertise, Common Sense and Moral Authority in Early Eighteenth-Century Dietetic Medicine’, BHM, 77 (2003). 2. We use the term ‘recipe’ throughout, as although some of the medical ‘recipe’ texts we have encountered in our research are more precisely prescriptions, the recipe is the more ubiquitous text format. 3. We would like to thank the editors of the volume for helping us to clarify these ideas. 4. Recent studies include R. Tannenbaum, ‘A Woman’s Calling: Women’s Medical Practice in New England, 1650–1750’ (Ph.D. thesis, Yale University, 1996); L. W. Smith, ‘Women’s Healthcare in England and France, 1650–1770’ (Ph.D. thesis, University of Essex, 2001). See also Note 19. 5. I. Mortimer, ‘The Triumph of the Doctors: Medical Assistance to the Dying, c. 1570–1720’, Trans. Royal Historical Society, 15 (2005), and in this volume. 6. R. Porter, ‘The Patient in England, c. 1660–c. 1800’ in A. Wear, ed., Medicine in Society: Historical Essays (Cambridge, 1992), esp. 101–106.

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7. Beier, Sufferers; L. Pollock, With Faith and Physick (1993); L. Hunter, ‘Women and Domestic Medicine: Lady Experimenters, 1570–1620’, in L. Hunter and S. Hutton, eds, Women, Science and Medicine, 1500–1700 (Stroud, 1997). 8. S. Pennell, ‘The Material Culture of Food in Early Modern England, c. 1650– c.1750’ (D.Phil. thesis, Oxford University, 1997), ch. 3; idem, ‘Introduction’, in Women and Medicine: Remedy Books 1533–1865, 33 microfilm reels (2004). For the relationships between diet and medicine in print, see J. O’Hara May, ‘Food or Medicines? A Study in the Relationship Between Foodstuffs and Materia Medica from the Sixteenth to the Nineteenth Century’, Trans. British Society for the History of Pharmacy, 1 (1971). 9. A. Wear, Knowledge and Practice in English Medicine, 1550–1680 (Cambridge, 2002), 49–50, 55; M. R. Best, ‘Introduction’, in Gervase Markham, The English Housewife, ed. M. R. Best (Montreal, 1986). 10. BL, Add. MS 45718, fols 44r, 92r-v, 94v. For printed versions of the inventories, contained within Freke’s manuscript Remembrances, see R. A. Anselment, ed., The Remembrances of Elizabeth Freke, 1671–1714, Camden Society, 5th ser., 18 (Cambridge, 2001). 11. E. Leong, ‘Medical Recipe Collections in Seventeenth-Century England: Knowledge, Text and Gender (D.Phil. thesis, Oxford University, 2005), 105–8; see also Pennell, ‘Material Culture of Food’, 182. 12. See, for example, the absence of reference to medical production in the most recent significant study of inventories and domestic production: M. Overton et al., Production and Consumption in English Households 1600–1750 (2004), 33–64. 13. Leong, ‘Medical Recipe Collections’, 98–105. 14. Wear, Knowledge and Practice, 55–103. 15. K. Siena, ‘The “Foul Disease” and Privacy: The Effects of Venereal Disease and Patient Demand on the Medical Marketplace in Early Modern London’, BHM, 75 (2001), 200. 16. See J. Walter, ‘The Social Economy of Dearth in Early Modern England’, in R. Schofield and J. Walter, eds, Famine, Disease and the Social Order in Early Modern England (Cambridge, 1991), 121–2; C. Muldrew, The Economy of Obligation (Basingstoke, 1998), ch. 6; Pennell, ‘Material Culture of Food’, ch. 6. 17. See B. Lemire, The Business of Everyday Life (Manchester, 2005), 86. 18. For example, see R. Porter, ‘The People’s Health in Georgian England’, in T. Harris, ed., Popular Culture in England, 1500–1850 (Basingstoke, 1995), 124–42, nn. 2, 32; Wear, Knowledge and Practice, 50–2. Joan Lane did not mention recipes or recipe collections in The Making of the English Patient (Stroud, 2000). Gender history texts make limited use of recipe collections, A. Laurence, Women in England, 1500–1760 (1994); S. H. Mendelson and P. Crawford, Women in Early Modern England, 1550–1720 (Oxford, 1998). 19. Stine, ‘Opening Closets’; Archer, ‘Women and Alchemy’; Leong, ‘Medical Recipe Collections’. See also S. Pennell, ‘Perfecting Practice? Women’s Manuscript Recipes in Early Modern England’, in V. Burke and J. Gibson, eds, Early Modern Women’s Manuscript Writing (Aldershot, 2004). 20. Shapin, ‘Trusting George Cheyne’, 296; Wear, Knowledge and Practice, p. 82. 21. G. Harvey, The Vanities of Philosophy and Physic (1669), 2, quoted by Stine, ‘Opening Closets’, 2.

Elaine Leong and Sara Pennell 151 22. Porter, ‘The Patient’, 101, 105. Cf. O’Hara May, ‘Food or Medicines?’. 23. For more detailed discussion of these issues, see Leong, ‘Medical Recipe Collections’, and Pennell, ‘Introduction’. 24. Stine, ‘Opening Closets’, 85–8, 192–6; Wear, Knowledge and Practice, 41–2. 25. Leong, ‘Medical Recipe Collections’, 220. 26. There was a great deal of variation among the 15 collections included in the study, highlighting the fact that each manuscript notebook was the product of unique compilation practices. However, family members were the source of up to one-third of the recipes in some collections and all 15 collections cited a medical practitioner labelled as ‘Dr’; Leong, ‘Medical Recipe Collections’, 188–92. 27. G. Uden, ed., The Recipe Book 1659–1672 of Archdale Palmer (Melton Mowbray, 1985), 8–9, 66–7, 78, 126–7, 139–41. Abraham Wright (1611–1690) was the rector at Oakham in Rutland during this period and was originally from London, thus the citation might refer to him: see ODNB, s.n. 28. BL, Stowe MS 1077, f. 13r. 29. Ibid., f. 45r. 30. Folger Shakespeare Library, Washington, MS W.a.303, pp. 120–1. ‘Ld Nowel Somerset’, is probably Sir Henry Noel Somerset, 4th duke of Beaufort, while ‘Watkin Williams’ might be Sir Watkin Williams Wynn (1693?–1749): ODNB. 31. Palmer, 22, 66–7, 108, 120–1 and 143. 32. Ibid., 106, 235. 33. Ibid., 152. ‘Lugborrow’ is likely to refer to Loughborough. 34. Ibid., 21. 35. Ibid., 19–20, 17–19. 36. M. Pelling and C. Webster, ‘Medical Practitioners’, in C. Webster, ed., Health, Medicine and Mortality in the Sixteenth Century (Cambridge, 1979), 233; Porter, ‘The Patient’, 94, 97; Stine, ‘Opening Closets’, 192. 37. New York Public Library, Whitney MS 9, f. 85v. 38. P. Findlen, ‘The Economy of Scientific Exchange in Early Modern Italy’, in B. T. Moran, ed., Patronage and Institutions (Woodbridge, 1991). 39. Wellcome Library, London (hereafter Wellcome), Western MS 213. See also Hunter, ‘Women and Domestic Medicine’, nn. 47, 60; Stine, ‘Opening Closets’, 44–6, for other copies of this MS; and Leong, ‘Medical Recipe Collections’, 131–3. 40. Will and testament of Rebecca Brandreth, 10 April 1740, transcribed in The Compleat Cook, or Secrets of a Seventeenth Century Housewife, by Rebecca Price, ed. M. Masson and A. Vaughan (1974), 344–8. 41. Wellcome, Western MS 184a, verso of second preliminary leaf. 42. Wellcome, Western MS 3082, f. 27r. 43. The exact date for the second marriage is not known; however, it must have occurred after the death of Johnson’s first wife, Jane, in July 1703: see ODNB. 44. E. Green, ‘Pedigree of Johnson of Ayscough-Fee Hall, Spalding, co. Lincoln’, The Genealogist, 1 (1877), 110. 45. Cf. K. Hess, ed., Martha Washington’s Booke of Cookery (New York, 1995), 463; P. C. D. Brears, ‘A North Yorkshire Recipe Book’, in C. A. Wilson, ed., Traditional Food East and West of the Pennines (Stroud, 1994). 46. BL, Sloane MS 3842.

152 Recipe Collections and Medical Knowledge 47. A. Rankin, ‘Medicine for the Uncommon Woman: Experience, Experiment and Exchange in Early Modern Germany’ (Ph.D. thesis, Harvard University, 2005), 69. 48. Bodleian, MS Don.e.11, ff. 52r-1v and 56r-3v. 49. Ibid., ff. 56r, 55v, 54v, 54r. 50. New York Public Library, MS ‘Collection of Household Recipes’, f. 8v. 51. New York Public Library, Whitney MS 9, f. 75v. 52. Wellcome, Western MS 3731, p. 66. Letitia Owen, of Condover, Staffs. (c. 1690–1755) married Richard Mytton, of Halston, Shropshire (c. 1687–1731) on 22 October 1719. 53. W. D. Churchill, ‘The Medical Practice of the Sexed Body: Women, Men and Disease in Britain, circa 1600–1740’, SHM, 18 (2005). 54. Wellcome, Western MS 3712, pp. 252–4. 55. Wellcome, Western MS 3731, p. 57. 56. G. Harvey, The Family-Physitian and the House Apothecary (1678), sig. A3v. See also Porter, ‘The Patient’, 111. 57. Harvey, Family-Physitian, sig. A4r. 58. W. Ellis, The Country Housewife’s Family Companion (1750), p. vii. 59. Wellcome, Western MS 3295, f. 46r, and MS 3731, p. 41. Mytton also has a recipe for Stoughton’s Drops on p. 25. 60. Cumbria Record Office, Kendal, WD/TE, box 16/1, p. 62; WD/TE box 8/3/1, diary and accts for 1717–18, passim. 61. On Daffy’s Elixir, D. B. Haycock and P. Wallis, eds, Quackery and Commerce in Seventeenth-Century London, Medical History suppl. 25 (2005); R. Porter, ‘Lay Medical Knowledge in the Eighteenth Century: The Case of the Gentleman’s Magazine’, MH, 29 (1985). 62. On rabies, J. D. Blaisdell, ‘A Frightful, But Not Necessarily Fatal, Madness: Rabies in Eighteenth-Century England and English North America’ (Ph.D. thesis, University of Iowa, 1997). 63. Dorset Record Office, Dorchester, D/BLX: F74. This collection also contains a long extract copied from the writings of Dutch physician Hermann Boerhaave (1668–1738) on prophylactic and curative treatments for rabies. 64. Wellcome, Western MS 3295, f. 45r. 65. W. Eamon, Science and the Secrets of Nature (Princeton, 1994); M. Hunter, ‘The Reluctant Philanthropist: Robert Boyle and the “Communication of Secrets and Receits in Physick”’, in O. P. Grell and A. Cunningham, eds, Religio Medici (Aldershot, 1996); Haycock & Wallis, Quackery and Commerce. 66. A. Vickery, The Gentleman’s Daughter (1998), 154. 67. Ibid., 155. For another example of a ‘domestic’ recipe entering the commercial fray, see Ellis, Country Housewife’s Family Companion, 144–5. 68. Vickery, Gentleman’s Daughter, 155, 390–3.

8 Midwifery in the ‘Medical Marketplace’ Adrian Wilson

The quotation marks in my title have been carefully placed: I shall be discussing not ‘midwifery in the medical marketplace’ but rather the way in which a model of the medical marketplace has been applied to midwifery in early eighteenth-century England. Specifically, it has been suggested that the rise of man-midwifery – that remarkable new form of medical practice in which the medical man came, by around 1750, to play the role of midwife – can be attributed to competition between medical men for a limited pool of patients. This model has been applied in three somewhat different ways, which nevertheless all invoke the ‘medical marketplace’ as an arena of competition, and see such competition as the universal currency of relationships between early modern practitioners. These claims are interesting in allocating to the ‘medical marketplace’ a dynamic role, as an agent of change; but I shall suggest that this particular application of the concept is not persuasive. After developing this argument, I shall go on to suggest some points of wider application, whose common burden is that the concept of the medical marketplace needs to be sharpened and refined. In its first application to man-midwifery, in the hands of Irvine Loudon, the marketplace model was chiefly designed to explain the origins of what would later be known as ‘general practice’. Loudon claimed that it was the practice of midwifery by men which transformed surgeons and apothecaries into the nascent general practitioners – though they were not yet so called – of the mid- and late eighteenth century. What brought these men to practise midwifery was competition; what made that practice particularly desirable was that it served as the entrée into general practice, seen above all as involving the family – rather than the individual patient – as the client base. Delivering the 153

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mother installed the male practitioner in the role of healer to the whole family; this was certainly what was happening in the early nineteenth century, and Loudon’s argument was that the men of an earlier generation (starting in the 1730s but accelerating around 1750) had deliberately sought to bring this about. And the motor for all of this was competition between male practitioners in an overcrowded market.1 Loudon enunciated this model in 1986; hard on its heels there came (in 1987) Lucinda McCray Beier’s rather different model. Here the rise of man-midwifery was seen as an aspect of the larger contest between ‘licensed’ and ‘unlicensed’ camps of practitioners. It was that contest which constituted the ‘medical marketplace’ of the seventeenth century: on the one side were ranged the licensed group, comprising physicians, surgeons and apothecaries, while on the other were their many unlicensed competitors – empirics, magical practitioners, healers by the touch, such as Valentine Greatrakes, and midwives.2 This picture faced the initial difficulty that midwives, alone of this group, were not technically ‘unlicensed’, since they came within the scope of episcopal licensing just as physicians and surgeons did; but this problem was handled partly by arguing that ‘the licensing of midwives had more to do with their moral character than their skill’,3 and partly by arguing that the licensed practitioners treated midwives with the same hostility that they meted out to the unlicensed at large. Here came the nub of the argument: what characterized the ‘medical marketplace’ was not just competition for patients but also a systematic campaign on the part of the licensed group against their unlicensed rivals. The broader claim was that this campaign was ultimately successful; and midwifery was simply one aspect of this. In particular, the eighteenth-century rise of the man-midwife was attributed to a successful campaign on the part of these male accoucheurs to ‘drive midwives from the birth chamber altogether’.4 The key to the fortunes of the medical marketplace, then, was negative advertising against unwanted competitors. By 1996 Loudon had abandoned his earlier model, reversing its causality (by arguing that the ‘sudden rise of the surgeon-apothecary as the family doctor’ led to man-midwifery, rather than the other way around), invoking a further factor (‘a new spirit of medical enquiry’), and pointing out the need for a whole additional explanatory dimension, namely patient demand: ‘the rapid adoption by the surgeon-apothecary of the role of man-midwife could have taken place only if it was actively sought by women and their husbands’.5 In the light of this last point of Loudon’s new position, it is worth examining how patient demand

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featured in Beier’s argument. I have already quoted from the opening sentence of the relevant passage; here is the full story:6 By the eighteenth century male accoucheurs, having gained in both confidence and popularity, were ready to drive midwives from the birth chamber altogether. The physician William Smellie created a pedigree for men-midwives, calling Hippocrates the Father of Midwifery, unearthing a worthy called Paulus Aegineta (a fourthcentury Greek medical writer who claimed to have been an accoucheur), and denying the existence of such ancient female physicians as the semi-legendary Trotula. He and other writers again accused midwives of ignorance, but refused to instruct midwives in the use of instruments, including the midwifery forceps which were introduced in the 1730s. They also exaggerated the dangers of childbirth, which encouraged those with sufficient means to consult more learned and higher-status male practitioners. Fashion also came to the aid of the man-midwives, ladies with upward mobility aspirations summoning them rather than lower-status females in times of need. Thus, despite the chorus objecting to the invasion of the birth chamber by male practitioners, by the end of the century men had virtually taken over the practice of midwifery among all but the lower classes in society. Patient demand is indeed invoked here, in the form of ‘fashion’; but the question as to how that fashion was constituted is left unexplained. More generally, this picture is circular, for it takes as its starting point the very things which need to be explained: that menmidwives ‘gained in both confidence and popularity’, and that the use of instruments – which all agreed were appropriate only for difficult deliveries – somehow helped men get access to normal births. To the extent that an explanation is offered, it requires us to believe that patients’ choices were influenced by the content of technical midwifery treatises such as that of William Smellie. This is of course in line with the wider picture of the eventually successful negative advertising campaign mounted by the ‘licensed’ practitioners against their ‘unlicensed’ rivals; but it can hardly be said to engage with developments in midwifery. The third model, advanced in 2000 by Doreen Evenden, merits more extended discussion as it is concerned specifically with midwifery (rather than with general practice or with wider marketplace structures)

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and is elaborated at much greater length. This revives and extends Loudon’s earlier model: There is evidence of increasing competition among the male medical practitioners, particularly in the second half of the [seventeenth] century, with apothecaries, barber-surgeons and physicians, as representatives of ‘professional’ medicine, all jostling for space in the health care system. . . . Young surgeons and apothecaries, struggling to become established, were enticed into midwifery as an untapped, pseudo-medical area of expansion and by the prospect of acquiring the family of the new mother as prospective patients for general practice. . . . The aggressiveness of surgeon-apothecaries as they sought ways of increasing their incomes and expanding their practices also contributed to the growing number of male midwives after 1730.7 While the end of the passage echoes Loudon (who is cited here), its opening (which rests on R. S. Roberts’s work in the 1960s) extends the competition picture back into the late seventeenth century, suggesting that the competitive process developed over several decades. This is part of a larger argument, involving the decline of episcopal midwifelicensing in the diocese of London and the male ‘appropriation of female experience’.8 The cessation of licensing between about 1690 and 1720 is held to have undermined midwives’ status and self-confidence,9 and the appropriation of female experience was required in order for male practitioners to gain experience of normal births; but the driving force for all of this (it is posited) was economic, change being fuelled by competition between practitioners.10 As a convenient shorthand, I shall refer to this as the competition theory of man-midwifery. Now if this theory turned out to be correct, the medical marketplace would be a powerful force indeed – overthrowing within a generation centuries of custom, creating an entirely new form of medical practice and wresting from women their control of childbirth, with the effect that ‘women and their infants were to be the losers for generations to come’.11 But I shall suggest that market considerations cannot carry this heavy explanatory burden, for the competition theory is beset with three major difficulties. In the first place, its economic foundation is dubious, for the ‘evidence of increasing competition’ is thin and contentious. Second, its auxiliary hypotheses about the decline of episcopal licensing and the appropriation of female experience founder upon the rock of geography. And third, the theory begs the question; for even if we grant, for the sake of argument, that competition was a

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significant motive for men to practice as midwives, there remains the issue raised by Loudon in 1996 – how childbearing women were persuaded that the switch to a man-midwife was in their interests, as distinct from interests of the male practitioner.

Professional competition? One might expect that the claim of increasing competition would rest on an estimate of the numbers of male medical practitioners, related to the size and wealth of the population. And for the early eighteenth century, a start might conceivably have been made on this using the wealth of information produced by the Project for Historical Biobibliography (PHIBB) project.12 Yet nothing of the kind has been provided; instead the claim rests upon other and mostly much older researches, principally those of R. S. Roberts.13 Now Roberts (who enunciated an early version of the medical marketplace concept14) actually advanced a different argument – to do with the changing balance of power between apothecaries and physicians. Still, it may be that Roberts’s classic essay admits of the ‘rising competition’ reading – but this is not the only possible reading. Indeed the actual state of the market for medical services in this period remain unclear and it is possible to derive precisely opposite interpretations from Roberts’s and others’ researches. This is in fact what Geoffrey Holmes did when he used Roberts’s work as a minor plank in the edifice of his now-classic Augustan England.15 It is worth discussing this study in some detail as it puts forward a picture which is radically at odds with the competition theory. According to Holmes, between 1680 and 1730 the English professions in general – including medicine – were transmuted into something like their modern form, characterized by high social status, substantial monetary rewards, rapidly rising standards of practice and a unifying esprit de corps.16 In medicine this involved an erosion of the old divisions between physicians, surgeons and apothecaries, all of whom were increasingly swept together under the designation of ‘the doctor’.17 As a result, by c. 1730, locality had become a more important determinant of financial rewards than ‘the old functional divisions’:18 that is, the greatest successes accrued to London medical practitioners of all stripes. But provincial physicians, surgeons and apothecaries also shared in the spoils and in the rising status of their newly consolidated profession. That profession was also a remarkably open one, for although improving standards considerably raised the cost of training, this did not restrict entry to the very wealthy (as was happening with the Bar).19

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In sum, Holmes depicted the three roles of physician, surgeon and apothecary as converging towards a single, more or less unified medical profession, with modern values and status. And what brought about this shift, Holmes argued, was increasing economic prosperity in a context of population stability.20 That is to say, the ‘market’ for all professional services, including medical ones, was expanding throughout the seven decades he covered – the very period which, according to the competition theory, laid the ground for the rise of ‘man-midwifery’.21 Admittedly, Holmes asserted at one point that provincial surgeons – for what he called ‘reasons that are obvious’ – were more liable to failure than apothecaries, and that even London surgeons ‘here and there hit hard times’.22 Yet ultimately Holmes endorsed the view of Richard Campbell’s London Tradesman (1747) that ‘none of the liberal arts’ was ‘more likely to procure a livelihood’ than surgery, and that ‘an ingenious surgeon, let him be cast on any corner of the earth, with but his case of instruments in his pocket, he may live where most other professions would starve’.23 And this fitted the larger thrust of Holmes’s argument, which with respect to surgeons was based on the premise that throughout his period (1680–1730), the demand for surgical services ‘outstripped supply’.24 What makes it possible for such different conclusions to be reached is that these studies have not directly assessed the levels of demand for medical services. More recently, however, Ian Mortimer has produced compelling evidence from probate records that this demand increased substantially between 1585 and 1705.25 But the critical period in the present context is the first half of the eighteenth century. In the next section I shall offer a complementary attempt to assess whether the demand for medical services was rising, falling or stationary at that time.

Measuring the ‘supply’ of medical practitioners An effective way to assess whether medical practitioners in this period were in oversupply or undersupply in relation to demand is to chart the levels of apprenticeship premiums: oversupply should lead premiums to fall, undersupply should bring about rising premiums, while a balance between the supply of practitioners and the demands for their services should be reflected in stable premiums. Such premiums can be identified thanks to a tax that was initially imposed under the 1709 Stamp Act, made perpetual in 1710, and continued until 1804:26 this levy (6d. in the £ for premiums up to £50, 1s. in the £ for larger premiums) was in addition to a flat-rate stamp duty of 6d on each indenture.27

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The tax was administered – though how effectively is not yet known – through the newly created Stamp Office in London and a system of local collectors, one per county.28 I have used the returns for Warwickshire, which – to judge from the account of them given by the late Joan Lane, an expert on these returns and on apprenticeship in general – are representative of those that have been indexed and published. They span the period from 1710 to 1760 and embrace over 1100 apprenticeships,29 of which 59 were medical:30 thus on average about 20 Warwickshire apprenticeships were registered each year, and roughly one taxedand-registered apprenticeship in 20 was to a medical master. These 59 medical apprenticeships were to 50 different masters (one medical master appears three times in the record, seven of them twice and the remaining 42 taking just one registered apprentice each).31 A word is in order about which masters are to be counted as ‘medical’. I have taken this to embrace apothecaries (the most numerous category); surgeons; combinations of these with each other (apothecary and surgeon; surgeon and apothecary); and combinations with other occupations – five masters described as ‘barber and surgeon’, one as ‘mercer and apothecary’ and one as ‘apothecary, surgeon and manmidwife’. I have excluded the 52 barbers (of whom 17 were also described as periwig-maker, peruke-maker or wig-maker) and five druggists.32 The solitary apprenticeship to a ‘man-midwife’ – to be precise, an ‘apothecary, surgeon and man-midwife’, Richard Bree of Solihull – is interesting as to its timing, taking place as it did in 1753.33 This first instance of the designation ‘man-midwife’ within the registered Warwickshire apprenticeships is in harmony with many other indications that the practice of midwifery by men came into being, or took a new form, rather suddenly at mid-century.34 On the other hand, it is difficult to know what to make of the designations ‘apothecary’ and ‘surgeon’. Only three masters, of whom Richard Bree was one, combined these two labels in their self-description, whereas some 45 masters (registering 50 apprenticeships between them) described themselves as one or the other. Are we to assume that none of the 34 ‘apothecaries’ practised surgery and that not one of the 11 ‘surgeons’ dispensed drugs? Surely not; yet we must also avoid the converse temptation of regarding the labels as having no descriptive significance. All that can be said is that together, these ‘apothecaries’ and ‘surgeons’ comprised the great bulk of the medical practitioners who can be identified from this source. Indeed, as will shortly emerge, they were on an altogether different plane from the handful of masters designated as ‘barber and surgeon’.

Coventry 1710–14 1715–19 1720–24 1725–29 1730–34 1735–39 1740–44 1745–49 1750–54 1755–59 1760 (Jan–Apr) Totals Source: see note 30.

87 98 74 21 4 — 28 2 23 1 — 338

Stratford-upon-Avon 13 4 7 5 2 1 13 — 6 — — 51

Warwick 9 5 7 3 — — 10 — 7 2 — 43

Birmingham 2 20 62 24 24 1 77 5 183 152 6 556

Other 11 9 24 6 3 4 30 5 26 8 2 128

Total 122 136 174 59 33 6 158 12 245 163 8 1116

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Table 8.1 Locations of recorded Warwickshire apprenticeships (1710–60)

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Table 8.1 gives a conspectus of the data, showing the numbers of registered apprenticeships by place and five-year period. It is at once apparent that the tax was very unevenly enforced: for instance, a mere six Warwickshire apprenticeships were taxed between 1735 and 1739, as against 158 in the next five years (1740–44). Such fluctuations were mostly county-wide, but there were also locality-specific variations. For example, it appears that in the early 1740s an attempt was made to bring in returns from other centres than the main four towns. Yet this effort must have been imperfect, for it picked up just one apprenticeship from Solihull, where there had been four in the early 1720s, and there would be five in the early 1750s. Such local peaks doubtless reflect briefly enhanced enforcement, and there are other instances of this – notably in Alcester, whose eight recorded apprenticeships, to eight different masters, all fell into either the early 1710s or the late 1730s (four in each period). Clearly these taxed-and-registered apprenticeships are far indeed from presenting us with a full record; and indeed there is reason to believe that even in periods of relatively good registration, only a small minority of apprenticeships were taxed-and-registered.35 Nevertheless the registered apprenticeships do reflect the main patterns of Warwickshire’s economic activity and development in this period: the numerical dominance of Birmingham and Coventry; the fact that the next two largest settlements were Stratford-upon-Avon and Warwick; and of course Birmingham’s spectacular rise and Coventry’s relative decline during the period. Thus the registered apprenticeships, for all their incompleteness and patchiness, are probably broadly representative of the larger pool from which they were drawn; and this is in line with the use that Dr Lane made of these materials. Certainly premiums large, middling and remarkably small all continued to be recorded throughout the period. We find premiums as high as £150; at the opposite extreme are premiums of around £1, such as the one guinea (21s.) which the Birmingham toymaker Gilbert Whitehouse received in 1754 with Thomas Beale, apprenticed for seven years; the overall median premium was £9. In short the taxation net, though it certainly had giant holes in it, was cast over the whole spread of apprenticeships, at least in Warwickshire. We are now in a position to look at the premiums. The first point to make is that here as elsewhere,36 and with the exception of the barbersurgeons, medical premiums were high. As for the five barber-surgeons, all their premiums were low, with a median of £6.6s.; in fact the pattern of their premiums exactly matched that of the barbers in general

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(including those who also made perukes and periwigs). This makes one wonder whether these men belonged to the medical sector at all; conceivably their ‘surgery’ was confined to phlebotomy and bandaging. In contrast the apothecaries and surgeons, taken together, had a median premium of £43 – far above the overall median of £9. Another way of bringing this out is to look at the very highest premiums, those of over £50, which as we have seen attracted double the rate of duty (so that a premium of £50 was charged £1.5s., but a premium of £51 cost £2.11s.): fewer than 5% of the non-medical premiums attained these exalted levels, but over 25% of the medical ones did so, with the effect that out of the 66 such high premiums among all occupations, some 15 were medical. Interestingly, the surgeons were more prominent than the apothecaries at these upper reaches: the spread of premiums in the two groups was much the same (in round figures, from £10 to £100), but proportionately more of the surgeons were to be found charging the highest fees within that range. What, then, of the pattern over time in which we are interested? Were medical premiums rising, falling or stable? This question is answered in Tables 8.2 and 8.3; the first of these includes the problematic barber-surgeons, the second excludes them. Here the premiums are aggregated by decade, except that the 1730s and 1740s have had to be combined (in view of the small numbers), and 1760 is attached to the 1750s. In each case I have tabulated the median premium – the one in the middle – and the two quartiles, that is, the medians of the lower and upper halves of the given set. The median is more robust as a measure of central tendency than the arithmetic mean, which is liable to be shifted dramatically upwards by one or two large values; and similarly the quartiles give a good impression of the range without being distorted by extreme values, for half of the cases always lie between the two quartiles.37 Table 8.2 Premiums paid to medical masters (including barber-surgeons), Warwickshire (1710–60)

1710–19 1720–29 1730–49 1750–60

Lower quartile

Median

Upper quartile

Number of apprenticeships

£30, £33 £20 £40 £48, £50

£40 £40 £49, £49 £60, £60

£45, £45 £50 £50 £60, £79.16s.

16 17 14 12

Source: see note 30.

Adrian Wilson 163 Table 8.3 Premiums paid to medical masters (excluding barber-surgeons), Warwickshire (1710–60)

1710–19 1720–29 1730–49 1750–60

Lower quartile

Median

Upper quartile

Number of apprenticeships

£30, £33 £40 £40 £50, £50

£40 £42 £49, £49 £60

£45, £45 £50 £50 £60, £79.16s.

16 13 14 11

Source: see note 30.

The results are decisive: with the sole exception of a dip in the lower quartile during the 1720s the trend of the premiums was stable or – and this was the main pattern – rising. As for the dip in premiums at the lower end of the spectrum in the 1720s, this arose solely from the fact that this decade witnessed four of the five apprenticeships to barbersurgeons. And whether the barber-surgeons are included or excluded, three-quarters of the premiums of the 1750s were higher than threequarters of those of the 1710s. Indeed by the 1750s the median medical premium had attained the lofty height of £60. For comparison, Table 8.4 shows the corresponding figures for all other Warwickshire apprenticeships, that is, those to non-medical masters – from attorneys and a solitary awl blade maker to worsted weavers, writing masters and a yeoman. These premiums were also increasing, and it might even be thought that they were rising more rapidly than the medical ones, since the median non-medical premium doubled (from £5 to £10) whereas the median medical premium rose only by 50 per cent (from £40 to £60). But this way of looking at the data is misleading; a more appropriate comparison would scale the changes against the underlying distributions. In the case of non-medical apprenticeships, fewer than half of the premiums of the 1750s exceeded the upper quartile

Table 8.4 Premiums paid to non-medical masters in four periods, Warwickshire (1710–60)

1710–19 1720–29 1730–49 1750–60

Lower quartile

Median

Upper quartile

Number of apprenticeships

£3 £4, £4 £5, £5 £5.5s., £5.5s.

£5, £5 £8, £8 £9 £10, £10

£10 £13, £14 £15, £15 £20, £20

242 216 209 404

Source: see note 30.

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premium of the 1710s – whereas among medical apprenticeships, over three-quarters of them did so. That is, medical apprenticeship premiums grew further, and faster, than did other premiums. This evidence is radically at odds with the notion that the emergence of the man-midwife around 1750 arose from competition driving medical men into the practice of primary midwifery. For what we have seen is that the relevant period witnessed a strong increase in premiums for medical apprenticeships, suggesting that at this time medical men were in undersupply relative to the expanding demand for their services. True, it remains possible in principle that the registered apprenticeships were unrepresentative,38 but prima facie, the registered Warwickshire apprenticeship premiums argue strongly against the competition theory.

Women Setting aside the problems so far discussed, let us suppose for the sake of argument that the competition theory is correct, that is, that male practitioners were pushed by pressure of competition to practise midwifery. We would then have half, and only half, of the explanation that we need – for we would now have to explain why women acceded to this particular male desire. And on this issue the competition theory is silent – necessarily so, because that theory confines itself to the motivations of male practitioners. The void is filled by a series of auxiliary hypotheses, chief among which are two institutional developments. First, the decline of episcopal licensing of midwives – which ceased in the diocese of London between about 1690 and 1720 – is said to have undermined the midwives’ own self-regulatory system, by depriving it of external validation. Second, it is suggested that the newly created lying-in hospitals and charities, which began in the capital in the 1730s and flourished there from the late 1740s onwards, allowed male practitioners to appropriate female experience of managing normal deliveries. It should first be noted that considerations of place argue strongly against these claims. Firstly, the diocese of London was apparently unique in abandoning the episcopal licensing of midwives as early as it did (for there are many instances of midwives being licensed elsewhere up to a century later); and what is more, other dioceses – at least all of those whose records I have so far investigated – experienced an increase of licensing at that time.39 In the diocese of Ely, midwife-licensing peaked in the early eighteenth century (specifically in 1716); in the diocese of Norwich, the numbers of midwives being licensed rose steadily between

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about 1700 and 1725, gradually declining thereafter (though in one of its four component archdeaconries, the archdeaconry of Suffolk, the licensing peak took place in the 1730s); in the archdeaconry of Leicester, part of the diocese of Lincoln and effectively for these purposes an independent jurisdiction, licensing intensified in the 1740s; and even in the diocese of Lichfield, where midwife-licensing was always implemented only very weakly, there are some signs of more active licensing at this same time. And the reason that this matters in the present context is that on all the evidence available, the rise of man-midwifery – in the specific sense of being called to deliver births in lieu of a midwife – was not confined to London but was a national development:40 we find it in selected localities in Essex (possibly a little earlier than in London), Somerset, Lancashire and Cheshire, in each case in the 1740s and generally around 1748, which was precisely when the change occurred in London.41 Secondly, the same issue rules out the significance attached to lyingin hospitals; for it cannot be supposed that these institutions, which were initially confined to London, exercised such action-at-a-distance as to influence what was happening as far afield as Somerset or Lancashire. Those hospitals, and their successor the Lying-in Charity (later the Royal Maternity Charity), were indeed bound up with the rise of man-midwifery – but as effect rather than as cause. It was in London that these institutions first came into being, because the vast concentration of population there made for charitable initiatives of all kinds.42 Man-midwifery itself sprang up virtually simultaneously in several different localities; whatever the reasons behind this shift, it did not depend on the rise of lying-in hospitals and charities.43 In short, circumstantial considerations argue strongly against the significance ascribed both to the decline of London episcopal licensing and to the rise of the lying-in hospitals and charities. Further, each of these claims rests on dubious assumptions as to the underlying processes. As to the licensing system, the argument requires that system to have regulated midwives’ entry into practice in the seventeenth century; to deal in the requisite detail with that assumption would take us too far afield, but suffice it here to say that it surely incurs a large burden of proof. What can be done here is to look at the specific claim that has been mounted for the effect of the lying-in hospitals and charities set up in London between the late 1740s and the mid-1760s. The establishment of these institutions, we are told, was ‘arguably the single most important factor in the demise of the authority and superiority of the female midwife’.44 This process, it appears, had two aspects. In the first place (it is argued), the very origin of the lying-in hospitals

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and charities was the desire of male practitioners to acquire experience of normal births, and in this (the argument continues) they succeeded, learning by observing deliveries conducted by midwives.45 Second, it seems that the various training initiatives of the 1740s, 1750s and 1760s brought about an imbalance: although a few midwives were trained and accredited within the lying-in institutions, their numbers were too low to keep pace with London’s rising population, with the effect that ‘women were forced to turn more frequently to male midwives who were acquiring the training and confidence which made child delivery more attractive and lucrative’.46 It has to be said that as an account of women’s motives this is remarkably thin: the first aspect can at most explain how men could set themselves up to compete with midwives, not why mothers would switch to such male practitioners, while the second comes perilously close to begging the question. But what particularly commands attention in this passage is the phrase ‘women were forced’, for this is the key to the wider argument that emerges as additional factors (over and above the lying-in institutions) are considered. Here are adduced various eighteenth-century testimonies, all from opponents of man-midwifery, the common burden of which is women’s gullibility: mothers mistakenly give the credit in difficult birth to the man who comes at the end (Sarah Stone), they are tricked by ‘lies and false representations’ (Frank Nicholls), they are seduced by ‘vivacity and the love of novelty’ (Philip Thicknesse), and so on.47 The end result, which has a certain paradoxical elegance, is to depict the women of eighteenth-century England in the guise of wholly passive victims: ‘the choices about childbirth that women could make’, we are assured by way of punchline, ‘were not really their own’.48 The beauty of this conclusion is that it brings out what was actually implicit in the competition theory from the outset: given the premise that man-midwifery was the product of male desires and initiatives, it is indeed appropriate to end by obliterating the agency of women. The competition theory is of course a market theory of a particular kind – one which stresses the ‘supply side’ of the market in question. And the burden of my critique, rephrased in market language, is that we need to pay at least equal attention to the ‘demand side’, that is, the demand for the given service. Couched in these terms, the original explanatory question would become: how was it that there came into being, in about the 1740s, a demand for male practitioners to act as midwives? This language of demand is certainly more appropriate than the practitioner-centred language of the competition theory. For everything to do with early modern childbirth was profoundly under the control of

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women – starting, but by no means ending, with the routine ritual by which the birth was managed. Despite some disagreement over the precise extent to which the ‘ceremony of childbirth’ empowered women,49 it is generally accepted that childbirth was under collective female control at least throughout the seventeenth century. Consequently, the male practitioner could only come – whether in an emergency capacity, or as an adjunct to the midwife, or in place of a midwife – with, at the very least, the consent of the mother, the midwife and the invited ‘gossips’ who thronged the delivery room. It is thus no surprise to find that where we have relevant evidence, it appears that each of these various ‘paths to childbirth’ (as I call them) was actually brought into being at the behest of women. In the seventeenth century Percival Willughby was pulled into what became a substantial emergency practice in midwifery against his own wishes, for he found it ‘dreadful unto my thoughts’ to ‘play with human life’ as this work demanded;50 as we shall see in a moment, he was also (though very rarely) summoned in lieu of a midwife, and this too was not of his choosing. So too in the mid-eighteenth century, when calls of this kind suddenly became common and indeed fashionable, this change – the one that we are trying to explain here – did not arise from any campaign on the part of male practitioners to displace the female midwife (for there was no such campaign, pace Beier’s claims mentioned earlier); on the contrary, it arose from new choices on the part of mothers-to-be, and it appears to have taken male practitioners by surprise. I have elsewhere put forward a suggestion as to how this new demand came into being: specifically, that there arose in the mid-eighteenth century a new collective female culture, the culture of ‘the ladies’, that is, of women who – in unprecedented numbers – enjoyed leisure and literacy, and who abandoned the female midwife in an attempt to demarcate themselves from their humbler fellow-women.51 This is not the place to defend that particular claim; but what I would contend is that it is the choices of women which historians of midwifery and medicine have to explain and to take seriously, not least because so much recent work on the British economy in the eighteenth century, and on consumption in particular, has emphasized women’s roles in the diffusion of new consumer goods.52

Conclusion Although this essay has been concerned specifically with midwifery, it suggests three points which apply to early modern medical practice at large. First, we still know remarkably little about the actual early

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modern medical marketplace, for the balance between supply and demand has only just begun to be investigated. Mortimer has paved the way with the imaginative use of probate records; on a smaller scale, the present essay has explored the potential of apprenticeship premiums; and no doubt there are many other materials which can be turned to this purpose. A second and related issue concerns the patient’s perspective. The nub of my argument has been that the market for midwifery services was patient-driven – contrary to the competition theory and its predecessors, which assign agency solely to medical practitioners. And this point may well be of wider relevance; for the patient’s perspective – a concept which was launched at the same time as that of the medical marketplace, that is, the mid-1980s – has been curiously underplayed within the medical marketplace genre. This becomes all the more curious when it is noted that Roy Porter played a major role in bringing about both of these historiographic shifts. Whatever the reason, the two concepts surely deserve to be integrated, by attending not only to what practitioners were offering but also to patients’ needs – very much what Porter called for over twenty years ago.53 Third – and I shall discuss this theme at slightly greater length – we need nevertheless to remember that the very notion of a marketplace tends to obscure the vast diversity of healing roles in early modern England. This can be illustrated in the first instance by early modern ‘midwifery’ itself – for this encompassed many different activities, roles and skills. We have already begun to see this in the case of male practitioners, but the same was true of female midwives. The richly varied meanings of ‘midwifery’ can conveniently be illustrated, in a seventeenth-century setting, by the father-and-daughter practices of the Willughbys, Percival and Eleanor. Percival was summoned to deliveries by some five different ‘paths’;54 and though he was usually called only as an adjunct to the midwife, or after serious difficulty had arisen, he did occasionally act in lieu of a midwife.55 Conversely Eleanor routinely delivered normal births, yet she had at least one emergency call of the kind familiar in her father’s practice (for in this case, which took place ‘in Staffordshire, nigh to Newcastle’, she was the fourth midwife summoned, and from a distance of some ten miles).56 And to add further layers of complexity, father and daughter could be summoned together as a team, while Percival sometimes passed cases on to Eleanor.57 Thus ‘midwifery’ in the practices of the Willughbys meant seven or more different social roles – Percival’s five paths, Eleanor’s two paths, plus combinations between them. And these different kinds of calls-to-deliveries were highly consequential as to

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what the practitioner experienced (normal versus difficult births), was expected to do (delivering a live baby or a dead one), and therefore could do once she or he arrived.58 How many kinds of demand, then, were in play here? One each for Eleanor (midwife) and Percival (male practitioner), one for each ‘path’ in their practices, or what? Similar questions might well be asked about the local surgeon who drew blood and teeth (markets in phlebotomy and dentistry?), cured ulcers, healed green wounds and so on. But the activities of early modern healers were diverse not just as to content – the skills of the practitioner – but also as to form; for healing was not confined to the commercial practice of medicine. On the contrary, such commercial medicine ran alongside, and was intertwined with, non-commercial modes of practice, namely domestic and charitable healing. Domestic healing was one standard activity of a wife and mother, and could easily extend outwards into healing of other kinds: charitable, in the case of women of the landed classes;59 commercial, on the part of their humbler sisters who needed to earn a living or at least to supplement it. As for charitable healing, this was widespread and complex, embracing a range of activities that extended from the petty bounty of the parish officers to that magnificent piece of monarchical theatre, the Royal Touch – not to mention its imitators, notably Valentine Greatrakes.60 The importance of the Royal Touch is indicated not only by the time and expenditure devoted to it by Charles II – he touched up to 200 subjects a week, giving each of them a gold ‘angel’ to wear – but also by the fact that Monmouth practised it during his brief and ill-fated rebellion of 1685.61 Although these three modes of healing can be, and should be, distinguished analytically, they were interconnected in various ways. For instance, charitable healing could serve as the starting point for a commercial practice – as with some of the ejected ministers in the 1660s;62 and as I have just suggested, the same was probably true of domestic healing. Another such interconnection can be seen in Poor Law medical aid; for this was charitable from the point of view of the recipient, yet commercial from the standpoint of the local apothecary or surgeon who provided the service, while the Overseers of the Poor – arguably the most important party, since they initiated the transaction – experienced it as both charitable and commercial.63 Further, there may have been a wider precedent for this in the relations of agricultural production, since it has been argued that servants in husbandry, when hired for a period of a year or more, were entitled to medical treatment at the expense of their employers – one reason among many for the drift towards

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subannual contracts.64 Again, even what might appear to be straightforwardly commercial healing was probably entwined with its charitable counterpart; for it seems likely that medical practitioners, particularly in the provinces, often gave their services gratis to the poor. Indeed the intermeshing of commercial and charitable healing is nicely illustrated in midwifery itself; for the midwife was commonly remunerated not by a fee but instead by a gift or ‘grace’ – whence her designation, apparently used in the north-west of England, as the ‘grace-wife’.65 So too the further tips that midwives received at baptisms from godparents reveal that midwifery was far indeed from being merely a market transaction.66 The danger, then, is that the marketplace model tends to flatten out the relations of healing, or to use a different metaphor, to homogenize them. Just as midwifery was not one practice but many different practices, so too relations of healing were not just commercial but had many other forms and aspects. Thus, at the same time as we deepen our understanding of the medical marketplace along the lines suggested above, we also need to capture the full variety of those forms and their interrelationships – which entails in the first instance recognizing the limits of the marketplace model.

Notes For help with this paper I wish to thank Cynthia Wilson; and I am also grateful to Mark Jenner and Patrick Wallis for their many detailed, penetrating and helpful comments, which have greatly improved the piece. 1. I. Loudon, Medical Care and the General Practitioner 1750–1850 (Oxford, 1986), 90 and passim. 2. Beier, Sufferers (1987), ch. 2. 3. Ibid., 15. 4. Ibid., 44. 5. I. Loudon, ‘Childbirth’, in I. Loudon ed., Western Medicine (Oxford, 1996), 211. 6. Beier, Sufferers, 44. 7. D. Evenden, The Midwives of Seventeenth-Century London (Cambridge, 2000), 176. 8. For a summary see ibid., 184. 9. Ibid., 175, 186, 200. 10. With respect to ecclesiastical licensing, it is suggested (ibid., 176) that ‘pressure from medical practitioners’, in the increasingly competitive environment of the late seventeenth century, may have been ‘a factor in the Church’s loss of interest in the licensing of midwives’ after about 1690. So too the male ‘appropriation of female experience’ is depicted as an effect of the prior desire to take over childbirth, and this desire itself arose (so it is suggested) for economic reasons. 11. Ibid., 184.

Adrian Wilson 171 12. P. J. Wallis, R. V. Wallis, J. G. L. Burnby and T. D. Whittet, Eighteenth Century Medics, 2nd edn (Newcastle-Upon-Tyne, 1988). 13. R. S. Roberts, ‘The Personnel and Practice of Medicine in Tudor and Stuart England. Part II. London’, MH, 8 (1964). 14. Ibid., 229. 15. G. Holmes, Augustan England (1982). 16. Ibid., 3–11. 17. Ibid., Ch. 6. 18. Ibid., 206. 19. Ibid., 209–14, 218. 20. Ibid., 12–15. 21. Evenden, Midwives, 176. 22. Holmes, Augustan England, 230. 23. Ibid., 235. 24. Ibid., 204. 25. I. Mortimer, ‘The Triumph of the Doctors: Medical Assistance to the Dying, C. 1570–1720’, Transactions Royal Historical Society, 15(2005), and Chapter 4 in this volume. 26. J. Lane, Apprenticeship in England, 1600–1914 (1996), 4. 27. N. J. Williams, ‘Introduction’, in C. Dale ed., Wiltshire Apprentices and Their Masters 1710–1760, Wiltshire Archaeological and Natural History Society Records Branch (Devizes, 1961), viii. 28. In all probability the local collectors were notaries public; in Wiltshire the job went to the man who had already been appointed as distributor of stamped parchment and paper for the county. The incentive for the collectors was substantial – 18d. in the £ (7½%) of all that they collected. To encourage payment, extra time was allowed under various subsequent Acts, and in 1745 the penalty of double duty was imposed on those who missed the already-permitted deadline. Nevertheless payments were sometimes delayed for as long as seven years. See Williams, ‘Introduction’, viii, and R. Garraway Rice ed., Sussex Apprentices and Masters 1710 to 1752, Sussex Record Society (1924), Introduction, xix–xx, xxvii. 29. 1192; for 1710 the transcript includes apprenticeships to some nonWarwickshire masters. 30. The records used here derive from K. J. Smith ed., Warwickshire Apprentices and Their Masters 1710–60, Dugdale Society Publications, 29 (1975). I am grateful to Patrick Wallis for suggesting analysing apprenticeship premiums, and to him and to Dr Andrew Hann who compiled the data, for making these returns available in electronic form. 31. Here I am adopting a conservative policy towards the apothecaries Thomas Bett of Coventry (1719, £40), Thomas Bett of Stratford on Avon (1719, £30), Thomas Bott of Coventry (1716, £35) and Thomas Bott of Stratford on Avon (1743, £60). It might well be the case that we have here just two masters, or perhaps three, but I have taken these to be four men; this decision does not affect any of the analyses which follow. 32. There were 35 apprenticeships to barbers; 9 to ‘barber and periwig maker’; 6 to ‘barber and peruke-maker’; 2 to ‘barber and wig-maker’; and 5 to ‘druggist’. The druggists perhaps call for comment: all these five apprenticeships took place in Birmingham in the 1750s and were to three masters, charging

172 Midwifery in the ‘Medical Marketplace’

33.

34.

35.

36. 37.

38. 39.

40. 41.

premiums of £50, £60, and three of £105, the latter three all to the same master, William Taylor. The very high premiums charged by Taylor suggest a wholesaling business, and I have assumed that the same was true of the other two druggists. To include these three would have no material effect on the results that emerge below. Bree was doubtless a member of the long-established Warwickshire medical family of that name (Lane, Apprenticeship, 133); his apprentice, William Bree, was perhaps a nephew of his. A similar pattern has been observed in ecclesiastical licensing: see D. Harley, ‘Provincial Midwives in England: Lancashire and Cheshire, 1660–1760’, in H. Marland ed., The Art of Midwifery (1993), 39–40. For the general case, see A. Wilson, The Making of Man-Midwifery (1995), passim. The only indication I have found comes from Coventry, where the freedom was based exclusively on apprenticeship and for which numbers of new freemen are known for some six years falling within this period; these ranged from 71 (in 1747) to a staggering 571 (in 1734). No doubt Coventry’s notorious sharp electoral practices were at work here (freemen were enfranchised, elections were tight, the corporation was in Whig hands) – but even the lowest figure implies at least 700 Coventry apprenticeships per decade, in which case the proportion paying tax was never more than one in seven and usually less than this. S. and B. Webb, English Local Government: The Manor and the Borough (1908), 296n; ‘The City of Coventry: Crafts and Industries’, A History of the County of Warwick: Volume 8: The City of Coventry and Borough of Warwick (1969), 162–89 (URL: http://www.british-history.ac.uk/ report.asp?compid=16026). Lane, Apprenticeship, 131–4. It will be observed that in some cells two values are entered, in others one. The reason for this is that the median of an odd-numbered set is a single figure, for example, the fourth out of seven cases, whereas for an evennumbered set the median is two cases, such as the fourth and fifth out of eight. The usual convention where two values arise (whether for the median or for a quartile) is to average them, but I have preferred to keep the two. A by-product of the present exercise is to point up the need for a systematic investigation of the administration and coverage of the apprenticeship tax. For Ely and Norwich, see A. Wilson, ‘Childbirth in Seventeenth- and Eighteenth-Century England’ (D.Phil. thesis, University of Sussex, 1982); I hope to publish my findings from eighteenth-century Leicester and Lichfield at a future date. Wilson, Making of Man-Midwifery, 164–9, and references there cited. The considerations put forward here might be thought to have little force, since ecclesiastical licensing in the diocese of London was unique in being linked to the deputy system – in effect, an informal apprenticeship – by which London midwives, remarkably and impressively, seem to have regulated their own recruitment. Thus it would be possible to argue that the fortunes of episcopal licensing elsewhere were irrelevant, and that what counted was London, since it is here that licensing had upheld the deputy system. Yet in fact the matter is strictly indeterminate, since the relationship between church licensing and the deputy system is depicted inconsistently within Evenden’s account: at one point it is held that ‘ecclesiastical licensing

Adrian Wilson 173

42.

43.

44. 45. 46. 47. 48. 49.

50. 51. 52.

53. 54.

55. 56. 57.

was not central to the expertise and competence of what was fundamentally a self-regulatory system of training and apprenticeship’, but that system is later refigured as ‘the self-regulating, co-operative and ecclesiastically based network of the seventeenth century’ (Evenden, Midwives, 175, 186, my emphases). I know of no study of the development of provincial lying-in charities; so far as I am aware, the first was at Newcastle in 1760. On London philanthropy in general, see D. T. Andrew, Philanthropy and Police (Princeton, 1989). On the significance of these institutions we now have two excellent detailed studies: B. Croxson, ‘The Foundation and Evolution of the Middlesex Hospital’s Lying-In Service, 1745–86’, SHM, 14 (2001); and L. Forman Cody, ‘Living and Dying in Georgian London’s Lying-In Hospitals’, BHM, 78 (2004). Evenden, Midwives, 187. This point is made in the specific contexts of the Middlesex Hospital and the Lying-in Charity: ibid., 189, 194. Ibid., 196. Ibid., 200–202. Ibid., 203. D. Cressy, ‘Purification, Thanksgiving and the Churching of Women in Post-Reformation England’, P&P, 141 (1993); U. Rublack, ‘Pregnancy, Childbirth and the Female Body in the Early Modern Germany’, P&P, 150 (1996); L. Gowing, ‘Secret Births and Infanticide in Seventeenth-Century England’, P&P, 156 (1997); L. Pollock, ‘Childbearing and Female Bonding in Early Modern England’, Social History, 22 (1997); A. Wilson, ‘The Ceremony of Childbirth and Its Interpretation’, in V. Fildes ed., Women as Mothers in Pre-Industrial England (1990). Percival Willughby, Observations in Midwifery (Wakefield, 1972 [1863]), 206. See Wilson, Making of Man-Midwifery, ch. 13. E.g., M. Berg, ‘Women’s Consumption and the Industrial Classes of Eighteenth-Century England’, Journal of Social History, 30 (1996); A. Vickery, ‘Women and the World of Goods: A Lancashire Consumer and Her Possessions, 1751–81’, in J. Brewer & R. Porter eds, Consumption and the World of Goods (1993); R. Sweet & P. Lane eds, Women and Urban Life in Eighteenth-Century England (Aldershot, 2003). See R. Porter ‘Introduction’, in R. Porter ed., Patients and Practitioners (Cambridge, 1985), 10; cf. the editors’ introduction to the present volume. Advance calls with midwife; advance calls in lieu of midwife; booked onset calls with midwife; booked emergency calls; and unbooked emergency calls (by far the commonest category). These comprised five of the eight theoretically possible such paths. For these categories and for the distinctions underlying them, see A. Wilson, ‘William Hunter and the Varieties of Man-Midwifery’, in W.F. Bynum and R. Porter eds, William Hunter and the Eighteenth-Century Medical World (Cambridge, 1985). Willughby, Observations, 29. Ibid., 134–5. See A. Wilson, ‘A Memorial of Eleanor Willughby, a Seventeenth-Century Midwife’, in L. Hunter and S. Hutton eds, Women, Science and Medicine 1500–1700 (Stroud, 1997).

174 Midwifery in the ‘Medical Marketplace’ 58. See the articles cited in notes 52 and 55 above, and also Making of ManMidwifery. 59. L. A. Pollock, With Faith and Physic (1995). 60. On the Royal Touch and on Greatrakes, see K. Thomas, Religion and the Decline of Magic (1971), 192–8, and M. Bloch, The Royal Touch (1973 [1961]). 61. Thomas, Religion and the Decline of Magic, 196; Bloch, The Royal Touch, 212–13. 62. A. G. Matthews, Calamy Revised (Oxford, 1934). 63. G. W. Oxley, Poor Relief in England and Wales, 1601–1834 (Newton Abbot, 1974). 64. K. D. M. Snell, Annals of the Labouring Poor (Cambridge, 1985). 65. See in OED, ‘grace’, noun, entries 8(e) and 21. 66. See D. Cressy, Birth, Marriage, and Death (Oxford, 1997).

9 Illness in the ‘Social Credit’ and ‘Money’ Economies of Eighteenth-Century New England Ben Mutschler It is curious to see how completely social ethics and relations have changed since olden days. Aid in our families in times of stress and need is not given to us now by kindly neighbors as of yore; we have well-arranged systems by which we can buy all that assistance, and pay for it, not with affectionate regard, but with current coin. The writer is Alice Morse Earle, whose Home Life in Colonial Days (1898) is both a rigorous treatment of domestic life in early America and tinged with the nostalgia of the colonial revival. There was, Earle confessed, ‘one curious and contradictory aspect of this neighbourliness, this kindliness, this thought for mutual welfare, and that was its narrowness’, especially in New England. For the poor and vulnerable removed from town to town and denied a place in community life, the colonial world could be cruel. But Earle considered this a ‘restraint of vision’, an incidental blot on a grander way of seeing one’s fellow beings. Somewhere between the colonial period and the late nineteenth century, something precious was lost when ‘current coin’ supplanted ‘affectionate regard’ as the means to address misfortune.1 Histories of the ‘market revolution’ in America have found such observations attractive. The change Earle describes seems discrete and profound: from an economy of good will to an economy of money; from informal institutions of care in families and neighbourhoods to ‘well-arranged systems’ of care mediated by cash. But discovering when, where and why these changes occurred has proven to be extraordinarily complex. There is no agreement about the timing, tenor and final meaning of the changes wrought by the market. Even the notion of ‘revolution’ has been called into question. As Richard Bushman has argued, the idea of a market revolution in farm society is built on an 175

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artificial ‘two-part typology’ of ‘household’ and ‘market’ producers, in which the latter replaced the former. But the scheme fails to account for evidence of intensive production for distant markets in the seventeenth and eighteenth centuries as well as the persistence of local barter, exchange and limited trade in surplus well into the nineteenth century. At best, Bushman suggests, we might shift our focus from the temporal dimensions of the revolution to the spatial: ports and inland towns all over early America undergoing transformations at different times, speeds and intensities.2 Historians of medicine in early America face similar challenges. In an effort to show historical change, one may draw too sharp a distinction between the world ‘before’ and ‘after’ the intrusion of the market.3 Paul Starr’s influential The Transformation of American Medicine may stand in for many. Starr’s primary concern is the slow, contested growth in professional medical authority in the nineteenth century and the rise of the medical industry in the twentieth, developments that he argues are inseparable from the growth of the market. With the growth of towns and cities, the care for the sick ‘increasingly shifted from the family and lay community to paid practitioners, druggists, hospitals, and other commercial and professional sources selling their services competitively on the market’. Starr acknowledges that ‘the family continues even today to play an important role in health care’, but he argues that ‘its role has become . . . secondary. The transition from the household to the market as the dominant institution in the care of the sick – that is, the conversion of health care into a commodity – has been one of the underlying movements in the transformation of medicine’. On this account, it is difficult to see anything but withered remnants of the pre-market past surviving the commercialized present.4 For historians of earlier periods, there are two major disadvantages to this scheme. First, the commercialization narrative downplays the degree to which family and domestic medicine continued into the modern period. Histories of informal care in the modern period suggest that even as the cultural authority of medical professionals increased in the decades before World War II, women continued to shoulder the burden of caregiving in their families. Tensions abounded as a result. There were questions of sovereignty to be addressed, as women tried to pick and choose between doctors’ directives that seemed reasonable and workable and those that seemed harsh and too difficult to carry out. Chronic illness raised particularly troubling questions. Poor white women and women of colour had to choose between the paid employment

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crucial to their family’s financial well-being and the unpaid domestic caregiving crucial to its physical well-being.5 Such dilemmas suggest that rather than thinking of domestic care as being supplanted by professional medicine, we might explore the ongoing negotiations between the domestic and the professional. A second difficulty that the medical marketplace has posed cuts in the opposite direction. In focusing on the shift from the familial to the professional and institutional, there is the risk of minimizing how many medical services could become part of family care. Works on the ‘mixed economy’ of healing in early modern Europe demonstrate that institutional care, including care of the sick poor, was often an extension of family care. Rather than seeing informal and institutional care as lying in opposition to one another, it may be more accurate to think of them as overlapping and often complementary.6 While the social history of medicine in early America is still in its early stages, it is clear that in addition to the informal care afforded by family members and neighbours, medical treatment could be sought from an enormous range of lay and learned practitioners in the eighteenth century. The density of practitioners in any given area and the extent of their complementary or competitive roles are problems that are still being worked out. But it is clear that there was a commercial context to domestic medicine in the eighteenth century that argues for important continuities with the nineteenth century.7 The elegiac accounts of colonial America and more recent histories of the market both tell a story of money replacing neighbourly good will. We might more profitably consider the ways in which money and good will had a long and interconnected, if not always tranquil, history in American life. This chapter examines the relation between familial and commercial ‘medical marketplaces’ in eighteenth-century Massachusetts. Refocusing our attention away from therapeutics to care systems, the chapter draws upon diary material and town, court, and provincial records to explore the spectrum of ways in which assistance for the sick was provided. At one end was neighbourly support, with family members, neighbours and the community rallying around their own in times of illness. At the other end lay the harsher realities of charitable and civic provision experienced by the sick poor. Travelling along this spectrum, we see how health care and sickness could operate in both a ‘social credit’ economy, where care for the afflicted was part of a system of social credits and debts, and in a ‘money’ economy, where explicit sums were attached to care for the sick. The tensions between these two methods of provision raised questions about individual and communal responsibility in

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the face of incapacity, and, ultimately, about the nature and meaning of dependence in early America.

On social credit, money, and New England A few preliminary words about the terms ‘social credit’ and ‘money’ economies and their place in New England are in order. Craig Muldrew’s work on the ‘credit economy’ of early modern England illuminates how the ‘value’ of exchange turned on questions of trust, reputation and other considerations that informed one’s ability to access credit. An examination of the ‘social credit’ economy of early New England helps us move beyond thinking of altruism as the driving force behind the extraordinary labour and allowance that could be accorded to the sick. Studies on the intersection of sociability and communal labour in early America have shown that interdependence was the norm in farm society; scarcities in labour and material resources meant that only through exchange could the needs of any farm be met. The favours granted to the sick further illuminate the breadth, depth and limitations of those networks. While the exchanges surrounding illness were rarely recorded formally, diaries and correspondence may be read as ledgers of ‘special kindnesses’ offered and received. A tally of those records allows us to explore the degrees to which any individual or family could command a social response to their incapacities, as well as the extent to which illnesses could stretch the limits of good will.8 By the ‘money economy’ I mean those exchanges in which debts had to be discharged with cash or coin. We should not make too neat a division between ‘social credit’ and ‘money’. Muldrew has shown that many transactions in early modern England were registered in coin in account books, but were discharged through instruments of credit; money was a measure of value, not the favoured medium of exchange in an economy in which coin was scarce. The same may be said more emphatically of the British colonies, in which imperial regulations kept coin limited and ensured that specie flowed back across the Atlantic. The ‘complex barter’ system of New England, in which debts could be reckoned in monetary terms but paid in labour or kind (lumber on the frontier, fish in the ports, and so on) was an artefact of money scarcity. Any simple and universal division between credit and money is untenable.9 Nevertheless, some moments in daily life required colonists to discharge their debts in cash: taxes, fees, land sales, long-distance transactions and dealings between strangers. Poverty and poor relief also became

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intertwined with questions of money. Persons called on to help the poor could expect money from public coffers; for those at the margins, poor relief itself was a way to procure limited cash. But entering the money economy could also be a significant cause of impoverishment. The poor themselves, particularly if they were transient, were limited in the credit they could draw, and so were asked to pay debts in money, further increasing the difficulty of their position.10 While a strain of writings on the medical marketplace have emphasized its liberating potential – the ways in which patient choice counters ‘medicalization’ – the connection between money and impoverishment should give us pause.11 The fact that social relations of poverty, including care for the sick poor, were infused with questions of money goes a long way to explaining the social politics that attended poor relief. New England is an interesting – and somewhat unusual – site to investigate social credit and money as they figured in the medical marketplace. The founding ideals of New England, its relative social homogeneity (compared to the ethnic diversity of the middle colonies and slave societies of the South), and its faltering economy in the eighteenth century set the region apart in mainland British North America. New England had been founded as a refuge from the corruptions of the Old World and an example of well-ordered society in which the Golden Rule would be enacted as a solemn social obligation. God’s covenant with the Puritans required an overriding commitment to community in which, in John Winthrop’s words, ‘every man afford his help to another in every want or distress’.12 Much writing on the early history of the region has focused on the confrontation between these ideals and worldly ambitions.13 By the eighteenth century, a synthesis lay in the social cohesion that could reside in self-interest and in an increasingly narrow legal definition of community. On the one hand, scarcity of labour and material resources (ploughs, draft animals, tools) intensified mutual dependence among households over the century.14 But the period also witnessed efforts to circumscribe the ability of outsiders to become legal inhabitants of local society, with special limits placed on the poor and transient. As population increase put pressure on land by the mid-eighteenth century, people migrated to the west or to port towns in search of new opportunities. These outsiders might be allowed to live in towns where they had no legal residence. But when they fell ill or otherwise threatened to become a public charge, the law was designed to protect town treasuries.15 Town concerns about cash outlays for the poor relate to larger debates about the shortage of hard currency in the region. New England ran an

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unfavourable balance of trade with most of its trading partners, especially with Britain. In the seventeenth century, the region had been supported by profitable exports to the West Indies. But crop failures in the eighteenth century, coupled with increasing competition from the mid-Atlantic and the South, dimmed New England’s ability to pay for the increasing volumes of imported goods from England. With the limited amounts of coin in the region going to English merchants, the colonies experimented with new forms of credit and currency, including emergency issues of bills of credit and land banks. The lack of a stable medium of exchange in New England fuelled divisiveness and could make ventures into the money economy confusing and dangerous.16 We turn now to an in-depth study of social credit in an eighteenthcentury town.

Sickness and social credit: Westborough, Massachusetts, 1739 The detailed diary can tell us much about social networks of care, chronicling the vicissitudes of the ailing body and the social response to it. One particularly rich source comes from the pen of Ebenezer Parkman, minister in Westborough, Massachusetts, a town some thirty miles west of Boston. From 1724 until his death in 1782, Parkman vigilantly recorded matters pertaining to his household and family life, his farm and his pastoral duties. Sickness occupied an important place in all these arenas. As a minister, Parkman saw illness as a crucial opportunity to apply himself to the afflicted and inquire into the state of their souls. As the head of a household and a farmer, Parkman knew well the disruption that illness occasioned. Minor ailments required special attention and changes in social schedule. More serious afflictions consumed family life.17 Parkman’s diary vividly illustrates how sickness became enmeshed in an economy of social credit. The year 1739 was particularly trying for the minister and Hannah (Breck) Parkman, his second wife. Parkman was in his mid-thirties, a respected figure in community life, and sought out on many occasions. Hannah Parkman turned twenty-three that year. A relative newcomer to Westborough, having married the minister two years earlier, she too was involved in the exchanges of neighbourhood and beyond, despite overseeing a household that included children from Parkman’s previous marriage. Ebenezer and Hannah’s serious illnesses during the year reveal the strength and limitations of a community’s capacity to care for its own.

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The year began with the death of the Parkmans’ infant daughter Elizabeth (14 January 1739). Hannah recovered slowly after the birth, being ‘exceedingly pained under her Breasts’ and later having ‘pain from Hip to Toe’ brought on by swelling in her legs (6 February 1739). Her condition and that of the child were severe enough to warrant a steady stream of watchers for the two weeks until the infant died. Watchers came again a week later when Hannah’s pains increased and it was feared that she would follow her child to the grave. Not until mid-February did Hannah feel ‘somewhat better’, allowing the Parkmans to send the afternurse home after a seven-week stay (14 and 17 February 1739). In September and October, Hannah was unwell enough (perhaps in relation to another pregnancy) that Parkman pleaded that his house was in ‘great Trouble’ (28 September, 15 October 1739). A final blow came at the end of November, when Hannah fell from her horse (26 November 1739). The accident was perhaps responsible for the year ending in much the same way it had begun: ‘About 12 (although she had gone but about 5 Months) She was deliver’d of a tender, lifeless, Male Child, The Measure of which was 13½ Inches long’ (25 December 1739).18 Ebenezer Parkman became seriously ill at the end of October, which posed significant problems for the family because Hannah was also unwell at the time. The diary narrates his dramatic decline over four days, as Parkman slipped from being a fully functioning man to being a helpless dependent: ‘Not well at Wards’ (26 October 1739); ‘Not well, but yet in my Study’ preparing for Sabbath (27 October 1739); ‘Grew worse. Not able to go to Meeting’ in the morning but preached in the afternoon (28 October 1739); ‘At Eve my pains exceedingly increas’d. Neighbor How came and got my bed down into the lower room, and lifted me on to it’ (29 October 1739); ‘I grew More helpless’ (30 October 1739). Neighbours and friends had come to visit and no doubt help the Parkmans during this time, but when Parkman’s family physician arrived at the parsonage and judged the minister to be afflicted with ‘high Inflammatory Rhumatism’, a more formal response from the community was needed (1 November 1739). For the next two and a half weeks the family secured watchers who sat up with Parkman singly and in pairs during the night. At the end of three weeks of severe illness, the long process of restoration to full health began. It was the end of December before Parkman returned to the pulpit, a little over two months since he had become bedridden. It was an especially trying year, and the Parkmans relied heavily on their neighbours, friends and relatives to help them through it. Parkman recorded their help in spare, unsentimental entries, such as ‘Rebecca Hicks

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watch’d’ or ‘Nathan Maynard was sent for Doctor’ or ‘Nei[gh]bours on the South side came and got wood’. The diary was a record of social action, a register of ‘special kindnesses’. Such actions were undoubtedly performed in the spirit of friendship and Christian charity. But by noting them in the diary, Parkman ensured that good deeds would not be forgotten. With the exception of the doctor or midwife, most of those whose names were registered in the diary would not be reimbursed with money or the exchange of goods. They could expect to be repaid instead with like action when they found themselves in desperate circumstances. Parkman was particularly attentive to who watched through the night with the family, a gesture that involved considerable sacrifice given the rigours of daily work. Circumstances at the Parkman house were dire enough during the year to require watchers on forty-one separate occasions. Some thirty-five different persons watched in total. Most watched only once. During his fever, Ebenezer Parkman was watched by twenty-two people, fourteen of whom were men. Only one watched more than once. Only three people watched both Ebenezer and Hannah Parkman: they were all women, two were neighbours and one a hired ‘girl’. Hannah Parkman’s circle was smaller than her husband’s and exclusively female. In the two weeks following the birth of her daughter, Elizabeth, eleven women took turns watching her. Four – her afternurse, a young woman hired to help run the household, and two neighbours – watched twice. Because Parkman recorded very little other than the name of the watcher and the date on which he or she watched, one is left with more questions than answers. How was such an orderly display of community care organized? Who decided who would watch? What stresses did watching place on watchers and their families? There is no explicit information to answer these sorts of questions. Nevertheless, three themes emerge. First is the social dispersal of care. Watching was distributed throughout the community. The principle of dispersal explains why there was less overlap than one might expect between those who helped Hannah Parkman deliver her child and the women who tended her in the weeks thereafter. With the exception of the midwife, of the seven women who assembled initially to help with Hannah’s delivery (a false alarm), only two, both neighbours, served as watchers in the following two weeks; one of these had been called out by Hannah’s false alarm and did not participate in the birth a few days later. One suspects that it was understood that these women had already performed an exhausting service, and there was no reason for them to watch while others could do so. In particular, older, experienced women might have needed to

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save their energies for future childbirths. Within the families that sent watchers to the Parkmans we see the same general principle of dispersal at work. The adult sons and daughters in these families most commonly watched; presumably it was less taxing to send energetic youths. Secondly, certain families played critical roles in care. The Hicks family is a good example. Parkman was related to Rebecca (Champney) Hicks through his first marriage. Sometime before 1736, Rebecca and her husband, John, moved to Westborough, where the Hicks family became neighbours to the Parkmans. In the years that followed, the families saw each other regularly. Parkman helped ‘brother Hicks’ get settled in town, and Hicks reciprocated, helping with special projects on Parkman’s farm and in field work and watching with the minister during his illness. ‘Sister Hicks’ and Hannah Parkman appear to have been especially close. In 1738 and 1739 they attended each other in childbirth and sat up with each other as those children lay dying. Two of the Hicks girls were part of the circle of caregiving as well, watching with both Ebenezer and Hannah. In all, the Hicks family watched for the Parkmans on ten out of forty-four nights. A final theme concerns social power. Few of the persons who tended the Parkmans were connected to them as intensely as the Hicks family. Yet the Parkmans were able to draw many watchers into their home. Parkman was, on the whole, well liked as a minister. He healed divisions in the town; his advice was sought in many non-ecclesiastical matters. Certainly the fact that a deacon and other leading men in the community served as watchers was related to Parkman’s public position. Parkman may have commanded a greater response to his illness than other prominent men of the town could have expected for themselves. Tending to the sick and dying was a special part of his calling; he had in the past few years visited many of the families of persons who watched for him in 1739. When Parkman became ill, he drew on these informal social debts. Because Parkman did not regularly record his wife’s visiting, one cannot know the connections she made with those who eventually came to the parsonage to help. Her circle of female watchers was smaller and perhaps more intensely connected than her husband’s. It is clear, however, that Hannah Parkman relied on a network of neighbourly exchange during her sickness. Rebecca Hicks and her daughters and the neighbouring Maynard families tended to Hannah more often than others. Yet Hannah Parkman’s connections in town were not limited to local visiting. Her husband’s diary makes it clear that she went beyond her immediate neighbourhood to show fellowship with those who

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were afflicted. Hannah not infrequently accompanied her husband to private meetings in the houses of the seriously afflicted and to funerals. As the parson’s wife, she had a special stature in the community of suffering. In all of these ways, the Parkmans were unusually capable of drawing watchers into their home. Through connections and calling came ready access to the social credit economy. And yet, even for the Parkmans, social credit was not enough to sustain them during their trials. On two occasions in the year, the length and severity of their illnesses forced the family to enter the money economy. Two and a half weeks into Parkman’s confinement, the orderly system that had brought watchers into his house appeared to be unravelling. The bulk of the watching in the first week had been exercised by the Hicks family and close neighbours; by the second week, Parkman was supported by a more eclectic group, dipping deeper into his social reserve and finding a deacon and a leading citizen from the far side of town to watch. But in the middle of the week, things began to go awry. Two watchers in succession failed to show, leaving Hannah to sit up with her husband. The matter was more than an inconvenience for the minister and his wife. Hannah was four months pregnant and had not felt well for sometime. Parkman was acutely aware of the dangers in exposing an ill wife to night watching; his first wife, Mary, had died three and a half years earlier under similar circumstances. This time the minister made plans to hire a maid from Boston. In 1739 the Parkmans had summoned young women from neighbouring households to help Hannah Parkman with heavy work for a few days at a time. The decision to call for a maid from Boston was different, more along the lines of hiring an afternurse in the wake of childbirth or hiring farm workers from April through September. Hiring a maid meant that, in all likelihood, Parkman would be contracted to pay wages – something he did not do lightly.19 But sick and facing the prospect of a long recovery, his wife pregnant, ill and caring for five children, and having already called repeatedly on friends and neighbours, Parkman may have deemed it prudent to hire long-term help. The economy of social credit had been an effective means of providing for the Parkmans for periods of a few weeks, but it could not do so indefinitely. Perhaps Parkman had these costs in mind when he had his second encounter with the money economy. On December 10, the town met to grant more money for a minister who had substituted for Parkman while he lay ill. That night Parkman wrote, ‘Sundry Neighbours here. N.B. Mr. Tainters advice to offer the Town to bear Some part of the Charge

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of preaching, he not duly Considering the great and extraordinary Charges which I was brought into by my Sickness’. One can imagine the conversation from Parkman’s perspective. It was true that his salary comprised a hefty chunk of the town’s budget, but it had never been enough to support himself and his family – for that he had to add the labours of a farmer to his calling as a minister. Now, at his most vulnerable, he was being asked to pay beyond even the ‘extraordinary charges’ of his sickness. Because Parkman’s accounts and almanacs from this time are lost, it is impossible to know what these charges were. Certainly the doctor, afternurse and maid would be paid in money, goods or notes. The watchers and visitors would be acknowledged in an informal tally of social credits and debts. And then there would be judgment calls. How much of the labour of neighbour David Maynard’s son, Jotham, who performed various tasks on the minister’s farm while Parkman was sick, would appear as debts to be paid? Would the neighbour who brought victuals or drink think to add this to his account? Or did Parkman have in mind all of the extra firewood that had to be secured to burn through the night while he lay ill, or the cost of entertaining all of the concerned persons who came to the house? However these would be tallied, it was clear that despite all of the ‘social work’ done for the minister and his family at no cost, Parkman still felt the palpable connection between sickness and extraordinary charge. If the Parkmans, with all of their social credits on the one hand and the minister’s salary on the other, felt the severe financial burden placed upon them in sickness, what kinds of additional pressures were faced by the impoverished sick, who found themselves without social connections in the towns in which they lived, or strangers in towns they were merely passing through? We turn now to the stories of the sick poor and the politics of providing them with care in the money economy.

The sick poor and the money economy In October, 1738, John Jackson, a stranger ‘providentially passing through’ Attleborough, Massachusetts, fell sick and died under the watch of Thomas Slack, an innholder. Little is known about Jackson. Evidently he had no place of legal settlement in the Bay Colony. When pressed about his residence, Jackson declared that he belonged to Great Britain. Jackson’s life simply left a long bill. After Jackson’s death, Slack drew up an account of his expenses in caring for the sick stranger and attached it to a petition to the General Court. It detailed a mug and a half of

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buttered flip; hiring a man and a horse to fetch the doctor and subsequent charges for his visit; and charges for those who nursed and watched with Jackson. There were charges for the interment, funeral and liquor that flowed after it. Lest anyone forget more mundane expenses, Slack added to all of this ‘The Trouble and Charge in the House not above Expence as Fire, Wood, Candles, and Washing & four days Trouble ’. All of this amounted to £9:19:9. Slack subtracted every possible ounce of worth left to Jackson: the six shillings he had in cash, two oxenbridge shirts (‘part worn’), a pair of shoes and stockings (‘almost worn Out’), an old hat and two old jackets (‘of small value’), all of which amounted to £1:6:0. The town selectmen pronounced the charges ‘just and reasonable’. Attleborough’s representative to the General Court drew up the petition on Slack’s behalf and was given permission by the innholder to receive any money granted.20 Here was a corner of the medical marketplace that lay opposite the Parkmans and the social credit economy. With no ties to family, neighbourhood or town, every element of care for Jackson was reduced to a monetary price. From a financial perspective, Slack had been fortunate that Jackson had died quickly. In just a few days, the cost of his sickness had well surpassed Jackson’s ability to pay. The General Court was responsible for strangers like Jackson who had no legal residence in Massachusetts, but as was the case at all levels of public relief, large bills received especially strict scrutiny. Had Jackson lingered, Slack would have likely suffered a loss. But with the backing of the town selectmen who verified his charges and the help of the town’s representative to the General Court, the financial burdens presented by a humble stranger worked their way through the highest levels of government. Innholder, selectmen and representative alike must have been relieved when the initial committee review of the account subtracted only 20 shillings from Slack’s request. In theory, public relief for the sick poor should have been an untroubled affair. In contrast to the ‘sturdy beggar’, whose poverty was thought a product of idleness and vicious habits, the impoverishment of the sick, infirm and impotent was understood to warrant compensation. But as recent scholarship on early modern England has suggested, we should not confuse theory and practice. In many cases, the sick and those caring for them could not expect immediate public relief and had to devise strategies to tap into public coffers.21 The same may be said of eighteenth-century New England, where two aspects of care for the sick poor led to confusion and contest. First, there were problems surrounding the indeterminacy of illness. Because there

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was a vast continuum between perfect health and death, any given sickness raised the question of the degree to which accommodation was warranted. How extreme was the condition and what public allowance should it be granted? Second, there were problems surrounding the local provision of care. Following the precedent of the Elizabethan Poor Laws, the responsibility for the poor belonged to local society; families and towns were obligated to care for those determined by law to belong to them. But when the people fell ill away from their family and place of legal inhabitancy, bills piled up well in advance of the determination who was responsible for them. Beneath the complaints about the care of the sick poor lay a fundamental disjuncture between the biological and the political: sickness and compensation operated according to two vastly different schedules. While the sick person’s condition called for immediate measures to ease pain or to address acute illness, political arrangements were slow and uncertain, as the sick, their families and towns tried to sort out the tangled lines of responsibility for the costs of care. Let us begin with a brief sketch of the ways in which care for the sick poor was provided, and then explore the underlying tensions as they affected the sick themselves, their families, their towns and finally the province as a whole. The poor were the responsibility of the town in which they had a legal settlement, which was most often a function of birth, marriage, parentage or continuous residence. The most common type of assistance in rural towns came in the form of outrelief, where submissions for nursing the sick who were legal inhabitants were added to the cost of their board, clothing and other sundry charges. Physicians in rural areas made a variety of arrangements to accommodate the poor and near poor, accepting payments in goods and labour, forgiving portions of their charges and running accounts directly with towns. In urban areas like Boston and Salem, indoor relief assumed greater importance over the eighteenth century, and physicians contracted with almshouses for annual salaries and fee schedules for visits. Finally, for those impoverished by epidemics and wartime illness, the sick and those who cared for them could turn to the provincial government for relief.22 Nevertheless, provisions for the sick poor were not automatic. Towns met yearly to ‘look into the circumstances’ of the poor and decide on what method and extent of aid they ‘thought most proper’, and while it is clear that considerable effort went into easing the plight of the ailing, contested cases reveal the pressures facing the sick and those tasked with their care. Consider the case of Thomas Stockbridge, of Situate,

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Massachusetts, who urged the Court of General Sessions at Plymouth to intervene with town authorities on his behalf. Stockbridge had asked his selectmen for an abatement of his poll tax, assessed on all male householders over age sixteen as a measure of the productive capacities of the household. Stockbridge had a rateable estate – he was not destitute – but he argued that at age seventy-nine he was so disabled that he should be excused from his poll, something the town had refused to allow from 1778 to 1781. He had ‘for above nine years [been] so lame as not to be able to do one Day’s work in a Day since, by reason of Rheumatick Disorders setting in both his knees; and for 3 or 4 years so blind and deaf as not to be capable to act or carry on Business, but that he has been obliged to leave it to his sons to manage his affairs . . . ’. Others pleaded in a related vein: ‘lameness’, ‘bodily indisposition’, and the decay of old age had incapacitated them from the labour that was taxed. Some, like Stockbridge, were awarded their back taxes; others were not. Regardless of outcome, the cases suggest the moral pressures faced by those asking for exemption. Towns might tell men who had worked their entire lives that to feel uneasy and unwell did not excuse them from the public’s claim to their labour or its cash equivalent.23 Stockbridge petitioned on his own behalf, but he made it clear that he was dependent on his sons. Before public relief could be issued to the aged infirm, families were legally bound to offer assistance, an obligation that could occasion anxiety and resistance. While a range of persons may have felt morally bound to care for their kin, the law defined family responsibility quite narrowly: grandparents, parents and children were responsible for each other. Towns regularly helped poor families care for their own with food, fuel, clothing or with limited cash outlays. But that relief was a fraction of what might be required, especially when the poor were sick or infirm. The case of the Plymouth shipwright, Samuel Kempton, is instructive. When Kempton petitioned the Court of General Sessions in 1739, he pleaded that he had supported his aged mother-in-law, Bathshua Donham, who was ‘much impaired in her healt[h] and Senses’, with just £4 allowed by her town selectmen. Despite repeated entreaties to other family members, no one would help. When the court found in his favour, it demanded that the children and grandchildren pay Kempton £36 a year, fully eight times his allotment by the town. It is little wonder that persons like Kempton feared that the ‘Necessitous Circumstances’ of the aged indigent could become their own.24 Nor is it surprising, given the costs, that some families neglected their legal responsibilities. Many petitions state that family members had

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been applied to and refused to contribute: brothers and sisters and grandchildren left a few of their hapless relations to shoulder the burden of care for those who could no longer support themselves. When cases like these reached the courts, the aggrieved were prepared to argue that others were able but simply unwilling to help. This may have been true, but the court’s solution to the problem, rounding up those legally responsible for care and dividing the costs among them, also suggests that refusal to provide for kin may have been a frank recognition of the potentially overwhelming burden of tending the aged indigent. When the court divided care into portions of sixteen, as it did when it assigned the son of the aged and infirm Ruth Drew five-eighths responsibility for her care and her six grandchildren one-sixteenth a piece, it was not only a comment on the legal definition and implementation of ‘family’ obligation, but also a statement about the need to spread thinly the burdens of care.25 When families could not be made to care for the aged infirm, the burden fell to the towns of their legal inhabitancy. Small farming towns like Wenham where cash and coin were scarce, gave especially close attention to finding ways of limiting outlays. The provisions for Sarah Batcheller, widow, who was boarded out to Lieutenant Josiah Herrick in 1770, were typical. Herrick was to take her into his family for the year, to provide her with food, drink, washing and lodging, and to return her clothes and bedding in the same condition in which they arrived. The town promised him nine dollars, the ‘Labour the sd widow can do, being Constantly Emply’d as she is able during sd Term’, and offered to pay the ‘Necessary Charges of Doctors & Nursing’ in case of sickness. Even as it acknowledged that the poor widow might face sickness during the year, the town traded on the cash value of her future labour; her steady employment, even in a limited state, became part of the negotiation. For her part, the widow could hope that the expectation that she would labour ‘constantly’ would be eased in her indisposition, and that the ‘necessary’ charges for her care would not be done on the cheap.26 When we turn from the town’s legal inhabitants to its provision for strangers, transients and others not entitled to relief, we find different sets of negotiations over costs and responsibility for illness. Towns protected their coffers by ‘warning’ outsiders, serving them legal notice that they would not be relieved should they become ill or impoverished. When non-residents came to town, the law demanded that they or their hosts announce their presence to officials and post bond for future care. In theory, such measures allowed persons to visit and labour

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without rendering the town vulnerable. In practice, there were complications. Officials and residents learnt to recognize persons who could be future liabilities, such as pregnant women, and have them summarily removed. But illness made this strategy problematic. It was not always manifest; one could enter a town healthy and fall ill soon after. More insidiously, the very thing that made sick strangers costly also made it quite difficult to remove them: it was not proper to expel a dangerously sick person, and in the meantime, care was provided without a clear sense of where the responsibility for payment would ultimately reside. The case of Nicholas Shaw, a yeoman of Abington, Massachusetts, is one of many that speaks to this ambiguity. Shaw complained at the Plymouth Court of General Sessions in 1766 that Sarah Richards, a single woman who had lived in town for several years in ‘poor and necessitous’ circumstances, had come to his house and ‘fell sick there and became burthensome to Petitioner for her support, though [he] is not nor ever was under any legal obligation to maintain her’. We do not know why Shaw allowed Richards in his house in the first place; perhaps it was an act of charity or an effort to secure household help. Whatever the case, Richards was soon confined to bed, and Shaw had to pay for her board, lodging, washing, nursing, watching, doctor’s visits and medicines. Shaw argued that the town should pay him for his ‘great expence’, but the selectmen and overseers of the poor in Abington refused, a common strategy when an indigent’s residency was in question (and one less aggressive than suing the townsman who harboured a stranger without properly notifying officials, a measure towns also pursued). The court found in Shaw’s favour, and ordered Abington to pay Shaw £25:6:0 for forty-five weeks of care and an additional £4:8:0 for the expenses of her final seven weeks, including digging a grave and the funeral. It was certainly a sweet victory for Shaw, but his need to provide immediate care for Sarah Richards had put him in considerable debt for a year, and one can only imagine the difficulties that this had caused in his other transactions.27 In like fashion, the sick transient figured in debates between towns. Warnings should have held towns immune to the costs of outsiders, but because warnings did not necessarily mean removal, when outsiders became sick, costs mounted as towns tried to sort out legal responsibility. Plympton had warned out Ruth Drew as early as 1757. When in 1762 the selectmen found that she was ‘sick and so poor she can’t support herself’, they applied to nearby Halifax, which they claimed was her legal residence. But the Halifax selectmen refused to pay for Drew. It was five weeks before the Plympton selectmen successfully presented their

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case to the Court of General Sessions and were awarded costs. They had been fortunate. In many other cases, the dispute over what town was responsible for the poor continued without resolution. Ambiguous settlement histories, failure to warn out in a timely fashion, improperly served notices and a host of other difficulties meant that although charges for care were immediate and pressing, the political solution for the sick poor could drag on.28 Finally, the difficulties posed by the sick stranger bubbled up to the General Court, where they were heard in petitions and accounts from individuals and towns asking for relief. There were two major sources of the problem. First, there were transients with no legal settlement in Massachusetts whose ‘stroll’ through the countryside and ports was interrupted by severe illness. Cases like John Jackson’s, with which we began, dot the provincial records. The sick stranger was most prominent in Boston, New England’s cultural capital and commercial centre, where selectmen placed a range of sick and ailing strangers on province rolls, including travellers and sailors from countries throughout the Atlantic, wanderers from neighbouring colonies, and free blacks and Indians from the province who had no access to legal settlement.29 The second source of province poor stemmed from the surges in violence and dislocation that punctuated colonial life. Starting with King Phillip’s War (1675–6), Massachusetts made special allowance for those wandering unfortunates who were ‘forced from their habitations’ and found themselves in towns to which they had no legal claim to assistance. The Acadian exiles deported to Massachusetts beginning in 1755 – a massive infusion of over 2000 impoverished refugees, whose homes and farms had been destroyed by the British – are the most spectacular example of this sort of colonial dislocation, and their extreme circumstances became deeply enmeshed in provincial government. Starting with the initial deportation and continuing for a decade, dozens of towns from every corner of the province submitted accounts for the support and medical attention given to ‘French Neutrals’, the geographic range of claimants widening as the exiles were relocated in response to towns’ pleas that they faced an overwhelming financial burden in providing care.30

Conclusion Any given sickness in eighteenth-century New England called forth a different arrangement of individuals; each sickness created its own society. At one end of the spectrum lay a family like the Parkmans. Deeply rooted in community and enmeshed in the social credit economy,

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the Parkmans could draw on a vast network of helpers during the family’s time of need. Such help would not be forgotten; it would be recorded as a social debt to be paid at a later date and constituted a major strand of interdependence in community life. At the other end of the spectrum lay the sick poor wholly at the public charge. Government commissioned people to care for those deemed incapable of providing for themselves, and almost every conceivable cost associated with care was assigned a monetary value. Individuals, families and towns then struggled to sort out responsibility for care and payment. An extensive realm lay between these two extremes, one that has only been hinted at here. It was dominated by a cruel logic that constructed two interconnected paths leading inexorably towards dependency. One path was travelled by those isolated from the community of social credit: the fewer social connections one had, the more likely it was that in times of sickness one would have to enter the money economy and become indebted. The other path was travelled by those whose illnesses were severe: even for those as well-connected as Ebenezer Parkman, the more severe a sickness, the more likely it was that the economy of social credit would not suffice, and one would need to enter the money economy for care. In either case, debt would grow because of the very conditions – isolation, weakness, incapacity – that made it difficult to repay obligations. The medical marketplace in early New England may have afforded those privileged with access to money and credit the ability to seek satisfying medical attention. But for the marginal and seriously afflicted, the forced confrontation with the market could fuel a dynamic of dependency, leading the sick and their caregivers to turn to the state to place a price on suffering.

Notes 1. A. M. Earle, Home Life in Colonial Days (Lee, Mass., 1993 [1898]), 388, 391. 2. R. L. Bushman, ‘Markets and Composite Farms in Early America’, WMQ, 55 (1998). For overviews of the ‘market revolution’ in the nineteenth century, S. Wilenz, ‘Society, Politics, and the Market Revolution, 1815–1848’, in E. Foner ed., The New American History (Philadelphia, 1990), 51–71 and C. Sellers, The Market Revolution (New York, 1991). A. Kulikoff, ‘The Transition to Capitalism in Rural America’, WMQ, 46 (1989) reviews how early Americanists have taken up the issue. 3. Bushman is sharp on this point in reference to the market revolution. See Bushman, ‘Markets and Composite Farms’, 351. 4. P. Starr, The Social Transformation of American Medicine (New York, 1982), 22. 5. E. Abel, Hearts of Wisdom (Cambridge, Mass., 2000); idem, ‘“Man, Woman, and Chore Boy”: Transformations in the Antagonistic Demands of Work and

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6.

7.

8.

9.

10. 11. 12. 13.

14.

15.

16.

17.

Care on Women in the Nineteenth and Twentieth Centuries’, The Milbank Quarterly, 73 (1995); idem, ‘A “Terrible and Exhausting” Struggle: Family Caregiving During the Transformation of Medicine’, JHM, 50 (1995). M. Pelling, The Common Lot (1998); P. Horden, ‘Household Care and Informal Networks: Comparisons and Continuities from Antiquity to the Present’; S. Cavallo, ‘Family Obligations and Inequalities in Access to Care in Northern Italy, Seventeenth to Eighteenth Centuries’, in P. Horden and R. Smith eds, The Locus of Care (1998), chs 1, 3. Prominent works, with a special emphasis on New England, include: P. Cash, E. H. Christianson and J. Worth Estes eds, Medicine in Colonial Massachusetts, 1620–1820 (Boston, 1980); E. H. Christianson, ‘The Emergence of Medical Communities in Massachusetts, 1700–1794’, BHM, 54 (1980); N. Gevitz, ‘“Pray Let the Medicines Be Good”: The New England Apothecary in the Seventeenth and Early Eighteenth Centuries’, Pharmacy in History, 41 (1999); P. Benes ed., Medicine and Healing, Annual Proceedings of the Dublin Seminar for New England Folklife 15 (Boston, 1990); P. A. Watson, The Angelical Conjunction (Knoxville, 1991); L. T. Ulrich, A Midwife’s Tale (New York, 1990); R. J. Tannenbaum, The Healer’s Calling (Ithaca, 2002). C. Muldrew, The Economy of Obligation (New York, 1998). On the ‘social work’ that fueled the social credit economy, see K. V. Hansen, A Very Social Time (Berkeley, 1994), esp. ch. 4. C. Muldrew, ‘“Hard Food for Midas”: Cash and Its Social Value in Early Modern England’, Past and Present 170 (2001). On ‘complex barter’, M. Merrill and S. Wilentz eds, The Key of Liberty (Cambridge, Mass., 1993), 12. The literature on the dimensions of the money economy is vast. R. L. Bushman’s, From Puritan to Yankee (Cambridge, 1967), chs 7–9, remains useful, and I am indebted (if I may use the term) to Professor Bushman for the term ‘money economy’. Muldrew’s insights on the marginal and credit are helpful here, ‘“Hard Food for Midas”’. E.g., Porter, Progress. J. Winthrop, ‘A Model of Christian Charity’, in C. Mulford ed., Early American Writings (New York, 2002), 238–9. For an exploration of these tensions, M. A. Peterson, ‘Life on the Margins: Boston’s Anxieties of Influence in the Atlantic World’, in W. Klooster and A. Padula eds, The Atlantic World (Upper Saddle River, NJ, 2005). B. H. Pruitt, ‘Agriculture and Society in the Towns of Massachusetts, 1771: A Statistical Analysis’ (Ph.D. thesis, Boston University, 1975). D. Vickers has argued that interdependent relations between family farms were rising during the eighteenth century in Essex County, Massachusetts, Farmers and Fishermen (Chapel Hill, 1994), ch. 5. D. L. Jones, ‘The Strolling Poor: Transiency in Eighteenth-Century Massachusetts’, Journal of Social History, 8 (1975); idem, ‘The Transformation of the Law of Poverty in Eighteenth Century Massachusetts’, in D. R. Coquillette ed., Law in Colonial Massachusetts 1630–1800 (Boston 1984), 153–190. For public debate over currency in New England, see M. E. Newell, From Dependency to Independence (Ithaca, 1998), chs 7–11. Newell emphasizes the liberating potential of paper money. Westborough’s population was 1110 in 1765 and hovered around 900 for the last quarter of the century, H. P. DeForest and E. C. Bates, The History of

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18. 19.

20. 21.

22.

23.

24. 25. 26.

27.

Westborough, Massachusetts (Westborough, 1891), part II, 345. The portions of the diary discussed here are in The Diary of Ebenezer Parkman, 1703–1782: First Part, Three Volumes in One, 1719–1755, ed. F. G. Walett (Worcester, 1974). On Parkman, see R. W. Beales, Jr, ‘Nursing and Weaning in an EighteenthCentury New England Household’, in Peter Benes ed., Families and Children (Boston, 1987); idem, ‘“Slavish” and Other Female Work in the Parkman Household, Westborough, Massachusetts, 1724–1782’, in P. Benes ed., House and Home (Boston, 1990), 48–57; idem, ‘The Reverend Ebenezer Parkman’s Farm Workers, Westborough, Massachusetts, 1726–1782’, Proceedings of the American Antiquarian Society, 99 (1989). See also Rose Ann Lockwood, ‘Birth, Illness, and Death in 18th-Century New England’, Journal of Social History, 12 (1978). On the stages of recovery after childbirth, see Beales, Jr, ‘Nursing and Weaning’, 52 (and Note 13); Ulrich, Midwife’s Tale, 188–190. There is no explicit record of the arrangement with the maid. Judith Rocke was eventually hired, arriving on 6 December 1739. She appears only once more in the diary (2 May 1740). On female workers in the Parkman household, Beales, Jr, ‘“Slavish” and Other Female Work’. Massachusetts State Archives, Massachusetts Archives Collection vol. 105: 156–7, 30 November 1738. S. King, ‘“Stop This Overwhelming Torment of Destiny”: Negotiating Financial Aid at Times of Sickness under the English Old Poor Law, 1800–1840’, BHM, 79 (2005). On settlement laws, J. Leavitt, A Summary of the Laws of Massachusetts Relative to the Settlement, Support, Employment and Removal of Paupers (Greenfield, 1810) and D. L. Jones, ‘The Transformation of the Law of Poverty in Eighteenth Century Massachusetts’. On medical provision, D. L. Jones, ‘Charity, Medical Charity, and Dependency in Eighteenth-Century Essex County, Massachusetts’, in Cash, Christianson and Worth Estes, Medicine in Colonial Massachusetts. See also the account book of E. Roby, 1749–72 (Countway Library of Medicine, Boston, Massachusetts), who ranged through Middlesex county; and physicians’ accounts with the Boston overseers, Massachusetts Historical Society, Boston Overseers of the Poor Records, 1733–1925, Box 1, folder 2. Petition of Thomas Stockbridge, in D. T. Konig ed., Plymouth Court Records 1686–1859 (Boston, 2002), General Sessions, October 1781 (hereafter PCCR). See also complaints and petitions of Ichabod King (PCCR, General Sessions, September 1737), Ephraim Norcut (PCCR, General Sessions, December 1739), Thomas Mansfield (PCCR, General Sessions, April 1769) and Benjamin Bates et al., (PCCR, General Sessions, April 1780). Petition of Samuel Kempton, PCCR, General Sessions, March 1740/41. On Ruth Drew, PCCR, General Sessions, April 1767. Wenham Town Records, 1730–1775 (Wenham, 1940), 246–7. Wenham ranked in the seventh decile in an assessment of the stock-in-trade, supply of specie and money lent at interest in all Massachusetts towns in 1784. See calculations in V. B. Hall, ‘‘Appendices to Politics wihout Parties,” unpub. mss., Hillman Library, University of Pittsburgh. Petition of Nicholas Shaw, PCCR, General Sessions, July 1766.

Ben Mutschler 195 28. On Drew, see PCCR, General Sessions, September 1755, April 1762, July 1762. Nowhere is the protracted process more visible than in the work of the Boston overseers, whose extant records fall beyond the chronological boundaries of this study. See, for example, the long list of letters, written monthly, to towns across the state that refused allowance for Boston almshouse residents. See Boston Overseers of the Poor Records, Daily Memorandum Book, 1 January 1816–31 December 1834, Box 14, Folder 5. 29. See examples in A Report of the Record Commissioners of the City of Boston Containing the Selectmen’s Minutes from 1742–3 to 1753 (Boston, 1887), 37. The almshouse, where the majority of province poor were sent, charged roughly one-sixth to one-quarter of its account to the province between 1758 and 1764. See Boston Overseers, Box 1, Folder 2. 30. For the initial law, see The Colonial Laws of Massachusetts (Boston, 1887), 238. On Acadians, see J. M. Faragher, A Great and Noble Scheme (New York, 2005), 373–5, 378–80 and the town petitions, found in Massachusetts State Archives, Massachusetts Archives Collection, vols 23–4.

10 Medical Marketplaces beyond the West: Bazaar Medicine, Trade and the English Establishment in Eighteenth-Century India Pratik Chakrabarti The theme of the medical marketplace has emerged as an important component of the history of medicine of early modern Europe. It has highlighted various aspects of the social and economic organization of health care there, including the commercialization of medical practice, competition between practitioners and the restructuring of professional hierarchies. Yet, this commercialization of medicine has so far been explored only within the problematic of European social and economic history, despite the fact that the experiences of trade with the Empire, of its markets, ports, bazaars and emporia formed a unique and important part of the commercial history of seventeenth- and eighteenth-century Europe. Such Eurocentrism within the social history of early modern medicine is surprising. The use of new and exotic medicaments increased in Europe massively between the sixteenth and nineteenth centuries with the importation of drugs from Asia and America. During the seventeenth century, imports of drugs from these parts soared at least twenty-five-fold, with many of these newer items like ipecacuanha proving effective and highly popular in Britain.1 Moreover, joint stock trading firms like the English East India Company (EEIC) were some of the largest employers in eighteenth-century Britain, and the clerks of the EEIC were part of an expanding well paid and highly educated middle class.2 From the seventeenth century the EEIC employed a massive fleet of medical professionals recruited from Britain. The effects of Empire have, however, been addressed within the history of science. Richard Drayton observed that with the increasing realization of how transoceanic empires changed the horizons of politics and culture within Europe, for imperial historians ‘the coastline of 196

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Science beckons with opportunity’.3 For the same reason, the coastline of empire has beckoned to historians of science. Moreover, commercialization has dominated the recent history of imperial science. The links between science and commerce have been explored, as have those between commerce, commodities and curiosities. Important arguments about how commerce shaped the representation of nature have been formulated.4 These have contributed to our growing understanding of the contribution of the periphery in the expansion of metropolitan knowledge systems.5 This engagement with trade and commerce in the historiography of imperial science provides us with an entry point from which to explore the possibilities and the profitability of the theme of ‘medical marketplace’ on Indian shores. How did commerce, markets, trading companies and merchants shape a new material culture of European medicine in eighteenth-century India? How far were the medical trajectories of these sites experiences in ‘laissez-faire’? Discussions of the medical marketplace in England and Europe from the seventeenth century onwards, have portrayed it as a laissez-faire system, with a general ‘deregulation’ of the medical profession and practice. In India, on the other hand, the experiences of the market and European laissez-faire, as I shall show, stimulated regulatory institutionalization. Marketplaces here were not just signifiers of free enterprise and autonomy; they were also sites of control by the EEIC and of monopolization. As Sudipta Sen has argued, from the mid-eighteenth century India’s marketplaces, like its land, became sites of control and ‘settlement’. The markets invited the attention of a colonial government driven by investments and additional revenue and increasingly facing demands for the firm regulation of inland trade. At the same time, there was reformist pressure to free commerce from what were manifestly feudal and despotic conditions. The burgeoning Company-state between 1770 and 1820 conducted a detailed inquisition into the validity of marketplaces and market rights as public and private property, supplanting traditional zamindari authority and undermining the mediation of indigenous intermediaries, brokers and traders. This exposed the contradictory pulls of laissez-faire and initiated close scrutiny of commercial activity.6 To explore these themes I will focus on the main site of eighteenthcentury Eastern commercial exchange, the bazaars, and survey their significance to the European medical profession and the EEIC in order to understand the processes involved in the formation of a non-Western medical marketplace.

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Markets and metaphors: Europeans and the world of bazaars At one level bazaars were sites of exchange, profit and provisions for Europeans in India. At another, they represented what they connote even today: an exotic, commercial, Oriental world of collection and sale; and a site of chaos and confusion. This chapter will demonstrate how these two identities of the bazaar, one as a site of everyday barter and the other as an unfamiliar and chaotic world engendered an essential aspect of European medical engagements in eighteenth-century India. The practice of medicine here aimed as much at everyday survival in a hostile land as at the collection and study of exotic cures. To understand the nature of the exchanges that European surgeons undertook in the Indian bazaars, we need first to appreciate the significance of the ‘bazaar’ in eighteenth- and nineteenth-century Indian history. Defined as ‘an Oriental market-place’,7 the term ‘Bazaar’ has been part of European languages from the time Europeans entered the bazaars themselves. Bazaars were of various kinds, sometimes contiguous lanes of shops, sometimes large single-roofed buildings, sometimes arranged over a large square in the village or town centre, or sometimes scattered around the ports.8 The bazaar of the seventeenth and eighteenth centuries has been generally described as the meeting place of several worlds. Holden Furber depicts the great ‘trading green’ and bazaar of the port of Surat in the 1680s as a world in itself: Here, say, in the sixteen-eighties, the visitor, from the ramparts of the nawab’s fort, could look down to his right upon the great trading “green,” and to his left see a long stretch of the Tapti river with the “godowns”—that is, warehouses—of the Portuguese, English, and Dutch below the fort, with the French upstream above, for they have been the latest to arrive. Coming up the river would be a long procession of flatboats manned by lascars bringing up the “Europe goods” from the annual visitation of East Indiamen lying at anchor at “Swallow hole” a little to the north of the estuary of the Tapti. Most goods were destined to be sold at “public outcry” on the “green”. Such an occasion would bring to the “green” the leading Hindu and Muslim merchants with their servants. Huge scales would be set for the weighing of copper, iron, and lead. The import warehouse-keepers of the European East India companies would be on hand with their peons and clerks. A horde of lesser folk would have come to see

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what new European novelties—knives, watches, scissors, needles— the “Europe-ships” officers had brought out in their privilege of private trade, and the proceedings might be livened by the appearance of European dogs and Arabian horses destined for an Indian prince.9 Bazaars were one part of the spatial and social plurality of a colonial port city, divided into White and Black Towns, with several districts with their own town centres and markets, large sections of indigenous, Armenian and European merchant groups. Indeed, this diversity provided a means by which the colonial powers could draw together the varied skills, the capital and dominant social groups which would serve their economic purposes as well as provide political legitimacy.10 The bazaar has become a signifier of interactions between the East and the West. This is not because India’s bazaars were peculiarly and intrinsically distinct, ‘representative’ or nodal sites, but because they catered to the essential and various aspects of European interest in the subcontinent: trade, profit, consumption and provisions. As Anand Yang’s recent sophisticated analysis of the bazaar argues, ‘the discourse relating to the bazaar in colonial India comes wrapped in layers of Orientalism’.11 Yet he still suggests that the bazaar was a peculiarly tangible entity, reflecting true Indianness and offering ‘an empirical counterweight to the imagined village’.12 Even so, the bazaar encapsulates the European imagination of the East more than the essence of India. It denoted, and continues to denote to Europeans, Indianness, localness and also alienness.13 Santhi Hajeebu has shown that scholars, particularly European imperial historians, have frequently highlighted the ethnic, gender and social hierarchies of the ‘bazaar’ thus assuming it to be categorically different from the scientific notion of a market.14 Next we will explore some of these links between such bazaars and the indigenous.

Bazaars and local provisions Bazaars were of course crucial to the main interest of the EEIC: trade.15 They also played an important role in its military logistics, often providing a solution to the army’s provisions crises through local civilian supplies, particularly when the EEIC’s commanders were reluctant to accept responsibility for organizing them. In order to sustain a field army in the interior of a country alien in climate, culture and politics, the Madras authorities adopted the simplest and most flexible logistical system available, the traditional Mughal method of supplying armies from Indian sutlers or traders who trailed along behind forming an accompanying

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bazaar. This was particularly important for the sepoys (the Indian soldiers in the British army disciplined and dressed in European style), who were expected to fend for themselves. These bazaars were largely unregulated, consisting of old men and children, often causing chaos if the army were ambushed. The Maratha or Mysore armies, by contrast, travelled light.16 Even when the EEIC took direct responsibility for feeding the European troops, who apparently disrupted the bazaars by bullying the sutlers for lower prices, the bazaars continued to provide supplies for the sepoys who were the bulk of the EEIC’s army.17 Bazaars long remained an important logistical resource for the EEIC’s army: even in the nineteenth century the army had a recognized ‘bazaar contingent’, including prostitutes, dhobis (washer men), tea-makers, servants, etc. who ‘matched the regular soldiers in numbers’.18 In eighteenth-century EEIC hospital records we find several references to ‘Bazaar medicine’. By the middle of the century, Country medicines or Bazaar Medicines, as they were interchangeably called, had become a regular and important part of the supply of drugs for the British military hospitals in India. The Surgeon General’s Records of the Madras Presidency maintained separate indents for European and Country Medicines.19 One proposal of a report in 1758 from the surgeons in Madras for the improvement of the hospital was to have a room large enough to store ‘European & Country Medicines’.20 In Bengal, too, regular allowances were paid to the surgeons for expenses in coolies, carriages, black assistants and bazaar medicines.21 Bazaar or Country medicine can thus be understood in terms of local supply in a colonial settlement. Anything procured locally and not sent from Europe thus constituted ‘Country Medicine’, and these, along with necessities like lamp oil, were often bought from the bazaars. The growing number of Indians recruited into the EEIC’s forces in the eighteenth century increased the Company’s need for Bazaar medicines. During 1765 a major expansion of the Madras Native Infantry took place. About the same time the government sanctioned the appointment of a Native Doctor to each Sepoy battalion with the pay of a ‘havildar’ (a non-commissioned Indian/Sepoy officer, corresponding to a sergeant).22 The Sepoys were thus generally under the charge of a ‘Black Doctor’ and were treated mostly with Bazaar medicines. These local Indian assistants formed an important component of British military health care in India, just as the Sepoys did in the army. By the end of 1786 ‘native doctors’ attached to sepoy battalions were paid on average about 31 rupees per month.23 In 1792 Indian contractors were appointed to supply Bazaar medicines to the General Hospitals.24 The

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salaries of the native doctors in the Sepoy Hospital were much lower than European surgeons’ at the General Hospital: native doctors earned £240 p.a. compared to the £2500 paid to the Physician General at Madras and the £2000 p.a. paid to his equivalent in Bengal, or the £1500 and £800 paid to the head surgeons of the general hospitals in Madras and Bengal, and Bombay £800 respectively.25 Salaries of servants were around 60 pagodas per month.26 Local procurement of medicines had many advantages. They were often cheaper and fresher. The Court of Directors once replied to a request for Russian rhubarb that London apothecaries reported that for several years there had not been any Russian rhubarb in the market, and that ‘what is now sold under that name, is nothing else but the best sort of India Rhubarb, it may therefore be a question whether the Medical Board at the EEIC’s Presidencies in India should not be informed about this; as they might have the same Rhubarb from China, perhaps cheaper, but certainly better, as it may be fresher’.27 The difficulties that could arise when local supplies were not available are most evident in the occasionally frantic efforts of the EEIC hospitals to obtain sets of surgical instruments from newly arrived or departing surgeons.28 The surgeons themselves were keen to make a case for the local procurement of medicine to the EEIC directors. In 1762 the Madras surgeon James Wilson submitted proposals for supplying the patients in his hospital with Country Medicines and all other necessities like cots, clothing, arrack, spirits, vinegar oil, syrup, tamarinds etc., except ‘Europe Medicine’.29 His proposals were accepted. Two decades later, in April 1786, when the Madras Medical Department and the Hospital Board were formed, Helenus Scott, the apothecary at the Bombay Fort medical establishment, critiqued the new regulations for entirely overlooking ‘the advantage of purchasing many medicines in the country’.30 He added that the responsibility of procuring such medicines should rest with a professional man, who ‘as he will be unengaged with other duties he might prepare many articles in this Country usually sent from Europe. These preparations will often be superior for the purposes of Medicines, to those sent so long a voyage, and as they could be afforded at a low price, a considerable saving must ensue’.31 Similarly, in his Materia Medica of Hindoostan Whitelaw Ainslie, surgeon at the Madras establishment, argued that medical substitutes from local markets and gardens could be useful: As might naturally be supposed, some of the drugs mentioned in that part of the 1st Catalogue, which treats of the British Materia Medica, cannot be found in these provinces in such quantities as to preclude

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the necessity of regular supplies from established stores; nor are they always to be met with of the best quality; yet it may be gratifying to know what those Medicines are that can be procured, in many of the Bazars, or Gardens of the Natives, in cases of extremity.32 Table 10.1 lists some of the bazaar medicines used in the eighteenthcentury EEIC medical establishments.

Table 10.1 Bazaar medicines used by the EEIC Name

Description

Gum arabic

Sub-Saharan Acacia senegal and Acacia seyal Leguminosae trees from Egypt Derived from species of two East Indian genera (Aloexylon and Aquilaia) From Camphora officinarum a tree indigenous to Java, Sumatra, Japan etc., and from other lauraceous trees, brought to India through China through country trade ships Derived from the sweet root of various species of Glycyrrhiza mostly from the East, Spain and Italy Rootstock of a species of Smilax, from south China and the East Indies From Mozambique Caryophyllus aromaticus of the Malacca islands From a kind of cane in the East Indies from Java and Surinam (Daemomorops Draco) A gum resin obtained from various trees of the genus Garcinia (natives of Cambodia, Thailand etc., used it as a drastic purgative) Sesame oil, Sesamum indicum, from India A dry and brittle resinous substance, with a fragrant odour and slightly aromatic taste, obtained from the Styrax benzoin, a tree found in Sumatra, Java A common item of trade and treatment in the Dutch trade from Ceylon The aromatic root of certain East Indian plants of the genera Alpinia and Kæmpferia, introduced to early medieval Europe by the Arabs A bitter, aromatic gum resin exuded by various Arabian and African trees of the genus Commiphora, in Abyssinia

Aloes Camphor

Liquorice root China root Columba root Cloves Dragons blood Gamboge

Gingilee oil Benzoin

Oil of Cinnamon Galingale

Myrrh

Source: Surgeon General’s Records (SGR), Vol. 6, 1790, G. no. 12443, p. 15; 9 October 1792, Fort St. George, Ibid., Vol. 8, 1792, p. 110; Ibid., Vol. 6, pp. 17–18.

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This tradition of local buying and selling was also fuelled by the fact that from the late seventeenth century surgeons generally engaged in private trade.33 The bazaars were often a source of profit for them. Robert Turing, an EEIC surgeon at Fort St George, Madras, participated prominently in such activities.34 There is evidence that the medical officers habitually bought drugs from the bazaar for the use of the Madras hospital, submitting the bills at long intervals initially and later monthly.35 In 1787, surgeon William Mallet of the Madras establishment was dismissed from service by a General Court Martial for selling hospital provisions in the local bazaar.36 At a more legitimate point on this conjunction of private trade and local markets in a colonial settlement, surgeon John Knox of Fort William in Bengal ran his own commercial arrack (a spirit distilled from palm sap) farm for which he paid rent to the EEIC.37

The bazaar and its riches The bazaars supplied more than provisions; they were sites for the fulfilment of the European pursuit of profits, curiosities, fantasies and exotica. Along with local supplies, they provided local indulgences. The European soldiers of the EEIC’s army visited the bazaars attached to their regiments for luxuries, especially arrack, while the Sepoys obtained their basic supplies from the bazaars too.38 Arrack was also used as part of the ‘bazaar medicine’, and was often listed beside with opium and camphor in EEIC medical records.39 In 1799, J. Christie, serving in the Nineteenth Foot Regiment in Bombay, described how the bazaar’s many ‘commodities’ enticed the common European, particularly the soldiers, and how the ‘excesses’ of exotic luxury and a languid Oriental lifestyle led to distraction from duty. Christie complained: The mind of man becomes in a variety of ways relaxed, and enervated, and peevish, and fond of sensual gratifications in an Indian climate. We know female charms, even in tawny Hindoo colours, in the cool mornings, on the shores of Coromandel, or the plains at Columbo, are very fascinating, very enticing; but surely the soft murmurs of languishment, or the toilsome pleasures of private duty, should never interfere with that duty which is indeed of an important nature—that duty where the lives of our fellow creatures are at stake, and in our hands.40 This world of the bazaar was a site of exploration for Europeans, but it was also often the demarcation of the limits of their habitation in India.

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In eighteenth-century European settlements like Calcutta, Madras and Bombay, the boundary between the White and the Black towns was often marked by the location of the bazaars with the nucleus of the Black town being the bazaar.41 In colonial Madras the urbanization of an erstwhile village in Mylapore district took place during the early 1800s with its bazaar becoming a centre for the southern section of the city.42 The Black town here was essentially a commercial centre with the majority of its inhabitants directly or indirectly dependent on trade.43 Peddanaikpet, where the EEIC settled its Dubashes and commercial castes, saw the construction of a large vegetable and grain market in 1804 by Indian merchants. It had become the principal mart for the Indian population of Madras by the middle of the nineteenth century.44 For nineteenth-century English women the ‘native’ bazaar, where their everyday food was purchased was seen paradoxically as an unhygienic site, unsuited to a lady’s presence.45 The bazaar was thus a near and yet a distinct site. This otherness sometimes added to its enticement. While the British military establishment in India sought to regulate and license prostitutes for its white soldiers through the army-controlled lal bazaars and lock hospitals, the soldiers found the prostitutes without certificates residing in the off-limit bazaars far more tantalizing and ‘exciting’.46 In Bombay the Hospital Committee decided to provide patients with tea and sugar as they often obtained ‘other particulars improper for them’ under the pretence of sending servants to the bazaars for these items.47 These coexistences of the local and the common, of exotic indulgences and everyday provisions were part of the European procurement of medicines and other goods from the bazaars. As a result the bazaar serves as metaphor for several kinds of European engagements in the East, for commercial prospecting as well as for the sensual and intellectual explorations of the native, exotic, commercial and Oriental world.

Bazaars and texts The bazaars and their merchandise, medicines included, catered also to European intellectual pursuits. The eighteenth century was the period of what Schiebinger calls ‘bioprospecting’, when international botanical enterprises were sponsored by European imperial powers to explore the natural riches of the colonies.48 This prospecting took place in different sites. It was a complex enterprise, involving searches in forests and mountains, in markets, in local texts, the study of botanical, mineral and medicinal specimens, and the analysis of the items continuously

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being procured. In this section we will see how the bazaar formed an essential component in this enterprise. In Europe, the search for medicinals had combined the study of the natural history of plants with the examination of ancient texts for ‘authentic ancient remedies’.49 This project had helped to lead to the ‘attempts of Europeans to find new trade routes to the East’ and to the establishment of English and Dutch gardens in South and South-East Asia. These sites became complex depots of the East’s medical, commercial and spice flora, but the enterprise also led to the creation of libraries of ancient texts, often located alongside the gardens.50 Missionaries and European naturalists initiated the European textual tradition in southern India. The missionaries’ textual and botanical interests were part of their larger engagement with Indian, particularly Tamil, languages and cultural traits. The Tranquebar-based Danish missionaries were eager to learn Tamil and study its ancient literature in order to get closer to the people among whom they were working. The introduction of print was an important development in the intellectual history of early eighteenth-century South India, and the Danish missionaries were the first to set up a printing press of the Evangelical Church in India.51 Their subsequent study of local knowledge and texts and their cataloguing and printing initiatives left its own imprint on the emerging material culture of Indian medical systems. For missionaries, as for most Europeans, a trip to the local market to buy medical ingredients was nonetheless likely to be as much for a cure as a curiosity. The Tranquebar-based Danish missionary Henry Plutschau (1676–1747) wrote in a letter, ‘I had once a Mind to have purchased such a Physical stone or Compound, but it would have stood me in Three-Score Rix-dollars. In the Kingdom of Ceylon, a Stone is found in Hogs, which is called Lepes de Porco, and said to be of an extraordinary Virtue for curing all manner of Distempers.’52 The missionaries found local medical expertise particularly useful, and trips to the bazaar in search of ingredients could also lead to a trip to the local practitioner. Plutschau added: Our Europeans or Blancks that are settled in India, do for the most part consult the black Physicians upon any emergent Occasion: And it must be supposed, they are best acquainted with the Quality of the Air, and the Nature of the Food and Climate. They often perform very successful Cures: But whilst a European is under their Hands, they absolutely restrain him from eating any thing but such Victuals as are prepared after the Manner of the Country, as do undoubtedly best agree with their physical Prescriptions.53

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Plutschau discussed local medicine in some detail. Interestingly, his analysis focused on therapeutics rather than theory. Although he emphasized that ‘The Ingredients they use in their Physical Compositions are quite different from what we apply in Europe’, he approached the subject through European categories: Their usual Prescriptions are Oils, Powders, and Potions. But those that are the most skilful and noted Pysicians among them, have always recourse to Chymical Preparations, particularly in high and dangerous Distempers . . . But then they seldom make use of any Spirits or Liquids, but generally of Stones made up of Pearls, Gold, and other Metals, and prepared in such a manner that, upon Occasion, one may scrape off a Doze for the use of the Patient. The Colour of such a Stone is commonly red and white. I have taken my self part of such a Stone, and have found effectual Help by it.54 Missionaries played a key role in constructing European knowledge of Indian medicine. Rev. John Peter Rottler helped Whitelaw Ainslie, Superintendent Surgeon of the Madras establishment, in his compilation of Hindu Materia Medica; his ‘scientific skill and accurate acquaintance with the native languages so particularly fit him for Indian research’.55 Another Tranquebar missionary Gruendler translated Tamil medical literature, and his work was eventually published as The Malabar Medicus, a Short Account of the Medical Principles of These Heathen, and Also of the Treatment and Drugs with Which They Cure Diseases. Rev. Samuel John appointed a ‘black Natural Philosopher’ (a local Malabari assistant) to collect plants, shells, seeds, insects and fishes from Nicobar Islands.56 Benjamin Heyne, who came to India as part of the Moravian mission, wrote Tracts, Historical and Statistical, on India, an important compilation of the plants, natural resources and medical preparations of those parts.57 The mission library at Tranquebar had a particularly interesting collection of manuscripts, especially on Indian medical traditions. Rottler mentioned: When I arrived in India I found in our Mission library a whole press of ancient manuscripts on palm leaves concerning the Hindoo or Brahmin religion, or Vedahs and shasters, and medical science, of which there was collected a manuscript book under the title of Medicus Malabaricus, and Mythologia Malabarica, and many more relics of botanical observations, with other testimonies of the many labours and attention of older Missionaries in different sciences.58

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A twelve-volume herbarium of plants from India, titled ‘Plantae Malabaricae’ was to be found in the Department of Systematic Botany, at the University of Göttingen by 1764. The university had acquired this as part of a large herbarium from the bequest of August Johann Von Hugo (1686–1760). Hugo was a friend of Haller and a personal physician of King George II at Hanover. This herbarium, with names in Tamil with German commentaries, had been compiled by the missionaries in Tranquebar under his instruction around the years 1732–3. It is probably the first botanical collection of such a scale from south India.59 Göttingen’s University Library too, had by the turn of the nineteenth century built up a comprehensive scholarly collection through these missionary sources particularly in British imperial dominions in the East.60 The more formal project of recording the medical products of the bazaars in systematic medical texts was taken up by Ainslie. His Materia Medica of Hindoostan was a compilation of ‘particular articles of the British Materia Medica [that] could be procured in the Bazars of Hindoostan, with their names in the language which are spoken in the Peninsula; or any arranged account of the Materia Medica of the Native Indians’.61 Ainslie elaborated how he identified these medicines as much in the ‘Bazars of Hindoostan’ as in texts like Agashtier Vytia Anyouroo by the Tamil scholar Agashtya.62 Ainslie’s study encapsulates the spatial and temporal complexity of this engagement with the locality and the dexterity with which the Europeans dealt with it. What was to be found in the local bazaars could also be identified in ancient texts and might entail stories of even more distant and exotic lands, finally to be incorporated into a new language and narrative. Most eighteenth-century European medical texts produced in India had similar close encounters with local markets and practitioners. In his Catalogue of Indian Medicinal Plants and Drugs, John Fleming, a British surgeon based in Bengal, described one instance of how a traditional practice entered the European Materia Medica.63 A ‘Mussalman Fakir’ named Azim Shah treated one Mr Robert Home successfully. He, after collecting further evidence of the efficacy of the medicine, the roots of Punica granatum, communicated it to Dr Francis Buchanan Hamilton, who inserted it in the Edinburgh Medical and Surgical Journal.64 Fleming’s Catalogue claimed that the root was even better than Fern root (Aspidium filix mas.) the celebrated remedy of Madame Nouffer.65 The work of the British botanist John Forbes Royle (1799 – 1858) is another important example of how the medicines of the bazaars entered mainstream discourses of science. Royle was born in Kanpur, studied medicine in England and, entering the service of the EEIC as an assistant

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surgeon, devoted himself to studying botany and geology, making large collections among the Himalayan Mountains. In 1837 on his return to England he was appointed to the professorship of Materia Medica in King’s College, London, which he held till 1856. Royle elaborated that he initially set out to compile his Manual of Materia Medica because the Medical Board wanted to ascertain whether supplies from Europe could be substituted by ‘articles indigenous in the country, or by cultivating exotics in the most suitable climates of the plains and mountains of North India’.66 But his search was also informed by his interest in ancient Indian wisdom, as he mentioned in his Introductory Lecture on the Course of Materia Medica and Therapeutics at King’s College. In ancient Indian Materia Medica he found an organic link between plants and medicine: ‘one of the gods of the East is represented (having assumed the character of a chief physician), as delivering his instructions on the doctrines of medicine, in a forest of medical plants, in the presence of gods, sages, and a large train of both orthodox and heretical hearers’.67 Royle’s own journey was interesting as well; he studied Materia Medica initially under Dr A. T. Thomson at University College, and Therapeutics and Dietetics under Dr Home at the University of Edinburgh. Once he joined the Medical Board of Bengal his role became that of a collector, ‘acquiring a knowledge of the substances at present in use in the several parts of the extensive Empire: as well as for pointing out the sources whence a still greater variety might be, if desirable, be obtained’.68 Thus he began visits to the bazaars, local practitioners and texts: ‘I made collections of everything that was procurable in their bazaars, tracing them as much as possible to the plants, animals, and countries, whence they were derived. I had the native works on Materia Medica collated by competent Hakeems and Moonshees . . . I made then a catalogue of the whole.’69 This was complemented by his work at the Saharanpur Botanical Garden, where he cultivated, ‘exotics in the most suitable climates of the plains and mountains of North India’.70 He catalogued this diverse information, adding synonyms in different languages, ascribing their medical properties, places of origin, inserting ‘Linnaean class and order’ and finally producing a more composite Materia Medica, ‘I took some trouble to make myself acquainted with the actual state of the Materia Medica of the East, and was thence enabled to pursue its history, and to trace individual articles, even under varying names and in different languages, from the present to the earliest times. It is by these means that I have been able to pick up one or two of the lost links in the history of science.’71

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Such a study of the Materia Medica, Royle pointed out, was impossible in Europe. The tension between a commercial Empire and gentlemanly imperial science is apparent here. Royle stressed that relocation was necessary, for in Europe scientific knowledge of the items of the Empire was dependant on traders, who ‘care little, except about the price of a drug, and the port where it may be purchased; and the brokers in this country, think only of the ship in which it was imported, and the place whence this was cleared; though the substance itself may have been first conveyed thither from very distant regions’.72 Validating the Orientalist project in science, Royle suggested that the scientific project was ‘very complicated’ without the historical and cultural knowledge of the East, ‘ . . . if we attempt to study it with respect to each particular drug; for many of these have been so long used, and described by a variety of authors, in so many languages, that it is sometimes difficult for any one, without particular training, to be able to recognise the most familiar articles’.73 From 1838 he kept a special department of correspondence at East India House relating to vegetable products, and also developed an impressive museum of Indian technical products. Royle’s work captures many of the interactions between tradition, ancient Eastern wisdom, commerce, and modern medicinal research. Thus one important aspect of the collection of these local curiosities continued to be their dissemination to Europe. A good example of this can be seen in the scientific analysis of the exotic, Oriental and somewhat mysterious drug called Tabasheer, produced from a bamboo extract much in use in Arabic medicine.74 This was initiated by the physician and naturalist Patrick Russell (1727–1805) who was based first in Aleppo and then South India. In 1788 he wrote a letter to Joseph Banks from Vishakapatnam (a port on the Coromandel Coast, India), which was published in the Philosophical Transactions. This letter discussed Tabasheer, which he had found mentioned in Arabic texts. It mentioned that the medicine originated in India; so, while there, he arranged for some of the bamboos which produced it to be sent to him. A fellow surgeon procured some from the bazaars of Hyderabad; more came from the markets of Masulipatnam. Russell submitted the specimens to the Royal Society for examination and James Louis Macie performed chemical experiments on them, the results of which were also published in the Philosophical Transactions.75 These new drugs and botanical discoveries entered mainstream medical compilations produced by European experts as well. The physician behind the important Edinburgh New Medical Dispensatory, Andrew Duncan Jr (1773–1832) was, for example, closely associated with

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medicinal discoveries in other parts of the world. He even wrote his 1794 M.D. dissertation on the bark Swietenia febrifuga discovered by William Roxburgh in South India.76 It was a concern Duncan shared with his father Andrew Sr. (1744–1828), the Professor of the Theory of Medicine in Edinburgh University, who published the journal Medical and Philosophical Commentaries from 1773, with the aim of keeping practitioners abreast of new developments in medicine.77 This engagement with the wider medical literature and tradition was reformulated under Duncan Jr as the Annals of Medicine, which catered more widely to the empire, explicitly seeking medical news from the East and the West Indies.78 The younger Duncan’s major work, the 1803 Edinburgh New Dispensatory reflected an important advance in medicine of the late eighteenth century.79 He mentioned in its preface that the period between the 1789 edition of the Dispensatory and his own had witnessed great developments in chemistry, pharmacy and natural history, ‘so as to render a complete reform absolutely necessary. This, to the best of my abilities, I have attempted’.80 He also pointed out that this was essentially the Edinburgh tradition; although on the Continent attempts had been made to bring a ‘new language of chemistry into pharmacy’, the credit of composing a pharmacopoeia in the ‘pure and unmixed language of science, belongs indisputably to the Royal College of Physicians of Edinburgh’.81 This new and avant-garde compilation was woven around new material. The New Dispensatory and its supplement, also written by Duncan Jr, drew on the researches of colonial botanists and surgeons like Roxburgh, Koenig, Ainslie, Fleming, Royle, Heynes and Buchanan Hamilton. It employed the materials of the commercial world of the Empire and thus discussed a myriad sources of information from the ‘bazaars’ to the ‘Mussulman Fakir of Calcutta’. The richness and complexity of the Empire was apparent in discussion of the ‘confusing commercial varieties’ of cinchona bark, the different cloves of Barbados and Cayenne, the several forms of ipecacuanha collected from the various parts of the Empire and the spurious Columba roots from the state of Barbary.82 Duncan Jr also mentioned the problems following from the distant sources of specimens. The bark of Swietenia febrifuga that Roxburgh had sent to Edinburgh, on which he had written his dissertation, was found in a condition where it could not be distinguished from the ‘kind of the shops’.83 Even worse, the only true specimen of cinchona he ever found in Europe was in the collection of a ‘drug-broker’ in Hamburg, M. Von Bergen.84

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Conclusion As a trading company the very success of the EEIC depended on exploring old markets and developing new ones, not only in the East, but also in Europe. While in the East, old bazaars were explored and exploited, in Europe, the importation of Asian luxuries demanded the ‘making’ of new consumer markets for goods.85 In the East, medical encounters in marketplaces opened up new channels of supplies and possibilities for the practice of medicine by Europeans. In the process, the bazaars of the East themselves were prospected upon, analysed and transcribed into a new medical discipline and language. Sometimes crucial to European survival in the tropics in the middle of wars and diseases, the medicines from the bazaars also filled the pages of Orientalist publications, as well as the Dispensatories and Catalogues of Europe. This engagement with bazaar medicine reflected dualities of European activities in these shores; between the local and the exotic and between profit and scholarship. In eighteenth-century India this commercialization and opening out of medical practice accompanied a process of opening up of the very sites of exchange. Thus medical experiences of the bazaars were not exactly those of laissez-faire exchanges, neither were the Europeans and Indians always equal participants in this trade. The Company surgeons were representatives of the largest trading company in the land: from 1717 they worked within an organization peculiarly privileged to trade duty-free in Bengal and from the middle of the eighteenth century, a territorial power as well. This is where the essential difference between the bazaar and the British medical marketplace was located. While markets in England experienced economic and institutional liberalization, markets and trading practices in India saw increasing monopolization, institutionalization and ultimately subjugation. The EEIC surgeons approached the markets, selected and collected items from there and incorporated them into their hospital practices or their textual traditions, with the same authority that the EEIC formed its bazaar entourage to follow their army or regulated prices and trading rights otherwise. It is in the markets of the East that the EEIC established its original base of power. Moreover, European medicine itself throughout the eighteenth century was undergoing massive professional, institutional and textual expansion, a fact that increasingly made such market exchanges in the nonWest one-sided. Thus ‘bazaar medicine’ of the eighteenth century had a distinct European content and proprietorship as did the bazaar itself. Edward

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John Waring in his nineteenth-century account of bazaar medicines specified what he saw as the balance of debt and credit in that exchange: Whilst on the one hand, I am perfectly prepared to admit that much of the knowledge I possess of the properties and uses of Indian drugs has been derived from Native sources, I think I may, on the other hand, without presumption, claim the credit of repaying the debt with interest, furnishing in return a considerable amount of information as the uses of even the same drugs, of which the Natives themselves had previously no idea.86 It is because of the centrality and profitability of markets to the EEIC’s functioning that markets and bazaars have remained so important in our analysis of the history of the Company Raj in India and in that process in ‘locating’ India in it. The exoticism, commercialism and classicalism associated with bazaar medicines need to be understood as signifiers of the particular engagement of Europe with the East which the trading companies engendered. Otherwise, they were simply medicines bought from the local market.

Notes 1. R. and D. Porter, ‘The Rise of the English Drugs Industry: The Role of Thomas Corbyn’, MH, 33 (1989). 2. H. M. Boot, ‘Real Incomes of the British Middle Class, 1760–1850: The Experience of Clerks at the East India Company’, EcHR, 52 (1999). 3. R. Drayton, ‘Science and the European Empires’, Journal of Imperial and Commonwealth History, 23 (1995), 510. 4. P. H. Smith and P. Findlen (eds), Merchants & Marvels (2002); K. D. Kriz, ‘Curiosities, Commodities, and Transplanted Bodies in Hans Sloane’s “Natural History of Jamaica”, WMQ, 3rd ser., 57 (2000). 5. See, for example, Z. Baber, ‘Colonizing Nature: Scientific Knowledge, Colonial Power and the Incorporation of India into the Modern World-System’, British Journal of Sociology, 52 (2001); F. Driver, Geography Militant (Oxford, 2001). Also see, J. McClellan, Colonialism and Science (Baltimore, 1992); J. Gascoigne, Science in the Service of Empire (Cambridge, 1998); Drayton, Nature’s Government (New Haven, 2000); and L. Schiebinger, Plants and Empire (Cambridge, 2004). 6. S. Sen, Empire of Free Trade (Philadelphia, 1998) 120–43. 7. OED, s.v. 8. S. Hajeebu, ‘Emporia and Bazaars’, in J. Mokyr ed., Oxford Encyclopaedia of Economic History (Oxford, 2003), II, 258. 9. H. Furber, ‘Asia and the West as Partners before “Empire” and After’, Journal of Asian Studies, 28 (1969), 712. 10. Neild, ‘Colonial Urbanism’, 246.

Pratik Chakrabarti 213 11. A. A. Yang, Bazaar India (Berkeley, 1999), 2. 12. Ibid., 14. Yang accepts Rajat Ray’s rather simplistic characterization of the bazaar as an ‘indigenous’ arena of trade and credit: Ibid., 267. 13. See, for example: J. Nightingale, The Bazaar, Its Origin, Nature, and Objects Explained (1816), 7, 10. 14. ‘Emporia and Bazaars’, 259. 15. See: S. Arasaratnam, Merchants, Companies and Commerce on the Coromandel Coast 1650–1740 (Delhi, 1986), 213–73. 16. G. J. Bryant, ‘Asymmetric Warfare: The British Experience in EighteenthCentury India, Journal of Military History, 68 (2004). 17. G. J. Bryant, ‘British Logistics and the Conduct of the Carnatic Wars (1746–1783)’, War in History, 11 (2004). 18. R. Rai, ‘Sepoys, Convicts and “Bazaar” Contingent: The Emergence and Exclusion of “Hindustani” Pioneers at the Singapore Frontier’, Journal of Southeast Asian Studies, 35 (2004). 19. Tamil Nadu State Archives (hereafter TNSA), Surgeon General’s Records, Vol. 5, 1789, G. no. 12442, p. 51. 20. Records of Fort St. George, D&C, (Public Department) 1758, Vol. 88, (Madras, 1952), 268. 21. National Archives of India, Home Department, Public Branch, Consultation 29 January 1766, no. 10+10 (2)–(6), [P.P. 159, and O.C. Jan. 29, no. 11]. 22. W. J. Wilson, History of the Madras Army (Madras, 1885), I, 224–37. 23. Wilson, History of the Madras Army, II, 176. 24. TNSA, Surgeon General’s Records, Vol. 8, 1792, pp. 135–6 (Fort St. George, Hospital Board, 29 October 1792). 25. Maharashtra State Archive (MSA), Bombay Hospital Board Diary, 1787–1789, vol. 289, pp. 3, 24–6 (14 September 1787). 26. TNSA, Surgeon General’s Records, Vol. 3, 1788, p. 45. A pagoda was equivalent to 8 shillings, W. Guthrie, A New Geographical, Historical, and Commercial Grammar and Present State of the Several Kingdoms of the World (Montrose, 1799) 1043. 27. National Archives of India, Medical Board, 1796, January–June, pp. 68–9. 28. Examples include: TNSA, Surgeon General’s Records, Vol. 3, 1788, G. no. 12440, pp. 144, 166–7, 200–1; Vol. 6, 1790, G. no. 12443, p. 10. 29. BL, Oriental and India Office Collections (hereafter OIOC), Madras Public Consultations, no. 177, 26/2/62, 240/20–1762. 30. MSA, Regulation 3, Hospital Board Diary, 1787–9, vol. 289, pp. 4–5; MSA, Bombay Hospital Board Diary, 1787–9, vol. 289, pp. 40–41. 31. Ibid., 42. 32. W. Ainslie, Materia Medica of Hindoostan (Madras, 1813), i. 33. D. V. S. Reddy, ‘The Origin and Evolution of the Madras General Hospital’, Madras Medical Journal, 17 (1937) 12. On private trade, see: S. Hejeebu, ‘Contract Enforcement in the English East India Company’, Journal of Economic History, 65 (2005). 34. Records of Fort St. George, Diary and Consultation Book of 1752, Vol. 80 (1939), 81, 106. 35. Reddy, ‘Origin of the Madras General Hospital’, 11. 36. TNSA, Surgeon General’s Records, Vol. 1, 1787, G. no. 12438, pp. 7–8 (Fort St. George, January 1787).

214 Medical Marketplaces beyond the West 37. BL, OIOC, Bengal Public Consultancies, 1750, P/1/24, p. 92 (Fort William 1 April 1750). 38. Bryant, ‘British Logistics’, 278–306. 39. BL, OIOC, Medical Board’s Collection, F/4/595 no. 14376, f. 7. 40. J. Christie, ‘To the Editors of the Medical and Physical Journal’, Medical and Physical Journal, 1 (1799). 41. See, for example, F. Hasan, ‘Indigenous Cooperation and the Birth of a Colonial City: Calcutta, c. 1698–1750’, MAS, 26 (1992) 77. 42. S. M. Neild, ‘Colonial Urbanism: The Development of Madras City in the Eighteenth and Nineteenth Centuries’, MAS, 13(1979) 231–2. 43. Ibid., 239. 44. Ibid., 240. 45. M. Procida, ‘Feeding the Imperial Appetite: Imperial Knowledge and AngloIndian Domesticity, Journal of Women’s History, 15 (2003) 128–9. 46. K. Ballhatchet, Race, Sex and Class under the Raj (New York, 1980). 47. MSA, Public Department Diary, 1770, no. 56, pt. II, p. 380 (Report of the Hospital Committee, 26 November 1770). 48. Schiebinger, Plants and Empire. 49. H. Cook, ‘Physicians and Natural History’, in N. Jardine, J. A. Secord and E. C. Spary eds, Cultures of Natural History (Cambridge, 1996), 92–3. 50. Ibid. 51. E. A. Lehmann, It Began at Tranquebar (Madras, 1956), 101. 52. ‘Extract of another Letter, relating to some diseases incident to the Malabarians’, in An Account of the Religion, and Government, learning, and Oeconomy, &c of the Malabarians (1717), 61. 53. Ibid. 54. Ibid., 62–3. 55. Ainslie, Materia Indica (1826), xxxvii. 56. BL, OIOC, Tranquebar, MS. Eur D 809 (Father John to Roxburgh, 9 December 1790). On the British and local informants, see C.A. Bayly, Empire and Information (Cambridge, 1999), 36–66. 57. B. Heyne, Tracts, Historical and Statistical, on India (1814), 125–48. 58. C. S. John, On Indian Civilization (1813), 39. 59. G. Wagenitz, ‘The “Plantae Malabaricae” of the Herbarium at Göttingen Collected near Tranquebar’, Taxon, 27 (1978), 493–4. 60. G. Jefcoate, ‘Asiatick Researches: English Sources for Oriental Studies in Göttingen University Library, 1735–1800’, Libraries & Culture, 33 (1998), 283. 61. Ainslie, Materia Medica of Hindoostan, i. 62. Ibid. 63. J. Fleming, A Catalogue of Indian Medicinal Plants and Drugs (Calcutta, 1810), 2. 64. Ibid., 62–72. 65. Ibid., 68–9. On Nouffer’s treatment of the tapeworm: Medical and Philosophical Commentaries, 4 (1779), 307–9. 66. J. F. Royle, A Manual of Materia Medica and Therapeutics (1847), i. 67. Royle, Antiquity of the Hindoo Medicine (1837), 2. 68. Ibid., 25. 69. Ibid. 70. Royle, Manual of Materia Medica, vii. 71. Royle, Antiquity of the Hindoo Medicine, 26.

Pratik Chakrabarti 215 72. Ibid., 23. 73. Ibid., 24. 74. A siliceous substance, white or translucent, occasionally formed in the joints of the bamboo, also called bamboo salt. 75. P. Russell, ‘An Account of the Tabasheer’, Philosophical Transactions of the Royal Society of London, 80 (1790), 273–83; J. L. Macie, ‘An Account of Some Chemical Experiments on Tabasheer, Philosophical Transactions of the Royal Society of London, 81 (1791). 76. A. Duncan, Tentamen Inaugurale de Swietenia Soymida (Edinburgh, 1794). 77. See, I. Chalmers and U. Tröhler, ‘Helping Physicians to Keep Abreast of the Medical Literature: Medical and Philosophical Commentaries, 1773–1795’, Annals of Internal Medicine, 133 (2000). 78. See, especially, The Preface to the first issue: Annals of Medicine, 1 (1796), A2. 79. Duncan, The Edinburgh New Dispensatory, 3rd edn. (Edinburgh, 1803). 80. Ibid., vi. 81. Ibid., vii. 82. Ibid., 57; Duncan, Supplement to the Edinburgh New Dispensatory, (Edinburgh, 1829), 4–5. 83. Duncan, Edinburgh New Dispensatory, 356. 84. Duncan, Supplement to the Edinburgh New Dispensatory, 37. 85. M. Berg, ‘In Pursuit of Luxury: Global History and British Consumer Goods in the Eighteenth Century’, P&P, 182 (2004). 86. E. J. Waring, Remarks on the Uses of Some of the Bazaar Medicines and Common Medical Plants of India (1874), vi [my emphasis].

11 Monopoly, Markets and Public Health: Pollution and Commerce in the History of London Water 1780–1830 Mark S. R. Jenner During the 1980s and 1990s advocates of a social history of medicine argued that it should focus on the history of health. They underlined how, in George Bernard Shaw’s words, the sick poor child ‘needs . . . not medicine, but . . . better clothes, better food, and a better drained . . . house’.1 Although partisans of this new approach coined the term the medical marketplace, it has, ironically, led historians away from this inclusive agenda, encouraging them to concentrate on the ‘doctor–patient relationship’.2 Furthermore, through its assimilation to the historiography of consumerism and economic expansion, the medical marketplace model has inclined scholars to write about premodern medicine with reference to affluence and advertising rather than discussing health and its relationship to deprivation, diet and the necessities of life. In consequence historians have so far researched only a few of the possible connections between medicine and the market. Studies of early modern famine have drawn on Amartya Sen’s work to show how groups’ differing access to the market determined the impact of food shortage.3 Ill health can be analysed in similar ways, but historians of medicine have yet fully to explore the various factors that shaped access not only to commercial forms of medicine but also to care, to the resources needed to sustain life, and to a healthy environment.4 They have, in consequence, neglected the broader preoccupations of eighteenth- and nineteenth-century doctors. For, as Hamlin showed, the necessaries of life – housing, wage levels, food and water – were central to the medical discourse of that period.5 Health was a central category by which to analyse commercial society; the workings of commercial society were seen to determine health. 216

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This chapter explores how thinking about the market illuminates such areas of medical history. It focuses on one ‘necessity’, discussing the relationship between the market, the market in water, and the emergence of a public health problem of polluted water supplies in 1820s London. Viewing pollution primarily as a perceptual category, its approach is broadly cultural. It does not quantify how far the cost and restricted availability of water led to greater levels of disease in poor districts. Rather it demonstrates how the changing commercial organization of piped water supplies undermined confidence in the probity of London water companies, and helped make it plausible that their supplies were grossly polluted. It further shows that perceptions and representations of water supplies and suppliers shaped, and were shaped by, debates about the nature and proper functioning of markets. Underlying this analysis, therefore, is a sense that historians of medicine and public health should attend to the histories of political arithmetic, political economy, and economics, and examine contemporary understandings of the market. As we shall see, in London, languages of dependency, monopoly and free trade helped produce pollution. *** On 9 April 1827 a large public meeting assembled in Willis’s Great Room, Piccadilly, to protest about the water piped into West London and to consider ‘the means of procuring a supply of pure and wholesome water’. The supplies, one speaker declared, were ‘so bad, that . . . everybody bore testimony to it’.6 ‘Several gentlemen’, papers reported, ‘produced phials, containing large worms . . . found in the water, . . . supplied by the Grand Junction Company’.7 The meeting condemned how the stretch of the Thames from which water companies pumped their supplies was ‘charged with the contents of great common sewers, the drainings of dung-hills and laystalls, the refuse of hospitals, slaughterhouses, color, lead and soap works, drug-mills, and decomposed animal and vegetable substances – rendering the . . . water offensive to the sight, disgusting to the imagination, and destructive to health’. It resolved to petition Parliament for an inquiry into the capital’s water supply. This was no spontaneous outburst of disgust. Handbills had advertised the meeting;8 newspapers had reported the preparation of a petition about the capital’s water companies;9 The Times printed medical opinions of the Grand Junction’s supply.10 The President of the Royal College of Physicians termed it a ‘filthy fluid’. James Johnson, editor of

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The Medico-Chirurgical Review, had ‘always looked upon water taken up at Chelsea as most disgusting to the imagination, and deleterious to health’. ‘We anger,’ he added sardonically, at the delicacy of Hindoo, who slakes his thirst at the same tank where his neighbour is sacrificing to Cloacina;11 but what shall we say to the delicate citizens of Westminster, who fill their tanks, and stomachs, with water from the Thames, at that very spot into which 100,000 cloacae, containing every species of filth, and all unutterable things, are daily disgorging their hideous and abominable contents! It is absolutely astonishing that, in these days of refinement, and in a metropolis whose inhabitants pride themselves on delicacy and cleanliness, a practice should obtain, at which posterity will shudder, if they can credit it. A time must come when the people of Westminster will open their eyes to this scene of corruption, veiled and concealed as it is by iron tubes and stone pavements.12 The paper was quoting The Dolphin, or Grand Junction Nuisance, a pamphlet published in March 1827 and composed, it soon emerged, by the journalist and publisher, John Wright.13 He had collected samples of the water, despatched them to members of the medical establishment and reproduced their opinions about its potability. The Times caught the tenor of their comments well. Wright’s description of the origin of the supply helped explain why professional opinion was unenthusiastic about the Grand Junction’s product. The company had placed its dolphin (the inlet from which it drew its supply) near Chelsea Hospital, where Ranelagh Sewer discharged into the Thames. It was, Wright stressed, ‘the duty of every head of a family, who values the comfort and health of his children, to . . . visit . . . this Tartarean gulph’. He would never ‘forget the sight’ of it after heavy rain.14 Filth of all hues and odours seem’d to tell, What street they sail’d from, by their sight and smell, Sweepings from butchers’ shops, dung, guts, and blood, Drown’d puppies, stinking sprats, all drench’d in mud, Dead cats, and turnip-tops came tumbling down the flood. Although Wright claimed that it was ‘not my wish to stir ... stomachs ... to “any sudden flood of mutiny”’, his Swiftian idiom galvanized metropolitan opinion.15 On reading it, the Westminster tailor and parliamentary reformer, Francis Place, resolved to ‘assist Mr Wright to the utmost of my power to abtain [sic] a remedy for so serious an evil’.16

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Once aroused, public concern did not simply disperse. Petitions were presented to Parliament in May 1827.17 A few days later a Commission to examine the quality and quantity of West London’s supply was proposed; this was swiftly extended to include the whole metropolis.18 Delayed by wrangles and by illness, the commissioners took ten months to complete taking evidence.19 Their report in April 1828 concluded that the sections of Thames where many London water companies drew their supplies were ‘loaded with . . . filth’ and that the River Lea (source of the New River and East London waterworks) was ‘susceptible of much improvement’.20 This was not, they reckoned, conducive to health. However, although the water, even when filtered, could not ‘be pronounced entirely free from the suspicion of general insalubrity’, the commission established no clear connection between diseases and contaminated water. It was unable to make decisive recommendations for the amelioration of the capital’s supplies.21 Three months later Parliament set up a Select Committee. This inquired further and investigated the possibility of bringing water from the unpolluted upper reaches of the Thames. However, after its (inconclusive) findings were published, the matter became bogged down in technical disputes; the condition of London’s water faded from the political scene. Nevertheless, this was the moment that ‘the question of the purity of London water supplies [was] first brought before the public eye’. It has been termed ‘the beginning of the sanitary reform movement’.22 It was not ‘natural’ for Londoners to have protested about this pollution. They had long accepted company assurances that river water became muddy in some weather conditions but soon cleared to exemplary brightness;23 the disgust of some eighteenth-century commentators at filthy metropolitan water produced no collective agitation.24 The outcry at this moment therefore requires explanation. The spread of water closets discharging into the Thames led to significant deterioration in river quality during the 1810s and 1820s;25 the sensory apprehension of this certainly contributed to the unease in the Willis Rooms.26 Furthermore, since the early 1820s the Grand Junction had worried about discharges from Ranelagh Sewer and had stated publicly that it needed to improve water quality; in 1826 Parliament required it to construct settlement reservoirs.27 However, although The Dolphin’s title page declared, ‘There is such a thing as Common Sense’, not everyone agreed with its ‘common sense’ characterization of the river.28 No commentator could demonstrate a link between disease and the Grand Junction’s supply;29 some people still hymned the salubrity of Thames water.30 Most importantly, historical ecology cannot explain or elucidate

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the way in which Wright and his contemporaries represented or understood the situation. If one analyses the language and imagery of these disputes, rather than trying to estimate the river’s fish stocks, one discovers that contemporaries linked price, power and pollution, denouncing the cost as well as the clarity of West End water, and reckoning that unsanitary water supplies were bound up with a distortion of the market. One gentleman who arrived at Willis’s Rooms carrying a bottle was the print seller, Samuel William Fores.31 From the platform, he declared that the meeting was omitting a ‘most important’ point: ‘the rent charged by the Company’. ‘Some time back’, he continued, they said . . . they would supply . . . inhabitants with water at a cheaper rate, . . . but, at the end of another year they increased their charges . . . in some instance [sic] 100 per cent. He then brandished his bottle of water. This, The Times noted, ‘presented a ... muddy appearance, but clear enough to render a small black leech ... quite visible’. Fores observed ‘... that two or three of these leeches, fastening themselves inside the mouth of a . . . man who took a draught of the water, might well be called “the Grand Junction.”’ 32 The assembly and subsequent petition did address this matter, protesting at how the Grand Junction, ‘having promised to supply their Customers with Water, at a comparatively small charge, have, nevertheless, exacted an increased Rate, equivalent, in no case, to less than fifty per cent., and . . . in most instances, to ninety and a hundred per cent’.33 Wright too complained about the increased cost of water, pointedly contrasting the New River’s former prices with those ‘now charged’. With heavy irony The Dolphin quoted Grand Junction publicity promising ‘a more abundant, a cheaper, and a purer supply’ and ‘expense comparatively small’, before detailing subsequent 50, 100, and even 200 per cent increases.34 Furthermore, it noted, the company had received parliamentary approval for even greater price increases.35 Contemporary commentary agreed that this controversy concerned both price and water quality. In Robert Cruickshank’s ‘Waterworks in Danger’ (May 1827) (Illustration 11.1) a London water company rent collector confronts Sir Francis Burdett, radical MP for Westminster and dedicatee of The Dolphin, in his breakfast parlour or study. The engraving emphasizes the social distance between the grubby-faced collector, ink pot round his neck, and the refined Burdett. The former holds out a slip demanding water rent, but, whereas his bowed posture,

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Illustration 11.1 Robert Cruickshank, ‘Waterworks in Danger, or a Grand Cut at the MP for Westminster’, copyright Trustees of the British Museum.

hat in hand, suggests supplication, he is in fact threatening the householder, declaring: Well Sir Francis, we must cut your cock off, if you don’t pay the four quarters due at Christmas last, it has been so long standing that no mercy can be shown. Burdett replies: You may cut it off as soon as you please, for my cook declares she can make no use of it. I am determined to resist a demand of so foul a nature. Why I found a dead man’s toe in my tea cup this very morning!!36 The MP’s characterization of London water as lethal and cadaverous is strengthened by the long list of fatal afflictions, unfurling onto the floor near his elegant boot. But balancing this scroll is the paper marked ‘gold’ hanging from the collector’s pocket. The composition is centred on an act of exchange, or, rather, the severing of a monetary relationship.37 The figures are surrounded by signs of pre-industrial, even Arcadian, cultures of water. Behind the rent collector is a painting of a

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copious fountain in a green landscape. Between the two men sits a jug of pump water. Father Thames hangs behind Burdett’s shoulder, declaring ‘Here’s a pretty go! I shall lose my good name’. The engraving insistently contrasts bucolic natural springs with soiled and sordid commercial supplies. Burdett’s comfortable surroundings indicate that he was well able to pay his bill. Many (perhaps most) signatories of the 1827 petitions could relatively easily have paid the ‘heavy and . . . partial tax’ which, Wright claimed, the Grand Junction sought to levy upon its customers.38 Theirs were not the concerns of London’s poor, who obtained their water from parish pumps and wells, from the Thames and other turbid bodies of water. Rather it was the conduct of the companies that outraged West Londoners: they felt that that these businesses had violated the proper relationship between a supplier and a purchaser of a good. With his red nose and misspelt bill, the water company official in ‘Waterworks in Danger’ commands no respect. Other commentators described the water companies as utterly untrustworthy. Reviving ancient anti-projector rhetoric, Wright termed the Grand Junction ‘water-jobbers’, ‘looking for their profits solely to an increase in the market price of the shares’.39 In the melodramatic phrase which recurred throughout this controversy, the water companies, he declared, ‘sported’ with Londoners’ lives.40 More specifically, The Dolphin intertwined its denunciation of the companies’ product with a critique of the organization of metropolitan water supply. Over the previous twenty-five years, Wright claimed, the water companies had shown bad faith and used corrupt business practices. His charges developed those elaborated by James Weale, an official in the Office for Forests and Woods,41 and other campaigners against the water companies between 1818 and 1821.42 These controversies were rooted in the recent history of London water. Between 1801 and 1831 the population of the metropolis rose from 900,000 to 1,595,000.43 The growth of middle class housing and technical innovations, such as cast iron pipes and better steam engines, created opportunities for water companies. The West Middlesex Water Company was founded in 1806; in 1810 it gained statutory approval to extend its business from villages like Kensington into West London;44 the East London Waterworks at Old Ford opened in 1809.45 Two years later the Grand Junction Water Company, centred in Paddington, was established.46 These were the first new London waterworks north of the Thames for nearly a century; they soon moved into districts where inhabitants already had access to piped supplies. The consequent competition was fierce.

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Firms’ publicity extolled the quality of their service and their water. The West Middlesex announced that their ‘WATER is taken from the Thames, near Hammersmith; is relieved from every impurity in spacious Reservoirs, and is superior to any other in London for all domestic purposes’, and that it had the ‘PUREST and softest quality’.47 The Grand Junction distributed cards promising water ‘so clear as not to tarnish the furniture in case of fire’ and handbills on which Frederick Accum, the analytical chemist and scourge of food adulteration, endorsed its purity.48 The Grand Junction and West Middlesex also offered extraordinarily generous deals, providing high service at no extra cost.49 Companies used aggressive door-to-door sales campaigns, undercutting each other’s prices. On occasions rival companies’ employees were bribed to turn customers against their existing supplier.50 In 1815 rival groups of workmen brawled along Gower Street.51 Such cut-throat business practices turned out to be suicidal. The companies had invested massively in pipes and pumps, but were chasing a finite number of customers. (Some streets contained three sets of mains.) The West Middlesex told Parliament that the companies had run ‘a race of competition in serving the Public with water, at such reduced rates as . . . scarcely defrayed the expenses’.52 Dividends dipped. Between 1790 and 1810 the New River paid on average £450 a share p.a.; in 1814 it paid £23. Its rivals did worse. Neither the Grand Junction nor the West Middlesex paid dividends between 1811 and 1819.53 Accordingly, at Christmas 1817, after long negotiations, the companies abandoned competition and divided up London between themselves. The New River and the Chelsea Water Companies, for instance, withdrew from Marylebone (population 96,000 in 1821).54 In the pious words of the Grand Junction, they acted ‘in order that the Public may be well & properly supplied . . . at as moderate a rate as . . . possible’.55 The public were less confident, particularly when the companies distributed leaflets announcing that they had to raise water rents. This disquiet intensified when the collectors demanded the increased charges in autumn 1818, not least because several companies introduced new ways of calculating what customers should pay. Some householders, notably those who had profited from previous good deals for high service, experienced steep increases. The average increase was fiercely disputed, but protesters documented cases where a company asked for 400 per cent extra.56 A ‘water fever’ ensued. Aggrieved individuals confronted company representatives; public meetings were held. A bill was moved in Parliament to limit the companies to a maximum increase of 25 per cent on the 1810 price for a basic supply.57 Fiercer rhetoric came to the

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fore when James Weale and others formed the Anti-Water-Monopoly Association (AWMA) in October 1819. Established ‘with the view of affording mutual protection against the arbitrary and oppressive proceedings of the . . . Companies, and of obtaining [a] . . . remedy of the . . . injuries which have already resulted’,58 it declared that the water companies’ agreement was a ‘highly illegal’ combination, contrary to the statutes which had established the Grand Junction and West Middlesex Water Companies. It further argued that the price rises contravened the companies’ statutory obligation to demand only a reasonable rate, and violated the contracts implied by their advertising material. The Association initiated a campaign of direct action. After a well attended meeting in November 1819 led by George Lamb, MP for Middlesex (who denounced the water company directors’ enormous salaries), it distributed handbills urging their fellow parishioners to resist the companies’ ‘illegal demand’ and to refuse to pay any increases in water rents. Its campaigns had initial success. That month the Grand Junction collectors told the directors that they were having great difficulty persuading people to pay.59 However, using blandishments and the threat of disconnection the companies gradually induced all but a hard core of resisters to pay up. The Association mounted legal challenges to the companies’ right to increase prices. The Lord Chief Justice ‘thought it very probable that Parliament and the Public might have been disappointed in . . . the hopes entertained from the competition among the Water Companies’, but he refused to rule what constituted a reasonable rate for the companies to charge or to command the West Middlesex Company to continue supplying at its former price. Parliament, he concluded, was ‘the only source of apposite remedy’.60 The Association petitioned successfully for a parliamentary inquiry, but the report in 1821 did not bear out allegations that the companies had conspired together. Nor did it endorse Weale’s rousing call for metropolitan water supply to be entrusted to public control,61 concluding instead that continued competition would have ended in calamity and that the increased water rents reflected the improved service possible with better pumping technology. The water companies felt vindicated, and faced by the renewed campaign in 1827 immediately appealed to the 1821 Report; Robert Peel, the Home Secretary, instructed the 1827–8 Commission not to reopen matters addressed in 1821.62 However, many Londoners remained dissatisfied. John Cam Hobhouse, MP for Westminster, told the Willis Rooms meeting that he had sat on the 1821 inquiry, but that it had not produced ‘any beneficial result’.63 In 1827 this deep and lingering

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scepticism about the companies’ conduct fatally weakened the latter’s credibility. Customers were not prepared to wait even a few months for the completion of state-of-the-art settlement reservoirs which the Grand Junction was building at a cost of £50,000.64 For many, Wright’s revelations of pollution were the culmination of one long story of commercial malpractice.65 There was, however, a more systemic explanation put forward by the water companies’ critics: monopolistic distortion of the market was, it was argued, the root of the problem. Reviving the arguments of the AWMA, Wright claimed that in direct contradiction to the statutes by which they had been established, the companies had carved up the capital and had thus ensured that each had a monopoly. In consequence, prices had soared and the level of service had dropped. Wright expressed incredulity: That, at a moment like the present, when . . . the Legislature and the Government are endeavouring to unfetter the commerce of the country, by removing oppressive prohibitions and inconvenient restrictions, and thereby giving greater facility and encouragement to the skill, the capital, and the industry of the people of England - that, at such a moment, there should exist, in the very seat of . . . Government, a Monopoly of an element of nature.66 Furthermore, this monopoly produced the appalling quality of supply. The highest legal authorities . . . long ago denounced all such monopolies, as . . . not only contrary to the ancient and fundamental laws of the realm, but injurious to the public: in the first place, by invariably raising the price of the article monopolized; and secondly, by deteriorating its quality.67 The Earl of Lauderdale, he reminded his readers, warned in 1818 that the consequences of monopoly ‘were not merely increased price to the consumer, but bad water’.68 These cautionary words, Wright argued, had come true. Pollution expressed and indicated monopoly. The Willis Rooms meeting concurred, doubtless remembering how the AWMA had warned of the other injuries ‘which may . . . reasonably be expected . . . to arise, from the . . . Monopoly of the supply of water’.69 It resolved that Parliament should inquire into ‘the constitution and practices of the . . . companies supplying the Metropolis’ because ‘a Monopoly in this Necessary of Life [had been] virtually established’. It hoped that

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the legislature would then place the supply of ‘pure and wholesome Water . . . on a sure and lasting foundation’.70 In this hope Westminster petitioners were joined by residents of Southwark and Lambeth who petitioned Parliament in June complaining ‘of the monopoly arranged by the water companies of London, . . . of the arbitrary charges and exactions of those bodies’, and that their water was ‘infected’ by ‘impurities’.71 The companies, particularly the new ones, were reaping whirlwinds which they had helped to sow. Embarrassingly the Grand Junction had had to abandon using the sources highlighted in their first publicity; in 1827 it was distributing Thames water instead. Wright and his allies used the kinds of analysis which they had invoked. Most damagingly, their initial campaigns had aggressively styled the older water companies’ complacent, self-interested monopolies. In 1809, for instance, the West Middlesex Directors informed their shareholders that they would compete head-to-head with Chelsea Water Company, declaring that this ‘struggle against an attempt at Monopoly will add . . . Lustre to the Patriotic Exertions of the Individuals who have so liberally advanced their Capital in this most Important Public Undertaking’.72 The public responded with enthusiasm. Londoners took full advantage of the available offers, playing companies off against each other;73 in collective statements they embraced this rhetoric, as when inhabitants of St. Mary Lambeth petitioned for their ‘supply of Water’ to ‘be thrown open to competition’.74 The Dolphin was thus clearly preoccupied with political economy. Previous scholars have noted Wright’s Radical connections, but have not fully elucidated the links between political languages and representations of water in the 1820s. One reason for this is that Wright’s politics are hard to pigeonhole. Born in Norwich, he spent most of his life as a journalist and publisher. During the 1790s he was a fierce anti-Jacobin, publishing the newspaper of that name and many of Cobbett’s Tory pamphlets.75 Thereafter, his politics mirrored the latter’s move away from Reaction. During the 1800s he was effectively Cobbett’s amanuensis, editing first his Political Register while it savaged jobbery and corruption, and then Cobbett’s Parliamentary History. The two, however, fell out. The row ended in lawsuits. By the late 1810s Wright was in contact with Francis Place and the Westminster committee, assisting them in the 1818 election campaign and working with them through the next decade, while editing Hansard.76 Wright’s attacks on the Grand Junction synthesized diverse political discourses. The denunciation of water-jobbers chimed with concerns which intensified with the speculative boom of

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1824–5 and financial crash of 1825–6.77 His concern at Londoners’ dependency upon the water companies had parallels with earlier themes of the Political Register and with Cobbett’s calls for self-sufficiency in order to escape profiteering merchants.78 Above all, however, Wright’s analysis drew on arguments for increased freedom of trade.79 Competition, it was claimed by many, would improve water supplies much as they would increase the affordability and availability of other goods; some advocates of political and economic reform, like the MP Joseph Hume, were vocal critics of London’s water companies.80 Monopoly, many maintained, had the opposite effect. Petitioning the Lords in 1819, James Weale claimed that the directors of the Grand Junction, West Middlesex and other water companies ‘did cunningly devise . . . the establishment of a Monopoly of Water’ and that it was a ‘criminal project’. For, he submitted, ‘all monopolies are against the ancient and fundamental laws of these Realms: That all endeavours to enhance the price of any victual or merchandise . . . are highly criminal’. Water, he continued, was ‘both in fact and at law, an article of victual, provision, and merchandise’; the directors had artificially forced up the price.81 In 1828, one physician declared that ‘the situation of housekeepers supplied by the new Water Companies is exactly what Adam Smith has described’ when writing about the consequences of monopoly.82 Such monopolies seemed particularly outrageous because entrepreneurs continued to propose new water companies, drawing on new or improved sources. In 1824 there appeared advertisements for a Thames Water Company, which undertook to filter its water,83 and public meetings heard plans for a company to bring water from the upper Thames because the lower reaches were now ‘contaminated by torrents of impure matter’.84 The next year a bill to establish a new London water company was read in Parliament. Intending to supply the City and East London from the River Lea, it promised a ‘constant supply of good and wholesome Water for domestic Manufacturing and other Purposes’.85 It would inevitably have competed with the New River and East London water companies. Even more threatening to the established water order was the abortive Metropolitan Water Works Company of 1825 which planned to supply London with pure, uncontaminated water from artesian wells.86 Some denounced it as a dangerous fantasy which would exhaust these reserves;87 others saw it as a obvious alternative to the Thames. The Morning Herald declared that ‘Standing . . . as . . . the . . . metropolis does, upon a stratum producing the finest spring water, it is a matter of wonder that these . . . doubts . . . do not produce a more ample

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supply of an article which neither common sewers, gas-works, nor other impurities can reach’.88 Offering apparent alternatives to existing supplies, these abortive ventures drew upon and fostered criticisms of London water and London water companies, further undermining their legitimacy. Wright, for example, had extensive contacts with one of them.89 Many of Weale and Wright’s contemporaries thought that the cost of other commodities was being increased and their quality reduced in similarly artificial ways. An orator at a public meeting about the water companies’ agreement linked it to other controversies over the allocation of necessities. ‘By the corn bill’, he noted, ‘they could not have bread for less than 1s. the quartern loaf. Now water was monopolized and sold dear, and thus the two most essential requisites of life were rendered precarious and difficult to be had’.90 George Smeeton’s Doings in London (1828) analysed the metropolitan cup of tea, revealing that the milk, the tea and the water were all nauseously adulterated.91 Monopoly was said to be having an equally ruinous effect on an even more important London liquid: beer. The language of these protests was strikingly similar to Wright’s. In 1818 14,000 Londoners signed a petition which declared themselves to be much aggrieved by the high price and inferior quality of the Beer . . . obtruded upon them, in consequence of the supply of that necessary of life being confined to certain privileged individuals and places; that high legal Authorities have declared all Monopolies to be against the ancient and fundamental laws of the realm, and injurious to the Public; first by raising the price of the commodities; secondly, by diminishing their quality.92 The following year public meetings in Westminster called for ‘a Free Trade in Beer’, attacking licensing laws as monopolistic, with a ‘manifest tendency to render Beer high in price, and of an inferior quality’.93 One MP reported that medical opinion attributed many chronic diseases to the ‘bad beer’ associated with monopoly; Sydney Smith denounced how the monopoly produced through the licensing of beerhouses had the ‘immediate consequence’ that ‘such trash [was] forced into the throats of the poor, as an hog of the smallest degree of refinement would revolt at’.94 However, it was not simply a matter of economic theory. Nineteenthcentury urban network technologies like water and gas ‘generated a complex material politics’;95 disputes over water, like those over bread

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and beer, were also controversies about the power of the large-scale concerns which produced, processed and distributed them. Because it cost so much to construct waterworks and lay pipes,96 there was rarely more than one supplier to whom the householder could turn unless she or he reverted to purchasing water from carts or dug a well.97 The consequent asymmetry of power between water company and consumer disquieted contemporaries. The 1821 Select Committee noted that the public was ‘without any protection’ from suppliers’ excessive demands.98 The 1828 commissioners, too, warned of the dangers presented by the companies’ monopoly.99 The situation threatened the sense of independence and self-worth so important to middle class metropolitan householders. Fores’s speech to the Willis Rooms was full of impotent rage at his inability to obtain redress, protesting that It was useless to talk of going to the Directors. They might hear the complaint as to the bad quality of the water, and if a threat were held out, that an inhabitant would discontinue taking the water, he would be told at once it was “Hobson’s choice, that or none.”100 The water companies ‘grasped at monopoly’, raged J. B. Sharpe at a public meeting in 1818. ‘By this combination’ [between the New River and East London Water Companies], he continued to loud applause, ‘whole districts were transferred, as cattle at a fair from one drover to another’.101 Wright developed this metaphor. By the water companies’ agreement, he wrote, ‘customers [were] counted out, and handed over, by these jobbers in one of God’s choicest blessings, from one set of monopolists to another, like so many negroes on a West Indian estate, or so many . . . cattle at a fair’.102 However, nineteenth-century joint stock water companies were perceived as political entities,103 not only because of their power, but also because they took on quasi-public functions, and presented themselves as serving the public. The statute establishing the East London Waterworks, for instance, began by listing the parishes that ‘have not a sufficient Supply of good and wholesome Water’, and declaring that this situation could be improved by building a new waterworks, before announcing the individuals ‘willing and desirous, at their own Expence’ to construct one for these ‘beneficial Purposes’.104 In 1809, for example, the West Middlesex Water Company styled their ‘Works [as] . . . worthy of the Country & Calculated to be most benificial to the Public’.105 But this language carried notions of duty and obligation, and opened companies to criticism if they seemed not to meet their responsibilities. In 1828,

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for instance, the physician Robert Kerrison demanded: ‘Have the new Companies fulfilled the engagements they entered into with Parliament as the legitimate guardians of the ‘salus populi’?106 Kerrison’s pamphlet exemplified not only tensions in his own and many of his contemporaries’ understanding of how water fitted into commercial society, but also broader uncertainties and debates about how to organize the allocation and distribution of the necessities of life. He cited The Wealth of Nations on prices and monopoly, but also wrote that ensuring the supply of wholesome water was a ‘prominent . . . feature in the domestic policy of a well-governed state’ and that such issues of police concerned the physician.107 Medical commentary on the water question thus extended broadly Hippocratic medicine (with its advocacy of fresh-flowing streams) from ‘the environment’ to the evaluation and regulation of commerce.108 Legislators, meanwhile, debated how far the agricultural interest should be protected, and worried about whether Parliament should permit water companies to go bankrupt. There was even dispute about the status of water companies’ charges. Did they express the price of the commodity supplied? Or were water rents akin to the compulsory rates charged by a public body? In the lawsuits between the AWMA and the water companies attorneys argued these issues without reaching consensus or even consistent adversarial positions.109 Addressing the 1821 parliamentary inquiry, Weale contradicted his own free trade rhetoric. ‘Water’, he declared, ‘must be considered as one of the elements necessary to existence, the same as light and air, and not merely as an article of subsistence like corn, nor of convenience like coal; and therefore its artificial supply to a great city ought not to be the subject of . . . any trade’. It ought rather to be publicly administered and provided gratis to the poor.110 The Dolphin contained similar strands: comparing water with air, it condemned the ‘Monopoly of an element of nature’ within London; it argued that the condition of water was a matter of public trust and health. ‘Every inhabitant of this . . . metropolis’, Wright wrote, ‘ought to have a rooted confidence, that the water sent into his house is, at all times, of a pure and wholesome quality – a confidence, not so much in the persons who sell the water, as in the Government of the country – that it will not permit any but such as is pure and wholesome to be pumped into their dwellings’.111 Metropolitan water supply thus sat astride the boundary of the agora and the polis, falling uncertainly between government, public health and the market. Whig, Radical and Tory all agreed that water was, as Wright insisted and the Willis Rooms meeting resolved, ‘a Necessary of Life’. Rich in symbolic and cosmological significance,112 water bridged

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the social and the biological. With pumps, pipes and turncocks, urban water companies turned the natural into the cultural and the commercial. What was crucial but less than clear was whether such technological alchemy improved or corrupted the supplies. The fluidity of the parties’ rhetoric reflected the inchoate nature of these campaigns about water price and quality. As we have seen, some commentators linked water prices and the Corn Law. There are parallels between some criticisms of the water companies’ high-handed conduct and denunciations of Old Corruption. But agitation about water was not confined to Radicals, reformers or doctrinaire free traders; nor is any correlation with particular religious affiliation detectable. Wright worked with Burdett, but the committee formed at the Willis Rooms included moderate Tories like Lord Wharncliffe and Whigs like the Earl of Sefton. The signatories of the 1827 petition came from every point on the political spectrum.113 The AWMA included Whig and Reformer activists, but also subscribers who plumped for Sir Murray Maxwell, the Tory candidate in the 1818 Westminster election.114 Weale’s politics remain obscure, but he sent his letters about Water Monopoly to the ultra-Tory The New Times. Indeed concern about the condition and cost of the capital’s water supply could reflect paternalistic attitudes and the concern about the social body characteristic of Tory economic writings.115 *** The politics of commerce and of pollution were thus closely entwined in early nineteenth-century London. But their association was not peculiar to these decades. Similar concerns about monopoly and the political economy of water permeated debates on public health throughout the nineteenth century.116 It is instructive to compare these developments with the 1690s. During this decade the Conduit Water Company’s advertisements recommended that ‘in ‘Winter and RainyWeather’ rivals’ customers should ‘watch their Waters, . . . to try whether the City-Conduit-Waters be not very Clear and most fit for Drinking and all other Uses’.117 The only time in the seventeenth or eighteenth centuries when one company questioned another’s supplies was thus when two were competing directly. Intense commercial competition, we might surmise, led enterprises to question rivals’ products, undermining the credibility and perceived quality of all supplies. Periods of rapid change in the commercial and social organization of water seem likely to reduce trust in those arrangements and to produce anxieties about the probity, potability and reliability of supply.118

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This suggests some broader conclusions about the relation between the market and public health. It is clear that in order to develop the historiography of health and the market one should consider the ways by which all kinds of necessities, not just therapies and remedies, are allocated and distributed. Integral to this is not only the changing role of society, state, community, household and market in these allocations, but also the historical processes in and by which these categories are constituted and understood. In particular, this chapter suggests that we should complicate the binary divide between economic activity and the natural world which still structures many histories of public health and the environment. ‘Pollution’ can be seen not only as the downside of industrialization and the commodification of nature, but also as a moralized perceptual category which critiques undesirable economic behaviour as much as the degradation of an ecosystem. Commerce muddies the waters in more ways than one.

Notes I thank the audiences in London and Manchester who discussed versions of this paper; Patrick Wallis for commenting on it; the Wellcome Trust who funded the research; and Patricia Greene for her support, critical commentary and much more. 1. D. H. Laurence & D. J. Leary eds, Bernard Shaw: The Complete Prefaces Volume 1: 1889–1913 (1993), 355. This broader literature included S. Szreter, ‘The Importance of Social Intervention in Britain’s Mortality Decline c. 1850–1914: A Reinterpretation of the Role of Public Health’, SHM, 1 (1988); A. Hardy, The Epidemic Streets (Oxford, 1993); P. Slack, ‘Dearth and Social Policy in Early Modern England’, SHM, 5 (1992); M. Pelling & R. M. Smith eds, Life, Death and the Elderly (1991). 2. Such scholars do not see ‘doctors’, ‘patients’ or their ‘relationship’ as historically unchanging. 3. E.g., J. Walter & R. Schofield eds, Famine, Disease and the Social Order in Early Modern Society (Cambridge, 1989). 4. On this, e.g., R. D. Bullard, Dumping in Dixie, 2nd edn (Boulder, 1994). 5. C. Hamlin, ‘Predisposing Causes and Public Health in Early NineteenthCentury Medical Thought’, SHM, 5 (1992); idem, Public Health and Social Justice in the Age of Chadwick (Cambridge, 1998), chs 1–2. 6. Morning Herald (10 April 1827), 4a. 7. The Courier (10 April 1827), 1; New Times (10 April 1827). Cf. R. Murdie, A Second Judgement of Babylon the Great, 2 vols (1829), i, 6–7. 8. Remarks upon the Resolutions Passed at the Meeting, Held at WILLIS’S ROOMS, . . . by the DIRECTORS of the Grand Junction Water Works Company [1827], 1 (GL, MS 173/4). 9. E.g., Morning Herald (20 March 1827), 2. 10. The Times (9 April 1827), 2e. See also The Morning Chronicle (9 April 1827), 3.

Mark S. R. Jenner 233 11. Johnson had worked in, and published on, India, M. Harrison, Public Health in British India (Cambridge, 1994), 41–8. 12. The Times (21 March 1827), 3d; (22 March), 6f. 13. The pamphlet was published anonymously, but Wright’s authorship was known before the meeting. BL, Add. MS 35146, 20–21 March 1827; W. M. Stern, ‘J. Wright, Pamphleteer on London Water Supply’, Guildhall Miscellany, 1 (1953). 14. [Wright], The Dolphin, or Grand Junction Nuisance (1827), 62. 15. Wright, Dolphin, 62. He was quoting Swift’s ‘After a City Shower’. 16. BL, Add. MS 35146, 19 March 1827. 17. Morning Chronicle (26 May 1827), 1–2. 18. D. E. Lipschutz, ‘The Water Question in London, 1827–1831’, BHM, 42 (1968), 518. 19. Ibid., 518–20. See also, J. Wright, The Water Question (1828). 20. Report of the Commissioners Appointed by His Majesty to Inquire into the State of the Supply of Water in the Metropolis (1828) (hereafter RC), 9–11. 21. RC, 11; C. Hamlin, A Science of Impurity (Bristol, 1990), ch. 3. 22. A. Hardy, ‘Water and the Search for Public Health in London in the Eighteenth and Nineteenth Centuries’, MH, 28 (1984), 260; Lipschutz, ‘Water Question’, 524. 23. Such assurances included, LMA, Acc.2558/WM/A/4/2 p. 237; Westminster Archives Centre, C779, pp. 253–6; Remarks upon the Resolutions . . . at WILLIS’S ROOMS, 3. 24. E.g., T. Smollett, The Expedition of Humphry Clinker, ed., L. M. Knapp (Oxford, 1966), 120. 25. B. Luckin, Pollution and Control (Bristol, 1986), 12–14. 26. On the senses and pollution, S. Mosley, The Chimney of the World (Cambridge, 2001), intro. and ch. 1; P. Macnaghten & J. Urry, Contested Natures (1998), ch. 4. 27. LMA, Acc.2558/GJ/1/20 pp. 302 & 326; Acc.2558/GJ/1/3/1 pp. 298–9 & 322; Acc.2558/GJ/1/32(1872); Commons Journals, 81 (1826), 25 & 382; Lords Journals, 58 (1826), 351. 28. This was the surgeon John Abernethy’s response when asked whether Grand Junction water was wholesome, Wright, Dolphin, 69. 29. Hamlin, Science, ch. 3. 30. LMA, Acc.2558/GJ/1/33/1–31(1), item 2397, p. 30; R. J. Reece, ‘The Thames Water’, Monthly Gazette of Health, 13 (1828), 58–9. 31. Morning Herald (10 April 1827); ODNB, s.n. 32. The Times (10 April 1827), 3. 33. Wright, Water Question, 6–7. 34. Wright, Dolphin, 40–57, quotations at 42 and 48. 35. Wright, Dolphin, 54–7. See also Wright, Water Question, 30–31 & Murdie, Second Judgement, i, 6–7. 36. British Museum, Dept. of Prints and Drawings, Political Satire 15401. The print’s pseudonymous signature, Peter Wilkins, and the quotations ironize the whole affair, F. G. Stephens & M. D. George, Catalogue of Political and Personal Satires, 11 vols (1870–1954), X, 680–81. 37. The scene is imaginary. Unlike his fellow MP John Joseph Hume, Burdett was not in dispute about his water rents and was never threatened with disconnection.

234 Monopoly, Markets and Public Health 38. 39. 40. 41.

42.

43.

44. 45. 46. 47. 48. 49.

50. 51. 52.

53. 54. 55. 56. 57. 58. 59. 60. 61. 62. 63. 64.

LMA, Acc.2558/GJ/1/32 (2410); Wright, Dolphin, 57. Wright, Dolphin, 41. See also, G. Smeeton, Doings in London (1828), 110–13. Wright, Dolphin, 42, 49 & 59. On Weale’s employment, TNA, LRRO2/26, pp. 56, 132, 244 & 376. Weale subsequently worked as a surveyor in Ireland, R. J. Scally, The End of Hidden Ireland (New York, 1995), 25–6. A significant number of people (such as Fores and the physician Robert Kennison) were involved in both campaigns, GL, 173/2 List of St. James Piccadilly; Minutes of Evidence Taken before the Select Committee on the Supply of Water to the Metropolis (1821) (hereafter MESCWM), 115–17; LMA, Acc.2558/NR13/82 pp. 26, 60 & 106. In support of ‘your endeavours to obtain an adequate remedy for the publick grievances in respect of the supply of water to the Metropolis’, Weale sent Wright unpublished evidence presented at the 1821 inquiry, GL, MS 172(82). L. Schwarz, ‘London, 1700–1840’, in P. Clark ed., The Cambridge Urban History of Britain, Vol. II (Cambridge, 2000), 650. The population in 1821 had reached 1,247,000. 46 GIII c.119; 50 GIII c.132. LMA, Acc.2558/EL/A/1/48 pp. 106–07, 110–11, 128–29. The company had gained statutory approval in 1808, 47 GIII c. 72. 51 GIII c. 169. Publicity cards c.1810 in LMA, Acc.2558/WM/22/1 & GL, MS 173/1. GL, MS 172(12). High service meant that water was piped to the upper floors of the customer’s house, requiring greater water pressure. The iron mains and steam engines introduced in the early nineteenth century made this possible. LMA, Acc.2558/NR/1/7, pp. 278–79. J. D. Graham-Leigh, ‘The Transformation of London’s Water Supply, 1805–1821’ (M.Phil. thesis, Open University, 1984), 36–7. LMA Acc.2558/GJ/1/30, No. 1284 (Case of the West Middlesex Water Works against the Bill Now in Parliament for Establishing a Parochial Water Company in St. Mary-le-bone, 1818), 1. B. Rudden, The New River (Oxford, 1985), 140, 308; J. Graham-Leigh, London’s Water Wars (2000), 49. Graham-Leigh, Water Wars, chs 4 and 5. LMA, Acc 2558/GJ/1/2/1, p. 143. Graham-Leigh, Water Wars, ch. 5. F. H. W. Sheppard, Local Government in St. Marylebone 1688–1835 (1958), 193–9; Hansard, 38 (1818), 31. The companies were willing to accept this. LMA, Acc. 2558/NR13/82, p. 1. LMA, Acc. 2558/GJ/1/2/1, p. 365. John Bull (2 December 1821), 405. MESCWM, 71. Remarks upon the Resolutions . . . at WILLIS’S ROOMS; RC, 12. He hoped that the actions advocated at the meeting ‘would have a more successful termination’, The Times (10 April 1827), 3f. The company stressed these developments, Remarks upon the Resolutions . . . at WILLIS’S ROOMS.

Mark S. R. Jenner 235 65. See RC, 44–5, 46–7, 97. Several of Cruikshank’s jokes were made in 1819–21, ‘John Bull’s Waterworks’ (British Museum, Satirical Prints No. 13196); The Ladies in the Dumps, for Fear of their Water Works (n.d.), in GL, MS 173/3. 66. Wright, Dolphin, 3–4. 67. Ibid. 68. Wright, Dolphin, 95; Hansard, 37 (1818), 1184. On water in Lauderdale’s theory of value, M. Paglin, Malthus and Lauderdale (New York, 1961), 44–45. 69. LMA, Acc. 2558/NR13/82, p. 1. 70. Wright, Water Question, 6–7. 71. The Standard (30 June 1827), 2c; RC, 114–15. 72. Quoted in Graham-Leigh, Water Wars, 32–33. 73. E.g., LMA, Acc. 2558/EL/A/1/48, p. 266; Acc. 2558/NR/1/7, pp. 164, 181 & 338; R. Ward, London’s New River (2003), 164–6. 74. Commons Journals, 82 (1826–8), 589. 75. E. Hawkins, ‘Authors of the Poetry of the Anti-Jacobin’, Notes and Queries, 1st ser., 3 (1851); G. Stones ed., Parodies of the Romantic Age, 5 vols (1999), I, pp. lii, 155n. 76. G. H. D. Cole, Life of William Cobbett (1924), 224; G. Spater, William Cobbett (Cambridge, 1982), 170–2, 252–4, 427–8. 77. R. Harris, ‘Political Economy, Interest Groups, Legal Institutions, and the Repeal of the Bubble Act in 1825’, EcHR, 50 (1997); E. Thomas, ‘The Crisis of 1825’ (M.A. thesis, University of London, 1938). 78. I. Dyck, William Cobbett and Rural Popular Culture (Cambridge, 1992), esp. ch. 5. 79. See, J. Wright, A Biographical Memoir of . . . William Huskisson (1831), iii. 80. For Hume and the water companies, LMA, Acc. 2558/MW/C/15/347/11a; Acc. 2558/WM/A/4/2, p. 510; Acc. 2558/WM/A/4/3, pp. 82, 162 & 165. 81. The Humble Petition of James Weale . . . on Behalf of Himself and Other Inhabitant Householders of London (1819), 2–3. This language did not operate one way – defending their right to increase prices, the water companies were happy to present themselves as ‘dealers in water’, GL, MS 172/2, cutting from British Press (29 July 1820). 82. R. M. Kerrison, A Letter to . . . Robert Peel . . . on the Supply of Water to the Metropolis (1828), 18. 83. The Times (15 & 25 September 1824). 84. Thames Water-Company (1824), 1. (GL, MS 172(8), Prospectus for proposed company of Thomas Taylor); LMA, Acc.2558/GJ/1/20, pp. 350 & 370–71. 85. A Bill for Supplying with Water the City of London and the Counties of Middlesex and Essex (1825), CLRO, PD/101/22; LMA, Acc. 2558/GJ/1/33/1(2), Item 1958. 86. New Times (19 November 1824); Morning Advertiser (15 March 1825), 2b (cutting in LMA, Acc. 2558/NR/13/133); LMA, Acc. 2558/EL/A/1/49, p. 72; Acc. 2558/GJ/1/33/1–31(2), Item 1888. 87. Weekly Dispatch (17 October 1824), 1; Morning Advertiser (15 March 1825), 2b. 88. Morning Herald (15 August 1827). Cf. The Sun (25 September 1827), cutting in LMA, Acc. 2558/NR/13/133. 89. Lipschutz, ‘Water Question’, 517–18; GL, MS 172 (66). These links were used to discredit Wright, Reece, ‘Thames Water’, 56. D. Sunderland,

236 Monopoly, Markets and Public Health

90. 91.

92.

93.

94. 95.

96.

97. 98. 99. 100. 101. 102. 103. 104.

105. 106. 107.

‘Disgusting to the Imagination and Destructive of Health’? The Metropolitan Supply of Water, 1820–52’, Urban History, 30 (2003), 371, 380 states that The Dolphin and subsequent campaigns ‘were motivated by self-interest’, and that the companies ‘should be applauded’. Far more important than Wright’s ‘true’ motives (if the historian could ever establish them) is the structure and plausibility of his arguments. The Times (31 October 1818), 2d. Smeeton, Doings, 105–13. It attributed the tea’s condition to the East India Company’s monopoly. See also, G. R. Searle, Morality and the Market in Victorian Britain (Oxford, 1998), 91–7. Commons Journals, 73 (1818), 153. On these campaigns, P. Matthias, The Brewing Industry in England 1700–1830 (Cambridge, 1959), 228–51; B. Harrison, Drink and the Victorians, Rev. edn (Keele, 1994), ch. 3; Searle, Morality and the Market, 240–4. Weekly Dispatch (21 February 1819), 58b & 60b; (28 February 1819), 67c & 68a. At least one AWMA activist – Hector Campbell – was vocal in both campaigns, ibid. (22 March 1818); GL, MS 172/4, letter of 11 June 1821; LMA, Acc. 2558/NR/13/133, cutting, entitled ‘THE NEW WATER COMPANIES’. Hansard, ns 7 (1822), 333; [S. Smith], ‘Licensing of Alehouses’, Edinburgh Review, 44 (1826), 447. M. Daunton, ‘The Material Politics of Natural Monopoly: Consuming Gas in Victorian England’, in M. Daunton & M. Hilton eds, The Politics of Consumption (Oxford, 2001), 87. For this reason Adam Smith considered ‘works . . . for supplying a great city with water’ one of only four types of enterprise for which a joint stock company was warranted, An Inquiry into the Nature and Causes of the Wealth of Nations, ed. R. H. Campbell & A. S. Skinner, 2 vols (Oxford, 1976), ii, 757. E.g., GL, MS 173/4 Samuel K/Teach to Weale, 31 January 1822; LMA, Acc. 2558/GJ/1/4/1, pp. 326–7. Report from the Select Committee on the Supply of Water to the Metropolis (1821), 8. RC, 1828, 12. The Times (10 April 1827), 3. The Times (31 October 1818), 2d. Wright, Dolphin, 7. T. L. Alborn, Conceiving Companies (1998). An Extract of the Act of Parliament of 47 Geo. III for Establishing the East London Water-Works (1808), 37–8. The statute establishing the West Middlesex Company used a similar rhetoric, 46 GIII c.119. LMA, Acc. 2558/WM/A/4/1, p. 17. Kerrison, Letter, 3. P. E. Carroll, ‘Medical Police and the History of Public Health’, MH, 46 (2002). There are parallels between these debates over water and earlier debates about whether the grain trade ought to be a matter of police, I. Hont & M. Ignatieff, ‘Needs and Justice in the Wealth of Nations: an Introductory Essay’, in I. Hont & M. Ignatieff ed., Wealth and Virtue (Cambridge, 1983), 13–26. See also A. Gambles, Protection and Politics (Woodbridge, Suffolk, 1999), 26–36.

Mark S. R. Jenner 237 108. Strikingly such figures drew on imperial evidence or experience. 109. LMA, Acc. 2558/WM/A/3/Y27.05(3); GL, MS 173/2, cuttings from British Press, New Times & Morning Herald, 29 July 1820. 110. MESCWM, 71. 111. Wright, Dolphin, 99–100. 112. E.g., R. Dodd, Observations on Water (1805), 8–10 & 17–8. 113. GL, MS 172(21–2); Wright, Water Question, 7; LMA, Acc. 2558/GJ/1/32 (2410). 114. The Westminster Poll Book 1818 (Exeter, 1996 [1818]); AWMA subscription list, St. James Piccadilly, GL, MS 173/2. I intend to publish a systematic discussion of the subscribers in future. 115. D. Eastwood, ‘Tories and Markets: Britain 1800–1850’, in M. Bevir & F. Trentman eds, Markets in Historical Contexts (Cambridge, 2004); Gambles, Protection and Politics. 116. E. Chadwick, Report on the Sanitary Condition of the Labouring Population of Gt. Britain, ed., M. W. Flinn (Edinburgh, 1965), 145; P. Schwarz, ‘John Stuart Mill and Laissez Faire: London Water’, Economica, 33 (1966); J. Taylor, ‘Business in Pictures: Representations of Railway Enterprise in the Satirical Press in Britain 1845–1870’, P&P, 189 (2005), 143–4; F. Trentmann and V. Taylor, ‘From Users to Consumers: Water Politics in Nineteenth-Century London’, in F. Trentmann ed., The Making of the Consumer (Oxford, 2006). 117. J. Houghton, A Collection for Improvement of Husbandry and Trade, 224 (13 November 1696). See also, M. S. R. Jenner, ‘From Conduit Community to Commercial Network? Water in London, 1500–1725’, in P. Griffiths & M. S. R. Jenner, Londinopolis (Manchester, 2000), 260–64. 118. On trust and water companies, M. S. R. Jenner, ‘L’Eau Changée en Argent? La Vente de L’Eau dans les Villes Anglaises au Temps de L’Eau Rare’, XVIIe Siècle, 55 (2003); V. Strang, The Meaning of Water (Oxford, 2004). More generally, M. Douglas, Purity and Danger (1966).

12 Medicine, Quackery and the Free Market: The ‘War’ against Morison’s Pills and the Construction of the Medical Profession, c. 1830–c. 1850 Michael Brown The medical wreath of laurel is now in dispute between the Hygeists and the Doctors and Surgeons. The public must be the great gainers from this competition, and will award the prize to the most deserving, notwithstanding the antiquity of their diplomas1 For many ‘regular’ medical practitioners in mid-nineteenth-century England, the spectre of unlicensed practice loomed large. In the Lancet in 1836, Thomas Wakley claimed that ‘[n]ever have quacks, quackish doctrines, and quack medicines, exercised a greater influence over the minds and bodies of the people of this country, than they exert in the present epoch’.2 Such sentiments are given comparatively little treatment in scholarship on the medical marketplace. The normal assumption is that the medical marketplace was an early modern phenomenon which ended in the mid-nineteenth century, but the nature and extent of its supposed demise remain unclear.3 Roy Porter’s Health for Sale, which unusually took the marketplace into the nineteenth century,4 suggests that a key factor in the demise of ‘quackery’ was its supersession by ‘fringe’ medicine such as homeopathy, hydropathy and medical botany. Porter argues that while ‘quackery’ ‘clung to the regulars’ coat tails’, ‘fringe’ medicine was an ideological movement whose opposition to ‘orthodox’ medicine ‘had designs on men’s minds more than their pockets’.5 There is much truth in this: many nineteenth-century popular medical ‘movements’ were ideologically opposed to conventional medicine. However, this change did not end the medical marketplace. If anything, the nineteenth and twentieth centuries constituted, economically and ideologically, a more competitive arena for the practice of medicine than the preceding ones.6 Yet this is not to deny that something important occurred in this period. The eighteenth-century marketplace 238

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was characterized by a fluidity and plurality of knowledge and practice and a culture of commercial individualism; the nineteenth century saw a hardening of boundaries and the elaboration of more antagonistic cultures within health care. To understand this shift one must consider a factor identified by Porter: medical professionalization and medical reform.7 The rise of the profession underwrites assumptions about the ‘suppression’ of the medical marketplace in nineteenth-century England.8 This chapter therefore revisits this material in order to explore the mechanisms of the transformation of the mid-nineteenth-century English medical marketplace.9 Individual ‘regular’ medical practitioners had denounced ‘quack’ practices and medicines before.10 However, in the mid-to-late 1830s, a broad front of geographically disparate, but ideologically linked, practitioners conducted a coordinated campaign to destroy the successful proprietary medicine business of James Morison. This chapter examines the ‘war’ against Morison’s pills. Analysing coroners’ inquests and criminal trials, it demonstrates how these were part of a wider attempt to establish the social, legal and intellectual authority of ‘orthodox’ medicine and so embeds anti-‘quackery’ campaigns within contemporaneous shifts in understandings of the medical profession. The movement for medical reform is essential to understanding changing perceptions of ‘quackery’ in this period. Its roots stretched back into the eighteenth century, but it was realizing its potential by the 1830s.11 As Burney has suggested, it was, in tone and substance, commensurate with a wider culture of political reform.12 However, while corporate corruption and the shortcomings of government were prominent issues for radical general practitioners and provincial medical men, the language of Wakley and his supporters hinted at a deeper ideological transformation. Throughout their calls for medical reform, these radicals appealed for ‘unity’ and ‘uniformity’ among practitioners. This period also witnessed a proliferation of provincial medical and surgical societies much of whose purpose was the coordination of local medical opinion and its projection to the level of national political debate. Eighteenth-century medical practitioners may have identified with a local ‘faculty’, but there was little sense of a wider collective. From the 1830s, however, reformers began to articulate a vision of the medical profession as a unitary and democratized body of practitioners connected by common ideals, knowledges and practices. As the (pre-1855) British Medical Association stated, they aimed to ‘unite the scattered members of our profession into one body’.13 Such sentiments had profound implications for medical conceptions of ‘quackery’ and the

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marketplace. Firstly, the definition of this collective identity entailed the construction of boundaries and the exclusion of those deemed ‘unorthodox’ in knowledge, practice or education.14 Secondly, central to this vision was the claim that its members should exercise dominion over all aspects of public health, something which demanded the elimination of other forms of health care provision.15 This issue of medical authority provides the focus for the second half of this chapter. The existing historiography suggests early modern health care was an almost entirely unrestricted market.16 While this is debatable, it is clear that the anti-‘quackery’ campaigns of the 1830s and 1840s sought radically to restructure the commercial status of medicine and its relationship to the public. As Burney and Barrow suggested, these campaigns embodied an essential irony: while men like Wakley regularly spoke of open and fair competition when decrying the nepotistic privileges of the metropolitan medical elites, they, in the same breath, demanded a state-sanctioned monopoly over the practice of health care.17 This contradiction was especially glaring in mid-nineteenth-century England where the doctrines of free trade and laissez-faire were ascendant and occasioned intense debate. Many political economists deprecated state intervention tending to curtail free-market competition. Others saw the legislative establishment of the medical profession and the elimination of ‘unorthodox’ practice as an affront to individual freedom of conscience, equivalent to the enforcement of a state religion.18 How then did medical reformers, many with broadly similar liberal sympathies, overcome these tensions? This chapter demonstrates how, through the language of the ‘public good’, they sought to exclude the practice of medicine from the operation of market forces and present themselves as the sole legitimate guardians of public health. Although they mostly failed to achieve their goals, these new discourses, and the accompanying forms of social action, helped transform the nineteenth-century medical marketplace and harden imaginative and legislative distinctions between the medical profession and ‘fringe’ practices.

James Morison and Hygeiaism By the 1830s ‘unorthodox’ medicine enjoyed widespread popularity. The later eighteenth and early nineteenth centuries appear to have witnessed an increase in the production and consumption of proprietary medicines.19 This period also saw the emergence of practitioners, such as John St John Long and Roderick Macleod, who performed and

Michael Brown 241

marketed therapeutic procedures in opposition to ‘orthodox’ medical thought.20 However, of those engaged in the unlicensed provision of health care, none was so vilified by medical contemporaries than James Morison, the self-styled ‘Hygeist’.21 Morison was born in 1770 at Bognie, near Aberdeen. He entered Marischall College aged thirteen, but soon relocated to Hanau, Germany, then to Riga, and then moved to the West Indies, where relatives had property and business interests. He apparently prospered there.22 But, like many accounts of patent medicine promoters, Morison’s biography then tells of suffering and redemption.23 He claims to have endured ‘inexpressible suffering . . . of body and mind’.24 Finding the West Indian climate aggravated these infirmities, he moved to Bordeaux ‘about 1814’, where he resided for some time.25 Morison allegedly sought the advice of numerous eminent surgeons and physicians, and even underwent an operation to remove ‘cartilage’ from his stomach. But when he turned fifty, the failure of his medical advisers convinced him of their error concerning the universal system of disease. He reasoned that the root of his illness lay ‘in my bad humours, which, from my stomach and bowels are diffused all over my body’. He therefore experimented with pills composed of vegetable-based purgatives and, after copious self-dosing, passed a ‘substance of a skinny, glutinous nature, four or five inches long, moulded like a gut’. Morison identified this as the cause of his suffering, and, in language resonant with the rhetoric of evangelical Christianity, ‘saw the light – the light that guided me to health’.26 In 1825 Morison established a factory in London, where he manufactured two types of pill, the ‘No. 1’ and ‘No. 2’, denominated the ‘Vegetable Universal Medicine’.27 Their composition became a matter of medical debate (Morison never revealed his ‘secret’), but they apparently contained a mixture of aloes, gamboge, jalap, cream of tartar and colocynth, all of which have emetic or purgative effects.28 Initially, Morison was the sole proprietor, but by 1830 he entered into partnership with Thomas Moat, a Devonshire businessman and convert to his ‘system’.29 ‘Morison’s pills’ became enormously successful and, sold through a network of local agents, made them rich. By 1833 Morison and Moat had sold 80,000,000 pills; in that year they paid some £10,000 in stamp duty.30 However, the real challenge to medical reformers came not from Morison’s pills, but their ideological packaging. They encapsulated a system of medicine opposed to contemporary medical orthodoxy, which Morison called ‘Hygeiaism’, after the Greek goddess of health. For Morison, blood was the primum mobile of life. Disease was produced

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by ‘obnoxious matter’ impeding the blood’s circulation and was cured by purging this matter from the body. Morison saw this as a resurrection, and partial revision, of humoural pathology, which he situated against contemporary ‘organic’ medicine. ‘Organic’ medicine, he claimed, ignored the fundamental simplicity and unity of the body and treated the human frame and its ailments as a ‘patchwork’, resulting in ‘a labyrinth of tales, ideas, system and conjecture’.31 From the mid-1820s, Hygeists (as his supporters were known) engaged in a propaganda campaign against the medical profession. They regarded medical theory as fundamentally wrong, and denounced established therapeutic techniques as ‘murder’. Surgery and pathological anatomy was a ‘bastard science . . . invented partly to amuse, and partly to torture mankind’. Medical practitioners were ignorant, incompetent, vicious and greedy, always seeking to extend their ‘guinea trade’.32 From the 1830s, the Hygeists produced prints attacking doctors. Illustration 12.1 presents two contrasting images, whose central motif is a tree, symbolizing the human body. The left-hand tree is under the ‘Organic or Doctors’ System’, and is full of ‘Corrupt Matter’ and in a ‘State of Decay throughout’. Doctors, treating isolated parts of the tree/body according to their theories, overwhelm it. Framing it are examples of medical greed, self-interest (note the caricature of Wakley in the door of ‘Lancet & Co.’) and exploitation (e.g. the Hospital and ‘Mad House’). On the right is another tree ‘Flourishing’ under the ‘Hygeian or Morisonian System’. Four Hygeists reveal that, by treating it ‘as a whole’, they have ‘drained’ it ‘of all impurities’. While Morison attacked doctors and surgeons, he gallingly mimicked their institutional structures and discursive practices. In 1828, he moved his business into the ‘British College of Health’ (Illustration 12.1, extreme right),33 styling himself ‘President’, his partner, Moat, ‘Vice-President’ and his agents ‘Honorary Members’.34 The Hygeists published numerous books, and, from 1842, a journal called the Hygeist, opposing the medical profession and promoting the Hygeian system. They established a Dispensary, where the poor were treated for free in accordance with their principles.35 Like medical and surgical societies, they even held public lectures and meetings wherein they discussed individual case studies.36 However, what most infuriated medical reformers was that Hygeists co-opted the rhetoric of reform.37 Morison and his supporters used the language of a progressive ‘march of intellect’, identifying medicine as a branch of ‘Old Corruption’.38 Whereas Wakley and his associates sought

Michael Brown 243

Illustration 12.1 ‘Fallacy of the Organic Theory’, reproduced by permission of the Wellcome Library, London.

to reform medicine’s political structures and establish new areas of medical authority and expertise, Hygeists demanded the disestablishment of the entire edifice. With the slogan ‘every man his own physician’, they advanced a democratizing ideology deriding doctors as a ‘medical priesthood’:39 Matters have already gone too far for the Doctors to suppose, that in this enlightened age, when the mechanic knows as much as the priests and princes formerly, they can put a stay to the Hygeian system, which has truth for its basis, nature for its instructor, and reason and experience for its guides.40 Morison was portrayed as a conduit for divine truth: That desired knowledge, and that light, which are the offering of heaven to universal man, without regard to school, class, corporation,

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colour, country, and clime, shone into one mind – . . . the mind of JAMES MORISON.41 ‘Orthodox’ medical reform rang hollow: The same observation will serve to evince the hypocrisy of Doctors when affecting to join in the political movement by echoing the cry of reform. Their system is literally based on corruption; corruption is indispensably necessary to its very existence; it must therefore either remain as it, or be entirely annihilated.42 Such claims appealed to working- and middle-class radicals, many of whom embraced Hygeiaism’s anti-establishment, democratizing and self-help dimensions.43 Images like Illustration 12.1 are thus open to more radical interpretations. The tree could be taken as a metaphor not only for the body, but, like the revolutionary ‘liberty tree’, for the body politic. Words such as ‘Corrupt’ and ‘Decay’ have a double meaning, and the image on the right figures a reformed political ‘constitution’ as much as a corporeal one. Unsurprisingly, many medical reformers loathed Morison. During the 1830s, they made a concerted attempt to discredit and destroy Hygeiaism. Inspired by the case of St John Long, convicted of manslaughter in 1830, they sought to harness the coroner’s inquest and the criminal court to their ends.44 Both routes provided the mixture of judicial coercion and public ‘instruction’ which defined the medical anti-‘quackery’ movement of the mid-nineteenth century.

The ‘War’ against Morison The first of three criminal cases involving Morison’s pills occurred in York. The defendant, Joseph Webb, was the local agent for the sale of the ‘Universal Medicine’.45 In June 1834 Thomas Sowray, a local linen draper, asked him to attend his apprentice, Richard Richardson, who complained of a rash on his chest, which he feared was smallpox. Webb administered Morison’s pills, ten in the morning and ten at night. When Richardson’s condition failed to improve, Webb asked him if he wished to see a doctor. According to Webb’s lawyers, Richardson declined, being ‘quite satisfied with Mr Webb’. On 27 June, however, Richardson complained that he felt much worse, and, under pressure from Richardson’s mother, Webb allowed the family surgeon, James Allen, to call on him. He pronounced Richardson to be

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in the advanced stages of smallpox. Despite his best efforts, Richardson died within hours. A woman (probably Richardson’s mother) then wrote to the city coroner and an inquest was arranged.46 The physicians Drs Wake and Belcombe and the surgeons Messrs Allen and Matterson performed the post-mortem. All agreed that the application of Morison’s pills had, at least, accelerated Richardson’s death. This opinion was communicated to the jury, all but one of whom passed a verdict of manslaughter.47 Webb was ordered to appear before the Summer Assizes. The case excited much interest. The York Courant noted: An intense anxiety has prevailed since the commencement of the Assizes respecting the issue of this trial, partly on account of the public feeling on the efficacy of this popular patent medicine, partly too by the interest taken in the question by members of the medical profession.48 Webb’s counsel claimed that public opinion regarding Morison’s pills was split between those who had benefited from their use, and those who opposed them. The latter were ‘still the most numerous’ including ‘nearly the whole body of medical practitioners’. ‘In York’, he added, ‘it is believed the influence of the medical men prevail, and a good deal of prejudice still exists on the subject’. Wake, Belcombe, Allen and Matterson all testified against Webb. Dr Wake was especially forthright, claiming that Webb’s treatment had actually caused Richardson’s death, by inflaming his stomach and intestines.49 Webb was on trial, but medical authority was at issue. The prosecution’s evidence consisted almost entirely of medical testimony. Their case questioned the right of laypersons to treat illness: Gentlemen, one cannot but lament that in a country like this, where there are so many colleges and medical schools . . . for the education of professional persons, where honours and degrees are confirmed, and where there are so many men of skill and science . . . that there should be people, who, possessing no skill, whatsoever, should be applied to in time of sickness to administer some medicine or other which they pretend is applicable to every species of disease.50 The defence resisted the extension of medical authority, claiming that to find against Webb would be ‘to gratify and flatter doctors . . . and

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licentiates in physic’. They called numerous ‘respectable’ members of the public who testified to the successful use of Morison’s pills, but only one medical witness, the York surgeon, James Overton. Summing-up, the judge, Lord Lyndhurst, deferred to medical authority, pointing out that Overton was the ‘only medical gentlemen of any consequence called on the part of the prisoner’, and noting that even he recognized the potentially deleterious effects of Morison’s pills. The jury were convinced. After ten minutes, they found Webb guilty of manslaughter, albeit with the recommendation of clemency. He was sentenced to six months in prison.51 Webb’s trial generated intense interest in the medical press. The Lancet welcomed the verdict, while expressing disappointment that Morison had not been charged. ‘If the sale of secret medicines be not suppressed by law’, it claimed, ‘the work of medical reform will not be rendered complete in this country’.52 Even the more conservative London Medical Gazette was enthused, claiming it was the ‘duty’ of medical practitioners to bring similar cases ‘to the cognisance of the public through the medium of legislative investigation’. If they could not secure criminal proceedings, by publishing their ‘findings’, they might subject such practitioners ‘to shame and ignominy at the bar of public justice’.53 Some medical practitioners attempted to do just that. Between 1834 and 1850 there were at least nine further coroner’s inquests at which, on the basis of medical testimony, it was deemed that death had been caused, or accelerated, by an inflammation of the bowels and intestines occasioned by the ‘immoderate’ use of Morison’s pills.54 In most cases the deceased had purchased and administered the pills themselves, and so no further action was taken. In two others Morison’s agents were, like Webb, found to have taken an active role in advising and administering the medicines and, with coroner’s juries passing verdicts of manslaughter, put on trial. The first case concerned John Mackenzie from Limehouse, London. Mackenzie was thirty-two years old, ‘healthy’ and of ‘temperate habits’. A month before his death, he had brought home some papers, given to him by his friend and neighbour, Miss Lane, describing ‘the wonderful properties of Morison’s . . . pills, in the removal of every disorder’. He bought two boxes from Lane’s shop, intending to ‘raise his spirits’. A week later he was seized with a ‘rheumatic affection of the knee’ and, on Lane’s advice, took increasingly large doses. Mackenzie deteriorated, however, and Lane sent for Robert Salmon, Morison’s principal agent in London. He recommended that Mackenzie take twenty pills in the morning, and thirty-five in the afternoon. Throughout his attendance, Salmon performed in the manner of a physician, charging for medicines and advice. When questioned by

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Mackenzie’s friends, he claimed to be a surgeon, but failed to produce a diploma from the College, maintaining that ‘it was not usual for the faculty to carry their diplomas . . . with them’. Losing confidence in Salmon’s abilities, Mrs Mackenzie called for a local surgeon. He advised the patient to discontinue the pills, but Mackenzie ‘continued to sink’ and died shortly afterwards.55 Salmon stood trial at the Central Criminal Court. After half an hour’s deliberation, the jury found him guilty of manslaughter, but recommended clemency ‘on the ground of his not being the compounder, but the vendor, of the pills’. Salmon, having acted ‘with gross want of skill and of great rashness in administering large quantities of Morison’s pills to an individual, the nature of whose disease [he was] ignorant’, was ordered to pay £200 to the Crown, a sum covered by Morison.56 The second case occurred the following year and involved Thomas La Mott, Hygeian agent for Hull and the East Riding of Yorkshire. La Mott was charged with killing Rebecca Russell, wife of a Hull mariner, who had suffered from a ‘kind of windy dropsy’. She had taken Morison’s pills for over two years and on 9 August 1836, having suffered a particularly acute attack, her husband bought a box of No. 1 and No. 2 pills from La Mott’s shop. La Mott called the next day and, taking charge of the case, ordered her to take six No. 1s at night and eight No. 2s in the morning. Over the next few days La Mott recommended increasingly high doses. However, as Russell’s condition deteriorated, he suggested a surgeon be summoned. A Mr Walworth was called, but to no avail. Rebecca died on 19 August.57 The coroner’s jury having passed a verdict of manslaughter, La Mott was tried at the York Assizes.58 As with Webb and Salmon, the jury found him guilty but ‘recommend[ed] him to the mercy of the court’ as he had ‘acted in the best way his abilities would permit him’, although ‘totally ignorant of the medicine he dispensed’. Lord Lyndhurst, observing that the lesson of Webb’s trial (at which he had also presided) had not been learnt, sentenced La Mott to nine months in prison ‘without labour’. The defendant was evidently taken aback at the severity of the sentence, exclaiming ‘I have taken no man’s silver or gold’.59 Both cases conformed to the pattern of Webb’s trial, and became arenas for the negotiation of medico-political authority. The Times noted that Mackenzie’s inquest ‘engaged the marked attention of the faculty, and several eminent physicians and surgeons, who have daily attended’. Ranged against them were ‘agents for the sale of Morison’s hygeist pills and other vendors of patent medicines’.60 In both trials, the prosecution asserted the legal and moral supremacy of ‘orthodox’ medicine.61 Their evidence consisted almost entirely of medical men, who provided anatomo-pathological and physiochemical testimony as

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to the potentially fatal effects of the Universal Medicine. Meanwhile, except for the odd medical practitioner, notably Robert Lynch, a physician turned Hygeian lecturer,62 defence witnesses came from a modest but ‘respectable’ section of the lay public. Called upon to demonstrate the efficacy of Morison’s pills they recounted how they had been ‘failed’ by ‘orthodox’ medicine and ‘cured’ by the pills. Several testified in at least two trials and many were probably ‘encouraged’ by Morison. Nevertheless, they represented a powerful voice for ‘patient’, or rather ‘consumer power’. Such evidence could backfire, however. In La Mott’s trial for instance, the middle class audience frequently burst into laughter when defence witnesses gave account of their ‘cures’.63 Such ridicule of the Universal Medicine featured in contemporary graphic satires (Illustration 12.2). As Ian Burney has demonstrated, the authority of medical knowledge, inside and outside the courtroom, was a prominent contemporary issue, for it was at this time that medical reformers like Wakley were campaigning for the medicalization of the coroner’s inquest.64 Commenting on the Mackenzie case, the Lancet argued it was ‘absolutely necessary that the power and ascendancy of the science of medicine should be instantly acknowledged by the non-medical officers who preside in those courts’.65 The very act of adjudicating the debate between ‘orthodox’ medicine and Hygeiaism in a court of law suggests that, in an age when the former possessed little legislative recognition, many medical reformers saw the courts as providing the most effective forum for self-regulation.66 However, in the 1830s court officials did not inevitably defer to medical authority. At the Mackenzie inquest the coroner repeatedly directed the jury to the ‘strong evidence in favour of the pills’, while, in his summingup Mr Justice Patteson stated that the issue of whether Salmon claimed to be a medical practitioner was irrelevant because all medical men, regular or not, were equal in the eyes of the law.67 Despite such reservations, these three manslaughter verdicts represented key victories for ‘orthodox’ medical authority. In particular they cemented the legal precedent, established some years before by the King vs. Simpson case, that, regardless of whether he charged for his services, ‘no man is at liberty, by the law of the land, to take upon himself to prescribe medicine, unless he is a competent medical scholar’.68 And yet they singularly failed to destroy Hygeiaism, ‘unorthodox’ practice or the proprietary medicine trade. The reasons for this lay with the limitations of the precedent. In the absence of statute or a formal system of licensing, what constituted a ‘competent medical scholar’ remained a subjective matter. Furthermore, in reality it did not prevent anyone from practising

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Illustration 12.2 ‘Extraordinary Effects of Morrisons Vegetable Pills’, reproduced by permission of the Wellcome Library, London.

medicine; it simply made some more liable than others if anything went wrong. Lastly, and perhaps most importantly, despite Wakley and his supporters’ tendency to conflate the two issues, this precedent was targeted at those who prescribed, not retailed, medicines. While it may have discouraged Morison’s agents, and others like them, from prescribing

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medicines or from acting in the manner of an ‘orthodox’ medical practitioner, it could not, and was not intended to, prevent them selling their product. Thus, although the negative publicity generated by these verdicts may have encouraged Morison to leave London for Paris in 183969 (where he died in 184070), their ‘coercive’ potential was limited: Morison’s pills continued to sell in huge numbers.71 Indeed, the Hygeists thrived on persecution. After Webb was released from prison, he was met by Morison and Moat, and escorted to the Merchant’s Hall in York, where a crowd of fellow Hygeists were gathered. There, he was presented with a silver epergne, inscribed to the ‘First Hygeian Martyr’ from ‘upwards of 48,000 advocates of . . . Medical Liberty . . . and ENEMIES OF PERSECUTION’.72 After the presentation, Webb reflected on his experiences. He singled out Dr Wake as the most active persecutor, but claimed that those who had testified against him were little more than a ‘cat’s paw’. If only the jury could have known, he argued, ‘that in the four Doctors who gave evidence against me was centred the whole of the Faculty of York’, they would not have been ‘deceived as they were’.73 A sympathetic commentator saw an even larger conspiracy: Nothing can be more clear, than that this victimising of Mr Web, personally, was not the sole aim of the junta of Doctors at York, but a mean subterfuge of the Faculty to disparage the efficacy of a new mode of treating human sufferings, which they found was alleviating and curing all complaints at so easy and cheap a rate.74 Such accusations had a basis in fact. Clearly there was a concerted campaign to destroy Hygeiaism. Dr Wake, for example, testified against the pills in both the Webb and La Mott trials. Moreover, when Morison and his sons sued the Weekly Dispatch, James Allen and Dr Wake travelled to London to testify against them. Wake even allegedly claimed that ‘he would do for Morison’s pills before he returned to York’.75 It is clear that many of the practitioners involved in prosecutions were medical reformers and were involved in associations which embodied new forms of medical practice and ideology. Of the four witnesses who testified against Webb, for example, three (including Dr Wake) were founding members of the York Medical Society.76 The prosecution of Morison’s agents played a key role in galvanizing medical reformers into other forms of collective action. Following the Mackenzie inquest, Wakley announced plans for an ‘Anti-Medical Quackery Society’ which would petition for the legislative elimination

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of unlicensed practice and distribute leaflets warning the public against consulting anyone other than a recognized licensed practitioner. With a permanent ‘central board’ based in London and local branches reaching ‘every town and village of the empire’,77 Wakley’s proposed society was a powerful (albeit metro-centric) imagining of the medical profession as a united and transnational body, resonating with emergent figurings of Britain as a nation-state and imperial power.78 Throughout the late 1830s, Wakley asserted that ‘it is in the power of the members of the profession, by a slight degree of organization among their members, to annihilate the pretensions of quacks, and their odious slaying nostrums’ and although his ‘Anti-Medical Quackery Society’ was never realized, many fellow reformers heeded the call for action.79 Some medical societies, including those of York, Leeds and Reading, petitioned Parliament demanding the outlawing of unlicensed practice.80 During the late 1830s many medical practitioners still believed the legislative suppression of the medical marketplace to be distinct from wider medical reform.81 However, with Sir James Graham and Henry Warburton’s Bills in Parliament in the 1840s, ‘quackery’ became increasingly bound up with competing conceptions of the medical profession’s present and future form. For a growing band of medical radicals the elimination of ‘quackery’ and unlicensed practice (including the ‘counter practice’ of druggists) became part of a grander vision of the medical profession as a united and democratized body with a state-sanctioned hegemony over health care.

Medical monopolization and the discourse of public utility Needless to say, Hygeists vigorously opposed this vision. One key trope of Hygeist rhetoric was that medical practitioners sought to monopolize the market in health care. Joseph Webb declared in 1835: I hope to live to see an enactment made, that every person, when ill, may send to a Doctor, if they like, or to a Hygeian agent . . . where most are cured, the money will go; for in this enlightened age, people like to go with their money to the best market. Why not a competition in medicine as well as in everything else? Are Doctors heaven-born, or do they cure all they go to?82 While many sympathized with such sentiments at the time,83 they achieved their broadest appeal in the 1840s, when the doctrines of political economy and free trade were ascendant with the repeal of the

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Corn Laws, and medical reformers were making increasingly vocal demands for the legislative protection of licensed practice. As Searle observed, liberals and political economists argued that the public were best served by open and fair competition between a multiplicity of practitioners. Whereas the vision of the profession articulated by reformers such as Thomas Laycock suggested that the public should recognize the licensed medical practitioner as embodying a collective authority,84 these men maintained that the relationship between patient and practitioner be based on an assessment of individual merit.85 Thus the Hygeist argued that ‘all monopolies, or exclusive privileges of any sort are injurious to the public and repugnant to common sense . . . Because a profession which cannot support itself by its own merits, should not be forced by enactment on the public – more especially that of medicine’.86 But medical monopolization was not simply an economic issue. The Hygeist championed the ‘Medical Liberty of the Subject’. Hence: [A]ll exclusive privileges granted to any party, must of necessity give them power, either directly to encroach upon the liberties of society, or else to prevent others from doing what they have a just right to do . . . Of this description is the medical monopoly.87 The ultimate expression of this freedom of conscience was religious faith. The Hygeists argued that, short of spiritual well-being, there was nothing so dear as bodily health. The legislative establishment of the medical profession was therefore tantamount to the elimination of religious self-determination.88 Such ideas were even echoed by medical practitioners. In the Quarterly Review, the moderate reformer, Benjamin Brodie, argued that while most ‘quack’ remedies and treatments were useless, and even potentially dangerous, to outlaw unlicensed practice was improper. ‘[I]f the art of healing had attained perfection’, and ‘physicians and surgeons could cure all those who apply to them’, that would be one thing. However, as things stood, ‘would not such a proceeding be a very tyrannical interference with the right of private judgement?’.89 The London Medical Gazette, which originally supported the prosecution of unlicensed practitioners abandoned this position, arguing that ‘each individual in society has a right to consult whom he pleases’.90 In language which meshed libertarianism with conservative notions of the rights of the ‘free-born Briton’, it claimed that legislation might eliminate ‘quackery’, as it had supposedly done in Prussia, but that the ‘price’ of this ‘iron hand of authority’ would be ‘the abrogation of liberty, in

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speech, writing or action, and the consequent conversion of men into infants six feet high’. The medical profession, it concluded, ‘must be content with the mingled yarn of liberty and take the evil with the good’.91 Radical reformers thus faced a difficult task in squaring their vision of a state-sanctioned medicine with the dictates of free trade and individual liberty. Above all, they distanced themselves from accusations of self-interest. As the issues of ‘quackery’ and medical reform became increasingly intertwined during the 1840s, the suppression of unlicensed practice was bound up with other demands, such as uniformity of practice, education and representation. Yet some realized that, in terms of public presentation, such associations were counterproductive. In 1842, the radical reformer D. O. Edwards argued: So far as these principles go they are unexceptionable, but their advocacy implies no great stretch of philanthropy. Class selfishness, or the esprit du corps [sic], would naturally suggest to the great majority of the profession the expediency of suppressing quackery, or of re-establishing civil equality amongst the members, and more particularly of enforcing uniformity of qualification, to be tested by a sufficient examination. But these narrow professional views extend no further than the formation of an enlarged monopoly. In contrast to such self-interestedness, he asserted: The communality of the medical profession desire in the alterations in the law which they advocate, that their particular interests should be consulted so far, and only so far, as they may be proved to be identical with the interests of the public. They ask nothing for themselves exclusively; they demand the establishment of a universal good.92 Such appeals to the ‘public good’ had been made before – the College of Physicians employed similar language during the seventeenth century.93 However, whereas this rhetoric had been invoked to defend particular corporate or sectional interests, there was an important difference in the manner in which mid-nineteenth-century medical radicals deployed it. While Wakley and his fellow reformers represented only a section of ‘orthodox’ medical practice, they claimed to speak for the entire profession. Furthermore, in this period, in part through the activities of ‘liberal’ medical practitioners, commentators began to conceptualize the ‘public’, not as a disparate collection of individuals, but

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as an aggregate ‘social body’.94 Thus, when mid-century medical reformers spoke of the ‘public good’, they, like continental medical physiocrats, conceived of the authority of medicine over the entirety of the population.95 Powerful though such arguments were, they were not innately compatible with a free market model. After all, many political economists might have countered that a medical monopoly could only subvert the public good. Wakley was generally sympathetic to the ‘doctrine of free trade and non-interference’. Yet when it came to medicine, ‘its friends expose[d] it to the discredit of absurd and mischievous applications’.96 Initially, Wakley had tried to normalize the relations between patient and practitioner. Denouncing the activities of druggists who offered medical advice, he asked why the circumstances which are justly applicable to society in all the usual relations of life, be inappropriate when they are brought to bear upon the treatment of the sick and the practice of medicine? In all other trades and professions, we hear the common-sense remark, “Let every man attend to his calling”. A carpenter is not consulted on questions of hosiery . . . With all tradesmen, in fact, it appears to be a principle to attend to what is and can be understood by the trader, with the single exception of the seller of drugs, who, stepping beyond the legitimate business of his occupation, plunges, at one step, into the very centre of the entire province of medicine!97 Such analogies did not justify medical monopolization, however, for these relations were still a matter of individual discretion. During the 1840s and 1850s, therefore, radical reformers like Wakley began to emphasize the exceptionality of medical practice. If the popularity of patent medicines and unlicensed practitioners proved anything, they argued, it was that the ‘consumer’ was no adequate judge of merit or skill. To ensure the health of the community it was consequently necessary for the state to protect the public from itself by preventing anyone without appropriate qualifications from practising medicine: What . . . can be more advantageous to the public than to say that all who will establish their competency shall be at liberty to practice medicine; but that unqualified persons shall not attend as medical advisers, nor be permitted to tamper with the lives of Englishmen? This restraint on the “freedom of trade” would be of precisely the same character as legal restraints on murder and suicide.98

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These arguments might appear at odds with the extreme laissez-faire wing of political economics. In fact, as Wakley was keen to point out, ‘the necessity of ensuring, though state regulation, an appropriate standard of medical education and qualification has been explicitly sanctioned by the leading political economists of the day’.99 Moreover, they were in keeping with another dimension of contemporary liberal thought. The 1840s and 1850s witnessed not only the high point of free trade but also a more Benthamite and interventionist approach to social policy.100 From the Public Health Act of 1848 to the Compulsory Vaccination Act of 1853 and numerous Factory Acts passed throughout the period, there were those who maintained that in order to protect the health and welfare of the public, there were aspects of social and economic life in which market forces and individual liberties had to be curtailed.101 Such appeals to ‘statist’ utilitarianism did not go unopposed. The Westminster Review had been established in 1824 as an organ of Benthamite philosophy, but in 1856, its editor, the physician John Chapman, published ‘Medical Despotism’, an article refuting recent proposals to grant legal recognition to the medical profession and protect it from unlicensed competition. Chapman was frustrated that, while the repeal of the Corn Laws had apparently signalled a move ‘in the direction of free trade’, the government had repeatedly passed legislation ‘in diametrical opposition to the principles which it proclaims’. Pointing to the France of Louis Napoleon, he asserted that any move towards a ‘State medicine’ with a governing Medical Council would ‘pave the way for the insidious advance of centralized tyranny’. Under such a regime, he argued, ‘citizens, deprived of the discipline of self-help and abandoned by the spirit of liberty, lose their manliness, independence and vigour’ and ‘will need an increasing amount of State protection and intervention in proportion as the habit of self-reliance diminishes’. The ‘medical body’ was, he wrote, not ‘of so exceptional a nature, and in so peculiar and responsible a relation to the public’ that it required ‘legislative protection’; he concluded that the public good, and medicine’s own development, could only be guaranteed by severing its connections with the state.102 Debates about the legitimacy of a state-sanctioned medical monopoly and the appropriate boundaries of medical authority continued throughout the 1850s and beyond, but the argument established in the 1840s that the legal establishment of the medical profession was necessary for the public good, continued to form a central component of reforming demands. Geoffrey Searle charted the use of this ‘public utility’ argument in medicine and in other areas of life. However, when it comes to medicine, Searle falls back on economic self-interest to explain

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its deployment.103 Yet clearly such arguments were more than a cynical ploy to fool the legislature into eliminating the profession’s financial competitors. We need rather to see this argument as constitutive of a more significant transformation in the nature of medical self-perception and self-presentation. By calling for the legislative elimination of unlicensed practice, radical reformers asked the state to recognize the image they were fashioning of themselves. This image, which began to take shape following the cholera epidemic of 1831–2, and the Poor Law Amendment Act (1834) and Civil Registration Act (1836), conceived of the profession, not simply as a unified and pan-national entity, but as a body of public servants. As a correspondent to the Lancet claimed in 1846, the ‘true’ medical practitioner saw his profession ‘in a higher or better light than that of a trade, . . . believing it to be part of his high vocation . . . to do all that in him lies for the protection of the public health’.104 Within this paradigm, the medical marketplace was transformed from an irritating source of financial competition into a morally repugnant affront to the rightful authority of a medical profession and, indeed, to the safety of the public.

Conclusion In 1843, the London Medical Gazette argued that to ‘suppose the extinction of quackery is almost to presuppose the arrival of the millennium’. And yet ‘it is entirely possible to imagine that, with another century or so of education and discussion . . . a belief in the wonder-working powers of quack medicines will rank with a belief in witchcraft, and be found only in remote districts and among uninstructed persons’.105 The Gazette’s prophecy was not too wide of the mark, for the mid-nineteenth century did signal the beginnings of a transformation of the medical marketplace. If the early modern marketplace was an arena in which ‘orthodox’ medical practitioners competed, on a more or less equal footing, with the ‘unorthodox’, as well as with each other, then these new collectivist conceptions of the medical profession and the willingness of medical reformers to seek redress through Parliament and the courts, tended to problematize the relationship between medical ‘orthodoxy’ and entrepreneurship, leading to a hardening of the boundaries between a professional ‘centre’ and a commercial ‘periphery’.106 Thus, while the register of licensed practitioners established by the 1858 Medical Act has been dismissed as little more than an ‘official consumer guide’, that it was the first real document to give expression to medical professional ‘orthodoxy’ is undeniably significant.107

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However, while this tended toward the marginalization and elimination of ‘quackery’, it did not mean an end to the marketplace. Indeed, despite the restraints of the Pharmacy Act (1868), the patent medicine trade expanded massively throughout the nineteenth and early twentieth centuries: Morison’s pills were on sale as late as 1929.108 This illuminates the tensions inherent in the campaigns outlined. As seen with the trial of Morison’s agents, the legal and moral grounds for eliminating ‘incompetent’ medical practice were always stronger than those for eliminating the retail or use of proprietary medicines. Thus, while Wakley’s reformist successors have sought an end to ‘secret medicines’, there was virtually nothing they could do about them, at least in legal terms, until the Dangerous Drugs Act (1920) and Rolleston Report (1926) effectively handed medical practitioners control over the prescription of drugs. Even then, the relationship between the medical profession and the emergent pharmaceutical industry was, and remains, an ambiguous one.109 Over the second half of the nineteenth and first half of the twentieth centuries, the vision articulated by radical reformers in the 1830s and 1840s of a state-sanctioned medical profession, free from the competition of unlicensed practitioners, gradually took shape.110 However, it was not until the establishment of the National Health Service (operational from June 1948) that ‘orthodox’ medicine was truly established as an instrument of state policy and its practitioners accorded the status of ‘public servants’.111 Thus the forms of collective identity which radical medical reformers began to articulate in the 1830s and 1840s underpin the social and intellectual authority which the medical profession enjoys to this day.

Notes 1. James Morison, Morisoniana: Or Family Adviser of the British College of Health, 4th edn (1833), vii. Some of this research was funded by the Wellcome Trust and I thank them for their support. 2. Lancet, 25 (1836), 948. 3. Cook, Decline. 4. Porter, Health. 5. Porter, Health, 232–4. 6. P. S. Brown, ‘Social Context and Medical Theory in the Demarcation of Nineteenth-Century Boundaries’, in W. F. Bynum and R. Porter eds, Medical Fringe and Medical Orthodoxy, 1750–1850 (1987); L. Barrow, ‘Why were Medical Heretics at their Most Confident around the 1840s? (The other side of mid-Victorian medicine)’, in R. French and A. Wear eds, British Medicine in an Age of Reform (1991); R. M. Ross, ‘Charlatans, Knaves

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7. 8. 9. 10.

11.

12. 13. 14. 15. 16. 17. 18. 19.

20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30.

or Opportunists? Private Enterprise in Nineteenth-Century Dentistry’, Dental Historian, 29 (1995); M. W. Weatherall, ‘Making Medicine Scientific: Empiricism, Rationality and Quackery in Mid-Victorian Britain’, SHM, 9 (1996); O. Davies, ‘Cunning-Folk in the Medical MarketPlace during the Nineteenth Century’, MH, 43 (1999); J. Bradley and M. Dupree, ‘Opportunity on the Edge of Orthodoxy: Medically Qualified Hydropathists in the Era of Reform, 1840–1860’, SHM, 14 (2001); M. Gijswijt, G. Van Heteren and E. Tansey eds, Biographies of Remedies (Amsterdam, 2002). Porter, Health, 222–8. See also, A. Digby, Making a Medical Living (Cambridge, 1994). Porter, Health, 228–31. R. Porter, ‘“I think ye both quacks”: The Controversy between Dr Theodor Myersbach and Dr John Coakley Lettsom’, in Bynum and Porter eds, Medical Fringe. I. Waddington, ‘The Struggle to Reform the Royal College of Physicians, 1767–1771: A Sociological Analysis’, MH, 17 (1973); I. Loudon, ‘Medical Practitioners 1750–1850 and the Period of Medical Reform in Britain’, in A. Wear ed., Medicine in Society: Historical Essays (Cambridge, 1992). I. Burney, ‘Medicine in the Age of Reform’, in A. Burns and J. Innes eds, Rethinking the Age of Reform: Britain, 1780–1850 (Cambridge, 2003), 163–4. Lancet, 31 (1838), 63. Brown, ‘Social Context’. J. L. Berlant, Profession and Monopoly (Berkeley, 1975). Porter, Health, 21–59; M. Fissell, Patients, Power and the Poor in EighteenthCentury Bristol (Cambridge, 1992), 37–73; Digby, Medical Living, 62–8. Barrow, ‘Medical heretics’, 175; Burney, ‘Medicine in the Age of Reform’, 178–181. G. Searle, Morality and the Market in Victorian Britain (Oxford, 1998), 119. R. Porter and D. Porter, ‘Rise of the English Drugs Industry: The Role of Thomas Corbyn’, MH, 33 (1989); E. M. Tansey, ‘Pills, Profits and Propriety: The Early Pharmaceutical Industry in Britain’, Pharmaceutical Historian, 25 (1995). Porter, Health, 224. W. H. Helfand, ‘James Morison and His Pills’, Transactions of the British Society for the History of Pharmacy, 1 (1970). A Biographical Sketch of James Morison, the Hygeist (1840), 3; J. M. Bulloch, Centenary of James Morison, the ‘Hygeist’ (Aberdeen, 1925), 2. Helfand, ‘Morison’, 108. J. Morison, Morisoniana: Or Family Adviser of the British College of Health, 4th edn (1833), 98. A Biographical Sketch, 3; Bulloch, Centenary, 4; Morison, Morisoniana, 230. Morison, Morisoniana, 98–100, 102, 363; Bulloch, Centenary, 4; Helfand, ‘Morison’, 108. Bulloch, Centenary, 5; Helfand, ‘Morison’, 114. Helfand, ‘Morison’, 101–7. Morison, Morisoniana, 46–7, 375–92, 411–4; Bulloch, Centenary, 10. Trial of Joseph Webb for Manslaughter at the York Summer Assizes, 1834 (1834), 4; Bulloch, Centenary, 8.

Michael Brown 259 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43.

44. 45. 46. 47. 48. 49. 50. 51. 52. 53. 54.

55. 56. 57. 58. 59.

Morison, Morisoniana, 5–13, 15–129, 165–6. Morison, Morisoniana, 76–7, 232, 244. Bulloch, Centenary, 1; Helfand, ‘Morison’, 114–5. Trial of Joseph Webb, 4. The Hygeist (1 August 1842), 1. York Herald (8 August 1835). Porter, Health, 229. Morison, Morisoniana, v, ix, 385. The Hygeist and Medical Reformer, and Defender of Liberty of Conscience and Private Judgement, new series, (15 August 1855), 58. Hygeian Proceedings at York, Consequent on the Liberation of Mr Webb (1835), 59. J. Fraser, Public Lecture on the Medical Liberty of the Subject and on the Hygeian System of Disease and Medicine (1855), 6. Hygeian Proceedings, 67. J. F. C. Harrison, ‘Early Victorian Radicals and the Medical Fringe’, in Bynum and Porter eds, Medical Fringe; K. Gleadle, ‘“The Age of Physiological Reformers”: Rethinking Gender and Domesticity in the Age of Reform’, in Burns and Innes eds, Rethinking the Age of Reform. Lancet, 11 (1829), 783; 15 (1830), 200–7, 265–8, 286; 16 (1831), 333–5. Trial of Joseph Webb, 3; Hygeian Proceedings, 6–9. Trial of Joseph Webb, 5, 11–13, 60–1; Hygeian Proceedings, 12–15. Yorkshire Gazette (5 July 1834). York Courant (24 July 1834). Trial of Joseph Webb, 5, 15, 70. Trial of Joseph Webb, 40–1. Trial of Joseph Webb, 73, 93–5, 107. Lancet, 22 (1834), 629. London Medical Gazette (hereafter LMG), 14 (1834), 610–6. These were: Rebecca Cross of Worcestershire; Lancet, 22 (1834), 761–2; LMG, 14 (1834), 759; Sarah Potter of Regent’s Park, London; LMG, 17 (1835), 357–8; The Times (28 November 1835; 1 December 1835); Anne Clemesha of Osbaldwick, near York; York Herald (5 November 1836); Yorkshire Gazette (5 November 1836); an unnamed sixteen-month-old child from Birmingham; LMG, 17 (1836), 623–4; The Times (8 November 1836); Anthony Ibbotson of New Lenton, near Nottingham; Lancet, 30 (1838), 846–7; The Times (3 and 4 September 1838); Thomas Wagg from Nottingham; Lancet, 32 (1839), 635–6. The last such inquest, at least before 1850, took place in 1846. Lancet, 48 (1846), 413. There were other cases in which a coroner’s inquest was not, or could not, be arranged. Lancet, 25 (1835), 349; 26 (1836), 188–9; 29 (1837), 162–3; LMG, 14 (1834), 614–5. TNA, CRIM 10, Central Criminal Court, Minutes of Evidence, April 6, 1836; The Times (19 February 1836; 7 April 1836). TNA, CRIM 10, Central Criminal Court, Minutes of Evidence, April 6, 1836; Lancet, 26 (1836), pp. 92–5; The Times (7 and 11 April 1836). Hull Advertiser (17 March 1837). LMG, 18 (1836), 927–8. Hull Advertiser (17 and 24 March 1837).

260 Medicine, Quackery and the Free Market 60. 61. 62. 63. 64.

65. 66. 67. 68. 69. 70. 71.

72. 73. 74. 75. 76.

77. 78.

79. 80. 81. 82. 83.

84. 85.

The Times (19 February 1836). Hull Advertiser (17 March 1837) [emphasis added]. The Times (19 February 1836). Hull Advertiser (17 March 1837). I. Burney, ‘Making Room at the Public Bar: Coroners’ Inquests, Medical Knowledge and the Politics of the Constitution in Early NineteenthCentury England’, in J. Vernon ed., Re-reading the Constitution (Cambridge, 1996); idem., Bodies of Evidence (Baltimore, 2000). Lancet, 25 (1836), 916. R. G. Smith, Medical Discipline (Oxford, 1994). Lancet, 26 (1836), 93; The Times (7 April 1836). Hull Advertiser (27 March 1837; 17 March 1837); Trial of Joseph Webb, 24–6, 40, 72–7. Helfand, ‘Morison’, 118. The Times (11 May 1840); Lancet, 34 (1840), 288. Bulloch, Centenary, 8. In 1838, the Leeds Medical Society’s ‘Anti-Quackery Committee’ reached the conclusion that such prosecutions were ultimately fruitless: ‘That it is expedient to discontinue any further attempts to procure the convictions of individual pretenders; such attempts being calculated, even when successful, to diminish the evil in a very partial degree only’, LMG, 21 (1838), 669. Hygeian Proceedings, 3; Fraser, Public Lecture, 16–7. York Courant (15 January 1835); Hygeian Proceedings, 15–18. Trial of Joseph Webb, 107. Lancet, 27 (1836), 764–5, 28 (1837), 130–1; The Times (13 and 14 February 1837). Baldwin Wake, Henry Stephens Belcombe and James Allen were among those who established the Society in March 1832. William Matterson junior joined the Society in 1838. Borthwick Institute of Historical Research, YMS 1/1/1/1, Minute Book of the York Medical Society, 1832–1844. Lancet, 25 (1836), 949, 976. L. Colley, Britons: Forging the Nation, 1707–1837 (New Haven, 1992); L. W. B. Brockliss, ‘The Professions and National Identity’, in L. W. B. Brockliss and D. Eastwood eds, A Union of Multiple Identities (Manchester, 1997); B. Porter, ‘Empire and British National Identity, 1815–1914’, in H. Brocklehurst and R. Philips eds, History, Nationhood and the Question of Britain (Houndmills, 2004). Lancet, 25 (1836), 978. Lancet, 29 (1838), 512, 646; 30 (1838), 846–7; 31 (1839), 875; LMG, 21 (1838), 688–9. Lancet, 31 (1838), 134. York Herald (1 November 1834). ‘A Rate Payer complains of the injustice of paying for the expenses of the prosecution of Mr Webb, out of the county rates, and contends that as the prosecution was not for the public good, but solely at the instance of the doctors, to promote their private interest’. York Herald (1 November 1834). Dublin Medical Press, 5 (1841), 266–7; M. J. Peterson, The Medical Profession in Mid-Victorian London (Berkeley, 1979), ch. 6. Searle, Morality, 117–9, n. 61.

Michael Brown 261 86. The Hygeist (4 December 1842), 33 [emphasis added]. 87. The Hygeist (1 October 1843), 104. 88. E.g., ‘Report of the British College of Health, New Road, London, for 1854’, appended to J. Fraser, Public Lecture; Searle, Morality, 119. 89. Quarterly Review, 71 (1842), 105–6. 90. LMG, 6 (1830), 922; 27 (1841), 554. 91. LMG, 27 (1840), 413; 21 (1838), 1032–3. 92. Lancet, 38 (1842), 744–5 [emphasis added]. 93. Cook, Decline; Pelling, Conflicts; P. Wallis, ‘Plagues, Morality and the Place of Medicine in Early Modern England’, English Historical Review, 121 (2006). See also, J. Barry, ‘Publicity and the Public Good: Presenting Medicine in Eighteenth-Century Bristol’, in Bynum and Porter eds, Medical Fringe. 94. M. Poovey, Making a Social Body (Chicago, 1995). 95. G. Rosen, From Medical Police to Social Medicine (New York, 1974); P. E. Carroll, ‘Medical Police and the History of Public Health’, MH, 45 (2002). 96. Lancet, 35 (1841), 827. 97. Lancet, 37 (1841), 93. 98. Lancet, 38 (1842), 585. 99. Lancet, 28 (1840), 791–2. 100. As Searle has argued, there were multiple points of tension (as well as similarities) between the ‘statist’ ideology of certain utilitarians and the Malthusianism of some political economists. Searle, Morality, 27–32. 101. Searle, Morality, 91–7, 145–6. 102. The Westminster Review, new series, 9 (1856), 530–62. 103. Searle, Morality, 122. 104. Lancet, 47 (1846), 613 [emphasis added]. 105. LMG, 32 (1843), 210. 106. Peterson, Medical Profession, ch. 6. 107. Berlant, Profession and Monopoly, 161. 108. Helfand, ‘Morison’, 107. 109. L. Loeb, ‘Doctors and Patent Medicines in Modern Britain: Professionalism and Consumerism’, Albion, 33 (2001). 110. N. R. Eder, National Health Insurance and the Medical Profession in Britain, 1913–1939 (New York, 1982); D. G. Green, Working-Class Patients and the Medical Establishment (New York, 1985); M. G. Dupree, ‘Other than Healing: Medical Practitioners and the Business of Life Assurance during the Nineteenth and Early Twentieth Centuries’, SHM, 10 (1997). 111. C. Webster, ‘Medicine and the Welfare State, 1930–1970’, in J. Pickstone and R. Cooter eds, Medicine in the Twentieth Century (2000); idem., The National Health Service: A Political History, 2nd edn (Oxford, 2002).

Index Abbot, John, 84 Aberdeen, 241 Abernethy, John, 233 Abington, Massachusetts, 190 Accum, Frederick, 223 advertising, 17, 121–2, 126, 222–3 afterbirth, 139 Ainslie, Whitelaw, 201, 206, 207 Alcester, 161 Aleppo, 209 Allen, James, 244, 245, 250, 260 “alternative economies”, 137 America, United States of, 5, 6, 20 American Medical Association, 109 Amersham, 27 annotation, 134, 143 Anodyne Necklace, 116, 118, 123–4, 125, 126 anonymity, 114 antimonial cures, 98 Apothecaries, Society of, London, 58 Apprentices, 49, 50–1, 244 apprenticeship, 60, 122, 158–64, 171, 172 Archer, John, 119, 121–2, 125, 131 Arderne, John of, 24, 35, 36 Aristotle’s Masterpiece, 115–16 army, 199–200 Arnold of Villanova, 38 arrack, 201,203 Arrow, Kenneth, 13 Arundel, Thomas, Bishop of Ely, 30 Ashford, 78 astrology, 118 Attleborough, 185 authorship, 114–15, 116, 118–19, 138–9, 144 Aylet, Nicholas, 61 Baninster, Benjamin, 61 Banks, Sir Joseph, 209 Barber Surgeons, Company of, 55 Barlow, Edward, 57

Batecombe, 145 Beaufort, Thomas, Duke of Exeter, 32, 33 Bedford, 59 beer, 228–9 Beier, Lucinda, 1, 7, 133, 154–5, 167 Belcombe, Henry Stephens, 245, 260 Bengal, 201, 207, 208 Bennet, Christopher, 119 Bennett family (C17 Somerset), 140–41 Betson, Thomas, 40 Bioprospecting, 204–10 Birmingham, 160, 161, 259 blood, 91, 95–6, 100 Bloxham, Thomas, 27 Blumston, John, 40 Boerhaave, Herman, 152 Bologna, 17 Bombay, 201, 203, 204 books, circulation of, 114 cost of, 111–12 see also print Boord, Sam, 145 Bordeaux, 241 Boston, Massachusetts, 180, 184, 187, 191, 195 botany, 204–10 Botreaux, William, Lord, 38 Bourgeois, Louise, 115 Bradmore, Nicholas, 33 Brandreth, Rebecca, 141 bread, 228 British Medical Association, 239 Britnell, Richard, 8 Brockliss, Lawrence, 4 Brodie, Benjamin, 252 Bromfield, Michael, 119 Brouvaert, Dr, 60 Bryan, Richard, 40 Buchan, William, 116 Buckinghamshire, 75 Buggs, John, 58 Burdett, Sir Francis, 220–2, 231 262

Index 263 Burney, Ian, 239, 248 Butler, George, 56 Butler, William, 61 Calcutta, 204, 210 Cam, Joseph, 122–4, 125 Canterbury, 78 Canterbury, Diocese of, 74 Care, personal, 15 See also nursing, washing Carey, Lady Mary, 144 Case, Dr John, 125 Catchmay, Lady Frances, 141 Catchmay, Sir William, 141 Ceylon, 205 chamber pots, 88 Chamberlain, Paul, 123 Chamberlayne, Thomas, 115, 130 Chapman, John, 255 charitable healing, 170 charity, 7, 30–2 Charley, Edward, 91, 103 charms, 33, 39, 40 Chapman, William, 55, 56 Chelsea Water Company, 223, 226 Cheshire, 165 Cheyne, George, 115–16 childbirth, 166–7, 181–2, 184 children’s diseases, 138 chymical medicine, 89 chymical remedies, 88, 90 cleanliness, 35 clergymen, 26–7, 81, 91, 139, 140 medical care by, 69, 72–6, 84, 86 Clerke, John, 30 Clotes, John, 30 clothes, 186, 187, 188, 201 cloves, 210 Cobbett, William, 226–7 coffee, 15 Cole, Peter, 102 College of Physicians, London, 49, 53–9, 61, 89–90, 92–3, 98, 125–7 Colne, 148 Colyton, 84 Cook, Harold, 1, 4–5, 10, 13, 15, 18, 19, 24–5, 35, 40, 50, 108, 125 Commodities, see medicine

Commercialization, 4–5, 8–9, 10–11, 120–7 consumption, history of, 10, 143–6, 169, 216 Cordials, 135, 139 Corn Law, 228, 252 Cornwall, 70–4, 75, 81–5 court, medicine at, 28–9, 119 Coventry, 40, 160, 161, 171, 172 Cranbrook, 77, 78 Crane, John, 61 Croll, Oswald, 92, 94 Crooke, Helkiah, 52–3 Crophill, John, 34 Cruickshank, Robert, 220 Culpeper, Nicholas, 14, 88–9, 90, 93, 99, 102, 112, 115, 116, 118, 126 Daffy’s Elixir, 147 D’Anvers, William, 139 Deal, 77, 78 Devon, 33, 65, 70–4, 75, 81–5 Dickman, Henry, 55, 56 diet, 29 See also food Digby, Kenelm, 95, 119 Distillers’ Company, London, 67 domestic medicine, 169 see also family medicine Domestic Medicine, 116, 134 Dover, 78 Draper, Hannah, 140–1 Drayton, Richard, 196 Drew, Ruth, 189, 190 druggists, 159, 171, 176 Duncan, Andrew Jr., 209 Duncan, Andrew Sr., 210 dung, human, 100, 101 Durante, Castore, 114 Dyer, Christopher, 8 Eagle, Gilbert, 40 Earle, Alice Morse, 175 East India Company, 15, 49, 196, 199–203, 207, 209 East London Water Company, 219, 222, 227, 229 Edinburgh, 209, 210 Edinburgh, University of, 208

264 Index Edmond, Thomas, 27–8 Edward IV, 28 Edwards, D. O., 253 Elizabeth I, 119, 120 Ellis, William, 146 Elwyes, Dr, 61 Ely, Diocese of, 164 Essex, 165 Evans, John, 98 Evenden, Doreen, 120, 155–7 Everard, John, 100 Exeter, 70, 71, 82, 84 expertise, 36–7, 62–3, 223, 226, 251–6

Goodall, Charles, 58 Göttingen, University of, 203 gout, 117, 122, 146 Graham, Sir James, 251 Grand Junction Water Company, 217, 219–20, 222–3, 225, 226 Great Linford, 75 Greatrakes, Valentine, 154, 169 Greinville, Humphrey, 81 Greuter, Master, 92, 98 guiacum, 15 guilds, 13, 26, 32–3, 36, 61 Gulston, Dr., 53

family, care by, 71, 76, 176–7 farriers, 140 Faversham, 78 Faye, Andrew, 56 Fayreford, Thomas, 33 Figge, Valentine, 54 Fleming, John, 207 Florence, 1, 16–17, 25, 40, 41, 52, 59, 69, 95 Fludd, Robert, 88–102 food, 16, 188, 189, 205, 216 see also diet Fores, Samuel William, 220, 229, 234 Forestier, Thomas, 35, 36 Foster, William, 91–2, 97, 104 France, 4, 39 free trade, 10, 217, 240, 253 Freke, Elizabeth, 135 Friedman, Milton, 13, 22 Fuller, Thomas, 93 Furber, Holden, 198

Hajebu, Santhi, 199 Halifax, Massachusetts, 190 Hambleton, Sir Alexander, 139 Hamburg, 210 Hamey, Baldwin, 93 Hamilton, Dr Francis Buchanan, 207 Hamlin, Christopher, 216 handbills, 122, 126, 147, 217, 224 Harowe, John, 32 Harley, David, 4 Harris, Edward, 55 Harrison, Christopher, 81 Harvey, Gideon, 137, 146 Harvey, William, 58, 96 Hatcliffe, 27 Haughton, George, 54 Helmont, Johann Baptista van, 88, 92 Henry IV, 23 herbaria, 207 herbs, 135 Hertfordshire, 146 Heyne, Benjamin, 206 Hicks, John, 183 Hicks, Rebecca, 181, 183 Hill, William, 148 Hinton, Dr., 56 Hobart, James, 37 Hobhouse, James Cam., 224 Hoby, Lady Margaret, 7 Hodges, Nathaniel, 56 Holcombe Burnell, 71 Hollings, Dr, 146 Holmes, Geoffrey, 157–8 Hooke, Robert 112 horses, 79, 140

gas, 228 Gassendi, Pierre, 91 Gay, Robert, 145 Gentilcore, David, 4, 41 Gentleman’s Magazine, 147 gentlewomen, medical care by, 69, 72–6, 84, 134–5 Getz, Faye, 25 Gilbert, William, 97 Gilbourne, Sir Nicholas, 97 Goclenius, Rudolf, 92 Goddard, Jonathan, 59 Goldwyn, 30

Index 265 hospitals, 16, 31, 200, 201, 204 Hoskins, W. G., 74 “housewifery”, 135 Howard, Catherine, 30, 36 Howell, John, 59 Hull, 247 Hume, John Joseph, 227, 233 Humfrey, Duke of Gloucester, 32, 33 Hyderabad, 209 India, 15, 196–212, 218, 232 ipecacuana, 196 Italy, 4, 59 Jackson, John, 185–6, 191 Jenner, Mark, 4 Jewson, Nicholas, 6, 19, 108 John of Cornhill, 35 John, Samuel, 206 Johnson, James, 217, 232 Jones, Colin, 4 Kellet, John, 98 Kempton, Samuel, 188 Kent, 74–83 Kerrison, Robert, 230, 234 kind, payment in, 29, 30 King vs Simpson, 248 King’s College, Cambridge, 27 King’s College, London, 208 kitchen physic, 134, 135, 137, 138, 143 Kymer, Gilbert, 27, 32 La Mott, Thomas, 247 laissez faire, 197, 211, 240, 255 Lake District, 147 Lamb, George, 224 lameness, 188 Lancashire, 148, 165 Lancet, The, 10, 242 Lane, Joan, 159 Lauderdale, Earl of, 225 Laune, Gideon de, 57–8 Laycock, Thomas, 252 Lee, Thomas, 33 Leeds, 251 Leicester, 140 Leicester, Archdeaconry of, 165

Leicestershire, 139 Lenham, 77 Leominster, 142 Libavius, Andreas, 92 licensing of medical practitioners, 72, 83–4 of midwives, 156, 164–5, 170, 172–3 Lichfield, Diocese of, 165 Lincoln, Diocese of, 39 Lincolnshire, 140 Lisle, Anne de, 147 London, 4, 27, 47–63, 89–92, 98, 99, 109–10, 111–12, 121–7, 157–8, 164–6, 201, 216–32, 241–2, 246–7 London, Diocese of, 156, 164 London, parishes St Clement Danes, 26–7 St Edmund’s Lombard St., 27 St Mary Lambeth, 226 London, places in Bishopsgate, 120 Charing Cross, 122 Chelsea Hospital, 218 Cheapside, 140 Coleman St., 99 Devonshire St., 120 Fleet St., 35 Garway’s Coffeehouse, 98 King St., 123 Knightsbridge, 122 Limehouse, 246 Lincoln’s Inn Fields, 124 Picadilly, 217 Regent’s park, 259 St Martin’s Lane, 120 Southwark, 226 Strand, 123 Tower of London, 38 Whitefriars, 56 Lord, Thomas, 52–3 Loudon, Irvine, 1, 5, 14, 153–5 Lucatello’s Balsam, 147 Lull, Raymond, 88, 92 Luter, John, 30 luxury, 203 Lynch, Robert, 248 Lyndhurst, Lord, 246, 247

266 Index McConaghey, R. M. S., 70–1, 72 Macleod, 240 Mackenzie, John, 246, 248 Maden, Dr. Peter, 55, 65 madhouses, 10 Madras, 200–01, 203, 204, 206 magic, 38, 91–2 magnetical medicine, 88, 89, 94, 97–8, 99–100 Maidstone, 78 Mallet, William, 203 Malverne, John, 28 market revolution, 175–6 Marten, John, 124–5 Masulipatram, 209 marketplaces as physical spaces, 126, 197–99, 204 material medica, 201–2, 206–9 Matterson, William, 245, 160 Maxwell, Sir Murray, 231 Maxwell, William, 100–01, 102 Mayerne, Theodore de, 57, 131, 144 Dr Mead’s Powder, 147 medical marketplace, history of term, 1–3 medical pluralism, 2, 6, 24, 33, 41 medical practitioners, selection of, 35–7, 61–2, 74–5, 164–7, 177, 181–2, 200 competition between, 6, 14, 24, 48, 153–70, 238–51, 257 cooperation between, 6, 14, 47–63, 91, 238–40, 245–51 regulation of, 1, 4, 9, 13, 32–3, 72–4 see also licensing, patient medical qualifications, appeal to, 118, 151, 244–5 medicine, as a commodity, 4, 6–9, 12–13, 41–2, 136–7, 141–3, 146–8, 167–70, 175–92, 216, 231–2, 249–50, 251–5 medicines, pills, 4, 55–6, 90, 98, 241–2, 257 see also by name mental illness, 37 Merrett, Christopher, 63 Mersenne, Marin, 91 Meverall, Dr., 55 Middleton, John, 28

midwifery, 9, 52, 120, 153–70 midwifery books, 114–5, 155 midwives, 53, 153–70 Mildmay, Lady Grace, 73, 134, 136 miracles, 38 Mirfield, John of, 27, 34 missionaries, 205–6 Mitford, Richard, Bishop of Salisbury, 28, 29, 36 Mixed economy of healing, 177 Moat, Thomas, 241, 250 Moffett, Thomas, 58, 119 monopoly, 10, 14, 217, 225–7, 228, 230–1, 251–2, 255–6 More, Dr., 56 Moretonhampsted, 81 Morison, James, 239, 240–4, 249–50 Morison’s pills, 241, 244–50, 257 Morstede, Thomas, 32 Mortimer, Ian, 158 Muldrew, Craig, 13, 25, 137, 178 mummia, 94, 95, 99, 100 Mytton, Letitia, 145, 146, 147 Nagy, Doreen Evenden, 73 See also Evenden, Doreen Napier, Richard, 59, 63, 73, 75, 81, 85 “native” doctors, 200–1 neighbourhood, 127 New College, Oxford, 120 New River Water Company, 219, 223, 227 Newcastle under Lyme, 168 Newtonian theory, 123 Norfolk, 36, 135 Norwich, 36, 135 Norwich, Diocese of, 164 Nottingham, 30, 259 Nouffler, Madame, 207 nurses, 55, 182, 184 nursing, 15, 182, 184, 189 oeconomy, 12 Onania, 118 opium, 15 Ormskirk, 148 Oundle, 139 Overton, James, 245

Index 267 Oxford, 28 Oxford, University of, 28 Palmer, Archdale, 139, 140 pamphlets, 113 paper, 113 Paracelsian remedies, 88–9 Paris, 250 Parkman, Ebenezer, 180–5 Parkman, Hannah, 180–5 Park, Katherine, 1, 16–17, 25–6, 35, 40 Parker, Elizabeth, 148 Parker, Robert, 148 Parliament, 218–9, 223, 224, 230, 251 Paston, Sir John, 37, 38 Paston, Margaret, 36, 38 patient choice, 2, 13, 61–2, 76–81, 102, 164–7, 251–6 power, 61–2, 81–2, 102 Pattson, Mr Justice, 248 Pechey, John, 119 Peel, Robert, 224 Pelling, Margaret, 1, 78, 108, 125, 127 Peruvian bark, 136 Peter, Charles, 120 pharmacoepia, 15 pilgrimage, 39 pills, see medicines Place, Francis, 218, 226 plague, 10, 114, 117, 118, 135 Plutschau, Henry, 205, 206 Plymouth, Massachusetts, 188, 190 political economy, 217, 226, 240 Pomata, Gianna, 17 pomatum, 140 poor relief, 16, 185–91 the popular, definitions of, 41, 110 Porta, Giovanni Battista della, 91–2 Porter, Dorothy, 13, 48, 133 Porter, Frederick, 55 Porter, Roy, 1, 5, 10, 13, 15, 48 Powell, Dr John, 144 pox, 55–6 prayer, 38–9 prescriptions, 57–8, 60 priests, 26–7 Primitive Physick, 116, 143 Primrose, James, 138 profession, ideas of, 47–8, 238–40

prostitutes, 200, 204 public good, appeals to the, 120–1, 229–30, 253–5 pulse, 97 Puritanism, 118, 179 quackery, 238–9, 250–1, 252–3, 260 Quick, Abraham, 84 quinine, 15 Rawcliffe, Carole, 25 Raach, John, 72 rabies, 135, 147–8 Read, Alexander, 54–5 Reading, 251 recipe books, 116–17 reform, language of, 239, 242 religion, 4, 14, 37–8, 208 rheumatism, 145 rhubarb, 201 Richard II, 28 Richards, Sarah, 190 Richardson, Richard, 244–5 rickets, 139 Riga, 241 Roberts, R.S., 5, 73, 156, 157 Rome, 98 Romney March, 82 Rose’s Case, 125 Rottler, Rev. John Peter, 206 Royal Society, 123 Royal Touch, 169 Royle, John Forbes, 207–8 Rueff, Jakob, 115 Russell, John, 33–4 Russell, Patrick, 209 Russell, Rebecca, 247 St John Long, John, 240, 244 Saharanpur Botanical Garden, 208 Salem, 187 Salisbury, 28 Salmon, Robert, 246–7, 248 Sandwich, 78 Sawyer, Ron, 57, 73 Scotland, 15 Scott, Helenus, 201 Scott, John, 91, 103, 104 scurvy, 117, 120, 122, 145

268 Index Searle, Geoffrey, 252, 255–6 Sefton, Lord, 231 Sen, Amartya, 216 Sen, Sudipta, 197 Sennert, Daniel, 95 sepoys, 200 servants, 50–1, 140, 182, 184, 194, 200 Shackleton, Elizabeth, 148 Shah, Azim, 207 Shambrooke, Peter, 58 Shapin, Steven, 35, 133, 137 Sharp, Jane, 114, 120 Sharpe, J.B., 229 Shaw, George Bernard, 216 Shaw, Nicholas, 190 Sheeres, George, 61 Shepard, Alex, 49 Sheppey, Isle of., 82 Siena, Kevin, 7 Sigerist, Henry, 5 Situate, Massachusetts, 187 skin diseases, 30 Slack, Thomas, 185–6 slavery, 179, 229–30 smallpox, 117, 244 Smeeton, George, 228 Smith, Adam, 227, 230, 236 Smith, Joshua, 81 Smith, Sydney, 228 Smollett, Tobias, 63 social capital, 133 social credit, 177, 178–9, 180–5 soldiers, 140 Solihull, 159, 161 Somerset, 27, 33, 140, 145, 165 Someset, John, 28, 31, 32 Sotherton, John, 56 South Africa, 2 Southwell, Thomas, 32 Sowray, Thomas, 244 Spalding, 140, 141–2 specie, 178–80 Spicer, Richard, 59 spices, 135–6 Stafford, Sir Edmond, 100, 101 Stafford, Thomas, Duke of Buckingham, 27 Staffordshire, 169 Stamp Act, 158

Starr, Paul, 5, 176 Stockbridge, Thomas, 187–8 the stone, 117 Stonor, Lady Agnes, 30 Stonor, Elizabeth, 37 Stonor, Katherine, 37 Stonor, Sir William, 37, 40 Stratford-upon-Avon, 160, 161, 171 Styles, Captain, 97 sugar–plums, 123 Suffolk, 30 Suffolk, Archdeaconry of, 165 Surat, 198 sutlers, 199–200 Swithland, 139 syphilis, 54 tabasheer, 209 Talbot, Alatheia, Countess of Arundel, 141 Tamil, 205–6 Tanquebar, 205, 206–7 Taussig, Michael, 18 taverns, 140 tea, 15, 228, 236 Temple, Sir Peter, 139 Tenterden, 77 Tentzel, Andeas, 95 Thanet, 82 Thewell, Sir Bevis, 97 Thirwell, Thomas, 28 Thurbarn, Robert, 27 Times, The, 3, 217 Titmuss, Richard, 20 Tiverton, 84 tobacco, 15, 121–2 Tole, William, 56 Tomand, Dr., 56 toymakers, 161 Troutbeck, 147 trust, 13, 35–6 Turing, Robert, 203 Turner, Daniel, 122 Turner, William, 55, 62 uncertainty, 13 University College, London, 208 urban demand for medical services, 11 urbanization, 11

Index 269 urine, 98, 100, 101 uroscopy, 28, 30, 55, 97 venereal disease, 117,118, 122 cures for, 7, 9, 120, 124–5 Vishakapatnam, 209 visiting the sick, 183–4 Wake, Baldwin, 245, 250, 260 Wakley, Thomas, 238, 240, 242, 249, 250–51, 253, 254–5 Wales, 15 Walter, Hubert, 40 Wanlip, 139 Warburton, Henry, 251 Warwick, 160, 161 Warwickshire, 159–64 washing, 15, 186, 189, 190 watching the sick, 15, 181–3, 190 Weale, James, 222, 224, 230, 231, 234 Weapon slave, 88, 91–2, 94, 97–8, 103 Wear, Andrew, 4 Webb, Joseph, 244–6, 251 Webster, Charles, 78 Wenham, Massachusetts, 189, 194 Wesley, John, 116, 143 West Indies, 180 West Middlesex Water Company, 222–3, 224, 226 Westborough, Massachusetts, 180–5, 193–4 Westminster, 218, 226, 228

Westminster Abbey, 34 Wharncliffe, Lord, 231 wig-makers, 159, 162, 171 Willis, John, 56 Willughby, Eleanor, 168–9 Willughby, Percival, 167, 168–9 Wiltshire, 28, 171 Wilson, James, 201 Winthrop, John, 179 Wisbech, 61 wise women, 138 Witchcraft, 39 Wix Priory, 34 Wodecock, William, 27 women, medical care from, 75, 76, 86 Woodcock, Agnes, 33 Woodmen, Margaret, 55 Worcester, 122 Worcestershire, 259 Wright, Dr, 139 Wright, John, 218–20, 222, 225–9, 231 Wright, Robert, 88 Wye, 86 Yang, Anand, 199 York, 244–6, 247, 248, 251 York Courant, 245 York Medical Society, 250 Zerbi, Gabriele, 30, 34