The General Practitioner

IN ENGLAND during America’s provincial age, a “profession” could be precisely defined as an occupation “fit for gentlemen.” Common usage referred (in Joseph Addison’s phrase) to “the three professions of divinity, law, and physic.” If none of these was sure to make a man rich, any one would give him a comfortably high social position. People included physicians among the professions; but they did not include surgeons or apothecaries, however skilled or learned, for theirs were not considered suitable occupations for members of the upper classes. These English boundaries between occupations, and hence between departments of knowledge, embodied the social snobbery of a well-established aristocracy. Exclusiveness, selfishness, and slothfulness had produced rigid corporations and petrified bodies of learning; they resisted new knowledge and new ways of doing things.

Next to the clergy, and perhaps the law, medicine was the earliest and most elaborately subdivided of English learned vocations. Nowhere were guild distinctions more subtle, more intricate, or more firmly entrenched. By the 18th century, however, the powerful forces of the Industrial Revolution were breaking down the ancient monopolies of the craft and commercial guilds; government regulation was becoming ineffective. But in areas of advanced and specialized learning, particularly in medicine, the old monopolies remained, and in some cases had even become more sharply defined. These occupational compartments perpetuated the compartments of thought.

In the early middle ages the “Doctor of Physick” was commonly trained in a monastic school; by the 15th century he was a man who had been graduated in medicine and had received from the University a license to practice. Yet his field was much more limited than that of the modern medical doctor. Necessarily a master of the classical languages in which medical knowledge from the past had been preserved, he was also a man of general learning. Thus, when Henry VIII chartered the Royal College of Physicians in 1518, he intended to set up both a learned academy and an exclusive guild for these practitioners of “physick.”

Surgery was quite another matter. It held a much lower status. It had not been studied in the medieval universities, partly because of the ban on shedding of blood by the clergy and partly because its manual character made it less dignified. The healing and curing of wounds and all surgery and tooth-drawing came within the province of the barbers, who had had a guild of their own from the early fourteenth century. After 1540, practitioners of these skills were organized as the Barber-Surgeons, but a distinction within the guild forbade the barber to act as surgeon (except for drawing teeth) and forbade the surgeon to shave anyone. A widening social gulf then separated medicine and surgery, the two great branches of medical practice which now seem to us so closely related.

Pharmacy was still another specialty. Apothecaries originally were a species of grocer and were members of the grocers’ guild, but in 1617 apothecaries received their own chartered monopoly and grocers were forbidden to sell drugs. Midwifery was yet another vocation. At least until the end of the 17th century it was practiced almost exclusively by women licensed by their bishops and later sometimes licensed by the Barber-Surgeons.

During the 17th and 18th centuries in England some changes—mostly for the worse—were taking place in the organization of the numerous medical professions. Rigidity and complexity increased, and there was no substantial improvement in the quality of instruction or in professional standards. By the 18th century, the Royal College of Physicians selected its entrants largely on the basis of their social accomplishments and ceased to offer any instruction worthy of the name; neither Oxford nor Cambridge had any longer an active school of medicine. Somehow or other—due perhaps to a line of brilliant practitioners—the surgeons’ branch of the Barber-Surgeons’ Company seems to have avoided fossilization. But they had troubles of their own; the physicians continued to lord it over them. A great nuisance which continued into the early 18th century was the ancient requirement that, before a surgeon could perform an operation, he had to secure a license from a bishop. Not until 1745 did the surgeons manage to secede from the barbers and form their own company. Apothecaries, following a lengthy conflict with the physicians, obtained legal authority in the early 18th century to carry on a limited and inferior type of medical practice. To add to this prolific confusion, there were numerous regional distinctions. By the end of the 18th century Great Britain had eighteen medical licensing authorities, each limited both in function and territory. Historians of the subject now throw up their hands at any effort to make sense of these myriad overlapping monopolies and regulations.

This attic-full of institutions was not transported to the New World, partly because of the lack of specialists. “Besides the hopes of being Safe from Persecution in this Retreat,” William Byrd wrote in 1728, “the New Proprietors [of New Jersey] inveigled many over by this tempting Account of the Country: that it was a Place free from those 3 great Scourges of Mankind, Priests, Lawyers, and Physicians. Nor did they tell a word of a Lye, for the People were yet too poor to maintain these Learned Gentlemen.” Although Byrd had oversimplified the reasons, he was accurate in observing that Americans were freer of learned monopolists than were their contemporaries in England.

The professional organization of doctors which developed here, in contrast with that of England, was loose; the boundaries of specialties were vague or non-existent. In the American colonies, governmental control over medical practice virtually disappeared. The tradition of licensing was not dead, but colonial regulations were unclear and unenforceable. The first medical law of Massachusetts Bay (1649) simply required that no person should administer any medical remedy “without the advice and consent of such as are skillfull in the same Art, (if such may be had) or at least of some of the wisest and gravest then present.” Most colonial legislation on the subject was concerned with fees rather than with professional standards. The Assembly of Virginia as early as 1639 responded to protests against “the imoderate and excessive rates and prices exacted by practitioners of physick & chyrurgery.” The Virginia Act of 1662 explained:

Whereas the excessive and immoderate prices exacted by diverse avaritious and gripeing practitioners in phisick and chirurgery hath caused several hardhearted masters swayed by profitable rather than charitable respects, rather to expose a sick servant to a hazard of recovery, than put themselves to the certaine charge of a rigorous though unskilfull phisician, whose demands for the most part exceed the purchase of the patient, many other poore people also being forced to give themselves over to a lingring disease….

The better-trained American physicians knew well enough that the European professional tradition required them to define their specialty and stick to it. Colonial students at the medical school of Edinburgh University, the main training-center for Americans abroad, formed a “Virginia Club” with articles signed by its members. The third article in 1761 was a solemn undertaking “That every member of this club shall make it his endeavor, if possible, for the honor of his profession, not to degrade it by hereafter mingling the trade of an apothecary or surgeon with it.” In America, however, where the very distinction of a gentleman (and hence what was “fit” for him) was blurred, it was not so easy to confine oneself to proper gentlemanly pursuits. In English and other European rural communities, the fine professional distinctions did, of course, sometimes break down or become unenforceable. But in colonial America disregard of them was widespread.

The professional subdivisions were in fact of little practical significance among American doctors. Advertisements and indentures tell us of many, like Dr. Gustavus Brown in Charles County, Maryland (1734-40), who were practicing “Physick, Surgery, and Pharmacy.” To these three distinct English occupations some colonials even added that of midwife. The occasional colonial non-conformist, like Dr. James McClurg, who had been educated at Edinburgh and stuck to his notions of a distinctive profession of physick, found himself unable to support his family. “This however is partly owing to my not uniting the apothecary’s and surgeon’s business with the physicians’ as is common in this country…. It is easier perhaps to succeed to a certain degree as a surgeon and apothecary in this country than in any other.” “I make use of the English word doctor,” wrote the Marquis de Chastellux on his travels through America in 1781, “because the distinction of surgeon and physician is as little known in the army of Washington as in that of Agamemnon. We read in Homer, that the physician Macaon himself dressed the wounds…. The Americans conform to the ancient custom and it answers very well.”

How, indeed, could nice distinctions be perpetuated in an America which lacked learned doctors, professional associations, academies, and legal or customary regulation? And so in America a fluid situation rather than ancient institutions shaped medical practice.

To earliest colonial New England, medical learning was transferred not so much by trained physicians as by ministers. In late 16th- and early 17th-century England some dissenting clergymen had studied medicine as a precautionary profession in case of their expulsion from the country. The Pilgrim Elder William Brewster, Edward Winslow, and Samuel Fuller all seem to have had such knowledge. For nearly a century after Fuller’s death in 1633, there was no prominent specializing physician in Massachusetts. The medical needs of the community were served by ministers (like Thomas Thacher, who wrote the layman’s brochure on how to treat smallpox), by schoolmasters, and by a remarkable line of governor-physicians. Governor John Winthrop, the first leader of Massachusetts Bay, was probably its leading medical adviser, treating patients about as well as did the average physician in England. His son, who became Governor of Connecticut, carried on an extensive practice, offering remote New Englanders by correspondence the best medical advice he could garner from his English books and acquaintances. There was hardly a political or religious leader of the region who did not dispense medical knowledge: Winslow treated the Indian chief Massasoit; the Apostle John Eliot tried to instruct the Indians in modern medicine; in times of epidemic the governors or assistants themselves commonly decided on proper health measures. The two great experimenters with the smallpox inoculation, Cotton Mather and Zabdiel Boylston, both lacked medical degrees. While in Old England the clergy had sometimes confined and stultified the practice of physick, in New England a versatile clergy helped both to free medicine from its old monopolistic bonds and to refresh it by a more empirical spirit.

Medical practice was thus dispersed into many different vocations. Of the fifteen pamphlets on medical subjects published in Boston between 1721 and 1752 of which we know the authors, only four (those by Dr. William Douglass) were written by a person who would have been accepted as a properly qualified physician in England. Not until 1781 was there a Medical Department at Harvard College or a Massachusetts Medical Society. The Society began spasmodic publication in 1790, but the printing of that year was not followed by another until eighteen years later. Protecting public health was a duty of the wise governor and the competent clergyman. Not only had numerous English specialties become amalgamated into the work of a general practitioner; the general practitioner himself had become more closely assimilated into the still larger class of persons concerned with the political and religious welfare of the community.

In the Southern colonies a similar result was produced by somewhat different causes. The European professional distinctions had not been imported there either, and a native professional organization had not yet come into being. If there was any distinction, it was simply between the men of more and of less education rather than between practitioners of different traditional specialties. On remote and widely dispersed plantations, the planters found responsibilities as new and varied as those of the New England clergy. The few Southerners who made their living from medicine in the 17th century were commonly active also as politicians, farmers, and lawyers. Not until 1691 were Virginia’s medical men—along with ferrymen and Negroes—specifically exempt from militia service.

Even in Philadelphia, where neither a dominant and versatile clergy nor the emergencies of plantation life were present to break down the European categories, there developed a wholesome vagueness of professional distinctions. During the 18th century that city boasted more respectable medical learning than could be found anywhere else in the colonies: of the seventeen “physicians” known to have practiced in Philadelphia between 1740 and 1775, all but three had received some training in Europe. In 1765 Philadelphia became the site of the first American medical school, which was the earliest concerted effort to import the academic institutions of European medicine. Here, if anywhere in America, one might have expected professional pride and professional distinctions, but the familiar European distinctions were not to be found. When Dr. Adam Thompson of Edinburgh went to Philadelphia in 1748 to “practice Physick, Chirurgery and Midwifery” but publicly advertised that he would not keep his own apothecary shop, he seems to have stirred the resentment of his colleagues. They considered this an implied criticism of their willingness to be jacks of all the medical trades, even including pharmacy.

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