Regency Medical Men

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

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

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

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

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

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

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

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

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

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

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

Apothecary's shop, 1752.

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

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

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