Hilary De Lyon's reflections on Trollope1 and her account of the ethical, professional and pecuniary conflicts between making a diagnosis and selling a treatment in the mid-19th century certainly have resonance at the beginning of the 21st. Interestingly, a much earlier fictional account, this time in the form of a short dramatic comedy, of the relationships between physicians, surgeons and apothecaries, has recently come to light.
Physick lies a-bleeding, or the apothecary turned doctor, by Thomas Brown, was performed during its world premiere week in Governors' Hall at St Thomas' Hospital on Saturday 21 May 2005. The play was discovered by Dee Cook, the Archivist of the Society of Apothecaries, in microform held by the Shakespeare Institute Library. Written in 1697, the piece highlights the greed and dishonesty prevalent among London apothecaries of the era, while at the same time showing the audience something of the hypocrisy and arrogance of contemporary physicians. At this time physicians, the medical aristocracy of the 17th century, made diagnoses and wrote prescriptions, but did not dispense drugs. Surgeons did what they have always done, and the apothecaries, who had seceded from the Worshipful Company of Grocers, and were incorporated as a separate city livery company in 1617, were supposed to stay in their shops and dispense the prescriptions written by the physicians.2 The sub-title of the play is:
‘A comedy, acted every day in most Apothecaries Shops in London, and more especially to be seen by those who are willing to be cheated, the first of April, every year. Absolutely necessary for all persons that are sick, or may be sick.’
The cast of characters includes Trueman, a Gentleman of honest principles, Dr John Galen, FRCP, Tom Gallypot, an Apothecary by trade, but who practises physic, as a doctor, near Covent Garden, Lancet Pestle, an apothecary by profession (but who boldly undertakes to be a physician and surgeon), Retorto Spatula d'Ulceroso, an Apothecary in Drury Lane, who pretends to be a great doctor, surgeon and chemist, and finally Jack Comprehensive, an Apothecary living in Fleet Street, who professes himself merely to be a doctor, surgeon, chemist, druggist, distiller, confectioner and (on occasion) corn-cutter, surely the forerunner of the modern-day GP.
Shortly after the play was written, a landmark challenge to the role and legal status of those providing care to the sick, or those who may be sick, came in the form of the Rose Case (1701–1704). William Rose, a Liveryman of the Society of Apothecaries, practising in St Martin's-in-the-Fields, was sued for ‘practising physic’ on information supplied by John Seale, a poor butcher of Hungerford Market. Rose compounded and administered various medicines to Seale, who was said to be ‘never the better but much worse’ for his treatment. He was apparently so angry when he was presented with an astronomical bill of £50 that he complained to the Royal College of Physicians and Rose was prosecuted and tried before the Court of the Queen's Bench in February 1701. The legality of Rose's actions were debated at great length and eventually, and apparently reluctantly, judgement in favour of the Physicians was handed down in November 1703.
On the advice of the Attorney General, the Society of Apothecaries applied for a Writ of Error in the House of Lords, which was heard on 15 March 1704. Part of Rose's defence included the contention that:
‘… selling a few Lozenges, or a small Electuary to any asking for a remedy for a cold, or in other ordinary or common cases, or where the medicine has known and certain effects, may not be deemed unlawful or practising as a physician, where no fee is taken or demanded for the same. Furthermore the physicians, by straining an act made so long ago, may not be enabled to monopolise all manner of Physick solely to themselves and be an oppression to the poorer families not able to go to the charge of a fee’.
The Lordships were unimpressed by the Physician's argument, which also included the assertion that Apothecaries may:
‘… slide themselves into practice in all, which if permitted would soon discourage the Faculty of Physick throughout this Kingdom and deprive the gentry of one of the professions by which their younger sons might honourably subsist and be a great detriment to the Universities’.
Further strong resonances in this troubled academic decade. Their Lordships regarded the physicians' argument as being based on upholding ancient privilege and not on the provision of care for the sick, and found for William Rose and, by extension, for all apothecaries, and reversed the judgement. This landmark ruling formed the basis for the legal recognition of apothecaries as doctors, and marked the beginning of the general practice of medicine.2 Forty years later, the apothecaries had added midwifery to their repertoire, sometimes adopting the inelegant title of ‘surgeon–apothecary and man–midwife’. This also marked a medical sea-change, because hitherto confinements were rarely attended by the medical profession. Writing on the history of general practice3 Irvine Loudon commented that ‘surgeon–apothecaries took to midwifery like ducks to water for one very good reason: it was essential for building a practice. Deliver the babies and you will have the family as patients for life.’ O tempora!, O mores!
The play itself is a complete delight, enormously entertaining, of direct contemporary relevance and deserving of a much wider audience. We should be very grateful to Dee Cook and also to Brian Hurwitz, D'Oyly Carte Professor of Medicine and the Arts at King's College London and to the Guy's and St Thomas' Charity for making this illuminating and rib-tickling slice of late 17th century life available to us.
- © British Journal of General Practice, 2006.