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Doctors in fiction: the medical profession through authors' eyes
Perspectives
The art of medicine Doctors in fiction: the medical profession through authors’ eyes
www.thelancet.com Vol 388 August 20, 2016
apothecary-surgeon. By then, many medical men below the rank of physician held a dual qualification known as the “College and Hall”: membership of the Royal College of Surgeons and the licence of the Society of Apothecaries. Dr Thorne also upsets his colleagues by ignoring the Royal College of Physicians’ ban on its members selling medicines, designed to preserve their status above that of the apothecary and druggist. The London medical press eventually enters the fray: “The Lancet took the matter up in his favour, but the Journal of Medical Science was against him; the Weekly Chirurgeon, noted for its medical democracy, upheld him as a medical prophet, but the Scalping Knife, a monthly periodical got up in dead opposition to The Lancet, showed him no mercy.” While the other three journals were fictitious, The Lancet clearly was not, and by putting the publication in the rebel’s corner, Trollope was keeping faith with the record set by its founder editor, the surgeon and Member of Parliament Thomas Wakley. The real Lancet was a relentless critic of the medical establishment, with Wakley making clear his contempt for what he saw as the greed, nepotism, and poor standards of training in the teaching hospitals and the professional bodies. In Middlemarch, written in 1872 but set in around 1830, 7 years after the launch of The Lancet, George Elliot discusses
Look and Learn/Bridgeman Images
In 1697, when Thomas Brown wrote his play Physick Lies A-bleeding, or the Apothecary Turned Doctor, the British medical profession enjoyed a reputation something akin to that of journalists and estate agents today. The eyewatering fees charged by some practitioners, along with bitter infighting between the three tiers of the profession— physicians, surgeons, and apothecaries—fuelled accusations of putting money and status above the interests of patients. Brown’s cast of characters include Tom Gallypot, “an apothecary by trade, but who practises physic as a doctor near Covent Garden” and 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”. Brown’s play used humour to expose the tensions in medicine at the time. 7 years after Physick Lies A-bleeding was written, the Royal College of Physicians sued William Rose, a liveryman of the Society of Apothecaries, for “practising physick” on John Seal, a London butcher. The College said that Rose “without the advice of a physician…made up several boluses, electuaries and juleps”. Apothecaries were supposed to trade as community pharmacists, preparing and dispensing drugs; prescribing and charging for advice was physicians’ territory. The court ruled in favour of the physicians. Rose appealed, saying that selling a known remedy without a prescription could hardly be deemed practising as a physician. For their part, the physicians argued that if the apothecaries were not curbed they would so damage medicine as a career as to “deprive the gentry of one of the professions by which their younger sons might honourably subsist”. The Lords found for Rose, saying the physicians seemed more concerned with upholding their privileges than with the welfare of the sick. While the Rose ruling has been hailed as a landmark case, more than 150 years later the divide between the ranks was still worth satirising. Anthony Trollope’s Dr Thorne, in the novel of that name, is a physician who horrifies his colleagues with his matter-of-fact attitude to money, behaving just like a common apothecary in their view. Thorne fails to observe the custom of taking his fee discreetly “without letting his left hand know what his right hand was doing”, announcing as soon as he arrives that he charges “seven and sixpence a visit within a circuit of five miles with a proportionallyincreased charge at proportionally-increased distances”. He would also “lug out half a crown from his breeches’ pocket and give it in change for a 10 shilling piece”. And instead of experimenting with drugs in his study “far from profane eyes”, Thorne spends his time “putting together common powders for rural bowels or spreading vulgar ointments for agricultural ailments” more like an
753
Perspectives
one of Wakley’s radical ideas: that coroners should be medically qualified: “‘Hang your reforms!’ said Mr. Chichely…’I hope you are not one of the Lancet’s men, Mr. Lydgate—wanting to take the coronership out of the hands of the legal profession: your words appear to point that way.’ ‘I disapprove of Wakley,’ interposed Dr. Sprague, ‘no man more: he is an ill-intentioned fellow who would sacrifice the respectability of the profession…for the sake of getting some notoriety for himself…But Wakley is right sometimes,” the Doctor added, judicially. ‘I could mention one or two points in which Wakley is in the right.’”
Further reading Jones R. Apothecaries, physicians and surgeons. Br J Gen Pract 2006; 56: 232–33 Hempel S. The inheritor’s powder. London: Weidenfeld & Nicolson, 2013
754
Elliot portrays Dr Lydgate as an idealistic, heroic figure, who represents the way that medicine is moving. He is a moderniser who has studied in Paris, London, and Edinburgh, and is intent on making medicine more scientific and evidence based. He also dreams of making a great scientific breakthrough. When he arrives in provincial Middlemarch, bringing with him his newfangled stethoscope, the local impression is that Lydgate is “not altogether a common country doctor”. He shares the then newly developing interest in anatomy and pathology, and he favours the healing powers of nature rather than active intervention, leading some of the locals to fear that if they call him in he will fail to give them any treatment. He also regards the patient as a partner in his or her own care. Like Dr Thorne, Lydgate upsets the local medical fraternity but in his case by sticking too much to the medical conventions, neither dispensing drugs nor taking a percentage from those who do. “This was an innovation for one who had chosen to adopt the style of general practitioner in a country town, and would be felt as offensive criticism by his professional brethren,” Elliot writes. By the mid-19th century, novelists were not only looking to medical politics for interesting material, however, but were also highlighting, and in some cases lampooning, how precarious a living medicine could be. The young surgeon Allan Woodcourt in Charles Dickens’ Bleak House is a less controversial figure than Dr Lydgate but, like Lydgate, he is serious and talented. Both men run into financial difficulties, Lydgate because his wife insists on a lifestyle beyond their modest means and Woodcourt because he is unable to earn a living wage. Woodcourt’s widowed mother spends her savings on his training but medicine was “not lucrative to a young practitioner with very little influence in London”. Woodcourt gives up the fight and signs on as a ship’s surgeon. Dr Haggage in Dickens’ Little Dorrit has also served as a ship’s surgeon but has failed to solve his financial problems. We find him in the infamous debtors’ prison, the Marshalsea: “The doctor was amazingly shabby, in a torn and darned rough-weather sea-jacket, out at elbows and eminently short of buttons…the dirtiest white trousers conceivable by mortal man, carpet slippers, and no visible linen.” And to help him cope with his dismal situation, Haggage self-medicates with one of the profession’s then most trusted remedies. When
he delivers a baby, the infant’s first gasp is “tinctured with Doctor Haggage’s brandy”. One theory has it that Haggage is based on Tobias Smollet’s fictional doctor Roderick Random in the book of that name, published more than 100 years before Little Dorrit, while Roderick Random, in turn, is said to draw on Smollet’s own experiences as a naval surgeon. But the character of Dr Haggage was not Dickens’ first sideswipe at the medical profession. In his first novel, The Pickwick Papers, we meet the opportunistic Dr Slammer. Slammer—“a little fat man, with a ring of upright black hair round his head, and an extensive bald plain on the top of it”—has a regular salary as surgeon to the 97th regiment, but his sights are set higher: “He was indefatigable in paying the most unremitting and devoted attention to a little old widow, whose rich dress and profusion of ornament bespoke her a most desirable addition to a limited income.” There is another doctor apart from Haggage in Little Dorrit, however; a mysterious figure not given a name. Described only as “a famous physician, who knew everybody, and whom everybody knew”, he goes about quietly “like the rain, among the just and unjust, doing all the good he could, and neither proclaiming it in the synagogues nor at the corner of streets”. Dickens took a keen interest in medicine and in the late 1830s he became fascinated by mesmerism, which had been developed in the 18th century by the German doctor Franz Mesmer. The main medical exponent in early Victorian Britain was Professor John Elliotson who was using it to treat patients at University College Hospital and attracting large public audiences to his demonstrations. Elliotson and Dickens became close friends, with the author learning the technique himself and practising it on some of his friends and family. Wakley was also a supporter at first and The Lancet reported on Elliotson’s performances. But Wakley later changed his mind, and exposed Elliotson—whom he appeared to regard as a dupe rather than a charlatan—in a series of public trials that he staged at his own house in front of a medical panel. The episode did much to establish the reputation and credibility of the new journal. Dickens, however, remained a firm believer and Elliotson is said to be the model not only for the anonymous doctor in Little Dorrit, but also for William Thackeray’s virtuous Doctor Goodenough in The History of Pendennis. Goodenough and the Little Dorrit physician show the medical profession at its best but neither character grabs the imagination in the same way as Dr Haggage, Dr Slammer, and Brown’s little band of chancers. As the 19th century advanced, so medicine evolved from a dubious, chaotic enterprise into a regulated profession and a secure career path. A small downside along the way, however, has been the loss of a rich source of comedy in British fiction.
Sandra Hempel [email protected]
www.thelancet.com Vol 388 August 20, 2016
The art of medicine Doctors in fiction: the medical profession through authors’ eyes
www.thelancet.com Vol 388 August 20, 2016
apothecary-surgeon. By then, many medical men below the rank of physician held a dual qualification known as the “College and Hall”: membership of the Royal College of Surgeons and the licence of the Society of Apothecaries. Dr Thorne also upsets his colleagues by ignoring the Royal College of Physicians’ ban on its members selling medicines, designed to preserve their status above that of the apothecary and druggist. The London medical press eventually enters the fray: “The Lancet took the matter up in his favour, but the Journal of Medical Science was against him; the Weekly Chirurgeon, noted for its medical democracy, upheld him as a medical prophet, but the Scalping Knife, a monthly periodical got up in dead opposition to The Lancet, showed him no mercy.” While the other three journals were fictitious, The Lancet clearly was not, and by putting the publication in the rebel’s corner, Trollope was keeping faith with the record set by its founder editor, the surgeon and Member of Parliament Thomas Wakley. The real Lancet was a relentless critic of the medical establishment, with Wakley making clear his contempt for what he saw as the greed, nepotism, and poor standards of training in the teaching hospitals and the professional bodies. In Middlemarch, written in 1872 but set in around 1830, 7 years after the launch of The Lancet, George Elliot discusses
Look and Learn/Bridgeman Images
In 1697, when Thomas Brown wrote his play Physick Lies A-bleeding, or the Apothecary Turned Doctor, the British medical profession enjoyed a reputation something akin to that of journalists and estate agents today. The eyewatering fees charged by some practitioners, along with bitter infighting between the three tiers of the profession— physicians, surgeons, and apothecaries—fuelled accusations of putting money and status above the interests of patients. Brown’s cast of characters include Tom Gallypot, “an apothecary by trade, but who practises physic as a doctor near Covent Garden” and 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”. Brown’s play used humour to expose the tensions in medicine at the time. 7 years after Physick Lies A-bleeding was written, the Royal College of Physicians sued William Rose, a liveryman of the Society of Apothecaries, for “practising physick” on John Seal, a London butcher. The College said that Rose “without the advice of a physician…made up several boluses, electuaries and juleps”. Apothecaries were supposed to trade as community pharmacists, preparing and dispensing drugs; prescribing and charging for advice was physicians’ territory. The court ruled in favour of the physicians. Rose appealed, saying that selling a known remedy without a prescription could hardly be deemed practising as a physician. For their part, the physicians argued that if the apothecaries were not curbed they would so damage medicine as a career as to “deprive the gentry of one of the professions by which their younger sons might honourably subsist”. The Lords found for Rose, saying the physicians seemed more concerned with upholding their privileges than with the welfare of the sick. While the Rose ruling has been hailed as a landmark case, more than 150 years later the divide between the ranks was still worth satirising. Anthony Trollope’s Dr Thorne, in the novel of that name, is a physician who horrifies his colleagues with his matter-of-fact attitude to money, behaving just like a common apothecary in their view. Thorne fails to observe the custom of taking his fee discreetly “without letting his left hand know what his right hand was doing”, announcing as soon as he arrives that he charges “seven and sixpence a visit within a circuit of five miles with a proportionallyincreased charge at proportionally-increased distances”. He would also “lug out half a crown from his breeches’ pocket and give it in change for a 10 shilling piece”. And instead of experimenting with drugs in his study “far from profane eyes”, Thorne spends his time “putting together common powders for rural bowels or spreading vulgar ointments for agricultural ailments” more like an
753
Perspectives
one of Wakley’s radical ideas: that coroners should be medically qualified: “‘Hang your reforms!’ said Mr. Chichely…’I hope you are not one of the Lancet’s men, Mr. Lydgate—wanting to take the coronership out of the hands of the legal profession: your words appear to point that way.’ ‘I disapprove of Wakley,’ interposed Dr. Sprague, ‘no man more: he is an ill-intentioned fellow who would sacrifice the respectability of the profession…for the sake of getting some notoriety for himself…But Wakley is right sometimes,” the Doctor added, judicially. ‘I could mention one or two points in which Wakley is in the right.’”
Further reading Jones R. Apothecaries, physicians and surgeons. Br J Gen Pract 2006; 56: 232–33 Hempel S. The inheritor’s powder. London: Weidenfeld & Nicolson, 2013
754
Elliot portrays Dr Lydgate as an idealistic, heroic figure, who represents the way that medicine is moving. He is a moderniser who has studied in Paris, London, and Edinburgh, and is intent on making medicine more scientific and evidence based. He also dreams of making a great scientific breakthrough. When he arrives in provincial Middlemarch, bringing with him his newfangled stethoscope, the local impression is that Lydgate is “not altogether a common country doctor”. He shares the then newly developing interest in anatomy and pathology, and he favours the healing powers of nature rather than active intervention, leading some of the locals to fear that if they call him in he will fail to give them any treatment. He also regards the patient as a partner in his or her own care. Like Dr Thorne, Lydgate upsets the local medical fraternity but in his case by sticking too much to the medical conventions, neither dispensing drugs nor taking a percentage from those who do. “This was an innovation for one who had chosen to adopt the style of general practitioner in a country town, and would be felt as offensive criticism by his professional brethren,” Elliot writes. By the mid-19th century, novelists were not only looking to medical politics for interesting material, however, but were also highlighting, and in some cases lampooning, how precarious a living medicine could be. The young surgeon Allan Woodcourt in Charles Dickens’ Bleak House is a less controversial figure than Dr Lydgate but, like Lydgate, he is serious and talented. Both men run into financial difficulties, Lydgate because his wife insists on a lifestyle beyond their modest means and Woodcourt because he is unable to earn a living wage. Woodcourt’s widowed mother spends her savings on his training but medicine was “not lucrative to a young practitioner with very little influence in London”. Woodcourt gives up the fight and signs on as a ship’s surgeon. Dr Haggage in Dickens’ Little Dorrit has also served as a ship’s surgeon but has failed to solve his financial problems. We find him in the infamous debtors’ prison, the Marshalsea: “The doctor was amazingly shabby, in a torn and darned rough-weather sea-jacket, out at elbows and eminently short of buttons…the dirtiest white trousers conceivable by mortal man, carpet slippers, and no visible linen.” And to help him cope with his dismal situation, Haggage self-medicates with one of the profession’s then most trusted remedies. When
he delivers a baby, the infant’s first gasp is “tinctured with Doctor Haggage’s brandy”. One theory has it that Haggage is based on Tobias Smollet’s fictional doctor Roderick Random in the book of that name, published more than 100 years before Little Dorrit, while Roderick Random, in turn, is said to draw on Smollet’s own experiences as a naval surgeon. But the character of Dr Haggage was not Dickens’ first sideswipe at the medical profession. In his first novel, The Pickwick Papers, we meet the opportunistic Dr Slammer. Slammer—“a little fat man, with a ring of upright black hair round his head, and an extensive bald plain on the top of it”—has a regular salary as surgeon to the 97th regiment, but his sights are set higher: “He was indefatigable in paying the most unremitting and devoted attention to a little old widow, whose rich dress and profusion of ornament bespoke her a most desirable addition to a limited income.” There is another doctor apart from Haggage in Little Dorrit, however; a mysterious figure not given a name. Described only as “a famous physician, who knew everybody, and whom everybody knew”, he goes about quietly “like the rain, among the just and unjust, doing all the good he could, and neither proclaiming it in the synagogues nor at the corner of streets”. Dickens took a keen interest in medicine and in the late 1830s he became fascinated by mesmerism, which had been developed in the 18th century by the German doctor Franz Mesmer. The main medical exponent in early Victorian Britain was Professor John Elliotson who was using it to treat patients at University College Hospital and attracting large public audiences to his demonstrations. Elliotson and Dickens became close friends, with the author learning the technique himself and practising it on some of his friends and family. Wakley was also a supporter at first and The Lancet reported on Elliotson’s performances. But Wakley later changed his mind, and exposed Elliotson—whom he appeared to regard as a dupe rather than a charlatan—in a series of public trials that he staged at his own house in front of a medical panel. The episode did much to establish the reputation and credibility of the new journal. Dickens, however, remained a firm believer and Elliotson is said to be the model not only for the anonymous doctor in Little Dorrit, but also for William Thackeray’s virtuous Doctor Goodenough in The History of Pendennis. Goodenough and the Little Dorrit physician show the medical profession at its best but neither character grabs the imagination in the same way as Dr Haggage, Dr Slammer, and Brown’s little band of chancers. As the 19th century advanced, so medicine evolved from a dubious, chaotic enterprise into a regulated profession and a secure career path. A small downside along the way, however, has been the loss of a rich source of comedy in British fiction.
Sandra Hempel [email protected]
www.thelancet.com Vol 388 August 20, 2016