1

Anne Cooper

S.I.D. 308142275

HPSC 4102

Exploring the History of Medicine

Dr Claire Hooker

In Australia at this time we are witnessing a shake up of the long standing traditional organization of health care. This has had orthodox medical practitioners at the top of the hierarchy, overseeing and gatekeeping through the national health insurance scheme the care offered by the ancillary and allied health care workers in public and private health, who sit lower down in the scheme. Outside of this system is the ‘unorthodox’, ‘irregular’ ‘alternative’, or ‘complementary’ health care providers who work in unsubsidised and mostly unregulated private practice, some of whom are only tangentially funded by the public purse[1].

The Australian government is engineering this change by, among other initiatives, offering provider numbers, item numbers and Medicare funding to health care professionals other than medical practitioners – nurse practitioners, midwives, pharmacists, psychologists, podiatrists, and other allied health practitioners[2]. In effect, these practitioners will be taking the role of doctors.

Medical doctors have consistently expressed their deep opposition to the legitimization of other providers in thundering editorials, opinion pieces and letter writing campaigns[3]. Nevertheless, the authority of medicine has been challenged because the system is unaffordable, creaking and understaffed. Consequently, the primacy of medical doctors’ position within the health-care system, and in particular, the health-care economy has been eroded. The medical profession finds itself on shifting sands, claiming on one hand that it’s members are overworked and underpaid but more money will reduce their stress; that more doctors need to be trained but at the same time, restricting numbers entering the profession, and claiming that even the most routine of tasks can only be done by fully trained medical practitioners; and that all this would be resolved if only the payments to doctors were increased. It has, as it has done before, amidst lofty concerned claims of public service,[4] calls for public safety and protection[5], resorted to disingenuous misinformation[6], threats[7], name calling and outright insults.[8]

None of this is new. Doctors have been defaming and insulting other health care providers (and they give as good as they get) in a curious dance for 450 years.

One of the mainstays of these insults is the term ‘quack’. This word is derogatory, used to describe the practice (‘quackery’) and poor character (‘quack’) of a practitioner who practices and profits from unconventional or irregular medicine.

But what is quackery, and who are the quacks? In this essay I hope to look, necessarily briefly, at the history of British quacks and quackery - to some individuals and categories of practitioners who were tarred with that brush, and some who escaped the charge despite apparently fulfilling the criteria.

I should confess at the outset that as an osteopath, according to many of the contemporary definitions, and the paucity of evidence, it appears that I practice quackery myself.

The term ‘quack’ derives from the Dutch term, "quacksalver," meaning "boaster who applies a salve”. The quacksalvers sold their wares in the market, loudly spruiking his products or services. Similarly, a “mountebank” was a hawker of quack medicines who attracted customers with stories, jokes, or tricks.

A quack was ‘all mouth and no skill’; and were incompetent and fraudulent. As playwright Ben Jonson so descriptively put it, a quack was a ‘turdy-facy-nasty-paty-fartical rogue’.[9] Dr Samuel Johnson’s dictionary defined a quack as inherently and knowingly fraudulent:

1. A boastful pretender to arts which he does not understand.

2. A vain boastful pretender to physic, one who proclaims his own medical abilities in public places.

3. An artful tricking practitioner in Physic.[10]

Modern day definitions also cast a wide net. Dr. Stephen Barratt, the webmaster of ‘Quackwatch’ writes:

Quackery can be broadly defined as "anything involving over-promotion in the field of health." This definition would include questionable ideas as well as questionable products and services, regardless of the sincerity of their promoters. In line with this definition, the word "fraud" would be reserved only for situations in which deliberate deception is involved.

Folk medicine, even when known to be erroneous, is not generally considered quackery so long as it is not done for gain. Thus, self-treatment, family home treatment, neighborly medical advice, and the noncommercial activities of folk healers should not be labeled as quackery. However, folk medicine and quackery are closely connected because folk medicine often provides a basis for commercial exploitation. For example, herbs long gathered for personal use have been packaged and promoted by modern entrepreneurs, and practitioners who once served their neighbors voluntarily or for gratuities may market themselves outside their traditional communities.

All things considered, I find it most useful to define quackery as the promotion of unsubstantiated methods that lack a scientifically plausible rationale. Promotion usually involves a profit motive. Unsubstantiated means either unproven or disproven. Implausible means that it either clashes with well-established facts or makes so little sense that it is not worth testing.”[11]

Dr Barratt’s definition of quackery has an unfortunate broad sweep, since according to his own definition, his own field, psychiatry, in his own country, the USA, fits the bill nicely.

Fraud is central to quackery. But on any examination, we can see that quackery cannot be defined only by the fraud test. It is apparent that many practitioners apparently guilty of the charge sincerely believe in the benefits of the ministrations they offer.[12] As the Appeals Court recently ruled in Britain, when applied to quackery, ‘bogus’ practice and fraud is knowingly deceptive.[13]

Neither can the charge be levelled based on a lack of educational qualifications. The charge of quackery based on a lack of acceptable training has been thrown about for hundreds of years and continues to be so. From the 17th century, not all quacks were uneducated and not all regulars had formal training. Some respected physicians bought their degrees from St Andrews or Aberdeen and known quacks sported irreproachable degrees from Edinburgh, Oxford or Cambridge.[14] Now, in Australia, NZ, the UK, Canada and the US, students of Allied Health and Complementary and Alternative Medicine (CAM) all study at University and graduate with at least one university degree, most with a Masters.

Barrett also puts a profit motive as central to quackery, but all professional health workers, corporations and companies work their profession, or trade, or business, for remuneration and profit. For that matter, faith healers, grower’s market reiki healers, Evangelical priests and so on, ask for no payment. Are they therefore not quacks?

So can we propose instead that quackery is identified by the inefficacy of its treatments? This works fairly well. But if applied to Georgian times and certainly any time up to the present, especially since the rise of scientific medicine in the late 19th century, we can see that this would be a brave move, since all would be tarred at some time with that brush. The study of medicine, like all areas of on going revelation – such as science - relies on failure to assess that which works. Scientific method requires us to prove that a theory is wrong, and in failing to do so, accept that it may be valid. Consequently, the ongoing development of science and medicine requires error; in fact if we use proven efficacy as a measure, then no innovation would ever occur. Nowadays we have an extraordinary and increasing number of patients killed and injured from iatrogenic causes such as ‘Golden Staph’ infection. Of course, all patients die, and only the sickest go to hospital, where it is very likely they will expire anyway. But these unfortunate occurrences are defined as error, or negligence, both of which are the result of both irresponsible clinical procedure, such as inappropriate prescribing of antibiotics, and on going care, such as a failure to wash hands in between patients. They are completely avoidable. Does this make hospitals, or the use of vancomycin, quackery?[15]

Is secrecy crucial to quackery? Purveyors had secret recipes for their nostrums, which were patented to ward off competitors and offer exclusivity and increased value. But it was not only the irregular quacks who did this – Epsom Salts was patented by medical man and Royal Society member Nehemiah Grew FRCP[16]. The Royal College of Physicians’ ire at the actions of Nicholas Culpeper, which I will describe later, would point to quackery on the basis of restriction of knowledge that should have been in the public domain. Even now, patents restrict widespread affordable distribution of lifesaving drugs, and it could be argued that the restriction of manufacture, trade and practice imposed on non-medical practitioners, and not on medical practitioners[17], as well the restriction of places in Universities and Professional colleges amounts to a form of secrecy... and therefore quackery?

Is it defined by a belief in and the ability to harness the supernatural? If so, the religious doctor who prays and believes in Christ’s resurrection is as culpable as the witch and the faith healer, since science and religion are incompatible bedmates.

What about evidence? Evidence in pre-scientific times would have been completely empirical, and validity scant, since medicine had very little to offer in addressing the major diseases. A random dive into any of the early major medical journals of the time will support this. Evidence now is measured by bench-marking RCT protocols which substantiate treatment protocols that clearly cannot reflect complex clinical real life situations in either the hospital, clinic or within the coven.[18] Is the medicine developed on the basis of RCT’s a fraud?

It seems obvious that the distinction between the regular and irregular, between legitimate medicine and quackery, is a wide blur, both historically and now. Quackery is a spectrum of qualities (or failings) best recognized by a combination of factors. In practice, quackery would have little therapeutic effect, no matter what the intention, the fee charged, the qualifications held, the profit gained, or the secrecy and restriction of practice and trade attached.

The furious reaction of the Australian medical profession to the opening up of the government coffers and licensing restraints is consistent with the profession’s behavior since the 15th century. At that time medicine was a shared industry of the lay practitioners and the elite doctors, but the high cost of attendance precluded the bulk of the population from the care of a professional. As early as 1421, Henry V was unsuccessfully petitioned to confine the practice of medicine to the orthodox, university trained doctors. In 1512 the Medical Act made it an offence to practice physic or surgery unless the practitioner was a university graduate or licensed by the bishop of the diocese. The preamble to this Act states that an increasing number of ignorant persons were practicing medicine ‘in which they partly use sorcery and witchcraft to the grievous hurt, damage and destruction of many of the King’s liege people...’[19] The Company of Physicians in was established in 1518, to become the Royal College in 1551. Its charter allowed it to license physicians, ensure the purity of the drugs sold by apothecaries, and to control the practice of medicine within a 7 mile radius of London. With the consent of Henry VIII, the surgeons started their own Union Company of Barber-Surgeons in 1540, and so were able to control standards, restrict entry and fine unlicensed surgeons in the London area. This self-regulation with royal protection ensured that fees remained high, supply limited, competitors thwarted and what was essentially a cartel legitimised.[20]

But in 1542 the Herbalists Charter was enacted. This exempted lay practitioners from the 1512 act, allowing a charge only for the herb or salve itself. The preamble admonished the barber-surgeons and physics for ‘minding their own lucre’ and for allowing many to ‘rot and perish to death for lack of help’.

‘It shall be lawful for every person being the King’s subject, having knowledge and experience of the nature of Herbs, Roots and Waters, or the operation of the same, by speculation or practice within any part... of the King’s dominions... to practice use and minister...without suit, vexation, trouble, penalty, or loss of their goods’.[21]

Consequently lay herbalists and surgeons were able to practice freely and untroubled by the litigious Royal College of Physicians, who instead concentrated on preventing surgeons from practicing medicine, who in turn concentrated on preventing barbers from performing surgery. Those who were beyond Society and notice – further than 7 miles from London – had free reign. It allowed for a charge for the medicine itself, but not the service, so undoubtably the service fee was surreptitiously included. The economic cartel had been smashed.

This was in this legislative environment that medicine found itself for the next 300 years, until the Medical Act of 1858. Even then, until the rise of science, and even into the 20th century, medical practice changed little and had little cause to do so.

It is difficult with hindsight to understand why the physics and barber surgeons held such primacy in the medical hierarchy. Reputation, connections and patronage obviously counted for much, because the descriptions of the treatments themselves fail to convince this writer of their therapeutic benefit. When the patron and founder of the Royal Society, King Charles II fell ill on the 2nd February 1685, he received the best orthodox medical care available. The royal barber hastily bled him of 600 ml. of blood. When the royal physicians arrived, the surgeons "scarified" Charles, afterward drawing off another 300 ml of blood with heated cups. Then he was purged, using an emetic of antimony to induce vomiting, and enemas to clear out his bowels. His hair was cut and a blistering agent applied to the scalp; elsewhere on his body, a red-hot cauterizing tool was used. To attract harmful humours down from the head, "noxious plasters" were applied to the soles of his feet. As well, the king was prescribed "the skull of a man that was never buried, being beaten to a powder and given inwardly," along with crushed stones "from the intestines of the wild Persian bezoar goat." His general Thomas Fairfax praised the physics’ work, proudly stating “All the means that the art of man thought proper, had been employed for the King's distemper" which shows us much. Despite these extraordinary measures, the King died 4 days later.[22]

Secrecy is often crucial to commerce and the restriction of medical texts to Latin kept that information well out of the reaches of the general public. Nicholas Culpeper (1616 – 1654) was a political radical, puritan and a Parliamentarian, educated at Cambridge. He was apprenticed to an apothecary in an orthodox education. Nevertheless, by translating the Royal College of Physicians’ bible, the Pharmacopoeia Londonesis from Latin into English, Culpeper made available to the public the otherwise secret information that had been deliberately obscured by the orthodox physicians. The men of the Faculty, Culpeper charged, imposed exorbitant fees and so could only attend to the rich - anametha to the puritan Culpeper - and had at heart primarily the advancement and protection of their own economic interests. The publication of his Physicall Directory was described by his College opponents as the product of ‘two yeeres drunken Labour...’, which could only be true if the righteous Culpeper had not been a teetotaler, which he was. In reply, he wrote:

‘It seems the College had a strange opinion that it would do an Englishman mischief to know what the herbs in his garden are used for.”’[23]

When we look into history for quacks and quackery, we are faced with a feast of examples, highlighted not so much by their reputation their skills and the cures they claimed and engineered, as by the attacks made upon them. Critics frequently resorted to attacks upon character and appearance rather than considering efficacy.

Royal patronage of the uneducated practitioner was particularly galling, and was bound to cause the charge of quackery. Joshua ‘Spot’ Ward (1685 -1761) lacked any medical training at all, having started off as a footman. He made a fortune with his ‘Pill and Drop’ preparation, (composed of benzoid balsam, wine and antimony – that is, it was toxic) which he on-sold to the Admiralty as a cure for scurvy. Indeed, because he correctly diagnosed and manipulated George II’s dislocated thumb, when the orthodox physicians had misdiagnosed gout, Ward was honoured with a knighthood, Royal patronage and the right to drive his six-horsed carriage in St James’ Park.

Sarah ‘Sally’ Mapp née Wallin was a bonesetter or ‘shape mistress’ from Wiltshire in the UK, born in 1706. As was the tradition, she learned her craft from her father John, also a bonesetter. As is typical of these derogatory descriptions, her Oxford Dictionary of National Biography entry dismissively claims that ‘he instilled in her only the barest knowledge of anatomy’.[24] Mrs. Mapp practiced in Epsom, then a fashionable area; and made an enviable and envied living, charging up to 20 guineas a session. She successfully treated the rich and influential, including the niece of the President of the Royal College of Physicians, and impudently rode in her ‘4 horse chariot’ up to London each week to return with the crutches of those she had cured proudly adorning the coach.[25]