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SURGERY and SURGEONS in 18TH-CENTURY LONDON Sir Clifford

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SURGERY and SURGEONS in 18TH-CENTURY LONDON Sir Clifford SURGERY AND SURGEONS IN 18TH-CENTURY LONDON Thomas Vicary Lecture delivered at the Royal College of Surgeons of England on 26th October 1967 by Sir Clifford Naunton Morgan, M.S., F.R.C.S., F.R.C.O.G., Hon. F.A.C.S. Honorary Consulting Surgeon, St. Bartholomew's, St. Mark's and Royal Masonic Hospitals, and King Edward VII Hospital for Officers THE ENDOWMENT OF the annual Vicary Lecture by the Worshipful Com- pany of Barbers of the City of London in 1919 has reforged the link, broken in 1745, between this ancient Guild and the Royal College of Surgeons of England. In November last, the foundation stone of the new Barber-Surgeons' Hall-to replace that destroyed by bombing during the last World War (Fig. 1)-was laid by the Lord Mayor of London, Sir Lionel Denny, past- Master of the Barbers' Company. The Barbers are looking forward to the day when Surgeons and Barbers may once again dine together in the Barber-Surgeons' Hall. The hand of Providence would appear to bless the friendship between the Company and the College for, though at the dissolution of the Barber- Surgeons' Company the famous Holbein painting of the granting of the Royal Charter to the Barber-Surgeons' Company remained with the Barbers, it has now been revealed that the painting bought by the Surgeons in 1786 was, in fact, Holbein's original cartoon (Cohen, 1967). The Bar- bers and the Surgeons thus share the hallmarks of the great master and each painting is a part of the other. Furthermore, the painting and the cartoon, which were sent separately out of London for safety during the last war, were found quite fortuitously side by side in Wales, the country of Henry Tudor. In this lecture, which encompasses the last decades of the Barber- Surgeons' Company and the new Corporation of Surgeons, I will endeav- our to recall, against a backcloth of 18th-century London, a few of those surgeons who, either by their foresight, writings, surgical skill or research, blazed the trail to modern surgery. The Royal Charter granted to the Company in 1540 by Henry VIII was followed by those of succeeding monarchs. These later Royal Charters, including that of Charles I, which required a Court ofExaminers, endeavoured to enhance the standard of surgical education and encourage advances in the art, as is shown by the granting of the Freedom of the Company, without the usual fine, to John Douglas in 1723 for his new method of cutting for stone. The Surgeons within the Company were enabled to improve surgical training by the selection of better educated apprentices bound for seven 1 SIR CLIFFORD NAUN rON MORGAN years to Master Surgeons, and the teaching of anatomy which, by anatomical dissection and operation on contralateral structures, became applied to surgical procedures. However, the name " Barber-Surgeon " led to confusion, dishonesty and corruption, exacerbated by the Bishop of London's right to grant a licence to practise. Quacks and untrained surgeons grew in number, in spite of many appeals by the Company to Parliament for increased power of control of surgical practice. Fig. 1. Barber-Surgeons' Hall in Monkwell Street (destroyed during the bombing in 1940). The Surgical Treatises of Richard Wiseman (Fig. 2a)-Master of the Barber-Surgeons in 1665 and Sergeant-Surgeon to Charles Il-record the standard of surgery during the last decades of the 17th century. Published in 1676, this text-book, the best then written, remained popular for over a hundred years and was praised by Percivall Pott. Wiseman practised during the twilight period between Elizabethan surgery and the dawn of scientific surgery in the latter half of the 18th century. He served in the Dutch Navy, in the Royalist Forces in the Civil War and, after Cromwell's victory, in the Spanish Navy, returning to England after the Restoration. In his book he mentioned that the cautery and caustics frequently had to be used as alternative treatment, because many patients abhorred the knife and thus sought the aid of quacks. 2 SURGERY AND SURGEONS IN 18TH-CENTURY LONDON Wiseman's writings reveal his skill and reasoning, as exemplified in the treatment of suffocation in a child during tonsillectomy, performed by the use of the snare and probe scissors, preceded by the application of a caustics Temporary post-operative regurgitation of fluid through the nose, he noted, was due to injury of the palate by the snare. Although the anatomy and aetiology of the types of haemorrhoids were described, treatment was non-operative and external applications were used, including "the fur of a hare" and suppositories. Degree of rectal Fig. 2. (a) Richard Wiseman (1622-1676). (b) Charles Bernard (1650-1711). prolapse following operations for bladder stone or childbirth depended upon the extent of injury to the musculature, and for its control he resorted to " a couple of sticks, whittled and placed near the anal orifice ". He reported 10 successful operations for anal fistula and stated that some such cases were inoperable. Cancer of the rectum was diagnosed by its appearance and palpation, but treatment by cauterisation resulted in a painful death. The importance of correct fitting of a truss and the need for continuous satisfactory positioning, especially in children, was emphasized. The dissolute behaviour of the Court provided him with much experi- ence in the treatment of gonorrhoea, but the cause of urethral stricture was not known. 3 SIR CLIFFORD NAUNTON MORGAN Erysipelas and ulceration of the scalp occurred in gentlemen of the period, who paid great attention to their coiffure, including the practice of boiling of the hair! Though he believed in the " magic of the Royal Touch " for scrofula, when the " Touch " was not available surgical operation could help. Lymphadenitis was the commonest manifestation of tuberculosis, which he stated also attacked bone, tendons and membranous structures, but not the nervous system. The differential diagnosis between inflammation and cancer of the breast was stressed and amputation for the latter recommended. D'Arcy Power refers to him as honest and independent, being one of the first consulting surgeons, since he practised in close association with a physician and only accepted patients who were referred to him by a doctor. Wiseman's text-book and Code of Practice undoubtedly did much to enhance the status of the surgeon. The growing number and influence of surgeons, the recognition by the College of Physicians in 1664 that surgical treatment was necessary in trauma and for certain diseases, and the irksome, expensive and frustrating traditional civic duties in the Livery Company caused increasing unrest among the Surgeons. Furthermore, they considered their union with the Barbers a handicap to progress, but repeated petitions to Parliament for separation were un- successful. The increasing competition in the training of surgeons by the two City Hospitals, St. Bartholomew's and St. Thomas's, is recorded in the Minutes of the Barber-Surgeons' Company in 1695. The surgeons of St. Thomas's Hospital were accused of " breeding so many illiterate and unskilled pretenders to surgery'" and of qualifying any person, however unfit, after only six or 12 months' apprenticeship. In 1702 the Governors of St. Thomas's ruled that a surgeon could not take more than three " cubs " at a time and for not less than one year. The surgeons then agreed not to accept apprentices without three references from reliable persons, such references to be sent to the Barber-Surgeons' Company. However, practice in the City of London, or within a radius of seven miles, was only permitted after admission to the Freedom ofthe Barber-Surgeons' Company. As the result of the foundation of more hospitals in London during the first half of the 18th century, the old apprenticeship system within the Barber-Surgeons' Company diminished, since the more ambitious trainees favoured attachment to hospital surgeons, for not only were there more opportunities for gaining experience, but also a better chance of a hospital appointment. It was the custom of the Governors and members of the staff and some- times patients of the two City hospitals to march in procession to church 4 SURGERY AND SURGEONS IN 18TH-CENTURY LONDON at Easter-tide, the surgeons walking in front of the Governors. The behaviour of some surgeons was uninhibited, rough, ungentlemanly and dishonest. On one such solemn occasion, Mr. Felton, Senior Surgeon at St. Thomas's Hospital, finding his junior, Mr. Ridout, placed in front of him, proceeded to assault and beat his colleague. Four years later, in 1703, Mr. Felton, together with the Senior Physician, was dismissed for embezzling fees paid for the treatment of seamen wounded in the War of the Spanish Succession. PREStNT STATE ~~~~r 3 RsAwn a rN A LIlTTL To h CR4 LBS ORt?(t),Vp '? r X u + Lt "rer N C T atWth k i l.... 5 3 --7i~ - S ILi , S703 (a) (b) Fig. 3. (a) The anonymous letter to Charles Bernard. (b) Sanitation in 18th- century London. An anonymous letter (published in 1703) to Charles Bernard (Fig. 3a), Master of the Barber-Surgeons' Company, entitled The Present State of Chirurgerie with some Short Remarks on the Abuses committed, records the sorry state of surgical practice at the beginning of the 18th century. The author appealed to the Company to provide better care of Her Majesty's subjects and quoted examples of unskilled practice which could be verified by patients occupying beds in the City Hospitals, so preventing the admission of the needy. He wrote, "A cheat in physick or chirurgerie is so very facile and so difficult to discover. Chirurgerie has somewhat of a disadvantage, whereas in physick very often an abuse is never detected." The letter also stated that a Bishop's licence could be purchased and that counterfeit licences were available.
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