He Became a Member of the Barber-Surgeons' Companyof London Masters of the Surgeons' Company and by Dr. John Smythe, Who

GENERAL MEDICAL PRACTICE IN THE TIME OF THOMAS VICARY Thomas Vicary Lecture delivered at the Royal College of Surgeons of England on 27th October 1966 by G. G. Macdonald, T.D., M.D., B.Sc., M.R.C.S. General Medical Practitioner and Past Master of the Worshipful Company of Barbers of London THOMAS VICARY (Fig. 1) was born, probably in Kent, about the year 1490. It is said that he was not gentle by birth or profession, but was one of Nature's gentlemen, with the best possession-an honest and true heart overflowing with kindly feelings towards his fellow men (South, 1886).

Fig. 1. Thomas Vicary (1490?-1561). From an etching after the picture by Holbein. He became a member of the Barber-Surgeons' Company of London about the time when licences to practise surgery were first introduced under the 1511 Act (3 Henry VIII, c. xi). On 28th March 1514 he, with 71 other surgeons, was licensed under this Act to practise surgery by Richard Fitzjames, the Bishop of London. He was examined by four past Masters of the Surgeons' Company and by Dr. John Smythe, who was later to become a Fellow of the Royal College of Physicians of London (Poynter, 1961). In his earlier years he is thought to have had a small practice in Maid- stone, where his friend John Halle was als6 in practice. He was in G. G. MACDONALD Canterbury in 1527, when Henry VIII was making a royal progress through the countryside. The king had a " sorre legge" which was to tiouble him for most of his life (Clippingdale, 1922). Vicary had the good fortune and skill to make the sore place heal and the king was so pleased that he promoted Vicary to be Surgeon to the king with a grant of £20 a year. He also promised him the reversion of the office of Serjeant Surgeon to the king when the holder of that office, Marcellus de la More, should resign, die or forfeit the post. Vicary at that time was not a simple country practitioner as might be deduced from this narrative. He was a well-known London Barber Surgeon who was in the same year promoted from Third to Upper Warden in the Barber Surgeons' Company. Thus there is no parallel between his career and that of the late Sir Arthur Fripp, whose surgical skill received royal notice when he treated the Duke of Clarence while doing a locum only 18 months after qualification. In 1536 Marcellus de la More died and Vicary became Serjeant Surgeon to the king, an office which he also held under King Edward VI, Queen Mary and Queen Elizabeth. He was largely instrumental in the union of the Company of the Barber Surgeons and the Guild of Surgeons in 1540. He was Master of the Barber Surgeons' Company five times between 1530 and 1557. Only one man has equalled Vicary's record number of times of being Master and that was Robert Halyday, who was Master five times between 1475 and 1496. Halyday was the Vicary of his times and was instrumental in bringing together the Company of Barber Surgeons and the Guild of Surgeons in 1492, when both companies signed a " Composition" unifying their professional standards (Young, 1890). The union of the two companies in 1540 is commemorated by two fine pictures. The picture in possession of the Royal College of Surgeons (Fig. 2) is painted over the cartoons which were used by Holbein for the painting of the picture in the possession of the Worshipful Company of Barbers. As a Member of the College and of the Company I can make no distinction of merit between the two great pictures except to state that each is in part better than the other. Both pictures are in the hands of the restorers and soon both will be seen much more clearly. Vicary became rich in his later years as is shown by the minutes of the Court in 1557, when the Company was in financial trouble. " Mr. Thomas Vicary shall paye and dyscharge the debts of the house . . . and shall have the plate of the Crafte in pawne or pledge, untill such tyme as the sayd sumes of mony be unto hym payde agyne " (South, 1886). Vicary's skill as a practitioner is shown by his treatment of his royal patients, his private patients and his devotion to the " sick pore" in St. Bartholomew's Hospital, of which he was appointed Governor in 1548 after the refounding of the hospital. He remained in active practice up to his death. Thanks to the researches of Mr. Emmison, the County 2 GENERAL MEDICAL PRACTICE IN THE TIME OF THOMAS VICARY Archivist of Essex, we have a more accurate knowledge of the approximate date of Vicary's death (Emmison, 1961). The Steward's accounts at Ingatestone Hall show that Vicary was alive on 31st January 1561 to receive payment of five shillings for a visit he had paid to Sir William Petre on 23rd January 1561 (Fig. 3). We do know that Vicary died before the end of 1561. His will was proved by his widow on 7th April 1562. It must be remembered that in England up to the year 1752 the year ended on 24th March. All the dates in this lecture will be given according to the old calendar, which was in use at the time. Vicary lived at the end of the Middle Ages. Fifteen hundred and forty- three is often taken to mark the end of that era because that year saw the

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Fig. 2. Commemoration of the Act of Union of 1540 between the Barbers' Company and the Guild of Surgeons. Painting by Holbein in the possession of the Royal College of Surgeons of England. publication oftwo epoch-making books, Defabrica Corporis humani by the 28-year-old Belgian, Vesalius (1514-64) (Fig. 4), and De revolutionibus orbium caelestium by the aged Pole, Nicholas Copernicus (1473-1543). From these two seeds of published observation and thought grew the scientific outlook of mind and ultimately the mental explosion of modern science. Men gradually felt themselves free to state in public what they thought and observed, and to throw off the chains of outworn authority and dogma. Scientific thought began to change in 1543, but other things changed more slowly. Even now we retain the mediaeval institutions of the Monarchy, the Peerage, the Commons in Parliament assembled, the English Common Law, the Courts of Justice interpreting the rule of law, the hierarchy of the Established Church, the parish system, the Univer- sities, the Public Schools and the Grammar Schools (Trevelyan, 1942). The study of general practice in Vicary's time is the study of mediaeval medicine and the mediaeval philosophy of the healing art. 3 G. G. MACDONALD In Roman Britain there was an excellent system of military hospitals with elaborate arrangements for the evacuation of the sick and disabled soldiers to Rome and other important cities, where noble ladies vied with each other in their civic duty of caring for the men in the hospitals and even taking them into their patrician homes for lodging and treatment. With the fall of Rome all this was lost, and the Dark Ages of mediaeval medicine began. They are dark ages only in our minds because we know so little about them. No one who has seen Ravenna will ever think that the age was dark in learning or achievement. In England at the beginning of the Middle Ages general medical practice was in the hands of leeches and wise women, and purveyors of magical

Fig. 3. " Money to the Surgeons. To Mr. Vicars the Surgeon on the 23rd day 5s. To Baltroppe the Surgeon that day 5s. To Baltroppe the 24th day 6s. 8d. To Baltroppe the 25th day 5s. To hym the 27th day and to hym the 28th day 5s. xxxj. s viiid." Transcription by the County Archivist of Essex, Mr. Emmison, by courtesy of the Essex Record Office (catalogue mark D/DP A9). incantations. In later Anglo-Saxon and Norman times the Church was the main provider of medical help. In Vicary's time the barber surgeons, the physicians, the surgeons, the apothecaries and a host of enthusiastic amateurs acted as general practitioners. There was little drama of new discovery until the time of Vesalius, and it took nearly a hundred years after him before the scientific method developed in this country. The work of Roger Bacon (1214-94) was the only bright flicker in the scientific darkness of the land. He was the European inventor of spectacles, but, fearing to be denounced by the Church as a powerful and dangerous magician of satanic origin, he left the method of construction secret, only confiding it to his friend, Heinrich Gothals, at the Monte Cassino monas- tery. Heinrich told Salvinus de Armatus, who passed on the knowledge and took the credit. Salvinus de Armatus also invented a modern form of truss in the second half of the 13th century (Gordon, 1960). 4 GENERAL MEDICAL PRACTICE IN THE T1ME OF THOMAS VICARY The leeches In England in the early middle ages some men and women in each community were outstanding in their luck or skill in the healing art. They became recognized as " Leeches "-the Anglo-Saxon term for healer. Their wisdom was handed down by word of mouth from generation to generation. It was not until early in the seventh century that the Angles and Saxons developed extensive written records. Some leeches were promoted on the battlefield. After his victory over the Wends at Lyrshaw-heath in North Schleswig, King Magnus the Good

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Fig. 4. Andreas Vesalius (1514-1564). looked to his wounded, " But Leeches were not so many in the host as were needed then. Then the king went to such men as seemed good to him, and felt their hands, then named he twelve men who seemed the softest handed, and told them to bind up the wounds of men, and yet none of them had bound a wound before, but all these became the greatest of Leeches" (Bonser, 1963). Most of the remedies of the leeches consisted of herbal mixtures gathered at certain times of the day and month. Many of the remedies contained Vitamin C, which would be of great value to the people whose food was deficient in this vitamin for a large part of the year. Leeches had considerable surgical skill, extracted arrowheads with forceps and set fractures by means of splints. They were well aware of the problems of 5 G. G. MACDONALD air-borne infection which they called the flying venom. Leeches were still in active practice in Vicary's time. In the 1495 rules of the Company of Barbers in Coventry there is one stating that all leeches and surgeons in Coventry must pay their dues to the Craft of Barbers (Whittet, 1964). Christianity The arrival of Christianity in this country at first made little change in the nature of men's beliefs. Diseases attributed to devils by the Church were still attributed to elves by the common folk. When the Church became responsible for the care of the sick, pagan prescriptions were Christianized so as to become operative against the pagan deities and spirits of evil which were thought to have caused the disease. The Church's method of converting a pagan charm into a Christian remedy was by adding a few words of Church Latin, or by substituting the name of Christ or of a saint for that of a heathen deity-accompanied by the ever- efficacious addition of a Cross (Bonser, 1963). The idols in the temples were destroyed and altars erected in their places. Throughout the Middle Ages the monasteries provided a refuge for the sick and infirm. This refuge was in two parts, an infirmary for the sick and aged monastic staff and a hospice or guest house into which travellers and pilgrims, rich or poor, healthy or sick, were admitted for hospitality or care. The chief concern of the Church was for the eternal soul and not for the temporal body. Cassiodorus had instructed his monks, " Learn to know the properties of herbs and the blending of drugs, but set all your hope upon the Lord, who preserves life without end ". The Church looked after the physical needs of the patient and, denied herbal remedies, sought supernatural methods of curing disease. Early Anglo-Saxon saints such as St. Alban, St. Cuthbert, St. Guthlac, St. John of Beverley and St. Oswald were greatly loved in their life times and, being men of great piety and force of character, wrought many miraculous cures among their believers. Through their own innate goodness they gave a sense of well-being to all with whom they came in contact. After death their remains were preserved and reverenced and protected from the many invaders of the land. It was noticed that ordinary priests, in the presence of the saintly remains, could continue to perform the miraculous cures. Such was the power of faith and prayer. Among the more famous of these relics were those of St. Oswald, killed in a battle in A.D. 642, and of St. Cuthbert, who died in A.D. 687, whose unpreserved body is said to have been without sign of corruption up to the time of the dissolution of the monasteries by Henry VIII, just as is the body of St. Bernadette at Nevers to this day. Other cures were effected at holy wells, many of which had been Christianized after long pagan use. The types of diseases cured by the Anglo-Saxon saints and their relics, and at holy places, were very similar 6 GENERAL MEDICAL PRACTICE IN THE TIME OF THOMAS VICARY to the well documented miraculous cures at Lourdes during the last hundred years. The second Council of Nicaea, in A.D. 787, decreed that no church might be consecrated without relics. A papal assertion that the relics were self- reproducing helped to countenance the manufacture of spurious relics and these multiplied rapidly all over the country. In the later mediaeval church the relics appeared to be used more to enrich the monasteries than to heal the sick, and to give no miraculous evidence of their existence except while they were in the hands of those who were making a profit out of them (Wright, 1861). Miraculous cures ceased to occur except at the shrines of saints of known piety and unworldliness. The pilgrims to St. Cuthbert at Durham a thousand years ago had the same diseases, the same thoughts, and the same hopes as have the present-day pilgrims to the Grotto of St. Bernadette at Lourdes. Only the means of transport has changed. It has often been stated that the Lateran Council of 1139 and the Council of Tours in 1163 forbade the clergy to practise surgery. In fact these Councils forbade the monks and regular canons to practise usury in any form and to go out of their monasteries to study medicine or civil law, because these occupations made them avaricious of worldly gain which could not be reconciled with the severe modesty of a monk. At the Lateran Council there was also a rigid decree prohibiting tournaments as a vain display of strength and valour leading to bloodshed (Milman, 1864; Mann, 1902). The Church was facing a severe shortage of skilled man- power. In England between the years 1100 and 1400, 527 hospitals and asylums were founded in addition to the monastic infirmaries. With the scarcity of skilled laymen to staff these hospitals, canons and monks largely monopolized medicine to the detriment of their own work. Ten Popes and Councils between 1131 and 1234 issued decrees and exhortations to the monks and the clergy to get on with their own work and to leave outside interests alone. The enforcement of these canons gradually trans- ferred the practice of medicine and surgery from the Church to the physicians and surgeons trained by the new universities and to members of the Guilds of Barbers and Surgeons (Parker, 1928). The Guilds and Companies Guilds were ancient English institutions. In the eighth century, they were associations of men for the observations of religious and funeral rites. After the Norman Conquest, Guild Merchants were formed. These included all who owned land or bought or sold on their own account and so included petty traders and artisans. In the 12th century Craft Guilds began to be formed. They comprised all the artisans who were in a single industry. It was only in the larger towns that there were sufficient numbers of artisans to form a Company or Mystery of one craft. Dr. Parker (1913) has traced Companies of Barber Surgeons in 20 towns in England. 7 G. G. MACDONALD In the smaller towns the companies were often joined together. So we find in Ipswich the Surgeons were in the Drapers' Company, the Barbers were in the Tailors' Company, while the Apothecaries and Physicians were in the Guild of Merchants (Whittet, 1964). This joining of crafts in a single company was a legal convenience and did not mean that the crafts were interchangeable in that company. In the Barber Surgeons' companies in the later Middle Ages, the Barbers did no surgery and the Surgeons did no barbering, except that tooth-drawing was shared by both. The teaching of the surgeons These companies were the teaching and licensing bodies of the surgeons in the towns. The training of the surgeons in Vicary's time is well shown by the 1556 Ordinances of the London Company. A seven years' apprenticeship was followed by an examination called the " first preferment of grace ". This gave the young surgeon a temporary licence to practise for a stated number of years. During this time he was expected to travel to increase his knowledge. Every six months he had to return to read an " Epistell to show how he hath profyted in his dilligent labor and studye ". The young surgeons who were unable to read or write were also examined every six months to see what they " doo in the practyce ". When sufficient skill had been shown, the candidate was admitted to be a Surgeon and a Master of Anatomy and was then allowed to apply for a Bishop's licence to practise under the 1511 Act (South, 1886). This was not the end of his professional education. All members of the Company were compelled, under penalty of a fine for default, to attend post-graduate lectures on anatomy, given four times a year on the body of an executed criminal made available to the Company under the 1540 Act. The first lecturer of the united Company was probably Vicary (Poynter, 1961). Vicary would lecture on mediaeval theories of anatomy on the lines of his book A profitable treatise on the Anatomy of Man's body, first published in 1548 (Fig. 5). It was his translation into English of an old manuscript by de Mondville. His successor, Dr. John Caius (Fig. 6a), was a brilliant anatomist who learned the new anatomy from Vesalius, with whom he had shared lodgings in 1541 in Padua. The registration of quacks Throughout the Middle Ages quacks and charlatans abounded. They visited country fairs, where they treated their patients and moved out of town before the full results of their treatment could be known. The London Company of Barber Surgeons treated these itinerant surgeons with the greatest courtesy and consideration. All who were willing were examined and, if they showed a glimmer of knowledge, were given a temporary licence to practise. This licence specified the time, usually three months, the place of practice, which was often at the applicant's 8 GENERAL MEDICAL PRACTICE IN THE TIME OF THOMAS VICARY house and nowhere else, and the speciality. The majority of these practitioners claimed skill in cutting for stone, healing of ruptures and couching of cataracts. A few were skilled in bone-setting or in cure of fistula (South, 1886). Anaesthesia In Vicary's time, strong assistants were used to hold the patient firmly during painful operations. Anaesthetics were rarely offered to or accepted

Fig. 5. Title page of Thte Anatomie of mans body by Thomas Vicary, dated 1577. by the patients. In the 12th century a monk had invented a " potion of oblivion ". The contents of this were kept secret and were rarely known to physicians and barber surgeons. It probably contained a mixture of opium and hyoscyamus. Jocelyn states: " It is certain, moreover, that many, having drunk the potion of oblivion (which physicians called lethargion) have slept and have never felt when they suffered incision and sometimes burning oflimbs and abrasion ofthe vitals, and after awakening from the sleep have been ignorant of what was done to them ". The correct dosage was hard to estimate, and many patients had eternal sleep 9 G. G. MACDONALD in place of temporary anaesthesia. This led surgical sufferers to prefer the pains of operation in this world to the distinct possibility of their prema- ture and painless arrival in the next. In Chaucer's time, John of Arderne (Fig. 6b) described a sleeping ointment, which had as its main ingredients herbane, mandragora, water hem- lock, poppies, opium and meconium, which was the name given to the gross expressed juice of the whole plant, " with which if any man be anointed he shall be able to bear cutting in any part of the body without

(a) and (b) reproduced by courtesy of the Wellcome Trustees (a) (b) Fig. 6. (a) John Caius (1510-1573). Physician to Edward VI, Mary and Elizabeth I. (b) John Arderne (1 307-1 390). After a drawing of the 15th Century in the possession of the British Museum. sensation or pain and when thou will use thereof, anoint his pulses, his temples, his armpits and the palms of his hands and the soles of his feet and soon he shall sleep so that he shall feel no cutting". " To wake a man who sleeps thus, put to his nose grey bread toasted and wet with strong vinegar, or put vinegar and mustard in his nose, or wash his head in strong vinegar or anoint his temples with the juice of rhubarb or give him some other things to make him sneeze and soon he shall wake " (Rickert, 1948). This anaesthetic must have been lethal at times and it did not continue in general use. Some herbal syrups continued to be used by barber surgeons before operations. Bailly of Troyes was heavily fined in the 17th century 10 GENERAL MEDICAL PRACTICE IN THE TIME OF THOMAS VICARY because, as a senior physician said, " Herbal poisons have worked mischief in more skilled hands than his. See to it that these practices are not allowed and do not let him go unpunished " (Gordon, 1960). So all in all it may be said that the strong arms of the assistants were the Barber Surgeons and the patient's safest friends. Local anaesthetics were rarely used. One consisted of lime mixed with Holland soap. This was so powerful that it corroded deeply through the skin, enough on one occasion to open the peritoneal cavity (Bonet, 1684). Knowledge of infection Many of the dangers of infection were known in Vicary's time. When Bullein (Fig. 7), in his book published in 1564, advises that a surgeon be asked to incise a swollen gland in a patient suffering from plague, he cautions: " now foloweth a peril to the Chirurgeon which must be richly rewarded for he putteth his life in danger in that he helpeth a sore bodie infected. He ought to be provident that doth take this matter in hand and, before he cometh to the pinch, to eat his antidotarie of Mithridatum or to have a sponge with strong vinegar applied to his nostrilles to arm hymself against the poisoned aire ". This surely is not unlike the modern practice of swallowing sulphadiazine and wearing a surgical mask. In the time of the pestilence there were ordinances compelling the burning or fumigation of clothing or bedding. Defoe, in his Journal of the Plague Year, tells us how the buyers in the meat market insisted on helping themselves to meat straight from the hook and not from the hands of the butcher. The butchers would not accept money direct from their custo- mers but had it dropped into a pot ofvinegar. The distribution of practitioners In the Middle Ages England was an agricultural land and, outside the towns and monasteries, few written records were kept, so it is hard to trace individual medical practitioners in the countryside. They served their generation and died, leaving few traces of their existence. It is probable that each small community would have a leech or wise woman whose herbal knowledge had been handed down from generation to generation, or a barber surgeon who had learned his skill by watching his master during his seven years' apprenticeship. Neither of these methods of learning leave much in the way of written record. The recent careful researches of Dr. Talbot and Dr. Hammond (1965), for the years before 1518, and Dr. Raach (1962), for the years between 1603 and 1643, have clearly demonstrated that throughout the country there were scattered large numbers of medical practitioners who were well qualified by the standards of their time. These men were found in the villages as well as in the towns. The majority of them had at least a B.A. degree, some an M.A. or even an M.D. of Oxford, Cambridge, or a Continental University. 11 G. G. MACDONALD They read Hippocrates, Aristotle, Galen and contemporary authors. They were trained to treat patients empirically. They were true students of human nature just like their modem successors. In the library of the Royal College of Surgeons of England there is a fine collection of mediaeval medical textbooks. They make difficult but fascinating reading. They show us that there was a wealth of written

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%Z4AwDtoma"ii±H4emi w L d7I; 71, iin o/=6a oj*w,ed* Reproduced by courtesy of the Wellcome Trustees Fig. 7. William Bullein (d. 1576). information available to guide the medical practitioners. Vicary treasured his copies of surgical books by Guido and Vigo which he mentioned in his will. The careful re-writing of the centre of John Halle's commonplace book leads me to suppose that it was being prepared for circulation in manuscript much as may have been the first edition of Vicary's book Profitable treatise on the anatomy ofman's body, published in 1548. One of the most helpful books for the general medical practitioner was the Boke of Chyldren published by Thomas Phaire in 1545 and frequently reprinted 12 GENERAL MEDICAL PRACTICE IN THE TIME OF THOMAS VICARY up to last year. It was the general practitioner's guide to paediatrics. It instructs in the treatment of such troublesome conditions as " Terryble dreams, colyke and rumblying in the guttes, bed wetting, gogle eyes and of falling of the Fundament ". It is still a joy to read and to re-read 400 years later, and some of its advice is sound to-day. Physicians It is sometimes thought that the university-trained physicians in the 16th century were medically ignorant and impractical and merely related their patients' troubles to the theories of the ancient authorities. This may be perfectly true, but the physicians had to earn their living by attract- ing and giving good service to their patients. They could compete successfully with the ubiquitous, more practical but equally ignorant barber surgeons and apothecaries. Moreover a study of the journals of Felix and Thomas Platter, written while they were at Montpellier in the middle and end of the 16th century, showed that the medical student of the day was carefully copying out the prescriptions of his masters and trying them out on innkeepers and friends. He also attended post-mortem examinations and anatomical demonstrations. He dissected bodies for his own instruction and sometimes had to steal a corpse from a cemetery for this purpose. He followed the surgeons and physicians round the town when patients were visited in their own homes. Then, as now, the fame of the specialist could be measured by the number of students following him on his rounds. After the 1511 Act many barber surgeons and apothecaries who had been trained by apprenticeship, applied for, and received from their Bishop, licences to practise physic. These men were termed " Physicians " because they held Bishops' licences to practise physic, but they did not act like university-trained physicians, who directed apothecaries to apply treatment. They practised from their house or shop and had apprentices. They treated patients directly, without the interveDtion of apothecaries. In addition to these learned and trained individuals, there were a large number of men who set themselves up in practice and after some time they had sufficient bluff and recommendations from their friends and colleagues to convince the Bishop's officers that they were of good character and had enough medical skill to merit a licence to practise. Marcellus de la More, who was Vicary's predecessor as Serjeant Surgeon, was almost certainly without official medical training of any kind (Talbot and Hammond, 1965). He was one of the numerous foreigners who came to England to seek their fortune. Some ofthese were in Royal favour, but many ofthem were medical impostors with quick wits and fIio medical training. John Halle In Maidstone, Vicary's great friend John Halle (1529 ?-1568?) (Fig. 8) was waiting to drive out of town the spurious claimants to medical skill. 13 G. G. MACDONALD In his short treatise, The Historical Expostulation against the Beastlye Abusers both of Chyrurgurie and Physyke in our Time (1565), he lists his successful prosecutions and the claims of the impostors. It is interesting to find John Halle supporting the Establishment so well only nine years after he had been imprisoned for his part in supporting Wyatt's rebellion against the proposed marriage of Queen Mary to King Philip of Spain (Power, 1918). John Halle was a member of the Barber Surgeons' Company of London and he practised as a surgeon at Maidstone. Surgeon was the name given to medical men in general practice from the 16th to early 19th centuries.

Fig. 8. John Halle (1529 ?-15689.). From his Excellent and Learned Worke of Chirurgie. He tried hard to raise the standards of orthodox medical practice in Maidstone and was a prolific writer on many subjects. He kept a commonplace book in manuscript which has been preserved, bound in leather, in the Bodleian Library (MS. 178). It gives us a fascinating picture ofgeneral medical practice in Vicary's time. It is written on vellum and the pages are numbered on one side only. Pages numbered 44 to 155 are written and corrected in a most beautiful script. They consist of Halle's translation or, more correctly, an epitome of the works of Benedictus Victorius (1481-1561) and Nicholas Massa (d. 1569). Both these men wrote on the cure of syphilis. Halle had a great reputation as a skilful healer of this disease. The first 43 and the last three leaves are in a more irregular script and are, I believe, in John Halle's own writing. Here he gives details of the preparations of many antidotes, medicines, laxatives, com- forting syrups and other remedies. This shows that John Halle, like most of the surgeons or general medical practitioners of his time, was 14 GENERAL MEDICAL PRACTICE IN THE TIME OF THOMAS VICARY preparing and applying remedies direct to his patients without the inter- vention of an apothecary. Thomas Gale, who was Master of the Barber Surgeons' Company in 1561, also included an antidotarie or collection of prescriptions in his book of surgery published in 1561. The Surgeons tended to keep quiet about their prescribing activities because it was illegal under the Act of 1542. This stated " no common surgeon may administer medicine outward . . . for although the most part of the said craft of surgeons have little cooning, yet they would take great soomes of money and doo little therefore: and by reason thereof they doo oftentymes im- paire and hurt their patients, rather than do them goode" (McNalty, 1952). The physicians also had decreed that the correct course of action was for the surgeon to request the physician to give a prescription to an apothecary who would apply treatment to the patient. The patient naturally preferred the surgeon who could save the cost by doing all parts of the treatment himself. John Halle copied into his commonplace book some of the corre- spondence between himself and a consultant, Dr. William Cunningham, and a fellow-practitioner, Dr. John Coldwell. These letters show that problems and diseases ofpatients have changed little, while the consultant's letters have become more brief and to the point during the last 400 years. Halle, like the surgeons of his time, treated the outward sores and swel- lings of his patients with herbs, ointments, baths, poultices and plasters. He treated their internal troubles with diet, sweating and fumigations. He gave drinks for stone, strangury and the agues. Barley-water internally and rosewater externally were common remedies. He lived at a time when many men went about the streets armed and the treatment of wounds was a frequent task of the surgeon. Bleeding Bleeding the healthy person to preserve health and bleeding the sick person as a form of treatment has been a task of the surgeon from the time of Ancient Greece. It was thought to be a sovereign remedy for all mental and physical ailments. The circulation of the blood had not then been discovered and great care was thought to be necessary to open the correct vein for each physical condition. In England, this vein was frequently the one nearest to the afflicted organ. The Arabian physicians with equal wisdom opened the vein farthest away from the site of the trouble. The correct day for bleeding the patient was determined by reference to astrological tables. Cupping, blistering, cauterization, purging, leeching and the administration ofemetics and enemata were all part ofthe general practitioner's treatment (Fig. 9). The account of a North Riding doctor in 1609 (LeFanu, 1961) shows that general medical practice had not changed in the 50 years after Vicary's death. It gives a list of the patients seen and of the diseases treated by the doctor in 1609. He charged a shilling for a vomit, a purge or the setting 15 G. G. MACDONALD of a broken arm, 2s. 6d. for more extensive treatment and four shillings for blood letting. He was often paid on the spot. The patients usually visited the doctor in his house. He dispensed his own medicines, and sometimes relatives would collect the medicines to be given to the sick persons in their homes. Vicary's treatment Unfortunately little is now known of Vicary's treatment of his patients. We know that he treated Henry VIII's " sorre legge " in 1527. He treated Sir William Petre, from 1555 to 1561. In 1555 Sir William was troubled by a chronic varicose ulcer and Vicary was among the many physicians,

Rpro, 1 hY crt,. .i t Ti!1o._. rut Fig. 9. Operating for removal of a sebaceous cyst of scalp. Painting attributed to Pieter Bruegbel the Younger (1564-1637). surgeons, apothecaries and amateur surgeons called in to help with the treatment. The steward notes-" to Vycars the surgeon 3s 4d "-and more camphorated ointment and rosewater was ordered from the apothecary, also white vinegar and rose leaves to make rose vinegar (Emmison, 1961). In 1560 Sir William asked Vicary how to make a lead plaster. The Steward again notes-" Tuesday 18th March 1560 to Vycars 6s 8d ". Vicary's final professional visit to Sir William was on 23rd January 1561, a short time before Vicary's own death. For this visit he was paid 5s. Sir William Petre suffered from a stone in the kidney, a hernia and a chronic varicose ulcer. It is interesting to note that a patient to-day, who refuses the benefit of modern surgery, is treated by his general medical practitioner in much the same way as did Vicary 400 years ago. A study of the extensive records of Sir William's illnesses between 1544 and 1572 shows the pattern of medical practice among the upper-class patients. 16 GENERAL MEDICAL PRACTICE IN THE TIME OF THOMAS VICARY It was customary to call in several practitioners. First a surgeon member of the Barber Surgeons' Company would be called with the hope, and possibly fear, that the surgeon would remove the disease. If the surgeon failed to cure the patient a physician was called in, and then more physicians and then amateurs. In April 1555, after Alsopp the Royal Apothecary, Dr. Wendy the Royal Physician and Thomas Vicary the Royal Serjeant Surgeon had all failed to cure Sir William Petre's ulcer, a servant was sent riding to Sir Philip Parys for advice. Sir Philip had ridden all over the land with Sir William 20 years before, arranging for the dissolution of the monasteries, and had a good reputation as an amateur surgeon (Emmison, 1961). The apothecary In Vicary's time the apothecaries also acted as general medical practitioners. They certainly knew much more of the compounding ofdrugs than did any other branch of the profession. They were in close contact with the patients so they had a much greater opportunity to observe the effects of the drugs. Officially they were but the handmaids of the physicians, but in fact they treated a large proportion of the population in an empirical way. They were allowed officially to do this under the 1542 Act (32 Henry VIII, c. 42), which has often been wrongly called the quack's charter. Under this Act they were permitted to charge the patient for the drugs and for making up the prescription, but not for their medical advice. After their charter in 1617 the apothecaries gradually became pre-eminent in the training and licensing of general medical practitioners and com- pletely displaced the barber surgeons by the second half of the 18th century (Parker, 1913). The apothecaries were members of the Grocers' Company in London and of various provincial guilds in all the main towns of England (Whittet, 1964). Their remedies were herbal, like the leeches of old, mystical such as unicorn's horn, and imported vegetable from the East, such as rhubarb, senna, ginger, camphor and clover, pepper and opium. From the time of Paracelsus (1493-1541) chemicals became available, such as antimony, arsenic, mercury, lead and iron. The apothecary's knowledge of these new and powerful remedies caused him to displace the amateur dispenser who had to remain content with herbal remedies. Monks Some monks, expelled from their monasteries, wandered around the countryside selling their medical remedies to the credulous and covering their ignorance with Latin incantations and signs of magic. After the dissolution of the monasteries the monks were all pensioned well by Henry VIII, except for a few who were hanged for treason (Emmison, 1961). Many of the pensioned monks enjoyed their escape from monastic seclusion and some of them set up as healers in opposition to the more orthodox practitioners. 17 G. G. MACDONALD Assistant surgeons In Tudor times there were no National Health doctors except in His Majesty's transports on the way to war and on the battlefield. Past Master Thomas Gale (1507-86, Master in 1561) a few years before had called them " dog Leeches for in two dressings they did commonly make their cure whole and sound for ever, so that their patients felt neither heat nor cold, nor any manner of pain after " (Lambert, 1881). Gale had been sent to investigate the high death-rate in the hands of the surgeons after the Battle of Muttrel in 1544. He found that the previous occupations of the " surgeons " were sow gelders, horse doctors, tinkers and cobblers. These ex-Army assistant surgeons were avoided by all wise patients. Midwifery In Vicary's time midwifery was no part of medical practice. It was in the hands of midwives and local wise women. Dr. Copeman believes that the high maternal and infantile mortality rate was the cause of the population remaining stationary in Tudor times in spite of a high birth-rate. The Bishop licensed the midwives. They had to be said to be of high moral character and to be skilled in their art. They had to be word perfect in the service of infant baptism. The destination of the soul of the infant seemed to be of more importance than the preservation of the life and health of the mother and child. There were widespread fears that a witch midwife might consign the soul of the infant to her master the devil (Forbes, 1964). The dissolution of the monasteries destroyed the small provision for lying-in mothers which had existed for the previous century. Hospitals By 1539 655 monasteries and 110 hospitals had been suppressed. This biought great hardship to the poor and sick, who had lost their one in- stitutional refuge. In 1538 Sir Richard Gresham, the Lord Mayor of London, wrote to the king on behalf of " the poor, sick. blind, aged and impotent persons ... lying in the street offending every clean person pass- ing by with their filthy and nasty savours ". The king took no notice ofthe appeal until 1544, when he wanted money and credit from the City for his war with Scotland and France. He then partly refounded St. Bartholo- mew's Hospital. It was not until he was in his final illness in 1547 that he would listen to the appeals of his physicians and City Councillors and earn his posthumous and unmerited distinction as the first founder of the Royal Hospitals (McNalty, 1952). His successor, Edward VI, re-opened St. Bartholomew's for the treatment of the sick and gave to the City St. Thomas's for the permanently infirm, Bethlehem for the insane and Bridewell as a kind ofprison hospital. The embalming of the dead The final duty of the Barber Surgeon was the embalming of the dead. 18 GENERAL MEDICAL PRACTICE IN THE TIME OF THOMAS VICARY This is rarely mentioned in the written records, possibly because it was common knowledge at the time and not worthy of mention. The apothecary's bill " for the funeralles " of Henry VIII consists of a list of spices, seven lots of which were " d.d to the syrgeons gross powderyd by their byll " and " ten lots bagges severally to put in the cofyn of lead with the corse ". The embalming of the dead is also mentioned at length in " a summary of such things as this Companie do beseech to have contained in letters patent from his Magistie (James 1st of England, 5th October 1604) ... 16th. It showeth the openinge, searing and embalming of the dead corpes to be properly belongeing to the science of Barbery and Surgery, and the same intruded into by Butchers, Taylors, Smythes, Chandlers and others of diverse trades unskillful in Barbery and Surgery . . . " The petition goes on to describe in vivid detail the un- pleasantness following unskilful embalming (South, 1886). This brief review of general medical practice in the time of Thomas Vicary has shown that England was well served by medical practitioners distributed throughout the towns and villages. They were taught by apprenticeship, university teaching, or the general experience of life. They were no more ignorant of dlsease processes than we shall seem to be in the eyes of our successors 50 or 400 years hence.

ACKNOWLEDGEMENTS Finally I must thank those without whose aid this lecture would not have been possible: Miss Jessie Dobson, curator of the Hunterian Museum; Mr. LeFanu and the staff of the Library of the Royal College of Surgeons of England; Dr. Poynter and his staff at the Wellcome Historical Medical Library; and the librarians of the Bodleian Library, British Museum, College of General Practitioners and the London Borough of Enfield. With this I conclude my address on general medical practice in the time of Thomas Vicary, Serjeant Surgeon to four monarchs, five times the Master of the Barber Surgeons Company of London, Governor and Assistant of St. Bartholomew's Hospital and general medical practitioner.

SELECTED REFERENCES BONET, T. (1684) A Guide to the Practical Physician. London, Thomas Flesher. BONSER, W. (1963) The Medical Background to Anglo-Saxon England. London, Wellcome Historical Medical Library. BULLEIN, W. (1562) The Bulwark of Defence against all Sickness . . . London, J. Kyngston. CLIPPINGDALE, S. D. (1922) Medical Court Roll. Manuscript in the Library of the Royal College of Surgeons of England. CocKAYE, T. (1864-6) Leechdoms, Wortcunning and Starcraft of Early England. 3 vols. London, Longmans. COPEMAN, W. S. C. (1960) Doctors and Disease in Tudor Times. London, Dawson. EMMISON, F. G. (1961) Tudor Secretary: Sir William Petre at Court and Home, p. 254. London, Longmans. FORBES, T. R. (1964) Med. Hist. 8,235-244. London, Dawsons. GORDON, B. L. (1960) Mediaeval and Renaissance Medicine. London, Peter Owen. 19 G. G. MACDONALD HALLE, J. (1565) The Historical Expostulation against the Beastlye abusers both of Chyrurgurie andPhysyke in our time, in Lanfranc, Chirurgerie. London, T. Marsh. Bodleian Library, Manuscript No. 178. JOCELYN. Quoted by B. L. Gordon (1960), p. 445. LAMBERT, G. (1881) History of City Livery Companies, p. 8. London, Brettell. LEFANU, W. R. (1961) Med. Hist. 5, 178. McNALTY, SIR A. (1952) Henry VIII, a difficult patient. London, Christopher Johnson. MANN, H. K. (1902) TheLives ofthePopes in the Early Middle Ages. 10, 66. London: Kegan Paul, Trench. MILMAN, H. H. (1864) History ofLatin Christianity, 6, 322-3. London, John Murray. PARKER, G. (1913) Proceedings of the 17th International Congress of Medicine, p. 286. (1928-29) Brit. J. Surg. 16, 39. PHAIRE, T. (1545) The Boke of Chyldren. Reprinted 1965, London and Edinburgh, Livingstone. PLATTER, F. (1961) Beloved son Felix. Translated by Sean Jennett. London, Frederick Muller. PLATTER, T. (1963) Journal ofa younger brother. Translated by Sean Jennett. London, Frederick Muller. POWER, SIR D'A. (1918) Proc. Roy. Soc. Med. 11, 55. POYNTER, F. L. N. (1961) Evolution of Medical Practice in Britain. London, Pitman. RAACH, J. H. (1962) A directory of English country physicians 1603-43. London, Dawsons. RICKERT, E. (1948) Chaucer's World. Oxford University Press. ROBERTS, C. (1937) Alfred Fripp. London, William Brendon. ROBERTS, R. S. (1962) Med. History, 6, 363. (1964) Med. History, 8, 217. SINGER, C. (1928) From Magic to Science. London, Ernest Benn. SOUTH, J. F. (1886) Memorials of the Craft of Surgery in England. London, Cassell. TALBOT, C. H., and HAMMOND, E. A. (1965) Medical Practitioners in Mediaeval England. London, Wellcome Historical Medical Library. TREVELYAN, G. M. (1942) English Social History, p. 96. London, Longmans. WHITTET, T. D. (1964) Med. Hist. 8, 245. WRIGHT, T. (1861) Essays on Archaeological Subjects, p. 259. Quoted by W. Bonser (1963), p. 207. YOUNG, S. (1890) Annals of the Barber Surgeons. London: Blades, East and Blades.

SIR ARTHUR PORRITT, Bt. EVERYONE AT THE Royal College of Surgeons of England was delighted to hear of the appointment of Sir Arthur Porritt, Bt., as Governor-General of New Zealand. Sir Arthur, who is Sergeant-Surgeon to Her Majesty The Queen, was President of the College from 1960 to 1963 and a member of Council from 1950 to 1966. Sir Arthur, who was born and educated in New Zealand, came to England as a Rhodes Scholar in 1923. After graduating in medicine at Oxford University, he was elected to the Staff of St. Mary's Hospital, London. His reputation as a surgeon and as an athlete is known throughout the world and, having held many important posts in surgery and in medical administration in this country, it is very fitting that one of our own elder statesmen should undertake even greater responsibilities and return to the country of his birth as Governor-General. He and Lady Porritt carry with them our very best wishes for a happy and successful term of office. 20