THE IDEAL DOCTOR

During the eighteenth century, it was standard practice for medical professors to present their subjects as a series of lectures based on textbooks written either by themselves or by other scholars. Many professors preferred to write their own text, no doubt in part for the income they hoped to earn from its purchase by students, but they could just as reasonably select someone else's work if it suited their purposes. Thus one student, who enrolled at the Prussian university of Duisburg in 1763, recalled later that during his first semester he heard one of his professors lecture on surgery “from his own manuscript”, and on anatomy “according to Heister's compendium”. More remarkable, perhaps, is what the student reported about the other member of the Duisburg medical faculty. From that professor, he wrote, “from 8–9 o'clock I heard physiology according to Boorhaave's [sic] compendium, from 9–10 o'clock pathology, likewise according to Boorhaave, and from 3–4 in the afternoon therapy, again from Boorhaave”.

Indolence surely had something to do with this complete reliance on Boerhaave, but the professor's contemporaries could scarcely have faulted his choice of authority, for Herman Boerhaave (1668–1738) was a figure of incomparable stature to eighteenth-century physicians. Time and again they invoked his authority in their writings, exalting him to an honored place in the pantheon of medical immortals. By the hundreds they flocked to the University of Leiden to hear him lecture on medicine, botany, and chemistry.

The emergence of the professoriate as a full-time career during the early years of the nineteenth century marked a signal change in the social organization of German intellectual life, which would have enormous consequences over the long term. In the first place, it would lead to the recruitment of students directly into the professorial ranks, creating in medical faculties a cadre of “physicians” whose attachment to the practice of medicine was uncertain. By mid-century, medical students like Carl Gegenbaur, Ernst Haeckel and Emil Du Bois-Reymond could take an M.D. without seriously intending to make a career as practitioners. Such career goals would have been virtually inconceivable in 1750, and were remarkable even in 1800. Secondly, these new professors would begin trading older forms of academic scholarship for the production of research more akin to our sense of the word: empirical discoveries meant to enrich the store of knowledge. While such research would eventually find its way into medical curricula, it was not conducted necessarily with pedagogical aims in mind, and much of what had once counted as scholarship in the eighteenth century (such as writing textbooks) no longer carried the same prestige. Of course, this is not to imply that empirical research had been unknown to eighteenth-century scholars, only to explain that the weight of research effort had shifted and that the environment for it – both institutional and cultural – had changed considerably.

In 1796, William Blizard, surgeon to the London Hospital and earnest Anglican, introduced one of his pamphlets with a revealing text. He chose a passage by William Blackstone, the eminent legal commentator, Member of Parliament, and judge.

Blizard went on to discuss the topic at hand – the importance of assistant surgeons in hospitals – as an application of this teleological principle. His essay resonated with the analogies he evoked with Blackstone's statement: hospitals were like “all Bodies politic,” like “Natural Bodies,” like God's creation. Inspired founders had shared God's vital spark, infusing their work with an all-encompassing Design. Blizard implicitly played out the rest of the analogy. Just as humans had to figure out God's Design to understand nature, hospital governors needed to grasp the founders' Design to carry out their “General Duties.” Unfortunately, like corrupted churchmen, governors tended to forget “all the great objects they comprehend” and to fail to “appreciate their own true, high relation to the public.” Blizard hastened to remind them that they were responsible “for their conduct to science, to humanity, to all mankind.”

This was rather heavy-handed rhetoric for introducing an argument that the surgeons of the London Hospital needed help with their charitable duties, but Blizard was not one to resist a high moral tone when he held a pen.

In the preface to their first volume of Medical Observations and Inquiries (1757), a “Society of Physicians in London” praised the publications of the Royal Society and the Parisian Academy of Sciences, yet noted that their scope “does not allow them to insert several things … calculated only for the improvement of physick.” Furthermore, the anonymous editor(s) continued, some

“Mixed company,” a phrase that evokes audiences of men and women, suggests that these physicians had extraordinary delicacy about presenting medical details to nonmedical men, unless prim ladies indeed visited the Royal Society meetings. Note how the physicians claimed to be the only “adequate judges” of their experiences. They could share the “entertaining” or “instructive” case with educated folk, but they were the appropriate interpreters of such matters of fact. Asserting their unique expertise had, of course, always marked medical practitioners, however much they negotiated their authority with patients and peers. So the editor(s) went on to explain the particular grounds for their valuable work:

On 1 May 1740, the Fellows of the Royal Society elected James Hawley, MD, to join them as an FRS. His nomination letter, exhibited at the society from 31 January to 24 April for his potential colleagues to examine, described Dr. Hawley as a

Signed by four relatively undistinguished members, Hawley's certificate followed a pattern already familiar to the Fellows: this man would fit in. In contrast, those had who nominated John Andrée the previous October had stated that he was a

Andrée's supporters included Sir Hans Sloane, President of the Society, and Cromwell Mortimer, MD, its Secretary. Yet it was unusual to detail publications in nomination letters: perhaps this man did not fit in.

“Sir,” wrote John Wood of Sittingbourne, Kent, on 28 May 1788, to George Neale, surgeon,

Nineteen years after walking the London's wards, John Wood found that evidence of that experience might “be necessary” for his practice in Kent. His brief request suggests the little ways that hospital training crept into the making of regular medical men in the eighteenth century. In 1769, Wood chose to pay to watch and assist elite surgeons in their charitable work, spending twelve months engaged in an activity hardly required for a surgeon, or surgeon-apothecary, to start treating patients in Britain. Yet it mattered. In 1788 the “Certificate from the Hospital” was valuable. It marked Wood as a practitioner with an appropriate background, whatever he actually learned under Neale and the other surgeons.

For the emergence of hospital teaching in London, Wood's decision to enter the wards evokes part of the story, the demand side, as it were, of institutional change.

“Charitable knowledge,” I have been told, is a rather peculiar conjunction of words. People are benevolent, generous, lenient, merciful, or philanthropic, giving of their time, compassion, or money; knowledge – well, knowledge, qua knowledge, is not. Yet “charitable knowledge” captures the major arguments in this book. Practitioners in eighteenth-century London hospitals used their medical knowledge and skills for charitable ends. They spent hours voluntarily attending to the sick poor. They tried to help ill men and women to get better, whether or not they were particularly successful with their cures or especially kind to the poor folk under their care. During the eighteenth century, hospital physicians and surgeons made teaching pupils on the wards integral to hospitals' charitable duties. In order to do that, they had to make the daily presence of large numbers of pupils on the wards fit into the meaning of charity for the lay governors whose time and money supported the hospitals. Using hospital patients as teaching objects had to become a good thing to do, a valuable contribution to social betterment for all people, not just a useful experience for a very small number of apprentices and personal assistants.

The modern teaching hospital exists because we – as a culture if not as individuals – in a fundamental sense value the moments when an experienced clinician instructs a medical student using the body and responses of a hospital patient.

“[L]ast night a nasty little dog was in the dissecting room shut up there for some experiment or other & made free with the Os Cuboides & the falanges of the little Toe, for wh. I have substituted part of an other foot,” wrote Hampton Weekes, a resident apothecary's pupil at St. Thomas's, to his father on 10 November 1801. Busy making anatomical preparations to send home, Hampton evinced complete disinterest in what that “experiment or other” might have been about, much less concern for the fate of the dog. Hampton later warned his family: “These things I suppose you will not circulate for what I tell you on this head I conceive goes no farther.” Hampton, happily participating in the clinical and anatomical rituals at St. Thomas's and Guy's, was quite blasé about the notion of animal experiments, yet clearly aware others might not have such enlightened views. Hampton, in short, even as a pupil on the fringes of hospital men's investigations, identified with the culture of “men of science.” He acquired those tidbits of theory that extended his repertoire not only into talk of constitutions and ultimate causes for disease, but also into experiments and science. He savored those delicious moments of knowing more about nature than others did: “I tell Dick ye source of animal heat is acertained ask him if he knows it,” he wrote to his sister, Mary Ann, “This is a chemical operation–.”