Renaissance Doctors Came in Four Tiers, and the Best Healer Was Called a Quack
Bone-setters worked the market circuit every week, far more practiced than a licensed surgeon who did a few cases a year, and the physicians called them quacks — title and skill were never the same thing.
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Eighty to ninety percent of medicine was provided free by women
Erin asks who was practicing medicine in this period, and Alanna Skuse's answer is ‘almost everyone’ — but the real base of supply was women: household healers carried roughly 80%, perhaps 90%, of medical care, and mostly charged very little or nothing. The reason they were ignored by history is concrete — they left too few written records. Knowledge passed down the maternal line: mother to daughter, aunt to niece, sometimes mistress to servant, carried in handwritten recipe books. They also wrote to each other exchanging ‘I found a good recipe’ and ‘I tried this and it didn't work’. This formed a medical network with no licenses, no college, that nonetheless covered the vast majority of the population.
— Alanna SkewsFirst you look at your purse: ten shillings a visit
The path to care was essentially a price ladder. At the very top was the physician, about 10 shillings a visit, extremely expensive, so only the wealthy called a doctor directly. Those without money worked up from the bottom: first a local woman, a midwife with extra medical skill, or a nearby gentlewoman with leisure and literacy; failing that, an apothecary, whose medicines started at a penny, like today's pharmacist, but almost every one sold his own special remedies and sometimes diagnosed and treated patients himself; failing that, or if a leg was obviously broken, a surgeon, about 3 shillings a visit, who handled everything on the body's surface — lumps, wounds, fractures. Skuse says plainly that how sick you let yourself get before seeking care depended on what it cost: ‘the doctor or dinner’.
— Alanna SkewsThe guild monopoly failed, but the idea of credentials stayed
Skuse characterizes the motive behind the founding of the College of Physicians bluntly as commercial: physicians resented surgeons and barber-surgeons encroaching on their turf and wanted to build a college and then monopolize all medical practice. The college was founded, but the monopoly was never won — it couldn't even control London, let alone the country. Yet the long-term consequence mattered more than the short-term outcome: this was the first systematic articulation of the idea that ‘those who practice medicine ought to be credentialed’. Skuse draws the line to today at the end: these institutions, initially weak regulators, evolved into bodies like the British Medical Association and the AMA, and our assumption today that doctors share uniform standards and a consensus begins here.
— Alanna SkewsCalling rivals quacks was the norm, not the exception
Asked how fierce competition was among doctors, Skuse says they were ‘horribly rude to each other’, and finding two who didn't quarrel was rarer — because there was only one pie and everyone wanted the biggest slice. So surgeons insulted apothecaries, physicians insulted surgeons, and everyone called everyone else a quack. She gives an example: someone claimed a certain doctor had gone off to exorcise a woman, when really she just had gas. Quack comes from the Dutch quacksalver, meaning someone who sells salves by boasting of his medical credentials; another word, mountebank, comes from Italian, meaning someone who climbs onto a stage to hawk cures. The key point is that the word's boundary was filthy: a bone-setter would be called a quack by a physician, because he had no credentials and no fixed shop.
— Alanna SkewsBone-setters were more practiced than licensed surgeons
This is the sharpest passage in the whole piece. Skuse asks: if you had a complex fracture, would you go to a licensed surgeon who does a few cases a year, or a bone-setter who travels to a different market every week and does nothing but set bones? Bone-setters usually also pulled teeth — teeth rotted badly in that era and there was no option but extraction — so they tended to be physically strong, and brought an equally strong assistant to hold the patient down during the procedure. Physicians classed these people as quacks on the grounds of no credentials and no shop. But by actual surgical volume, their skill far exceeded that of their licensed peers. Credentials and competence here are two independent axes.
— Alanna SkewsEfficacy was not the main source of trust
Erin asks directly whether efficacy affected trust, and Skuse's answer is: people didn't expect to be cured in the first place. They didn't expect a life free of pain, nor that a doctor could fix everything wrong with them — but they did judge when a doctor did something wrong. She gives the example of Elizabeth Freke: her husband was gravely ill with a gangrenous leg, she went away for a few days to rest, came back to find him worse, and said outright ‘you have murdered my husband’. So trust was more commercial: a doctor who gossiped about his patients would lose business; if a practitioner held up, people would use the same healer for life, even across generations — a midwife's daughter delivering the daughter of the woman her mother had delivered. She also mentions Henry Moore bringing in famous physicians from the Continent and mailing remedies for Lady Anne Conway, when she might have done better with a local doctor.
— Alanna SkewsOpponents of bloodletting often believed other nonsense too
Skuse concedes that although the vast majority believed in the humors and everyone bloodlet, there were public dissenters, and George Thomson was one of the leading figures of that camp. The problem is that these people often believed other quite absurd things at the same time, which undermined their credibility. On the starting point of evidence-based medicine, she says it's hard to answer, because in a sense medicine has always had evidence-based medicine: in the 16th century they were already testing antidotes on condemned criminals, which looks like experiment; what we call the scientific method roughly appeared with the Royal Society, and James Lind's scurvy trial in 1746 was the first clinical trial in the modern sense. What actually helped people was mostly gentle remedies — sage and rosemary gargles, ginger and mint for the stomach — plus symptom relief and narrative medicine: a doctor who sat at your bedside for an hour listening to you might have you sleeping better that night.
— Alanna SkewsBloodletting, vomiting and purging were listed as the three great therapies
Asked about the greatest cost of medical progress, Skuse first gives an institutional answer: surgeons, physicians and apothecaries all crossed boundaries, and it was precisely by crossing boundaries that they learned — at the cost of large numbers of patients dying from mercury, arsenic, useless operations and aggressive purging. Because experimentation was not systematic or organized, the toll far exceeded what was necessary. She also gives a more specific, quantitative judgment: the College of Physicians called bloodletting, vomiting and purging the three great therapies, and heaven knows how many people already at death's door were pushed through it by these purging treatments. There was also a cost in quality of life — these therapies were extremely unpleasant.
— Alanna SkewsIn their own words · checked verbatim
And we always forget that the biggest providers of medicine in this period are women. And they are mostly doing it either very cheaply or for free.
Alanna Skews10:55
But a physician's visit is about 10 shillings, which is a lot.
Alanna Skews17:11
Is it a case of seeing the doctor or eating?
Alanna Skews24:20
horrifically rude about each other all the time. It's more uncommon to find two of them who aren't fighting.
Alanna Skews29:26
But if you have a complex fracture, do you want to go to the surgeon who maybe does a couple of them a year? Or do you want to go to the bone setter who all he does is every week goes to the market in different towns setting bones?
Alanna Skews31:28
I think people don't have the same expectation of cure. So they don't expect to live a life that is completely free from pain.
Alanna Skews36:45
The College of Physicians calls letting blood, causing vomiting and causing diarrhea, the three great remedies. So God knows how many people were on death's door and were just pushed through it by those purging remedies.
Alanna Skews46:55
Figures
| Share of medical care provided by women | About 80%, perhaps 90% | 10:55 |
| Cost of a physician's visit | About 10 shillings | 17:11 |
| Cost of a surgeon's visit | About 3 shillings | 18:13 |
| Starting price of apothecary medicines | From 1 penny | 17:11 |
| Membership of the College of Physicians at its founding | No more than a few dozen | 27:23 |
| Share of men aged 18 to 50 who served | Over 50% (Charles Carlton's estimate) | 40:48 |
| Year of the first modern clinical trial | 1746, James Lind's scurvy trial | 38:47 |
Glossary
- humors
- The four fluids — phlegm, black bile, blood and yellow bile — corresponding to cold-wet, cold-dry, hot-wet and hot-dry, whose imbalance caused disease.
- apothecary
- A practitioner who sold medicines and also saw patients, like today's pharmacist, but who often made and sold his own special remedies.
- quack
- From the Dutch quacksalver, meaning someone who sells salves by boasting of his medical credentials; it was an insult.
- mountebank
- From the Italian, meaning someone who climbs onto a stage to hawk cures.
- uroscopy
- Diagnosis by looking at, smelling and sometimes tasting the patient's urine.
- non-naturals
- In Galenic medicine, the six external factors affecting health, including diet, exercise, sleep, emotions, excretion and air.
How to listen
Listeners interested in medical history, the origins of professional credentials, and the stratification of the medical marketplace; anyone building a healthcare startup or working on policy should listen to the credential-monopoly section.
The first two minutes of show promotion and book club introduction can be skipped.