TY - JOUR
AU - Mulcahy, Ursula, Mary
AB - Summary This article investigates how most surgeons and surgeon-apothecaries in eighteenth-century Scotland earned a living. I argue that the evidence suggests that their main source of income was selling drugs and treating infectious diseases. Approximately, two-thirds of them practised without a licence. This situation came about because apprentices were not trained to do high-risk surgery, and the article discusses the problems Scottish surgeons faced in obtaining such training. These circumstances were not unique to Scotland. Where records exist, they indicate that very few eighteenth-century surgeons performed high-risk procedures such as amputation and lithotomy. surgeon, surgery, eighteenth century, Scotland Most historians agree that during the eighteenth century, medical care was usually provided by family, friends, local clergy and ‘wise women’.1 But, as Christopher Lawrence commented, ‘the late seventeenth century saw the establishment of small surgical elites, who … had the means to avail themselves of the high quality medical and surgical tuition available. It is from this surgical elite, rather than from rank-and-file practitioners that much of our knowledge of eighteenth-century surgery is drawn’.2 This article attempts to redress the balance by investigating what the rank-and-file did. At the time, many surgeons and surgeon-apothecaries were trained through the apprenticeship system.3 This meant that they were taught by a master in his household, so very little of their work load was actually recorded. This investigation will try and overcome that difficulty in four ways. First of all, by examining the probate records of men who worked in eighteenth-century Scotland and were described by their next-of-kin as surgeons or surgeon-apothecaries.4 Of that group, 63 of the records contained a detailed inventory. I argue that a study of their books and instruments may give a more accurate picture of what work they were doing than official records and students’ lecture notes. The study of probate records will be supplemented with a discussion of what is known of surgical training in Scotland, what diseases were prevalent at that time, surgeons’ accounts and account books and how the practice of surgery in Scotland compared with that of France and the Netherlands.5 While there is no conclusive evidence from any of these sources individually, I argue that when all the evidence is put together, it indicates that Scotland, like France and the Netherlands, had what could be described as a ‘two-tier’ system of surgical care. This consisted of an elite group, who had the training to do high-risk operations and the rest, who were the majority.6 They made a living mainly by treating what would now be described as medical conditions and by selling drugs. In Edinburgh, surgical practice was controlled by the Incorporation of Surgeons of Edinburgh (ICSE), which was the premier guild organisation in the city.7 In Glasgow, it was the Faculty of Physicians and Surgeons of Glasgow (FPSG). Membership of both organisations was dependent upon passing an examination and payment of an admission fee. In theory, before they could be admitted, trainees had to complete a 5-year apprenticeship to a recognised master surgeon. The system in Edinburgh was further complicated by a long-running dispute between the apothecaries who made a living solely by selling medicines and the surgeons.8 Apothecaries were allowed to join the Surgeon’s Incorporation in 1645.9 This resulted in some surgeons being trained in pharmacy. Initially, there was a distinction between the work of surgeons and surgeon-apothecaries.10 However, in 1657, the surgeon-apothecaries insisted that pharmacy and botany were added to the examination syllabus of surgeons.11 Although they were members of different guilds, by the beginning of the eighteenth century, the training and qualifications of surgeons and surgeon apothecaries was identical. It was noted that ‘no man would bind his son to either trade only’.12 During the eighteenth century, university and apprenticeship systems were starting to coalesce. Because there were no entrance requirements for Edinburgh University, surgical apprentices could do university courses without taking a degree.13 In addition, surgeons and surgeon-apothecaries began to admit university students to their shops without them being formally apprenticed.14 This allowed the trainee to gain practical experience of treating patients without being obliged to spend several years doing the menial duties of an apprentice.15 Because of the rather ad hoc nature of resultant training, it is impossible to judge how much of the teaching recorded in university student note books was utilised in practice.16 The FPSG had fairly modest beginnings. When Peter Lowe returned from training as a surgeon in France in 1596, he took steps to set up the Faculty to protect the city from unlicensed practitioners.17 Glasgow was at that time only a small town, much smaller than Edinburgh, and it remained so until the early eighteenth century. Probably because of the small numbers, it was forced to incorporate physicians, surgeons, apothecaries and barbers from its inception. Basically it served the same function as the ICSE. The only difference was that holders of an MD degree were admitted without examination, although they were not allowed to practise surgery.18 Regular courses in anatomy were established in Glasgow University in 1714 by John Gordon. They were open to all who wanted to attend, both medical students and apprentices.19 Candidates for the examination for membership of the FPSG were also required to have a good knowledge of drugs.20 In 1793, the ICSE published the regulations for the conduct of the diploma examination, which they had established about 1770.21 After ensuring that the candidate knew about anatomy, surgery and bandaging, the examiners questioned him on botany, materia medica, chemistry, pharmacy and the uses of medicines. Finally, if the examiners were satisfied with the candidate’s knowledge of theory, he would be asked to prepare a drug from the Edinburgh Pharmacopoeia. If the examiners thought it necessary, the candidate could be also be asked to demonstrate an operation. The candidates were told some days in advance what the drug and/or the operation were going to be, so they could provide the ingredients for the drug or a subject for operation. Common sense suggests that demonstrating an operation was an option that was rarely used. It is difficult to see how a man could find someone at short notice, who was not only suffering from a specified disease but also willing to be used for demonstration purposes. These regulations are similar to those described for the FPSG.22 Although sitting an examination had always been necessary to become recognised as a surgeon or surgeon apothecary, it is impossible to judge the scope and rigor of those examinations.23 Even at the time, James Gregory (1753–1821), Professor of the Principles and Practice of Medicine cast doubt upon their value. He stated that some surgeons ‘will be grossly ignorant of their profession, of which perhaps they have never learned any more than just to pass their examination by means of a short catechism and even the little they may have learned … they never understood but got by rote’.24 This was not only a Scottish problem. De Moulin in his History of Surgery described an identical situation in the Netherlands in the eighteenth century.25 He concluded that examinations per se had done nothing to improve the standard of surgery. General Information from Probate Records This section sets out the results of a study of the probate records for the years 1700–99 for men who were described by their next-of-kin as surgeons or surgeon-apothecaries. Although probate inventories can give a misleading impression of total wealth, Margaret Spufford concluded that they ‘do provide an index of domestic comfort and consumption’.26 A. A. G. Bijdragen used such records to conduct a study of agricultural development, the distribution of wealth in communities and material culture.27 I start by discussing what probate was and describe the information provided by a general study of the records. Probate is the English term for the legal process of disposing of an individual’s property after death. In Scotland, where wills were termed Testaments, the equivalent term was proving the Testament. If the deceased had made a will, it was described as a Testament Testamentor. If there was no will, then it was a Testament Dative.28 The Consistory Courts were responsible for proving testaments in eighteenth-century Scotland, and all these records are held in the National Records of Scotland (NRS) in Edinburgh. Using the NRS’s website, I was able to trace 237 surgeons or surgeon-apothecaries whose testaments were proved between 1700 and 1799, of which 63 contained an inventory. Unfortunately, one of them was completely illegible and has been excluded from this study. The number of records and inventories for each decade of the century is set out in Figure 1. Fig. 1. Open in new tabDownload slide Number of records per decade. Longer lines = total number of records; shorter lines = those containing inventories. Fig. 1. Open in new tabDownload slide Number of records per decade. Longer lines = total number of records; shorter lines = those containing inventories. Probate records are essentially an account of the deceased’s financial status. In a few cases, probate was obtained by creditors because the deceased had died bankrupt. In a small number of others, there were amounts of money owed to the deceased in unpaid medical bills, but most of the records gave details of financial bonds.29 A major problem with probate records is that there was no legal requirement for anyone to make a will, and the majority of people died intestate.30 They probably did not apply for probate because the court fee was usually one-twentieth of the value of moveable property. As a result, probate records are available for only a minority of the population. This poses the question of how representative a sample the 237 records are. It is possible however to go some way to answering it. Roger Emerson researched the numbers of men who practised some form of medicine in the eighteenth century.31 He estimated that there were 1,400 medics who were trained without attending a university and another 1,259 who had spent time at a university without graduating.32 If the majority of that group were surgeons or surgeon-apothecaries, it means that there are probate records for roughly 10 per cent of them. Emerson commented that the most difficult group of medics to trace were surgeons trained solely through the apprenticeship system.33 As the probate records contain only two well-known names, they appear to have captured some of that group.34 Comparing the names in the probate records with those on the membership lists of the ICSE and the FPSG shows that only about a third of them were members of those organisations, (73 out of a total of 237).35 It is impossible to get accurate figures for the FPSG because their records for the years between 1682 and 1733 have not survived.36 However, as there are only two men with probate records from the Glasgow area between 1700 and 1732, it would not make a significant difference to the conclusion that most surgeons and surgeon-apothecaries practised without a license. The reason was almost certainly financial.37 Alexander Duncan, who wrote a history of the FPGC commented ‘doubtless not a few surgeons were prepared to run the risk of practising without a licence rather than pay a (license) fee they considered to be exorbitant’.38 The probate evidence strongly supports the conjecture that surgeons and surgeon-apothecaries provided the bulk of what could be described, albeit anachronistically, as ‘professional’ medical care. There were records for only 79 men described as physicians; 22 of them were from Edinburgh, 9 from Glasgow, 12 from Aberdeen and the rest from the Border Regions. The title apothecary had virtually disappeared from the records by the middle of the century. This applied not only to those who were described as surgeon-apothecary but also to the eighteen men who were described as apothecaries. The last probate record for an apothecary was dated 1742. The probate records show that the vast majority of surgeons and surgeon-apothecaries practised in the cities and towns of Lowland Scotland; 76 of the deceased came from Edinburgh and the surrounding areas (Figure 2). The chart contains the number of probate records dealt with by each Consistory Court, which covered the same geographical area as the pre-Reformation dioceses. Fig. 2. Open in new tabDownload slide Geographical distribution of probate records Fig. 2. Open in new tabDownload slide Geographical distribution of probate records Although the geographical spread of the names of surgeons and surgeon-apothecaries with probate records is wider than those in Wallis’ book, Eighteenth-Century Medics, there were still areas, especially in the Highlands, where there were no probate records for surgeons.39 John Dixon Comrie discussed the difficulties of travelling around the area, even after General Wade’s road building programme.40 This situation was similar to that in the rest of eighteenth-century Europe. Robert Heller showed that there was a Europe-wide shortage of rural medical practitioners at that time.41 He attributed this to poverty, ignorance and difficult travelling conditions. Guenter Risse agreed and like Heller, quoted studies that showed that peasants were much more likely to consult clergy or ‘wise women’.42 Probate Inventories The inventories were an evaluation of the deceased’s movable property, which took the form of cash, household goods, clothing, crops, animals and included books and surgical instruments. Land and the buildings on it were known as heritable property and always passed to the next-of-kin. Movable property could be divided up among relatives or sold off to pay the deceased’s debts. It was valued by someone with some expertise whose qualifications were noted. For example, the name of the bookseller, who estimated the value of the books, and the surgeon or apothecary, who valued the drugs. In many cases, it was the total value that was recorded rather than an itemised list, although this does give some indication of how wealthy that individual had been. Normally, it was the next-of-kin who applied for probate and was appointed executor. All sixty-two available inventories list at least some of the apparatus needed to dispense drugs. They included pestles (always spelt pistol or pistoll) and mortars, weighing scales, various types of bottles, jars and ointment pots. A few men owned stills. Drugs and the means to dispense them seem to have been standard equipment for the surgeon and the surgeon-apothecary. This is illustrated by two of the inventories, which contain detailed lists of the drugs found in the shops of a surgeon, William Carruthers of Lockerbie and a surgeon-apothecary, John Deans of Edinburgh.43 This evidence suggests that the practice of pharmacy was at least as important as operative surgery. I think it is reasonable to conclude that all surgeons and surgeon-apothecaries sold drugs, hence the relatively small number of apothecaries. The title druggist, used to describe those who made their living solely by selling drugs, does not start to appear as a job-description in probate records until the end of the century and does not occur with any frequency until after 1820. Twenty-one of the inventories stated that the deceased possessed operative surgical instruments, which were valued between 3s and £15 (see details in Appendix 1). Only 8 of the 21 inventories gave detailed lists of surgical instruments. The first inventory containing instruments was dated 1726. Between that date and 1755, there were 15 inventories listing instruments, and all but one of the surgeons had lived in Edinburgh.44 Between 1755 and 1796, there was a wider geographical spread with two surgeons from Glasgow, two from Fife and the last record, dated 1796, was of a surgeon who had practised in Doune. Although one man owed a large sum of money and another three of them had died in debt, the group as a whole had been wealthy judging by the contents of their houses. The question, which is vital for this study, is the absence of instruments from the other 41 inventories. There is a possibility that the instruments had been removed before the probate inventory was compiled. As most of them died intestate, investigating this is no longer possible. However in the next section, I will put forward evidence to show that this lack of instruments is probably a genuine finding. There was no correlation between the possession of instruments and the description of the individual as a surgeon or surgeon-apothecary. One of the men concerned was John Mc Gill, Professor of Anatomy in Edinburgh. His occupation was given as Professor. Seven others were designated surgeon-apothecary, and the remaining men were entitled surgeon. This provides further confirmation of the fact that there was no essential difference between the type of work done by surgeons and surgeon-apothecaries. The title appears to indicate where the man trained and nothing more. Twenty-seven of the inventories listed books and manuscripts.45 The details are given in Tables 1 and 2. The numbers of books and their values varied widely from 2s for ‘a few books’, which had belonged to James Hyslop, to a total value of £125 for books owned by John Mc Gill.46 As with instruments, they were usually associated with wealth. Those with few worldly goods had few, if any books. Five inventories contained large numbers of medical, scientific volumes and also books of more general interest. Three of them listed books in French. Unfortunately, it has not been possible to decipher all of their titles because of a combination of appalling handwriting and some rather unorthodox spelling, especially of Latin and French titles.47 As the handwriting in the originals did not vary for years, it suggests that the records may have been dictated; the clerk recorded phonetically what he heard. It is impossible to make any generalisations about surgeons leisure-time reading matter because their tastes in literature seemed to have been very varied. Chemistry and Natural History were the commonest non-medical scientific interests. Table 1. The names of the men whose probate inventories cited book titles Name Identification number inTable 2 Date of probate Reference number Charles Lumsden 1 1735 CC8/8/97 John Deans 2 1738 CC8/8/101 George Murray 3 1747 CC8/8/111 Andrew Main 4 1749 CC20/4/20 Alexander Rammage 5 1751 CC8/8/113 John Douglas 6 1752 CC8/8/114 John Smith 7 1760 CC9/7/63 Andrew Main 8 1767 CC8/8/120 William Anderson 9 1787 CC8/8/127 James McGill 10 1796 CC6/5/30 Name Identification number inTable 2 Date of probate Reference number Charles Lumsden 1 1735 CC8/8/97 John Deans 2 1738 CC8/8/101 George Murray 3 1747 CC8/8/111 Andrew Main 4 1749 CC20/4/20 Alexander Rammage 5 1751 CC8/8/113 John Douglas 6 1752 CC8/8/114 John Smith 7 1760 CC9/7/63 Andrew Main 8 1767 CC8/8/120 William Anderson 9 1787 CC8/8/127 James McGill 10 1796 CC6/5/30 Notes: The table includes the year the probate was obtained and the reference number of the National Records of Scotland. It also assigns an identification number for the surgeon/surgeon-apothecary which is used in Table 2. Open in new tab Table 1. The names of the men whose probate inventories cited book titles Name Identification number inTable 2 Date of probate Reference number Charles Lumsden 1 1735 CC8/8/97 John Deans 2 1738 CC8/8/101 George Murray 3 1747 CC8/8/111 Andrew Main 4 1749 CC20/4/20 Alexander Rammage 5 1751 CC8/8/113 John Douglas 6 1752 CC8/8/114 John Smith 7 1760 CC9/7/63 Andrew Main 8 1767 CC8/8/120 William Anderson 9 1787 CC8/8/127 James McGill 10 1796 CC6/5/30 Name Identification number inTable 2 Date of probate Reference number Charles Lumsden 1 1735 CC8/8/97 John Deans 2 1738 CC8/8/101 George Murray 3 1747 CC8/8/111 Andrew Main 4 1749 CC20/4/20 Alexander Rammage 5 1751 CC8/8/113 John Douglas 6 1752 CC8/8/114 John Smith 7 1760 CC9/7/63 Andrew Main 8 1767 CC8/8/120 William Anderson 9 1787 CC8/8/127 James McGill 10 1796 CC6/5/30 Notes: The table includes the year the probate was obtained and the reference number of the National Records of Scotland. It also assigns an identification number for the surgeon/surgeon-apothecary which is used in Table 2. Open in new tab Table 2. Summary of the books detailed in the inventories Identification number 1 2 3 4 5 6 7 8 9 10 Dispensatory and/or pharmacopoeia + + + + + + + + Book(s) on physic + + + + + + + + + Book(s) on fever + + + + + Boerhaave’s aphorisms + Boerhaave’s institutes + + + Book(s) on anatomy + + + + + Book(s) on surgery + + + Versalius De Fabrica + + + Book(s) on midwifery + + + Book(s) on botany + + + + Book(s) on chemistry + + + + Identification number 1 2 3 4 5 6 7 8 9 10 Dispensatory and/or pharmacopoeia + + + + + + + + Book(s) on physic + + + + + + + + + Book(s) on fever + + + + + Boerhaave’s aphorisms + Boerhaave’s institutes + + + Book(s) on anatomy + + + + + Book(s) on surgery + + + Versalius De Fabrica + + + Book(s) on midwifery + + + Book(s) on botany + + + + Book(s) on chemistry + + + + Notes: At the head of each column is the number assigned to the man in Table 1. The books are listed in the left-hand column. As there were often a number of books on the same topic by different authors, in most instances they have been grouped together to simplify the graphics. A + sign indicates that the man owned the at least one book of the type listed in the left-hand column. Open in new tab Table 2. Summary of the books detailed in the inventories Identification number 1 2 3 4 5 6 7 8 9 10 Dispensatory and/or pharmacopoeia + + + + + + + + Book(s) on physic + + + + + + + + + Book(s) on fever + + + + + Boerhaave’s aphorisms + Boerhaave’s institutes + + + Book(s) on anatomy + + + + + Book(s) on surgery + + + Versalius De Fabrica + + + Book(s) on midwifery + + + Book(s) on botany + + + + Book(s) on chemistry + + + + Identification number 1 2 3 4 5 6 7 8 9 10 Dispensatory and/or pharmacopoeia + + + + + + + + Book(s) on physic + + + + + + + + + Book(s) on fever + + + + + Boerhaave’s aphorisms + Boerhaave’s institutes + + + Book(s) on anatomy + + + + + Book(s) on surgery + + + Versalius De Fabrica + + + Book(s) on midwifery + + + Book(s) on botany + + + + Book(s) on chemistry + + + + Notes: At the head of each column is the number assigned to the man in Table 1. The books are listed in the left-hand column. As there were often a number of books on the same topic by different authors, in most instances they have been grouped together to simplify the graphics. A + sign indicates that the man owned the at least one book of the type listed in the left-hand column. Open in new tab Turning to the medical works, all but two of the inventories contained either a dispensatory or a pharmacopoeia. Some possessed both. This was by far the commonest type of book owned, and it is suggests that dispensing drugs was almost certainly an important source of income. Books on physic appear more frequently than those on surgery. Despite the popularity of Boerhaave in Scotland in the eighteenth century, more men owned copies of Shaw’s and Sydenham’s works. This however may be a reflection of the small number of inventories available for study. Sydenham’s works were owned by three men while four had Shaw’s.48 One man owned a copy of Hippocrates’ Opera, two had books by Cheyne and another two owned Riviere’s work. The two inventories from the end of the century, dated 1787 and 1796 respectively, contained copies of Cullen’s First Lines. Books on fever were also common and almost certainly an expression of the prevalence of infectious diseases in the eighteenth century. The emphasis on anatomical knowledge for the practice of surgery was reflected in the book titles, in that more men had books on anatomy than surgery.49 Paradoxically, it seems that the better equipped they were to practise surgery, the less likely they were to own a book on the topic. Of the five men who owned the instruments needed for high-risk surgery and whose book titles were listed, only two of them had books on surgery per se, although all five had books on anatomy. Three of the five had books on midwifery. Books on this topic do not appear in the probate inventories until 1760 and illustrate the growing trend in the eighteenth century for child birth to be conducted by a man-midwife or accoucher.50 Midwifery, like the ability to perform the more complex forms of operative surgery, needed extra training.51 Books seemed to be regarded as treasured possessions and kept indefinitely. This is evident from the fact that three men owned copies of the sixteenth-century De Humani Corporis Fabrica by Versalius, and two of them also possessed the seventeenth-century work, Ambrose Pare’s Livres de Chirurgie. While the contents of the bookshelves do give some information about what surgeons and surgeon-apothecaries read, probably the most significant fact is the absence of books from most inventories. This suggests that many surgeons and surgeon-apothecaries relied on experience, rather than book learning in their day-to-day practice. John Bell (1763–1820), a prominent Edinburgh surgeon, noted the limited education and lack of interest in science of many surgeons.52 Scotland was not unique in that respect. The lack of educational requirements for surgical trainees in France and Holland has also been documented.53 Surgical Training in Scotland in the Eighteenth Century In the following paragraphs, I present evidence that indicates that the lack of instruments in most inventories can be explained by the system of surgical training and practice in Scotland, during the eighteenth and at the beginning of the nineteenth centuries. While there is no one conclusive piece of evidence, there are enough pieces of the jigsaw to show the over-all picture. That picture depends on the fact that operative surgery is a manual skill. There is only one way to learn it—by doing it. It is impossible to acquire such skills by reading or watching someone else perform operations.54 If it is assumed that apprentices learned from their masters, then question arises, ‘Who trained the masters?’ It goes without saying that masters could not teach their apprentices a skill they did not have. Furthermore, even if they did possess that skill, without a large number of cases to practise on, there was no way the apprentice could learn. Although there must have been some variation between practices, given how few operations were done during the eighteenth century, it is difficult to see how any man trained solely under the apprentice system could learn how to do high-risk surgery like lithotomy or amputation.55 The problem of acquiring the necessary manual dexterity was solved by dissecting corpses. This had the additional benefit that the trainee learned detailed anatomy. It was generally agreed that anatomising was the best form of training.56 However, there were no proper facilities to teach that sort of anatomy in Scotland. The leading teachers of anatomy in Edinburgh were the three generations of Monros, and although the majority of medical students attended their courses, only Monro Primus was a surgeon.57 The Monros described operations while at the same time demonstrating them on corpses in front of a large crowd of students.58 For their lectures, they were usually only able to acquire about three bodies every year, and students were too far away to see the structures properly.59 This meant the Monros could not provide the specialised training needed for surgery.60 There was no doubt that Paris was the best centre in Europe to learn operative surgery, although by the end of the century, London was able to provide similar facilities.61 In 1749, John Moore wrote to William Cullen from Paris. In the letter, he described his training. He recalled how he had not only performed dissections but “had taken the courses of two celebrated surgeons, where under their inspection had performed every operation several times upon dead subjects particularly for the stone and some others which I have never performed on living persons”.62 This type of training needed money. Benjamin Bell (1749–1806), no relation of John Bell, asked his father for £150 to enable him to obtain it.63 Because it was so expensive, it was only available to a relatively small number of men, a fact supported by the probate records. All the men who possessed instruments had been wealthy, and the majority had lived in and around Edinburgh, which was the centre of the country’s affluence. There is other evidence that supports the generally poor standard of training in operative surgery in Scotland. In 1738, one of the arguments advanced for building an operating theatre in the Surgical Hospital was that if such an operating theatre were to be established, ‘how many thousands of pounds will be saved to our country in a few years which are now being spent in Leyden and Paris’.64 This argument would not have been accepted if Edinburgh had been capable of training all its own surgeons. When the Edinburgh Infirmary first opened in 1729, the only surgeon was Alexander Monro. He was soon joined by five others, and there were complaints that they charged excessive fees for apprentices.65 Rosaline Stott quoted a pamphlet complaining about the practice. In support of the claims made in the pamphlet, she cited the indentures of one such apprentice. The fee charged was twice the normal one.66 By 1748, the Infirmary in Edinburgh had established itself as a teaching hospital, and the managers of the hospital insisted that surgical dressers were appointed from men who had bought tickets to attend the hospital, not just the apprentices of a few surgeons.67 Being appointed to such a post was dependent on patronage and was only available to about 20 students every year.68 The dresser’s job was the basic care of the surgical patient. Their duties consisted of dressing the patients’ wounds, assisting at operations and were sometimes allowed to perform minor operations themselves.69 A letter from Benjamin Bell to his father suggests that it was possible to learn to operate that way, given sufficient time. ‘I must,’ he wrote ‘in order to acquire advantages of the same nature (as the training in Paris) and these not to the same perfection, remain in the Infirmary for six to eight years’.70 The reason was that even in a teaching hospital, only a very small number of operations were done.71 This lack of surgical training opportunities in Edinburgh was confirmed by an Austrian, Johann P. Frank, who visited the Edinburgh Infirmary in 1803. He commented that most students were spectators, except for a few clerks and dressers, and that no operations were performed by the dressers.72 There was no teaching hospital in Glasgow until the end of the eighteenth century.73 Edinburgh was a popular destination for any American students who could afford to travel to finish their medical education. They noted that while medical theory was well-taught in Edinburgh, London and Paris afforded better facilities for surgical training.74 At the end of the century, J. Johnson in his A Guide for Gentlemen wishing to Study in Edinburgh commented on the lack of cadavers available in Edinburgh.75 He went on to state that the shortage was only of interest to men intending to specialise in surgery and concluded that such men could acquire the necessary dissection practice in London or Paris. As late as 1803, when a French invasion was feared, John Thompson sought to have a professorship of military surgery established. He reasoned that ‘the army and navy … must be supplied with surgical officers from among young men educated in the Medical School in Edinburgh who, from the narrowness of their circumstances could not afford to attend the London Hospitals’.76 This argument would not have made sense if comprehensive surgical training was widely available to all trainees in Scotland. As his recommendation was accepted by the College of Surgeons, they evidently agreed with his assessment.77 The most forthright condemnation of the situation came from James Spence (1812–82), Professor of Surgery in Edinburgh. In a lecture on the history of surgery given in 1864, he described the teaching in Paris and London and continued, ‘Let us now inquire “what was the condition of the Edinburgh School of Surgery at the same period?” It was evidently a rhetorical question, because he went on, “It can scarcely be said to have existed. This may startle some of my hearers”’.78 He then explained that the Monros, especially Secundus and Tertius, were primarily anatomists and opposed the appointment of a dedicated professor of surgery. He added that proper surgical training only began to develop in Edinburgh at the beginning of the nineteenth century. In fact, the first private school of surgical anatomy was opened by John Bell, in 1790. He was forced to close it down in 1799 and to stop operating in the Infirmary, after an attack on him by a faction led by James Gregory.79 In response, John Bell defended himself by writing a book entitled Letters on the Training of a Surgeon and the Duties and Qualifications of a Physician, which includes numerous accounts of the deficiencies of the Edinburgh system and supports Spence’s arguments. While no doubt there were a few men with sufficient wealth and influence who may have been able to train in Scotland, there seems to be little doubt that for most of the eighteenth century, men aspiring to do the high-risk operations like lithotomy had to be able to find the money to study in London or Paris. So was the finding that only a minority of surgeons possessed instruments genuine? The evidence suggests that it is. In addition to the difficulties of obtaining necessary training, detailed earlier, the anonymous writer of a pamphlet entitled The History and Statutes of the Royal Infirmary of Edinburgh cited the regulations that were to be enforced by the hospital’s clerk when leasing instruments to surgeons.80 Those arrangements would not have been needed if all surgeons possessed their own instruments. In his Principles of Surgery, John Bell described how some practitioners referred patients to the Infirmary in Edinburgh because they felt that some operations were ‘too much for them to attempt’ as they were ‘ill-appointed with instruments or apparatus and unassisted’.81 In one inventory, expensive dispensing equipment and other valuables were present when the inventory was compiled. There seems to be very little reason for anyone to take instruments and leave other expensive equipment. There is some evidence that surgeons did not acquire instruments until they had been trained to use them. Richard Kay (1716–51), the son of a surgeon in Bury, kept a diary. In it, he described how, even though he made up medicines and generally helped his father in his busy practice, he was sent to London to learn surgery. He did not acquire instruments until he had finished that training nor did he do any operating himself.82 Kay’s experience supports the view that it was almost impossible to learn how to operate through the apprenticeship system. Another example comes from Benjamin Bell. He served an apprenticeship in Dumfries with James Hill (1703–76). We know the sort of cases he was seeing because, unusually, Hill published his experiences of 30 years of practice.83 In his book, Hill described the treatment of 88 skin cancers, 18 severe head injuries, a number of what he described as ‘hydatid cysts’ and some sebaceous cysts.84 There is nothing to suggest Hill did any of the high-risk operations like lithotomy. That means if Bell served a 5-year apprenticeship, he would have seen about a dozen skin cancers removed and two serious head injuries treated. Certainly Bell did not think his apprenticeship had provided him with the training he needed because as soon as he had finished that apprenticeship, he went to Edinburgh. Once there, he asked his father for the money to go to Paris. It was not until he returned from Paris that he set himself up in practice as a surgeon. The feud between John Bell and parts of the medical establishment in Edinburgh has already been referred to. It was part of an on-going struggle between the Incorporation of Surgeons, the Managers of the Infirmary and the University.85 A man writing under the pseudonym Jonathon Dawplucker put forward his own ideas on surgical training.86 In his book, Bell responded by deploring the training methods being suggested. The interesting thing about some of Bell’s responses was that he recognised the type of individual Dawplucker was denigrating. Rather than refuting the allegations being made about such men, he sought to explain them: Those young men whom you upbraid as with wilful incapacity and want of zeal, are born in ignorance the sons and relatives of surgeons, they have their little knowledge by inheritance and their trade by their birth right. Educated in the duties of the shop and the labours of the mortar, they are, at the end of their apprenticeship, at two and twenty years of age taught to run about the streets and call it practice … they inherit their father’s patients, their father’s alliances, their father’s propensities and like yourself, they most willingly barter all pretentions to learning or reputation for DAILY BREAD.87 It is clear from Bell’s descriptions that such apprentices were not being taught operative surgery. The picture he paints is almost certainly accurate because most apprenticeships were arranged through a man’s family and their connections.88 It is also supported by the examination regulations that stipulated that the only practical demonstration required from candidates was the preparation of some form of medication. De Moulin, writing about the situation in the Netherlands, has shown that surgeons trained solely under the apprenticeship system survived well into the nineteenth century, especially in rural areas. In Holland, they were barber surgeons, and we know what the procedures they were able to do because the instruments they were obliged to have were stipulated by law. They were tourniquets, basic suturing materials and catheters. In other words, they did not have the equipment needed for high-risk operative surgery, such as amputation and lithotomy.89 A similar situation existed in nineteenth-century France where officers de sante provided health care, especially in rural areas.90 They were allowed to practise after 4 years of study as an apprentice or after an attachment to a peripheral hospital. They too were forbidden by law to carry out major surgery, unless a fully trained surgeon was present.91 Given the close cultural ties between France, the Netherlands and Scotland, it is likely that surgical practices were similar in both countries.92 That similarity is re-enforced by the fact that, at the other end of the social scale, in both the Netherlands and Scotland, there were instances of physicians trained to do operative surgery.93 Adding this evidence to the lack of instruments in the probate inventories indicates that many of the men who called themselves surgeons were neither trained nor equipped to do operative surgery. It would be almost impossible to demonstrate this phenomenon in Scotland without the use of probate records for three reasons. Firstly, because surgical practice was not governed by statute law, there are no official records of the duties surgeons were expected to perform. Secondly, most surgeons had no connections to the elite groups controlling the ICSE, FPSG, the Infirmary and the universities. As a result, neither they nor their workloads appear in any of the official records of those organisations.94 And, as both Helen Dingwall and Catherine Crawford noted, ‘legal scrutiny of a patient-practitioner encounter was a relatively rare occurrence’, which makes court records too unsuitable for the investigation of the entire body of surgeons.95 Surgical Practice in Scotland in the Eighteenth Century The previous section has shown how only a small, elite group of surgeons had the equipment and training needed to undertake high-risk operations. So, the question remains, what did most surgeons actually do in order to make a living? In what follows, I will attempt to make an assessment of their work. In order to give some idea of the type of illnesses they were called upon to treat, I start with a brief discussion of the type of diseases which were common during the eighteenth century. I continue with one of the few records of the day-to-day activities of a medical practitioner working outside of a hospital, namely, the case book of a man who practised in Dalkeith between 1733 and 1735.96 This will be followed by a discussion of contents of the account books of three Scottish surgeons, William Cullen (1713–1790), David Wishaw of Thornhill near Dumfries and James Steedman of Kinross.97 That discussion will be supplemented with references to 51 accounts sent by 26 surgeons to whoever they regarded as responsible for their payment. As analysing the drugs they list would need a separate study, this article will concentrate on the procedures they contain. There seems to be little doubt that during the eighteenth century, the majority of deaths in Scotland would now be classified as infectious diseases of one sort or another.98 The health of any population is dependent on its diet, and T. C. Smout has documented the increased mortality rates associated with bad harvests in Scotland.99 Malnutrition and the spread of epidemics meant that the incidence of disease varied from time-to-time even in the same area. One common cause of epidemics was smallpox. While inoculation against the condition was theoretically possible, when introduced, it was an expensive and risky procedure but by the end of the century could be afforded by many people.100 Steedman’s accounts support this fact, recording one vaccination done in 1790 and the vaccination of four children 1794. There is also a letter, dated 1780, from a surgeon in Rannoch to the local authorities requesting payment for vaccinating ‘14 or 15 poor children’.101 As expected, the commonest conditions recorded by the Dalkeith practitioner were infectious diseases. He noted epidemics of small pox, ‘chin cough’ and scarlet fever.102 He also commented on patients who had over-indulgenced in alcohol and diagnosed others as infested with worms.103 His usual treatment was bleeding, and he routinely used purgatives and emetics. One noticeable feature was that on two occasions, the patient arrived having already been bled by a gardener.104 There were only three patients who needed what would now be termed surgery. One was a boy who had fallen from a horse and fractured his arm, and two others had abscesses that were treated by surgeons. They used cataplasms until the swelling ruptured spontaneously.105 He also recorded two patients with bladder stones causing retention of urine, both of whom died, although neither was operated on. A woman with ascites was referred to Alexander Monro for tapping. If this account is in any way typical, then the only operative surgery that was being done was minor, and the only procedure that carried any risk was referred to Alexander Monro Primus.106 Turning to the accounts and the account books, they listed the medicines supplied and the procedures performed but, unlike the case book, did not usually give a diagnosis. They often included drugs supplied to several family members and the family’s servants. The drugs were essentially the same as those listed in the probate inventories. None of the accounts or account books make any reference to an operation. Most surgeons were probably not tempted to try them because of their high failure rate.107 The accounts and account books have several features in common, including the reluctance of some patients to settle their bills, which was just as common in the eighteenth century as it had been during the seventeenth.108 The most striking feature, to modern eyes, is that there was there no distinction made between human and veterinary medicine. Surgeons treating the gentry were also expected to treat their horses and dogs. Examples include a surgeon who sent a bill to the Marques of Tweeddale for the treatment of ‘two worried sheep’.109 William Cullen prescribed Theriac, not only for the Duke of Hamilton but also his horses. Anyone employing servants was regarded as having a duty to pay for any treatment they needed, although the number of medicines prescribed were almost invariably fewer and cheaper than those given to family members. Conspicuous by their absence are leg ulcers. Although they were very common at the time, they do not appear in any of the accounts.110 Despite the large number of cases of venereal disease which were treated in the Infirmary, there was only one case recorded in the community and that was a man treated by the Dalkeith practitioner.111 The patient was eventually cured by a long course of mercury administered by an Edinburgh surgeon. Also contrary to what might have been expected, trauma rarely featured in the accounts.112 Only two fractures were recorded, the arm fracture in the Dalkeith practitioner’s case book and a compound fracture of the tibia in James Steedman’s accounts book.113 Both fractures were caused by falls from horses. James Steedman treated a wound on James Watson’s arm, a dog bite, a burned foot, a bruised toe and sent a bill for ‘dressing a sword wound on the back of the apprentice to William Wilson’. Apart from the fracture, they were the only trauma cases recorded over a period of almost 40 years. David Wishart treated two cases in 4 years. One was a head wound that was sutured, and the other was recorded as ‘dressing of wounds’. What the wounds were, he did not say. There is no record of William Cullen treating trauma. There were also a few bills sent to patients requesting payment for the treatment of their trauma. The most severe injuries were the facial lacerations sustained by Donald Douglas in 1772, which required suturing.114 George Langlands sent a bill to Robert Blackwood for (among other things) curing a wound on Jeannie Blackwood’s toe and Patrick’s head. The bill remained unpaid from August 1727 to August 1737.115 Another surgeon demanded settlement of a bill for the treatment of a head injury sustained in an accident on a farm.116 This suggests that the relatively high incidence of trauma previously reported may have been a feature of time and place.117 The evidence contained in the accounts, and the account books confirm that surgeons and surgeon-apothecaries derived their income by selling drugs (and presumably advice) for what would now be termed medical conditions. This is in keeping with what was stated at the time. The most famous quotation comes from Adam Smith, who maintained that the surgeon was ‘the physician to the poor in all cases and of the rich when the distress and danger is not too great’.118 This emphasis on what would now be considered medical conditions was reflected in the large number of books on physic listed in the probate inventories. As it applies to the majority of collections, it is unlikely to be a coincidence and must surely say something about the nature of their practice. Treatment of medical conditions had a surgical aspect in the form of blood-letting and similar procedures. Gunter Risse investigated the practices at the Edinburgh Infirmary. Using student note books as his source, he listed a total of 1,211 physical procedures carried out on 880 patients between 1771 and 1799.119 As hospitals at that time excluded contagious diseases and patients thought to be incurable, Risse’s figures are unlikely to be a completely accurate reflection of diseases in the community, but the contents of the inventories and the accounts suggest that these minor, physical procedures were practised widely.120 The commonest procedure mentioned by Risse was bloodletting, and lancets were by far the commonest instrument in the inventories, with eight listing them. If the blood-letting was to be confined to an inflamed area of the body, a process known as scarification was carried out. Three men had owned scarifiers.121 Other treatments were cupping (one man owned cupping glasses), the application of plasters (equipment in two inventories), the use of a machine to apply an electric current to weak or paralysed muscles (two men had the equipment) and catheterisation (one man had owned a catheter). A more invasive treatment was paracentesis, and two inventories included the trocars needed. Although Risse’s list included the use of a sweat box, it was not recorded in any of the inventories. The list also mentioned blistering, creation of an issue, insertion of a seton, head shaving, bathing, fomentation, friction and arterial compression, but as these procedures did not need special equipment, they would not have appeared in any of the inventories. Blistering and bleeding were by far the commonest procedures recorded in the accounts and account books.122 Both were done frequently by many surgeons, and they were often repeated in a week or so, if the patient had not recovered. James Steedman used leeches on one occasion. Tooth extraction was another common procedure.123 This was done by both Steedman and Wishart. Steedman also recorded the use of cupping glasses on one patient and carried out scarification on two others, for a whitlow and ‘on your wife’s breast’. He also catheterised two female patients. There is no record of the use of electrical machines or trocars. Cullen did not do any bleeding or tooth extractions. The evidence suggests that in rural areas, surgery was not always a full-time job because some rural practitioners had other occupations. Farming was by far the most common by-employment, with 10 inventories listing farming equipment. The probate records also cite John Robertson working as a tacksman (land agent) on Islay, Lachlan Campbell from Campbelltown, as a surveyor of customs and James Naismith from Hamilton was post master.124 David Wishart’s account book provides another example of diversification. In his shop, he not only sold drugs, bled patients and extracted teeth but also traded various non-medical items. These included soap, candles, buttons, nails, bread and ribbon. The situation was not confined to Scotland. Margaret Pelling analysed the records for the town of Norwich in the seventeenth century and noted the diversity of trades associated with barber surgeons. She also noted the variations in their life styles and the fact that many of them did not take out their ‘freedom’ when they finished their apprenticeships, i.e. they did not join the relevant regulatory body.125 She suggested that the reason for this was financial. In Holland, where most surgeons were barber-surgeons, it was barbering that provided many of them with their day-to-day income.126 The separation of the Surgical Incorporation from the Barber-Surgeons in 1722 is usually presented as an advance for surgical practice, (which it was) but the evidence from the Netherlands suggests that it may have removed a source of regular income from some surgeons.127 To summarise, the evidence from the accounts and account books supports that from the probate records and suggests that most surgeons earned their livings by treating medical conditions. Some supplemented their incomes by other means, often farming. Minor physical procedures like blood-letting, blistering and tooth extraction were common, but the evidence strongly suggests that very few surgeons did the high-risk procedures, such as lithotomy and amputation. Conclusion As De Moulin pointed out, the results of evaluating surgical practice in any period will differ depending on whether one focuses on its prominent exponents or the rank and file.128 The latter group have always been the larger, and as a result, their activities are more representative of the usual practices for the time in question. Much of the evidence for Scottish surgical practice in the eighteenth century has come from the relatively few accounts of ‘Great Men’, but probate records show that they were the minority of surgeons and surgeon-apothecaries. Scotland was not unique in this respect. The situation there was similar to that in France and the Netherlands (and probably the rest of Europe) until well into the nineteenth century.129 The modern idea of a surgeon as someone who does operations simply did not apply to most surgeons during the eighteenth century. The distorting feature has been produced by the available historical sources. Apart from a few personal papers, scattered around different archives, they are mostly records of elite groups attached to the ICSE, the FPSG.130 Because the activities of such elites are documented, the tendency is to regard them as the rule rather than the exceptions they usually were. In Edinburgh, another factor was the excellent medical training which its university provided. This means that the difficulty of obtaining surgical training there in the eighteenth century has tended to be overlooked. If that is taken into account, a different picture emerges. The evidence suggests that most surgeons or surgeon-apothecaries had the sort of practice that would have been familiar to the old-fashioned general practitioners of the late nineteenth and early twentieth centuries. Acknowledgements The author thanks Professor Matthew Eddy, Department of Philosophy, Durham for reading the early drafts of the manuscript and for his helpful suggestions. My thanks also to the archivists working in the NRS, the Royal Colleges of Physicians and Surgeons in Edinburgh, the Special Collections in Edinburgh University Library and the Wellcome Library in London. Footnotes 1 Andrew Wear, ‘Early Modern Europe’, in Lawrence Conrad et al., eds, The Western Medical Tradition: 800 BC to AD 1800 (Cambridge: Cambridge University Press, 1995), 232. 2 Christopher Lawrence, Companion Encyclopaedia of Medicine, W. F. Bynum and Roy Porter (eds) (London: Routledge Press, 1993), 970 3 Rosemary O’Day, The Professions in Early Modern England (Harlow: Longmans, 2000), 20–21. 4 Men who were described as physicians or apothecaries were excluded, as were the 21 army and navy surgeons. The reason to exclude the latter group was that their practice was significantly different from that of civilian surgeons. Military surgeons spend their time looking after young, fit men, unless they happen to find themselves in a war zone. During the eighteenth century, the mortality rates among the crews of Royal Navy ships were lower than men on shore. 5 During the eighteenth century, French surgery was generally regarded as the best in the world, so wealthy, aspiring surgeons went to Paris to train. If their parents could afford it, Scottish students of medicine also studied at the University of Leiden in Holland. Edinburgh’s Medical School had been founded by such men. Alexander Monro Primus, for example, studied in both Leiden and Paris. See Toby Gelfend, The Professionalizing Modern Medicine: Paris Surgeons and Medical Science and Institutions in the Eighteenth Century (Westport, CT; London: Greenwood Press, 1980), 31; Christopher Lawrence, ‘Ornate Physicians and Learned Artisans: Edinburgh Medical Men 1726–1776’ in W. F. Bynum and Roy Porter, eds, William Hunter and the Eighteenth Century Medical World edited by (Cambridge: Cambridge University Press, 1985), 153. 6 Daniel De Moulin, A History of Surgery with Emphasis on the Netherlands (Dordrecht Boston Lancaster: Kluwer Academic 1988), xviii. De Moulin cites lithotomy and amputation as examples of major surgery performed during the eighteenth century. De Moulin, although he is now a Professor of Medical History at Nijmegen University began his career as a surgeon, so is qualified to make this assessment. 7 Michael Barfoot, ‘The 1815 Act to Regulate Mad Houses in Scotland: A Re-interpretation’, Medical History, 2009, 53, 57–76 8 Helen Dingwall, A Famous and Flourishing Society (Edinburgh: Edinburgh University Press, 2005), 68–71. 9 John Dixon Comrie, History of Scottish Medicine (London: Balliere, Tindall and Cox, 1932), 93. 10 The Apothecaries Guild continued to exist for those who practised pharmacy alone. 11 Rosaline M. Stott, ‘The Incorporation of Surgeons and Medical Education 1696–1755’ (unpublished PhD thesis, University of Edinburgh, 1984), 20–21. 12 Quoted by Stott, ibid., 101. 13 Lisa Rosner, Medical Education in an Age of Improvement (Edinburgh: Edinburgh University Press 1991), 87. 14 James Rymer, An Essay on Medical Education with Advice for Young Gentlemen Who Go into the Royal Navy as Surgeons’ Mates (London: R. Snagg and T. Evans, 1776). 15 Stott, ‘The Incorporation of Surgeons’, 174. 16 Rosner, Medical Education, 12. 17 Johanna Geyer-Kordesch and Fiona Macdonald, Physicians and Surgeons in Glasgow: The History of the Royal College of Physicians and Surgeons of Glasgow 1599–1858 (London: Hambledon Press, 1999), 4. 18 Alexander Duncan, Memorials of the Royal College of Physicians and Surgeons 1682–1850 (Glasgow James MacLehose and Sons: 1896) Available online through the College’s web site, www.rcpsg.ac.uk (Consulted July 2017). 19 Geyer-Kordesch and Macdonald, Physicians and Surgeons in Glasgow, 215. 20 Ibid., 203. 21 Laws and Regulation of the College of Surgeons (Edinburgh: William Smellie, 1793). See also Dingwall, A Famous and Flourishing Society, 115–16. 22 Geyer-Kordesch and Macdonald, Physicians and Surgeons in Glasgow, 193. 23 Dingwall, A Famous and Flourishing Society, 115–6. 24 Quoted by John Bell in Letters on the Education of a Surgeon and the Duties and Qualifications of a Physician (Edinburgh: Longman Hurst, Reece and Orme, 1810), 284. 25 De Moulin, History of Surgery, 160. 26 Margaret Spufford, ‘The Limits of Probate Investigation’, in J. Chatres and D. Hay, eds, English Rural Society 1500–1800: Essays in Honour of Joan Thirsk (Cambridge: Cambridge University Press, 1990), 145. 27 A. A. G. Bijdragen, Probate Inventory: A New Source of Study of Wealth, Material Culture and Agricultural Development (Utrecht: HES Publications, 1980), 2. 28 Taken from the official web site of the National Records of Scotland: http://www.scotlandspeople.gov.uk/guides/wills-and-testaments#Background information (accessed 18 May 2019). 29 S. G. Checkland, Scottish Banking: A History 1695–1973 (London, Glasgow: Collins, 1975), 7 explains the origin and significance of bonds. In the chapter, Checkland described the situation before banks were established. Anyone with money which they wanted to invest could loan it to another individual who had land to use as security. As land always passed to the next-of-kin the bonds were known as a Heritable Bonds. Such bonds were often registered with lawyers who may have been responsible for negotiating the loan. The bond served as a source of income because the holder of the bond was paid interest, as well as an incremental return on their capital, rather like a modern mortgage. 30 See note 28. 31 Roger L. Emerson, ‘Numbering the Medics’, in Essays on David Hume, Medical Men and the Scottish Enlightenment (Farnham, Burlington: Ashgate Publications, 2009), 173 for the non-university-trained surgeons and 169 for those who did a university course but did not graduate. 32 Those who had an MD degree practised as physicians and were not included in the study. 33 Emerson, ‘Numbering the Medics’, 170. 34 John Mac Gill (1660–1734) and John Monro (1670–1740). 35 The list of members was supplied by the Librarian of the Royal College of Surgeons of Edinburgh and the comparison was made from 1649 because any man with a probate record in the early eighteenth century was likely to have become a member in the previous century. 36 Duncan, Memorials of the Royal College of Physicians and Surgeons, 19. 37 The fee for admission to the Incorporation of Surgeons in Edinburgh was £5 at the beginning of the century. By the end of the century, it had risen to £43-6s-8d. In Glasgow, the entrance fee was 5 guineas for a surgeon trained in the city and 15 for another trained elsewhere. In 1783, this was raised to 25 guineas, and in 1789, it became 50 guineas. 38 Duncan, Memorials of the Royal College of Physicians and Surgeons, 99. 39 P. J. and R. V. Wallis, Eighteenth Century Medics (Newcastle-upon-Tyne: Project for Historical Biography 1988). The Wallis searched 80,000 documents like apprenticeship records and book subscriptions and recorded the names of medics who practised in the eighteenth century. Roger Emerson in ‘Numbering the Medics’ showed that the Wallis’ list is an underestimate. 40 Comrie, History of Scottish Medicine, 224. 41 Robert Heller, ‘Priest Doctors as a Rural Health Service in the Age of Enlightenment’, Medical History, 1976, 20, 361–83. 42 Guenter Risse, ‘Medicine in an Age of Enlightenment’, in Andrew Wear, ed., Medicine in Society: Historical Essays (Cambridge: Cambridge University Press), 187. 43 Carruthers CC5/6/10; Deans CC8/8/101. 44 The exception came from Fife. 45 It should be noted that the date of the probate record is related to the date of the man’s death. It gives no indication of when a book was published or how long the man had owned it. 46 James Hyslop CC20/4/15 John McGill CC6/5/30 47 For example, the author of De Corporis Humanis Fabrica was named as Vassilly, (Versalius). 48 Sydenham was owned by John Deans CC8/8/101, George Murray CC8/8/111, John Smith CC9/7/63 and William Anderson CC8/8/113. Shaw was owned by John Deans, John Smith, James McGill CC6/5/30 and Alexander Rammage CC8/8/113. 49 Andrew Cunningham, The Anatomist Anatomis’d:The Experimental Discipline in Enlightened Europe (Farnham Burlington: Ashgate Publications, 2000), 83–84. 50 Roy Porter, ‘The Eighteenth Century’, in Lawrence I. Conrad et al., The Western Medical Tradition (Cambridge: Cambridge University Press, 2005), 429. 51 Ibid., 430. 52 Bell, Letters on the Education of a Surgeon, 286. 53 R. Heller, ‘Officers de Sante: the Second Class Doctors of Nineteenth-Century France’, Medical History, 1978, 22, 25–43, esp. 38. 54 The horrific results of attempting to do so are described in John Bell’s book, Letters on the Education of a Surgeon (Edinburgh: Longman, Hurst, Reece and Orme) , 561. 55 Roy Porter, The Greatest Benefit to Mankind (London: Fontana Press, 1999), 277. 56 Cunningham, The Anatomist Anatomis’d, 83–84. 57 Rosner, Medical Education, 47. 58 J. Johnson, A Guide for Gentlemen Studying Medicine at the University of Edinburgh (London: Robinsons, 1792), 11. 59 Bell, Letters on the Education of a Surgeon, 579. 60 Porter, The Greatest Benefit to Mankind, 291. 61 Benjamin Bell in a letter to his father dated 19 January 1771 stated that ‘To be sure, medicine is taught in greater perfection in Edinburgh than in any other part of Europe … but there are some particular branches which are to be had in Paris and nowhere else and which cannot possibly be got in Edinburgh and particularly with regard to surgery’. The Life, Character and Writings of Benjamin Bell by His Grandson, B. Bell (Edinburgh: Edmonston and Douglas, 1868), 23. 62 Glasgow University Library, Special Collections MS Cullen, 91. 63 To put this figure into some sort of context, a naval surgeon earned £5 per month for the whole of the eighteenth century. N. A. M. Rodger, The Command of the Ocean: A Naval History of Britain (London: Allen Lane, 2004), 623. 64 Quoted by Stott in ‘The Incorporation of Surgeons’. 65 Dingwall, A Famous and Flourishing Society, 97. 66 Stott, ‘The Incorporation of Surgeons’, 155. 67 P. M. Eaves Wilson, ‘The Early Years of the Infirmary’, in R. G. W. Anderson and A. D. C. Anderson, eds, The Early Years of the Edinburgh Medical School (Edinburgh: Scottish Museum, 1976), 77–78. 68 In his letter to his father dated 19 January 1771, Benjamin Bell gave his father a list of men to approach to secure his appointment. GUL, MS/Cullen is a letter to Cullen from a pupil’s father asking Cullen to exert his influence of his son’s behalf to secure a job in the Infirmary. 69 It is impossible to decide from Walton’s account what was meant by minor surgery but a similar regulation at the Newcastle-upon-Tyne Infirmary makes it clear that minor surgery was blood-letting, the insertion of setons and ‘cutting an issue’. George Haliburton Hume, The History of the Newcastle Infirmary (Newcastle-upon-Tyne: Andrew Reid, 1906), 100. 70 Bell, The Life, Character and Writings of Benjamin Bell, 24. Bell estimated he could get the same training in 6 months in Paris. 71 Porter, The Greatest Benefit to Mankind, 360. Guenter Risse, Hospital Life in Enlightenment Scotland: Care and Teaching at the Royal Infirmary Edinburgh (Cambridge: Cambridge University Press 1986), 170. 72 Quoted by Risse, ibid., 273. 73 Andrew Kent, An Eighteenth-Century Lectureship in Chemistry (Glasgow: Glasgow University Press, 1976), 104. 74 J. Rendell, ‘The Influence of the Edinburgh Medical School on America in the Eighteenth Century’ in The Early Years of the Edinburgh Medical School, 331. 75 Johnson, Guide, 12. 76 John Thompson, William Thompson and David Craigie, ‘Life of John Thompson’, in John Thomson and William Thomson, Life, Lectures and Writings of William Cullen, Part 2 (London, Edinburgh: Blackwood, 1859), 22. Emphasis added. Thompson was eventually secured the post for himself. 77 Ibid., 27. 78 James Spence, ‘The Edinburgh School of Surgery: an Introduction', Edinburgh Medical Journal, 1864, 10, 483–97, 487. 79 E. W. Walls, ‘John Bell 1763–1820’, Medical History, 1964, 8, 63–69. 80 The History and Statutes of the Royal Infirmary of Edinburgh (Edinburgh: Thomas and Walter Ruddiman, 1749), 40. In order to lease the instrument, the hirer was to hand over the value of the instrument plus one twelfth of its value. If the instrument was returned in good condition, the cost of the instrument was returned to the borrower and the Infirmary kept the twelfth of its value. If the user damaged the instrument, then he kept the instrument and the Infirmary kept the money. There is a second edition of this pamphlet dated 1778, which does not include the rules and regulations to be followed by the various members of staff. 81 John Bell, Principles of Surgery, vol 3 (London: Longman, Hurst, Rees and Orme, 1808), 294. 82 Richard Kay, The Diary of Richard Kay 1716–1751, W. Brockbank and F. Kenworthy (eds) (Manchester: Manchester University Press), 88. 83 This practice was very unusual during the eighteenth century. This can be demonstrated by studying the names and publications of the students who attended William Cullen’s chemistry courses. Of the 530 men listed, only 26 went on to publish their experiences, less than 5 per cent. 84 James Hill, Cases in Surgery Particularly of Cancers and Disorders of the Head from External Violence. To Which is Added an Account of the Sibbens (Edinburgh, 1772). 85 Dingwall, A Famous and Flourishing Society, 97–104. 86 Walls, ‘John Bell’, 66. It was thought at the time that James Gregory may have been responsible, although Gregory always denied it. In his paper, Walls speculated that one of Bell’s assistants, John Barclay was responsible. 87 Bell, Training of a Surgeon, 286. Block capitals: Emphasis in Original. 88 O’Day, The Professions in Early Modern England, 224. 89 De Moulin, History of Surgery, 207. 90 Heller, ‘Officers de Sante’, 31. 91 Ibid., 29. Gustave Flaubert was the son of an officer de sante so he knew how the system operated. In Madam Bovary, he described the results of a minor procedure done by Monsieur Bovary, which went wrong. As a result, the patient needed to have his leg amputated. Bovary had to send for a surgeon to do the operation. 92 Helen Dingwall, Physicians, Surgeons and Apothecaries: Medical Practice in Seventeenth-Century Edinburgh (East Lothian: Tuckwell Press, 1995), 237. 93 De Moulin, History of Surgery, 163. In his key-note lecture to the British Society for the History of Medicine in September 2017, What Was Different about Eighteenth-Century Scottish Medicine, Professor Malcolm Nicholson discussed two Scottish physicians who were skilful operators. 94 The exceptions were men who had been accused of malpractice, but those cases also were too few to draw any general conclusions. 95 Catherine Crawford, ‘Patient’s Rights and the Law of Contract in Eighteenth-Century England’, Social History of Medicine, 2000, 13, 381–94, quotation from page 381; Helen Dingwall, ‘“General Practice” in Seventeenth-Century Edinburgh: Evidence from the Burgh Court’, Social History of Medicine, 1993, 6, 125–42, esp 137. 96 National Library of Scotland MS 3774. The man’s identity is unknown. 97 Royal College of Physicians, MS Cullen 34. Cullen’s accounts cover the years 1737–1741 when he was working as a surgeon in HamiIton. In 1740, he obtained his MD, which meant that he was qualified as a physician even though the nature of his work did not change. David Wishart’s books are held by NRS, CS96/1301 and cover the years 1785-86. James Steedman’s book is in the Wellcome Library, MS 4702 and covers the years 1758–1827, although it was only searched until the end of 1799. It is unlikely that one man worked for 69 years, but there are at least four different handwritings in the book. 98 Michael Finn et al., Scottish Population History: From the Seventeenth Century to 1930s, Michael Finn, ed. (Cambridge: Cambridge University Press, 1977), 289–95. 99 T. C. Smout, ‘Famine and Famine Relief in Scotland’, in T.C. Smout and L.M. Cullen, eds, Comparative Aspects of Scottish and Irish Social History 1600–1900 (Edinburgh: John Donald, 1977), 21–22. 100 Deborah Bruton, ‘Smallpox Inoculation and Demographic Trends in the Eighteenth Century’, Medical History, 1992, 36, 403–29, 404. 101 NRS E788/11. The letter explains that he had gone ahead without authorisation because there was an epidemic and a delay might have been fatal. 102 Chin cough is the Scottish term for whooping cough or pertussis. 103 Between 1783 and 1785 there were eight patients admitted to the Infirmary in Edinburgh with a diagnosis of worms, so it seems to have been relatively common. Treatment for worms occurs in James Steedman’s accounts. All the patients were children. 104 It was the usual practice during the eighteenth century for gardeners to bleed patients who felt they needed it but could not afford a surgeon’s fees. See the pamphlet, Information for James Calder, gardener in Glasgow, against Robert Wallace, collector to the Faculty of Physicians and Surgeons in Glasgow 1761 105 Opening the abscess was thought to introduce infection, Risse, Hospital Life in Enlightenment Scotland, 140 106 Oxford Dictionary of National Biography. In the eighteenth century, the trocar was sometimes inserted into the centre of the abdomen, which meant there was a significant risk of bowel perforation. 107 A. B. Shaw, ‘The Norwich School of Lithotomy’, Medical History, 1970, 14, 221–59. In a footnote on page 238, Shaw quoted a paper by A. C. Hutchinson, written in 1830, which noted that some Scottish surgeons refused to do lithotomy in case their reputations suffered in the event of failure. He also recorded that about half of the 200 lithotomies performed in 1820 were done in London. 108 Dingwall, ‘"General Practice” in Seventeenth-Century Edinburgh’, 128. Richard Somner waited for 3 years for the Marquis of Tweeddale to settle his bill for £30. NRS, GD110/976 is a request to man to settle the bill for his grandfather’s treatment. GD 136/1206 letter to William Sinclair for requesting settlement of account for £35. GD 38/1/767 William Spence, surgeon in Dunkeld sued Thomas Stewart for £21-8s (Scots pounds). GD 40/8/396 Account to the Marquess [sic] of Lothian from June 1729 to February 1731. Total amount was £24–12s-9d. Paid through Robert Hepburne, writer to the signet. The Duke of Hamilton never paid William Cullen for medicine supplied for himself, his family, horses and dogs; he died owing Cullen about £70. GD 150/3294 Between 1763 and 1775, James Watson and his family ran up a bill for £180 to James and Robert Kirklands of Gogar. They eventually paid in cash and bonds. In 1775, there was an account from another surgeon, William Brown for £2-2s. There is no record of any payment. 109 National Library of Scotland MS 1462. This phenomenon was noted in English practice, see E. M. Sigsworth and P. Swan, ‘An Eighteenth-Century Surgeon and Apothecary: William Elmhirst (1721–1773)’, Medical History, 1982, 26, 191–98. 110 I. S. Loudan, ‘Leg Ulcers in the Eighteenth and Early Nineteenth Century’, Journal of the Royal College of General Practitioners, 1981, 31, 263–66, esp 263. 111 The Edinburgh Infirmary record books were searched from 1783 to 1785. 112 NRS GD 51/16/73 is an account submitted to the government by Alexander Walker of Haddington, who sent his apprentices to dress the wounds of those injured after the battle of Prestonpans. He also treated a few of the wounded who had made their own way to Haddington. In addition, he asked for £130 for his care of the ‘great number of sick left at Haddington when the army marched to Culloden and furnishing them with medicines and provisions for a long time’. These experiences were obviously exceptional. 113 He treated the fracture conservatively, and the patient recovered quickly. 114 NRS GD 136/1092. 115 NRS SC 39/112/7. 116 NRS GD 1/755/22. 117 Dingwall, ‘"General Practice” in Seventeenth-Century Edinburgh’, 129; Hill, Cases in Surgery, 85–164. 118 Adam Smith, An Inquiry into the Nature and the Wealth of Nations (London: Routledge, 1946), 87. 119 Risse, Hospital Life in Enlightenment Scotland, 203. 120 Ibid., 203. 121 For a succinct description of the procedures mentioned, see the anonymous textbook The Edinburgh Practice of Physic and Surgery (London: G. Kearsley, 1800), 705–15. 122 As these procedures do not appear in every single account, it is evident that such practices were not carried out on every patient. For instance, the unknown practitioner in Dalkeith did not use blistering. 123 Andrew T. Chamberlain, ‘Morbid Osteology: Evidence for Autopsies, Dissection and Surgical Training from the Newcastle-upon-Tyne Infirmary’, in Piers Mitchell, ed., Anatomical Dissection in Enlightenment England and Beyond (Farnham: Ashgate Press, 2012), 14. The Infirmary opened in 1751 and closed in 1906. About half the burials in the hospital’s graveyard were examined, and over 50 per cent had dental caries and missing teeth. Almost certainly there was a similar incidence of tooth decay in Scotland. SRO GD 150/3294 Tooth extraction also appeared in the account that James and Robert Kirklands sent to James Watson. 124 NRS reference numbers Lachlan Campbell CC2/3/125; John Robertson CC12/3/6; James Naismith CC10/5/10. 125 Margaret Pelling, ‘Occupational Diversity: Barber Surgeons and the Trades of Norwich 1550–1640’, Bulletin of the History of Medicine, 1982, 56, 484–511. Freedom was the term used for an official acknowledgement by the relevant Guild that an apprentice had completed his training. Like membership of the ICSE and FPSG, it involved parting with a large sum of money. 126 De Moulin, History of Surgery, 270. 127 Dingwall, A Famous and Flourishing Society, 42. 128 De Moulin, History of Surgery, 178. 129 Ibid., 179. 130 Helen Dingwall, A History of Scottish Medicine (Edinburgh: Edinburgh University Press, 2003), 113. Appendix Appendix 1. Surgical instruments in inventories * Indicates that the man had been a member of the Edinburgh College or the Glasgow Faculty. The year that probate was granted and reference number for the National Records of Scotland is also given. Inventories stating only that the deceased had owned instruments Thomas Aitken, 1786, CC20/4/25 *George Balderstone, 1727, CC8/8/91 William Carruthers, 1735, CC5/6/10 *William Gib, 1742, CC8/8/105 Alexander Graham, 1755, CC9/6/10 William Lithan, 1733, CC8/8/95 Charles Lumsden, 1735, CC8/8/97 *John McGill, 1735, CC8/8/97 Colin McKenzie, 1728, CC8/8/91 John Nisbet, 1726, CC8/8/90 *Patrick Rattray, 1729, CC8/8/92 Robert Scot, 1765, CC8/8/120 John Spence, 1777, CC20/4/24 Detailed Inventories *William Anderson, 1746, CC8/8/127. Amputation saw, forceps, catheter, cupping glasses, electric machine Patrick Carmichael, 1761, CC8/8/118. Lancets, trocar John Deans, 1738 CC8/8/101. Few small broken instruments, 3 lancets Ebenezer Donaldson 1786, CC5/6/17. Amputation saws, Trefines, needles, syringe Alexander McDonald 1767, CC8/8/120. Amputation saw and tourniquet, trephine, catheter, embowelling needle *James McGill 1796, CC6/5/30. Pulse glasses, clister pipes and an electric machine Alexander Rammage 1751, CC8/8/113. Amputation saw, trefine and artery needles John Smith, 1760, CC9/7/63. Midwifery instruments, amputation saw, catheter, trocar and bullet extractor © The Author(s) 2019. Published by Oxford University Press on behalf of the Society for the Social History of Medicine. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)
TI - How Did Eighteenth-century Scottish Surgeons Earn a Living?
JF - Social History of Medicine
DO - 10.1093/shm/hkz077
DA - 2006-02-01
UR - https://www.deepdyve.com/lp/oxford-university-press/how-did-eighteenth-century-scottish-surgeons-earn-a-living-b0zGSXCTu3
SP - 1
VL - Advance Article
IS - 
DP - DeepDyve
ER -