Introduction
The licensing of provincial surgeons and physicians in the post-Restoration period
has proved an awkward subject for medical historians. It has divided writers between
those who regard the possession of a local licence as a mark of professionalism or
proficiency,1 those who see the existence of diocesan licences as a mark of an essentially
unregulated and decentralized trade,2 and those who discount the distinction of licensing
in assessing medical expertise availability in a given region.3 Such a diversity of
interpretations has meant that the very descriptors by which practitioners were known
to their contemporaries (and are referred to by historians) have become fragmented
and difficult to use without a specific context. As David Harley has pointed out in
his study of licensed physicians in the north-west of England, “historians often define
eighteenth-century physicians as men with medical degrees, thus ignoring … the many
licensed physicians throughout the country”.4 One could similarly draw attention to
the inadequacy of the word “surgeon” to cover licensed and unlicensed practitioners,
barber-surgeons, Company members in towns, self-taught practitioners using surgical
manuals, and procedural specialists whose work came under the umbrella of surgery,
such as bonesetters, midwives and phlebotomists. Although such fragmentation of meaning
reflects a diversity of practices carried on under the same occupational descriptors
in early modern England, the result is an imprecise historical literature in which
the importance of licensing, and especially local licensing, is either ignored as
a delimiter or viewed as an inaccurate gauge of medical proficiency.
The exception to the above is the recent work on records relating to the licensing
of midwives. Several scholars have recently attempted to explain more clearly the
role of midwives, showing the relationships between licence applications and their
clients' support, their repeat business with known clients, the range in status of
their clients, and the importance of their moral standing.5 With regard to ecclesiastical
licensing, the important implication of this research is that it has involved a systematic
re-evaluation of the records accompanying grants of licences, generally given the
group name “testimonials”, rather than an eclectic approach drawing upon one or two
examples.
This article is an attempt to examine more closely the functions of the ecclesiastical
licensing system in a provincial part of southern England. Through a detailed and
systematic examination of the extant testimonials and Act Books of the diocese of
Exeter, covering Devon and Cornwall and two parishes in Somerset,6 it aims to establish
what purposes the system served to all parties concerned: patient, parishioner, practitioner
and ecclesiastical official. As will be seen, this presents few constants. It does,
however, permit a view of the multifaceted and changing importance of licensing in
a geographically disparate but largely self-contained diocese, and its dramatic decline
in the second quarter of the eighteenth century, and suggests reasons for these changes.
Trends in Episcopal Licensing
It is well known that episcopal licensing was introduced by legislation in the reign
of Henry VIII.7 It is also well known that it remained the principal means of legally
recognizing practitioners without the benefit of a university education for more than
250 years.8 For those with a degree it also served as a means of securing the approbation
of an ecclesiastical authority for paid healing and medical advice. It is less widely
known that it was a minority attribute; most non-university trained practitioners
were not licensed by the diocesan authorities, and locally licensed practitioners
dealt with a minority of cases.9 Only about 160 practitioners were licensed locally
in the six decades 1661–1720. As the population of the two counties which make up
the major part of the diocese in 1660 was in the region of 330,000,10 this equates
to approximately one licensed practitioner per 5,000 population every thirty years,
a fraction of the overall practitioner/patient ratios of 1∶200 noted for Norwich and
1∶400 noted for London and rural East Anglia by Margaret Pelling and Charles Webster
in the late sixteenth century.11 The ratio of licensed practitioners in Devon and
Cornwall was hardly any greater when the system was at its peak, in the period 1610–40,
when only 86 diocesan licences were granted, and only about 250 are known to have
been issued in total between 1610–1774.12 Given these numbers it is unlikely that
more than 80 locally licensed practitioners were practising at any one time in the
diocese.
To go beyond this point, and to use the extant records quantitatively to establish
patterns of application, grant, remit, refusal and types of qualification reflected
in the records of licensing is problematic. The difficulties arise largely from doubts
about the completeness of the records; even the series of bound registers or Act Books
that purport to contain a complete record of “all the acts expedited in the Principal
Registry” are known to be lacking entries. Five extant applications for licences carry
codicils referring to grants not recorded in the Act Books.13 The Subscription Books
cannot be used as a check since these are not extant for some crucial periods.14 While
a degree of human error may be acknowledged to be present in all recording work, and
more or less constant, other forms of human error are not, or at least cannot be presumed
to be constant. For example, the failure of a record clerk to note grants of licences
made away from Exeter at visitations may be counted a human error, but the frequency
with which such an error was made depends very much on the regularity and thoroughness
of visitations, and licences being granted at them. However, in this case the entries
lacking in the Act Books do not appear to be connected to regular visitations or other
events since they are not clustered about a particular time but fairly evenly spread.
In addition, a further forty-five extant applications do have similar codicils referring
to grants which tally with the Act Books, suggesting there was no particularly wayward
period in the institution's record keeping. The implication that there is an approximate
10 per cent under-recording rate should be borne in mind when considering the figures
in Table 1.15
These figures illustrate a number of trends. First, there is a shift in practitioners'
nomenclature, from the strict adherence to “physic” and/or “surgery” in the 1660s
to combinations of descriptions more in line with the great preponderance of “surgeon-apothecaries”
noted by Joan Lane in her study of the 1783 edition of the Medical Register.16 Second,
there is a paucity of licences granted for midwifery, in great contrast to London,
where Doreen Evenden has consulted “hundreds” of applications and grants.17 With an
average of only one licence per decade, the system was clearly of little importance
as a means of supervising midwives in Devon and Cornwall, and it would appear from
the extant applications that very few midwives even applied. But the most notable
feature is the rate of grants, and especially the overall decline of licences after
1718. All but one of the eleven licences recorded as granted in the period 1719–35
date from 1723–24 (the exception is dated 1731), and only five were conferred between
1738–47. Moreover this small number was not due to a general lack of activity in the
diocesan registry; the number of schoolmasters' licences in the period 1725–30 was
maintained at a high level, approximately two-thirds of that of the 1690s. In effect
there is evidence of a collapse rather than a decline of the medical licensing system
in 1718–19, followed by a minor resurgence in the period 1747–61, and another minor
resurgence 1767–74.18
These figures are also significant for a reconsideration of the importance of dates
which historians have regarded as pivotal in the history of provincial medical control.
The comparatively high level of licensing at the beginning of the period is particularly
noticeable. Indeed, one might say that in the diocese of Exeter the system was at
its height immediately after the Restoration, in a seemingly determined move to return
to the pre-Commonwealth situation. Notwithstanding the fact that no licences had been
available since 1646, and that therefore the increase after 1660 should be understood
in the context of stifled demand, the figures easily bear comparison with totals for
earlier decades. More detailed inspection reveals that most of this demand was indeed
immediately after the Restoration: 30 licences were granted in the period 1663–75,
a rate of 2.3 per year; but in the immediate post-Restoration period 1661–62 at least
15 grants were made (7.5 per year).19 Similarly close examination of the grants around
1687–88, when the College of Physicians attempted to impose control on all the dioceses
by insisting that only physicians examined in London should be licensed,20 reveals
the effect in the region. In the period 1678–87, 30 licences were given; none were
granted in the year after the receipt of the letter (1688), and only 15 licences were
recorded in the period 1689–97. On the strength of this evidence one might postulate
that the College of Physicians dealt a significant blow to the medical licensing system
in the south-west.
It is one thing to say the system was at its height in the early 1660s based upon
numbers of licences issued and quite another to claim it was also performing at its
peak in terms of efficiency and quality of assessment of candidates. Margaret Pelling
has identified the regime of Archbishop Laud in the 1630s as the “most rigorous” period
of medical licensing, especially for midwives.21 Unfortunately, it is not possible
to say whether this was the case in the diocese of Exeter since no applications for
licences survive from before 1660.22 But for the period 1660–1780 a number of applications
do survive, although not all, and thus some assessment of the thoroughness with which
the system was operating in the south-west may be attempted.
There are testimonials and letters relating to 209 applications or appeals for help
in the years 1661–1783.23 Needless to say, these documents do not closely correspond
with the 216 recorded grants in the same period. There are 71 recorded grants for
which no testimonial is present, and 58 applications or related documents for which
no licence appears to have been granted. However, the most important question is not
how many testimonials survive but how representative is the extant series. As far
as can be judged, the series is random. Certain dates are lacking, such as the January
1663 to August 1665 period, and 1675–86, but these are wholly absent, and do not represent
any bias other than temporal. There is no sign of any geographic bias. Approximately
one-quarter of the extant documents relate to each of the four archdeaconries (Cornwall,
Barnstaple, Totnes and Exeter). There is no indication that only successful applications
were kept, nor that certain types of practitioners' application were kept more than
any other, and no evidence that only certain types of “difficult case” were retained
for future reference. While there are very few relating to women, this is also reflected
in the evidence of the grants in the Act Books. Although no doubt a number of applications
were made which are no longer extant, and it is of course possible that there was
an increasing tendency to preserve only successful applications, an examination of
the surviving testimonials in relation to each other and to the Act Books reveals
a definite trend.
As far as can be gauged from the existing testimonials, the proportion of successful
applications increased steadily between 1660 and 1760. Unless all unsuccessful applications
were disposed of after c.1750, applicants during the mid-eighteenth century “revival”
of licensing in the south-west were almost guaranteed their licence, revealing either
a looser control of practitioners or a better quality of application. The latter of
these might relate to more knowledgeable applicants or more appropriate applications,
as some types of application were more acceptable than others, as will be discussed
later.
Episcopal licences could be issued for a range of geographical areas: for the whole
diocese, for Devon only, Cornwall only, or for the vicinity of a single town or city.
A number of factors may have influenced this: first, the applicant himself could have
paid a higher fee for a diocese-wide licence rather than a county-wide one (although
no applications state area of jurisdiction for which the practitioner was applying).
The method of application also may have had a bearing on the geographical area of
the licence, locally supported practitioners being only locally licensed, although,
if this were the case, one has to ask why towns were very rarely specified as areas
in which to practise (in only 5 cases out of 135 is the remit specified), and why
intermediate jurisdictions, such as archdeaconries, were never specified. Finally,
it is possible that status had a bearing on the area; it seems that holders of degrees
and most “gentlemen” were licensed to practise throughout the diocese. This runs parallel
to the suggestion that the weakening system was less discriminating in the post-1718
period than before; after that date very few practitioners were refused a licence,
and invariably they were permitted to operate throughout the whole diocese.
If there was a hierarchical aspect to the geographical remit, and a diocese-wide licence
reflected a lower level of control than a local licence, it could be argued that the
late seventeenth century was the period of strictest control of practitioners. In
this sense “control” is to be distinguished from the “rigour” of the College of Physicians
in supervising the granting of licences in the 1630s, but it may have had as great
an effect. In the last quarter of the seventeenth century there seems to have been
an attempt to limit the areas in which licensed practitioners might operate. This
is probably not attributable to practitioners themselves choosing not to pay for a
diocesan licence, for in no application did any practitioner apply for a licence only
to practise in a single county, or a single town, in the way that some applied only
to perform a single type of cure. Furthermore, before 1641 the proportion of those
receiving a licence to operate throughout the diocese was regularly in excess of 70
per cent (in the period 1568–97 it was 87 per cent). If the change in remit normally
granted in the early eighteenth century is interpreted as a slackening of ecclesiastical
control, or a greater deference by the church authorities to medical expertise, the
second half of the seventeenth century should be seen as the period of greatest restrictions
on geographical freedom to practice, possibly in reaction to increasing numbers of
itinerant practitioners.
To conclude this examination of trends in the system, it is possible to say that medical
licensing in the diocese of Exeter underwent significant changes on at least two occasions,
after the intervention of the College of Physicians in 1688, and about the years 1718–20.
The first of these probably damaged the credibility of the system, albeit only temporarily.
The 1718–20 changes were much more profound and permanent. Before then, an average
of about three practitioners per year had applied for a licence, and a significant
proportion, perhaps 40 per cent, had been turned down; and licentiates had been permitted
to practise only in their own county or locality. After 1718 the numbers applying
dropped. Licences were granted to most of those who applied after this date, and they
did so increasingly on the strength of their peers' approval, and were permitted to
describe themselves by composite titles such as “surgeon, apothecary and man-midwife”,
which previously had not been allowed. They were also given leave to practise throughout
the whole diocese. It would appear standards were adapted—if not lowered—to prevent
the complete collapse of the system. A brief revival took place in the 1740s. This
was possibly an attempt by the ecclesiastical authorities to prop up their rights,
either against or alongside the new medical authority created by the opening of the
Devon and Exeter Hospital in 1741, or perhaps in order to help establish man-midwifery
on a more moral footing; but this revival was over by 1761. Only a handful of licences
were granted after this date.
The Nature of an Episcopal Licence
Since the only systematic studies of medical testimonials have been those relating
to midwifery, it may be considered useful to take as a starting point one of the key
findings relating to northern provincial midwifery licentiates, viz. that they “usually
became licensed because they had been reported to a visitation as unlicensed”.24 Certainly
for the diocese of Exeter there is evidence that triennial bishop's visitations played
a part in the licensing process. Five surgeons' licences were recorded in an Act Book
as granted “during the Episcopal Visitation” of 1699,25 and in 1677 one Mr Fox was
“cited to appear at the visitation on Thursday next for practising Physic without
a licence”.26 But two key questions have to be answered. To what extent was this a
punitive process, as opposed to a convenient time to present one's credentials? And
how common was it for applications and grants to be submitted at or just after the
visitation?
With regard to the first of these questions, there are few lists of presentments in
the period for practising without a licence,27 and those for the seventeenth century
exclusively relate to schoolmasters.28 However, the evidence of a few testimonials
themselves may be used. The application of Richard Hanbury in 1692 asks that he be
licensed by the bishop “at this his present visitation, that he may thereby be enabled
farther to practise the said art”.29 This document carries the signatures of two clergymen,
neither of them the incumbent of the practitioner's own parish, and rather than being
presented for acting without a licence in a punitive way, the indications are that
he was being furnished with a letter of recommendation as a means of assisting him
in his career, possibly enabling him to care for individuals in the parishes serviced
by the signing incumbents. Although situations did arise at which a practitioner was
presented for practising without a licence, as in the case of Mr Fox above, the role
of the triennial visitation seems to have been relatively unimportant. Visitations
in the diocese in the seventeenth century almost always took place in the months of
August and September, the exception being November in the year 1662. In the period
1661–1701, there were 157 grants of a licence, of which 52 fell in a visitation year,
showing no bias towards this as a means of successful licensing. A similar evaluation
of extant testimonial dates shows that, in the period 1661–1701, 54 of the 96 applications
were made in the same year as a visitation, and that 75 per cent of those made in
a visitation year were made in the month immediately before, the month immediately
after or the month of the visitation. However, when disregarding the abnormal year
1662, these figures shrink to 37 out of 74 applications (50 per cent).30 Thus one
may conclude that while visitations at the end of the seventeenth century acted as
a spur to practitioners to obtain a licence, they were not a hugely important factor.
Up to three years was a long time to wait for a licence, and while some practitioners
may have obtained one shortly after being presented, many who wanted a licence did
not wait until the next visitation.
Whether in a visitation year or not, in most cases some form of testimonial was required
for the aspiring licentiate. Scholars and archivists alike have rather lazily lumped
all such documents under the single heading “testimonial” in the past, but in fact
a great variety of documents were put forward in the favour of applicants. The most
common of these, a certificate of competency, is referred to in a letter relating
to the application of Thomas Bryant in 1717. Bryant sought the help of an influential
friend, Mr W Dinham, to write to Mr Edward Cooke, the Diocesan Official, on his behalf.
Dinham explains the procedure as he understood it:
[A surgeon's licence] I presume must come from your office, I presume he must get
a certificate signed by two surgeons of his skill and of his being well-affected to
the Present Gov't the forme of which Certificate I desire you to send me per return
of post, and when that is sign'd and returned I presume you'l be able to send the
licence without giving him the trouble of an Exeter journey …31
Dinham seems to have been mistaken regarding the necessity of a visit, for a journey
was undertaken. The next letter from Dinham reads: “The bearer (Mr Bryant) waits on
you with his certificate signed by two skilful persons both well known to me soe that
I hope we will meet with a Quicke despatch, upon his paying you the usual fees.” The
application in this case was granted ten weeks later.32
Such applications as this, carrying the signatures of two known practitioners, were
common, far more so than those signed by the four examiners required by the Act of
1511.33 Sixty-two of the 203 applications bear two signatures. Not all of these were
the signatures of medical practitioners; a number of testimonials were signed by two
clergymen, or one medical practitioner and one clergyman. Thirty-six testimonials
bear three signatures, these most commonly being the names of a MD and two surgeons.
Sixteen bear four signatures, and 33 per cent bear five or more. Two documents carry
six medical men's signatures attesting to the proficiency of the applicant. Twenty
per cent of documents have between eight and thirty-five signatures. The series of
testimonials represents a wide range of approaches, from a letter to a communal petition.
Using the number and nature of the signatories as well as the texts, testimonials
may be broken down into certain subgroups. First and most commonly, there is the certificate
of competency that an applicant was “of sober life and conversation”, “conformable
to the law and doctrine of the Church of England”, and “well-skilled in the art”.
This could be signed by two surgeons as above, or by a physician and two surgeons,
or by a physician, clergyman and surgeons. The use of the three key phrases above
was normal. Sometimes this certificate of competency is restricted to medical matters
and accompanied by a separate testimonial to the “sober life” of the applicant, signed
by a clergyman. The inclusion of both sorts of testimonial in several cases accentuates
the differences between the two documents.34 Some degree of rule seems to have governed
what was acceptable, at least on the combined sort of testimonial, since John Abbot
wrote to the Diocesan Official in 1675 from Colyton:
I have got the draught of the certif[icate] which you sent me and have gotten 3 handes
two ministers and one physition as for chirurgions we have never a one in our parts
noe nearer than Exeter Sir I should desier you to give me a line or two in answer
whether these are sufficient and when the Chancellor will be at home …35
Similar in type to the above is the certificate of examination which was issued in
a number of cases, normally signed by at least one MD, and sometimes three. At the
other extreme are the petitions from communities for their practitioners to be given
licences, often containing more than a dozen signatures. In between these there are
personal petitions, signed only by the applicant or an acquaintance, and documents
comparable with those which have provided the basis for the work on midwifery: certificates
of skill signed by a number of patients (often the “customary” six noted by Evenden)
attesting to the practitioner's skill with reference to particular medical acts.36
Quite common are composite testimonials, which include medical practitioners' names,
the names of local clergymen and officers, and the names of patients cured by the
practitioner in the past. The ten midwives' testimonials also vary, one being signed
by four women, others from the seventeenth century being signed by churchwardens and
clergy, and mid-eighteenth-century ones by surgeons.
The wide range of testimonials can be reduced to two non-exclusive varieties: those
which predominantly show a social need for a licence to be granted, and those which
predominantly demonstrate a practitioner's medical competence and moral suitability.
With regard to the latter, in cases where applicants were acquainted with a medical
practitioner, it seems they obtained the relevant signatures and submitted a certificate
of competency or combined testimonial. Where they had no well-known medical acquaintances
on whom to rely for a certificate, they had to submit themselves to examination, at
Exeter or a similar regional town, such as Plymouth or Liskeard. While it is difficult
to distinguish between the certificates of competency signed in advance, and certificates
of ability signed by the examining practitioners, several facts stand out. Supervising
the examinations was a coterie of MDs, such as William Durston, Gray Holland, John
Osmond, Thomas Pyne, Ellis Veryard, John Andrew, George Beal, Anthony Salter and Thomas
Glass (to name only those most obviously acting in this capacity). In some documents
they explicitly refer to examinations having taken place. The handful of candidates
whom they each certified came from quite distinct regions, making it highly unlikely
they knew them personally.37 Acting with these doctors was a group of licensed surgeons,
such as James Briet, Richard Chilcott, and John Pearce, who also occasionally refer
explicitly in their certificates to the fact that an examination has taken place.
Where the candidate was applying for a licence in surgery, sometimes only surgeons
were present at the examination. A good example is that of Noah Mahun:
Wee Chyrurgeons of the Citty of Exon doe hereby certifie to your Lord shipp that wee
have strictly examined Mr Noah Mahun of St Endellion … in the art of chirurgery, who
wee finde fitt and qualified therein, and who deserves your Lordshipps lycence for
the performing thereof … 1 August 1709. [signed:] [Thomas] Downton surgeon. John Pearce
surgeon.38
In other cases clergymen were also present, as in the examination of Joseph Hemminge,
gent, and Nicholas Cary, gent, examined in physic and surgery, and surgery respectively,
by Thomas Pyne MD, with the vicar of Menheniot, the vicar of Liskeard, and Benjamin
Berry (a local surgeon) in July 1723.39
While it is important not to assume that such examinations were particularly searching
or of a comparable standard, there is evidence that examiners did discriminate against
those who were felt to be insufficiently skilled. A detailed examination of the extant
applications for licences to practise both physic and surgery compared with the arts
for which the applicant was eventually licensed reveals that 16 such applicants (out
of 52) were only granted part of their application: 9 were licensed only for surgery
and 7 only for physic. In addition, a significant number of applications for licences
to practise both arts have one or the other deleted in the certificate. The Latin
certificates of competence upon examination note that candidates were examined in
both theory and practice. In 1666 the examining doctors at Plymouth (William Durston
and Gray Holland) wrote that “Johanem Fleming chirurgum examinatum fuisse coram nobis
in re medica et compertum esse adeo peritum et puratum tum in theoris tum praxi medicinae”.40
Similarly William Durstan and Roger Kemble testified in 1687 that Elias Scobel had
been found skilful not only in medicine but also in anatomy, pharmacy and botany “post
varia examina”.41 The theory examination was obviously the hard part for those lacking
formal training, such as Mr Abraham Every. On his behalf in 1739 one Mr Geare wrote
to the diocesan official noting that Every “hath done many great cures, but is wanting
in the Theorie part”.42 Although licences were more frequently granted to applicants
after 1740, as late as 1750 examinations were still being carried out. The application
of Robert Goss of Wembworthy was signed by two surgeons, Robert Smith of Chulmleigh
and George Marie Grossard of Hatherleigh, each separately making an explicit reference
to the fact they had examined the said Goss.43
If examinations were taking place, and if different approaches were being made in
order to obtain a licence, it should be possible to say something about those who
were turned down. For a start one can say a brief word about discrimination on grounds
of sex. There are only ten applications for midwives in the collection of applications,
and there is no indication that five of these were granted. Thus it seems likely that
not only were very few successful, but that applications were positively discouraged.
With regard to female practitioners of surgery, Exeter did in theory permit female
practitioners, but in the period under study actually licensed only one.44 No petitions
survive for female surgeons, and it seems likely that applications from women were
discouraged for both surgery and midwifery.
Using the fact that most certificates of medical competence have fewer than five signatures
and communal petitions by definition have more than this, it is possible to distinguish
what sorts of approach yielded the best results in gaining a licence. Overall, 36
out of 131 extant applications with fewer than five signatures appear to have failed
(27 per cent). By comparison, 21 out of 48 extant applications with seven or more
signatures appear to have failed (44 per cent). The first category, of course, includes
not only medical certificates of competence but also those certificates of good behaviour
signed by clergymen, and combined certificates. Restricting these solely to those
certificates signed by known medical practitioners, and only by them, a more striking
figure emerges. A maximum of 8 out of 47 applications appear to have failed (17 per
cent), and, given the known under-recording level, this is almost certainly an exaggeration.
Thus it can be seen that an application supported directly by a certificate of medical
competence was much more likely to succeed than an application with the backing of
the local community and clergy, or with a series of testimonies from cured patients.
Certificates of medical competence other than those relating to examinations very
often stress the credentials and qualifications of the applicant. From these we can
build up a picture of the range of backgrounds from which licensed practitioners came.
Joseph Lillycrap, aged twenty-three, having completed a local apprenticeship as a
surgeon, is representative of the younger licentiates.45 To this category should be
added those who had completed a year or two of formal training at a London hospital,46
or a seven-year apprenticeship with a London surgeon,47 or an apprenticeship split
between Devon (three years) and London (four years).48 Eight candidates (4 per cent)
were clergymen who had a university education and required a licence to assist them
in their cure of bodies as well as souls. Several seventeenth-century applicants had
served in the recent wars or had a military surgical training.49 One licensed candidate
in this period—the notorious Nathaniel Eaton—already had a medical doctorate from
Leiden,50 and an apparently unsuccessful applicant, Gray Holland, already had a MB.51
A significant number had spent time assisting in the practices of kinsmen.52 But the
most notable and common qualification is that applicants had “for many years practised
the art”. In the diocese of Exeter, practitioners' pre-licensing careers could be
just as long as the twenty or thirty years noted in respect of practitioners in other
regions:53 William Tucker had “byn a practitioner of physsick … for the space of fforty
yeares upwards”.54 Mr James Bush was “of above thirty years successful practice”.55
Rice Morris had “been a practitioner of the Art of Chirurgery this twentye years”.56
Many stress periods of experience in excess of ten years. While long service was the
easiest distinction to claim and the hardest to disprove, and therefore perhaps should
not be taken at face value, these applications point to a significant proportion of
licensed practitioners being older men from diverse backgrounds. A medical licence
therefore should be seen not so much as relating to a specific learning path or qualification
but as having a grounding in basic medical theory and a proficiency in certain arts,
gained from a variety of sources. It purported to be a “kitemark”: a symbol of trustworthiness,
or an official endorsement.
The reliability of the licence as a symbol of trustworthiness or quality depended
on the integrity of those acting as referees and examiners of new candidates. As mentioned
above, a wide range of practitioners signed certificates of competence for one another.
A total of 356 signatures known to be those of medical practitioners have been identified
on the 202 applications 1661–1780. Of these 287 are known to have been MD, MB or licentiates
(of one form or another, but mostly diocesan). The following table shows numerical
evidence to support an observation made with regard to the licensing of midwives in
the north-east, viz. that medical practitioners' involvement in licensing increased
in the early eighteenth century.57 However, it also shows that, as the average number
of medical signatories per application increased, the proportion of these in the south-west
who held medical degrees declined. Thus it seems that, even before the 1718–20 watershed,
licences were more frequently being granted as a result of medical authority than
in the 1660s, and that this medical authority was being exercised not by medical graduates
but by licentiates, most of whom were themselves diocesan licentiates, forming an
increasingly distinct professional group of their own.
The Politics of Licensing
The above view of licensing as conveying a mark of official approval suggests a fundamental
reason why a practitioner might seek a licence, but it is only one reason, and to
suggest it was always the most important one would be an over-simplification. Furthermore,
it is not a sufficiently full reason to answer the basic question: why, if few practitioners
had a licence and few prosecutions were brought against those practising without one,
and many clergymen claimed not to know whether their local practitioners were licensed
or not,58 did practitioners submit themselves to the trouble and expense of obtaining
them? Indeed, what actually was their significance to their holders and the communities
they served?
To begin with, but probably of minor importance, there was a straightforward legal
and economic rationale to licensing. In theory no one could charge for medical advice
or visiting without obtaining a licence to practise.59 Thus, by obtaining a licence
a person also obtained freedom from worry about being called to account for practising
without one. It is also possible that a practitioner obtained wealthier clientele,
and very likely that he was able to charge more for his services. However, it would
be wrong to apply these motives to practitioners who had practised for ten, twenty
or thirty years, especially considering that in practice the rule of non-payment was
not altogether followed. One 1750 applicant even went so far as to imply that he was
already charging his wealthier clients, if not his poorer ones:
… and hath thereby cured & recovered divers & sundry persons of good ranke & quality
besides an Innumerable company of other people of a lower degree of and from greate
lingeringe and dangerous deseases & sicknesses & in so charitable a manner as that
from the poore sort of people hee hath taken & receaved little or no reward att all
for his paynes …60
There was a more subtle legal and economic reason for obtaining a licence, which may
be seen clearly through the case of Thomas Bryant, mentioned above. The certificate
attesting to Bryant's capabilities as a surgeon is accompanied by a petition of Thomas
Hoskyn, yeoman of St Brewer, Cornwall. This states that the petitioner's wife had
been affected by a sore in her thumb for seven years, and, about two years earlier,
one Thomas Bryant, a vagrant claiming first to be a hop-buyer and then to be a surgeon,
gave her some black salve to put on it. This failed to work, but on his next visit
he demanded twelve shillings for the treatment, possibly in part payment of a successful
remedy. A disagreement ensued. Only then, it was claimed, did Bryant set about gaining
a licence. According to Hoskyn, he bribed “an indigent decayed apothecary”61 of Bodmin
with a guinea to procure a certificate, with which he obtained a licence in Exeter.
Bryant then took legal action against Hoskyn for non-payment of the twelve shillings.
Clearly from Bryant's point of view, a medical licence afforded legal protection.
Not only did it support his claim to be a good surgeon it also removed the risk he
would lose his case by being found guilty of acting without a licence. If the latter
had happened, he would also have been fined and prevented from practising again. This
may well explain why a number of individuals with many years' experience sought a
licence: they increasingly required the support of the law to enforce payment, or
to provide a legal defence in case of being taken to court. Several other documents
repeat this desire for legal recognition, or are letters addressed to the diocesan
official on behalf of individuals in danger of being prosecuted. One such letter in
particular requests “the protection of a licence to practice Physick” for a practitioner
and bailiff of Dartmouth in 1689, who
… by executing the precept for electing too Burgesses in opposition to too bad men
[who] were like to be put upon us has enraged the gentry here to seek all occasions
against him. And being engaged often to go beyond the bounds of his profession as
an apothecary especially amongst the ordinary sort of people, I doubt should he not
be licenced they will that way ensnare him.62
Clearly the legal threats to an unlicensed practitioner came from a number of quarters:
from the gentry, aggrieved patients and rival practitioners, as well as the clergy
and the triennial visitation.
It is of course necessary also to consider religious conscience as a motivating factor.
This is especially so in the cases of clergymen, who perhaps felt more keenly than
most the ecclesiastical requirement to be licensed if charging for services. But it
is also important to consider the perceived effect upon the very process of healing.
Rosemary O'Day has pointed out that the sixteenth-century concept of a profession
as a striving to follow God's calling underpinned the skills of the “professions”.63
With regard to medicine, this set the licensed practitioner at an advantage over the
unlicensed: by obtaining a licence the practitioner was confirming his spiritual calling,
and, if correct in assessing God's will, would inevitably benefit from cures effected
through his love of God. Several seventeenth-century applications stress that cures
have been achieved “by Gods blessing on his endeavours”, and the implication is that
the practitioner has only been the instrument of Divine healing.64
The practitioner was not the only member of a community affected by religious conscience;
his patients also were subject. In this way one can understand why the inhabitants
of a locality, as well as the clergy, wanted a man of honest character and of sober
life and conversation; to have put oneself in the care of a profligate loose-living
practitioner would have been to jeopardize oneself twice over: first, under the practitioner's
erring hand, and second, as the sacrificial victim of God's judgement upon his character.
The fact that such hints of divine intervention in the healing process are stated
overtly in seventeenth-century applications but not eighteenth-century ones helps
to explain the shift in emphasis from religious signatories to medical ones, and the
decline in numbers of licences sought and issued during the Enlightenment.
It would be wrong, of course, to try and explain the licensing of medical practitioners
in terms of economic, legal and religious motives, and neglect what is arguably the
most important aspect of all, medical proficiency. As with religion, this offers two
opportunities for examination: the medical role of the practitioner as an individual
with a service to sell, and the role of the community in purchasing that service.
As David Harley has remarked, “Any effective system of medical licensing limits competition
between practitioners by restricting entry into the market and punishing interlopers”.65
Punishment of interlopers has already been discussed, but the question of “restricting
entry into the market” requires further expansion. Religious preferences have been
mentioned above. Other market restrictions probably were directed most heavily at
strangers; and it has to be noted that many practitioners settled in parishes far
from where they grew up. Thus licensing was desirable in cases such as that of Mr
Jonas Griffin, who had been in Dartmouth for about four months when he applied for
a licence to practise physic there. Surgeons qualified in the navy and army also may
have settled more easily into a community if they were known as a licensed practitioner,
fulfilling a preconceived and commonly understood role. This also applies to licences
to practise throughout the diocese, obtained by itinerant practitioners who chose
to travel through the two counties. Most of all, however, it seems that recognition
as “skilful” was principally sought by the practitioner. As has been shown, a licence
implied that its holder had undergone a process of examination or certification. The
sense of “merit” in holding a licence is borne out by some community petitions, such
as that on behalf of Michael Hobbs of Fowey, written by the rector in 1662, which
states “so that (as we conceave) his good … skill and abilities may very well merritt
licence for the Administration of Physick”. This also suggests why Abraham Harward
obtained a certificate of medical competence, signed and sealed by two practitioners,
in 1659, when the diocesan system was not functioning.66 The most logical explanation
of Harward's action is that a certificate of competence was by itself seen to be a
distinction.67 Even if the holder of a licence was actually incompetent, the important
aspect is that he was still seen to be recommendable, and thus could justify charging
more for cures, or for taking on an apprentice. The fact that “the range of the irregulars
was very wide and they shaded off imperceptibly into the regulars”68 exactly explains
the purpose of a licence and why licences continued to be sought for so long; licentiates
could number themselves among the ranks of those with official approbation, as opposed
to the quacks with whom they might otherwise be associated.
Elitist implications of licensing suggest one reason why members of the gentry and
other responsible local men made concerted efforts to stop certain practitioners from
obtaining licences.69 Just as interesting are the very positive attempts to obtain
licences for certain practitioners by communities. The form of testimonial best described
as a communal petition, signed by a number of substantial members of a community,
including the mayor and clergy, churchwardens, constables, gentry and sometimes other
practitioners, has been mentioned above as more frequently being turned down than
accepted as a certificate of medical competence, and as more often resulting in a
geographically limited remit, but it may be seen as the most forceful attempt to use
licensing as a form of parochial control of practitioners. Many of these petitions,
testimonials and certificates were written by the rectors, vicars and mayors of the
towns in which the applicant was resident.70 For example, one 1706 petition begins
“We the Mayor of the said Towne together with the Ministers churchwardens and other
the choice inhabitants and also the gentlemen of the neighbourhood whose names are
subscribed”.71 That of Edward Chenhall is even more significant. Chenhall had
… at all times been ready to use his utmost endeavour and skill in order to [obtain]
our relief in which he hath been blessed with uncommon success, and restor'd great
Numbers from extreme misery to perfect Ease. But finding ourselves likely to be depriv'd
of his great usefulness by the malice of some who we hear would prosecute him for
his good services to us and the poor in our neighbourhood and your petitioners living
very remote from any other helps of the like kind, and believing it would be for the
Comon good if the said Edward Chenhall had liberty to act in this capacity more freely
… [we ask that you] grant [him] … a licence to practise chirurgery.72
If the several cases of communities applying for a licence on behalf of a specific
practitioner are to be taken at face value, and there is no reason why they should
not be, they suggest that the licensing system was used by local authorities as a
safeguard against unapproved practitioners. They could prevent their community being
visited by itinerant quacks, or, if they did visit, they could deprive them of the
right legally to practise without jeopardizing their established medical service.
What is particularly interesting is that this appears to have happened in large towns
as well as in the small ones. The mayor of Plymouth headed the list of signatories
of one such petition in 1715, and the mayor of Okehampton submitted one in 1665. In
these towns the emphasis may well have been on favouring particularly well-connected
practitioners or those who were acting on behalf of the poor of the town.73 A number
of petitions stress the numbers of poor people cured, and a town's action in effectively
appointing its principal physician or surgeon helped not only to secure the services
of a trusted practitioner but at the same time established an exclusive market for
his services.
Another interesting fact about this method of applying for a licence is that it was
in decline throughout the period in question. As Table 5 shows, the majority of these
petitions date from the decade after the Restoration. Thus the involvement of local
communities in the licensing process appears to have been strongest at the same time
as the involvement of medical degree holders. This seems to be a conflict of interests—locality
against expertise—until one reflects that this is also the period when the greatest
proportion of licence applications was turned down. As a result, one may interpret
the evidence of Table 5 as showing the declining influence of local communities, similar
to the declining influence of university-trained practitioners mentioned above.
Conclusion
The history of medical licensing by diocesan authorities deserves far more detailed
study than it has hitherto received, especially with regard to practitioners of medicine.
Despite some methodological problems, changes in the number of licences sought and
granted can be traced, and a wealth of detail may be drawn out about provincial communities,
which are otherwise difficult to study systematically with regard to medicine. In
the diocese of Exeter it is clear that the licensing system underwent fundamental
changes over the period in question, and while one may debate the relevance of such
procedural factors as visitations, nevertheless, the geographical control of practitioners
in the late seventeenth century and the simultaneous decline in the religious aspects
of licensing are both clear. Equally clear is the decline in importance of two social
groups: university-trained practitioners and local social élites. These groups lost
influence to the licentiates themselves, and one might suggest that the reason was
the same: a growing specialization of medical ability among the emerging surgeon-apothecaries.
What is certain is that, even in its last decades, the system was able to adapt. No
study of medical professionalization can be considered complete if it ignores the
development of the types of licences granted by the church, and the more professional
way in which licences were sought and obtained in the eighteenth century.