A Book about Doctors Part 11

CHAPTER IX.

FEES.

From the earliest times the Leech (Leighis), or healer, has found, in the exercise of his art, not only a pleasant sense of being a public benefactor, but also the means of private advancement. The use the churchmen made of their medical position throughout Christendom (both before and after that decree of the council of Tours, A.D. 1163, which forbade priests and deacons to perform surgical operations in which cauteries and incisions were employed), is attested by the broad acres they extracted, for their religious corporations, as much from the grat.i.tude as from the superst.i.tion of their patients. And since the Reformation, from which period the vocations of the spiritual and the bodily physician have been almost entirely kept apart, the pract.i.tioners of medicine have had cause to bless the powers of sickness. A good story is told of Arbuthnot. When he was a young man (ere he had won the patronage of Queen Anne, and the friendship of Swift and Pope), he settled at Dorchester, and endeavoured to get practice in that salubrious town. Nature obviated his good intentions: he wished to minister to the afflicted, if they were rich enough to pay for his ministrations, but the place was so healthy that it contained scarce half-a-dozen sick inhabitants. Arbuthnot determined to quit a field so ill-adapted for a display of his philanthropy.

"Where are you off to?" cried a friend, who met him riding post towards London. "To leave your confounded place," was the answer, "for a man can neither live nor die there." But to arrive at wealth was not amongst Arbuthnot's faculties; he was unable to use his profession as a trade; and only a few weeks before his death he wrote, "I am as well as a man can be who is gasping for breath, and has a house full of men and women unprovided for."

Arbuthnot's ill-luck, however, was quite out of the ordinary rule.

Fuller says (1662), "Physic hath promoted many more, and that since the reign of King Henry VIII. Indeed, before his time, I find a doctor of physic, father to Reginald, first and last Lord Bray. But this faculty hath flourished much the three last fifty years; it being true of physic, what is said of Sylla, 'suos divitiis explevit.' Sir William b.u.t.ts, physician to King Henry VIII., Doctor Thomas Wendy, and Doctor Hatcher, Queen Elizabeth's physician, raised worshipful families in Norfolk, Cambridge, and Lincolnshire, having borne the office of Sheriff in this county." Sir William b.u.t.ts was rewarded for his professional services by Henry VIII. with the honour of Knighthood, and he attended that sovereign when the royal confirmation was given, in 1512, to the charter of the barber-surgeons of London.

Another eminent physician of the same period, who also arrived at the dignity of knighthood, was John Ayliffe, a sheriff of London, and merchant of Blackwell-Hall. His epitaph records:--

"In surgery brought up in youth, A knight here lieth dead; A knight and eke a surgeon, such As England seld' hath bred.

"For which so sovereign gift of G.o.d, Wherein he did excell, King Henry VIII. called him to court, Who loved him dearly well.

"King Edward, for his service sake, Bade him rise up a knight; A name of praise, and ever since He Sir John Ayliffe hight."

This mode of rewarding medical services was not unfrequent in those days, and long before. Ignorance as to the true position of the barber in the middle ages has induced the popular and erroneous belief that the barber-surgeon had in olden times a contemptible social status.

Unquestionably his art has been elevated during late generations to a dignity it did not possess in feudal life; but it might be argued with much force, that the reverse has been the case with regard to his rank. Surgery and medicine were arts that n.o.bles were proud to practise for honour, and not unfrequently for emolument. The reigns of Elizabeth and her three predecessors in sovereign power abounded in medical and surgical amateurs. Amongst the fashionable empirics Bulleyn mentions Sir Thomas Elliot, Sir Philip Paris, Sir William Gasgoyne, Lady Taylor and Lady Darrel, and especially that "goodly hurtlesse Gentleman, Sir Andrew Haveningham, who learned water to kill a canker of his own mother." Even an Earl of Derby, about this time, was celebrated for his skill in _chirurgerie_ and _bone-setting_, as also was the Earl of Herfurth. The Scots n.o.bility were enthusiastic dabblers in such matters; and we have the evidence of Buchanan and Lindsay as to James IV. of Scotland, "quod vulnera scientissime tractaret," to use the former authority's words, and in the language of the latter, that he was "such a _cunning chirurgeon_, that none in his realm who used that craft but would take his counsel in all their proceedings." The only art which fashionable people now-a-days care much to meddle with is literature. In estimating the difference between the position of an eminent surgeon now, and that which he would have occupied in earlier times, we must remember that life and hereditary knighthood are the highest dignities to which he is now permitted to aspire; although since this honour was first accorded to him it has so fallen in public estimation, that it has almost ceased to be an honour at all. It can scarcely be questioned that if Sir Benjamin Brodie were to be elevated to the rank of a Baron of the realm, he would still not occupy a better position, in regard to the rest of society, than that which Sir William b.u.t.ts and Sir John Ayliffe did after they were knighted. A fact that definitely fixes the high esteem in which Edward III. held his medical officers, is one of his grants--"Quod Willielmus Holme Sirurgicus Regis pro vit? su?

possit, fugare, capere, et asportare omnimodas feras in quibuscunque forestis, chaccis parcis et warrennis regis." Indeed, at a time when the highest dignitaries of the Church, the proudest bishops and the wealthiest abbots, practised as physicians, it followed, as a matter of course, that everything pertaining to their profession was respected.

From remote antiquity the fee of the healer has been regarded as a voluntary offering for services gratuitously rendered. The pretender to the art always stuck out for a price, and in some form or other made the demand which was imprinted on the pillboxes of Lilly's successor, John Case,

"Here's fourteen pills for thirteen pence, Enough in any man's own con-sci-ence."

But the true physician always left his reward to be measured by the grat.i.tude and justice of the benefited. He extorted nothing, but freely received that which was freely given. Dr. Doran, with his characteristic erudition, says, "Now there is a religious reason why fees are supposed not to be taken by physicians. Amongst the Christian martyrs are reckoned the two eastern brothers, Damian and Cosmas. They practised as physicians in Cilicia, and they were the first mortal pract.i.tioners who refused to take recompense for their work. Hence they were called Anargyri, or 'without money.' All physicians are pleasantly supposed to follow this example. They never take fees, like Damian and Cosmas; but they meekly receive what they know will be given out of Christian humility, and with a certain or uncertain reluctance, which is the nearest approach that can be made in these times to the two brothers who were in partnership at Egea in Cilicia."

But, with all due respect to our learned writer, there is a much better reason for the phenomenon. Self-interest, and not a Christian ambition to resemble the charitable Cilician brothers, was the cause of physicians preferring a system of gratuities to a system of legal rights. They could scarcely have put in _a claim_ without defining the _amount claimed_; and they soon discovered that a rich patient, left to his generosity, folly, and impotent anxiety to propitiate the mysterious functionary who presided over his life, would, in a great majority of cases, give ten, or even a hundred times as much as they in the wildest audacity of avarice would ever dare to ask for.

Seleucus, for having his son Antiochus restored to health, was fool enough to give sixty thousand crowns to Erasistratus: and for their attendance on the Emperor Augustus, and his two next successors, no less than four physicians received annual pensions of two hundred and fifty thousand sesterces apiece. Indeed, there is no saying what a sick man will not give his doctor. The "cacoethes donandi" is a manifestation of enfeebled powers which a high-minded physician is often called upon to resist, and an unprincipled one often basely turns to his advantage. Alluding to this feature of the sick, a deservedly successful and honourable pract.i.tioner, using the language of one of our Oriental pro-consuls, said with a laugh to the writer of these pages, "I wonder at my moderation."

But directly health approaches, this desirable frame of mind disappears. When the devil was sick he was a very different character from what he was on getting well. 'Tis so with ordinary patients, not less than satanic ones. The man who, when he is in his agonies, gives his medical attendant double fees three times a day (and vows, please G.o.d he recover, to make his fortune by trumpeting his praises to the world), on becoming convalescent, grows irritable, suspicious, and distant,--and by the time he can resume his customary occupations, looks on his dear benefactor and saviour as a designing rascal, bent on plundering him of his worldly possessions. Euricus Cordus, who died in 1535, seems to have taken the worst possible time for getting his payment; but it cannot be regretted that he did so, as his experiences inspired him to write the following excellent epigram:--

"Tres medicus facies habet; unam quando rogatur, Angelicam; mox est, c.u.m juvat, ipse Deus.

Post ubi curato, poscit sua pr?mia, morbo, Horridus apparet, terribilisque Sathan."

"Three faces wears the doctor: when first sought, An angel's--and a G.o.d's the cure half wrought: But when, that cure complete, he seeks his fee, The Devil looks then less terrible than he."

Ill.u.s.trative of the same truth is a story told of Bouvart. On entering one morning the chamber of a French Marquis, whom he had attended through a very dangerous illness, he was accosted by his n.o.ble patient in the following terms:--

"Good day to you, Mr. Bouvart; I feel quite in spirits, and think my fever has left me."

"I am sure it has," replied Bouvart, dryly. "The very first expression you used convinced me of it."

"Pray, explain yourself."

"Nothing is easier. In the first days of your illness, when your life was in danger, I was your _dearest friend_; as you began to get better, I was your _good Bouvart_; and now I am Mr. Bouvart: depend upon it you are quite recovered."

In fact, the affection of a patient for his physician is very like the love a candidate for a borough has for an individual elector--he is very grateful to him, till he has got all he wants out of him. The medical pract.i.tioner is unwise not to recognize this fact. Common prudence enjoins him to act as much as possible on the maxim of "accipe dum dolet"--"take your fee while your patient is in pain."

But though physicians have always held themselves open to take as much as they can get, their ordinary remuneration has been fixed in divers times by custom, according to the locality of their practice, the rank of their patients, the nature of the particular services rendered, and such other circ.u.mstances. In China the rule is "no cure, no pay," save at the Imperial court, where the physicians have salaries that are cut off during the continuance of royal indisposition. For their sakes it is to be hoped that the Emperor is a temperate man, and does not follow the example of George the Fourth, who used to drink Maraschino between midnight and four o'clock in the morning; and then, when he awoke with a furred tongue, from disturbed sleep, used to put himself under the hands of his doctors. Formerly the medical officers of the English monarch were paid by salary, though doubtless they were offered, and were not too proud to accept, fees as well. Coursus de Gungeland, Edward the Third's apothecary, had a pension of sixpence a-day--a considerable sum at that time; and Ricardus Wye, the surgeon of the same king, had twelve-pence a day, and eight marks per annum.

"Duodecim denarios per diem, et octo marcas per annum, pro vadiis suis pro vit?." In the royal courts of Wales, also, the fees of surgeons and physicians were fixed by law--a surgeon receiving, as payment for curing a slight wound, only the blood-stained garments of the injured person; but for healing a dangerous wound he had the b.l.o.o.d.y apparel, his board and lodging during the time his services were required, and one hundred and eighty pence.

At a very early period in England a doctor looked for his palm to be crossed with gold, if his patient happened to be a man of condition.

In Henry VIII.'s reign a Cambridge physician was presented by the Earl of c.u.mberland with a fee of ?1--but this was at least double what a commoner would then have paid. Stow complains that while in Holland half-a-crown was looked upon as a proper remuneration for a single visit paid by a skilled physician, the medical pract.i.tioners of London scorned "to touch any metal but gold."

It is no matter of uncertainty what the physician's ordinary fee was at the close of the sixteenth and the commencement of the seventeenth century. It was ten shillings, as is certified by the following extract from "Physick lies a-bleeding: the Apothecary turned Doctor"--published in 1697:--

"_Gallipot_--Good sir, be not so unreasonably pa.s.sionate and I'll tell you. Sir, the Pearl Julep will be 6_s._ 8_d._, Pearls being dear since our clipt money was bought. The Specific Bolus, 4_s._ 6_d._, I never reckon less; my master in Leadenhall Street never set down less, be it what it would. The Antihysterick Application 3_s._ 6_d._ (a common one is but 2_s._ 6_d._), and the Anodyne Draught 3_s._ 4_d._--that's all, sir; a small matter and please you, sir, for your lady. My fee is what you please, sir. All the bill is _but_ 18_s._

"_Trueman_--Faith, then, d'ye make a _but_ at it? I do suppose, to be very genteel, I must give you a crown.

"_Gallipot_--If your worship please; I take it to be a fair and an honest bill.

"_Trueman_--Do you indeed? But I wish you had called a doctor, perhaps he would have advised her to have forebore taking anything, as yet at least, so I had saved 13_s._ in my pocket."

"Physick lies a-bleeding" was written during the great Dispensarian War, which is touched upon in another part of these pages; and its object was to hold up physicians as models of learning and probity, and to expose the extortionate practices of the apothecaries. It must therefore be read with caution, and with due allowance for the license of satire, and the violence of a party statement. But the statement that 10_s._ was the _customary_ fee is clearly one that may be accepted as truthful. Indeed, the unknown and needy doctors were glad to accept less. The author of "The Dispensarians are the Patriots of Britain," published in 1708, represents the humbler physicians being nothing better than the slaves of the opulent apothecaries, accepting half their right fee, and taking instead 25 or 50 per cent. of the amount paid for drugs to the apothecary. "They (the powerful traders)," says the writer, "offered the Physicians 5_s._ and 10_s._ in the pound, to excite their industry to prescribe the larger abundance to all the disorders."

But physicians daily received more than their ten shillings at a time.

In confirmation of this, a good anecdote may be related of Sir Theodore Mayerne. Sir Theodore Mayerne, a native of Geneva, was physician to Henry IV. and Louis XIII. of France, and subsequently to James I., Charles I., and Charles II. of England. As a physician, who had the honour of attending many crowned heads, he ranks above Caius, who was physician to Edward VI., Mary, and Elizabeth--Ambrose Par?, the inventor of ligatures for severed arteries, who was physician and surgeon to Henry II., Francis II., Charles IX., and Henry III. of France--and Sir Henry Halford, who attended successively George III., George IV., William IV., and Victoria. It is told of Sir Theodore, that when a friend, after consulting him, foolishly put two broad gold pieces (six-and-thirty shillings each) on the table, he quietly pocketed them. The patient, who, as a friend, expected to have his fee refused, and therefore (deeming it well to indulge in the magnificence of generosity when it would cost him nothing) had absurdly exhibited so large a sum, did not at all relish the sight of its being netted.

His countenance, if not his tongue, made his mortification manifest.

"Sir," said Sir Theodore, "I made my will this morning; and if it should appear that I refused a fee, I might be deemed _non compos_."

The "Levamen Infirmi," published in 1700, shows that a century had not, at that date, made much difference in the scale of remuneration accorded to surgeons and physicians. "To a graduate in physick," this authority states, "his due is about ten shillings, though he commonly expects or demands twenty. Those that are only licensed physicians, their due is no more than six shillings and eight-pence, though they commonly demand ten shillings. A surgeon's fee is twelve-pence a mile, be his journey far or near; ten groats to set a bone broke, or out of joint; and for letting blood one shilling; the cutting off or amputation of any limb is five pounds, but there is no settled price for the cure." These charges are much the same as those made at the present day by country surgeons to their less wealthy patients, with the exception of a fee for setting a bone, or reducing a dislocation, which is absurdly out of proportion to the rest of the sums mentioned.

Mr William Wadd, in his very interesting "Memorabilia," states, that the physicians who attended Queen Caroline had five hundred guineas, and the surgeons three hundred guineas each; and that Dr. Willis was rewarded for his successful attendance on his Majesty King George III., by ?1500 per annum for twenty years, and ?650 per annum to his son for life. The other physicians, however, had only thirty guineas each visit to Windsor, and ten guineas each visit to Kew.

These large fees put us in mind of one that ought to have been paid to Dr. King for his attendance on Charles the Second. Evelyn relates--"1685, Feb. 4, I went to London, hearing his Majesty had ben, the Monday before (2 Feb.), surprised in his bed-chamber with an apoplectic fit; so that if, by G.o.d's providence, Dr King (that excellent chirurgeon as well as physitian) had not been actually present, to let his bloud (having his lancet in his pocket), his Majesty had certainly died that moment, which might have ben of direful consequence, there being n.o.body else present with the king save this doctor and one more, as I am a.s.sured. It was a mark of the extraordinary dexterity, resolution, and presence of mind in the Dr to let him bloud in the very paroxysm, without staying the coming of other physicians, which regularly should have ben done, and for want of which he must have a regular pardon, as they tell me." For this prompt.i.tude and courage the Privy-Council ordered ?1000 to be given to Dr. King--but he never obtained the money.

In a more humourous, but not less agreeable manner, Dr. Hunter (John Hunter's brother), was disappointed of payment for his professional services. On a certain occasion he was suffering under such severe indisposition that he was compelled to keep his bed, when a lady called and implored to be admitted to his chamber for the benefit of his advice. After considerable resistance on the part of the servants, she obtained her request; and the sick physician, sitting up in his bed, attended to her case, and prescribed for it. "What is your fee, sir?" the lady asked when the work was done. The doctor, with the prudent delicacy of his order, informed his patient that it was a rule with him never to fix his fee; and, on repeated entreaty that he would depart from his custom, refused to do so. On this the lady rose from her seat, and courteously thanking the doctor, left him--not a little annoyed at the result of his squeamishness or artifice.

This puts us in mind of the manner in which an eminent surgeon not long since was defrauded of a fee, under circ.u.mstances that must rouse the indignation of every honourable man against the delinquent. Mr.

---- received, in his consulting room, a gentleman of military and prepossessing exterior, who, after detailing the history of his sufferings, implored the professional man he addressed to perform for him a certain difficult and important operation. The surgeon consented, and on being asked what remuneration he would require, said that his fee was a hundred guineas.

"Sir," replied the visitor with some embarra.s.sment, "I am very sorry to hear you say so. I feel sure my case without you will terminate fatally; but I am a poor half-pay officer, in pecuniary difficulties, and I could not, even if it were to save my soul, raise half the sum you mention."

"My dear sir," responded the surgeon frankly, and with the generosity which is more frequently found amongst medical pract.i.tioners than any other cla.s.s of men, "don't then disturb yourself. I cannot take a less fee than I have stated, for my character demands that I should not have two charges, but I am at liberty to remit my fee altogether.

Allow me, then, the very great pleasure of attending a retired officer of the British army gratuitously."

This kindly offer was accepted. Mr. ---- not only performed the operation, but visited his patient daily for more than three weeks without ever accepting a guinea--and three months after he had restored the sick man to health, discovered that, instead of being in necessitous circ.u.mstances, he was a magistrate and deputy-lieutenant for his county, and owner of a fine landed estate.

"And, by ----!" exclaimed the fine-hearted surgeon--when he narrated this disgraceful affair, "I'll act exactly in the same way to the next poor man who gives me his _word of honour_ that he is not rich enough to pay me."

The success of Sir Astley Cooper was beyond that of any medical pract.i.tioner of modern times; but it came very gradually. His earnings for the first nine years of his professional career progressed thus:--In the first year he netted five guineas; in the second, twenty-six pounds; in the third, sixty-four pounds; in the fourth, ninety-six pounds; in the fifth, a hundred pounds; in the sixth, two hundred pounds; in the seventh, four hundred pounds; in the eighth, six hundred and ten pounds; and in the ninth, the year in which he secured his hospital appointment, eleven hundred pounds. But the time came when the patients stood for hours in his ante-rooms waiting to have an interview with the great surgeon, and after all, their patients were dismissed without being admitted to the consulting-room.

Sir Astley's man, Charles, with all the dignity that became so eminent a man's servant, used to say to these disappointed applicants, in a tone of magnificent patronage, when they reappeared the next morning after their effectless visit, "I am not at all sure that _we_ shall be able to attend to-day to you, gentlemen, for _we_ are excessively busy, and our list is perfectly full for the day; but if you'll wait I will see what can be done for you!"

The highest amount that Sir Astley received in any one year was ?21,000. This splendid income was an exceptional one. For many years, however, he achieved more than ?15,000 per annum. As long as he lived in the City after becoming celebrated he made an enormous, but fluctuating, revenue, the state of the money-market having an almost laughable effect on the size of the fees paid him. The capitalists who visited the surgeon in Broad Street, in three cases out of four, paid in cheques, and felt it beneath their dignity to put pen to paper for a smaller sum than five guineas. After Sir Astley moved to the West End he had a more numerous and at the same time more aristocratic practice; but his receipts were never so much as they were when he dwelt within the Lord Mayor's jurisdiction. His more distinguished patients invariably paid their guineas in cash, and many of them did not consider it inconsistent with patrician position to give single fees. The citizens were the fellows to pay. Mr. William Coles, of Mincing Lane, for a long period paid Sir Astley ?600 a year, the visits of the latter being princ.i.p.ally made to Mr. Cole's seat near Croydon. Another "City man," who consulted the surgeon in Broad Street, and departed without putting down any honorarium whatever, sent a cheque for ?63 10_s._, with the following characteristic note:--

"DEAR SIR--When I had first the pleasure of seeing you, you requested, as a favour, that I would consider your visit on the occasion as a friend. I now, sir, must request you will return the compliment by accepting the enclosed draft as an act of friendship. It is the profit on ?2000 of the ensuing loan, out of a small sum Sir F. Baring had given, of appropriating for your chance."