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Ian Mortimer, The dying and the doctors: the medical revolution in seventeenth-century England, Royal Historical Society Studies in History, Woodbridge and New York, Boydell Press, 2009, pp. xiv, 232, £50.00, $95.00 (hardback 978-08-619-3302-0).
Ian Mortimer's The dying and the doctors is probably the most important book on the history of medicine published in recent years. He is not the first to identify a medical revolution in the seventeenth century, but his is the most substantial claim, and his findings should fundamentally change our narrative of the medicalization of English society. Mortimer's methods and arguments deserve serious consideration by all historians of medicine.
Mortimer's most important conclusion is that there was a “huge social shift towards medical solutions to life-threatening problems between 1610 and 1670” in southern England (pp. 39–40). This affected rich and poor, men and women, urbanites and rural folk. Demand for medical services grew dramatically—by around 400 per cent for the rich and 1000 per cent for the relatively poor. By the late seventeenth century, most of the dying who required medical assistance obtained it through the market. Mortimer's work makes a concrete claim for a real “medical revolution” in the seventeenth century that should become the new orthodoxy.
Much earlier work on the consumption of health care has taken practitioner density as a proxy. Strikingly, Mortimer suggests that this increase in demand was not matched by an expansion in the number of practitioners. Rising demand was instead met by the ruralization of practitioners, shifts in the nature of medical assistance, and practitioners abandoning some parts of provision, such as astrological consultations. Practitioners’ medical identities—essentially the occupational labels they were given—fit loosely, with a few exceptions (apothecaries in particular). Moreover, practitioners were mostly licensed by the ecclesiastical authorities: this was no free market of irregulars.
Mortimer's book offers much aside from this central argument. Rural England was, he concludes, not medically remote after 1660—distance was no longer a barrier to medical services. Unusually, nursing is given serious consideration: he shows that palliative services—nursing in kind if not in name—were widely used in the late sixteenth century, and demand for nursing increased with the rise in other medical services. Nursing perhaps became more clearly defined as an occupation, although it is hard to be sure that changes to the labels for palliative services reflected changes in the substance of nursing. By contrast women's role in medical services was very limited. The clergy also played seemingly little part in health care. Only plague and smallpox can be isolated in the accounts, and Mortimer shows that they were treated differently to other diseases. Those afflicted by plague and smallpox largely relied on nursing rather than medical care; only latterly did smallpox attract increasing attention from doctors.
Some will debate the firm line Mortimer draws between medical and non-medical services. Others will no doubt question the lack of “theory”. But this would be to miss the point. This is a serious study of “revealed preferences”. While we can and should debate the motivations and meanings involved in purchasing medical goods and services, we should be convinced that people did purchase in increasing number and frequency.
Fundamental to Mortimer's achievement is his use of Probate Accounts, essentially lists of debts compiled after death. Accounts survive in large numbers for a few counties: Mortimer uses around 18,000 accounts. As a source, accounts present numerous challenges, to which he pays close attention. To the extent that the limitations of accounts can be resolved, he has achieved this. However, they impose some serious limitations that cannot be overcome. Four deserve discussion because they set particular boundaries to his conclusions.
First, Mortimer's study centres on east Kent, with supporting evidence from other southern English counties. As he notes, these are relatively wealthy lowland regions; east Kent has an unusual abundance of practitioners; their proximity to London exposed them to metropolitan developments; and they accommodated many continental refugees. Whether other regions saw a similar growth in medical consumption remains to be seen: England was not so well integrated that long lags are out of the question.
Second, probate accounts are primarily records of debts. Given the centrality of credit in the period, this is less of a problem than might appear, but it does mean that itinerant healers, who are less likely to offer credit and may have been particularly important in rural areas, are likely to be under-recorded. Third, probate accounts—as Mortimer emphasizes— over-represent the rich. He convincingly shows that some survive for relatively poor folk. Yet, as he notes, they may miss the very poor: did medical and nursing care feature in the makeshift budgets of those on the margins of society?
Fourth, probate accounts record engagements with the market. They exclude domestic, charity or neighbourly assistance. Mortimer is alert to this, and exploits gender differences to underline the significance of domestic care. The implications of this limitation are wider though. First, the increasing reliance on commerce to supply medical and nursing care marks a profound extension of the cash nexus into people's lives and households. Services which had been aspects of neighbourly duty become paid employment. This has significant implications for our understanding of social and kin relations. Second, the non-commercial care which these new commercial agents supplemented or displaced was not necessarily different in concept or content to that which they supplied. Therapeutic advice and remedies are not made medical by the act of purchasing, and “medical” knowledge was widely diffused in lay settings.
Mortimer's identification of the changes he identifies as medicalization therefore holds only if we use one definition of the term: a generalization of the use of medical practitioners during sickness. He is on shakier ground in concluding that a conceptual shift occurred, with people's understanding of disease adopting a “medical” framework. Mortimer sees the rise in demand for medical services as initially fitting with existing spiritual strategies for death: medicine supplemented prayer. However, the repeated use of doctors and drugs “resulted in the focus shifting from God as the provider to the therapy itself…. The power to affect the fate of a sick individual had been relocated, from the exclusively divine to the largely physical” (p. 208). This is too heroic a conclusion. There is no proof here that doctors displaced divines, nor that people's view of medicine became secularized. Exploring these hypotheses would require a different kind of source.
Medicalization is the effect of the changes Mortimer surveys. What was the cause? Mortimer focuses on the easing of supply constraints: practitioners moving outside towns, abandoning supplementary occupations, and changing the “nature of medical assistance itself” (p. 65). These are plausible partial explanations, but are they sufficient? Ruralization is clearly part of the story. However, the degree of rural development seems too small to explain such a large change in consumption. The urban share of practitioners declined slowly until the 1690s: between 1590–1619 and 1660–89 it fell from 78 per cent to 73 per cent on one of Mortimer's measures and 86 per cent to 81 per cent on another. Around two-thirds of practitioners are still living in towns at the close of the period. Ruralization is the only hypothesis that Mortimer's data allow him to explore. We must look beyond probate accounts to identify changes in the nature of medicine, particularly the questionable move to chemical medicines that Mortimer suggests.
However, even if we explain practitioners’ ability to meet rising demand, we have not explained what drove this explosion in consumption. Two possible explanations, falling prices and shifting disease burdens, can be quickly dispatched. First, prices rose significantly. Second, consumption grew before plague and mortality declined. A fuller explanation will need to consider the wider consumer revolution, changes in taste, middle-class incomes and, I would add, the availability of imported medicines. Explaining demand stands as the major challenge left to us at the close of Mortimer's groundbreaking project.