Past And Present

Dr Doubledose: a taste of one's own medicine

BMJ 1994; 309 doi: http://dx.doi.org/10.1136/bmj.309.6970.1714 (Published 24 December 1994) Cite this as: BMJ 1994;309:1714
  1. Roy Porter, professor of the history of medicinea
  1. a Wellcome Institute for the History of Medicine, London NW1 2BE

    Jokes, Freud taught us, are the acceptable face of aggression. Humour has, not surprisingly, provided a way for the people to fight back against the powerful; and, on account of their own highminded aspirations, the liberal and learned professions traditionally laid themselves particularly open to lampoon. Anti-priest and anti-doctor satire was not only a form of revenge, it was also designed to deflate, exposing pretension and humbug.

    Medical satire was particularly near the bone since its humour was black. Laughter was a way of keeping the dread of death at bay—of handling the insidious suspicion that the medical profession might not after all be fighting death but could prove a double agent.

    Such themes became specially prominent from the 18th century with the spread of fairly cheap prints and engravings alongside traditional verbal expressions like proverbs, riddles, and rhymes. Hogarth's commercial talents led the way from the 1730s. The decades around 1800 brought the golden age of the cartoon with Rowlandson, Gillray, and the Cruikshank family. The verbal and the visual joined forces to produce maximum impact in an age notably uninhibited in its depiction of sex and violence in political prints and professional satire alike.

    The standing of early modern medics was precarious and it is not hard to see why. Disease and death still held sway. Faced with hordes of waterborne, airborne, and bugborne fevers, medicine had little power to cure the sick or save the dying. Doctors had to do their feeble best in a cut-throat trade, exposed to non-stop vilification. “If the world knew the villainy and knavery (beside ignorance) of the physicians and apothecaries,” the gossipy antiquarian John Aubrey was told by a doctor, “the people would throw stones at 'em as they walked in the streets.” Scepticism ran high: “God heals and the Doctors take the Fee,” judged Ben Franklin. Proverbial wisdom warned that death and the doctors were thick as thieves, or at least always conducted joint consultations: practitioners, it was said, fleeced the public first and slew them afterwards. “When a Nation abounds in Physicians,” bantered Addison and Steele's Spectator, “it grows thin of people.”

    Doctors were taunted with caring only for their fees. Himself a practitioner, Bernard Mandeville versified this slur in The Fable of the Bees (1714):

    Physicians valued Fame and Wealth

    Above the drooping Patient's Health,

    Or their own Skill: The greatest Part

    Study'd, instead of Rules of Art,

    Gave pensive Looks, and dull Behaviour;

    To gain th' Apothecary's Favour,

    The Praise of Mid-wives, Priests and all,

    That served at Birth, or Funeral.

    Ubiquitous antidoctor diatribes suggest disquiet was heartfelt and not just hackneyed. Gravest of all was the charge that physicians were fatal. Should one consult an old or a young physician? someone inquired of Dr Frank Nicholls. “The difference,” replied the anatomist, is this: “The former will kill you, the other will let you die.”

    Doctors were mocked as men on the move, men on the make, a money-mad medical mafiosi:

    You tell your doctor, that y'are ill

    And what does he, but write a bill.

    —thus Matthew Prior put the matter in a nutshell. The faculty warned the public against imposters. But the common retort was that the profession itself was quackery in camouflage, cashing in whenever it could—a point Hogarth epitomised in The Company of Undertakers. Was there truly any difference between the stately bewigged faculty physicians at the foot of the print and the infamous contemporary quacks above—Joshua (“Spot”) Ward, Sally Mapp the bone manipulator, and John (“Chevalier”) Taylor, the oculist? No: because Hogarth's motto said et plurima mortis imago: everywhere the face of death.

    People were, of course, always bellyaching against doctors. “Met Mr Forbes the surgeon going to kill a few patients”, jotted Parson William Holland in his diary. No wonder medical men and issues commanded media prominence but mixed feelings. Of the 1300 satirical prints produced by the prolific Rowlandson during the reign of George III, up to 50 dealt directly with medical subjects. The stereotypes created, however, were negative or equivocal. Doctor bashing was nothing new: medieval illuminators and carvers depicted them as apes. But there were also singular aspects of public disquiet that Georgian cartoonists exploited.

    Threats to the body

    What is most striking about the portrayal of medicine in early cartoons is violence. Practitioners endlessly perform procedures that invade, wound, and pain their patients. They wield the lancet and let blood; they prescribe violent and disgusting purges; they yank out teeth. In a Rowlandson cartoon titled The Toothache, or Torment and Torture, Barnaby Factotum, the village jack of all trades, is caught drawing a fang, while, suffering from raging toothache, an old lady awaits her turn. “Draws Teeth, Bleeds and Shaves,” reads the testimonial pasted to the wall, “Wigs made here, also Sausages, Wash Balls, Black Puddings, Scotch Pills, Powder for the Itch, Red Herrings, Breeches Balls and Small Beer by the Maker.”

    Illness is painful but being physicked is equally agonising. Moreover, artists wished to intimate a endemic fiendishness in medicine, a theatre of cruelty. This is supremely expressed in the finale of Hogarth's Four Stages of Cruelty, set literally in a theatre, an anatomy theatre. Tom Nero (evidently the name means “no hero”) is being dissected. In the first print Tom was caught tormenting a dog. He descends into seducing a maidservant, later murdering her. After his execution it is his ghastly fate to become an exhibit in the dissecting room, being ritually disembowelled and having his eyes gouged out by surgeons and his guts guzzled by another dog (fig 1). What is there to choose, Hogarth invites us to ponder, between the murderous malefactor and the dissecting doctors?

    FIG 1
    FIG 1

    “The Reward of Cruelty” — Hogarth's non-hero meets a retributive fate

    Doctors in prints and the press thus presented threats to one's body, not just through therapeutic violence but sexually too. There are scores of leering sketches featuring the physician as lecher and clinical consultations as erotic skirmishes. Rowlandson's doctors gawp, grope, and glyster their patients in a most un-Hippocratic manner. In Medical Dispatch or Doctor Doubledose Killing Two Birds with One Stone (fig 2), with one podgy hand the physician takes the pulse of the cadaverous senseless invalid, while throwing an arm around the neck of the nubile girl. The “Composing Draught” and the opium pillbox on the table suggest the physician may be giving his patient a helping hand out of this world, so as to switch his medical ministrations to her maid.

    FIG 2
    FIG 2

    Rowlandson's Doctor Doubledose

    Sex and medicine coalesce; physical examination becomes a motif for fornication, and the practitioner's apparatus—his cane, enemas, lancets, squirts, and clyster pipes—assume an erotic air, sometimes bawdily comic.

    Medical violence and medical violation clearly preyed on people's minds. It may therefore have been obliquely comforting to perceive that, if the doctor were a threat, he was also a fool. The physician as pedant had long featured in the Commedia dell'Arte, offering models for Moliere's prating physicians and the asinine doctors in picaresque novels where they are duped by their wives and valets while pretending to omniscience.

    Lives at stake

    The black humour of fatuous physicians physicking gullible patients out of their lives never palled.

    Rowlandson's A Visit to the Doctor shows a rustic couple visiting a doctor's book-lined consulting room. “Do you see, Doctor,” the husband ventures, “my dame and I be come to ax you advice—we both of us eat well and drink well, and sleep well—yet still we be somewhat queerish.” Luckily the bewigged physician can solve all their problems. “You eat well—you drink well, and you sleep well—very good—you was perfectly right in coming to me, for depend upon it, I will give you something that shall do away with all these things!”

    Sometimes they neglect, sometimes they kill: and whenever two or three are gathered together, they fall out. In “The Chamber War,” part of Rowlandson's English Dance of Death series, the civil war among the physicians is so gross as to obviate description. Some attached verses gloss the skit:

    Sir Samuel, as it appears,

    Had reach'd the age of four score years.

    Lame, weak and deaf and almost blind,

    To his arm chair he was confined:

    But while there's Life, there's Hope, they say;

    And three physicians every day

    Came, gravely, for their daily pay.

    A nurse too, who her labours plied

    In watching sick men till they died,

    Had all that time, and longer, been

    The Mistress of the Chamber Scene.

    She did the sick man's food prepare,

    And nurs'd him with unwearied care.

    But still the Doctors came each day,

    And bore their golden Fees away.

    Sometimes the cartoon doctor is just a dupe, more naive than his ignoramus patients. In Cunicularii, or the Wise Men of Godliman in Consultation (1726), Hogarth mocked the noted accoucheur, Sir Richard Manningham, the Princess of Wales's man-midwife. With other doctors, Manningham had testified on behalf of a peasant women, Mary Toft, who had professed to give birth to litters of rabbits, enabling her to come to London, put herself on display and so make a fast buck. Small wonder Manningham appeared as “an occult philosopher searching into the depth of things.” Belief in the rabbit woman was a medical foible Hogarth often milked for a laugh.

    Not just fatuous, doctors were also depicted as pretenders to fashion. Dressed up to the nines in distinctive “physical wigs,” sporting their gold-headed canes, all pomp and polish, prattling on, indifferent to their charges, these practitioners were full of themselves. And vanity rode with mercenariness.

    Quackery

    If regular doctors suffered from such egregious faults and bad publicity, were not quacks ten times worse? Georgian culture took endless potshots at charlatans. Mountebanks in full cry offered the artist's dream subject: it was theatre, comic and grotesque, and it could serve as an all-purpose allegory. In Hogarth's Southwark Fair, a quack appears almost central, below the booth covering the church-tower. Promoting a pamphlet puffing his nostrums, the doctor eats fire to attract attention (and so becomes a fiery dragon). In zany's garb, his sidekick patters away, peddling the pills. Other artists also presented the charlatan as showman, singling out their weird and wonderful contraptions, as in Gillray's terrifying expose of Elisha Perkins' Metallic Tractors. These consisted of brass and iron rods, united like a tuning fork, one end rounded, the other pointed. Sold at a knock down five guineas, they concentrated galvanic electricity upon affected areas and wrought instant, painless cures.

    Cartoons played on the risque aspects of the irregulars. Many showed the nerve doctor and pioneer sex therapist, James Graham. He developed a mudbathing establishment; he employed scantily clad “goddesses of health” to arouse public curiosity (allegedly, one was Emma Lyon, the later Emma Hamilton), promoted a Celestial Bed guaranteed to restore potency, and lectured on the restoration of national virility.

    The quack who dominated the prints, however, was James Morison, whose “Universal Pills” were early Victorian England's best-selling medicine:

    My “Universal Pills” are quite divine!

    If one don't do, you may take nine.

    A caricature by George Cruikshank shows a huckster standing on a box of Universal Vegetable Pills—Morison's brand name—in a “before and after” scene. Morison was the most successful medical entrepreneur of his time. He first launched his pills in 1825, and they proved immensely popular. Rejecting the harsh “heavy metal” drugs of the faculty and advocating vegetable and herbal cures, Morison (in a manner today all too familiar) denounced the establishment and made a fortune.

    Contemporaries assailed quackery. But we must beware hindsight, for our judgments of quack cures do not always coincide with theirs. Thus it was perfectly plausible around 1800 to represent Jennerian vaccination as balderdash. In The Cow-Pock, Gillray spoofed variolation, implying that the vaccinated would develop horns, tails, and udders, while Lord Byron casually lumped Jenner together with Perkins:

    What varied wonders tempt us as they pass!

    The Cow-pox, Tractors, Galvanism, Gas

    In turns appear to make the vulgar stare,

    In the swoll'n bubble bursts—and all is air.

    Death's captains, Death's disciples

    Healers of all stripes were ubiquitously portrayed in popular culture as menacing buffoons. What might render the comedy not frivolous but black was that disease was no joke. To be precise, Death was the satanic jester, the grave enemy, the bitter fool. Medical humour was the child of desperation (fig 3).

    FIG 3
    FIG 3

    Death the jester's disciple

    And diseases were Death's captains. Maladies were represented as sinister manikins: goblins, demons, imps—energetic, well drilled, and deadly effective. Rowlandson excelled in personification of maladies as funny devils. Ague and Fever depicted a patient, teeth chattering, sitting holding his hands to a blazing fire. Ague—that is, malaria, then common in marshy areas—a sinuous, snaky monster, clutches at him, while Fever, a furry fiend, waits its turn. Personification of diseases remained popular, and Cruikshank often brought microbe men to life. Endless variations appeared on such themes: headache French style, headache English style; cholic, male and female alike.

    The black comedy of all these topoi was that death watermarked them all. Of course, there was nothing new in this. From the medieval danse macabre, death had partnered life, and the memento mori taught that one lived to die and died to live. Mutability and mortality, art historians have shown, constitute the hidden meanings of Dutch still life. The shocking fact about the cartoons is not just death's omnipresence but the role of doctors as Death's disciples; an unholy entente unites death, disease, and the doctors. Medicine itself is a plague—a theme magnificently embroidered in Rowlandson's wonderful English Dance of Death sequence. In dozens of images of Death stalking the living, the doctor there serves as Death's deputy. Death shadowed the anatomist in the mortuary and rode with the undertaker. And quackish apothecaries were also confederate with death. The image of Death as the doctor's overlord had an enduring resonance.

    Maladies and medicine loomed large in pre-modern culture precisely because it was all so near the bone. Disease, disfigurement, disability, and death elicited anger, explosive laughter, and all the elemental passions. Medicine was a double agent. It was desperately in demand. Yet it could be suspected as sleeping with the enemy. Doctors, death, and the devil easily changed places.

    A change of image

    The medical prints and jokes of the Georgian age really packed a punch. The later humour of Punch by contrast seems sedate. Above all, in Punch cartoons from the Victorian period through into the present century, practitioners rarely seem to be doing anything to their patients: they have ceased to be muggers, rapists, or murderers in disguise. No longer are patients being given enemas or having their legs sawn off, and surgeons no longer look like soldiers.

    These changes may in part reflect the fact that, in certain respects, medicine became less nakedly threatening to the body in the Victorian era. With the gradual demise of phlebotomy, therapeutics ceased to be automatically associated with bloodshed; the coming of anaesthesia took the unbearable pain and terror out of surgery; the dragon-like Sarah Gamp type of nurse became a thing of the past.

    They also doubtless register the triumph of Victorian prudery and highmindedness. Whatever John Bull and his wife might have felt about disease, death, and the doctors, it had ceased to be acceptable to display in the public press images of physicians touching up nubile patients or surgeons mangling bodies. The first 20 years of George Cruikshank's long career—he lived from 1792 to 1878—were marked by bawdiness; the last decades by the strictest decorum.

    But the distinctive style of Punch prints is also symptomatic of a real shift in the public image of, and fears about, medicine. The 18th century practitioner was chiefly lampooned as a dangerous ignoramus. His 19th and early 20th century successor was satirised for his aristocratic pretensions. He gave himself airs and graces, dressed in style, never got his hands dirty—and he was exceedingly expensive (fig 4). The standard cartoon physician was menacing through his insidious mixture of gentility and greed. Modern American medical humour has, not surprisingly, been obsessed with medical fees.

    FIG 4
    FIG 4

    Doctors in “Punch” aspired to an aristocratic lifestyle (1878). Reproduced by permission of “Punch”

    Another trend has become evident during the last hundred years: jokes have increasingly been directed not against the doctors but against the patients. Perhaps as the medical profession has grown more august and medicine more arcane, humorists find it easier to make fun of the ignorant folly of the client particularly in the guise of a bird brained, sexy woman: it is noteworthy that female doctors were also routinely caricatured earlier in the century (fig 5).

    FIG 5
    FIG 5

    The new breed of doctor — female — was routinely caricatured. Reproduced by permission of “Punch”

    And it is appropriate that the man who taught us the unconscious meaning of wit should have triggered the best modern humour. Today's most biting medical jokes (members of the BMA will be relieved to hear) are invariably targeted (fig 6) against the shrinks.

    FIG 6
    FIG 6

    Now psychiatrists are the main target of medical jokes

    It has been impossible to illustrate this paper as fully as one would like. No matter, for three anthologies of medical cartoons exemplify these themes very well. Kate Arnold-Forster and Nigel Tallis's The Bruising Apothecary: Images of Pharmacy and Medicine in Caricature (London: Pharmaceutical Press, 1989) is especially strong on the 18th century. Mr Punch Among the Doctors (London: Methuen, 1933) covers the first century of Punch; The New Yorker Book of Doctor and Psychiatrist Cartoons (London: Aurum Press, 1993) gives a taste of modern medical humour.