The
Pharmaceutical Journal Vol 266 No 7134 p191-195
Echoing down the years |
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The tercentenary of the Rose case |
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By John A. Hunt, PhD, FRPharmS |
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In February, 1701, a legal case commenced in London which would legitimise the place of the apothecary in the practice of medicine. This, together with subsequent events, set pharmacy in England and Wales on a path which differed from that in Scotland and in almost all countries in continental Europe. Its echoes are still with us today
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In 17th century Britain, medical services were available from physicians and from apothecaries, in addition to the inevitable collection of irregular and unqualified practitioners, wise women and quack doctors. Many of the sick had to rely on family recipes and advice from neighbours and grandmothers. The apothecaries had developed from the pepperers and spicers of the middle ages and had originally been members, in London, of the Grocers’ Company, founded in 1373. With increasing specialisation, the London apothecaries broke away and founded their own body, the Worshipful Society of Apothecaries, which received its Charter from King James I in December, 1617. It involved those practising up to seven miles from the City of London. Apprenticeship to an established apothecary was the usual route for admission to the society. Physicians were university-educated men versed in the classical traditions of medicine and the writings of Hippocrates, Galen and the other great figures of the past. By tradition the apothecary was the purveyor and compounder of drugs and dispenser of the physicians’ prescriptions. Some physicians would employ an apothecary; others would use the services of an apothecary as required. The Royal household and some of the larger estates in the land employed their own apothecaries, who would supply materials for spiced wine and other domestic requirements in addition to medicines. The demarcation between the activities of physicians and apothecaries outside London was ill-defined. No formal system of education existed for either and there were many grey areas. It is believed that, as late as the 18th century, some grocers who sold drugs as part of their stock-in-trade gradually moved into the medical field and in due course changed the board over the shop door to "apothecary" or "surgeon", as they wished.1 In this situation it was inevitable that some operators would stray into the territory which the physicians regarded as their own, and that the *College of Physicians would be requested by its members to safeguard their interests. It has been suggested that, in Tudor London, the simple practicalities of life made the physicians’ situation untenable. With an estimated two dozen or so licensed physicians in the city in the later part of the 16th century, and population rising towards 200,000 by the end of the century, resort to apothecaries and others in the first instance was inevitable.2 The college attempted prosecution of apothecaries or others who indulged in medical practice. The result was an extended dispute in which London physicians and apothecaries, supported by their official bodies, fought over the demarcation between their roles. Both sides sought parliamentary support through Bills at various times and arguments varied between pamphlets, insults, lawsuits, joint meetings seeking improved understanding and the setting up of rival dispensaries. |
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*The Royal College of Physicians, founded in 1518, is referred to as “the college” throughout this article. The Royal appellation was not applied at any specific date but appears to have been adopted gradually by custom. The adoption probably began after the Restoration and is believed to have been well accepted by the time of the Rose case. References to “the society” indicate the Worshipful Society of Apothecaries of London. |
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Commonwealth and restorationThe members of the College of Physicians were normally graduates of the universities of Oxford or Cambridge. Their services were expensive and beyond the reach of the great majority of the population. Their patients were drawn from the wealthy classes and in the great unrest during the reign of Charles I their sympathies were largely with the royalist cause. When civil war commenced in 1642 a period began in which many of these wealthy patrons left the capital. During the interregnum of 1649 to 1660 the absence of the King’s Court from London removed opportunity and influence from the college. The Society of Apothecaries included some royalist members but the trading apothecaries favoured the parliamentary cause. For example, Paul de Laune, brother of Gideon de Laune, the founder of the society, had royalist connections, but served as a physician with the parliamentary army of the Earl of Essex.3 When members of the college returned to London with the restoration of the monarchy in 1660 they discovered that the apothecaries had prospered in their absence and that it could prove difficult to re-establish themselves. The college obtained a new charter in 1663 but a subsequent Bill to Parliament intended to strengthen their position does not appear to have been ratified.4 Plague and fire
These difficult events for the college were soon
to be overtaken by the severe plague of the summer of 1665, resulting,
in London, in an official total of 68,596 deaths. During the emergency
most physicians left the city in the wake of their wealthy patrons. ReconstructionIt took two days for the Great Fire to spread from Pudding Lane, to reach Blackfriars on September 4, 1666, when Apothecaries’ Hall was destroyed. The delay allowed time to save records, portraits, pewter and plate. Following the Rebuilding Act of February 1667 property owners were able to proceed with reconstruction. The society moved quickly and, by August 1668, some 22,000 bricks were ready for the rebuilding, which proceeded rapidly. Following their loss of influence during both the Commonwealth period and the plague, the physicians must have envied the prosperity of the apothecaries, who had rapidly rebuilt their hall. The physicians were unable to meet in their own new hall until 1675. It has been suggested that during this period patients were increasingly calling in the apothecaries direct and addressing them as "doctor", thus granting them a title previously reserved for physicians holding a doctorate from a university,6 although some apothecaries did hold doctorates from continental universities. Presumably patients regarded apothecaries as being equally well qualified for the title. The description was obviously convenient to patients and gradually became the universally accepted title for a medical practitioner. Bearing in mind the state of medical and pharmaceutical knowledge in the 17th century, one wonders who would have provided the most effective treatment. As late as 1810 Jeremiah Jenkins was writing: "The apothecary of this country is qualified by education to attend at the bedside of the sick, and, being in general better acquainted with pharmacy than the physicians of English universities . . . is often the most successful practitioner."7 Disputes and dispensariesThe physicians attributed their comparative loss of influence and prosperity to the invasion of their monopoly of practice by "apothecary empirics" who had diverted their fees away. The apothecaries objected to the use of secret remedies by physicians and to their dispensing their own medicines. Numerous pamphlets were printed during the dispute, exercising the various claims and arguments. In 1690, a joint committee of physicians and apothecaries was set up in an attempt to draft proposals for fair dealing, but appears to have had little effect. In June, 1697, the college moved into the enemy’s territory by opening a public dispensary in Warwick Lane, followed by two branches. An attempt was also made to secure the supply of drugs to the navy but was not successful. The dispensary was never very successful and closed in 1725. The tide, it has been suggested, was running in favour of the apothecaries.8 Possibly they outnumbered the physicians by 10 to one at the beginning of the 18th century and by at least as many in the provinces.1 The physicians had obvious cause for grievance. In a further initiative they sought to institute a system in which directions to the patient, in English, would be handed directly to him or her, and not disclosed to the apothecary as part of the prescription, the argument being that apothecaries were learning medical treatment from directions included in prescriptions. Known as the "Statute of English Directions", it was unsuccessful and was withdrawn in 1707. The apothecary of St Martin’s-in-the-Fields and the butcher of Hungerford MarketWilliam Rose was an apothecary and a liveryman of the society, practising in St Nicholas Lane, St Martin’s-in-the-Fields. During the winter of 1699–1700 Rose treated William Seale, a butcher in nearby Hungerford Market, compounding and administering medicines to him. Seale, who claimed that his condition deteriorated following treatment, received a charge from Rose for medicines of £50 — a very large sum at that time. By tradition, physicians charged for consultation and advice, whereas apothecaries charged for medicines supplied — an obvious temptation to over-medication. Seale claimed to have then visited the dispensary of the college, where he was successfully treated for £2. Seale sought redress against Rose by taking his case to the College of Physicians, which must have seen it as an attractive subject for a test case. The Rose caseIn February, 1701, the college brought its case against Rose, based on an Act of Henry VIII which confirmed the original charter of the college. The case was brought before the Court of Queen’s Bench under Lord Chief Justice Holt and a jury. It was established by the court that Rose had attended Seale at home and administered medicine to him, and had sent to him "boluses, electuaries and juleps", without licence from the college, without the direction of any physician and without taking or demanding any fee for his advice. The court agreed that "practising physic" constituted "judging the disease and its nature from the constitution of the patient and many other circumstances; in judging the fittest and properest remedy for the disease; in ordering the application of the remedy to the disease. That the proper business of an apothecary was to make and compound or prepare the prescription of the doctor pursuant to his directions and that Rose had taken it upon himself to judge the disease and fitness of remedy." Judgment and appealJudgment was given in favour of the college, albeit reluctantly. It was evident that Rose was only following custom and practice which had, by then, become well established. While the Lord Chief Justice had felt compelled to concede the point of law he described the college’s action as "extravagant". Following the judgment, the Attorney General advised the Society of Apothecaries to bring a "Writ of Error" to the House of Lords, giving his opinion that a reversal would follow. Rose, supported by the society, proceeded on that basis. The case was heard in the Lords on March 15, 1704. Counsel for Rose, Mr Samuel Dodd, submitted that, notwithstanding the charter of the college and the Act of Henry VIII ("that only those who have learned and studied physic should be permitted to practise it"), that long before and ever since that Act, the trade of apothecary had been looked upon as a lawful and esteemed trade in making and compounding medicines and giving them to all persons at reasonable prices, and that several physicians were taking on various methods of monopolising the whole business of physic, both compounding, selling and prescribing; that they were setting up shops for making and selling medicines for their own gain and bringing vexatious prosecutions upon pretence of a clause in their charter. In this spirited attack Dodd had not missed the opportunity of using the college’s move into dispensaries as a weapon against them. In summing up, Dodd claimed that:
The response of the college
The case for the college was made by its counsel Mr Francis Brown, who argued that the college was seeking to prevent the apothecaries from attending the more serious cases. Stating the principal arguments he summarised:
Interestingly, Brown went on to claim that "the true reason" was that the apothecaries might "slide themselves into practice in all", which would discourage the faculty of physic and "deprive the gentry of one of the professions by which their younger sons might honourably subsist, and be a great detriment to the universities". Seen against the health care needs of the multitude, the observer of today asks himself how much weight the needs of the younger sons of the gentry might have carried in the argument. Continuing with, perhaps, more consideration for the general population, Brown concluded his case with the statement: "In order to suppress quacks and empirics, for the security of the Queen’s subjects in general, but more especially the common people, it is humbly hoped your Lordships will affirm the judgment." Outcome and consequences of the appeal
Having heard counsel, their Lordships reversed the judgment of the Queen’s Bench, holding that it was contrary to custom but also against the public interest to prevent the giving of advice and treatment by the apothecaries. After the case, the feud died down and, particularly when Sir Hans Sloane became president of the college, relations became more amicable. The result of the Rose case was to legitimise the activities of apothecaries in the practice of physic and this was to have long-lasting effects. Apothecaries gradually moved into the area which we now regard as "general practice", although as late as the mid-19th century the terms "apothecary" or "surgeon-apothecary" were still in use. In his major study of the history of general practice, Dr Irvine Loudon was unable to discover reference to the term "general practitioner", in its modern sense, until 1809. The Metropolitan Society of General Practitioners was founded in 1830 but it was late in the century before the term was widely employed. Despite this movement, not all apothecaries followed the trend. Some continued to concentrate on pharmacy business and became very successful. For example the major company Allen & Hanburys was founded in the city by the apothecary Sylvanus Bevan in 1715, after the Rose case. The chemists and druggistsWhile moving into the field which the physicians had regarded as their own preserve, the apothecaries still sought to retain their compounding and dispensing traditions and business. In this endeavour they found themselves in competition with the rapidly developing trade of the chemists and druggists, who kept open shop for the supply and dispensing of medicines. It is probable that the latter were encouraged in some areas by the physicians, who would send their own prescriptions in that direction in order to deny business to their rivals, the apothecaries. In an attempt to exercise control over the chemists and druggists, who had no formal system of training or any regulatory body, the Society of Apothecaries attempted to promote a Bill through Parliament which would empower them to visit shops and destroy unsatisfactory material. They already had this right in respect of apothecaries’ shops in London. However, Parliament decided to address the problem by reviving a lapsed Physicians’ Bill of 1724 which gave the college the right to inspect the shops of all medicine traders without reference to the society. The society, believing that the college was not competent to do this, found itself having to oppose what it had intended to be its own Bill. It petitioned Parliament and a parliamentary committee was ordered. In the event, Parliament was prorogued and the Bill became known as "The Failed Bill of 1748".8 While many apothecaries were developing their business in the practice of family medicine, the chemists and druggists were, by custom and practice, consolidating their own position as compounders and dispensers of medicines. From these roots, they would evolve into the pharmacists of the 20th century. The Apothecaries Act 1815
In 1812, a heavy tax on glass was introduced to help finance the Napoleonic wars. Due to its impact on the users of glass bottles, an association was formed to protect the interest of apothecaries and surgeon apothecaries. The association soon turned its concerns to the encroachment of the chemists, druggists and "improper persons" on the dispensing business of its members, and sought to introduce educational requirements and licensing as a means of controlling the chemists and druggists. A Bill was promoted but was opposed by the colleges of physicians and surgeons and also by London chemists and druggists. Later, the College of Physicians agreed to reopen the matter provided that the administration of any Act would be the responsibility of the Society of Apothecaries, and that apothecaries would be obliged to dispense the prescriptions of physicians whether they wished to do so or not. This, suggests Loudon, was as though they wished for retaliation for the college’s defeat in the Rose case a century earlier.9 After prolonged arguments between the various interests, the Apothecaries Act received Royal assent on July 12, 1815. It gave the society power to examine and license apothecaries who had served a five-year apprenticeship and received "a sufficient medical education", and also to search the premises of apothecaries and destroy faulty drugs. Clauses in the Act prevented it from interfering with the activities of the colleges of physicians and surgeons or with the business of chemists and druggists. With effect from August 1, 1815, nobody was permitted to practise as an apothecary unless licensed by the Society or previously so engaged, but otherwise the Act did little to prevent irregular practice by unqualified persons, over which there was little control until the Pharmacy Act of 1852 and the Medical Act of 1858. The emerging pattern of primary health care
Apart from the Rose case and the Apothecaries Act there were many other factors influencing developments. Dr Juanita Burnby has drawn attention to the case of Thomas Edwards, an Exeter apothecary, who won the right to practise as a physician as early as 1607, which had as much impact in the provinces as the Rose case had in London.8 The combination of these influences was such that, by the 19th century, the apothecaries had evolved from those who originally were compounders and dispensers of drugs, to become general practitioners of medicine. In turn, the traders keeping open shop for the sale of chemicals and drugs had moved into the operations of compounding and dispensing which were being neglected by the apothecaries in their pursuit of medicine. These chemists and druggists, through the foundation of the Pharmaceutical Society and its promotion of education, examination and registration, evolved into the pharmacists of the later 19th and 20th centuries. But a major problem remained for pharmacy. The emerging general practitioner, although trained primarily in medicine, held to his roots in the world of the apothecary and insisted, in most cases, on dispensing for his own patients, rather than writing a prescription to be taken to a pharmacist. ScotlandThe Rose case occurred shortly before the Act of Union of 1707 and had no effect in Scotland. The College of Physicians of Edinburgh, founded in 1681, was empowered to inspect the premises of apothecaries and destroy substandard materials. For a period it held powers to prevent medical practitioners from dispensing and the place of the apothecary as the compounder and dispenser of medicines was established. The Society of Druggist-Apothecaries of Edinburgh was founded in Edinburgh in 1785 and imposed high standards. In consequence the Scottish apothecary did not move into the field of medicine but concentrated on pharmaceutical developments. This resulted in businesses of high standing, such as those of John Duncan, Andrew Flockhart, Thomas and Henry Smith and John Macfarlan. Edinburgh became an centre of pharmaceutical excellence and remains a major world producer of alkaloids to this day. Importantly, the Scottish general practitioner wrote prescriptions to be taken to the pharmacy and did not carry out his own dispensing as a routine. In this way, Scotland developed along the lines of pharmacy in continental Europe.10 Only in England and Wales did medical practitioners routinely carry out their own dispensing. Dispensing doctorsAt the end of the 19th century, community pharmacy in England and Wales was not well placed. A large part of the nation’s dispensing was carried out by the doctors themselves or by unqualified staff. It has been estimated that over 90 per cent of prescriptions were dealt with in this manner.11 Some pharmacies rarely or never saw a prescription and the Pharmaceutical Society’s examiners were faced with students who had served their apprenticeships in pharmacies where the dispensing of a doctor’s prescription was a rare event. In this situation the pharmacist was compelled to make his living from counter-prescribing and the sale of drugs and proprietaries, in the face of price-cutting by the emerging chain stores and large department stores. This sad state of affairs persisted until the National Insurance Act of 1911, which required that medicines prescribed for the 14 million people covered by the scheme must be dispensed by or under the supervision of a pharmacist operating in a pharmacy contracted for the purpose. It is thought that one factor bringing about this revolutionary change in pharmacy was the partial modelling of the National Health Insurance scheme on the well-established health insurance scheme operating in Germany, where, as in other European countries, dispensing by doctors was not permitted. Trade or profession?The concentration on over-the-counter business, which was forced upon late 19th century pharmacists in England and Wales by the presence of the dispensing doctor in both rural and urban locations, inevitably conveyed the impression that pharmacy was a retail trade. It can be argued that this was a contributory factor to the obvious contrast with the far more professional style of pharmacies, such as those of France and Germany. These differences have persisted. The image of pharmacy as a trade was reflected in government attitudes and legislation. The Pharmacy Acts of 1868 and 1908 concerned themselves with the sale of poisons: dispensing as a professional activity was completely ignored. When the National Insurance Bill was introduced to Parliament by Lloyd George on May 4, 1911, the Pharmaceutical Society was faced with the threat that the dispensing of prescriptions might be carried out in dispensaries opened for the purpose, rather than in pharmacies. Many readers, at the time, must have been astonished when, in a perceptive editorial, the Lancet wrote: "In view of the anomalous condition of pharmacy law this provision [of the Bill] appears inadequate to secure that the dispensing of medicines for insurance patients should be done by pharmacists. Dispensing does not necessarily entail a sale, and under the Pharmacy Acts it is the sale of a poison by an unqualified person and not the dispensing of it which constitutes an offence."12 It is remarkable that over half a century of pharmacy legislation had ignored the professional control of dispensing, and that pharmacists had no legal protection in connection with that activity, other than their restricted titles. Pharmacy was regarded, by the law, as a retail trade. Echoes of the pastThe introduction of the National Health Service in 1948 brought about the end of doctor dispensing in urban areas of England and Wales. Before that, many doctors had continued to dispense for those of their own patients who were not covered by the National Health Insurance scheme. This meant that many "dependants" — the wives and children of employed men — still received a "doctor’s bottle" when visiting the surgery, until July, 1948. Many of these mixtures were dispensed from concentrates supplied by wholesale druggists. The National Health Service, like the National Health Insurance scheme before it, allowed doctors to dispense in rural areas, causing ongoing problems for pharmacies in some localities to this day. The English apothecary who, encouraged by the Rose case, moved into the general practice of medicine has never quite relinquished his earlier dispensing tradition. The faint echoes of the Rose case ring down three centuries, both in some attitudes to dispensing, and in the public image of British pharmacy. |
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Note on dating Throughout this article ‘new style’ dating is used. The Gregorian calendar was adopted in England in 1752, when the New Year commenced on January 1 (as it had done in Scotland since 1600) instead of on Lady Day, March 25. Before that time dates occurring before Lady Day were dated with the number of the previous year. For example the March date of the Writ of Error in the Rose case appears in original documents as 1703, whereas we regard the whole of that year as 1704. |
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Acknowledgments The author acknowledges with
thanks the help given by Mrs D. Cook, archivist of the Society of Apothecaries,
by allowing access to the Society’s archives and supplying illustrations
and advice. |
Dr Hunt is a retired industrial pharmacist and a past president of the British Society for the History of Pharmacy