The nineteenth-century was arguably the most significant period in medical history, famously known as the period of medical reform. This century saw legislative milestones reached, advances in medical education and professional unity achieved, as well as the development of medical ethics literature in Britain. By building a more sophisticated industry, medicine was given professional qualities that did not exist in the centuries before. In this essay, I shall present the more general ways in which medicine was professionalised such as the growth of medical education and the introduction of various professional societies, and from there highlight the more specific actions and reforms which these societies initiated, all contributing towards a newer, more polished medical industry. Given that the term 'professionalise' has multiple definitions and connotations, I shall clarify its meaning for each different point I make. However, as a standard reference point, I will define the term professionalise as 'to give (an occupation, activity, or group) professional qualities, typically by increasing training or raising required qualifications' (Oxford English Dictionary, 2018).
In the nineteenth-century there was a substantial growth of academic medicine and professional unity. 'Voluntary hospitals became centres of teaching, care and research, whilst medical education at London University and several provincial medical schools was established' (quizlet, 2018). As a consequence, required qualifications to become a practitioner were raised, with the introduction of the 'License of the Society of Apothecaries' (LSA) in 1815 and the 'Member of the Royal College of Surgeons' in 1800. The introduction of the dual qualifications of the early 'general practitioner' ('College and Hall') is quoted not only as 'evidence of the rise of the lower ranks of the profession, but also of the protection of the public from unqualified medical practitioners' (Loudon, 1986), which meant the pool of practitioners became more competent and able to provide an increasingly professional service. Moreover, professional societies were founded, including the Provincial Medical and Surgical Association in 1832 which became the British Medical Association in 1856, and is cited 'as evidence of the birth of a new spirit of professional unity' (Loudon, 1986). The nineteenth-century was also coined the birth of scientific medicine, a subject which Bynum specifically focuses on in his work 'Science and the Practice of Medicine in the Nineteenth Century' (1994). Within it, he details many advances in medical technology such as Laennec's stethoscope and Ludwig's kymograph which measures changes in arterial blood pressure. By broadening the definition of 'professionalise' to giving professional character to medicine, these inventions led to the increase in specialist knowledge which in turn resulted in a significant rise in medical knowledge, which could then lead to practitioners' patients being treated in a manner which is far more professional than it would have been without these inventions.
As aforementioned, in this century legislative milestones were reached in the form of two acts. Firstly, the Apothecaries Act and secondly the Medical Act, enacted in 1815 and 1858 respectively. Before the Apothecaries Act, 'regular practitioners' were mere 'academic doctors with no certain indication of professional qualification, physicians who held appointments to a hospital dispensary, army and navy surgeons or even members of the 'Company of Surgeons' and 'Company of Apothecaries'' (quizlet, 2018). Importantly, there were a relatively small number of university-trained doctors. The act, therefore, aimed to eliminate the gap between regular practitioners and elite doctors by increasing their medical knowledge, 'in this way creating a uniform licence to practise medicine in Britain' (quizlet, 2018). The immediate cause of this movement, however, was due to the competition from 'dispensing druggists, who, formerly were only wholesalers supplying raw drugs to medical practitioners but began setting up their own shops and selling medicines over the counter, dispensing medicines, giving medical advice, performing venesection and bone-setting as well as visiting the sick' (quizlet, 2018). As a consequence, regular practitioners took exception and demanded that all physicians, surgeons and apothecaries were assessed under legal regulation, a system which involved the undertaking of education, examination and licensing. Thus, in 1812 the Association of Apothecaries and Surgeon-Apothecaries was established, amassing in excess of three thousand members by 1815, and within this group the attempt to filter out druggists and midwives in order to create a select group of practitioners commenced. However, this movement was successfully opposed by the Royal College of Physicians and by the Royal College of Surgeons founded in 1800. The latter was 'dominated by elite London surgeons and excluded surgeons practising midwifery or pharmacy from office or privilege in the college' (quizlet, 2018). As a result, this particular movement for a more professionalised industry was obstructed and slowed.
However, the Apothecaries Act was enacted by the Government. This forced people to study for an LSA, and those who practised without an LSA could now be prosecuted. It was sometimes used against regular competitors such as Edinburgh graduates practising without LSA in England, but there was bitterness within the medical profession about this law and there is a case to argue that this Act actually had a minimal effect on the general professionalism of medicine. Moreover, 'a general problem of an overlap in clinical practice between physicians, surgeons and surgeon-apothecaries emerged, with complaints about overcrowding of the profession becoming common' (quizlet, 2018). However, the fact that the industry was demanding higher qualifications and therefore higher standards, as well as the strong intra-professional competition indicates that there was, in fact, an increase in professionalism. The Act undoubtedly highlights a major transition in British medical education: 'the shift from hap-hazard, individualistic and unregulated instruction to a standardised, monitored, and required series of course and clinical practice for non-university medical men' (Wear, 1991). Thus, despite the drawbacks, the reform did generate professional qualities for medicine.
After 'fifteen unsuccessful bills since 1840, the 1858 Medical Act established the General Medical Council as a place of registration (licensing) of medical practitioners' (quizlet, 2018). Despite clearly involving ulterior motivations such as a degree of monopoly and 'the maintenance of superior remuneration and status' (Waddington, 1994) from which practitioners could benefit, there is no doubt that the Act also had a significant effect on the professionalism of medicine. It became a 'general consensus amongst medical men on the need to restrict entry to the profession' (Waddington, 1994), and the Lancet reviewed a selection of schemes to fulfil this. They came to the conclusion that the best way to achieve this was by 'making the standard of qualification high, as well as in medicine as in letters and science' (Waddington, 1994). Consequently, the number of unqualified practitioners entering the profession reduced in the twenty years following the passage of the Act, 'the growth in number of medical practitioners in England and Wales was quite minimal and was far outstripped by the growth of the total population' (Waddington, 1994). The quality of practitioner also improved as a consequence of increasing competition from medical schools, and therefore public welfare flourished. This process is known as 'occupational closure' and is a typical symptom of professionalization. Furthermore, the 'Medical Act ratified the pluralistic system which stated that either the corporations (Colleges of Physicians and Surgeons) or the universities could examine and certify a candidate's fitness to practise medicine, who was then put to the General Medical Council's Medical Register' (quizlet, 2018). The Council had also been charged with overseeing educational standards of medical schools and examining bodies, ensuring the required criterions were being met and professional conduct was maintained. The fact that the council was initiated to supervise the conduct of medical members and demark the qualified from the unqualified is certainly a shift towards a profession of higher competence.
Not only was medicine professionalised by raising the standards of qualification and reducing the number of unqualified practitioners in the profession as a result of the Medical Act, but also by establishing a code of Medical Ethics. Before the General Medical Council was founded, medical ethics literature was known and appreciated in Britain but was not binding on medical practitioners. The Council thus had two functions; firstly, 'the registration of medical practitioners by setting and monitoring educational standards and secondly, the erasure of names from the register' (quizlet, 2018). The latter was achieved by holding judicial, disciplinary inquiries and declaring standards of professional conduct and medical ethics. In exercising these functions, the Council became indirectly 'involved in the declaration of acceptable standards of professional conduct and medical ethics' (Smith, 1993). Before this, there were no standards of conduct stated, nor ethical guidelines, and whilst Thomas Percival's book Medical Ethics (1803) was very influential in America, 'it would not appear to have been available for British students to buy in the mid-nineteenth-century' (Baker, 1995). Consequently, standards of good professional conduct developed out of decisions in disciplinary cases between doctor and patient, with other agendas concerning 'the doctor's social responsibilities, and his attitudes towards actual or suspected criminals and their victims' (Baker, 1995) left out. From a legal standpoint, in section XXIX of the Medical Act, the General Medical Council was able to 'erase the name of a medical practitioner from the Register' (Smith, 1993), if the person had been convicted of a felony or misdemeanour in a British court or has been found guilty of 'infamous conduct [by the Council] after due inquiry' (Smith, 1993). By enacting legislation and clamping down on disciplinary issues of practitioners by ensuring each practitioner was carrying out their job in the correct, ethical and most beneficial way, the Medical Act created a much tighter and professionalised medical industry.
The nineteenth-century also saw the dramatic disappearance of the patient's narrative. Using an example from June 1744, Mary Fissell wrote that after a patient visited surgeon Alexander Morgan, he noted down how his patient had fallen ill, and yet 'while these were Morgan's words, they were also those of his patient. For it was the patient who supplied him with the details of how he came to fall ill…it was the patient who constructed a narrative from the physical manifestations of his or her illness' (Wear, 1991). Early modern medicine was dominated by the client and doctors clearly lacked confidence to assert their own decisions on matters. Fissell agrees with this as she argues that doctors 'lacked control over the production or consumption of such knowledge and had to tailor their diagnosis and treatment accordingly' (Wear, 1991). This is where the invention of hospital medicine became so pivotal; it knocked the patient's narrative down from its pedestal into redundancy as medicine began to focus on signs and symptoms, which provided doctors with a diagnosis rather than a mere estimation. By the nineteenth-century the patient's narrative had entirely vanished, with descriptions of a boy in hospital coming from 'the physical examination of the patient…the sole mention of the patient's perception, 'he complained of a slight headache', was merely formulaic' (Wear, 1991). Medical knowledge had evolved, and doctors had a medical knowledge which was far greater than the levels centuries before, with 'the patient's narrative being replaced by physical diagnosis and post-mortem dissection' (Wear, 1991). Thus, they provided medical diagnosis' far superior from previous centuries, in this way providing a much clearer and professional service to their patients.
Whilst it is true that there were limitations to the various strategies implemented in the nineteenth-century in relation to medical practice, there is no doubt that medicine in this century saw a dramatic increase in professionalism. By introducing the Apothecaries Act and Medical Act, general practitioners were better qualified as well as more specialised, which meant they could provide more professional information to their patients. This was not only maintained but also increased by the General Medical Council who enforced the upkeep of the practitioners' professional conduct, and also played the key role of updating ethical guidance which would preserve suitable standards and morally sound practice. The disappearance of the patient's narrative ties all these points together nicely. As practitioners developed a deeper, more scientific knowledge, required by the Acts and enforced by the General Medical Council, patients were exposed to a more reliable, structured and professional medical system.