‘The primitive does not distinguish between medicine, magic and religion. To him they are one, a set of practices intended to protect him from evil forces.’
Sigerist (1951: 127)
This topic and the next provide an historical overview of the development of the principle of medical self-regulation, as institutionalised in the United Kingdom in the form of the General Medical Council. They give a necessary background to subsequent discussion in topics four and five of sociological perspectives pertaining to the study of professional regulation. For many sociologists, medical power ultimately rests on the professions ability to exclude third parties – be they patients, other professional groups or the state – from the technical evaluation of group members’ activities. This may well be true and the 1858 Medical Act certainly established professional control over entry onto and exit from a legally underwritten register of state approved medical practitioners. However, before the 1858 Act is discussed it is necessary to tell the story of the development of modern scientific medicine to draw out a key theme for subsequent exploration in relation to the theoretical frameworks sociologists have utilised when analysing the professions. Namely, that the state may well have acted in recent times to limit the amount of occupational control the medical profession collectively possesses over the regulation of medical training and practice, but nevertheless medical and state forms of governance are interdependent, as well as to no small degree, mutually sustaining. Indeed, as will become clear as the next five topics unfold, perhaps the key challenge facing current sociological theorising of contemporary reforms in medical regulation is how best to understand the nature of contemporary changes in the governance of the professions in relation to broader social-political changes in the nature and goal of legitimate governing regimes (Rose 2000). Consequently, it is necessary to tell the story of the development of modern medicine and its governance from its early beginnings. This requires going back in time well over two thousand years.
Western philosophy typically views ancient Greek civilization as the cradle of rational enquiry and modern science. According to canonical tradition, modern science in the form of natural philosophy is said to have begun when Thales of Miletus predicted an eclipse of the sun in 585 BC. Thales was the first in a succession of thinkers known as the Pre-Socratic philosophers who lived before or during the lifetime of Socrates (470-399 BC). These individuals did not belong to any unified school of thought, but shared a commitment to rational empirical inquiry and the belief that the natural world could be explained in terms that did not refer to anything beyond nature itself. This viewpoint influenced the early teachers of Greek society – the Sophists – and Socrates whose pupil Plato established his Academy as a learning institution built upon dialectical argument and the cultivation of the mind. It is also what separates early Greek from Egyptian and Babylonian thought. True, the Babylonians and Egyptians made advances in mathematics, astronomy and medicine that informed the development of early Greek philosophy and science, but unlike the Greeks they did not possess a thorough going commitment to observation, reason and experiment. For example, the famous Edwin Smith papyrus, which dates from at least 1600 BC, contains an account of forty eight surgical cases divided into sections pertaining to title, examination, diagnosis and treatment. Illustrating that the Egyptians were committed to recording empirical data in much the same way as later Hippocratic doctors did (Allen et al 2005). Yet even this text, which is generally free of superstition, turns in case nine to supernatural aids when it details a charm that is to be recited to ensure a recommended remedy is effective. Conversely, early Greek medical texts in the Hippocratic tradition, for instance the treatise On the Sacred Disease (400 BC), illustrate a growing refutation of superstitious beliefs. In this case in regards to epilepsy:
‘I do not believe that the “Sacred Disease ” is any more divine or sacred than any other disease but, on the contrary, has specific characteristics and a definite cause. Nevertheless, because it is completely different from other diseases, it has been regarded as a divine visitation by those who, being only human, view it with ignorance and astonishment.’
Chadwick and Mann (1950: 1)
Hippocrates (450 BC to 370 BC) is best known for his oath, which combined the practice of medicine with moral values which are still highly relevant today. Including a duty to help the sick, to reframe from doing harm as well as maintain patient confidentiality. The oath also includes a call for an apprenticeship model of medical learning with masters passing on ‘trade secrets’ to selected apprentices. This being an early sign of medicines exclusive attitude towards outsiders – Hippocrates believed that medicine should be practiced by a special elite group of people (i.e natural philosophers) who share knowledge and insights freely with each other but not patients (King 2001). Additionally, the oath precluded practitioners from carrying out surgery, it being deemed not suitable for early Greek gentlemen of learning to perform surgical procedures as these were deemed to be manual work. So creating early on the distinction which is still with us today between physician and surgeon. While the all male make up of the ancient Greek medical club somewhat supports the view of authors operating from a Feminist perspective that far from being a ‘gender neutral’ enterprise medicine in fact has historically reflected, and indeed in many ways reinforced, the patriarchal nature of society through endorsing social practices which seek to place women firmly within the private sphere of home and family (Riska 2001). A point discussed in more detail in topic four.
The Hippocratic Oath of the early Greek medical club can be said to have began the long public relations exercise still present today of viewing doctors as an elite group of individuals providing a disinterested service to the needy with absolute integrity and honesty. Hippocrates successor and the father of western learned medicine, Galen (129 to 200 AD), similarly stressed that a good physician should possess a detailed knowledge of the body, a love of philosophy and respect for human life. Given that it is Galen’s theoretical framework that medieval medicine in Europe drew upon until the rise of modern scientific biomedical model in the eighteenth and nineteenth centuries, it is necessary to outline its main features and historical trajectory.
‘Certain basic physiological concepts and associated therapeutic methods – notably humoral theory and the practice of bloodletting to get rid of bad humors – had a continuous life extending from Greek antiquity into the nineteenth century.’
Siraisis (1990: 70 – 71)
Though it was first challenged as early as the sixteenth century by the Swedish physician Paracelsus (1493 to 1541) it is generally accepted by medical historians (i.e. Siraisis 1990 and Porter 1995) that the Galenic humoral tradition dominated western medicine throughout the middle ages and was influential until the beginning of the nineteenth century. As Turner (1995: 29) notes, ‘Galen’s work ‘On the Conduct of Anatomies’ became the definitive source for medical understanding of the structure and function of the human body until it was successfully challenged in the late sixteenth century’. The topic will discuss the challenges to the Galenic tradition in a moment but first it will briefly outline the main features of the Galenic worldview.
The ancient Greek Hippocratic-Galenic medical tradition, along with much of early Greek science and philosophy, was transmitted from Arabic and Latin texts to the West in the twelve and thirteen centuries as the first modern centres of academic learning – the University – were established in Italy, France, Germany and England (O’Malley 1970). As would be expected the Galenic tradition believed in natural causes for disease. Indeed it perceived disease to be an environmental but ultimately an individual humoral phenomena. The world was conceived in terms of consisting of four elements – fire, earth, air and water – and individuals as having four humors – black bile, yellow or red bile, blood and phlegm – as well as four personality types – sanguine, phlegmatic, choleric and melancholic (Lindeman 1999). Those individuals with a preponderance for phlegm tended to be heavy and slow, those with to much blood sanguine, those with too much yellow or red bile quarrelsome and, finally, those with to much black bile melancholic (Temkin 1973). Good health rested on the proper balance of a person’s four humors in line with their personality type. Illness and disease came about due to their imbalance. A state of affairs that could be influenced by the environment, for instance, having hot summers when ones personality type and humors required a mild one could cause illness. Particularly as disease was specific to individuals and any alteration in their humors due to changing environmental conditions could place them in mortal danger. Standard therapies to readjust imbalances included inducing vomiting and, of course, bleeding (a tradition which went back to ancient Greece). Yet humoral medicine was also heavily focused on prevention.
‘In humoral medicine, prevention…was as important as treatment. The best means of maintaining health was to practice moderation in all things, especially in the use of…(l) air, (2) sleep and waking, (3) food and drink, (4) rest and exercise, (5) excretion and retention and (6) the passions or emotions. A healthy regimen was predicted on observing these rules of nature and avoiding exhaustion, overheating, overeating, excessive consumption of spirits, and immoderate desires. Such ideas were prevalent, and informed not only medical theories but more popular versions of health and illness as well.’
Lindeman (1999: 10)
Galenic Medicine and the Christian Worldview
This focus on prevention as much as cure reflects humoral medicines origin in ancient Greece and its affiliation with natural philosophy and concern with the good life. To be sure, as Turner (1995: 20) notes, ‘there was considerable conflict between the secular assumptions of Greek Medicine and the spiritual aims of Christian religious practice’. But it equally can be argued that there was considerable congruence between the two, particularly given humoral medicines’ focus on moderation and the need for the individual to take responsibility for their humor to ensure healthy living. In short, both operate within a moral discourse which promotes a set of practices for the regulation of the body and the mind (and the Christian concept of the soul) at the level of the individual and the population. Indeed, at this point in time the church had powers to license practitioners due to its control of the early universities. With Henry VIII for example making it offence in 1511 to practice ‘physic’ without a university degree or license directly obtained from a bishop (Copeman 1960).
The decline of the Galenic worldview and the ecclesiastic stranglehold over medical practice started with the Renaissance and ended with the Enlightenment and the rise of hospital medicine (Tenkin 1973). Renaissance artists such as Michelangelo (1475-1564) and da Vinci (1452 – 1519) familiarised themselves with human anatomy, producing detailed drawings of the body as perhaps only an artist can, and in doing so highlighted that Galen had actually dissected animals, not humans, when constructing his anatomical principles. This viewpoint was supported by the Flemish physician Vesalius (1514 – 1564) in his anatomical text 0n the fabric of the human body (1543) (Siraisis 1990). For instance, Vesalius showed that the human breastbone actually has seven segments not three as Galen held. Meanwhile, William Harvey (1578 – 1657) established the circulatory system demonstrating the attachment of veins and arteries and the movement of blood in a circular motion around the body. A point of view which was at odds with the essentially static conception of blood that existed in the humoral system (Tenkin 1973). While Paracelsus (1493 to 1541) broke completely with the Galenic tradition of seeing disease as the result of humoral imbalance and laid the foundations for modern medical practice by conceiving it as an entity – an archeus -which entered the human body (Siraisis 1990).
The Enlightenment and the Clinical Gaze of the Biomedical Model
‘At the end of the eighteenth century a new type of medicine swept away the old humoral theories of illness that had dominated clinical practice for hundreds of years. The distinctive feature of the new medicine was its claim that illness existed in the form of localized pathological lesions inside the body….The new model of disease – often called biomedicine because it reduced illness to a biological abnormality inside the body – led to enormous resources being invested in the examination of anatomical and physiological processes, both normal and abnormal, to identify the underlying basis ofpathology.’
Armstrong (1995: 1)
Though he had what can be said to be a modern view of disease Paracelsus relied on mystical and magical explanations in some of his teachings. For instance he held that the stars influenced a person’s health. Yet his obsession with dissection promoted a scientific basis for medical practice by refocusing it away from the rote learning of ancient texts and towards the gaining of direct experience through conducting anatomical experiments (Siraisis 1990). Inspired by Paracelsus and Harvey, Bichat (1772 to 1802) examined the tissues of organs and searched for disease in decidedly natural origins (Carter 1991). Similarly Morgagni (16821771) used an early microscope to identify, amongst other things, the clinical features of pneumonia, while Baillie (1761 – 1823) accurately described cirrhosis of the liver. Morgagni, Baillie and Bichat signify the beginning of medicines focus on abnormality as much as normality and its use of morbid anatomy as a methodology to further medical knowledge and practice. Indeed, Bichat is quoted by Carter (1991: 543) as saying ‘open up a few corpses (and) you will dissipate at once the darkness that observation alone could not dissipate’. For though corpses had been dissected since the thirteenth century at least humoral medicines’ dominance had meant that symptoms expressed in life were until now not directly related to findings made during a dissection.
Medicine in the Eighteenth century
The decline of humoral medicine was not however a straight forward affair divorced from broader socio-economic changes and the power dynamics at play between the different social groups essential to the organisation of medical training and practice. Medical historians typically hold that at the beginning of the eighteenth century they were three categories of medical practitioner in England. Each reflected an elemental aspect of medicine: as learned profession (the Physician), as craft (the Surgeon) and as trade (the Apothecaries) (Parry and Parry 1976). Although they were provincial affiliated societies based in major towns and cities, each aspect had its headquarters in London – The Royal College of Physicians, The Royal College of Surgeons and the Worshipful Company of Apothecaries. The Royal College of Physicians of London was established in 1518. Surgeons joined the Barbers in 1540 to form the Barber-Surgeons Company, but they broke this association in 1745 and subsequently the Royal College of Surgeons of London was established in 1800. Apothecaries were at first medicinal shopkeepers, but they were granted a Royal Charter as the society of Apothecaries of London in 1617. This was primarily because though Physicians may prescribe medicinal remedies, as gentlemen they certainly were not going to engage in trade and actually sell such items. As Carr-Saunders and Wilson (1933: 421) note: ‘A gentleman might be rich and might even seek riches. But certain roads to the acquisition of riches were closed to him; in particular he must not seek riches through the avenue of ‘trade’.
Entry to each of these three occupational corporations (which were all male) was different with each possessing their own tests of competence. Entry into the Royal College of Physicians was available only to men of good social reputation who held a degree from Oxford or Cambridge, though those with Scottish medical degrees could become affiliated members. Surgeons and apothecaries, unlike physicians, learnt their trade by apprenticeship. When a surgeon or apothecary took on an apprentice, they signed a legally binding contractual agreement with them. More than often, given the apprentice was a child, this agreement was made with their parents. The apprenticeship process was designed to teach the trade, the mystery and the business of surgery or apothecary. For instance, the physician prescribed drugs and the apothecary sold them. Therefore, as Latin was the preferred language of the learned physician, the apothecaries’ apprenticeship typically also included some Latin. The apprenticeship system by and large did produce competent practitioners but there was concern that ‘at its worst, if the master neglected his duties, or the pupil was idle and cared little to learn, the period of apprenticeship too often represented so much precious time wasted’ (Muirhead-Little 1932: 6).
Two factors are immediately apparent about these early arrangements for the organisation of medical practice and training. First, as will be discussed in more detail later in relation to the 1858 Act, although women administered medical care in the domestic and local community, they were excluded from these early formalised arrangements for ensuring the quality of ‘state licensed’ medical training and practice (Porter 1997). Second, the system was centralised in London and largely concerned on a day-to-day basis with a geographical area of roughly seven miles outside of the city. At the time, the three medical corporations possessing little control over countryside areas. The only real control the corporations exercised outside of London was in the main cities through various provincial societies (Porter 1995). In short the medical marketplace in the countryside was unorganised, largely unregulated and dominated by women and ‘quacks’ (defined by the colleges as individuals who has not passed their exams) who operated in direct competition with a few officially licensed practitioners (typically apothecaries). It can be said that nationally at this time it was still a buyer’s market with the sick actively involved in choosing their treatment. The state of affairs outside of London was about to become even more fluid, as the beginning of the industrial revolution and ascent of enlightenment ideals led to a huge increase in urban populations, the development of new industrial cities and the application of laissez faire philosophies to marketplace economics. As Holloway (1966: 114) notes: ‘Administrative difficulties, partly the result of the sudden growth of the new industrial towns, and a doctrinaire belief in the efficacy of free competition to ensure the interests of the consumer, led to the decay of. the mediaeval system of local regulation’.
The Industrial Revolution, the Growth of Modern Medicine and the Birth of the Clinic
The stable system of separate medical streams, centralised in London with associated provincial societies in the countryside, had its origins in the early commercial guilds and was well suited to the essentially static social order of the medieval era. However, the industrial revolution brought with it liberal ideals and marketplace economics which engendered an upward mobility for medical practitioners that gradually broke down the old compartmentalised view of medical practice. This breakdown happened first between the ‘trade’ and ‘craft’ elements of medicine – the apothecary and the surgeon – creating the surgeon-apothecary. Indeed, by 1783 they were some 2,067 registered surgeon-apothecaries, compared to 89 surgeons and 105 apothecaries (Lane 1985). At the same time, physicians educated in Scotland were clashing with those educated in London. This was mainly over their lack of voting rights in regards to College decision-making machinery, which was monopolised by the medical men of Oxford and Cambridge. In addition, Scottish medical training was heavily influenced by ‘the birth of the clinic’ in Europe, so it therefore rejected the Galenic tradition that had long lain at the heart of the traditional Oxbridge approach to medical training and practice.
It is often asserted that the pre-eminence of the modern medical profession lies in its scientific knowledge base and, in turn, this is linked to the historical development of pathological anatomy and the establishment of the hospital clinic as a site for the application of the biomedical model. Certainly many medical sociologists would hold that modern medicine’s technological and diagnostic advancements and successes throughout the last hundred and fifty years, have led to a biomedical discourse dominating contemporary debate surrounding public health as well as the organisation and delivery of health care (Lupton 1995). Here it is argued that biomedicine is a ‘cultural system comprised of numerous variations, the many medicines…[it is]..a more or less coherent and self-consistent set of values and premises, including an ontology, an epistemology and rules of proper action/interaction, embodied and mediated through significant symbols’ (Gaines and Hahn 1985: 4). Although it is a somewhat diverse entity, biomedicine at heart is reductionist and materialistic: it largely seeks to explain the phenomena of health and ill health in terms of cellular and molecular processes and events. This approach has generally proven to be diagnostically successful throughout the last hundred years or more. Here it must be remembered that the work of Foucault (1989) highlights that the new mode of medical perception and understanding bound up with the birth of the clinic, and which gradually replaced Galenic humoral medicine, was founded upon the discipline of pathological anatomy. This enabled the doctor to treat disease in the form of lesions and processes located within the organs and systems of the body. Observable signs and symptoms were increasingly matched to the findings of pathological science. With emerging techniques such as palpation, auscultation and percussion reinforcing the legitimacy of this new approach to medical practice. Consequently, the individual body was firmly established as a site for social surveillance and inspection as well as the advancement of rational, scientific, medical knowledge (Turner, 1995). The hospital increasingly became a location for medical research and training as the body was sampled, measured and generally coerced into revealing its secrets by a growing number of specialist medical disciplines, departments and laboratories. As Armstrong (1983: 2) notes: ‘[the] medical gaze, in which is encompassed all the techniques, languages and assumptions of modern medicine…[established]…by its authority and penetration an observable and analysable space in which.[was].crystallised that apparently solid figure – which has now become familiar – the discrete human body’.
Foucault (1989) notes that in addition to laying the foundation stones of modern medicines formal scientific knowledge base, the birth of the clinic also placed the emphasis of medical training and practice on gaining direct personal experience of a phenomenon. This laid the foundation stones for the development of modern medicine’s ‘craft expertise’, as a direct result of a doctor’s own direct scrutiny of a patient becoming paramount. Indeed, Foucault (1989: xvii) says that: “clinical experience …was soon taken as a simple, unconceptualised confrontation of a gaze and a face, or a glance and a silent body, a sort of contact prior to all discourse, free of the burdens of language, by which two living individuals are trapped in a common, but non-reciprocal situation.”
Although not necessarily influenced by the work of Foucault, this emphasis on the primacy of tacit clinical knowledge and expertise gained through obtaining direct clinical experience under apprenticeship, has been a regular feature of sociological accounts of medical training. Becker (1961: 225) comments on how personal expertise gained from actual clinical experience is often contrasted by clinical teachers to available scientific knowledge, ‘[so even] though it substitutes for scientifically verified knowledge, it can be used to legitimate a choice of procedures for a patients treatment and can even be used to rule out the use of some procedures that have been scientifically established”. Similarly, Atkinson (1981: 19) in his ethnographic study of bedside teaching and learning in Edinburgh, comments that students experience a ‘recurrent reinforcement of the primacy of clinical knowledge over ‘theory’. Sinclair (1997), in his more recent study of medical training in London, highlights that during clinical training students encounter an occupational culture that reinforces the primacy of personal knowledge gained through experience. Students are told “quite explicitly. that they must learn how to think in a medical way, that preclinical teaching has stopped them being able to think and so on ” Sinclair (1997: 223).