POOR LAW

The Tudor period which marked the end of the Middle Ages and the beginning of a new order was characterized by a great increase in poverty which was perceived as a serious threat to the social order. The first Elizabethan Poor Law of 1601 was a milestone in the social organisation of the poor and whilst it did not specifically mention health care (such a concept was only then beginning to form in the minds of legislators), this law was intended to help the “lame, impotent, old, blind and such other among them being poor and not able to work”. As the well-to-do sick were not a burden on the state and, as such, inconspicuous, the terms “poor” and “sick” appear to have been synonymous. In any case, with the passage of time, the provisions of the law were interpreted to include the delivery of medical and nursing care, and the parish, the unit of ecclesiastical administration, was the division of local government that was charged with this responsibility, and thus became closely associated with the country’s poor. In the Puritan’s mercantilist value system, poverty was regarded as a personal vice as well as a collective failing, and efforts were made to nurse the sick back to health and to make the poor more productive in manufacture and to increase national wealth. To facilitate this in Bristol, a busy English port then heavily dependent on the profits from the Slave Trade, an Act of Parliament combined all the parishes into a single unit. Other towns followed suit and there was a steady increase in the number of workhouses. As provision for all the poor sick was beyond the capabilities of the parish and its officers, local medical practitioners and/or apothecaries were “contracted” for the medical treatment of the poor and for inoculations (2). Much of the basic health care was provided by priests and women workers.

An increasing awareness of need of certain vulnerable groups in society for medical assistance, led, in the period 1714 to 1719, to the creation of dispensaries and general hospitals, in London and the provinces, and also of special hospitals, as the basis of the new social order was created.

THE HISTORY OF THE HOSPITAL

The evolution of hospitals must be considered against the background of the prevailing economic, social, cultural, political and ideological conditions. From the earliest times, it was recognised that the sick, the wounded and the handicapped required not only health care but also personal and social assistance. Institutions for the care of these groups in society have existed in Western cultures since Graeco-Roman times, examples being the Temple of Aesculapius, the buildings for the care of the ill in ancient Rome (3) and the hospitals created by the Christians during the latter part of the Roman Empire. These latter continued through the Dark and Middle Ages.

From the fourth century on, hospitals were founded on a more formal basis and endowed by rulers and Emperors usually with a grant of land. Hospitals in the Byzantium Empire reached a high level of organisation with a clear division of labour (4). The hospital attached to the Monastery of the Savior Pantocrator at Constantinople had even an out-patient department. The in-patient side had five sections, viz., for surgical cases, for cases of infectious diseases, for gynaecological cases and for minor cases (two sections). In each section there were separate areas for emergencies and for the critically ill. There were a large number of medical staff and these consisted of male and female physicians, surgeons, midwives, assistants and orderlies. A further full complement of staff were in attendance for ambulatory patients in the dispensary. There were two chief physicians who supervised all the medical staff and these two were, in their turn, accountable to the two medical administrators. Earlier in the fourth century, institutions to care for the sick and needy were built in Cappadocia, Alexandria and the Eastern Empire. In these hospitals all the staff were resident; each hospital was administered by two priests. The hospitals were divided, again, into several sections and catered for the travellers, the indigent, the infirm and the sick, including those suffering from infectious diseases such as leprosy. Although these early institutions combined social and medical functions, it was recognised that the functions of a hospital were different from those of other institutions that catered for groups with different needs(5).

The Moslems who overran the Eastern Empire were impressed by this hospital system and built their own in the countries under Islamic rule in the tenth, eleventh and twelfth centuries. About thirty-four large well organised institutions were built from Cairo to Baghdad, some of them with facilities for teaching, or with specialist units, or with separate units for the treatment of women.

In the West, the concept of a hospital developed from the “infirmitorium” which was a part of the larger monastery of the early Middle Ages and which, together with the monastery’s pharmacy and garden with medicinal plants, catered for sick monks, as well as pilgrims and travellers. In Tintern Abbey (founded 1131) of the Cistercian order in Monmouthshire, the Abbey’s infirmary included a large hall, a cloister, a kitchen and a latrine and was connected to the church via a passageway (6). During the next three hundred years, hospitals for the poor and the sick were built in connection with cathedrals and by various religious communities.

During the Crusades, several orders of Knights founded and maintained hospitals along the routes of the Crusades, e.g. the Knights of St. John (Malta). The hospital itself then became an institution around which other hospitals and nursing orders were founded. Hospitals were also founded by royal or rich benefactors and by the guilds(7). The first hospital to be built in England (in 937 A.D.) was founded at York, by Athelstan, grandson of Alfred the Great; after a fire it was rebuilt by King Stephen. Its basement storey still survives.

At the beginning of the sixteenth century, there were more than six hundred (hospital) institutions in England, ranging from small foundations to large establishments(8). The medieval hospital cared for the material, spiritual and medical needs of its inmates. Whilst smaller institutions tended to specialise, the larger ones professed to render a comprehensive service; in addition to looking after the sick, they catered for lepers, orphans, pregnant women, the aged and invalid, and strangers, although not necessarily under the same roof. There were no formal criteria for admission to hospital or on the indications for ambulatory as opposed to institutional treatment in any individual case. Hospital law was mainly concerned with property rights and the status of the institution vis-a-vis other religious and civil authorities(9).

The religious character of the medieval hospitals did not change when they were taken over from the church by the infant local authorities and municipalities. Hospitals were funded by charity; during medieval times charity was a powerful concept. Together with good works, it earned the donor sure salvation. Unfortunately, abuses of the system were not uncommon and a law was passed in England in 1414 to help reduce the frequency of financial irregularities(10). This notwithstanding, the medieval hospital system continued to suffer. Ecclesiastical and civil authorities failed to stem abuses, and the system was further overburdened by intensifying poverty due to increasing unemployment, higher prices, enclosure of peasant lands, and vagrancy, though the hospital continued to remain an institution performing many functions in society; it was an old-age home, an almshouse, an orphanage and a guest-house as well as a hospital.

By the middle of the sixteenth century, hospitals in London were becoming well organised(11). At the top of the administrative hierarchy was the Board of Governors. Members of the Board were elected for a two-year term and were drawn from aldermen, commoners, citizens, freemen and notaries. Each of four subcommittees supervised one of the four London hospitals, viz., St Bartholomew’s, Christ’s, Bridewell and St Thomas’s. Administrative staff comprised business management and staff officers. The former again comprised a controller/surveyor, an administrator/director, a treasurer, three almoners, two collectors (for gifts, legacies and bequests) and a rent collector. The staff officers comprised a clerk/ secretary/book-keeper, the matron and nurses, the steward, the cook, the butler, the porter and the beadle. A surgeon and a barber were attached to the hospital to provide professional services. At this stage medical men were still not yet a part of the hospital and remained independent.

AGRICULTURAL REVOLUTION : INDUSTRIAL REVOLUTION

The revolutionary Parliament of the 1640s and the events of 1688 removed the old feudal tenures and paved the way for capitalist agriculture. This hastened the “enclosure” of the common land and meant that areas long used for communal pasture and cultivation were fenced in, “squatters” evicted and the land taken over by private landlords. Mass poverty supervened, and the theft of animals for food was common. Inconveniencing, as it did, Britain’s infant capitalist class, sheep-stealing was designated a capital offence, and men and women were hanged in batches for this crime. Because juries were loathe to convict for this reason, this draconian sanction had to be withdrawn, and transportation was introduced. Of the dispossessed peasants, many relied on the inadequate poor law relief, some became farm labourers whilst others gravitated to the newly expanding hellholes of the connurbations of the industrial revolution to become the new proletariat. The industrial revolution resulted in the centralization and radical transformation of production so much so that domestic spinners and weavers, like the small farmers, their counterparts of the agricultural revolution, were forced out. The single most important source of the capital that fed the industrial revolution came from the profits of slave labour and from the triangular trade between Europe, Africa and the New World(12).

In the eighteenth and early nineteenth centuries, there was an increase in the number of hospitals in Britain; there was concern over the necessity to maintain and augment a healthy population for the political and economic strength of the state and over the need for medical assistance to the more vulnerable groups in society.

The first half of the eighteenth century saw the creation of dispensaries, hospitals, and special hospitals in London and the provinces, funded by a combination of private benefactions, private initiative and contributions, and co-operative action through local government. Hospital building flourished in London during this period. Mercantile capitalism had brought prosperity to the capital and the rural poor were attracted to the city where waged labour was a considerable improvement on abject poverty. The Act of Settlement of 1662, however, gave parishes the right to eject outsiders who were unable to rent a dwelling and who were a burden on public funds(13). As the resources of the two large hospitals serving London at this time were overstretched, a whole range of general and special hospitals were founded, viz., Westminster (1719), Guy’s (1724), St George’s (1733), the London Hospital (1740), the Middlesex Hospital (1746), and, initially, for small pox cases and for the purposes of initiating an inoculation campaign, the Lock Hospital (1746, later for patients with venereal diseases) and St Luke’s Hospital (later, for patients with mental illnesses). Hospital building programmes were also initiated in Scotland, Ireland and in the English provinces, viz., Bristol (1737); York (1740); Exeter (1741) and Liverpool (1745). Although by 1840 there were 114 provincial hospitals in England, there had already been hospitals in most of the larger towns in Great Britain by the end of the eighteenth century(14).

In the latter half of the eighteenth and in the early nineteenth century, fourteen more hospitals were built in London. Among these were the special hospitals, such as the London Fever Hospital (1802), the Royal London Ophthalmic Hospital (1804), the Royal Chest Hospital (1814), the Royal Ear Hospital (1816), and the Royal National Orthopaedic Hospital (1838). The hospital system was supplemented by an ambulatory care system, i.e. the more permanent type of dispensary. In the second half of the eighteenth century, fifteen dispensaries were founded in London and thirteen in the provinces.(15). The explosive increase in scientific knowledge at this time laid the basis for the application of science (and empiricism) to medical care. The ruling class were not slow in exploiting this to attempt to produce healthy men, women and children to service the increasing needs of industrial capitalism. The profound structural changes in societal organisation consequent upon the industrial revolution threatened the status quo and resulted in calls for order, efficiency and social discipline by the bourgeoisie. It was the concern with poverty and the consequences of ill-health that led to the hospital and dispensary, infant welfare and poverty relief movements in the burgeoning conurbations. These concerns generated a social conscience amongst the capitalist and middle classes, a conscience that was tempered by a firm belief in hard work, sobriety, efficiency, simplicity and cheapness.

The hospitals that were founded in Britain at this time were voluntary undertakings and were funded by private donation, subscription and bequest. With men, women and children working in the factories, the sick could only be cared for in hospital.(16) However, it was general hospital policy that only the curable were admitted to hospital. Patients with chronic, incurable or terminal illnesses were rejected by hospital doctors and, instead, were relegated to the almshouses or the workhouses. This was thus the beginning of the role of medicine in social control. Voluntary hospitals were places where the poor, in the interests of capitalism, could be cared for more economically then in their own homes. Patients here tended to be of the acutely-ill, short stay type of cases; the chronically-ill, the incurable, the insane and those suffering from communicable diseases were taken into public institutions. According to Abel-Smith (17), there were about 3000 patients in British hospitals in 1800, and 7619 hospital patients in 1851 when hospital censuses were recorded for the first time. In 1871 there were 19,585 patients in general and special voluntary hospitals, but over 50,000 patients in workhouse infirmaries. (18). Then, as now, with the latter, a deterrent philosophy was the basis of the whole system of poor law administration.

As interests of economy were paramount in hospital administration, wards were overcrowded, hygiene poor and nursing below the standards of the time.. Humanitarian motives sometimes took a back seat as doctors and administrators insisted that hospitals should be limited “to those who have no homes and to those who cannot be assisted at their homes” (19) These very doctors, however, were quick to realise that patients were necessary for teaching purposes and also for the establishment of teaching hospital doctors’ own medical prestige.

Other changes in hospital organisation were introduced in the last quarter of the nineteenth century, e.g., patients with communicable diseases were carefully segregated, asepsis introduced and hospital laboratory services organised. As the whole hospital system expanded, specialisation amongst hospital staff resulted in more and complex roles for the staff, as trained nurses, hospital administrators and social workers entered the scene.

During the nineteenth century, the medical profession, in England, was beginning to take up its modern form.Then it found women healers, who played a not inconsiderable role in society at that time, somewhat threatening to its own developing status. Women healers were branded as witches and a whole range of punishments were visited on them. In the nineteenth century, the medical profession, for a time at least, felt that its position was also being threatened by the trained nurse who had arrived on the scene. Professional roles had then to be carefully defined. Matron, as head of nursing, came to hold a position of authority between the medical staff and the lay administration. With further urbanization and population growth, more hospitals were built. For a long time after this, however, the rich continued to receive medical care, and have their relatively minor operations, at home, whilst the poor regarded hospitals as way stations to the cemetery. At the beginning of the twentieth century, and with the rapid development of more sophisticated medical techniques, asepsis and ancillary radiological and diagnostic laboratory facilities, hospitals began to be accepted as institutions of social good and as educational institutions for physicians, surgeons, nurses, ancillary workers and medical students. With the increasing development of hospital services, there was a further need for other and more complex services, such as social work, nutrition, hospital record-keeping and business proceedures, as well as for specialist personnel, facilities, equipment and organisation. Hospital administrators came into their own and, with increasing costs, voluntary prepayment and hospital insurance were introduced and government began to play a more important role in the building and financing of hospitals.

The increasing complexity of the organisation of the voluntary hospital soon led to conflicts amongst, and between, the various groups with vested interests in the delivery of medical care. Initially, the senior physician or surgeon gave his services free to the voluntary hospital, but, in the process, was able to build up his own prestige and attract an increasing private clientele, as well as to use interesting cases for teaching and research. In the presence of changing social and economic conditions and an increasingly vocal consumer lobby, the contradictions within the health care delivery system soon surfaced. Authoritarian and individualistic senior doctors had to accomodate to teamwork and to subject their professional skills to peer scrutiny and consumer challenge. (20).

We can now see how the English hospital, at least, has evolved, from medieval times, through the ages, throwing light, en route, on the social priorities of the different periods. The medieval hospital was, first and foremost, an ecclesiastical institution, not primarily concerned with medical care. In the sixteenth century, the hospital was placed under government control, secularized and designated a community responsibility. It was to aid in the maintenance of the social order, whilst caring for the sick and needy; medical care was not its primary function. Over the past three centuries and as a result of social forces acting in concert with technological developments, organisational rationality and financial constraints, the hospital has been transferred from being a hostel for the sick-poor into a medical centre for everyone, a veritable health workshop and medical factory.(21).

THE ROLE OF THE HOSPITAL IN THE DEVELOPMENT OF MODERN MEDICINE

An important aspect of the development of hospitals was that they enabled doctors to see many more patients than would have been possible in private practice. Furthermore, the hospital in the nineteenth century set the stage for the development of a new type of doctor-patient relationship. (22). In the eighteenth century, the wealthy and aristocratic patient was dominant in the professional relationship between doctor and patient. On the basis of power and patronage, the wealthy patient defined his needs and the manner in which those needs were to be fulfilled. As Holloway wrote,(23) “the patient, not the doctor, determined the conditions on which service was rendered. The client demanded a cure; the practitioner was no position to suspend judgement and proceed with caution. He had to act quickly; treatment had to be given and conclusions drawn from partial evidence or even from pure speculation. The doctor, faced by the powerful, wealthy, critical, demanding, and ill-informed patients was forced into the role of lackey and mere comforter”.

In that century, the physician was, first and foremost, a gentleman who moved in the same social circles as his wealthy patients. Under the control of his patient patrons, his main qualifications were elegance, a classical education and wit, not technical competence. In fact, the emphasis on the social graces was to last until about the middle of the nineteenth century. Notable practitioners such as Sir Samuel Garth, Mark Akenside and John Arbuthnot were noted then more for their literary writings than for their medical publications. Medical careers were made through social contacts rather than through technical competence, and research fell into abeyance. Moreover, doctors were loathe to carry out innovations on their wealthy patrons who, in any case, were unlikely to agree to subject themselves to painful and dangerous treatment methods. Enterprising physicians advertised their successes in the treatment of every conceivable symptom; symptoms, rather than disease entities, were what troubled patients and were what their doctors were aiming to cure.

It is said that with the development of hospitals, there was a radical shift in the relationship between doctor and patient, for, in the hospital,, the doctor emerged as the dominant partner in the relationship. There were other factors as well, which pushed the relationship in this direction. One of the important changes in early nineteenth century medical practice was a shift in the emphasis from simple observation of the patient to actual physical examination. Later a wide variety of instruments were invented to aid patient examination, such as the stethoscope, the clinical thermometer, the pulse count watch and, later, endoscopes for the visualization of hollow internal organs. The physical examination of patients had a whole lot of implications for the newly changing doctor-patient relationship involving consent, problems of access, discomfort, privacy, confidentiality, intimacy and modesty. In the first quarter of the nineteenth century, medical disciplinary and professional codes had not yet been institutionalised, elaborated or enforced, and yet patients did not, or, rather, could not, object to inconvenient, uncomfortable, distressing, embarrassing or immodest medical examinations. There was a reason for this. In the hospital milieu, the consultant doctors were an upper middle class elite, highly educated, holding coveted positions supported by clinical research facilities, and maintained outside the hospital by a wealthy, fee-paying clientele. On the other hand, hospital patients were sick, poor, and in hospital only because they could not afford to be treated in their homes. Describing conditions in English hospitals, at, this time, and, especially, the high incidence of cross-infection, Abel-Smith has written that “some of those, who did not have fatal diseases when they entered hospital, acquired them after admission”.(24). Hospitals, then, rarely met Florence Nightingale’s dictum that “the very first requirement of a hospital is that it should do the sick no harm”.(25).

In this new doctor-patient relationship, the patient was not in a position to define his needs; and the doctor was in a position not only to define the problem but also as to how the problem should be tackled, according to professional criteria. The patient was in no position to insist on a cure and the doctor was no longer the servant of a wealthy patron. The emphasis in medicine at this time was not so much on treatment and the patient, but on diagnosis, classification and research. The logical extension of this was that, for a period at least, therapy was a low priority in overall medical thinking, whilst hospital doctors concentrated on basic research, and the study of anatomy and pathology, although these efforts were, of course, to lay the groundwork for future improvements in medical therapy. In the short term, developments in therapy “seemed to have come to a dead end on the high road to human betterment”(26), and “.....it appeared only as if that little, which the patient had, had been taken away”. So it was that".......the most hopeful period in the history of medicine was the one in which the patient looked to medicine with the least hope”(27). The acclaimed French physician, Laennec, was accused of being more interested in performing autopsies than he was in preventing them(28).

The overall effect of all this was to accentuate the dominant position of the doctor in the professional (producer) - client (consumer) relationship. In contrast to what obtained in private practice where a doctor’s professional reputation and even social prestige depended on success in therapeutic methods, the patient and/or his relatives, here (in hospital), were in no position to criticise or object to the treatment even if an experimental module turned out to be a failure. Throughout Western medicine, at least, at this time, experimentation, by upper class hospital doctors, especially, on the more disadvantaged sections of society was not uncommon. An account of practices in Parisian hospitals during the nineteenth century is given by Rosen(29).
George Orwell wrote(30) that “If you are seriously ill, and if you are too poor to be treated in your own home, then you must go into hospital, and once there you must put up with harshness and discomfort, just as you would in the army”. More grotesque was some of the work of J, Marion Sims, the distinguished American gynaecologist, whose Sim’s vaginal speculum is still a universally used diagnostic medical instrument. Sims experimented exclusively on black women handed over to him by slave owners for periods of upto four years. One woman underwent as many as thirty operations.(31)

There was a further manner in which the already fragile autonomy of the hospital patient was undermined. As Abel-Smith wrote(32): “While the paying patient had a legitimate right to object to being observed and prodded by a group of students, a person in receipt of charity was hardly in a position to complain about such invasions of his privacy”. The famous French surgeon, Roux, whose Roux-en-Y operation on the small intestine is still widely practised throughout the world, was wont to operate on conscious young women during which time their genitals were exposed to the gaze of a couple of hundred medical students(33). Medical research was carried out not only on the living but also on the dead. Here, English doctors, at least, had difficulties in access, although there was a source of supply from the ranks of the indigent and the mendicant, and when this, at times, dried up, English doctors availed themselves of the services of the bodysnatchers.

HISTORY OF THE MEDICAL PROFESSION

In the Middle Ages, physicians had an ecclesiastical connection and were generally products of the higher centres of learning, which were themselves strongly influenced, if not controlled, by the Church. In the pre- industrial mercantilist period of capitalism, doctors were regarded as the domestic, albeit medical, attendants of the wealthy. Whilst the wealthy were often over-serviced, medically speaking, the poor, of course, had to be content with the local village healer, and when that failed, were consigned to the almshouses or the workhouses. The practice of surgery evolved independently of medicine (called “physic”), as the ecclesiastical authorities of the day strongly disapproved of blood-letting. Physicians used their influence with the upper classses to increase their prestige and to form a monopoly on the practice of medicine (“physic”). In 1421, legislation provided that physicians were to be approved by universities and surgeons by the guilds. An Act in 1511 provided that physicians were to be licensed by examination. Candidates would be examined by the Universities of Oxford or Cambridge, or by the Dean of St Paul’s or a bishop, assisted by a panel of qualified and licensed physicians. In 1518, Henry VIII granted a charter to the Royal College of Physicians and an Act in 1522 granted a monopoly on the practice of medicine to those who had passed the approved examination of the Royal College of Physicians or the Universities of Oxford or Cambridge. The surgeons, who at the time, were regarded as little more than unlettered technicians, joined with the barbers in 1540, although each group kept to its own professional occupation. This notwithstanding, demarcation disputes between the barbers and the surgeons grew in intensity until an Act of Parliament in 1745 established the Company of Barbers and the Company of Surgeons. In 1800, the Company of Surgeons received its Royal Charter and moved from the City to its present premises in Lincoln’s Inn Fields. In 1843, it became the Royal College of. Surgeons of England.

Repeated abuses by the Royal College of Physicians in its determined efforts to maintain its monopoly and restrict its membership resulted in attempts to organise by the apothecaries. By the end of the seventeenth century, the Royal College of Physicians “had lost its commitment to medical advance, and its affairs were being conducted purely in the interest of its members”(34).

The apothecaries began life as grocers, but, in 1617, they received a charter, separate from that of the grocers, which, the Society of Apothecaries felt, gave its members the right to prescribe, as well as to supply, medicines. In the last quarter of the seventeenth century, the Royal College of Physicians and the Company of Barber-Surgeons “showed little interest in providing for the general population” (35). In 1703, the House of Lords ruled that the apothecaries could prescribe medicines, recommend treatment and dispense drugs, thus paving the way for them to practise as fully recognised medical practitioners in their own right. An Act of 1748 made the Society of Apothecaries a licensing body and, in 1815, a further Apothecaries Act gave the Society the right to examine candidates. Apothecaries were, by this time, also beginning to train as surgeons. The Society of Apothecaries introduced a five year apprenticeship and written examinations, and tightened up the licensing system. Its qualifications were accepted by the Royal College of Surgeons and its licentiates were recognised as general practitioners. There were, by the middle of the nineteenth century, eighteen licensing bodies. The Medical Act of 1858 created the General Medical Council to supervise and control the existing licensing authorities, and to register suitably qualified persons. The new Council itself neither taught nor examined candidates. In 1884, an Act ended the separation between medicine (“physic”) and surgery at general practitioner level, and the Royal College of Physicians and the Royal College of Surgeons held their examinations jointly.

The creation of the General Medical Council with wide powers to control and discipline members of the profession led to a massive increase in professional power vis-a-vis the consumer. From the mid-nineteenth century onwards, working men, and sometimes their families, took on voluntary health insurance through various working men’s associations, viz., Works Clubs (Medical Aid Societies), Provident Dispensaries, Medical Aid Companies (Doctors Clubs), and, especially, Friendly Societies, Lodge Practices and Medical Institutes. In the case of each of the latter three, control was in the hands of the workers (beneficiaries) themselves. These were self-help organisations where the workers were in a buyers’ market vis-a-vis the doctor and where free market forces operated. This was not to the liking of the organised profession and many attempts were made to regain the whip hand over the consumer; but this could only be done with the aid of the state. For example, the high-minded General Medical Council (GMC) sanction against advertising by doctors was, in reality, an attempt to prevent any doctor from bringing to the notice of prospective customers the nature and extent of the services that he was prepared to offer, and thus to deny consumers the wherewithal to make an informed choice.

The 1911 National Insurance Act, which brought in compulsory health insurance for working men, did not insure their families. The Act broke the back of the very successful attempts by working men to organise health care for themselves (and, very often, for their families as well). The Act was welcomed by the medical profession as it cut out competition amongst doctors for custom and led to very much increased control by professionals, vis-a-vis the customer, over health care delivery, as well as to increased professional representation on health insurance panels. Furthermore the contention by the profession that the consumer would have a free choice of doctor was a specious argument (36). The medical institutes had, previously, given subscribers, as well as their families, a wide choice of doctor, as well as a satisfactory service.

When the state intervened in the delivery of health care in 1911, it did so on the side of the profession. Doctors had recruited state coercion to obtain increased concessions from the consumer as well as further opportunities for the exercise of professional power. Similarly, with the National Health Service (NHS). Although the NHS has brought benefits to the working class, it has benefited even more the middle classes who previously had to accept medical treatment, in the main, as private patients. But the NHS has benefited, most of all, the medical profession through increased financial rewards, power, prestige and privilege, and, to those at the top, sizeable secret merit awards. The medical profession had graduated, in the space of a little over two centuries, from the level of domestic servants to that of the wealthy, to the level of socio-economic group 1 in today’s class structure.

In regard to their position in the state’s overall system of social control, the profession is also an arm of the state. A later chapter will describe, in detail, how the recruiting to, training in, and staffing of the country’s health care delivery system reflects this important aspect of the function of today’s medical profession.

MEDICAL KNOWLEDGE AND THE PATRONAGE SYSTEM.

THE NATURE OF MEDICAL KNOWLEDGE IN EIGHTEENTH CENTURY ENGLAND

In the eighteenth century, medicine was regarded as an intellectual occupation in its own right. Medicine had not been affected by the enormous increase in the corpus of scientific knowledge that occurred in the seventeenth century. Under the umbrella of medical knowledge had been included subjects such as chemistry and botany. Medical men then were concerned with the classification of illnesses according to symptom complexes, rather than according to pathological and disease entities. This led to the proliferation of contradictory and speculative systems of medicine and pathology. There was no interest in the causation of disease, and illness was defined in terms of the patient’s symptoms and complaints. A distinguished eighteenth century physician, Sydenham (after whom one of the forms of chorea is named) declared that doctors were only capable of “perceiving the superficies of patients’ bodies, not the minute processes in nature’s ‘abyss of cause’ “(37), and this helped to validate the current taxonomy of illness which failed to differentiate between disease processes which happened to share common symptoms. Most medical men shared Sydenham’s belief that diseases should be classified according to their external characteristics(38).

In the eighteenth century, illness was not thought of as a precise physiological or anatomic lesion; rather health was thought of in terms of the patient’s overall general state, and illness arose from an underlying state of the body(39). The theories of pathology then prevailing provided for an explanation for each and every ailment afflicting mankind, and they maintained that each patient’s illness and symptoms were unique to himself. “Universalistic theory was reconciled with particularistic therapy”( 40). There was no separation between illnesses of the mind and of the body; the state of one was believed to influence the state of the other. Hypochondriasis was commom amongst the wealthy, the cultivated, the educated and the fashionable, and, as it was the client who paid the professional piper and who called the medical tune, doctors showed a great interest in the subject. They reckoned its cause to lie in the upper abdomen, something which could be triggered off by physical or mental factors.

Before the creation of the General Medical Council by Act of Parliament in 1858, there were serious rivalries and conflicts between some of the senior members of the profession who propounded differing theories of the causation of disease and who founded opposing schools of thought. Vilifications, denunciations and libel flew thick and fast, but underlying these matters there were always the questions of power and privilege, and competition and empire-building amongst a wealthy, influential and powerful clientele, who, in the final instance, called the shots and, by their patronage, defined the standards and boundaries of medical care in the eighteenth century.

The class structure of England was beginning to change in the mid-seventeenth century; these changes led to the rise of an industrial bourgeoisie in the last quarter of the eighteenth century. In the first half of the eighteenth century, English society was rigidly stratified with a tiny group of rich and powerful nobles and aristocratic landlords at the top of the social pyramid. At the beginning of the industrial revolution, English society was, as described by Perkin, “a finely graded hierarchy of great subtlety and discrimination in which men were acutely aware of their exact location in relation to those immediately above and below them, but only vaguely curious, except at the very top, of their connections with those at their own level” (41).

Stratification was effected by a whole set of social customs such as speech, manners, education, clothes, and cultural tastes. Whilst the domination of the nobility and of the aristocracy was almost total, the main social differentiation was between gentlemen, who, in the main derived their wealth from the ownership of land, and commoners, from whom the former were to be distinguished by their elegant lifestyle, as demonstrated in their effortless display of good manners and breeding, and by social acceptance(42).

Similarly, stratification in the medical profession obtained without much difficulty, as medical men in the eighteenth century were a pretty disparate lot, as Holloway has shown(43). At the top were the physicians, the gentlemen of the profession and a wealthy elite, who were separated from the rest by background, education, social ties, income and wealth, as well as by recruitment, training, occupational associations and skills. They were members of the Royal College of Physicians and had gone through an expensive six year academic and professional training in Oxbridge, a training which also included a period of exposure to the classics. Axtell has calculated that, at the end of the seventeenth century, the costs of medical education were £1000 for a physician, £120 for a surgeon and £50 for an apothecary(44).

And so it was that the physicians attended the wealthy and considered themselves gentlemen and scholars of standing. Surgeons were a lowly breed and the skilled manual workers of the profession, being associated with the barbers in the Company of Barbers until 1745. The expertise of the surgeons only extended to those areas of the human body that were accessible, in those days, to the scalpel. Owing to the absence of anaesthesia and the sequelae of infection, surgery was a pretty limited speciality.

The apothecaries, who were the lowliest of the three types of legally recognised practitioners, started life, historically, as grocers and sellers of medicinal portions, but, as they increased in numbers in the seventeenth century, it was inevitable that they should be perceived by the physicians as a threat. The matter was settled, once and for all, by the House of Lords in 1703, when, in the important Rose case, they ruled that apothecaries could prescribe medicines, recommend treatment and dispense drugs. Because of the low cost of apothecary training, their numbers swelled and standards of practice, varied. Finally, there were a large number of unqualified persons whose personal reputation for effecting cures for various illnesses led to their being consulted by the sick from all sections of society.

The senior physicians were the ruling elite of the profession and, because of their close ties with the ruling class and the fact that their own ranks were often bolstered by the lesser sons of the ruling class(45), enjoyed a number of professional privileges, not the least of which was the right to inspect the drugs in the shops of the apothecaries (their professional rivals). The apothecaries deferred to the physicians by calling them in or consulting with them in cases of serious illness. The physicians exercised a certain amount of patronage within the medical profession as they virtually controlled the access to wealthy and influential patients, by more humble or aspiring members of the profession. The physicians also defined the parameters of research and progress by virtue of their ties with the ruling class and, in a period in which the patient had the whip hand in the consultative relationship, these parameters were greatly influenced by the ruling class.

It must be understood that, although the profession’s ruling elite, viz., the physicians were gentlemen, they were near the bottom of the social strata that comprised the upper classes, coming after the aristocrats, Baronets, Knights and Esquires(46). Medicine was at this time not considered a prestigious profession and physicians derived their power, influence and wealth solely from their close professional relationships with their aristocratic and wealthy patients, with whom they ingratiated themselves. Physicians had a vested interest in maintaining the status quo, and it is easy to see why medical progress itself was held back. That the aristocracy itself influenced medical innovation is clearly illustrated in the case of smallpox inoculation(47), a measure that was initially opposed by the medical profession. When, after satisfactory clinical trials on convicts, the Sovereign, George III, had the royal children inoculated, the trend was set, inoculation became popular and the physicians then readily supported the measure, having realised its financial advantages to the profession.

Whilst allowing medical practitioners; some freedom in determining the precise nature of their cures, the ruling class in the eighteenth century had overall control over the practice of medicine. This was the period during which education and learning was based on the classics and the works of the Graeco-Roman era, and the ruling class had set the seal of approval on Newtonism. The social order was later beginning to change and the medical profession was keen to appear not to be lagging behind(48). The result was that, although the physician’s noble or wealthy patient defined the concepts of both physical and mental illness and evaluated the doctor’s performance, the doctor himself was anxious not to appear as a somewhat passive agent in the process of cure. For if patients were seen to cure themselves, the doctor’s professional standing and social status would be seriously undermined And so it was that a whole series of heroic cures with which patients had to wrestle became fashionable at this time. As it was individual symptoms rather than disease entities that physicians were attempting to cure, there were no limits to the number of cures that doctors invented, a fact which was not lost on the patient and which helped to keep the patient in awe of his medical attendant. Furthermore, as the patient’s own assessment of his doctor depended on the patient’s own state of mind, doctors began to be interested in the whole subject of psychotherapy.

PROFESSIONAL ADVANCEMENT

As a result of the nature of medical practice in the eighteenth century, the patient rather than the disease remained the focus of medical theory and practice. Diagnosis was a matter of the physician’s personal judgement rather than the result of a precise and quantitative assessment of facts. This could be illustrated by a simple fact. Whilst a pulse watch, which quantitatively measured the pulse, was invented by Sir John Floyer in 1707, it was ignored in favour of a whole pseudo-science associated with a supposedly qualitative assessment of the pulse that could only be carried out by a physician.

The most notable scientific advances during this period are associated with the names of the likes of Pringle and James Lind (who discovered that the drinking of lime juice could prevent scurvy) who were themselves military surgeons in the humblest ranks of the profession. They were not particularly subject to the principle of accountability and their patients, like the hospital patients of a later century, were in no position to object to the treatments rendered to them.

In the furtherance of his career, the eighteenth century physician had to reconcile a whole lot of contradictions. He was a product of the upper class, although of its humblest orders, and aspired to the manner and bearing of a gentleman, not to say the wealth of a gentleman. He had a classical Oxbridge education and adopted the social and political ideas of his upper class patients. Yet he was obliged, for his own success and survival in a medical world of physicians, surgeons and apothecaries, not to mention a whole order of “unqualified” quacks and amateurs, to indulge in every form of self-advertisement, including the criticism of rival colleagues, and to ingratiate himself with his fee-paying clientele. The medical theories that were propounded at this time were as much an extension of these other considerations as they were of the physician’s interest in medical phenomena. It is not surprising, then, that medical systems were continuously subject to revision and reformulation.

In any case, as a result of patient dominance in the doctor-patient relationship, scientific research and quantitative mensuration were relegated to a position of little importance or of no relevance. The wealthy sick were interested in cures and the relief of pain and discomfort, rather than long-winded explanations, even if these were scientific. As a result, the study of the basic medical sciences, such as anatomy and physiology, was neglected and a concern with medical research was absent. Further, public distrust of the medical profession did not permit detailed examination of the human body (49). The doctor-patient relationship had not yet developed to the point where personal information and confidences were offered to the doctor and mutual trust between the professional and his client could not be taken for granted. Anatomical dissection was permitted only on paupers and social outcasts whose bodies remained unclaimed, and, in any case, there was popular feeling against dissection and post-mortem examinations.

Medical societies were few at this time as doctors considered each other rivals in their quest for wealthy clients, and also engaged in self-advertisement. Accidental discoveries were regarded as trade secrets and the exchange of information between doctors was kept to a minimum in a situation where clients held the key to career advancement. The pressure of peer competition led physicians to the derogation of each other’s supposed achievements, with the result that medical advances lagged far behind other scientific achievements in the seventeenth and eighteenth centuries. All this changed in the nineteenth century, with the development of the hospital system that catered for the needs of the new industrial proletariat and where the professional was dominant in the new professional-client relationship.

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