Nineteenth-Century Medicine in the United Kingdom
At the turn of the nineteenth century, medicine was hardly the enlightened profession it is today. Medical practices were often barbaric, employing methods that had been used for centuries, yielding little or no results and often killing the patient with a different affliction than the original ailment. Leeching (or blood letting), purgation, poor liquid diets, and cold water dousing were common practices as late as the 1850's. Even after newer, more effective methods of medical treatment had been introduced, many of the physicians, surgeons, and apothecaries hesitated to use them. Fearing the loss of their reputations, they hung on to superstitious beliefs, doubting the effectiveness of such advances, and were basically unwilling to try something new.
Medical men weren't always respected as educated, intelligent members of society because some "practiced with university degrees, various forms of medical licenses, sometimes a combination of these, and sometimes with none at all" (Peterson 5). Part of the problem with educating and licensing doctors was in the conflicting struggle for rights and power between licensing bodies; there were nineteen of them in the United Kingdom alone. There was also no representation of any reputable doctors within the medical universities and corporations that voted in Parliamentary elections. By the end of the century, medical training facilities were forced to upgrade their standards due to pressure within some parts of the medical community and because discoveries in fields like chemistry and physics ultimately led to advances in medicine.
Early nineteenth-century medical training was extremely diverse. While some practitioners held university degrees from the most respected medical colleges of the world, some were apprenticed to apothecaries where they "spent most of their time capping bottles and rolling pills" (Youngson 12). Still others were quacks and drug peddlers who practiced freely with no legal sanctions against them.
There was, in the United Kingdom, a defined social structure of medical men which was divided into three orders. There were three divisions of legitimate medical groups. They were the Royal College of Physician, the Royal College of Surgeons, and the Society of Apothecaries. These impressive-sounding organizations reflected status groups in medicine and detailed the differing duties, legal privileges, and social ranks within the medical community.
Physicians were university-educated and considered the most knowledgeable about medicine. They were not permitted to act as surgeons or dispense drugs as apothecaries before 1858. They were only permitted to examine patients, diagnose disease, and prescribe medications. In 1800, there were 179 licensed physicians; by 1847 there were 683.
Surgeons performed operations, set broken bones, and treated accident cases and skin disorders. The nature of a surgeon's work separated him from a physician in that a surgeon had to cut, manipulate, and treat disorders on the outside of the body. A surgeon was considered a skilled craftsman as his work "demanded speed, dexterity, and physical strength, as well as expertise" (Peterson 9). The most significant difference between surgeons and physicians was in their education. Surgeons were apprenticed just as other traditional craftsmen, while physicians were university educated. By 1800, there were 8000 members of the Royal College of Surgeons. It was easier to become a surgeon than a physician because one only had to have enough money to be apprenticed but, in order to make a living, a surgeon often had to dispense drugs in a dual role as licensed apothecary. Unlike physicians, surgeons were permitted to be licensed as both surgeon an apothecary.
Apothecaries were not only druggists responsible for the sale, compounding, and supply of drugs but, thanks to the Apothecaries Act of 1815, were able to provide medical advice and prescribe medication themselves. Apothecaries, like surgeons, were apprenticed as skilled tradesman for a minimum of five years, with an age requirement of twenty-one years. The Society of Apothecaries was an important qualification to obtain so that a surgeon could also practice as an apothecary. More that 6000 apothecary licenses were issued between 1815 and 1834, half of these to surgeons.
During the first fifty years of the nineteenth century apothecaries and surgeons were taking apprentices for as much as 500 guineas, and the apprentices were typically sons of other apothecaries or surgeons, clergymen, lawyers, and some schoolmasters. They were the sons of men with enough money to educate their children (women during this century were nurses or midwives, rarely physicians, apothecaries, or surgeons.). A few businessmen, tradesmen, and some farmers could manage to apprentice their sons, but they often lacked any primary education prior to their apprenticeship. More alarming was the lack of a proper education of the medical students in the universities.
Licensing bodies of the United Kingdom required preliminary examinations for medical students, but "These examinations varied greatly, both in subjects tested and in the standards for passing" (Peterson 57). The exams were supposed to keep out uncultured men by requiring competence in English, literature, math, Latin, Greek, physics, logic, and a foreign language. However, with a little tutoring in French, Latin, and algebra just before the exams, a medical school candidate could get into a university. Even as late as 1800, "English and elementary philosophy (i.e. basic anatomy) were enough to begin medical training" (Peterson 57). Many of the students were sons of existing physicians or wealthy men and were able to buy their way into the university.
To further compound the problem, even some of the best medical colleges examined students in only four divisions of medicine (those four divisions being chosen by the college), although the colleges required at least four years of training to graduate. These years had to be filled in somehow, and they "were apt to be spent in idleness and sensual gratification; medical students had an unenviable reputation for drunkenness and debauchery" (Youngson 14). To graduate, students often employed a "grinder," someone who prepared the student by teaching him the questions and answers to the exam by rote. Favoritism and nepotism also helped a student to graduate. These practices were typical of medical schools as late as 1870.
There were nineteen different licensing bodies at this time and ten prominent medical universities in the United Kingdom during the nineteenth century. English universities were Oxford, Cambridge, London, Victoria, and Durham. In Scotland they were Edinburgh, Aberdeen, Glasgow, and St. Andrew's, and Trinity College Dublin was in Ireland. Medical colleges were all expensive regardless of what country they were in. Medical students had to be relatively wealthy or from a wealthy family that could afford to pay for tuition, books, fees, and room and board. In 1860, the total cost of four years of medical school at the University of London was between 228 and 268 pounds. This was considered a moderate budget. Although tuition and fees varied from college to college, 600 pounds for four to five years of medical colleges was considered an average figure in obtaining the best medical education available. (Peterson 69-74).
In 1848, Edinburgh was considered to offer the best organized and most thorough medical training to be had. But, by 1880, London University held the highest reputation for training medical students and for giving difficult and probing final exams.
Oxford and Cambridge Universities lured "students who wanted to pursue a medical degree in an environment of splendid opportunities both for social and general literary and scientific culture" (Peterson 66). Previously considered social clubs for rich boys, Oxford and Cambridge had, by 1880, better trained their graduates in scientific and medical techniques although the number of graduates was fewer. During the first thirty years of the nineteenth century, Oxford had educated 75 to 80% of the physicians in the UK. This number dropped significantly by the end of the century to only 30%, but the quality of graduating physicians was better. London University was the leader in graduating medical students with 32% of the physicians. Scottish universities and western European universities account for the other 38%. The profession, at this point, shifted the conditions from wealthy and conservative to more middle class and progressive, and from Oxford to London and Edinburgh.
During the first half of the nineteenth century medical research and education in the UK were still relatively poor in relation to other western European countries and in some instances were deplorable. It wasn't until the passage of the Medical Act of 1858 that any attempts to change existing conditions were made. This act was the "Bill to regulate the qualifications of Practitioners in Medicine and Surgery" (Peterson 34). Despite efforts to control unlicensed practitioners, "Qualified medical men gained only partial protection from competition with unlicensed practitioners" (Peterson 36). It wasn't until the Medical Act Amendment Act of 1886 that representation was given to general practitioners during corporate and university elections. Previously, seventeen different bills were introduced into Parliament between 1840 and 1858 to reorganize medical education and licensing in the UK. Medical reform was not a priority because "failure of all but one of these medical reform bills reveals the conflicting interests and needs of the elites of the corporations, on the one hand, and those of the rank and file, on the other. Parliamentary handling of the matter of medical reform also reveals some of the attitudes of Victorian society towards the profession and toward the place of medical science in the life of the English public" (Peterson 30).
Outside of the UK, important medical research and medical training was taking place. France, between 1790 and 1840, was the most prominent center on the continent for medical instruction and life science investigation. Although understanding of human anatomy was well developed by 1800, physiology was founded on superstitions and suppositions. In France, "physicians in Parisian hospitals were affecting a revolution in medicine by combining careful postmortem examinations of diseased patients with the clinical descriptions of the patients' disease during life" (Pfeiffer 10). Clinical pathophysiological observations of postmortem dissections were often published and the physicians and the general public outside of France were often disturbed by these kinds of practices going on in Paris. People considered their medical experiments radical and sacrilegious. Grave robbing had been a popular practice to obtain cadavers for dissection in the UK for those who wanted to study the human body. It wasn't until the Anatomy Act of 1832 that bodies became legally available for dissection.
Parisian physicians were beginning to specialize in different areas of medicine such as obstetrics, lunacy, and ophthalmology. Ultimately the specialist posed a threat to the general practitioners despite their humane and scientific motives and activities. The prevailing theory of the time was that the body was a whole unit, its parts being interconnected in such a way that specialization of one function or part would jeopardize the functions of the whole body. The bitter practitioners also feared they would lose their patients to specialist hospitals, depriving the doctors of an income. Eventually the widespread success and fame of specialists was tarnished by the practitioners "labeling the specialist as a greedy profiteer, seeking only to line his pockets" (Peterson 272).
The income of a medical man varied widely. While most apothecaries and surgeons had to play dual roles to earn enough to survive, high ranking physician consultants in London (between 1824 and 1846) could earn between 1500 and 2000 pounds a year. By the end of the century this figure increased to between 4000 and 5000 pounds a year. Wealthy physicians often owned estates, country homes, and many horses and carriages, and employed many servants. Financial success depended on clientele, expertise, and whether or not the physician was considered fashionable within social circles.
Ironically, most physicians regardless of status were ignorant of drug actions, even as late as 1850, and "were content to enquire about previous illness and present appetite: to feel the pulse, and to observe the appearance of the eyes, tongue, urine, and faeces, in that order of interest" (Younson 19).
These kinds of practices were to change with the passing of the Medical Act Amendment Act of 1886. The small group of dedicated and knowledgeable men of medicine, whose goal was to reform medical education and thereby change medical practices, finally had a voice in Parliament. Gone were the antics such as "Steeplechases in the dissecting room, cheating on the Latin examination, flirting with the barmaid, gin-and water until three o'clock in the morning" (Peterson 40). By the 1880's, these stereotypical university scenes were replaced by "a new image of the medical student: surrounded by books, a model of human skull at his elbow, he labored over his studies with gravity and decorum late in to the night" (Peterson 40). Because of the efforts of the enlightened few, and because of the discoveries happening in other European countries, the United Kingdom was finally able to give the medical profession the much desired respect and reform that it needed, making medicine a profession to be revered and a source of pride to all those who practiced it.
Peterson, M. Jeanne. The Medical Profession in Mid-Victorian London. Berkeley, Los Angeles, London: U of California P, 1978.
Pfeiffer, Carl J. The Art and Practice of Western Medicine in the Early Nineteenth Century. Jefferson, NC, and London: McFarland, 1985.
Youngson, A.J. The Scientific Revolution in Victorian Medicine. New York: Holmes and Meier, 1979.