Competition and monopoly in a profession
The campaign for medical registration in Britain
Ivan Waddington
T h e 1858 M e d i c a l A c t is r i g h t l y r e g a r d e d as a
l e g i s l a t i v e l a n d m a r k in the d e v e l o p m e n t o f the
m e d i c a l p r o f e s s i o n in B r i t a i n , for it w a s this
A c t w h i c h e s t a b l i s h e d the G e n e r a l M e d i c a l C o u n c i l ,
a n d w h i c h r e q u i r e d the C o u n c i l to m a i n t a i n a
r e g i s t e r o f d u l y q u a l i f i e d p r a c t i t i o n e r s . It is,
t h e r e f o r e , h a r d l y s u r p r i s i n g t h a t the A c t s h o u l d
h a v e b e e n t h e s u b j e c t of a g o o d d e a l of c o m m e n t
b o t h b y m e d i c a l h i s t o r i a n s and, m o r e r e c e n t l y ,
b y a n u m b e r of s o c i o l o g i s t s w i t h a p a r t i c u l a r
i n t e r e s t in the s o c i o l o g y o f t h e p r o f e s s i o n s . In
g e n e r a l , t w o b r o a d a p p r o a c h e s to u n d e r s t a n d i n g
the s i g n i f i c a n c e o f the A c t m a y be i d e n t i f i e d in
the l i t e r a t u r e . T h e first o f th e s e , w h i c h m a y be
r e g a r d e d as the m o r e t r a d i t i o n a l one, has e m p h a s i s e d
the b e n e f i t s o f m e d i c a l r e g i s t r a t i o n to t h e pub l i c ,
w h i l s t the b e n e f i t s a c c r u i n g e i t h e r to the
p r o f e s s i o n as a w h o l e , or to p a r t i c u l a r s e g m e n t s
w i t h i n the p r o f e s s i o n , h a v e r e c e i v e d r e l a t i v e l y
l i t t l e a t t e n t i o n . Thus, in a p a p e r w r i t t e n to
c e l e b r a t e the c e n t e n a r y of the G e n e r a l M e d i c a l
C o u n c i l , A.P. T h o m s o n a r g u e d t h a t "the C o u n c i l c a m e
i n t o e x i s t e n c e for the p r o t e c t i o n o f the p u b l i c "
(1), w h i l s t m o r e r e c e n t l y , Dr. P o y n t e r has
s u g g e s t e d t h a t "The i m p o r t a n t t h i n g to r e m e m b e r
is t h a t the A c t w a s not f r a m e d f o r the b e n e f i t
o f the p r o f e s s i o n (...) b u t w a s o n e d e s i g n e d to
p r o t e c t the p e o p l e in t h e i r i n d i v i d u a l a n d
c o r p o r a t e c a p a c i t y " (2). It is, p e r h a p s , n o t
s u r p r i s i n g to f i n d a s i m i l a r p o s i t i o n e c h o e d b y
the G e n e r a l M e d i c a l C o u n c i l i t s e l f . Thus, in 1970,
the G. M . C . p o i n t e d o u t that the p r e a m b l e o f the
1858 A c t s t a t e d t h a t it w a s " e x p e d i e n t t h a t p e r s o n s
r e q u i r i n g m e d i c a l aid s h o u l d be e n a b l e d to d i s t i n ­
guish q u a l ified from unqualified practitioners",
a n d w e n t on to a r g u e that "the w h o l e o f the C o u n ­
cil's functions flow from that original objective
28 8
(...) It c a n be s a i d t h a t
C o u n c i l is to p r o t e c t the
by keeping and publishing
q u a l i f i e d d o c t o r s (...)"
the g e n e r a l d u t y of the
p u b l i c , in p a r t i c u l a r
the R e g i s t e r o f d u l y
(3).
In r e c e n t y e a r s , h o w e v e r , s o m e s o c i a l s c i e n t i s t s
h a v e b e g u n to d e v e l o p a m o r e s c e p t i c a l a n a l y s i s
o f the s i g n i f i c a n c e of r e g i s t r a t i o n . Thus, in t h e i r
a n a l y s i s o f the r i s e o f the m e d i c a l p r o f e s s i o n , the
Parrys have suggested that registration may best
be seen as p a r t of "an o c c u p a t i o n a l s t r a t e g y w h i c h
is c h i e f l y d i r e c t e d t o w a r d s the a c h i e v e m e n t of
u p w a r d c o l l e c t i v e s o c i a l m o b i l i t y and, o n c e
a c h i e v e d , it is c o n c e r n e d w i t h the m a i n t e n a n c e of
s u p e r i o r r e m u n e r a t i o n a n d s t a t u s " (4). T h u s , they
argue, r e g i s t r a t i o n a l l o w s p r a c t i t i o n e r s to a c h i e v e
"a d e g r e e of m o n o p o l y w i t h r e s p e c t to the p r o v i s i o n
of p a r t i c u l a r t y p e s o f s e r v i c e s in the m a r k e t
pla c e " (5). P e r h a p s t h e m o s t d e t a i l e d a n d s y s t e m a t i c
a n a l y s i s o f m e d i c a l r e g i s t r a t i o n as a m o n o p o l i ­
z a t i o n s t r a t e g y , h o w e v e r , is c o n t a i n e d in the w o r k
of B e r l a n t , w h i c h r e v o l v e s a l m o s t e x c l u s i v e l y
a r o u n d t h i s theme. Thus, he s u g g e s t s t h a t the 1858
M e d i c a l A c t s h o u l d be seen, a l o n g w i t h s u c h thi n g s
as the d e v e l o p m e n t of m e d i c a l e t h i c s , as p a r t of
a m u c h b r o a d e r a t t e m p t at m o n o p o l i z a t i o n ; the
c a m p a i g n f o r r e g i s t r a t i o n , he s u g g e s t s , w a s d e ­
s i g n e d to r e d u c e c o m p e t i t i o n f r o m o u t s i d e the
p r o f e s s i o n , w h i l s t the d e v e l o p m e n t of m e d i c a l
ethics had the effect of regulating competition
w i t h i n the p r o f e s s i o n (6).
B e a r i n g t h e s e two c o n t r a s t i n g p e r s p e c t i v e s in mind,
it is the o b j e c t of t h i s p a p e r to e x a m i n e the
doctors' l e n g t h y c a m p a i g n for m e d i c a l r e g i s t r a t i o n
in the m i d d l e y e a r s of the n i n e t e e n t h c e n t u r y . On
the b a s i s o f this e x a m i n a t i o n , it w i l l be s u g g e s t e d
t h a t d o c t o r s w e r e b y n o m e a n s u n a w a r e of the r e l a ­
tionship between registration and monopolization;
n o r w e r e t h e y u n a w a r e o f the b e n e f i t s - p a r t i c u l a r l y
in terms o f the c o n t r o l o f n u m b e r s e n t e r i n g the
p r o f e s s i o n - w h i c h t h e y s t o o d to g a i n f r o m r e g i s ­
tration. O n the o t h e r hand, h o w e v e r , it w i l l also
be s u g g e s t e d t h a t a n y a t t e m p t to see the c a m p a i g n
for r e g i s t r a t i o n s i m p l y in t e r m s o f a m o n o p o l i z a t i o n
strategy necessarily involves considerable over­
s i m p l i f i c a t i o n . T h u s it w i l l b e a r g u e d t h a t the
28 9
c a m p a i g n for r e g i s t r a t i o n w a s n o t s i m p l y an a t t e m p t to
e r e c t a l e g a l b a r r i e r b e t w e e n the q u a l i f i e d a n d t h e u n ­
q u a l i f i e d , b u t t h a t a c e n t r a l d i m e n s i o n of the c a m p a i g n
i n v o l v e d the a t t e m p t to r e s t r u c t u r e the r e l a t i o n s h i p s
b e t w e e n d i f f e r e n t s e g m e n t s o f the p r o f e s s i o n i n s u c h a
w a y as to d e s t r o y the m o n o p o l i s t i c p r i v i l e g e s o f the
m e d i c a l c o r p o r a t i o n s . T h u s , in an a p p a r e n t l y c o n t r a ­
d i c t o r y m a n n e r , the c a m p a i g n for r e g i s t r a t i o n s i m u l t a ­
neously involved both monopolistic and a nti-mono­
p o l i s t i c e l e m e n t s . T h i s a p p a r e n t c o n t r a d i c t i o n , it
w i l l be s u g g e s t e d , can be u n d e r s t o o d b y a n a l y s i n g
the c a m p a i g n for r e g i s t r a t i o n w i t h i n the c o n t e x t
of the n e t w o r k o f r e l a t i o n s h i p s b o t h b e t w e e n
d i f f e r e n t s e g m e n t s of the p r o f e s s i o n , a n d b e t w e e n
qualified and unqualified practitioners.
T h e c a m p a i g n for r e g i s t r a t i o n , as is w e l l k n o w n , w a s
an e x t r e m e l y l o n g one; the b i l l w h i c h r e q u i r e d a
m e d i c a l r e g i s t e r to be c o m p i l e d , a n d w h i c h f i n a l l y
r e c e i v e d the R o y a l A s s e n t on 2nd A u g u s t , 1858, w a s
the s i x t e e n t h (7) in a l o n g line o f b i l l s o n t h i s
s u b j e c t , the f i r s t of w h i c h h a d b e e n i n t r o d u c e d in
1840. O n e r e a s o n for this l e n g t h y d e l a y b e f o r e a
b i l l w a s p a s s e d w a s that, as w e s h a l l see, d i f f e r e n t
g r o u p s w i t h i n the p r o f e s s i o n h a d r a d i c a l l y d i v e r g e n t
i n t e r e s t s , a n d t h e r e was, t h e r e f o r e , v i o l e n t d i s ­
a g r e e m e n t w i t h i n the p r o f e s s i o n as to w h a t s o r t of
b i l l w a s r e q u i r e d . It is, h o w e v e r , i n t e r e s t i n g to
n o t e that t h e r e w a s no s i g n i f i c a n t g r o u p w i t h i n the
p r o f e s s i o n w h i c h w a s o p p o s e d to t h e p r i n c i p l e of
r e g i s t r a t i o n as such, for a l t h o u g h it was the
g e n e r a l p r a c t i t i o n e r s w h o w e r e m o s t v e h e m e n t in
t h e i r d e m a n d s for a r e g i s t e r , e v e n the c o n s e r v a t i v e
R o y a l C o l l e g e s w e r e n o t o p p o s e d to s u c h a m e a s u r e .
T h u s , in his e v i d e n c e b e f o r e the S e l e c t C o m m i t t e e
on M e d i c a l R e g i s t r a t i o n in 1847, t h e P r e s i d e n t of
t he C o l l e g e o f P h y s i c i a n s , J.A. P a r i s , s t a t e d t h a t
the C o l l e g e h a d n o o b j e c t i o n to a r e g i s t e r (8),
w h i l s t the C o l l e g e R e g i s t r a r , F r a n c e s H a w k i n s ,
w e n t c o n s i d e r a b l y further, a n d e x p r e s s e d t h e v i e w
t h a t it w o u l d be " v e r y d e s i r a b l e t h a t the m e d i c a l
p r o f e s s i o n s h o u l d be r e g i s t e r e d in a m a n n e r b e t t e r
t h a n it is n o w " (9). H e n r y H o l l a n d s i m i l a r l y a r g u e d
t h a t it w a s " d e s i r a b l e t h a t the r e g i s t r a t i o n of
m e d i c a l m e n s h o u l d be m u c h m o r e a u t h e n t i c a n d
e f f e c t i v e t h a n it n o w is" (10). F o r the C o l l e g e
of S u r g e o n s , the P r e s i d e n t , W i l l i a m L a w r e n c e , s a w
n o o b j e c t i o n to "a r e g i s t r a t i o n o f m e d i c a l
p r a c t i t i o n e r s t h a t s h o u l d set f o r t h the q u a l i f i 290
c a t i o n s u n d e r w h i c h t h e y p r a c t i s e " (11), w h i l s t
S i r B e n j a m i n B r o d i e , a m e m b e r of the C o u n c i l of
the C o l l e g e , h e l d t h a t a s y s t e m of r e g i s t r a t i o n
of all m e d i c a l p r a c t i t i o n e r s " w o u l d be a v e r y g o o d
thing; it w o u l d b e p o p u l a r w i t h the p r o f e s s i o n ,
a n d r a t h e r u s e f u l for the p u b l i c " (12).
T h e r e was, then, l i t t l e d e s a g r e e m e n t w i t h i n the
p r o f e s s i o n on the d e s i r a b i l i t y of r e g i s t r a t i o n .
T h e r e was, h o w e v e r , m a j o r d i s a g r e e m e n t o v e r w h a t
f o r m t h a t r e g i s t r a t i o n s h o u l d take, a n d to u n d e r ­
s t a n d the s o u r c e s of this d i s a g r e e m e n t it is
n e c e s s a r y to e x a m i n e b r i e f l y the s t r u c t u r e of
m e d i c a l practice d u r i n g t h i s p e r i o d . T h e c h a n g i n g
s t r u c t u r e of the m e d i c a l p r o f e s s i o n d u r i n g the
first h a l f o f the n i n e t e e n t h c e n t u r y has b e e n
a n a l y s e d in d e t a i l e l s e w h e r e (13), so t h a t a
b r i e f s u m m a r y is all that is r e q u i r e d in this
context.
As is w e l l k n o w n , the s t r u c t u r e of the m e d i c a l
p r o f e s s i o n h a d t r a d i t i o n a l l y i n v o l v e d the d i f f e r ­
e n t i a t i o n o f t h r e e s e p a r a t e o c c u p a t i o n a l gro u p s :
p h y s i c i a n s , s u r g e o n s a n d a p o t h e c a r i e s . E a c h of
t h e s e t h r e e g r o u p s h a d its o w n l e g a l l y d e f i n e d
s p h e r e of p r a c t i c e , a n d c o r r e s p o n d i n g to t h e s e
groups there w ere three major controlling bodies
e n g a g e d in g r a n t i n g l i c e n c e s to p r a c t i s e m e d i c i n e
a n d s u r g e r y , n a m e l y the R o y a l C o l l e g e of P h y s i c i a n s ,
the R o y a l C o l l e g e of S u r g e o n s ( f o r m e r l y the C o m p a n y
of Surge o n s ) a n d the S o c i e t y o f A p o t h e c a r i e s .
Moreover, this tripartite structure was not simply
a t e c h n i c a l d i v i s i o n of labour; e q u a l l y i m p o r ­
tantly, it w a s a s y s t e m of s o c i a l s t r a t i f i c a t i o n
for, as P e t e r s o n h a s p o i n t e d out, the t h r e e o r d e r s
of m e d i c a l p r a c t i c e r e f l e c t e d "the s o c i a l d i v i s i o n
of m e d i c a l p r a c t i t i o n e r s i n t o t h r e e s t a t u s g r o u p s
or e s t a t e s " (14).
H o w e v e r , d u r i n g the e a r l y n i n e t e e n t h c e n t u r y , due
p a r t l y to c h a n g e s in the d e m a n d for m e d i c a l care
a s s o c i a t e d w i t h the I n d u s t r i a l R e v o l u t i o n , the
t r a d i t i o n a l t r i p a r t i t e s t r u c t u r e of the p r o f e s s i o n
w a s s t e a d i l y b e i n g ero d e d , a n d r e p l a c e d by the m o d e r n
p r o f e s s i o n a l s t r u c t u r e , b a s e d on the d i f f e r e n t i a t i o n
between general practitioners and consultants. The
d e v e l o p m e n t of g e n e r a l p r a c t i c e , h o w e v e r , p r o v e d to be
the s o u r c e of a g o o d d e a l of i n t r a p r o f e s s i o n a l
291
c o n f l i c t . T h u s the d e v e l o p m e n t o f g e n e r a l p r a c t i c e
n e c e s s a r i l y s e r v e d to u n d e r m i n e t h e t r a d i t i o n a l l y
rigid barriers separating the different branches
o f p r a c t i c e , for the w o r k o f the g e n e r a l p r a c t i ­
t i o n e r i n v o l v e d , as the n a m e i m p l i e s , n o t o n l y
m e d i c i n e a n d s u r g e r y , b u t a l s o a g o o d d e a l of
m i d w i f e r y , a n d g e n e r a l l y p h a r m a c y too. W h a t w a s
p a r t i c u l a r l y s i g n i f i c a n t in t h i s d e v e l o p m e n t a n d it w a s this w h i c h p a r t i c u l a r l y d i s t u r b e d the
Royal Colleges - was that general practitioners
were not only carrying out what had traditionally
b e e n r e g a r d e d as h i g h s t a t u s m e d i c a l work, b u t
w e r e a l s o p r o v i d i n g s e r v i c e s s u c h as t h o s e i n v o l v e d
in m i d w i f e r y a n d p h a r m a c y , w h i c h the R o y a l C o l l e g e s
saw as e x c l u s i v e l y m a n u a l a n d t r a d i n g o p e r a t i o n s , a n d
t h e r e f o r e o f low status. T h e R o y a l C o l l e g e s
r e s p o n d e d to this s i t u a t i o n b y t r y i n g to m a i n t a i n
the t r a d i t i o n a l b a r r i e r s s e p a r a t i n g the d i f f e r e n t
b r a n c h e s o f p r a c t i c e , a n d b y t r y i n g to i n h i b i t the
d e v e l o p m e n t o f g e n e r a l p r a c t i c e , for t h e y f e a r e d
t h a t the i n c o r p o r a t i o n of m a n u a l a n d t r a d i n g
e l e m e n t s i n t o the d o c t o r ' s r o l e t h r e a t e n e d the
high status whi c h physicians had long enjoyed, and
w h i c h s u r g e o n s h a d r e c e n t l y a t t a i n e d . T h u s the
R o y a l C o l l e g e s n o t o n l y p e r s i s t e n t l y r e f u s e d to
m a k e p r o v i s i o n for the t y p e o f e d u c a t i o n r e q u i r e d
for g e n e r a l p r a c t i c e , but, u n d e r the o p e r a t i o n of
their bye-laws, also excluded general practitioners
from their governing Councils. General practitioners
w e r e thus d e n i e d a n y p a r t i c i p a t i o n in the p o l i c y ­
m a k i n g p r o c e s s e s w i t h i n the t w o m o s t i n f l u e n t i a l
medical corporations. The situation of general
p r a c t i t i o n e r s w i t h i n the m e d i c a l p r o f e s s i o n was, as
P e t e r s o n h a s no t e d , a n o m a l o u s , for t h e y w e r e a
" h y b r i d c l a s s " (15), for w h o m t h e r e w a s no
r e c o g n i s e d p l a c e w i t h i n the t r a d i t i o n a l t r i p a r t i t e
structure. Whilst general practitioners held
l i c e n c e s f r o m o n e or m o r e o f the m e d i c a l c o r p o r a ­
tions, t h e r e w a s "no c o r p o r a t i o n d e d i c a t e d to
safeguarding and advancing their interests and
sta t u s . T h e y w e r e r e l e g a t e d to i n f e r i o r p o s i t i o n s
w i t h i n the c o r p o r a t i o n s a n d n e g l e c t e d b y t h e i r
l e a d e r s h i p " (16).
It is hardly s u r p r i s i n g t h a t g e n e r a l p r a c t i t i o n e r s
should have expressed their dissatisfaction with
this s i t u a t i o n , a n d t h r o u g h o u t the f i r s t h a l f of
29 2
t he n i n e t e e n t h c e n t u r y , t h e y c a r r i e d on a long
s t r u g g l e for a v a r i e t y of m e d i c a l r e f o r m s . Thus,
a m o n g s t o t h e r thi n g s , t h e y p u t f o r w a r d d e m a n d s
for the d e m o c r a t i c r e f o r m of the m e d i c a l c o r p o r a ­
tions, a n d f o r the r e f o r m o f m e d i c a l e d u c a t i o n .
I n c r e a s i n g l y , h o w e v e r , g e n e r a l p r a c t i t i o n e r s came
t o see the m a i n t e n a n c e of the t r a d i t i o n a l t r i p a r ­
t i t e s t r u c t u r e as the c e n t r a l s o u r c e of m a n y of
t h e i r p r o b l e m s , for it w a s this, a b o v e a l l else,
w h i c h w a s t h e s t u m b l i n g b l o c k to t h e i r p r o f e s s i o n a l
a s p i r a t i o n s . T h u s the g e n e r a l p r a c t i t i o n e r w a s
neither physician, nor surgeon, nor apothecary,
a n d as s u c h t h e r e w a s n o t - n o r c o u l d t h e r e be a n y p l a c e for h i m w i t h i n a p r o f e s s i o n a l s t r u c t u r e
which recognised only these traditional categories;
only by breaking down these traditional p r o f e s s i o n ­
al d i v i s i o n s , a n d r e p l a c i n g t h e m w i t h o n e s w h i c h
c o r r e s p o n d e d m o r e c l o s e l y to the n e w l y e m e r g i n g
professional structure, could general pra c t i ­
t i o n e r s h o p e to a c h i e v e c l e a r r e c o g n i t i o n of w h a t
t h e y h e l d t o be t h e i r r i g h t f u l p l a c e w i t h i n the
p r o f e s s i o n . It w as, t h e r e f o r e , of m a j o r i m p o r t a n c e
to the g e n e r a l p r a c t i t i o n e r s t h a t a n y p r o p o s e d
s y s t e m of r e g i s t r a t i o n s h o u l d be one w h i c h s e r v e d
to b r e a k down, r a t h e r t h a n to p e r p e t u a t e , t h e s e
t r a d i t i o n a l p r o f e s s i o n a l d i v i s i o n s . T h u s o n e of
t he c o m m o n l y e x p r e s s e d d e m a n d s of the g e n e r a l
p r a c t i t i o n e r s w a s for a s i n g l e r e g i s t e r w h i c h w o u l d
g i v e all q u a l i f i e d p r a c t i t i o n e r s a s i m i l a r l e g a l
s tatus, w i t h the l e g a l r i g h t to p e r f o r m the c o m p l e t e
r a n g e of m e d i c a l a n d s u r g i c a l tasks. T h e R o y a l
C o l l e g e s , o n the o t h e r hand, w h i l s t n o t b e i n g
o p p o s e d to the p r i n c i p l e of r e g i s t r a t i o n , i n s i s t e d
t h a t th e r e s h o u l d be n o t o n e c o m m o n r e g i s t e r for
all p r a c t i t i o n e r s , b u t r a t h e r t h r e e s e p a r a t e
r e g i s t e r s f o r p h y s i c i a n s , for s u r g e o n s a n d for
a p o t h e c a r i e s ; in t h i s way, the t r a d i t i o n a l "orde r s "
of the p r o f e s s i o n , e a c h w i t h its o w n e x c l u s i v e ,
l e g a l l y d e f i n e d s p h e r e of p r a c t i c e , w o u l d be
m a i n t a i n e d . T h u s the g e n e r a l p r a c t i t i o n e r s ' d e m a n d
for a c o m m o n r e g i s t e r c a n be s e e n as a g e n u i n e l y
r a d i c a l d e m a n d , a n d o n e in w h i c h , as we s h a l l see,
the a n t i - m o n o p o l i s t i c e l e m e n t s of the r e g i s t r a t i o n
m o v e m e n t w e r e m o s t c l e a r l y r e v e a l e d . T h u s the
d e m a n d for a s i n g l e r e g i s t e r w a s , in e f f e c t , a
d e m a n d for the a b o l i t i o n of t h e t r i p a r t i t e s t r u c ­
ture, a n d f o r t h e d i s m a n t l i n g o f t h o s e l e g a l
293
r e s t r i c t i o n s w h i c h w e r e v e r y m u c h a p a r t of t h a t
s t r u c t u r e , a n d w h i c h w e r e d e s i g n e d to r e s e r v e a
p a r t i c u l a r k i n d of m e d i c a l w o r k for e a c h of the
t h r e e g r a d e s o f p r a c t i t i o n e r . A s such, it a l s o
r e p r e s e n t e d an a t t a c k on the e x c l u s i v e p r i v i l e g e s
a n d j u r i s d i c t i o n s of the m e d i c a l c o r p o r a t i o n s ,
a n d an a t t e m p t to u n d e r m i n e the t r a d i t i o n a l s t a t u s
d e s t i n c t i o n s w i t h i n the p r o f e s s i o n . G i v e n t h i s
s i t u a t i o n , it is h a r d l y s u r p r i s i n g t h a t the h i g h
s t a t u s g r o u p s w i t h i n the p r o f e s s i o n - t h a t is, the
consulting physicians and surgeons who controlled
the R o y a l C o l l e g e s - s h o u l d h a v e r e s i s t e d w h a t
t h e y s a w as the " l e v e l l i n g p r i n c i p l e s " i n v o l v e d
in the c a m p a i g n for a c o m m o n r e g i s t e r .
T h e a t t i t u d e o f the R o y a l C o l l e g e s to the p r o p o s e d
p l a n for a c o m m o n r e g i s t e r can, p e r h a p s , be b e s t
i l l u s t r a t e d b y r e f e r e n c e to the e v i d e n c e g i v e n by
t h e i r s p o k e s m e n to the 1847 S e l e c t C o m m i t t e e on
Medical R e g i s t r a t i o n . The committee had been
established shortly after Henry Warburton and
T h o m a s W a k l e y , the r a d i c a l e d i t o r of the L a n c e t ,
h a d i n t r o d u c e d i n t o the H o u s e o f C o m m o n s a b i l l
" F o r t h e R e g i s t r a t i o n of q u a l i f i e d P r a c t i t i o n e r s " ,
a n d m u c h of the e a r l y e v i d e n c e g i v e n b y the
C o l l e g e s ' s p o k e s m e n r e l a t e d to t h i s bill. O n e
a s p e c t of the b i l l w h i c h the R o y a l C o l l e g e s f o u n d
p a r t i c u l a r l y u n p a l a t a b l e w a s t h e f a c t t h a t it m a d e
p r o v i s i o n for the c o m m o n r e g i s t r a t i o n of the t h r e e
" o r d e r s " of the p r o f e s s i o n (17), w i t h all q u a l i f i e d
p r a c t i t i o n e r s e n j o y i n g a s i m i l a r l e g a l sta t u s . T h u s
J.A. Paris, t h e P r e s i d e n t o f the C o l l e g e of
P h y s i c i a n s , h e l d t h a t the e f f e c t of the b i l l w o u l d
be to c r e a t e o n e c l a s s of m e d i c a l p r a c t i t i o n e r . He
a r g u e d t h a t "the h i g h e s t g r a d e w o u l d c e a s e to
e x i s t " , w i t h the r e s u l t t h a t m e d i c i n e w o u l d no
l o n g e r be a l e a r n e d p r o f e s s i o n (18). A l t h o u g h n o t
o p p o s e d to r e g i s t r a t i o n as such, P a r i s h e l d t h a t
" m e d i c a l m e n s h o u l d be r e g i s t e r e d in c l a s s e s o r
g r a d e s " (19). F r a n c e s H a w k i n s , the C o l l e g e R e g i s ­
trar, s i m i l a r l y h e l d t h a t "if the r e g i s t r a t i o n
w e r e to b e f o r m e d u p o n the p r i n c i p l e o f t h e i r
(the t h r e e o r d e r s of the p r o f e s s i o n ) b e i n g p l a c e d
t o g e t h e r , it w o u l d t e n d to d e s t r o y t h o s e d i s t i n c ­
t i o n s w h i c h h a v e b e e n f o u n d to b e b e n e f i c i a l to
the w h o l e p r o f e s s i o n , a n d a l s o to the p u b l i c " (20).
T h e e f f e c t o f the b i l l of W a r b u r t o n a n d W a k l e y , he
294
he l d , w o u l d b e to " t h r o w all the o r d e r s of the
p r o f e s s i o n i n t o o n e c l a s s (...) I t h i n k the
a t t a i n m e n t s o f t h o s e w h o h a v e h i t h e r t o b e e n the
m o s t h i g h l y e d u c a t e d in the m e d i c a l p r o f e s s i o n
w o u l d u n d o u b t e d l y be l o w e r e d " (21). G e o r g e B u r r o w s ,
Senior Censor of the College of Physicians stated
t h a t "I s h o u l d be m o r e c o n t e n t w i t h the p r e s e n t
s t a t e of t h i n g s t h a n h a v e t h i s R e g i s t r a t i o n B i l l
p a s s e d as it s t a n d s , b e c a u s e I f e e l c o n v i n c e d in
m y o w n m i n d t h a t it w o u l d r e v o l u t i o n i z e a n d d i s ­
o r g a n i z e the p r o f e s s i o n , a n d t h a t it w o u l d d e g r a d e
o u r p r o f e s s i o n " (22). H e n r y H o l l a n d h e l d t h a t the
b i l l of W a r b u r t o n a n d W a k l e y w a s " p e r n i c i o u s " (23);
it w a s , he a r g u e d , " e x c e e d i n g l y i m p o r t a n t for the
p r o f e s s i o n a n d the p u b l i c t h a t t h e r e s h o u l d be
g r a d e s in the p r o f e s s i o n , a n d that a n y m e a s u r e
t h a t m i g h t t e n d to a b o l i s h t h o s e gra d e s , or e v e n
to w e a k e n t h e i r i n f l u e n c e , w o u l d b e as i n j u r i o u s
to the p u b l i c as to the p r o f e s s i o n " (24). T h e
p h y s i c i a n s ' c o n c e r n to m a i n t a i n a r i g i d b a r r i e r
b e t w e e n t h e m s e l v e s a n d the " l o w e r o r d e r s " of the
profession was, perhaps, most clearly expressed
b y the P r e s i d e n t of the C o l l e g e in r e l a t i o n to
s o m e t h i n g w h i c h , to the m o d e r n r e a d e r , m i g h t s e e m
a t r i v i a l c h a n g e in the l e g a l s t a t u s of the
p h y s i c i a n b u t w h i c h , to the C o l l e g e , w a s c l e a r l y
o f c o n s i d e r a b l e i m p o r t a n c e . F o r a n u m b e r of years,
b o t h s u r g e o n s a n d a p o t h e c a r i e s h a d h a d the legal
r i g h t to sue a p a t i e n t for r e c o v e r y of c h a r g e s .
H o w e v e r , p h y s i c i a n s , as b e f i t t e d g e n t l e m e n , w e r e
c o n s i d e r e d , as far as the l a w w a s c o n c e r n e d , as
a t t e n d i n g p a t i e n t s for a h o n o r a r i u m , a n d as such,
t h e y w e r e u n a b l e to m a i n t a i n an a c t i o n for fees.
T h e b i l l of W a r b u r t o n a n d W a k l e y , h o w e v e r , p r o p o s e d
to e x t e n d to a l l r e g i s t e r e d p r a c t i t i o n e r s t h e r i g h t
o f r e c o v e r i n g p a y m e n t of c h a r g e s for t h e i r
a t t e n d a n c e . T h e R o y a l C o l l e g e of P h y s i c i a n s was,
as ever, a l e r t to a n y t h r e a t to its e x c l u s i v e
sta t u s , e v e n f r o m s u c h a m i n o r c h a n g e in the law.
"We o b j e c t to t h a t v e r y m u c h " , s a i d t h e i r P r e s i ­
dent, "we c o n s i d e r t h a t the p h y s i c i a n w o u l d u n d e r
t h o s e c l a u s e s be c o n v e r t e d i n t o a t r a d e s m a n ; we
s h o u l d feel t h a t w e h a d l o s t c a s t e b y a l l o w i n g
t h o s e c l a u s e s to p a s s " (25).
L i k e the C o l l e g e o f P h y s i c i a n s , the R o y a l C o l l e g e
of S u r g e o n s a l s o o b j e c t e d to a n y p r o p o s e d f o r m of
29 5
registration whi c h did not clearly differentiate
b e t w e e n the h i g h a n d low s t a t u s g r o u p s w i t h i n the
p r o f e s s i o n , for the c o n s u l t i n g s u r g e o n s , l i k e the
p h y s i c i a n s , w e r e e q u a l l y k e e n to p r e s e r v e t h e i r
e x c l u s i v e s t a t u s a g a i n s t the t h r e a t o f t h e p a r v e n u
g r o u p of g e n e r a l p r a c t i t i o n e r s . T h u s W i l l i a m
L a w r e n c e , the P r e s i d e n t o f t h e C o l l e g e of S u r g e o n s ,
criticized "those levelling principles of equality
w h i c h are f o u n d to be i n j u r i o u s w h e r e v e r t h e y e x i s t
in p r a c t i c e " (26), a n d he w e n t on to a r g u e that
"If y o u h a v e a l l on one level, it m u s t be b y
d e p r e s s i n g t h o s e w h o are h i g h e r to the l e v e l of
t h o s e w h o a r e l o w e r in p u b l i c o p i n i o n a n d c o n f i ­
d e n c e " (27). L a w r e n c e c o n s i d e r e d that a r e g i s t r a ­
t i o n in c l a s s e s or g r a d e s w o u l d b e "the o n l y k i n d
o f r e g i s t r a t i o n w h i c h w o u l d g i v e the p u b l i c p r o p e r
i n f o r m a t i o n " (28). S i r B e n j a m i n B r o d i e s i m i l a r l y
held that the bill of Warburton and W akley would
t e n d to " c o n f o u n d all g r a d e s o f the p r o f e s s i o n
t o g e t h e r " , a p r o c e s s w h i c h h e h e l d to be " n o t at
a l l d e s i r a b l e " (29). G e o r g e J a m e s G u t h r i e , a
C o u n c i l l o r a n d f o r m e r P r e s i d e n t of the C o l l e g e of
S u r g e o n s d i d n o t o b j e c t to a r e g i s t e r o f q u a l i f i e d
p r a c t i t i o n e r s , b u t he h e l d t h a t "they s h o u l d be
k e p t d i s t i n c t as to t h e i r b e i n g p h y s i c i a n s or
s u r g e o n s , o r s u r g e o n - a p o t h e c a r i e s " (30). U s i n g a
p a r t i c u l a r l y a p p r o p r i a t e m e d i c a l a n a l o g y , he w e n t
o n to a r g u e t h a t "a c e r t i f i c a t e w h o u l d s a y the
i n d i v i d u a l is q u a l i f i e d t o p r a c t i s e as a s u r g e o n or
as a p h y s i c i a n , o r a g e n e r a l p r a c t i t i o n e r as the
c a s e m a y be; b u t it d o e s not d o so, and t h a t is w h a t
t he C o l l e g e s h a v e o b j e c t e d to, as p o u n d i n g us all
up in the s a m e m o r t a r , in fact" (31).
Q u i t e c l e a r l y , o n e c o n s e q u e n c e o f the r e f o r m
m o v e m e n t w i t h i n the p r o f e s s i o n w a s the p o l a r i s a t i o n
of general practitioners and consultants into
o p p o s i t e c a m p s , for w h i l s t t h e g e n e r a l p r a c t i ­
t i o n e r s w e r e i n t e n t on the a b o l i t i o n o f t h e t r i ­
p a r t i t e s t r u c t u r e , the c o n s u l t a n t s h a d an e q u a l l y
s t r o n g v e s t e d i n t e r e s t in m a i n t a i n i n g t h a t s t r u c ­
ture. M o r e o v e r , the v e r y c o n s i d e r a b l e p r e s t i g e and
i n f l u e n c e o f t h e R o y a l C o l l e g e s e n a b l e d t h e m to
e f f e c t i v e l y res i s t , for m a n y ye a r s , all t h e g e n e r a l
p r a c t i t i o n e r s ' d e m a n d s for ref o r m . H o w e v e r , the
t a s k o f d e f e n d i n g the t r a d i t i o n a l i n s t i t u t i o n a l
s t r u c t u r e w a s b e c o m i n g i n c r e a s i n g l y d i f f i c u l t , for
the t r i p a r t i t e s t r u c t u r e was, in e f f e c t , b a s e d on
a c o m p l e x s y s t e m of m o n o p o l i e s a n d r e s t r i c t i v e
296
practices which were becoming increasingly un­
a c c e p t a b l e w i t h i n t h e c o n t e x t of m i d - n i n e t e e n t h
c e n t u r y p o l i t i c s . T h u s t h e r e w e r e s e p a r a t e laws
r e l a t i n g to p h y s i c i a n s , to s u r g e o n s a n d to
a p o t h e c a r i e s , the e x p l i c i t p u r p o s e of w h i c h w a s
to r e s e r v e a p a r t i c u l a r b r a n c h o f m e d i c a l p r a c t i c e
for a p a r t i c u l a r g r a d e of p r a c t i t i o n e r . In a d d i t i o n ,
s o m e of the m e d i c a l c o r p o r a t i o n s e n j o y e d l e g a l l y
defined monopolies within certain geographical
l imits. T h u s it h a d l o n g b e e n i l l e g a l for a n y o n e
e x c e p t Fellows a n d L i c e n t i a t e s o f t h e C o l l e g e of
P h y s i c i a n s to p r a c t i s e as a p h y s i c i a n w i t h i n L o n ­
d o n a n d for s e v e n m i l e s around; b y t h i s r e g u l a t i o n ,
m a n y h i g h l y e d u c a t e d m e d i c a l g r a d u a t e s of S c o t t i s h
and continental universities were excluded from
p r a c t i c e in L o n d o n , w h e r e of cou r s e , the m o s t
l u c r a t i v e p r a c t i c e s w e r e to b e found.
O f r a t h e r g r e a t e r i m p o r t a n c e , h o w e v e r , s i n c e it
a f f e c t e d m a n y m o r e p r a c t i t i o n e r s , w a s the m o n o p o l y
w h i c h h a d b e e n g r a n t e d to the S o c i e t y o f A p o t h e ­
c a r i e s by t h e A p o t h e c a r i e s ' A c t of 1815. M o s t
g e n e r a l p r a c t i t i o n e r s h a d long b e e n in the h a b i t
o f d i s p e n s i n g m e d i c i n e s for t h e i r o w n p a t i e n t s and,
indeed, in c o u n t r y d i s t r i c t s a n d s m a l l towns, w h e r e
t h e r e w a s a m i n i m a l d i v i s i o n of l a b o u r w i t h i n the
p r o f e s s i o n , this p r a c t i c e w a s a l m o s t u n i v e r s a l .
H o w e v e r , the A c t of 1815 m a d e it i l l e g a l for a n y o n e
t o p r a c t i s e as an a p o t h e c a r y in E n g l a n d o r W a l e s
w i t h o u t h a v i n g f i r s t o b t a i n e d the l i c e n c e o f the
S o c i e t y o f A p o t h e c a r i e s ; thus all t h o s e w h o w i s h e d
t o e n g a g e l e g a l l y in g e n e r a l p r a c t i c e w e r e o b l i g e d
to b e c o m e l i c e n t i a t e s of the Society.
T h e A p o t h e c a r i e s ' A c t had, as H o l l o w a y h a s noted,
"a c l o s e r a f f i n i t y to a S t u a r t p a t e n t of m o n o p o l y
t h a n to a s t a t u t e in the age of ' l a i s s e z - f a i r e ' " ,
a n d the m a j o r e f f e c t of the A c t w a s "to m a i n t a i n
the a n c i e n t h i e r a r c h i c a l s t r u c t u r e o f the m e d i c a l
p r o f e s s i o n a n d the a p o t h e c a r y ' s i n f e r i o r s t a t u s
w i t h i n it" (32). T h u s the s o c i e t y s o u g h t to e n f o r c e
its m o n o p o l y n o t o n l y a g a i n s t w h o l l y u n q u a l i f i e d
practitioners, but also against physicians and
s u r g e o n s in g e n e r a l p r a c t i c e . In 1833, for e x a m p l e ,
a S c o t t i s h e d u c a t e d p h y s i c i a n w a s c o n v i n c t e d for
i l l e g a l l y p r a c t i s i n g as an a p o t h e c a r y and, f o l l o w i n g
t h i s c o n v i c t i o n , the S o c i e t y of A p o t h e c a r i e s sent
297
t h r e a t e n i n g l e t t e r s to S c o t t i s h g r a d u a t e s in
g e n e r a l p r a c t i c e , i n s i s t i n g on t h e i r a c q u i r i n g the
S o c i e t y ' s l i c e n c e (33). In h i s e v i d e n c e b e f o r e a
S e l e c t C o m m i t t e e in 1848, t h e s o l i c i t o r to the
Apothecaries' Society a d mitted that whilst he was
n o t a w a r e of a n y p r o s e c u t i o n a g a i n s t a c h e m i s t
f or p r a c t i s i n g as an a p o t h e c a r y , the S o c i e t y h a d
p r o s e c u t e d a n u m b e r of m e m b e r s o f the C o l l e g e of
S u r g e o n s (34).
T h e r e q u i r e m e n t t h a t all g e n e r a l p r a c t i t i o n e r s be
l i c e n s e d b y the A p o t h e c a r i e s ' S o c i e t y u n d e r ­
s t a n d a b l y c a u s e d a g r e a t d e a l o f r e s e n t m e n t on the
p a r t of m a n y g e n e r a l p r a c t i t i o n e r s , for the
association between Apothecaries' Hall - or
" R h u b a r b H a l l " , as the L a n c e t c a l l e d it - s e r v e d
s i m p l y to e m p h a s i s e the i n f e r i o r s t a t u s of the
g e n e r a l p r a c t i t i o n e r w i t h i n the p r o f e s s i o n . "While
the c o n s u l t i n g p h y s i c i a n a n d s u r g e o n c o u l d c l a i m
to b e m e m b e r s of R o y a l C o l l e g e s , the g e n e r a l
practitioner was associated by law with a London
t r a d i n g c o m p a n y " (35). T h e i s s u e w a s n i c e l y s u m m e d
up b y o n e c o n t e m p o r a r y o b s e r v e r w h o r e m a r k e d t h a t
"It d o e s n o t s e e m q u i t e so r e a s o n a b l e , that, b e c a u s e
the a p o t h e c a r i e s h a v e c e a s e d to b e g r o c e r s , t h e y
s h o u l d be f o r t h w i t h i n v e s t e d w i t h the e n t i r e
r e g u l a t i o n o f the p r a c t i c e o f m e d i c i n e in E n g l a n d "
(36) .
T h e i n t e n t i o n b e h i n d the g r a n t i n g of t h e s e m o n o ­
p o l i e s had, o f cou r s e , b e e n to c o n f i n e p r a c t i ­
t i o n e r s t o a p a r t i c u l a r b r a n c h o f m e d i c i n e or
s u r g e r y , a n d thus to m a i n t a i n the t r a d i t i o n a l
tripartite s t r u c t u r e . A s such, t h e c h i e f s u f f e r e r s
f r o m the o p e r a t i o n of t h e s e m o n o p o l i s t i c p r a c t i c e s
w e r e the g e n e r a l p r a c t i t i o n e r s , a p o i n t w h i c h the
L a n c e t w a s n o t s l o w to note. T h u s , in an e d i t o r i a l
o n the m e d i c a l c o r p o r a t i o n s , the L a n c e t n o t e d that
as a r e s u l t of the p a s s i n g o f t h e A p o t h e c a r i e s '
Act, "a s t a t e of t h i n g s h a s r e s u l t e d w h i c h is
e n t i r e l y w i t h o u t p a r a l l e l . V a r i o u s h a v e b e e n the
p e r s e c u t i o n s w i t h w h i c h u n p r i n c i p l e d p o w e r has
t o r m e n t e d its v i c t i m s . T h e r e h a v e b e e n r e l i g i o u s
persecutions, and political persecutions, and
literary persecutions, and scientific persecutions;
b u t the g e n e r a l p r a c t i t i o n e r s of E n g l a n d a r e the
first men who have groaned under a rhubarb p e r s e ­
298
cution, - most nauseous and disgusting"
(37).
In addition to the monopolies which had been
granted to individual medical corporations there
were other monopolistic practices within the
medical profession which also gave rise to a good
deal of resentment on the part of general practi­
tioners. Thus, as has been briefly noted already,
in a vain attempt to stem the rise of the general
practitioner, both Royal Colleges had, under the
operation of their bye-laws, excluded general
practitioners from their governing Councils, thus
concentrating power in the hands of the consultants.
The situation of general practitioners within the
Royal Colleges was accurately summed up by the
observation of James Bird that "neither the College
of Surgeons nor the College of Physicians has any
sympathy with the general practitioners; the
interests of that body have at all times been
placed in abeyance, and for want of a recognised
position they have hitherto been disregarded in
all communications with the Government". The result
of the general practitioners' exclusion from the
Councils of the Colleges was that "there is no
body, no head, to represent the interests of ninetenths of the profession" (38).
Given that monopolies of all kinds were increasingly
coming under attack during this period, it is not
surprising that, in seeking to undermine the tri­
partite structure, the general practitioners and
their parliamentary allies should have emphasised
the monopolistic character of the institutions
against which their attack was directed. Thus, in
an editorial in 1832, the L a n c e t suggested that
"The preamble of the Apothecaries' Act ought, in
consistency with its general tone and spirit, to
have run, - 'Whereas, it is expedient to grant a
monopoly to the Apothecaries' Company', - for there
is scarcely a clause in the act which is not framed
with a view of putting money into the pockets of
these incorporated tradesmen" (39). Two years later,
in the parliamentary debate in which Warburton
moved for an enquiry into the medical profession,
one M.P. pointed out that the Apothecaries' Act
"operated only as a most injurious monopoly", and
he went on to add that "At a period when Government
299
was putting an end to all monopolies, it was
singular, that the monopoly of mind alone should
remain" (40). In the same debate, another M.P.
called for the abolition of what he termed the
"ungenerous and selfish" monopoly of the College
of Physicians in London (41). Shortly after the
Select Committee of Enquiry had been established,
the licentiates of the College of Physicians
presented two petitions to Parliament, listing
their grievances. In the first of these, they
claimed that "the f e l l o w s have u s u r p e d all the
corporate power, offices, privileges, and emolu­
ments, attached to the college" by the operation
of a series of "invidious bye-laws, made in the
spirit of corporate monopoly", whilst the second
petition complained that the system of choosing
the members of the council of the College "is
framed on a close and narrow system of monopoly
and exclusion, exhibiting some of the worst
features of a close corporation" (42).
By the early 1840's, the monopolistic privileges
of the medical corporations had become a consistent
target of attack by the general practitioners.
Thus in 1842, the L a n c e t , a consistent campaigner
on behalf of general practitioners, asked "Is it
not true that even the multitudes of all civilised
nations are raising their voices against monopolies
in trade and commerce?" The fact that monopolies
continued to exist within the medical profession
was, said the L a n c e t , a "thousand times more
baneful and detestable" (43). In 1847, when it
became known that the Royal Colleges were opposing
the bill of Warburton and Wakley, discussed
earlier, a group of practitioners in Cirencester
petitioned Parliament expressing their view that
"the said colleges etc. (an irresponsible few) are
endeavouring to hold to themselves, as heretofore,
an usurping and monopolizing power, for their own
selfish and exclusive interests, without regarding
the best interests of the profession or public"
(44). Equally importantly, the attack on the medical
corporations continued from within Parliament.
Thus, on the second reading of Cowper's bill, which
eventually became the Medical Act of 1858, one
M.P. claimed that what was required was a bill "to
repeal all Acts hitherto passed which had given a
300
monopoly to the body of physicians in London, and
pieced restrictions upon the other branches of
the profession" (45), whilst the radical M.P.,
Tom Duncombe, held that the monopoly of the College
of Physicians was "a nuisance to everybody in
London and seven miles around" (46).
Clearly discernible within many of the reformers'
comments was the anti-monopolistic sentiment of
l a i s s e z - f a i r e ideology. Sometimes, however, general
practitioners drew on l a i s s e z - f a i r e ideology in a
much more detailed and explicit way in order to legiti­
mate their opposition to the tripartite structure.
A particularly clear example of this was provided
by a series of articles published by the L a n c e t
on "the real and imaginary grievances of the
medical profession" (47). The author of these
articles, D.O. Edwards, argued that "the mainspring
of everything great or useful in medicine and its
collateral arts, is, and ever has been, private
enterprise" (48), and he went on to argue, in an
almost classical statement of l a i s s e z - f a i r e
philosophy, "that no restraint ought to be placed
on the liberty of the subject which is not clearly
and unequivocally conducive to the public benefit.
From this principle it is deducible, that that
government is the best which attains its object
with the fewest restrictions" (49). This principle
should, he suggested, also be applied to the
government of the medical profession: "For my part
I have such a horror of monopoly and exclusiveness
in every shape, that I would carry out this
liberating principle to its utmost limits, and I
would make it the Ithuriel test by which the
genuineness of every plan of reform should be
determined" (50). Amongst the major grievances of
the general practitioners were, said Edwards, "the
bonds and shackles which monopoly had forged”
(51), the effect of which had been "to impede and
smother" enterprise in medical practice, and to
"shackle the free agency and lessen the usefulness
of the medical man" (52). Edwards bitterly criti­
cised what he called the "capricious and forcible
arrangement of the medical profession, into three
different classes" (53) and in a clear reference
to the Royal Colleges, he pointed out that amongst
the major opponents of reform were "the monopolists,
301
who oppose the removal of those restrictions which
'cabin, crib and confine' the profession" (54).
What was required by way of reform was "the
emancipation of the profession from the restraint
of all unjust and unnecessary laws" (55). What
Edwards was asking for, amongst other things, was
the removal of those restrictions which confined
medical men to one particular branch of practice,
for all practitioners would then be able to compete
on equal terms. What the commonalty of the profes­
sion were demanding, he said, was "'a clear stage
and no favour' for the enterprise of all" (56),
a statement of l a i s s e z - f a i r e philosophy which was
subsequently echoed in Parliament when one M.P.
argued that the medical profession should be given
"a fair field and no favour" (57).
Quite clearly, any attempt to see the general
practitioners' campaign simply in terms of a
monopolization strategy necessarily involves
considerable oversimplification for, as we have
seen, the campaign involved from the very beginning
a clear attempt to undermine the monopolistic
priviliges and exclusive status of the Royal Col­
leges. Moreover, when a registration bill was
finally passed, it represented at least in some,
if not in all, respects, a considerable triumph
for the general practitioners. Thus the 1858
Medical Act required the names of all qualified
practitioners, whatever their legal status prior to
the Act, to be entered in a common register, rather
than in three separate registers, as the Royal
Colelges had wanted; all registered practitioners
were thus accorded the same legal status. As
Holloway has noted, the 1858 Act "thus ended the
rigid hierarchical division of the profession into
three estates" (58), for the Act was not framed
around the maintenance of the separate privileges
of physicians, surgeons and apothecaries, but around
the common status and common privileges of all
registered or "duly qualified" practitioners.
The Act thus effectively ended the tripartite
structure, with its monopolistic restrictions
designed to confine practitioners to one particular
branch of practice (59). It also abolished all
regional monopolies, like that of the Royal College
302
of Physicians in London, for under clause 31 of
the Act, all registered practitioners were given
the right to practise "in any Part of Her Majesty's
Dominions". Under the same clause, Scottish grad­
uates, many of whom had been practising under the
continual threat of prosecution by the Society of
Apothecaries, were also given the legal right to
practise in England and Wales without having to
take out a licence from one of the English
corporations. Thus, the network of legal restric­
tions which had served to "cabin, crib, and
confine" the profession was finally removed.
What has been said above should not be taken as an
indication that the 1858 Act represented an un­
qualified victory for the general practitioners
for, as Newman has pointed out, there were a
number of aspects of the Act with which general
practitioners were dissatisfied (60). However, what
is important within the present context is that
the general practitioners' campaign was largely
directed against, and was largely successful in
getting abolished, a number of longstanding mono­
polistic restrictions within the medical profes­
sion. Moreover, it is, of course, precisely this
aspect of the registration movement which is missed
if one regards the campaign for registration simply
as a monopolization strategy.
The major problem with any framework such as that
adopted by Berlant and the Parrys is that it
appears to be premissed on the assumption of a
unified profession with a common interest which
is best served by registration. Such an assumption
is not altogether invalid; it may be useful, for
certain purposes, to see the medical profession as
a group with a common interest in, for example,
excluding unqualified practitioners, though even
here, as we shall see, there were significant
differences between general practitioners and
consultants. For other purposes, however, such an
assumption is wholly misleading. Thus the medical
profession in the mid-nineteenth century was not
a unified profession; indeed, it was, as Dr. Poynter
has noted, "a profession in chaos (...) split from
top to bottom by jealous rivalries and competing
interests" (61). The profession consisted, prior
303
to 1858, of a number of separate occupational
groups, each with its own distinct legal status,
its own distinct system of education and, most
importantly, its own distinct occupational
interests. As such, the campaign for registration
was concerned at least as much with the restruc­
turing of relationships between different segments
of the profession as it was with excluding the
unqualified from practice, and it is, of course,
in the former aspects of the campaign that its antimonopolistic elements can most clearly be seen.
However, as has already been noted, the campaign
for registration simultaneously involved both antimonopolistic and monopolistic elements. Thus the
campaign sought not only to destroy the monopolis­
tic privileges of the medical corporations, but
also to restrict entry into the profession, and to
exclude the unqualified from practice. It is to an
examination of these monopolistic elements of the
campaign that we must now turn.
In the early 1830's, the L a n c e t argued that "the
members of the medical profession are not a body
of wealthy individuals" (62), and there is, indeed,
considerable evidence to indicate that whilst the
incomes of consultants were often very high, many
general practitioners were forced to live on
extremely modest incomes (63). The two most
frequently identified causes of what medical
practitioners saw as the depressed level of medical
incomes were, firstly, that there was an oversupply
of qualified practitioners, and secondly, that
qualified practitioners had to face unfair compe­
tition from those who were not qualified. Thus, in
relation to the first point, the L a n c e t held that
one reason why so few practitioners earned what it
called "the paltry sum of 500 I (pounds) per annum"
was that "the colleges are tempted by their
charters to admit such a number of practitioners,
that sufficient rewards cannot be afforded to
them" (64). The evils of excessive competition,
arising from an oversupply of qualified practi­
tioners, were also pointed out by the author of an
article which was published anonymously in the
Q u a r t e r l y R e v i e w in 1840. Thus the author - believed
304
to have been Sir Benjamin Brodie - argued that "the
supply of medical practitioners is in fact not only
very much beyond the demand, but very much beyond
what is necessary to ensure a just and useful
degree of competition (...) and to this cause may
mainly be attributed the present restless and un­
easy state of the profession. In this, as in all
other pursuits, a certain degree of competition is
required for the security of the public; but in
the medical profession it is easy to conceive that
the competition may be not only beyond what is
really wanted, but so great as to be actually
mischievous" (65). Moreover, the view that the
profession was overcrowded was not one which was
confined to medical practitioners. Thus in the
debate on the second reading of his registration
bill in the House of Commons in 1858, William Cowper
held that "at present there were more young men
entering the profession than could gain a livelihood
by it" (66), whilst, as Musgrove has pointed out,
the term "overcrowded professions" was freely
applied to both the medical and legal professions
in vocational handbooks of the period (6 7).
Whether the profession really was overcrowded, how­
ever, is something which is extremely difficult to
determine with any precision, not least because
there was no official register prior to the 1858
Medical Act. There were certainly many contemporary
complaints of overcrowding, though as Perkin has
noted, these should be treated with caution, since
such complaints were almost as old as the profes­
sions themselves (68). On the other hand, however,
Peterson is in no doubt that the profession was
overcrowded. Thus she argues that one reason why
medical men, particularly those in public employ­
ment, salaried posts, and sick clubs, were so
dependent on their lay employers was "because of
the overcrowding of the profession and the conse­
quent competition among medical men for practice
wherever it could be found" (69). Whether the
profession was or was not overcrowded, however, it
is clear that the belief that it was overcrowded
was widespread amongst contemporary medical men.
Moreover, it is equally clear that any restriction
of entry to the profession could only affect
medical incomes in an upward direction, and thus
305
could only be advantageous, in a pecuniary sense,
to medical practitioners. The effect of restricting
entry to the profession had, in fact, been dealt
with by no less an authority than Adam Smith, in
a letter which he had written to William Cullen
in 1774. Cullen, who was at that time President
of the Royal College of Physicians of Edinburgh,
had written to Smith asking for his views on the
practice of some Scottish universities of selling
medical degrees, often without requiring any
residence. In his reply, Smith criticized those
institutions for taking part in what he called
"a most disgraceful trade" in degrees, but he went
on to point out that the "facility of obtaining
degrees, particularly in physic, from those poor
universities, had two effects, both extremely
advantageous to the public, but extremely dis­
agreeable to the graduates of other universities,
whose degrees had cost them much time and expense.
First, it multiplied very much the number of
doctors, and thereby no doubt sunk their fees, or
at least hindered them from rising so very high as
they otherwise would have done. Had the universi­
ties of Oxford and Cambridge been able to maintain
themselves in the exclusive privilege of graduating
all the doctors who could practise in England, the
price of feeling a pulse might by this time have
risen from two or three guineas, the price which
it has now happily arrived at, to double or treble
that sum (...) Secondly, it reduced a good deal the
rank and dignity of a doctor" (70).
The effect of monopolistic practices on price
levels was, of course, widely appreciated in the
nineteenth century, and it is clear that the
logic of Adam Smith's argument was not lost on the
medical profession. Thus the L a n c e t held that "It
is admitted on all hands that many of the evils
under which the medical profession now labours,
are owing to the teeming multitude of practitioners.
This necessarily involves an impoverished state of
the profession, and has, doubtless, contributed
largely to that depression of intellect and morals
among its members (...) The means of restraining
this superfluity of doctors, and rendering the
number of the profession more proportionate to the
population, become, therefore, very important
306
objects of medical legislation". The L a n c e t then
went on to review a number of schemes for
restricting entry to the profession, including
the imposition of a direct numerical limitation,
a plan which was rejected as being "incompatible
with the institutions of a free country, and
extremely difficult to reduce to practice under
any circumstances". Eventually, the L a n c e t argued
that the best way to restrict entry was by "making
the standard of qualification high, as well in
medicine as in letters and science". If this scheme
were adopted, "the numbers of the profession would
be effectually limited without any injurious
exclusions; the character of the profession would
be greatly elevated, and the public welfare would
be promoted" (71). It is interesting to note that
the L a n c e t 's ideas were echoed almost exactly by
William Cowper when he sought leave to introduce
his bill which, it should be remebered, subsequent­
ly passed into law as the 1858 Medical Act. Thus
Cowper argued that the standard of qualification
for medicine was too low, and that his bill sought
to establish an adequate minimum standard. "If the
low standard were raised", he argued, "benefit
would be obtained by more skilful treatment, and
to the profession by reducing the competition of
those who underbid one another from the want of
remunerative practice" (72). These were, of course,
relatively sophisticated statements of what was
essentially an economic argument for restricting
entry to the profession; the rather less sophisti­
cated form of this argument was neatly expressed
by a correspondent of the L a n c e t who pointed out,
albeit rather bluntly, that "a fair system of
undisputed remuneration" depended upon "an effective
system of registration" (73). There can, in fact,
be little doubt that one dimension of the campaign
for medical registration involved a quite conscious
attempt on the part of medical practitioners to
restrict entry to the profession; nor can there be
much doubt that practitioners were fully aware of
the likely effect of this on the level of their
own incomes. It is difficult to disagree with Musgrove's comment that the "movement towards regis­
tration and the stipulation of minimum training
requirements is an indication of a felt need to
restrict entry" (74) and, as we shall see later,
307
there is some evidence to suggest that the 1858
Act met this felt need very adequately.
The other aspect of the campaign for registration
which involved a clear element of monopolization
was, of course, the attempt to prevent unqualified
practice, and here, once again, economic consider­
ations were of major importance. Thus in 1843, the
L a n c e t argued: "That 'the profession is overstocked'
we daily hear exclaimed, and the assertion is true.
The 'profession' is overstocked, and with a super­
abundance of unqualified men, mere speculators in
drugs and chemicals". The result was that "educated
practitioners are deprived of their legitimate
means of obtaining a subsistence". Medical men,
continued the L a n c e t , "who scorn to make their
liberal profession a trade, complain of this
usurpation of their rightful field of profit, and
of this degradation of medicine, in vain" (75).
A few years later, a petition in favour of the 1847
bill of Warburton and Wakley, discussed earlier,
held that "a very grievous injury is inflicted
upon those members of an honourable profession who
have complied, at a great cost, both of time and
money, with the provisions of the law, and the
regulations of the Colleges and Examining Boards,
but who are now left without adequate protection
in the exercise of their profession" (76). The
view that medical education was an investment, and
that unqualified practitioners were denying the
qualified a legitimate return on that investment
was, in fact, a recurrent theme. This idea was,
for example, very precisely expressed by one con­
tributor to the L a n c e t , who held that "no person
should risk the expenditure of time, labour and
money necessary to the attainment of his qualifi­
cation of licence to practise, unless he felt
himself to be effectually guarded by the laws
against the competition of unlicensed and ignorant,
though impudent and plausible empirics" (77).
Whilst demands for the suppression of unqualified
practice were almost invariably accompanied by
the claim that unqualified practitioners were
taking income away from those who were qualified,
these purely economic arguments were sometimes
coupled with other arguments relating to the
308
protection of the public; indeed the profession had
to put forward arguments of the latter kind if it
hoped to persuade the legislature to grant a
monopoly of practice to those who were qualified.
Thus, the contributor to the L a n c e t , cited above,
argued that if unqualified practice were made
illegal, this would not only secure "the rights
and privileges of medical men", but would also
serve to protect "the public health" (78). The
purely scientific arguments in favour of limiting
practice to the qualified were not, however, very
strong. Thus, as Peterson has pointed out, much
of the available medical treatment was of
questionable value, even by the standards of the
day (79), whilst what little authority medical
men had "came not from their medical knowledge
but had its origins in connection, social origins,
or social style" (80). Most importantly, however,
medical men themselves, as Peterson has correctly
noted, "seemed to see the issue more in terms of
protection from competition than in terms of the
superior claims of medical science" (81).
In demanding protection from competition, the rank
and file of the profession was, of course,
demanding what was in effect the creation of a
new monopoly, although most practitioners were
understandably reluctant to express their demands
in those exact terms. Indeed, Edwards, in the
series of articles referred to previously, attempted
to defend the profession against such charges. Thus
he criticised "a belief too prevalent in society,
that the medical professions are a sordid exclusive
caste, who seek by vexatious barriers and invidious
distinctions to secure a monopoly of the healing
art" (82). A "monopoly of the healing art" was,
however, precisely what the rank and file of the
profession was seeking, and it was in relation to
this demand that a clear split emerged within the
profession itself.
Whilst there were, doubtless, some unqualified
practitioners who made a handsome living by
practising amongst the middle and upper classes,
there was considerable agreement amongst contem­
porary observers that the great majority of un­
qualified practitioners were practising amongst
309
the lower classes of mid-Victorian society (8 3).
Nor is this particularly surprising, for it was,
of course, these people who had the greatest
difficulty in paying even the relatively modest
fees of the general practitioner; as one M.P.
observed in the debate on Sir James Graham's bill
in 1844, it was primarily the poor "who were in the
habit of asking the druggists to prescribe, in
order to avoid the expense of a doctor" (84). As
such, it was, of course, the incomes of general
practitioners which were most affected by the
competition of unqualified practitioners, for they
were often competing for the same market amongst
the ranks of both industrial workers and rural
labourers; by contrast, consultants normally drew
their private patients from the higher social
classes, and hence their practices, and their
incomes, were much less affected by the activities
of unqualified practitioners. Thus, to the extent
that unqualified practitioners were taking income
away from those who were qualified, it was the
general practitioners, rather than the consultants,
who suffered.
This difference between the everyday work situations
of general practitioners and consultants was of
major importance in shaping the attitudes of these
two groups towards the question of whether or not
qualified practitioners should be given a legal
monopoly of practice. Not surprisingly, it was the
general practitioners who were most vociferous in
their demands for the imposition of legal penal­
ties for unqualified practice. Thus, for example,
one of the reasons why general practitioners
opposed Sir James Graham's bill of 1844 was because
it did not make unqualified practice illegal (85).
Thomas Wakley, defending as ever the interests of
general practitioners, told the House of Commons
that "it was the paramount duty of that House to
prevent any person from practising who was not duly
qualified", and he begged Graham "to listen to the
petitions of the medical practitioners themselves"
(8 6 ) .
Consultants, on the other hand, as Peterson has
noted, "had little interest in the control of
unqualified practice, inasmuch as it had little
310
effect on their positions, prestige, or practice"
(87), and they were, accordingly, able to adopt a
less punitive attitude towards unqualified practi­
tioners. Thus, in the article believed to have
been written by Sir Benjamin Brodie, and published
in the Q u a r t e r l y R e v i e w in 1840, the author argued
against giving a legal monopoly of practice to
those who were qualified. The question to be
decided was, he said, "Should those who have passed
their examination, and received their licence, have
a monopoly of practice? Should there be penal laws
to prevent their being interfered with by the
competition of the ignorant, the uneducated, and
unlicensed? Or is it sufficient that the public
are supplied with a list of those who are supposed
to be qualified practitioners, it being then left
to individuals to procure medical assistance where
they please?" (88) He recognised that it was
"natural that licensed practitioners, who have
expended considerable sums of money, and no small
portion of their lives, in their education, should
be jealous of the competition of others" (89), and
he also recognised that it was not so much con­
sultants as "those who belong to the class of
general practitioners, that require the especial
attention and protection of the legislature" (90).
Nevertheless, he was firmly of the opinion that
the profession ought not to seek legislation to
suppress unqualified practice; the "empire of
opinion", he held, "will do more than legislative
enactments" (91).
Such arguments found no sympathy amongst the rank
and file of the profession, some of whom pointed
out in no uncenrtain terms the difference between
their own social situation and that of consultants.
Thus, referring specifically to the article in the
Q u a r t e r l y R e v i e w , one practitioner wrote that
"Court physicians and surgeons are better acquainted
with the avenues of palaces than the thresholds of
cottages. They are utterly ignorant of the kind of
practice which is witnessed in rural districts and
in poor neighbourhoods". If they had more knowledge
of such things, claimed the writer, "they would not
talk so coolly of 'leaving quacks to their fate'.
As it is, the fate of the pretender is often much
better than that of the genuine therapist" (92).
311
Another correspondent of the L a n c e t pointed out,
in very sarcastic tones, that the London consultants
who controlled the Royal Colleges had never
supported the campaign to make unqualified practice
illegal. "On this point", he said, "the Colleges
h a v e never sympathized with us; they do not - they
w i l l not. They affect not to believe in the
existence of the evil: Cruikshank's caricature of
the well-fed flunkies lazily asking, 'What are
taxes?' might with equal fidelity represent two
or our wealthy self-elected rulers asking one the
other, 'What are quacks?'" (9 3)
Despite all their efforts, however, the general
practitioners' campaign to have unqualified prac­
tice declared illegal was, in the end, unsuccess­
ful, perhaps partly because the campaign received
no support from the Royal Colleges, but also
because, as Cowan has pointed out,the House of
Commons regarded anything which smacked of mono­
poly with a good deal of suspicion (94). Thus
whilst the Medical Act of 1858 made it an offence
for any person to "wilfully and falsely pretend to
be" a qualified or registered practitioner, it did
not make unqualified practice as such illegal. The
Act did, however, create a monopoly of practice
for registered practitioners in all public insti­
tutions. Thus no unregistered practitioner was to
be allowed to hold any appointment as a medical
practitioner in the army or navy, or in "any
Hospital, Infirmary, Dispensary, or Lying-in
Hospital, not supported wholly by voluntary
contributions". In addition, unqualified practi­
tioners were excluded from holding any appointment
in "any Lunatic Asylum, Gaol, Penitentiary, (...)
Parochial or Union Workhouse or Poorhouse, Parish
Union, or other public Establishment"; nor were
they allowed to hold any medical appointment "to
any Friendly or other Society for affording mutual
relief in Sickness, Infirmity, or old Age, or as a
Medical Officer of Health" (95).
Although many general practitioners were dis­
satisfied with the fact the the 1858 Act did not
make unqualified practice illegal, the exclusion
of unqualified practitioners from all government
medical services was, in the medium and long term,
312
to assume greatly increased importance with the
continual expansion of the public sector of health
care in the late nineteenth and twentieth centuries.
Thus, as Carr-Saunders and Wilson pointed out in
19 33, the effect of the National Insurance Act of
1911 was to "very substantially" increase the
value of registration, for the 1911 Act directed
that only registered practitioners could be
accepted on the medical list (96) . Moreover,
although the 1858 Act did not, except in the area
of government services, create a legal monopoly of
practice for those who were qualified, it did
impose certain disabilities on unregistered practi­
tioners. Thus unregistered practitioners could not
certify any statutory documents, and they were not
entitled, as were registered practitioners, to re­
cover at law any charges for medical services which
they may have rendered. In addition, as Berlant
has noted, the Act also conferred an advantage on
registered practitioners "by providing them with
apparent state approval; that is, the prestige of
the state was thrown behind members of the organized
profession" (97).
In conferring these advantages on those who were
registered, the Act followed closely the principle
laid down by Sir James Graham in 1844, when he
argued that the law should not be used to prohibit
unqualified practice, but it should be used to
"discourage it by securing exclusive advantages
to the regular practitioner" (98) . Thus the effect
of the 1858 Act was not only to exclude unregistered
practitioners from the steadily expanding public
sector of medical care but also, in the private
sector, to give registered practitioners what
Berlant has described as "a competitive advantage
in the open market" (99). Moreover, the competitive
advantages enjoyed by registered practitioners
were, like the monopoly of government service, to
become increasingly important, so that the long
term effect of registration was to create what
became virtually_ a de f a c t o , if not a de j u r e ,
monopoly of medical practice for registered practi­
tioners .
If, however, these competitive advantages accruing
to registered practitioners were to become more
313
apparent with the passage of time, the impact of
the 1858 Act on the level of recruitment to the
profession appears to have been one which took
effect almost immediately. As we have seen, one
reason why many medical practitioners supported
the campaign for registration was because they
were concerned about overcrowding within the
profession, and they hoped that registration
would make it possible to restrict entry to the
profession more effectively, thus reducing over­
crowding and excessive competition between practi­
tioners. Moreover, there is reason to believe that
the Act had precisely this hoped for effect. Thus,
in the twenty years or so following the passage
of the Act, the growth in the number of medical
practitioners in England and Wales was quite
minimal, and was far outstripped by the growth of
the total population. In 1861, there were 14.415
medical practitioners in England and Wales. In
the decade from 1861-1871, this number increased
by just 269, or 1.8%, and in the period from 187181, there was a further increase of 407, or 2.7%
(100). Thus, over the twenty year period from 18611881, the number of medical practitioners in Eng­
land and Wales increased by under 5%, compared
with a 24% increase in the employed male pupulation,
and an increase in the total population of no less
than 29% over the same period (101).
In the two decades following the 1858 Act, there
was therefore, a marked reduction in the provision
of qualified medical care to the population. In
1861, there was one medical practitioner for every
1392 persons, or 7.1 doctors per 10.000 population;
by 1871 this had been reduced to one practitioner
for every 1547 persons, or 6.4 doctors per 10.000
population, and by 1881 there had been a further
reduction to one doctor for every 1721 persons, or
5.8 doctors per 10.000 population (102). It is true
that in the two decades from 1881-1901 there was a
considerably more rapid expansion of the profession,
perhaps partly due to the fact that by the late
1870's and early 1880's there was a clearly
recognised shortage of doctors, but as late as 1911
there were still fewer medical practitioners in
relation to population than there had been fifty
years previously (10 3). What is particularly
314
pertinent within the context of the present argu­
ment, however, is that a situation which was gener­
ally recognised as being characterised by a surplus
of doctors prior to the 1858 Act had, within two
decades of the passing of the Act, become one in
which there was a serious shortage of qualified
practitioners. Thus in his Carmichael Prize essay
of 1879, Walter Rivington drew attention to "the
decrease in the supply of medical men", and he
pointed out that William Farr, who was at that time
Superintendant of the Statistical Department in the
Registrar General's Office, had also expressed his
concern that qualified medical care had become
steadily less available; indeed, Farr held that the
shortage of medical practitioners was such that
there was "an imminent danger" that qualified
medical care might become "quite inaccessible to
vast numbers of people" (104).
The shortage of qualified practitioners was also
an issue which concerned the 1882 Royal Commission
which had been appointed "to Inquire into the
Medical Acts", and some of the evidence which was
submitted to the Commission makes it quite clear
that the L a n c e t had not been mistaken when, many
years previously, it had quite openly argued that
the most effective way to restrict entry to the
profession was "by making the standard of qualifi­
cation high". Thus Professor Humphry, the Professor
of Anatomy at Cambridge University, noted that
medical men had "decreased in number relatively"
(105), and he agreed that there was a "danger of
the examinations becoming too strict" (106). He
pointed to the "greatly increasing proportion of
rejections" of candidates for a licence to practise
medicine, a proportion which had increased from 14
per cent in 1867 to 23 per cent in 1875 (107). Asked
directly whether he felt that "this increasing
stringency of examinations has interfered with the
public interest by diminishing too much the supply
of medical men", Humphry replied "I believe it is
so to some extent. When the examinations were
increased, after the recommendations of the General
Medical Council (...) were adopted, there was a
sudden diminution of members in the profession"
(108). The link between the 1858 Medical Act and
the subsequent shortage of qualified practitioners
315
could not have been made more explicit. The Act
had proved to be, as most practitioners had hoped
it would, a most effective way of restricting
entry to the profession.
In this case study of the campaign for medical
registration in Britain, attention has been focused
on the fact that the campaign involved both antimonopolistic and monopolistic elements. The
development of these apparently contradictory
elements, it has been suggested, can be understood
by analysing the campaign for registration within
the context of the network of relationships both
between different segments of the profession,
and between qualified and unqualified practitioners.
Thus the structure of relationships between
consultants and general practitioners gave rise to
an attempt by general practitioners to undermine
the monopolistic privileges of the Royal Colleges,
whilst the competitive relationships between
qualified and unqualified practitioners, as well
as the attempt to reduce competition amongst those
who were qualified, gave the campaign its monopolis­
tic elements. From this analysis it is clear that
doctors - and in particular, general practitioners,
who provided the major impetus for the campaign
for registration - were in principle neither
opposed to, nor were they in favour of, monopolies
as such; rather, their attitudes towards medical
monopolies varied depending on the way in which the
operation of any particular monopoly affected their
own social and economic situation both within the
profession and in the wider society. Finally, it
is hoped that this analysis, by bringing out some
of the complexities of the campaign for registra­
tion, has shown that those writers who have seen
the campaign simply as a monopolistic strategy have
ignored the very clear anti-monopolistic elements
of the campaign, whilst those writers who have
argued that the 1858 Act was passed for the benefit
of the public have traditionally ignored not only
the fact that the profession derived monopolistic
advantages from registration, but also that these
potential advantages were clearly recognised within
the profession from the very beginning of the
campaign.
316
Notes
1. A.P. Thomson: The Influence of the General Medical
Council on Education, Brit. Med. J. , 1958, 2, p. 1249.
2. F.N.L. Poynter: Education and the General Medical
Council, in F.N.L. Poynter (ed.): The Evolution of
Medical Education in Britain, Pitman Medical Publishing
Co., London, 1966, p. 196.
3. Report of the Committee of Inquiry into the Regulation
of the Medical Profession, Cmnd. 6018, H.M.S.O., 1975,
p. 3.
4. Noel Parry and Jose Parry: The Rise of the Medical Profes­
sion, Croom Helm, London, 1976, p. 79.
5. Noel and Jose Parry: Social Closure and Collective Social
Mobility, in R. Scase (ed.): Industrial Society: Class,
Cleavage and Control, George Allen and Unwin, London,
1977, p. 112.
6. Jeffrey Lionel Berlant: Profession and Monopoly: A Study
of Medicine in the United States and Britain, University
of California Press, 1975, especially chapters 3 and 4.
7. A seventeenth bill was subsequently introduced by the
radical M.P.'s buncombe and Butler.
8. Report from the Select Committee on Medical Registration,
1847, (620), Q. 87.
9. Ibid., Q. 1186.
10. Ibid., Q. 1478.
11. Ibid., Q. 1576.
12. Ibid., Q. 2031.
13. A much more detailed analysis of the changing structure
of the medical profession in the early nineteenth century
may be found in Ivan Waddington: General Practitioners
and Consultants in Early Nineteent-Century England: the
Sociology of an Intra-Professional Conflict, in J. Wood­
ward and D. Richards (eds.): Health Care and Popular
Medicine in Nineteenth Century England, Croom Helm,
London, 1977, pp. 164-188. See also M. Jeanne Peterson:
The Medical Profession in Mid-Victorian London, University
of California Press, 1978, especially chapter I.
14. Peterson, op.cit., p. 6.
15. A Few Words on the Fellowship, with a Suggestion Concerning
the Present Crisis, addressed to the President and Council
of the Royal College of Surgeons of England by an Old
Member of the College, London, Churchill, 1845, pp. 17
and 19, cited in Peterson, op.cit., p. 22.
16. Peterson, op.cit. , pp. 22-23.
17. The bill of Warburton and Wakley provided for a separate
register for each of the three kingdoms, but not for a
317
I—1
CD
19.
o
CM
21.
22.
23.
24.
25.
26.
27.
00
CM
separate registration for each of the "orders" of the
profession.
Report from S.C.M.R. , 1847, Q. 62-63.
Ibid. Q . 89.
Ibid. Q . 1146.
Ibid.
Q. 1106.
Ibid. , Q . 575.
1462.
Ibid.
Q.
146 3 .
Ibid.
Q.
104.
Ibid.
Q.
Ibid. , Q. 1650.
Ibid. , Q. 1695.
Ibid. , Q. 1577.
Ibid. , Q. 2 0 1 0 - 2 0 1 1 .
,
,
,
,
,
,
29.
30. First and Second Reports from the Sel
Medical Registration and Medical Law
(210), Q. 138.
31. Ibid. , Q. 305.
32. S.W.F. Holloway: The Apothecaries' Act, 1815: A Re­
interpretation, Medical History, 10, 1966, p. 221.
33. Ibid. , p. 226.
See also Lancet, 1847, 1, p. 127.
34. First and Second Reports from the Select Committee on
Medical Registration and Medical Law Amendment, Q. 602.
35. Holloway, o p . c i t p. 223.
36. The Companion to the Newspaper; and Journal of Facts in
Politics, Statistics, and Public Economy, August, 1833,
p. 119, quoted in Holloway, op.cit., p. 223.
37. Lancet, 1842-43, 1, pp. 721-22.
38. First and Second Reports, Q. 1152.
39. Lancet, 1832-33, 2, p. 121.
40. Hansard, 21, 1834, col. 234.
41. Ibid., 21, 1834, col. 235-6.
42. Both petitions appear to have been drawn up in the mid1830's, and were reprinted in the Lancet, 1840-41, 2,
pp. 668-70.
43. Lancet, 1842-43,
1, p. 218.
44. Lancet, 1847, 1, p. 599.
45. Hansard, 150, 1858, col. 1409.
46. Ibid., 150, 1858, col. 1419.
47. Thoughts on the real and imaginary grievances of the
medical profession, Lancet, 1841-42, 2, pp. 510-514;
606-614; 742-747; 776-783.
48. Ibid., 1841-42, 2, p. 606.
49. Ibid., 1841-4?, 2, p. 606.
50. Ibid., 1841-42, 2, p. 606.
51. Ibid., 1841-42, 2, p. 510.
52. Ibid., 1841-42, 2, p. 606.
318
53.
54.
55.
56.
57.
58.
59.
60.
61.
62.
63.
64.
65.
66.
67.
68.
69.
70.
Ibid., 1841-42, 2, p. 746.
Ibid., 1841-42, 2, p. 742.
Ibid., 1841-42, 2, p. 510.
Ibid., 1841-42, 2, p. 745.
Hansard, 150, 1858, col. 1409.
S,W,F, Holloway: Medical education in England, 18301858: A Sociological analysis, History, 1964, 49, p. 299.
As Charles Newman has noted, the 1858 Act seems to have
been generally interpreted as giving to all registered
practitioners the right to practise all branches of
medicine and surgery; indeed, it was precisely because
of this that there developed the scandal over "qualified"
general practice on the strength of a single qualification,
This situation was, of course, remedied by the Act of
1886, which required all practitioners registering after
the Act to have a triple qualification in medicine,
surgery and midwifery. See Charles Newman: The Evolution
of Medical Education in the Nineteenth Century, O.U.P.,
London, 1957, pp. 227-8.
The general practitioners' major grievances were that they
were not given direct representation on the General Medica]
Council, control of which was vested firmly in the hands
of the medical corporations and the Universities, and
that the Act did not impose penalties for unqualified
practice, although it did impose penalties on unqualified
practitioners who claimed to be qualified. See Newman,
op.cit., p. 190.
F.N.L. Poynter: The Centenary of the General Medical
Council, Brit. Med. J., 1958, 2, p. 1245. On intra­
professional conflicts, see Ivan Waddington: The develop­
ment of medical ethics - a sociological analysis, Medical
History, 1975, 19, pp. 36-51, and also Waddington, op.cit.,
note 13 above.
Lancet, 1831-32, 2, p. 88.
See Waddington,op. cit. , note 13 above, especially pp. 170-174
Lancet, 1831-32, 2, p. 89.
Medical Reform, Quarterly Review, 1840--41, 67, p. 64.
Hansard, 150, 1858, col. 1407.
F. Musgrove: Middle-class education and employment in
the nineteenth century, Econ. Hist. Rev. , second series,
12, 1959-60, especially pp. 108-110.
H.J. Perkin: Middle-class education and employment in the
nineteenth century: A critical note, Econ. Hist. Review,
second series, 14, 1961-62, p. 127.
Peterson, op.cit., p. 116.
The letter, dated 20th September 1774, is to be found in
The Wealth of Nations, ed. by J.R. McCulloch, Edinburgh
319
and London, 1838, Note XX, pp. 582-585.
71.
72.
73.
74.
75.
76.
77.
78.
79.
80.
81.
82.
83.
84.
85.
86.
87.
88.
89.
90.
91.
92.
93.
94.
95.
96.
97.
98.
99.
100.
101.
102.
Lancet, 1842-43, 1, p. 764.
Hansard, 149, 1858, col. 650.
Letter signed "Adverso Jacobo", Lancet, 1847, 1, p. 135.
Musgrove, op.cit., p. 106.
Lancet, 1842-43, 1, pp. 795-796.
Ibid., 1847, 1, p. 600.
Ibid. , 1841-42, 2, p. 650.
Ibid. , 1841-42, 2, p. 650.
Peterson, op.cit., p. 130.
Ibid., p. 134.
Ibid., p. 36.
Lancet, 1841-42, 2, p. 781.
See, for example, Hansard , 1844, 76, col. 1910, and Lancet,
1841-42, 2, p. 133, and ibid., 1858, 2, p. 120. See
also the evidence of William Lawrence before the 1847
Select Committee, op.cit., note 8 above, Q. 1962.
Hansard, 76, 1844, col. 1905.
Newman, op.cit., pp. 161-162; Peterson, op.cit., p. 32.
Hansard, 76, 1844, col. 1910.
Peterson, op.cit., p. 31.
Medical Reform, Quarterly Review, 67, 1840-41, pp. 55-56.
Ibid. , p. 57.
Ibid., p. 60.
Ibid., p. 56.
Lancet, 1841-42, 2, p. 513.
Ibid., 1847, 1, p. 627.
David L. Cowan: Liberty, laissez-faire and licensure in
nineteenth century Britain, Bulletin of the History of
Medicine, 1969, 43, pp. 30-40.
These restrictions were set out in Clause 36 of the Act.
A.M. Carr-Saunders and P.A. Wilson: The Professions,
reprinted by Frank Cass, London, 1964, p. 88.
Berlant, op.cit., note 6 above, p. 156.
Hansard, 76, 1844, col. 1898.
Berlant, op.cit., p. 167.
These Census figures are taken from Musgrove, op.cit.,
p. 105. It should be noted, however, that Musgrove's
figure of 15.901 practitioners in 1881 is a mistake; this
should read 15.091.
The percentage growth of the exployed male population and
the total population has been calculated from the figures
in Perkin, op.cit., p. 128.
When Walter Rivington calculated doctor/patient ratios in
his Carmichael Prize essay of 1879, he used slightly
different figures for the increase in the total population
from those given in Perkin, op.cit. However, these
320
differences were too small to make any significant
difference between his conclusions and those set out
in this essay. Thus Rivington calculated that the
reduction in the provision of qualified medical care had
been from 7.2 doctors per 10.000 population in England
and Wales in 1861, to 6.4 per 10.000 in 1871. See Walter
Rivington: The Medical Profession, Dublin, 1879, p. 2.
103. In 1861 there was one practitioner for every 1392
persons, and in 1911, one to every 1469.
104. Rivington, op.cit ., p . 2.
105. Report of the Royal Commissioners appointed to Inquire
into the Medical Acts, 1882, (C-3259-1), Q. 1671.
106. Ibid. , Q. 1165.
107. Ibid. , Q. 1166.
108. Ibid. , Q. 1168.
Acknowledgements
I wish to acknowledge the helpful comments which I received
on an earlier draft of this paper, both from colleagues at
Leicester and from colleagues and students at the Sociolo­
gisch Instituut, University of Amsterdam, where I was a
visiting lecturer in 1979. Special thanks are due to
Professor Ilya Neustadt, Eric Dunning and David Field, of
Leicester, and Joop Jaspers of Amsterdam.
321