Medical Practitioners and Medicine

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MEDICAL PRACTITIONERS AND MEDICINE

Matthew Ramsey

Medicine is connected to so many aspects of human experience that we cannot easily isolate it from other areas of social history. Certain key topics are addressed separately in the entries cross-listed below. This article deals primarily with medical practice and secondarily with ideas about health, illness, and the treatment of disease in their social context.

VARIETIES OF EUROPEAN MEDICINE

The first part of this article surveys the kinds of medical practitioners, practices, and beliefs and situates them in the diverse societies and cultures of Europe. It provides a framework for the second part of the article, which describes the evolution of the organized medical occupations, from their appearance in the late Middle Ages through the twentieth century. The emphasis throughout is on medical pluralism: elucidating the many forms that medicine and medical practice have taken has been one of the major contributions that social history has made to the history of medicine.

A diversity of practitioners. Throughout history, family, friends, and neighbors have ministered to the sick, and patients have treated themselves with domestic remedies. In addition, a very heterogeneous group of men and women have offered medical services based on their reputed special knowledge and skills. In Europe some have had formal training and credentials, but many have not. For some, medical practice has been a full-time occupation. For others it has been a sideline or an occasional activity.

The very vocabulary used to refer to medical practitioners reflects this complex social reality. The title "doctor," which derives from a Latin word for teacher, was conferred on holders of the highest university degree. Over time it came to mean, very broadly, a medical practitioner. In this article, it will refer to M.D.s, to distinguish them from other kinds of authorized practitioners. A memory of this traditional convention has survived in the British custom of addressing surgeons as "mister."

Numerous other terms designated a medical practitioner, who might or might not possess a university degree. In medieval Europe, the Latin term medicus (medica in the feminine) simply meant someone devoted to the healing arts, as it had in ancient Rome, which lacked a formal system of training and licensure. In the Romance languages, it gave us médecin in French, medico in Italian, and médico in Spanish—the common word for "physician." That English word (and the old verb "to physic") come from a Latin word for natural science and ultimately from the Greek word for natural, recalling the long association between medicine and specialized learning. In medieval texts, medicus physicus referred to a well-educated practitioner. The common German term for physician, Arzt, also once had lofty connotations; it ultimately derives from a Greek word that designated the chief court physician during the period of the Roman Empire ("archiater" in English).

In contrast, "surgery" and its cognates derive from the Latin chirurgia, which in turn comes from a Greek term meaning "working with the hand"; the medieval medicus chirurgicus dealt with wounds (an old German word for a simple surgeon was Wundarzt), performed rudimentary operations that did not invade the body cavity, and treated "external" disorders, including skin conditions. With some exceptions, surgeons through the early modern period were members of a separate occupation. Some practitioners dealt with a particular condition or part of the body—bonesetters, tooth pullers, lithotomists who cut for bladder stone, oculists who operated on cataracts; midwives are a special case of the same phenomenon. In France before the Revolution, practitioners who concentrated on a particular surgical condition were collectively known as experts, from the Latin word for experience, since their competence derived mainly from practical experience of a particular kind.

In the vernacular, there were also a series of terms meaning one who heals: "healer" in English,guérisseur in French, Heiler or Heilpraktiker in German, curandero in Spanish, quaritore in Italian, and lekar' in Russian. Over time these terms came to refer to a practitioner without formal training, though in nineteenth-century Russia the title of lekar' was given to a qualified practitioner below the level of the more highly trained doktor meditsiny, and Germany has had a system of certification for Heilpraktiker since the 1930s.

We now commonly refer to formally trained and certified practitioners as the medical "profession." For the sake of convenience the same term can be applied to practitioners in earlier periods who shared these basic characteristics. It is important to bear in mind, however, that until the nineteenth century the boundaries between "professionals" and other practitioners were poorly defined. The network of approved practitioners encompassed a wide range of occupations and of individuals with uneven training and different types of authorization. The right to practice might be based on anything from a university degree to a privilege accorded by the Crown or by town officials. Itinerant drug peddlers might be authorized to sell and even administer a few particular remedies. Members of the clergy who cared for parishioners and property owners who gave medical assistance to their servants and tenants or to the poor were also an accepted part of the medical scene.

A great variety of other practitioners also sold remedies and offered medical advice. The most colorful were the traveling "charlatans," often accompanied by a troupe of clowns and other entertainers, who set up medicine shows in marketplaces and town squares, where they hawked panaceas and "secrets" for particular diseases. (A less pejorative term for untrained practitioners was "empiric," which suggested that they owed their knowledge and skills to experience—empeiria in Greek—rather than formal study.) They flourished in the early modern period, bringing their specialized products and services to out-of-the-way places. In addition, local residents of all descriptions sold a few remedies or were thought to enjoy a special skill to heal particular diseases. Cunning-folk were believed to possess special knowledge or powers, often including an indwelling gift to heal, or to identify and counteract witches whose spells had caused disease and other misfortunes; other magical services might include predicting the future or finding lost objects. In European languages and dialects, these various healers (the preceding is a composite portrait) had a multitude of names, which often suggested esoteric knowledge; the Russian word znakhar' (znakharka, fem.), like the English word "cunning," comes from a root meaning "to know."

Traditional empirics and healers persisted in rural areas into the twentieth century, though they were to a large extent displaced by mass-marketed proprietary remedies and by practitioners of newer forms of what we now call alternative medicine—magnetizers, for example, the progeny of the Mesmerist movement of the late eighteenth century, who claimed to diagnose and cure disease through a form of animal magnetism. At no point has the profession enjoyed a de facto monopoly of medical practice.

Multiple beliefs and practices. Medical beliefs and practices were similarly characterized by pluralism. A common intellectual thread, however, has run through Western learned medicine since classical antiquity. From the late Middle Ages through the early nineteenth century, the dominant tradition drew on Greek sources mediated first through Arabic translations and then passed on through Latin retranslation to the centers of learning in western Europe. The core of the Greek tradition derived from the body of writings traditionally attributed to Hippocrates, which provided a naturalistic explanation of health and disease without reference to a supernatural realm. The key principle was equilibrium. Four critical humors—blood, phlegm, and black and yellow bile—affected the functioning of mind and body, and an imbalance of these humors produced disease. Therapy, such as bloodletting and drugs that purged, induced vomiting, or otherwise acted on the humors, was intended to restore the equilibrium. Greek learned medicine was codified by Galen (c. 129–199 c.e.) in the second century c.e. in a set of treatises whose extraordinary authority endured for centuries. Although his physiology and therapeutics did not go unchallenged in the early modern period, Galenic principles continued to dominate the university curriculum into the early nineteenth century.

In addition to Galenism, Europe also inherited from classical antiquity an immense body of empirical medical lore concerning the healing properties of natural substances. Some found its way into texts that were integral parts of the Greek medical canon. A different perspective appears in the Natural History of Pliny the Elder (23–79 c.e.), a vast and uncritical compendium of miscellaneous information on the properties of animals, plants, and minerals. Pliny shared with some of his Roman compatriots a hostility to the theoretical pretensions of Greek physicians.

Drawing on this tradition, early modern pharmacy incorporated a multitude of plants, as well as animal parts and excreta (the Dreckapotheke or filth pharmacy, as the latter sorts of remedies came to be called in German). Even human secretions had a place in the pharmacopoeia, as did human fat and preserved tissue, discreetly known as "mummy," which was typically prepared from the cadavers of executed criminals. The animal products began to disappear from the codices, or official lists of medications, over the course of the eighteenth century. By the early nineteenth century, nearly all were gone and a small number of active ingredients, such as quinine from cinchona bark, had been isolated from a few of the many remaining plant remedies. Although the initial results were modest, pharmacology increasingly relied on chemistry to produce pure drug substances.

Throughout European history, we also find therapeutic practices that we would characterize as magical or religious, though there were no clear dividing lines. These categories would not always have made sense to participants; the potency of a particular herb, for example, might depend on performing a certain ritual or saying a prayer while gathering it. One of the most common magical procedures sought to transfer a disease from the patient to an animal or plant. Religious healing has been even more widely practiced. Greek and Roman patients appealed for divine intervention to cure disease and travelled to shrines seeking cures. Christians did the same, sometimes adapting pagan shrines to their purposes. Many healers, for their part, saw themselves as imitating the example of Jesus caring for the sick. The cultic veneration of the saints and the concept of patron saints as they developed in western Christianity also became closely identified with healing. The brothers Cosmas and Damian, physicians and Christian martyrs in the third century, became the patron saints of medicine; but many others were invoked for particular diseases, typically associated with an aspect of the saint's life or death. The martyred Saint Apollonia, whose teeth were broken, was invoked for toothache and became the patron saint of dentists.

In the modern period, new types of unconventional medicine emerged, sometimes linked to a form of spiritualism. Their adepts were often well organized, particularly in Germany, Britain, and the United States (which exported its medical movements to Europe), and they explicitly rejected official medicine and its central tenets. Homeopathy, for example, founded at the beginning of the nineteenth century by the German physician Samuel Hahnemann (1755–1843), treated disease with substances that caused similar symptoms, on the principle that like cures like, but in minute doses at very high levels of dilution. Homeopaths contrasted their gentler and (in their view) more efficacious therapeutics with the drastic remedies of the "allopaths"—bleeding, purging, and toxic drugs, such as mercury, the standby against syphilis since the sixteenth century. Rather than disappearing with the rise of modern biomedicine, alternative medicine grew along with it.

Many Europes. The two previous sections have discussed aspects of medicine and medical practice common to many parts of Europe. Both were shaped to a significant degree, however, by particular cultural, social, and political environments.

We tend now to think mainly in terms of modern national cultures. Well into the nineteenth century, however, many Europeans thought of a province or some smaller region as their "country," and might not have recognized themselves as belonging to a nation-state, such as France or Spain. At the same time, many people thought in terms of larger affiliations. For centuries, educated Europeans recognized two great but ill-defined civilizational divides, between north and south, east and west, with implications for medicine and medical practice. The north-south divide was in part the product of climate, geography, and the relationship with the land, reflected in some of the ingredients frequently used in remedies—olive oil for ointments and wine for cleansing wounds and macerating herbs in the south, for example. This division was also cultural and historical, as could be seen, for example, in the prevalence of Roman law codes in the south and customary law in the north. The Protestant Reformation of the sixteenth century originated and took hold in the north, where it produced distinctive religio-medical practices and sectlike alternative medical movements. In part for this reason, the north has been more tolerant of medical pluralism than the south.

The east-west divide had deep roots as well. The Roman Empire permanently split in two in the fourth century c.e. The Greek eastern half, with its capital at Constantinople, outlasted the Latin empire in the west by a millennium, falling at last to the Ottoman Turks in 1453. Christianity divided along similar lines, with reciprocal excommunications marking the Great Schism of 1054. Eastern Orthodox rites, together with the associated popular religio-medical practices, diffused throughout the Balkans and eastern Europe to Poland and Russia.

A third division followed the emergence of Islam in the seventh century. It spread rapidly outward from Arabia, reaching the Iberian peninsula in the early eighth century. The Christian reconquest of Spain was not completed until the end of the fifteenth century, by which time Constantinople had fallen and the Ottoman Turks had begun to expand into southeastern Europe. Although Ottoman power subsequently declined, the Balkans stayed in Turkish hands. Islam remained a powerful force in this land marked by ethnic and religious pluralism and helped shape the medical cultures of the region. Although the Qur'an has little to say about medicine, subsequent commentators developed a medicine of the Prophet. Something of Arabic popular medicine, with its emphasis on jinns (spirits below the rank of angels) passed into southeastern Europe as well.

As we move forward in time, a fourth distinction between East and West becomes increasingly important. In the Ottoman and Russian empires and many other parts of eastern Europe, limited resources and an undeveloped market economy meant that full-time medical practitioners were thinner on the ground than in the West. The small number of doctors—most of them foreign or foreign-trained—were concentrated in the capital and a few other urban centers.

Finally, Soviet domination of Eastern Europe for nearly half a century after World War II established a fifth east-west divide with important implications for medical practice. Institutions with very different traditions were incorporated into a system of state medicine that greatly diminished professional autonomy.

The rise of the nation-state led to a new set of medical traditions; they most clearly left their mark on institutions and the organized medical profession, which will be discussed in subsequent sections of this article. But it is important to remember that ethnic and cultural divisions often did not coincide with political boundaries, particularly in the east. European Russia, for example, was at one end of a vast region stretching out through Siberia in which the Ural-Altaic peoples practiced shamanism. The shaman owes his healing powers to his ability to commune with the spirit world. Although he undergoes a kind of apprenticeship, his function depends less on acquired learning than on a calling thrust on him at birth. In the West, too, large pockets of cultural difference survived within or astride national frontiers, each with certain distinctive features in its medical culture. Brittany, for example, apart from a Celtic language completely unrelated to French, had an unusually high concentration of prehistoric megaliths (giant stones) known as menhirs in Breton. A patient might rub against a menhir or scrape it to obtain a powder for use in preparing medications.

ROMANI ("GYPSY") MEDICINE

In the Romani cosmos, the marime (morally or physically unclean) is a source of disease; the same term applies to exclusion from the community for violation of purity rules and other norms. Many key practices serve to keep the unclean lower half of the body and its products separate from the wuzho (pure) upper half; this distinction applies particularly to women, who are considered potential sources of pollution. Outsiders (gadje) who do not observe these precepts are unclean and a source of disease. Such diseases can be successfully treated by outsider physicians, but only drabarni, the Roma's female healers, can treat illness originating within the community. The worst of the latter are attributed to the Devil or to Mamioro, a spirit attracted to unclean houses, though they are also the source of powerful remedies. Mamioro's johai (ghost vomit), most often found in garbage dumps, is the most potent available remedy. More routine maladies can be treated with herbal preparations. The Roma tend to use the gadje health care system only when their own medicine has failed, except for childbirth, which is unclean and would make the home marime if the mother delivered there.

Two widely dispersed groups constituted minorities within every European society. The Jews and the Roma ("Gypsies") shared a long history of diaspora and persecution culminating in genocide at the hands of the Nazis; each also had a distinctive place in the social history of European medicine, though of very different kinds. Jews played a disproportionate role as learned physicians in both Christian and Islamic lands, serving all communities, despite a series of restrictions and prohibitions in the former. Judaism also powerfully affected views on health and healing within the Jewish community. Although in the Torah only Yahweh appears as a healer, a long tradition supported both learned medicine and popular practices. On the one hand, the revered status of the man of learning demanded respect for the physician (rofe) and contempt for quacks. Although the sick and suffering might avail themselves of prayer, they were to rely first of all on natural means. On the other hand, the laws and customs governing hygiene and diet were inextricably linked to religious obligations. Popular medical traditions included magical elements, such as charms. The medieval mystical system called the Kabbalah, which greatly influenced modern Hasidism, was equally non-naturalistic. Hasidism developed in the eighteenth century from a widespread popular revival movement in the Poland-Ukraine region, led by charismatic tsaddikim, or holy men. The most celebrated, Israel ben Eliezer (c. 1700–1760), was called Ba'al Shem Tov (Master of the Good Name) because of his reputation as a miracle healer. The term was also applied more generally to Jewish itinerant healer-magicians, whose gifts were attributed to their mystical knowledge of the secret and unspeakable names of God.

The Roma reached southeastern Europe from the Indian subcontinent by the fourteenth century. Their powerful concepts of purity and impurity and of insider-outsider status, together with the itinerant life some of them led, set them apart from the surrounding society and medical cultures. Because of their distinctive and uncompromising views on health and healing, encounters with physicians often produced a reciprocal sense of dislocation. A similar experience recurred with increasing frequency in the late twentieth century with the arrival of large numbers of immigrants from former colonies and elsewhere overseas—immigrants whose customs contributed to a growing medical multiculturalism.

THE ORGANIZED MEDICAL OCCUPATIONS

The first section of the second part describes the occupational structures that emerged in the late Middle Ages and lasted, with some changes, through the eighteenth century. They were primarily corporatist in organization, with guildlike bodies supervising medical practice. The second section concerns the development in the late eighteenth and nineteenth centuries of many of the features we associate with the modern medical profession, including new forms of organization and licensure. The dominant model in western Europe was liberal in the sense that medical professionals, once certified, were free to practice as they wished. It was also bureaucratic or statist in that government increasingly controlled the process of licensure. The third section focuses on the development in the late nineteenth and twentieth centuries of national health insurance, social security, and other forms of third-party payments, which transformed not just the economics of health care but also its place in the larger society.

The medieval and early modern medical field. Through most of the Middle Ages, an aspiring physician would have learned medicine at a cathedral school or monastery or through apprenticeship. The first universities appeared in England, France, Italy, and the Iberian Peninsula in the late twelfth and thirteenth centuries, and then in the German lands and central Europe in the fourteenth and fifteenth centuries. The doctorate was the highest degree, normally following the baccalaureate and licentiate, and in some cases came in higher and lower versions; it was not necessarily required for medical practice.

The first medical graduates, many of them members of the clergy, coexisted with the highly diverse network of practitioners described in the first part of this article. Priests and monks made up a sizable percentage of the total number of active practitioners. Their role declined after about 1500, though religious houses continued to maintain dispensaries and care for the poor. Women, though a minority of active practitioners, won public recognition as physicians. They were excluded from the new universities, however, and gradually from the organized medical occupations other than midwifery.

Physicians also shared the medical arena with authorized surgeons and apothecaries, plus the various trades, such as herbalists, spice dealers, and grocers, that sold medicinal plants or other ingredients for making remedies. In principle, the physician, the man of learning, supervised both surgeon and apothecary. The surgeon might bleed a patient at his direction; the apothecary would provide the medication he prescribed, if necessary compounding it according to his directions. This triad was at best an approximation of the social reality; as long as it existed, practitioners regularly complained about boundary violations.

Except in parts of southern Europe, physicians were a distinct minority even of authorized practitioners. In most of eastern Europe they remained scarce; it has been estimated that at the beginning of the seventeenth century, there were perhaps twenty western-trained physicians in all of Russia. Thanks to charity work, sliding fee scales, and public appointments, physicians might treat the indigent and patients of modest means, but the mass of the population did not make regular use of their services.

Physicians did not on the whole enjoy the status or income that we associate with the medical profession today, though it was possible to rise through court appointments and other forms of patronage. In a society of legally defined orders, they usually ranked among the respectable bourgeoisie; the most successful sometimes purchased a patent of nobility where that was possible. In Russia, the Table of Ranks established by Peter the Great (1672–1725) in 1722 placed a university-trained medical doctor at Rank IX, which conferred personal but not hereditary nobility.

The case of surgery is more complex. A tradition of academic surgery existed, mainly in France and southern Europe; in Italy, especially, it gained a place in the university curriculum. "Surgeons of the long robe" as they were sometimes called, in reference to their academic gowns, shared the physicians' acquaintance with the Latin corpus of medical texts and a commitment to practice guided by theory. Most surgeons, however, trained exclusively through an apprenticeship system comparable to that of other manual crafts, and many may have been illiterate. At the lower end, surgery was linked to barbering; barbers commonly performed minor operations, pulled teeth, and used their razor for bloodletting.

In most places, lower-level surgeons were the most numerous and widespread of practitioners, serving all the basic medical needs of the population. In central and eastern Europe, one finds special categories, including "practical surgeons" who lacked the full education of master surgeons but could serve the rural population. In the eighteenth century, German states established collegia medico-chiururgica to train Wundärzte and Feldscherer (feldshers). The latter term, which dates from at least the sixteenth century, derives from a German word whose literal meaning is "a military man working with shears"—a clear reference to the old association between barbering and surgery. From their origins as surgeons in German and Swiss military companies, the feldshers spread through central, eastern, and parts of southern Europe; they treated increasing numbers of civilians and became the principal providers of medical care to the rural populations.

The more ambitious surgeons aspired to separation from the barbers and autonomy from the physicians. In eighteenth-century France they succeeded spectacularly. The Paris surgeons definitively severed the link with barbering in 1743 and in 1748 won formal recognition of a Royal Academy of Surgery. (Their London counterparts achieved separation from the barbers in 1745.) A decree of 1750 recognized a Paris College of Surgery independent of the University of Paris.

Over the course of the eighteenth century, several other intersecting trends transformed the world of surgery. A growing number of practitioners trained in both medicine and surgery. When the French revolutionaries unified medical and surgical education in 1794, some surgeons regretted the loss of their distinct identity, but the decision simply reinforced and formalized an already well-established trend. Moreover, surgeons increasingly delivered babies, treated teeth, and began to perform and improve operations once generally left to the experts. The term "dentist" first came into common use in this period, starting in France. A new conception of specialization was beginning to emerge, in which the specialist would first acquire a general medical education.

Although more clearly tradesmen than surgeons, apothecaries underwent a similar apprenticeship. Most practiced at least a little medicine and surgery, in addition to selling drugs. In England, where apothecary-medical practitioners were particularly numerous, one of them won a notable legal case in 1704, which affirmed their right to treat patients, though they could still charge only for the medicines they sold. A growing number of practitioners qualified as both surgeons and apothecaries, and the "general practitioner" emerged from this dual occupation in the nineteenth century.

In keeping with the legal and social order of the Old Regime, physicians, surgeons, and apothecaries formed corporations—guilds and guildlike organizations—in cities and major towns. The first major urban craft guilds appeared in Italy in the thirteenth century, and the institution subsequently spread throughout southern, western, and northern Europe. The arrangements in the medical field were complex, sometimes bringing together physicians and surgeons, but more often not. Just as surgeons were frequently linked with barbers, apothecaries were often joined with spice dealers. It should be added that universities and faculties were themselves corporations of masters and students, chartered by emperors, kings, popes, and other rulers.

The corporations were probably strongest in France. In England laissez-faire increasingly prevailed, and on the rest of the Continent state and municipal institutions played a larger role in regulating the medical field. The corporations admitted candidates to practice, typically requiring special examinations and fees, and prosecuted unauthorized practitioners, who might include members of another corporation who had crossed the boundary between the two fields. In France, some medical faculties offered little instruction and had become more regulatory than educational institutions. In London, the Royal College of Physicians, established in 1518, theoretically enjoyed a monopoly of medical practice in the capital and its outskirts, though this did not keep many others from working there.

In most of the rest of Europe, a more bureaucratic regulatory system emerged, though outside the east it often coexisted with fairly robust corporations. In Spain, the Royal Protomedicato, or medical board, conferred licenses and prosecuted those who violated the medical regulations; in many areas practitioners also had to belong to local corporations, but they functioned as mutual-aid societies, religious confraternities, and the like. In Italy, the kingdoms of Naples, Sicily, and Sardinia adopted protomedicati on the Spanish model. In the northern and central states of the peninsula, guildlike colleges enjoyed the power to license practitioners since the late Middle Ages. By the sixteenth century, though, some of the colleges had become virtual state agencies; Florence established a state board with licensing powers in 1560. In northern and central Europe, state medical boards (collegia medica) emerged in the late seventeenth and eighteenth centuries. In France, although the corporations retained control over practice, the SociétéRoyale de Médecine, chartered in 1778, was empowered to regulate mineral waters and the remedy trade.

Licensure was not the only way in which government impinged on medical practice and practitioners. Physicians found employment with the public health boards pioneered by the city-states of the Italian Renaissance. The northern Italian cities also hired public physicians and surgeons, starting in the early thirteenth century. The institution of the municipal and district physician, who typically treated the poor and discharged certain public health functions, spread widely, especially in the German lands, where he was given the title of Physikus. Apart from these official functions, in much of central and eastern Europe the government closely supervised the activities of practitioners after they had been licensed, telling them how and where they could practice and even, in some cases, whether they could marry. In Russia, medical practitioners were formally members of the civil service; very few could have sustained a private practice on the open market. In most German states they were recognized as public health officials. Finally, the military, with its great need for surgeons, played an important role in providing not just employment but also instruction. In the eighteenth century, the Berlin Collegium Medico-Chirurgicum (1724) and the Josephinum Academy in Vienna (1785), both devoted to training future military surgeons, were among the most distinguished surgical schools in Europe.

By the end of the eighteenth century, the corporations were on the defensive, challenged not only by new institutions, but also, in the west, by the burgeoning medical marketplace. Commercialized brand-name remedies, heavily advertised in the new periodical press, sometimes reached an international clientele. The wide dissemination of medical literature at all levels also encouraged new kinds of self-help; in the view of some practitioners, it undermined the physicians' authority over the medical field.

The nineteenth century. The Revolution (1789) had destroyed the old corporate order in France, including the faculties and guilds. After a period of laissez-faire, which its critics characterized as "medical anarchy," France in 1803 adopted a new medical regime, a cross between a bureaucratic and a liberal model. The state alone would certify new practitioners, but from that point on they were essentially free from government oversight. French military victories during the revolutionary and Napoleonic wars brought analogous reforms to neighboring countries. Some of these changes were reversed after the fall of Napoleon, and in places outside the French sphere of influence many older institutions remained intact. But the deeper transformations reflected in the legislation of 1803 were not unique to France.

In the new model, credentials were standardized and based on uniform examinations. The French not only educated future surgeons and physicians together (a doctorate of surgery was available but required the same basic preparation); they also eliminated the variations in the requirements of the faculties, which had been only partly coordinated by a royal edict of 1707. Doctors could work anywhere in France; under the Old Regime the right to practice in a city required affiliation with a local corporation as well as a medical degree. After some debate, the legislators decided to retain a second tier of practitioners; the officiers de santé (health officers) were in theory to meet the needs of rural populations, like the old country surgeons. Although they received a simpler, shorter, and more practical training, they were members of the same occupation as the doctors and were entitled to call themselves physicians.

Henceforth there would be no more special privileges or royal dispensations. There would be no authorizations to practice some part of the medical arts. France led the way in the development of new specialties, including orthopedics and psychiatry, but the M.D. degree was a sine qua non. (The exceptions were midwifery, which had its own diplomas, and dentistry, which remained unregulated until 1892.) Anyone who practiced without an official credential was ipso facto guilty of illegal medical practice. Authorized practitioners now, more clearly than before, embodied what by the mid-nineteenth century had come to be called "official medicine." By the same token, it became easier to identify alternative medicine, especially as unlicenced practitioners and proponents of unconventional medical systems formed their own organizations and even schools.

The new French medical regime became the model for strict regulation of the medical field throughout the Western world, though it was not universally emulated. To some it smacked of Napoleonic authoritarianism. England never imposed a national professional monopoly; indeed, the Medical Act of 1858 rescinded the local monopolies of the old corporations. In Germany, the trades ordinance of the North German Confederation introduced Kurierfreiheit, or freedom of healing, in 1869, while lifting the old regulations governing the activities of physicians; it was extended to the unified German Empire in 1871.

France continued to license health officers until 1892. It was the German states that led the way in eliminating the two-tiered system in the 1840s and early 1850s, closing practical schools and making the university essentially the single point of access to the profession. Russia, at the other extreme, retained an elaborate multitiered system. A law of 1838 provided for seven medical degrees (lekar' was the lowest). These nice distinctions mattered less among lay people; after around mid-century they generally applied the term vrach' (physician) to all medical practitioners, as they still do. The feldshers, however, remained a distinct category; they dominated medical practice in many rural areas, resisting efforts by physicians to impose their authority.

In England, the general practitioners trained in hospitals or by apprenticeship formed a broad lower tier compared with the university-educated physicians, especially the elite of the Royal College of Physicians in London. The Medical Act of 1858 created a single register of qualified practitioners without either standardizing education or replacing the old certifying bodies. A conjoint Board of Examinations was created in 1884, and two years later a Medical Amendment Act imposed a general requirement for qualification in medicine, surgery, and obstetrics. The medical field thus had a basic credential, though practitioners remained stratified into general practitioners and hospital consultants. This distinction had parallels elsewhere. Though the degree might be the same, the elite was set apart by hospital and faculty appointments, high government positions, and membership in academies. In France the internat, a form of postgraduate hospital training available only to a small cadre chosen by competitive examination, sorted practitioners at a very early stage in their career.

THE FRENCH MEDICAL PRACTICE LAW OF 19 VENTÔSE YEAR XI/10 MARCH 1803

TITLE 1. General Provisions

ARTICLE 1. Starting on 1 Vendémiaire Year XII [24 September 1812], no one may pursue the occupation of physician, surgeon, or health officer, unless he has been examined and licensed as set forth in this law.

ARTICLE 2. Those who are authorized to practice medicine after the beginning of the Year XII will be called doctors of medicine or surgery, if they have been examined and licensed at one of the six special medical schools, or health officers if they have been licensed by the boards described in the following articles.

. . .

TITLE TWO: Examinations and Licensure of Doctors of Medicine or Surgery

ARTICLE 5. Examinations for doctors of medicine or surgery will be given in each of the six special medical schools.

ARTIClE 6. There will be five examinations: the first on anatomy and physiology; the second on pathology and nosology; the third on materia medica, chemistry, and pharmacy; the fourth on hygiene and legal medicine; the fifth on internal or external clinical medicine, depending on whether the candidate is seeking the title of doctor of medicine or surgery. The examinations will be public; two of them must be in Latin.

ARTICLE 7. After the five examinations, the candidate must defend a thesis written in Latin or French.

ARTICLE 8. Students cannot take the examinations until after they have studied at one of the special schools for four years and paid the appropriate charges.

. . .

TITLE 3. Training and Licensing of Health Officers

ARTICLE 15. Young men who plan to become health officers are not obliged to study at the medical schools; they can be licensed as health officers after having been a private student with doctors for six years, or having worked at a civilian or military hospital for five nyears. Three consecutive years of study in medical school can substitute for the six years with the doctors or the five years in the hospices.

ARTICLE 16. In order to license health officers, a medical board (jury) will be established in the capital of each département [administrative district] composed of two doctors residing in the département appointed by the First Consul [Napoleon Bonaparte], and by a commissioner selected from among the professors of the six medical schools, and appointed by the First Consul.

. . .

ARTICLE 17. The departmental boards will conduct the examinations for licensing health officers once a year. There will be three examinations: one on anatomy; the next on the rudiments of medicine; the third on surgery and basic pharmacy. They will be given in French, in a room open to the public.

. . .

TITLE 4. Registration and Lists of Doctors and Health Officers

[All authorized practitioners must register with the local authorities, who will draw up a list for their district.]

ARTICLE 28. Doctors licensed by the medical schools may practice their profession in every locality in the Republic.

. . .

ARTICLE 29. The health officers can set up a practice only in the département in which the board examined them, after registering as has just been indicated. They cannot perform major surgical operations except under the direction of a doctor, where one is available.

. . .

TITLE 5. Training and Licensing of Midwives

ARTICLE 30. In addition to the training conducted in the medical schools, the most frequently used hospice in each département will establish a free annual course on the theory and practice of delivering babies, especially intended for the training of midwives.

. . .

TITLE 6. Penal Provisions

ARTICLE 35. Starting six months after publication of this law, any individual who continues to practice medicine or surgery, or to deliver babies, without being on the lists [described in the preceding articles], and without having a diploma, certificate, or letter of licensure, will be prosecuted and sentenced to pay a fine to the hospices. . . . The fine will be doubled for repeat offenders, who in addition may be sentenced to prison for no more than six months.

In many places, recruitment became less socially exclusive over the course of the century. In Russia, medical education was reorganized in 1856, part of the larger program of modernization and social reform, (including emancipation of the serfs) following defeat in the Crimean War (1853–1856). The changes gave access to many who had previously been ineligible. (See Table 1.) An even more striking development in the last decades of the century was the admission of women to medical training, starting in Switzerland and France. Russian women showed a strong early interest and figured disproportionately among the first female candidates for degrees at Zurich and Paris. Many others qualified as feldshers, a title for which graduates of midwifery schools were eligible. By 1913, 10 percent of Russian medical practitioners were women.

In addition to educational reform, medical practitioners felt a need for new organizations to fill the void left by the passing of many of the old corporations, and by the restricted membership and diminished influence of those that remained. In France, where revolutionary legislation prohibited occupational organizations to defend common economic interests, physicians formed mutual aid societies, which federated in 1858 as the General Association of French Physicians. The whole was greater than the sum of its parts and functioned in many ways as a national professional association. A generation later, physicians began to form more militant unions—syndicats, the same word used for labor unions—though they remained technically illegal until 1892. In that year, the syndicats received not only legal recognition but also the right to initiate prosecutions for illegal practice. Germany also had a wide range of voluntary professional organizations, many of which came together in 1873 to form the Federation of Medical Associations. In Britain, the old corporations survived but provided no representation for the rank and file. The British Medical Association (1855) grew out of a Provincial Medical and Surgical Association (1832), an organization primarily for general practitioners hostile to the privileges of the medical elite, on the one hand, and competition from unqualified practitioners on the other. In Russia, the progressive Pirogov Society, named for the celebrated surgeon and scientist Nicholas I. Pirogov (1810–1881), held a series of national congresses starting in 1885 and used a network of local branches to promote medical reform throughout the empire.

In societies where the liberal model of medical practice prevailed, professional misconduct by licensed practitioners posed one of the most troublesome challenges to the new order. In France some physicians called for "disciplinary councils" and other neocorporatist solutions. Later the syndicats tried to discipline their membership, but the only sanction they could enforce was expulsion. In Britain, the General Medical Council established by the 1858 act could strike errant practitioners off the Register, though they could still practice so long as they did not claim registration. In the German Empire, elected but official chambers of physicians were empowered to police the conduct of licensed physicians; those accused of professional misconduct could be sent before "courts of honor" (Ehrenräte). Professional ethics, which became a prominent topic of public discourse at the beginning of the nineteenth century, met a similar need in a less formal way: published codes could take the place of the old corporate statutes in guiding the conduct of practitioners. "Medical deontology," as it was sometimes called, primarily concerned relations with other practitioners; a physician should not lure away a colleague's patients, for example. Increasingly, though, it also emphasized patient rights, such as confidentiality.

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Another challenge to the liberal model was the expanding role of government, even outside the countries where the physician was a kind of public servant. Medical practitioners found a growing number of appointments in schools, prisons and other institutions, in public health services, and as physicians to the poor. In Russia, as part of the program of reform that followed the Crimean War, Alexander II (1818–1881) established elective district and provincial councils known as zemstvos. Public health was among their top priorities, and they hired practitioners to provide medical services in the countryside. By the early 1890s zemstvo physicians made up 10 percent of the profession in Russia—a minority, to be sure, but a vocal one, committed to political populism.

Although the principle of government health care programs received wide support from those looking for a middle way between outright socialism and laissez-faire liberalism, the form it should take became a subject of intense debate. The zemstvo physicians, whose position recalled the town and district physicians of the Old Regime, represented only one possible approach. The pioneering system of social insurance established in the German Empire by the Chancellor Otto von Bismarck (1815–1898) in 1883 was another, very influential model. Introduced as part of a campaign of reforms designed to steal the thunder of the left, Bismarck's plan amalgamated a great number of existing local sick funds for workers into a program that employers and employees would jointly administer; workers at the lower end of the pay scale were required to join. The funds signed contracts with individual physicians, who normally received either a fixed salary or an annual payment for each patient covered (capitation). Eventually the system was opened up to all licensed physicians, who would be paid on a fee-for-service basis. In France, a law of 1893 on rural medical assistance left the decision on the form of payment to the districts (départments); the great majority chose fee-for-service.

In addition to government programs, a growing number of physicians signed contracts with traditional mutual-aid societies, large employers, and insurance companies, which could use competitive bidding to force costs down. Beyond the economic threat, contracts with third parties, private or public, aroused concerns in western Europe about the future of the liberal physician-patient relationship, in which the two were supposed to agree freely on a service for which the patient would pay directly. More and more often, the purchaser was no longer the consumer. Even though third-party payments benefitted the profession by greatly expanding the market for its services, many physicians resisted such proposals, wary of becoming subordinated to lay managers. These fears were a powerful motive behind the drive at the end of the century to develop more effective medical organizations, whether modeled on the old corporations or on the newer trade unions.

TRAINING PHYSICIANS IN THE GERMAN EMPIRE: A MODEL OF SCIENCE-BASED MEDICAL EDUCATION

The unification of Germany in 1871 resulted in uniform criteria for medical education and licensure throughout the new Empire, drawn essentially from the Prussian model. Training emphasized both laboratory science and practical clinical experience. Candidates had to possess a diploma from a classical secondary school (Gymnasium), study medicine for four years at a university (including two semesters spent in medical and surgical clinics), and deliver four babies. One part of the licensure examination covered the basic medical sciences; it included a demonstration of practical skills in histology, physiology, the preparation of pathological specimens, and the use of the microscope. The remainder of the examination comprised written, oral, and clinical tests on general medicine and surgery, together with ophthalmology, obstetrics, and gynecology. Each candidate had to perform at least one dissection. The clinical work entailed examining and caring for six patients over an eight-day period. The candidate also had to deliver a baby and show on an anatomical model how to deal with different presentations of the fetus. The German standards were generally recognized as the most rigorous anywhere in the nineteenth century.

Bonner, p. 254, citing Reglemente für die Prüfung derÄrzte und Zahnärzte vom 25. September 1869. Berlin, 1869.

The twentieth century. The continued development of ambitious national health care plans was one of the hallmarks of twentieth-century medicine in Europe. Britain established National Health Insurance (NHI) on Bismarckian lines in 1911; compulsory for low-wage workers, and financed by joint worker and employer contributions, it provided sickness benefits and paid for treatment by a general practitioner chosen by the patient from the NHI list—a "panel doctor." Physicians received a capitation for each name on their list. After World War II, the new National Health Service (authorized in 1946, fully implemented in 1948) extended this system to the population at large, funding it mainly with general tax revenues. With the hospital system fully incorporated into the plan, medical care now became famously "free." France followed a somewhat similar path, implementing a social insurance plan in 1930 that included medical coverage; it was compulsory for low-wage industrial and commercial employees. The major difference between this plan and the British model was that patients would pay the physician of their choice and then be reimbursed 80 percent of a standard fee by their chosen insurer; several insurance options were available, including mutual-aid societies, which also offered supplementary policies to reimburse the 20 percent copayment. The Social Security system adopted in 1945 eventually extended coverage to virtually the entire population; it retained the expensive fee-for-service system, but with provisions intended

TABLE 2
SOVIET INTERMEDIATE MEDICAL PERSONNEL BY SPECIALTY IN 1950 AND 1974
	End of 1950		End of 1974
Specialty	Number	%	Number	%
* This is a conjectural translation of dezinstruktori.
† Not given in source; obtained by subtracting numbers listed under each specialty from the grand total.
Sources: Narodnoe Khozyaistvo SSSR for 1970, p. 692; and for 1974, p. 730. Michael Ryan. The Organization of Soviet Medical Care. Oxford, 1978, p. 71.
Feldshers	160,000	22.2	525,100	21.7
Feldsher-midwives	42,000	5.8	78,500	3.2
Midwives	66,500	9.2	244,100	10.1
Assistants to environmental health doctors and assistants to epidemiologists	18,500	2.6	45,500	1.9
Nurses	325,000	45.2	1,185,500	48.9
Medical laboratory assistants	25,300	3.5	105,300	4.3
X-ray technicians and x-ray laboratory assistants	7,500	1.0	29,800	1.2
Dental technicians	6,700	0.9	30,000	1.2
Disinfectors* and disinfectionists	27,000	3.8	87,000	3.6
Residual group†	40,900	5.7	92,300	3.8
Totals	719,400	100	2,423,100	100

to limit physicians' actual charges in most cases to the maximum set in an approved fee schedule. These mechanisms were of some help in protecting patients, but the system as a whole had no budgetary cap. The escalating costs led to further restrictions but not to a capitation system; France clung to its version of socialized medicine with a liberal face.

In Russia, the social insurance law adopted in 1912 was in many ways comparable to the Bismarckian system, but the October Revolution (1917) brought far more radical changes. After initially coopting the insurance system, the Bolsheviks found themselves embroiled in a protracted conflict between proponents of workers' insurance and of a rival vision of universal, state-controlled Soviet medicine. The 1920s were a period of flux, in which Lenin's New Economic Policy (NEP) made room for a significant private medical sector. With the end of the NEP in 1928 came a campaign against private medical practice (though it was not outlawed) and much tighter controls over the work of physicians. The government set up numerous medical centers, dispensaries, and health stations in factories and on the new collective farms, elements in a comprehensive national health care system. The return to an insurance model started only in 1991, just before the Soviet Union collapsed, part of the broader move away from the planned economy. The basic system introduced in the Russian Federation consisted of national and regional compulsory insurance plans, with the possibility of private insurance as a mostly symbolic affirmation of free-market values.

The October Revolution transformed not just health care coverage but also the entire medical field, particularly after the demise of the New Economic Policy. The Pirogov Society was abolished in 1922; medical personnel in the Soviet Union became "health workers," most of them state employees; a central Health Commissariat was established to oversee public health and medical care; the medical faculties, detached from the universities, became training institutes under the jurisdiction of the Commissariat. Although populist pressures for physician care for the entire population led to a move away from lower-level practitioners in the 1920s, the feldshers became a central part of the new Soviet health program in the 1930s, promoted by the Communist Party as more genuinely proletarian than physicians. (See Table 2).

Under the Soviet system, the medical profession declined to a level of pay and status below that of technical workers. Its position deteriorated further in the unstable economy that followed the disintegration of the U.S.S.R. Soviet medicine also became increasingly feminized, reinforcing the pattern established in Russia before 1917. Generous policies on maternity leave, child care, equal educational opportunities, equal pay, and the theoretical right to hold any job or political office contributed to the trend. But the percentages also reflected a tendency for men to seek more attractive opportunities elsewhere.

The structure of the medical occupations changed in western Europe as well. The number of specialists, on the one hand, and of paramedical personnel, on the other, increased substantially, though not to the same degree as in the United States. Graduates of new nursing schools increasingly replaced the old nursing orders; other auxiliaries provided special services, such as rehabilitative therapy, under a physician's supervision. What the Russians called "intermediate-level practitioners" suffered varying fates but generally declined, apart from midwives, who remained much more strongly implanted in Europe than in the United States.

CONCLUSION: ENTERING THE TWENTY-FIRST CENTURY

At the end of the twentieth century, the European medical scene was not what many would have predicted at its beginning. In 1900, recent advances in the medical sciences, especially microbiology, seemed to promise a new science-based medicine that would dramatically improve the health of the population, raise the status of the medical profession, and discredit alternative medical systems. These expectations were fulfilled in part. Yet the last years of the century also saw the rise of antibiotic-resistant microorganisms, particularly tuberculosis, and the emergence of frightening new diseases, one of which, acquired immunodeficiency syndrome (AIDS), established a significant presence in Europe. Many other diseases and disorders remained beyond the power of medicine to cure or even to explain, and although life expectancy reached new heights (except in some of the former Soviet republics, where it declined), this was not necessarily true of the quality of life. Moreover, despite the triumphs of biomedicine, alternative medicine flourished as never before, borrowing freely from Chinese, Indian, and other non-Western philosophies and medical systems, as well as from indigenous healing traditions. Medical consumers had a wider choice of therapies for self-treatment than ever before, many of them available on the Internet, or at least the prosperous ones did. Europe still suffered from social inequities in medical care, though they were far less pronounced than in the United States.

Except for a relatively small number of highly paid specialists, most practitioners in the late twentieth century saw their incomes stagnate and their autonomy decline, as the cost restrictions imposed by the various forms of public health care plans began to bite more deeply. In the 1970s, a common radical critique had denounced the excesses of professional and medical power; by 2000 it seemed clear that much of the real power lay elsewhere.

The situation at the beginning of the new millennium confirmed the basic theme of this article. Although the development of modern biomedicine has been a powerful force, medicine is also shaped by larger social, cultural, political, and economic factors. New forms of medical pluralism replaced older ones. The social history of medicine cannot be written simply as a linear story of the rise of medical science and the medical profession.

See alsoProfessionals and Professionalization (volume 3) and other articles in this section.

BIBLIOGRAPHY

General Works on Medical History

Bynum, W. F., and Roy Porter, eds. Companion Encyclopedia of the History of Medicine. 2 vols. London and New York, 1993. Seventy-two articles by specialists on topics ranging from anatomy to war and modern medicine.

O'Malley, C. D., ed. The History of Medical Education. Berkeley, Los Angeles, and London, 1970. Based on a 1968 symposium at UCLA. Includes chapters on Italy, France, England, Scotland, Germany, the Netherlands, Scandinavia, Russia, classical antiquity, the Middle Ages, and the Renaissance.

Porter, Roy. The Greatest Benefit to Mankind: A Medical History of Humanity from Antiquity to the Present. New York and London, 1997. Best single-volume history of medicine.

Medieval and Early Modern

Brockliss, Laurence, and Colin Jones. The Medical World of Early Modern France. Oxford and New York, 1997. Sweeping synthesis of French medical history, with observations on broader European context.

Cook, Harold John. The Decline of the Old Medical Regime in Stuart London. Ithaca, N.Y., and London, 1986.

Gentilcore, David. Healers and Healing in Early Modern Italy. Manchester, U.K., and New York, 1998. Focuses on the kingdom of Naples.

Lindemann, Mary. Medicine and Society in Early Modern Europe. Cambridge, U.K., and New York, 1999. Especially useful introduction for students and the general reader.

Park, Katharine. Doctors and Medicine in Early Renaissance Florence. Princeton, N.J., 1985.

Porter, Roy. Health for Sale: Quackery in England, 1660–1850. Manchester, U.K., and New York, 1989. Medical practitioners as competitors in the marketplace.

Siraisi, Nancy G. Medieval and Early Renaissance Medicine: An Introduction to Knowledge and Practice. Chicago and London, 1990. Very informative survey of medical theory and practice.

Modern: General and Comparative

Bonner, Thomas Neville. Becoming a Physician: Medical Education in Britain, France, Germany, and the United States, 1750–1945. New York and Oxford, 1995.

Bonner, Thomas Neville. To the Ends of the Earth: Women's Search for Education in Medicine. Cambridge, Mass., and London, 1992.

Bynum, W. F. Science and the Practice of Medicine in the Nineteenth Century. Cambridge, U.K., and New York, 1994. Emphasis on Britain.

Ramsey, Matthew. "The Politics of Professional Monopoly in Nineteenth-Century Medicine: The French Model and Its Rivals." In Professions and the French State, 1700–1900. Edited by Gerald L. Geison. Philadelphia, 1984. Comparison of regulation of medical practice in Europe, the United States, and other parts of the world.

Modern: National Histories

Britain

Digby, Anne. Making a Medical Living: Doctors and Patients in the English Market for Medicine, 1720–1911. Cambridge, U.K., and New York, 1994.

Fissell, Mary Elizabeth. Patients, Power, and the Poor in Eighteenth-Century Bristol. Cambridge, U.K., and New York, 1991.

Lawrence, Christopher. Medicine in the Making of Modern British, 1700–1920. London and New York, 1994.

Loudun, Irvine. Medical Care and the General Practitioner, 1750–1850. Oxford and New York, 1986.

Peterson, M. Jeanne. The Medical Profession in Mid-Victorian London. Berkeley, Los Angeles, and London, 1978.

Porter, Dorothy, and Roy Porter. Patient's Progress: Doctors and Doctoring in Eighteenth-Century England. Stanford, Calif., 1989. Pioneering study of social history of medicine from the patient's point of view.

France

Faure, Olivier. Histoire sociale de la médecine. Paris, 1994. Social history of medicine in France since the eighteenth century.

Gelfand, Toby. Professionalizing Modern Medicine: Paris Surgeons and Medical Science and Institutions in the 18th Century. Westport, Conn., and London, 1980.

Léonard, Jacques. La médecine entre les savoirs et les pouvoirs: Histoire intellectuelle et politique de la médecine française au XIXe siècle. Paris, 1981.

Ramsey, Matthew. Professional and Popular Medicine in France, 1770–1830: The Social World of Medical Practice. Cambridge, U.K., and New York, 1988.

Germany

Broman, Thomas Hoyt. The Transformation of German Academic Medicine, 1750–1820. Cambridge, U.K., and New York, 1996.

Huerkamp, Claudia. Der Aufstieg derÄrzte im 19. Jahrhundert: Vom gelehrten Stand zum professionellen Experten: Das Beispiel Preussens. Göttingen, Germany, 1985. Social history of the medical profession in nineteenth-century Prussia; useful introduction to German medical institutions.

Jütte, Robert. Geschichte des alternativen Medizin: Von der Volksmedizin zu den unkonventionnellen Therapien von heute. Munich, 1996. Wide-ranging synthesis on alternative medicine in Germany since about 1800.

Lindemann, Mary. Health and Healing in Eighteenth-Century Germany. Baltimore and London, 1996. Focuses on state of Braunschweig-Wolfenbüttel, but addresses broader questions in history of medical practitioners and practice in eighteenth-century Germany.