During the 19th century Western society underwent a radical transformation. At the time of the French Revolution, Europe was still largely rural. It took three days to get from London to Paris, and even longer if the roads were muddy and the sea rough. Farming was still the main occupation, and while the Industrial Revolution was firmly rooted in Britain its impact elsewhere in Europe or overseas was very modest. Annual mortality could still fluctuate wildly, and the last European-scale subsistence crisis occurred in 1817. National mortality rates, however, could be no more than mere estimates; it was just then and only in some countries, among other things, that a census of the population and the office of the civil registry for the registration of births and deaths had not yet been established. The population increase that would characterize modernity was underway, even as Thomas R. Malthus essay on the principle of population (1798) had challenged the old belief that a larger population constituted an indisputable social and political advantage for a country.
Despite the venerable history of many professional organizations, such as royal colleges and royal academies , the skill levels and behavior of practicing physicians, especially outside the major cities, and often sick people were forced to choose who to seek treatment from on the basis of informal referrals or local reputation. Medicine of the Ancien Régimeit has been described as dominated by the patient, especially since the boundaries between the knowledge of laymen and that of doctors were practically indistinct. In many places the logic of the local market dominated the practice of medicine, with doctors willingly talking about their 'business' and 'charlatans' competing for customers with the 'regulars'. Even in a country like France, where the activity of charlatans was regulated, the Revolution had had to deal, albeit briefly, with the maxim "everyone is his own doctor". In the great English country houses, doctors were let in through the entrance reserved for suppliers, and satire and caricaturists found abundant material in their pomp and self-confidence.
As society changed, so did its medical facilities and institutions. Industrialization transformed the human and environmental landscape, accelerating the growth of cities and creating new types of relationships between workers and their employers. Steamships began to appear in the first decade of the century, and the advent of the railways in the 1930s reduced journey times beyond belief; the telegraph appeared even more miraculous: the morning paper could carry yesterday's news from virtually anywhere in the world. The new printing methods greatly reduced the price of books and magazines and created a large new readership. Electric lighting and
In these and many other ways, science and technology merged over the course of the century and produced our modern world. The 19th century it is considered the century of the affirmation of the bourgeoisie, or of the professions, or of the masses, but there is no doubt that the physical and social world of Europe, and its colonies, was changing radically. These changes also had repercussions within the category of doctors who, like other respectable professional groups, achieved a more precise collective identity at the end of the century. The teaching imparted to them was very different from that received from previous generations, with respect to which they had also acquired new skills in the public sphere. Their most prestigious exponents, such as Virchow, Louis Pasteur, Robert Koch and Joseph Lister, they were personalities of international standing, created in part by the new means of mass communication and in part by the successes and promises of a medicine (and surgery) based on the application of science and technology. The medical profession continued to be generally overcrowded, leading to continued competition within it and wide income inequality. Nonetheless, their claims were more easily taken into consideration by public authority, and the place of medicine in the social fabric was more secure and clearly defined than it had been a century earlier. application of science and technology. The medical profession continued to be generally overcrowded, leading to continued competition within it and wide income inequality. Nonetheless, their claims were more easily taken into consideration by public authority, and the place of medicine in the social fabric was more secure and clearly defined than it had been a century earlier. application of science and technology. The medical profession continued to be generally overcrowded, leading to continued competition within it and wide income inequality. Nonetheless, their claims were more easily taken into consideration by public authority, and the place of medicine in the social fabric was more secure and clearly defined than it had been a century earlier.
MONOPOLY AND THE LIBERAL MEDICAL PROFESSION
Two elements above all characterize the medical professionals of the Modern Age: the knowledge reserved for initiates and the deontological codes of conduct. Knowledge gives them the right to autonomy and internal regulation, since the 'laymen' are not competent to judge them, lacking the necessary training. Selfless behavior ensures that society receives benefit from their business. Doctors have the patient's best interest at heart, and therefore deserve the trust of society; Sir William B. Osler observed that the medical profession was distinguished from all others by its singular beneficence. An alternative representation of the reconstruction of this historical scenario takes its cue from George B. Shaw's joke that " they go after the power and incomes of their members first. From both perspectives, a professional association tends to establish a monopoly on the practice of the profession, whether state-controlled or not, as a discerning clientele is inclined to recognize the higher claims of a suitably qualified professional. they go after the power and incomes of their members first. From both perspectives, a professional association tends to establish a monopoly on the practice of the profession, whether state-controlled or not, as a discerning clientele is inclined to recognize the higher claims of a suitably qualified professional.
The rigorous control over the exercise of the profession was in contrast with the principles of 19th century liberalism, which valued freedom and individualism much more than regulation and centralization. As summarized by Matthew Ramsey in The Politics of Medical Monopoly : "Simply put, where laissez-faire liberalism flourished, de jure monopoly was generally weak or non-existent; where prevailing liberalism was heavily committed to reform from the center monopoly was scarcely touched; where liberalism was absent, professional monopolies thrived best" (Ramsey 1984, pp. 225-305).
The situation of the medical profession in Europe and North America in the 19th century offers an illuminating example of Ramsey's generalization. Traditionally, the regulation of medical personnel and the control of training standards had been under the jurisdiction of an Academy or Collegium. In many German states still tied to the old traditions, the 'professions' of carers, including midwifery and pharmacy, were strictly regulated, like other professions. In Great Britain, where Adam Smith's Wealth of Nations (1776) provided the theoretical elaboration of laissez-faireeconomic, the guilds had lost much of their power and the freedom to exercise professions was the norm. The Royal College of Physicians and the Company of Surgeons (which became the Royal College of Surgeons after 1800) controlled the practice of medicine and surgery in London, and similar institutions performed the same function in Edinburgh, Glasgow and Dublin. Outside the major cities, the free market in medicine reigned, and even in areas controlled by the jurisdiction of professional organizations, reporting illegal practitioners and charlatans was costly and rarely triggered. A fragile licensing system for physicians gradually developed in the United States in the decades following the War of Independence, at the local or state level.
Napoleon exported both law and hostility to the guilds wherever French armies were stationed. In the annexed German regions of the Rhineland, the medical profession had long been protected by the state and many doctors were de facto civil servants. This arrangement, despite some economic advantages, had some drawbacks, such as the obligation to practice in the place established by the state authority and the Kurierzwang, i.e. the duty to help anyone in need. German liberal voices, such as those of Alexander von Humboldt (1769-1859) and, from 1848, of Virchow, rose to challenge the restrictive constraints imposed by the old order, arguing that social reform and mass education would also ordinary people able to choose their doctors wisely, and that in any case the freedom to decide on treatment ( Kurierfreiheit ) was as fundamental for doctors as for patients. The Gewerbeordnung(Professional Regulations) of 1869 ‒ then extended to the whole Empire in 1871 ‒ finally opened the free market in medicine. It allowed for a rapid increase in all kinds of irregular practitioners, who often formed their own professional associations. In Berlin in 1879, there were thirty-four regular physicians for every full-time empiric; by 1903 the ratio had collapsed to just three to one.
Most observers interpreted the Gewerbeordnung as a blow against medieval protectionism, while at the same time recognizing that in matters of public health and medical care complete laissez-faire could be detrimental to the well-being of the population. In practice, the state continued to protect regular professionals by imposing certain limits on illegal workers, who were not allowed to treat venereal disease or cancer, give injections or use narcotics. Only with the advent of Nazism was the German liberal system abandoned, but not out of any particular regard for scientific medicine but because the protection of the health of the community was recognized as a priority over individual freedom.
Apart from France, which stands out for the continued protection afforded by the state to the medical profession (together with the regulation of many other professions), a general convergence can be identified between many European countries and the United States. Liberal ideals did not allow medical monopolies to be enshrined in law, even though officially the state entrusted regular doctors with the task of supervising public health initiatives, dealing with medically dangerous situations, treating military personnel , to treat venereal disease, and to staff health posts and government hospitals. In the middle decades of the century, medical associations were established in many localities: the Provincial Medical and Surgical Association (later to become the British Medical Association) in 1832; the American Medical Association in 1847; the Berliner medicinische Gesellschaft in 1860. Many of these associations pursued educational, professional and political aims, and helped to give a unified voice to the profession. The development of science and technology in the medical field changed thetraining process of doctors, diagnosis and therapy (especially surgical), subjected medicine to the ideologies of progress and separated the 'regular' practitioners from the followers of what is now called alternative medicine. In Britain, the emergence of anti-vivisection groups undoubtedly had the effect of bringing doctors together more closely. Health insurance policies established by governments gave preference to regular doctors, and so did public entities investing in the treatment and prevention of disease. Thus, although consumer choice prevailed in most localities, the medical profession had grown stronger and was more cohesive and powerful than it was at the turn of the century.
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