Summary Medicine is both a science and an art, and is plagued by uncertainty. The skills-based side of medicine is best represented by apprenticeship, which has a continuous but not linear history up to the present. In the early modern period apprenticeship was an essential albeit flexible institution involving most regular practitioners. Medical reform after 1800 performed a sleight of hand whereby apprenticeship was preserved in a liberal occupation at the same time as it was discredited by a climate of laissez faire owing much to the influence of Adam Smith. To achieve this, a privatised form of apprenticeship which had become the norm in the eighteenth century was transformed by a countervailing ethos deriving from classical humanism, which idealised the one-to-one relationship between senior and junior. This made it possible to divest apprenticeship of the associations which educated middle-class practitioners found most repellent, including poverty, servitude, trade and low status. apprenticeship, privatisation, humanism, medicine, uncertainty Medicine has always had the problem of being both a study and a practice. This article begins with two premises: first, that for the practitioner, the crux of the relationship between theory and practice is the uncertainty involved in the outcome of the individual case; and secondly, that uncertainty in its turn is linked to status insecurities. The article then offers reflections on how the social strategies of medicine have changed, leading to the abandonment of some forms of solidarity in favour of a privatised set of relationships within a humanistically inspired ethos.1 These broad issues will be tackled by focusing on apprenticeship, arguably a fundamental relationship or set of connections within medicine, as well as a method of teaching and learning, but one which changed—or seemed to change—over time. It is in the context of apprenticeship that we come closest to the uncertain, skills-based, practical side of medicine. In part the aim here is to try to bridge the chronological divide which tends to exist between the early modern and the modern histories of medicine. This is not a return to a linear approach, but an exploration of how concepts and practices, such as humanism and apprenticeship, both persist and evolve. A further aim is to stress the need to consider medicine not in isolation but in relation to other occupations, and also to the social, economic, and cultural changes affecting all occupations, including medicine, within a society undergoing industrialisation. Apprenticeship as part of medical education has been investigated by a number of historians, mainly in the context of the voluntary hospitals from the later eighteenth century onwards.2 But this is to view apprenticeship as part of medical education unrelated to apprenticeship in general. In terms of its long-term history, medicine presents the paradox of an occupation which has managed to obscure its early history of customary apprenticeship. There is no doubt that medical practitioners, who, as many historians have shown, suffered from status and other insecurities until a comparatively recent date, found the connotations that apprenticeship took on in the nineteenth century even more repellent than did other middle-class groups. Medicine has clothed itself in the apparently contrasting garb of professional status, and yet it has preserved, even in its most modern formats, modes of learning and relationship which bring apprenticeship forcibly to mind. A fully recognisable form of apprenticeship lasted well into the nineteenth century as the dominant form of entry into the medical occupation in Britain, yet this is hardly a salient feature of medicine’s image of itself, either today, or indeed earlier. It is worth looking at how this sleight of hand was achieved. What follows will necessarily be an overview, making extensive use of a wide range of essential secondary material, but I hope I can justify this approach by drawing on more specific studies based on primary sources, especially from the early modern period. In particular, a case study exists of medical practice in Norwich, then the second city after London, for which there are extant records not available elsewhere. As a framework I would like to cite previous publications on status insecurities in medicine, including the disadvantages arising for male medical practitioners from associations in their work with female stereotypes.3 This last study in particular emphasises the differences between status claims in medicine and actual clinical experience, as well as the value of seeing many medical attitudes, or proceedings, in terms of a need to avoid cultural associations seen by contemporaries as prejudicial. This set of problems arguably persisted well into the twentieth century, if not longer. The current relatively high status of medical practitioners in Britain is largely a feature of the period after the Second World War. Modern doctors are not of course immune from criticism, but it is clear that as an occupational group they enjoy a standing and respect which contrast markedly with earlier periods. Nonetheless, as we will see, insecurities remain, most notably in terms of the handling of individual cases, and it is in this region of medicine that apprenticeship, with its skills-based content, is most relevant. Medicine as Binary: The Uncertainties of Practice A sense of insecurity, such as medical practitioners regularly experienced, provokes attempts at self-definition, which often clash with each other. Medicine, as we know, is an occupation which has always spent much time defining itself, or defining part of itself in contradistinction to other parts. It is necessary to see this process as socially constructed before defining the occupation in terms of its content. From a very early period, medicine’s subject matter was defined in terms of binary elements yoked together—the most common and enduring formulation being that medicine was both a science and an art, involving both theory and practice. A careful analysis of these terms is beyond my scope here, but they lie at the root of medicine’s uncertainties and of medicine’s sense of itself. Other binaries which have been applied over the centuries include humaniora versus realia, theory (episteme) versus practice (techne), knowledge versus experience, and words versus things. To these, more recent developments seem likely to add the cognitive and the ethical, or the universal versus the existential—versions of medical science versus the medical humanities. To some extent these binaries seem to organise themselves around a standard epistemological divide, like deductive and inductive, the hard and the soft sciences, the quantitative and the qualitative. However this is to adopt a post-nineteenth-century point of view.4 In spite of more recent and exemplary attempts to look at what practitioners actually do, the historiographical argument has most often been constructed in terms of changes, from ancient to modern, in only one side (the theoretical) of the divide of theory and practice.5 One better-known historical location for this debate, which will be relevant later on, is the contest between clinicians and advocates of laboratory science which took place around the end of the nineteenth century. An interesting aspect of this contest is the attempts to define what could be meant by clinical science, in other words, the science, if any, of actual practice.6 The nature of theory, and its means of expression, obviously changed considerably over the centuries. As we shall see later, by the late nineteenth century the weapons of the medieval and renaissance medical theorists and humanists, the classical languages, were being seen as either a wholesome discipline for upper-class youth, along with mathematics, or a hotly defended element on the humane (and gentlemanly) side of medicine.7 The constant deployment of these binaries by medical practitioners has served a wide range of purposes, including internecine warfare and self-definition, but also mutual reassurance. The need for a fixed body of theory in medicine can be seen as a reflection of the need for reassurance, but we need to stress for present purposes that skills-based practices in a teaching or consultative context can also serve this function. The persistence of skills-based learning in medicine is closely related to the management of uncertainty. Even for a late-twentieth-century physician, certainty in clinical medicine could be described as ‘fundamentally unattainable’. Systems that have evolved in diagnostic reasoning, in ‘workup’ and management tactics, and in therapeutics, are all techniques for managing uncertainty.8 This uncertainty centres round the individual patient, who embodies, figuratively, the needle’s eye of the single outcome. This can be put purely negatively, in terms of (to quote just two examples) ‘the persistent inability of science to predict or explain much of what happens to individual patients’, or a regret that the ‘melange of speculation, argumentum ad hominum [sic], facile generalization, and descriptions of habits of practice … all live on vigorously in our oral teaching’. However the same authors, noting the fact that bioethics was beginning to demand a greater knowledge of the patient, also produce the aphorism ‘medicine is a social interaction rather than a system of beliefs’ and state that ‘the physician as detached scientist is an unhappy role model at a time when society, the patient and the physician are examining with renewed interest the importance of the physician–patient interaction in medical care’.9 Even modern medicine, then, is recognised as having to involve both uncertainty and human relationships. Strenuous attempts have been made to formalise, and thereby to bring under some kind of intellectual control, these worrying areas of medicine. As already mentioned, we now have clinical scientists, but social scientists, such as R. K. Merton, have for over 50 years been playing an obvious role in organising and even scientising areas of medicine recognisably subject both to uncertainty and to the persistence of skills-based techniques. Nonetheless, whole areas of verbal and tacit communication, of which apprenticeship largely consists, remain intractable. Importantly in the present context, these can be put in a positive rather than a negative light. The pioneering work of Kathryn Hunter, for example, adopted a non-reductionist perspective with respect to the use of anecdote in modern medical practice. She gives medical anecdote a defensible function in scientific investigation, in that it tends to identify anomalies, but she also singles out medicine as being in general dependent upon narrative. Stories are another way of coping with uncertainty, but, she argues, they are not a mere palliative: ‘neither medicine nor information science has improved on the story as a means of ordering and storing the experience of human and medical complexity’.10 Who, among the wide range of practitioners, was most inclined to order their experience in this way? Historical studies of medical practice have tended to focus on physicians, who are more likely to have left written records. But it is interesting, and will perhaps be surprising to some, to note that Nancy Siraisi, writing about the medieval period, finds that Hunter’s kind of anecdotage is most common in the texts produced by surgeons, rather than physicians.11 As we shall see, surgeons, of all the parts of practice, have had by far the longest contact with guild organisation and apprenticeship. It may also be significant that it is surgeons, in the context of the modern hospital, who are most comfortable (or, perhaps, the least uncomfortable) with the semi-public discussion of mistakes—that is, the results of uncertainty.12 For historians of the early modern period, this is highly reminiscent of the long-standing ordinances within barber-surgeons’ guilds aimed at damage-limitation in respect of the treatment of dangerous cases by junior or less qualified members of the craft.13 By contrast, the strategy of early modern physicians was more to shift attention away from outcomes in favour of prognosis, and to undermine customs in which the practitioner and the patient came to an agreement—an informal contract—on the basis of a specific guaranteed outcome or cure.14 The Demolition of Customary Apprenticeship: The Role of Adam Smith Whatever the challenges of the individual case, the overall emphasis now is on medicine as a science. In the past, medicine usually aspired to the status of the liberal, non-scientific professions, law, or the church. Agriculture may seem a much less obvious source of useful comparisons, as well as a far less palatable one. However strong their sense of the intractability of their natural subject matter, it is unlikely that modern medical practitioners would see any parallels between themselves and agriculturalists. Indeed, Sir William Osler (d. 1919), Canadian, clinician, man of letters, and object of reverence for physicians seeking to preserve humanistic values in their profession, characteristically stated that the measure of the value of a nation to the world was not the bushel or the barrel but the mind, adding (he was writing surrounded by the natural abundance of North America) that ‘the kindly fruits of the earth are easily grown’.15 But Osler’s view was very much of its time, when the project of professionalisation was well advanced. I would like here to look beyond medicine and draw attention to the very different perspective of the eighteenth-century moral philosopher and political economist Adam Smith. Smith is central to this discussion because it was in his name that the nineteenth century dismantled customary apprenticeship. For Smith, agriculture was difficult to divide into components for specialisation, so that rich and poor countries showed less difference in agriculture than they did in manufacturing. However, for him, this resistance to industrial change raised rather than lowered the status of husbandry. Smith said of it that ‘after what are called the fine arts, and the liberal professions, … there is perhaps no trade which requires so great a variety of knowledge and experience’. What he called a ‘common mechanic trade’ could be reduced to, and explained by, a few pages of text, but in ‘country labour’, the condition of the materials was as variable as the instruments worked with, and both needed to be managed with much judgement and discretion. Admittedly the country labourer might have been unable to articulate his skills, or to teach otherwise than by example. Thereby he certainly differed from the liberal professions if not from painters and sculptors, but this did not alter the case. Smith does not develop here the parallel between agriculture and the professions, but he does stress another virtuous feature they had in common: apprenticeship was not the mode of training in either.16 For Smith, then, contrary to what we have been suggesting until now, apprenticeship was on the other side of the divide from uncertainty, skills-based teaching, and intractable subject matter. Instead, its associations, if we can put it anachronistically, would be with the standardised short textbook and multiple-choice questions. That Smith apparently did not see apprenticeship as a feature of the liberal professions needs more investigation than is possible here.17 He creates a puzzle for us, for which the most obvious solution—that when speaking specifically of the medical profession Smith meant only physicians—is factitiously true, but not really a solution at all, because, as we shall see in more detail later, apprenticeship remained integral within physic as well as other parts of practice. That Smith drives a wedge between apprenticeship and medicine is nonetheless noteworthy as well as puzzling, especially given his hostility to corporations and the corporate town. True skills, he seems to suggest, were to be found only outside the city walls.18 Historically, this would certainly exclude prima facie the bulk of medical practitioners who were trained in towns by means of formal apprenticeship. It is possible, however, that Smith was indifferent to the implications of his views for medical training.19 Overall, Smith’s views seem to mark a drastic change in apprenticeship from how it was practised in periods before the eighteenth century. His views matter, because it is the early nineteenth century’s interpretation of his views on laissez faire in trade and industry which justified the dismantling of what remained of the institution of ancien régime apprenticeship taken as a whole.20 It is true that the customary forms of apprenticeship were clung to and strongly advocated by groups of skilled artisans well into the nineteenth century, but their advocacy was undermined by the employers of labour and by the tendency of the middle and upper classes to associate apprenticeship with poverty, unlawful combinations, conspiracy, and the emergent trades unions. Smith’s version of apprenticeship as a species of over-specialised, cheap labour, in which the apprentice learned very little, effectively became dominant in the course of the century, in spite of attempts to revive it in something like its traditional form. By then it was a wholly unregulated private matter between employer (or his proxies) and employee.21 This privatisation of apprenticeship had, however, begun in the eighteenth century, largely as a result of the terminal decline of most English guilds as corporate bodies dedicated to occupational supervision. What is peculiar about medicine, therefore, is not so much privatisation, as the retention of versions of apprenticeship in a climate, and within a class, actively hostile to that institution. To appreciate the nature of this paradox, we need to look at how important apprenticeship was in medicine before 1800. Early Modern Apprenticeship in Medicine and Elsewhere So far, we have been talking about physicians, surgeons and apothecaries as if their identities were well defined and straightforwardly created. This is not the case and it is necessary to provide some definition of what we mean by the occupational group. In spite of the existence of registers, exclusive institutions like colleges and hospitals, and relatively uniform qualifications, medicine is still an occupation with no clear boundaries, even if the definition of a practitioner is limited to those who earn their living by practising. For earlier periods, much has been gained historically by adopting an inclusive rather than an exclusive approach. Early modern English medicine was subject not to one form of regulation but to several, none of which was sustained or comprehensive. Defining a practitioner by means of educational qualifications, or licensing, produces far too narrow a view and distorts the actual mode of operation of the institutions concerned. That is, we are not talking here about a necessary and sufficient curriculum or examination, institutionally defined and enforced. To a considerable extent, and until a late date, medical practitioners constructed their own forms of initiation into the subject (or part of it), and this process was naturally one which could also be undertaken by those who were interested but who did not practise.22 If good faith, some knowledge, and actual practice are regarded as important for legitimacy, then responsible medical practice is likely to be a broader rather than a narrower phenomenon. A broader definition is also justified in terms of the demand side of the equation. Early modern people, as is now clear, consumed a vast amount of medical care, and were ready to consult a wide range of practitioners according to the judgement of themselves and their friends. As far as patients were concerned, it was social or even individual sanction that conferred legitimacy on a practitioner. Obviously, an occupation can be defined in a circular way by giving primacy to a particular form of training or qualification. However, as many historians over recent decades have shown, this usually leads to anachronism and the ignoring of those areas of the occupation most subject to change. More importantly, this proceeding almost inevitably leads to the exclusion of women, who tended to gain access to occupations when the tasks involved were new or little-regarded, only to be excluded once the occupation is formally organised or mechanised.23 Nevertheless, even bearing these points in mind, there is a strong case to be made for the importance of formal apprenticeship in early modern English medicine. The most obvious source for information on this is records of the occupation as organised into guilds or, as they became after the Reformation, companies. One stumbling-block is of course the well-known problem of the absence of records of provincial companies, to which medical companies are no exception. Barber-surgeons’ ordinances relating to apprenticeship, among other company matters, survive in various forms for only a few provincial towns in England before 1600. Most constitutional and regulatory information in fact derives from the defensive and antiquarian petitions and ordinances presented to town authorities in the 1670s and 1680s, when corporate towns were defending their privileges against the later Stuarts. We do have good records for Chester, Newcastle, York and possibly Durham, but these valuable survivals hardly do justice to a situation in which barbers’ guilds existed from at least the late fourteenth century in all the most important corporate towns. By piecing together such information as we can retrieve, separate barber-surgeons’ companies can be found in at least 26 English urban centres outside London. In other centres, barber-surgeons can be located in conglomerate companies, a feature which used to be seen entirely as a sign of weakness, but which can also be attributed either to local forms of organisation, or to actual common interests between the trades concerned. We can note here that some of these provincial companies included physicians on an ad hoc basis.24 Barber-surgeons may justifiably be called the excluded middle: they have been neglected, compared with physicians at one end of the spectrum, and quacks at the other. This neglect is particularly true of the provinces outside London. But they were, in towns, not only the most ubiquitous type of ‘regular’ medical practitioner, but were also numerous compared with other trades. They were numerically the largest of the London companies in the sixteenth century, and appear among the twelve leading trades in towns such as Coventry, Chester, Leicester and Bristol. On the same basis in Norwich, freeman barber-surgeons and surgeons were as numerous as the carpenters and were outnumbered only by the worsted weavers, tailors, cordwainers, grocers and bakers.25 The routine regulatory, supervisory, and educational functions carried out by barber-surgeons’ companies in a great many urban centres tend to be ignored when we think of early modern medicine as a ‘marketplace’. To the barber-surgeons can be added the apothecaries, also well-represented in provincial guilds and higher in status than barber-surgeons, being associated in the mercantile sector with goldsmiths, mercers, spicers and grocers. It was relatively unusual for apothecaries to be organised separately, London again providing an obvious exception, albeit not until the early seventeenth century. Compared with the barber-surgeons, apprenticeship among the apothecaries followed a more mercantile pattern: premiums were paid to the master from an earlier date, premiums tended to be higher in amount, the terms to be served were longer, and the apprentice might expect to learn languages or to be sent abroad for experience. Such apprenticeships included a wide range of forms of education and training and are too often neglected when apprenticeship in general is discussed.26 There is of course no straight line linking the fraternities of the pre-Reformation period and the corporate institutions so disliked by Adam Smith and identified by him with mechanic manufacturing processes of limited range. By the time Smith was writing, guilds were very much in decline, although the residual usefulness of such organisations meant that new ones could still emerge. The decline of the guilds was a subject given considerable attention by economic historians in the early twentieth century, only for interest in guilds in general to fade. When interest revived it was at first rather different in kind, focusing on the causes of stability, especially on the part of historians of early modern London. Although the implication of this work was that the companies managed to enlist a high proportion of adult males even in a metropolis as subject to migratory flows and occupational diversity as early modern London, the stress was still on the companies as socially and politically as well as economically restrictive. Most recently, there has been an attempt to rehabilitate the guilds as effective economic institutions, but this has been met with vigorous opposition on fairly traditional lines.27 It has proved difficult to move far away from a linear account of the guilds as essentially medieval, strait-jacketed institutions, acting as a drag on the developing capitalistic economy, and later as ancien régime relics needing to be undermined by the Enlightenment principles of laissez faire. As part of this negative interpretation, apprenticeship is seen as overlong, resistant to innovation, and involving little or no effective teaching on the part of the master. Here again, the problem is partly due to the richness of records for the companies of London, and the absence of them for the provinces. Some reconstruction is possible by using the records of town administration—the ‘town books’. This in itself is an indication of the extent to which company organisation had to be re-imposed, or restructured, by civic authorities according to economic opportunities or threatened decline. One phase of decline and reconstruction necessarily occurred as a result of the Reformation, with the suppression of chantries and the confiscation of much guild property. The 1550s saw a continued flow of industrial legislation preceding the statutory codification of all apprenticeship in 1563, the Statute of Artificers attributed by later artisans to ‘Good Queen Bess’, and a dimension of apprenticeship unique to England. In Norwich, England’s second city, this took the form of the companies’ being required to produce revised sets of ordinances for ratification by the city authorities. This was not a takeover by the city, but rather an attempt at effective delegation. The Norwich barber-surgeons’ company, which was one that included physicians, becomes visible to us at this time, as it does again in the early seventeenth century when the city was obliged to adopt a centralised administration of the companies owing to the failure of the attempt at delegation. Throughout this period, Norwich was attempting to encourage new trades and to support trades in decline, partly by manipulating apprenticeship and the terms of entry to specific trades. This was far from laissez faire, but it cannot accurately be characterised as restrictive.28 For other towns with different histories, the functioning of the companies and their relationship with the town administration would also have been different. Norwich was a comparatively open city, and sources other than formal occupational records, such as parish registers, reveal a vast range of specific occupations many of which would never appear in the freemen’s rolls, but some of which would develop to form the nucleus of new companies. These may represent the new economic opportunities—or expedients—perceptively identified some years ago by Joan Thirsk, but such ‘acorn’ occupations should not necessarily be seen as developments taking place only in the supposedly freer air outside the city walls.29 It would therefore be a mistake to take the English Statute of Artificers as creating a single form of apprenticeship which was rigidly enforced and incapable of change. It could indeed be suggested that for every town for which we have evidence of the formal existence of medical occupations, there might be a somewhat different history of how apprenticeship, as a socioeconomic institution, was adjusted to meet the challenges of the time and place. I can only outline here the situation in Norwich, but this does present some features which are of interest with respect to later developments, and which have been noted for other centres.30 Norwich records are particularly valuable, and rare, in preserving the full text of some apprenticeship indentures as enrolled by the city. Most forms of enrolment were limited to taking down the names and nominal occupations of the parties involved, and this is true even of some later indentures. Norwich’s early indentures, by contrast, show how a complexity of activities can lie behind the uniform façade of a single occupational designation, even at the formal level. By a process of piecing together, it is possible to construct networks and career paths from the Norwich evidence. For example, among the barber-surgeons who can be linked in any way to the Norwich company, there is only a relatively small proportion of individuals who can be seen to have followed the conventional path from apprenticeship to mastery (and freedom) and the enrolment of their own apprentices in their turn. On the other hand, there is little sign at this time (around 1600) of medicine’s being dynastic—Norwich barber-surgeons’ fathers came from all economic sectors, and their sons were rarely apprenticed to them or indeed became apprentices in barber-surgery at all.31 Apprenticeship itself, however, was much in evidence: two-thirds of the relevant group between 1550 and 1640 were either apprentices, or claimed a background in apprenticeship. The existence of a group claiming apprenticeship without any evidence for it in the city’s record should be noted: it points to the crucial difference between indenturing, a semi-private proceeding, and official or corporate enrolment, that is, the public ratification of apprenticeship. Norwich’s barber-surgeon apprentices were only typical of those of other major urban centres in that, for more than a third of them, nothing further is known.32 This major gap in the record hints at an emerging role for apprenticeship independent of the corporate structures which are generally accorded a restrictive function. Obviously some of these apprentices died, but others of them went on to occupy their trade while ignoring the freedom, just as some of those barber-surgeons who became freemen by means unspecified may have been apprentices elsewhere without bothering with enrolment. Lastly, many Norwich barber-surgeons—formally, at any rate—seem never to have taken on an apprentice of their own. This can of course be simply a measure of the master’s short life-span as well as his comparative poverty, although my own impression for London at a slightly later date is that masters could be surprisingly young. We should note here that for every member of a barber-surgeons’ company who was actually engaged in other occupations, at least part-time, there is likely to have been at least another, either in some other company or outside company organisation, who ‘intruded’ into medicine. Overall, the Norwich evidence of apprenticeship in the early modern period, together with a picture of the occupational group taken as a whole, shows the adaptability of apprenticeship, as well as some fragility of its corporate organisation. It also provides a contrast as much with Adam Smith’s narrow, minutely divided techniques, in which one person did only one thing, as with the conventional view of the full-time, vocational professional. In response, Smith might have argued that surgery, of all parts of the medical occupation, was that part most limited to a relatively narrow range of standardised techniques. Surgery would then take its rightful place among Smith’s limited, over-protected, mechanical skills characteristic of the ‘improved’ corporate town. For the sixteenth and seventeenth centuries, even though some contemporary satire would imply it—by, for example, concentrating on the surgeon’s dependence on violence and wounds—there is, as already suggested, little historical justification for such a view. In the first place, the barbery end of barber-surgery performed a wide range of maintenance and cosmetic tasks on the bodies of early modern people. Secondly, the numerous, and ubiquitous, tribe of barber-surgeons were effectively the general practitioners of their day. Particularly in relation to sexually transmitted diseases, but also more generally, they offered their clients a full regime of preparation, treatment, and aftercare which involved internal as well as external remedies and often went on for months or even years. Many of their diversifications, into such areas as music and the food and drink trades, were aimed at attracting patients, maintaining patients, and improving the likelihood of patient compliance. These are areas which the social sciences of today are only now systematising for the modern practitioner. Thirdly, the broad range of activities of barber-surgeons meant that there was considerable overlap between them and physicians. Adam Smith was a Scot, albeit one familiar with France, Switzerland and London, and because Scottish institutions were disinclined to make a distinction between physicians and surgeons, it seems unlikely that Smith would have associated surgery with the mechanic skills, even in his own century.33 However, it is perhaps unsurprising, as well as significant, that it is the surgeon, rather than the physician or the apothecary, for whom Smith can apparently find no place in his analysis. Had he reflected more on surgery per se, I would argue, he might have had to modify some of his analysis of apprenticeship. Privatisation in the Eighteenth Century: Apprenticeship Declines but also Flourishes By the early eighteenth century, the elite surgeons in London were finally able to do without the barbers, an attempt at self-definition on the surgeons’ part which had been tried without success at intervals from the fifteenth century onwards. The new surgeons’ company emulated the London College of Physicians in avoiding responsibility for both education and supervision of the craft.34 From the 1730s, the surgeons’ institutional centre of gravity was indeed shifting increasingly from the company to the voluntary hospital, but such hospitals, we should also note, were until a late stage a feature not of new industrial centres but of old corporate towns. It should be stressed, however, that the voluntary hospital was not an institution comparable to a guild, being under lay rather than occupational control, unless one regards the early modern guild or company as similarly dominated by the municipal oligarchies. The administration of a voluntary hospital was of course effectively more exclusive in social terms even than the eighteenth-century companies. Those barber-surgeons’ companies about which something is known for the later period participated in the general politicised decline of the guilds, although some survived, becoming little more than dynastic dining-clubs. Others continued to embrace diversifications no longer acceptable to those seeking gentlemanly status, such as periwig-making. So far, my argument has given least attention to the apothecaries, who, as we have seen, were initially more highly placed in the corporate hierarchy than the barber-surgeons. Interestingly, Adam Smith was prepared to defend the apothecaries, who, at the time at which he was writing, were popularly regarded as doing far too well for themselves. In Smith’s view, ‘the greater part of the apparent profit is real wages disguised in the garb of profit’, and ‘the skill of an apothecary is a much nicer and more delicate matter than that of any artificer whatever’. In addition, he pointed out, apothecaries had an office of trust, being ‘the physician of the poor in all cases, and of the rich when the distress or danger is not very great’; and in his view offices of trust, as in the liberal professions, should be highly recompensed, with honour if not with financial reward.35 However, Smith’s apothecaries were not the same as the relatively highly placed civic apothecaries of the sixteenth century. The mercantile apothecaries effectively became known, in the seventeenth century, as druggists; the rank-and-file apothecaries proliferated either as grocers (another trade for which Smith had a soft spot) or as general medical practitioners, often being known as surgeon-apothecaries.36 As most of these apothecaries operated out of a shop, the occupations of grocer, apothecary and medical practitioner readily overlapped, which did not, ultimately, improve the status of any of them, whatever their usefulness in society. This proliferation of shopkeepers occurred particularly in small centres, and was made possible partly by the increase in imported and proprietary drugs and partly by their better distribution. The extra-mural apothecary came to provide for the countryside a version of the service that the barber-surgeon provided for the town, but with a greater emphasis on consumables. His location outside the corporate town was probably part of his appeal for Smith, although Smith seems to ignore the role of apprenticeship in creating the apothecary in the first place. For these country apothecaries, it was virtually essential to take on an apprentice, given the logistics of running a shop and visiting patients. This development marks a definite shift, not away from apprenticeship in medicine, but towards the predominance of what may be called a private version of it. ‘Private’ apprenticeship—which could be defined as apprenticeship without enrolment or oversight and perhaps even without formal indentures—clearly occurred in the earlier period, as is implied both by the Norwich evidence already mentioned and by the repeated attempts at reform on the part of both company and municipal authorities. However, at some point, probably in the eighteenth century, the strictly private indenture became, in the medical as well as other occupations, the rule rather than the exception. Interestingly, in view of the unlikelihood of its ever being seen as a model, midwifery, which in England entirely lacked a guild structure, featured well-developed informal and possibly purely verbal apprenticeship arrangements between women in the urban environment and probably also in rural areas.37 There were of course major changes in the institutional structure of medical education from the late seventeenth century onwards. For a few, walking the wards of a hospital became a possibility, and subsequently, attendance at courses offered privately by a wide range of freelance lecturers.38 However, this combination of opportunities could be seen not so much as novel, as a version of the kind of apprenticeship which had traditionally been offered to the mercantile apprentice. That is, the master would guarantee to allow or make possible the acquisition of a range of special skills, some of which might be taught in institutions or in a relatively formal way. A second resemblance between earlier practices and later forms of medical training is the period of experience which traditionally came towards or at the end of apprenticeship, and which often involved travel. This custom of wanderjahre is only sporadically visible in English records, but is better established in the city states of continental Europe.39 For early modern barber-surgeons, this period could be spent on board ship, but this option, when it was attractive, was often appealing for the wrong reasons—some of these apprentices were actually absconding, seeking to avoid the final years of their term, or pushed into it by their master. A third parallel between earlier and later is the period of practice which was traditionally prescribed for medical students in most universities as a pre-requisite for the higher medical degree. In the early modern period, the London College of Physicians also tried to impose this requirement on younger men, but neither the universities nor the College specified how, or at whose expense, this essential experience was to be gained.40 In most cases, however, a relationship with an older or more seasoned practitioner was presumed, and these relationships can only be described as private.41 With respect to hospital experience, some masters—masters in all but name—guaranteed to facilitate this as a term of the indenture. Where such an arrangement was formalised, the agreement was not with the hospital, which we could count as public, but was set up privately, with the individual practitioner who had an appointment at the hospital. In the eighteenth-century voluntary hospitals, students’ fees were paid to the honorary medical staff, in effect in their private capacity. Hospital teaching of this kind did not occur on a significant scale until the second half of the eighteenth century. A period at one of the Scottish universities could be added by the more ambitious apprentice, particularly in Edinburgh, where the university and the infirmary (1729) were closely linked to the town corporation. In general, as already indicated, the periods of education and experience of medical apprentices—or students—could be constructed to suit individual requirements or resources, as had always been the case even with enrolled apprenticeship indentures, especially in the more prosperous trades.42 Overall then, far from fading out, provincial apprenticeship in medicine consolidated its position at this later period. Irvine Loudon indeed regards it as best established around 1800.43 In other respects also, medical apprenticeship seemed to be immune from the radical changes occurring in other occupations. One of these radical changes took place in the household. As has been suggested, seventeenth-century urban conditions involved factors, including disease, which pressed hard on the customary obligation on the master to house the apprentice under his own roof. The boarding-out of apprentices was arguably both a cause and an effect of apprenticeship’s decline.44 In medicine, on the other hand, it remained conventional that the apprentice would board with his master, although this was probably more general in rural than in urban areas, and there are suggestions that apothecaries’ apprentices at least were expected to sleep not with the family but in the shop. Secondly, medical apprenticeship managed to preserve another of the perceived advantages of traditional apprenticeship, namely the continuing informal contact between master and apprentice in later life. Thirdly, premiums, traditionally paid to masters in high-status and competitive trades, remained a valuable source of income for many medical practitioners well into the nineteenth century. At the same time, however, apprenticeship had come to combine well with the increasingly dynastic tendencies in medicine, which were above all an expression of aspirations tempered by financial insecurity in a competitive environment. If master and apprentice were related, a premium could be avoided; the same could apply if the apprentice’s father had died, or if he were the son of a medical man.45 The Apothecaries’ Act (1815): Affirmation, Rejection and Persistence In the eighteenth century, then, medical apprenticeship was atypical in flourishing rather than declining. Early in the nineteenth century, it reached an apparent apotheosis with the Apothecaries’ Act of 1815. This Act specified for the first time a minimum examinable level of education for a licence to practise medicine, and was so-called because the examining was placed in the hands of the Society of Apothecaries, first founded as a London city company or guild in 1617. This unexpected pre-eminence of the Apothecaries and their company was due partly to the perceived needs of provincial practitioners, which tended to be defined by the London medical elites as limited, and partly to the wishes of the other London medical corporations, the colleges, both to retain their privileges and not to become involved.46 Originally, the Act was to specify either apprenticeship or hospital training; in the event only apprenticeship was made compulsory, probably again to suit the requirements of country practitioners, although in Loudon’s view this was unnecessary, or at least a mistake. Loudon stresses the disrepute into which apprenticeship in general had fallen by this time.47 However, Holloway concludes that apprenticeship was included at the insistence of the London College of Physicians, who wanted the old hierarchies preserved. The Act ‘had a closer affinity to a Stuart patent of monopoly than to a statute in the age of “laissez-faire”’.48 Thus, ironically, apprenticeship was established as essential training for one of the liberal professions at almost exactly the same time as the repeal of the Elizabethan Statute of Artificers (1814), an Act regarded as the symbolic end of apprenticeship and a victory for free trade.49 It was also embedded in a London guild or company after decades in which these corporations had been losing their legitimacy. David van Zwanenberg’s case study of Suffolk shows how apprenticeship continued to be practised in the provinces.50 However, strong objections to the ‘obnoxious’ apprenticeship clause of the Apothecaries’ Act arose almost immediately, in terms showing that many practitioners shared in the contemporary disparagement of apprenticeship in general. The clause was therefore abolished by the Medical Act of 1858. Ambitious Scottish medical graduates were especially critical. Nonetheless, the contradictions remain: apprenticeship could still be defended.51 Loudon also states that ‘the physicians were all for apprenticeship’, and something known as ‘the apprentice question’ was still being discussed in the 1880s and beyond.52 It is worth looking a little more closely at the problems that medical apprenticeship was still expected to solve in the later period in order to suggest exactly what the continuities and discontinuities might be. The first issue, which cannot be developed fully here, is that of opposition to specialisation. Apprenticeship in its ideal form involved the apprentice learning the whole of the craft or trade, not just some aspect of it, or some minute division of labour within it, such as Adam Smith described. Orthodox clinical medicine in England, until well into the twentieth century, harboured a similarly universalist ideal, akin to that which had been advocated by humanist physicians in the early modern period.53 A second issue is that of discipline. A major role for apprenticeship had always been that of controlling and socialising males at a particularly unstable phase in their life cycle. As far as Adam Smith was concerned, discipline and apprenticeship had become dissociated: apprentices were idle by definition, as they learned too little and had too little to do. Medical practitioners indeed reported, around the turn of the nineteenth century, misdemeanours on the part of their apprentices which bear an uncanny resemblance to those complained of in apprenticeship disputes of the seventeenth century. For example, apprentices lost business by not minding the shop or by not taking messages properly, they received payment for goods and did not record the transactions, they worked on their own account, they were conceited and dandified in their clothing and behaviour, they were slovenly and failed to get up early.54 At the same time, medical men continued to see the one-to-one relationship as a means of applying discipline and imparting moral instruction. Throughout the nineteenth century, there was deep concern among parents and practitioners about the dangers of exposing boys too early to the corrupting environment of the metropolitan hospitals.55 In this context too, hospitals were certainly no substitute for the civic and corporate functions of the now largely defunct guilds or companies. It is interesting that the stereotypical coarse medical student, Dickens’s Bob Sawyer, emerged around 1836 just as formal apprenticeship declined and the hospital medical schools become established. Some medical writers were convinced that it was the hospital wards, and even the dissecting room, that were most liable to breed habits of idleness and dissipation.56 The issue of discipline is inseparable from that of what the apprentice was expected to learn, and which only an apprentice could learn. This area of non-textual expertise, including various forms of skills-based learning, encompassed management skills (how to run a shop or a practice) or essential ancillary skills (how to ride or drive a horse), or vital social skills (how to talk to patients and their families). At the end of the nineteenth century, mature practitioners could complain that assistants straight from hospital were nothing but a nuisance, because they could do none of these things. To some extent this reflects the difference between the hospital connection in a city, to which most practitioners aspired, and the country practice ‘nine out of ten’ had to settle for. Here we return to the insecurities and uncertainties which beset medical practitioners even at the end of the nineteenth century. ‘I take it’, stated one advocate of apprenticeship, a country physician, in 1885, ‘that few who seek medicine as a means of living are born with a silver spoon in their mouths’; and that ‘if he [the apprentice] learn tact, the art of pleasing, and how to be useful, and how to see that medicine is not put in a dirty bottle, or carelessly wrapped up, he learns what will often make the difference whether he succeeds or fails in his future career’.57 It was also stressed that apprentices came into contact with types of patient who were not seen in hospitals, and that they came to know not just patients but humanity itself. They learned about medicine in terms not of generalisations but of particularities, an observation which returns us to the irreducible problem of the individual patient mentioned at the start of this article. Moreover, they not only saw the circumstances in which diseases might develop, they were also necessarily confronted with the outcomes of treatment. This is an interesting point of comparison between earlier and later periods in that one of the defects by which early modern practitioners, especially barber-surgeons, defined the empiric as opposed to themselves was that the empiric avoided the consequences of treatment, often simply by moving on to the next town. The moral meaning of this type of experience is what gives it the connection with discipline. Apprentices were seen as gaining a knowledge of the (real) world, by which was meant not urban sophistication, but the ‘still sad music of humanity’, including their own. They learned qualities such as tact, prudence, good manners, and circumspection. They learned, in effect, how best to live with uncertainty, and the fear of failure. Obviously this tempered vision of the medical life, however realistic, was not one which suited aspirations in this later period. To a considerable extent, as a number of historians have pointed out, this was (still) a matter of uncertain social and economic status.58 Hence, even by the late eighteenth century, medical practitioners were attempting to expel the notion of servitude from their version of apprenticeship. The guilds and companies had of course presented servitude not as a permanent, degraded condition but as an essential and formative stage in the life cycle, the base of a vertical ladder which in theory all could, and should, climb in order to become masters and citizens in their turn. In reality, ‘glass ceilings’ developed at different times depending on the nature of the trade, and the frustrations of those unable to rise—the yeomanry, or journeymen—have been a long-standing focus of attention for historians interested in the rise of capitalism and the trade unions, and more recently, for social historians.59 Thus for late eighteenth-century medical practitioners, as the class system began to establish itself, the notion of servitude had only negative connotations, and represented a condition, not a stage of life. Hence they substituted ‘pupil’ for ‘apprentice’, and ‘tutor’ or ‘instructor’ or ‘senior’ was preferred to ‘master’. The idea of being ‘bound’ by an indenture or any other form of agreement was also distasteful.60 Consequently, medical practitioners may seem to have been allowing a greater degree of equality between master and apprentice—in spite of the complaints about apprentices’ being above both themselves and their masters—but this should be seen more as an attempt to claim gentlemanly status for the profession as a whole. This concern for consistency of status is highlighted by the position of domestic servants. Medical apprentices were, as already mentioned, still to a large extent household apprentices, which meant, as in the seventeenth century, close contact with servants. There is certainly concern in the seventeenth century about the demarcation of responsibilities between servants and apprentices on the part of all those involved, but this concern is different in its nature and implications, and ‘servants’ were not then predominantly domestic servants. At the later period, the proximity of servants and apprentices had become a ‘delicate’ matter: medical masters wanted to keep the apprentice out of the kitchen, and the servants out of the shop.61 The advent of hospital-based teaching caused further status-related problems. Patients came to associate being ‘taught over’ with their lowly status as poor non-payers in the voluntary hospitals; they did not want to be ‘taught over’ if they had paid a fee to be visited at home. For some medical commentators, the vast social distance enforced between patient and practitioner in hospital, whereby the practitioner became very much the superior, was premature as far as most practitioners’ position in the world was concerned. It constituted an argument in favour of the more widely applicable skills learned by apprenticeship: ‘the apprentice generally possesses some of the art of pleasing a patient, or, at least, of showing an assumed deference—an art in which the hospital-student is sometimes deficient’.62 Conclusions: Medical Apprenticeship, Privatised and Transformed Clearly, by the nineteenth century, English medical practitioners were full participants in the general middle-class rejection of apprenticeship as a social institution negatively associated with trade, trade unionism, lower status, servitude, poverty and even unrest. However, as we have seen, this discontinuity was more apparent than real, even though the medical version of apprenticeship could be said to have lost many of the merits and functions of customary apprenticeship. Medical professionals managed to avoid most of what they perceived to be the negative associations of apprenticeship while retaining some of its usefulness, by converting it into a private matter, even a non-contractual one. In the process, they abandoned nearly all of the civic or communal structures, like companies and the town authorities who supervised them, in which apprenticeship used to be embedded and regulated. In order to disguise the very real continuities, they needed a countervailing or compensating ethos with which to dignify that relationship between master and pupil which was still essential for both personal advancement and solidarity within a much-divided profession. Irvine Loudon, in his account of the rise of the general practitioner, has emphasised the group loyalty of the hospital, conceding the profession’s own claims by likening this to the collective ethos of the club, the regiment, or the college: ‘the old-style apprenticeship, even at its strongest, had none of this element of tribal or institutional loyalty’.63 This may be true of the ‘private’ kind of apprenticeship quietly evolved by the profession, but it definitely does not hold for the guilds and companies as they operated in the early modern period. I would also argue that, while the hospital was a focus of loyalty for the chosen few, and of aspirations for the many, it was also, like the royal colleges, extremely exclusive and therefore divisive in its overall effects—as the tribal or regimental analogies tend to imply. Lastly, I would suggest that the most enduring ideal for the medical practitioner remained, not the collective loyalty of the hospital, but the one-to-one relationship between senior and junior which was also a characteristic of apprenticeship, and which was accentuated in ‘private’ apprenticeship.64 Ideally, it was within the context of this relationship that skills-based ‘wisdom’, as opposed to mere knowledge, was most effectively conveyed. As already indicated, a connection between senior and junior was built into the education of humanist physicians from an early date. It is the ideals of humanism and of university-educated physicians which in the nineteenth century had most influence on medical professionalisation, regardless of the fact that these practitioners were always only a tiny minority. This did not relate only to practice: the student acquired medical theory not so much via a prescribed curriculum as by private study and individual connections with his seniors. Although the English universities, crudely speaking, were more or less irrelevant to the cognitive legitimation of medicine in terms of the rise of science, their influence on the definition of a liberal profession remained extremely strong.65 An important element in this was the one-to-one relationship between tutor and student, a relationship which gave meaning to later life for each.66 ‘With influence there is life’, stated William Osler, quoting John Henry Newman, who had added that this ‘influence’ broke out dangerously if deprived of its right context. Although making rhetorical use from time to time of terms like ‘guild’ and ‘apprentice’, Osler also rejected ‘apprentice’ in favour of ‘brother’, and repudiated the word ‘master’, even though it was, as he said, ‘in a most delightful way’ used by the French, to convey a bond of intellectual filiation.67 For Osler and his contemporaries, a medical man lived on in his pupils, even though some of them were inevitably disappointing. This vital relationship did not, however, have to be confined to the early phases of medical education; it could even be forged after graduation, for example between a senior practitioner and his assistant.68 In this way the ideal was available even to those not fortunate enough to experience it in the major hospitals, while at the same time they could gain by spending their earlier years in academic education rather than in the more menial phases of apprenticeship. There was, I believe, a further gloss on this humanist ethos, which provided both compensation and camouflage. In the early modern period, the patronage relationship raised particular difficulties for the emergent ‘professional’ occupations.69 In the later period, with the rise of the middle class, patron and protégé were closer together in social status, and the craving of medical practitioners for the status of literary gentlemen could supply a literary rationale based on the education they supposedly had in common with their clients.70 Although knowledge of mathematics probably distinguished a man far more, it was to the classics that nineteenth-century medical men most often turned for their intellectual credentials and common heritage.71 Classical stereotypes offered a highly acceptable and dignified set of exemplars for the relationship between senior and junior. The example of Osler, a totemic figure of the late nineteenth and early twentieth century, shows that in terms of practice and teaching the scientific ideal could only go so far.72 The lasting appeal of a clinician like Osler was (and is) in part attributable to his ability to place medical relationships in the context of a broader Western culture. Osler on occasion drew a contrast between the ‘Chinese’ mode of education, by which he meant rote learning and examinations, and the ‘Greek’ model, which valued private reading, travel, relationships, observation and experience.73 By following the Greek model, the one-to-one relationship between senior and junior could become the conduit for that learning about life which could not be conveyed by the pages of a textbook. Thus, for good and sufficient reasons, connected to the ‘realistic’, skills-based, uncertain side of medicine, the apprentice relationship was never wholly abandoned by the medical profession. Instead it was transformed, via a process of privatisation and rejection of unwanted social and cultural associations, away from its civic and customary origins, and into something ‘fine, and noble, and antique’. Adam Smith might well have agreed with Osler as to the contrast between Chinese and Greek models of education. He observed that ‘apprenticeships were altogether unknown to the ancients’.74 For all medical men, skills-based training and uncertainties remained, but at least these could be confronted within a reassuring, even dignified, set of classically inspired personal relationships. Margaret Pelling is a Senior Research Associate at the Wellcome Unit for the History of Medicine, University of Oxford. Her early work was on nineteenth-century epidemiology and public health. For most of her career she has focused on the lower orders of medical practitioner, health, disease and social conditions in early modern England. She is the author of Medical Conflicts in Early Modern London: Patronage, Physicians and Irregular Practitioners 1550–1640 (2003) and her most recent work is on John Graunt and the seventeenth-century London Bills of Mortality. Footnotes 1 ‘Humanism’ here refers primarily to the sixteenth-century programme for medical reform based on the recovery and translation of original texts by Galen, Hippocrates and others. Knowledge of classical Greek and Latin was fundamental to this programme. One of the main proponents of humanist reform in England was Thomas Linacre, founder of the London College of Physicians. 2 See for example L. Rosner, Medical Education in the Age of Improvement: Edinburgh Students and Apprentices 1760–1826 (Edinburgh: Edinburgh University Press, 1991); G. B. Risse, Hospital Life in Enlightenment Scotland: Care and Teaching at the Royal Infirmary of Edinburgh (Cambridge: Cambridge University Press, 1986). See also note 42 below. 3 M. Pelling, ‘Compromised by Gender: The Role of the Male Medical Practitioner in Early Modern England’, in H. Marland and M. Pelling, eds, The Task of Healing: Medicine, Religion and Gender in England and the Netherlands 1450–1800 (Rotterdam: Erasmus Publishing, 1996), 101–33. 4 The literature bearing on these aspects of medicine is huge and varied, but see for example S. Pender, ‘Between Medicine and Rhetoric’, Early Science and Medicine, 2005, 10, 36–64; L. Demaitre, ‘Theory and Practice in Medical Education at the University of Montpellier in the Thirteenth and Fourteenth Centuries’, Journal of the History of Medicine, 1975, 30, 103–23; G. Pomata, ‘Praxis historialis: The Uses of Historia in Early Modern Medicine’, in Pomata and N. G. Siraisi, eds, Historia: Empiricism and Erudition in Early Modern Europe (Boston: MIT Press, 2005), 105–46; G. L. Engel, ‘The Care of the Patient: Art or Science?’, Johns Hopkins Medical Journal, 1977, 140, 222–32; N. Hammerstein, ‘The Modern World, Sciences, Medicine, and Universities’, History of Universities, 1989, 8, 151–78; K. A. Eagle, ‘Finding Humanism in Medicine’, Perspectives in Biology and Medicine, 1985, 29, 109–14; S. Toulmin, ‘Knowledge and Art in the Practice of Medicine: Clinical Judgment and Historical Reconstruction’, in C. Delkeskamp-Hayes and M. A. Gardell Cutter, eds, Science, Technology and the Art of Medicine (Dordrecht: Springer, 1993), 231–49, and other chapters in the same volume. 5 The call for more on practice is of long standing: see E. H. Ackerknecht, ‘A Plea for a “Behaviorist” Approach in Writing the History of Medicine’, Journal of the History of Medicine, 1967, 23, 211–14. Recent work includes: M. Dinges et al., eds, Medical Practice, 1600–1900. Physicians and their Patients, Clio Medica (Leiden: Brill, 2016); W. Wild, Medicine-by-Post: the Changing Voice of Illness in Eighteenth-Century British Consultation Letters and Literature (Amsterdam: Rodopi, 2006); G. Risse and J. H. Warner, ‘Reconstructing Clinical Activities: Patient Records in Medical History’, Social History of Medicine, 1992, 5, 183–205; B. Duden, The Woman Beneath the Skin: A Doctor’s Patients in Eighteenth-Century Germany, trans. T. Dunlap (Cambridge, MA: Harvard University Press, 1991). 6 A. E. Garrod, ‘The Laboratory and the Ward’, in C. L. Dana, ed., Contributions to Medical and Biological Research Dedicated to Sir William Osler, 2 vols (New York: Paul B. Hoeber, 1919), I, 59–69; C. Lawrence, ‘Incommunicable Knowledge: Science, Technology and the Clinical Art in Britain, 1850–1914’, Journal of Contemporary History, 1985, 20, 503–20. On the continuation of the debate into the twentieth century, see C. Lawrence, ‘A Tale of Two Sciences: Bedside and Bench in Twentieth-century Britain’, Medical History, 1999, 43, 421–49. 7 M. L. Clarke, Classical Education in Britain 1500–1900 (Cambridge: Cambridge University Press, 1959); C. Stray, Classics Transformed: Schools, Universities and Society in England, 1830–1960 (Oxford: Clarendon Press, 1998); A. Warwick, ‘Exercising the Student Body: Mathematics and Athleticism in Victorian Cambridge’, in C. Lawrence and S. Shapin, eds, Science Incarnate: Historical Embodiments of Natural Knowledge (Chicago: University of Chicago Press, 1998), 288–326. But cf. the neo-classical programme for medicine of Enlightenment thinkers such as Cabanis: Pender, ‘Between Medicine and Rhetoric’, 37ff; L. Jordanova, ‘Reflections on Medical Reform: Cabanis’ Coup d’Oeuil’, in R. Porter, ed., Medicine in the Enlightenment (Amsterdam: Rodopi, 1995), 166–80. 8 See especially R. C. Fox, ‘Training for Uncertainty’, in R. K. Merton, G. G. Reader and P. L. Kendall, eds, The Student Physician (Cambridge, MA: Harvard University Press, 1957), 207–41. On early modern approaches, see S. Pender, ‘Examples and Experience: On the Uncertainty of Medicine’, British Journal for the History of Science, 2006, 39, 1–28, with particular reference to Francis Bacon and Michel de Montaigne. 9 J. C. Rose and M. Corn, ‘Dr. E. and Other Patients: New Lessons from Old Case Reports’, Journal of the History of Medicine, 1984, 39, 3–32: at 5, 19, 30. The authors usefully quote and consider numerous examples of case reports by Gull, Allbutt, Shattuck, Osler, and others. 10 K. M. Hunter, ‘“There was this one guy …”: The Uses of Anecdotes in Medicine’, Perspectives in Biology and Medicine, 1986, 29, 619–30. See more recently Hunter, ‘Narrative, Literature, and the Clinical Exercise of Practical Reason’, Journal of Medicine and Philosophy, 1996, 21, 303–20; Hunter, Doctors’ Stories: the Narrative Structure of Medical Knowledge (Princeton, NJ: Princeton University Press, 1991). Others exploring this theme include J. Epstein, Altered Conditions: Disease, Medicine and Storytelling (New York: Routledge, 1995); B. Hurwitz, ‘Form and Representation in Clinical Case Reports’, Literature and Medicine, 2006, 25, 216–40; M. Kennedy, Revising the Clinic: Vision and Representation in Victorian Medical Narrative and the Novel (Columbus, OH: Ohio State University Press, 2010); S. Vasset, ed., Medicine and Narration in the Eighteenth Century (Oxford: Voltaire Foundation, 2013). For admirable clarity on classical, medieval and renaissance traditions and models of medical narrative, see N. Siraisi, ‘Girolamo Cardano and the Art of Medical Narrative’, Journal of the History of Ideas, 1991, 52, 581–602. 11 N. Siraisi, Medieval and Early Renaissance Medicine: An Introduction to Knowledge and Practice (Chicago: Chicago University Press, 1990), 170. 12 See for example Hunter, Doctors’ Stories, 31; A. Gawande, Complications: A Surgeon’s Notes on an Imperfect Science (London: Picador, 2003). Although perhaps this comes at a price: see J. Cassell, ‘On Control, Certitude, and the “Paranoia” of Surgeons’, Culture, Medicine and Psychiatry, 1987, 11, 229–49. But see C. L. Bosk, Forgive and Remember: Managing Medical Failure, 2nd edn (Chicago: Chicago University Press, 2003), which meticulously analyses, following Durkheim, the ‘collective conscience’ of surgeons. 13 S. Young, Annals of the Barber-Surgeons of London (London: Blades, East and Blades, 1890; repr. New York: AMT Press, 1978), 77, 119, 180, 182; T. Vicary, The Anatomie of the Bodie of Man , ed. F. J. and P. Furnivall, Early English Text Society (London: Trübner, 1888), 255, 275, 276. 14 Siraisi, Medieval and Early Renaissance Medicine, 133–6; M. Pelling, Medical Conflicts in Early Modern London: Patronage, Physicians and Irregular Practitioners 1550–1640 (Oxford: Clarendon Press, 2003), ch. 7. 15 W. Osler, Aequanimitas, with Other Addresses (London: H. K. Lewis, 1904), 29. 16 A. Smith, The Wealth of Nations (1776; Everyman edn, 2 vols, repr., London: Everyman, 1937), I, 6, 90ff, 114–15. 17 For some reference to Smith, although not on this point, see Rosner, Medical Education in the Age of Improvement, esp. 63–4, 180. 18 Smith, Wealth of Nations, I, 112ff. Although see ibid., I, 108, where Smith categorises the ancient universities and their graduates as a later development of the incorporation of trades. It is worth noting also that Smith became a burgess and ‘guild brother’ of Glasgow as well as burgess of Edinburgh: I. S. Ross, ‘Adam Smith’s “happiest years” as a Glasgow Professor’, in A. Hook and R. B. Sher, eds, The Glasgow Enlightenment (East Linton: Tuckwell Press, 1995), 85; E. C. Mossner and I. S. Ross, eds, The Correspondence of Adam Smith, 2nd edn (Oxford: Oxford University Press, 1987), xx, xxi. 19 Smith’s most extended discussion of medical education seems to be his long letter (a requested response) to William Cullen in 1774 about the Scottish universities, which shows deep scepticism about the value of formal medical qualifications and indeed about medical science itself: Mossner and Ross, eds, Correspondence of Adam Smith, 173–9. For a parallel between degrees and apprenticeship as equally restrictive, see p. 177. See also M. Barfoot, ‘Dr William Cullen and Mr Adam Smith: A Case of Hypochondriasis?’, Proceedings of the Royal College of Physicians of Edinburgh, 1991, 21, 204–14, esp. 204–7. 20 E. Rothschild, Economic Sentiments: Adam Smith, Condorcet, and the Enlightenment (Cambridge, MA: Harvard University Press, 2001), ch. 4, stresses the ‘different Smiths’ in the context of apprenticeship. See also the edition of Wealth of Nations edited in 1805 by William Playfair, who, although probably writing for money, diverges from Smith in championing rather than discrediting the cause of apprenticeship. 21 This is necessarily a very brief summary from an extensive literature. See for example J. Humphries, ‘Rent Seeking or Skill Creating? Apprenticeship in Early Industrial Britain’, in P. Gauci, ed., Regulating the British Economy 1660–1850 (London and New York: Routledge, 2016), 235–58; K. D. M. Snell, ‘The Apprenticeship System in British History: The Fragmentation of a Cultural Institution’, History of Education, 1996, 25, 303–21; J. Rule, The Experience of Labour in Eighteenth-Century Industry (London: Croom Helm, 1981), ch. 4; D. Green, From Artisans to Paupers: Economic Change and Poverty in London, 1790–1870 (Aldershot: Ashgate, 1995); M. Chase, Early Trade Unionism: Fraternity, Skill and the Politics of Labour (Aldershot: Ashgate, 2000); G. Howell, ‘Trades Unions, Apprentices and Technical Education’, Contemporary Review, 1877, 30, 833–57; R. A. Bray, ‘The Apprenticeship Question’, Economic Journal, 1909, 19, 404–15. A. Levene, ‘“Honesty, sobriety and diligence”: Master–Apprentice Relations in Eighteenth- and Nineteenth-century England’, Social History, 2008, 33, 183–200, analyses charity apprenticeship, which, although providing for as many girls as boys, arguably preserved (or recreated) many features of ancien régime apprenticeship. Change and decline in apprenticeship from the seventeenth century onwards is the subject of a major quantitatively-based project being conducted by Patrick Wallis of LSE and his collaborators. See for example P. Wallis, ‘Apprenticeship and Training in Premodern England’, Journal of Economic History, 2008, 68, 832–61. 22 See for example P. M. Jones, ‘Reading Medicine in Tudor Cambridge’, in V. Nutton and R. Porter, eds, The History of Medical Education in Britain (Amsterdam: Rodopi, 1995), 153–83. 23 S. Ogilvie, ‘Guilds, Efficiency and Social Capital: Evidence from German Proto-industry’, Economic History Review, 2004, 57, 286–333: at 289–90. 24 M. Pelling, ‘Occupational Diversity: Barber-surgeons and Other Trades’ (1982), repr. in Pelling, The Common Lot: Sickness, Medical Occupations and the Urban Poor in Early Modern England (London: Longman, 1998), 203–29; Pelling, Barber-Surgeons’ Guilds and Ordinances in Early Modern British Towns—the Story so Far, Working Paper No. 1, ‘The Medical World of Early Modern England, Wales and Ireland, 1500–1715’ (Exeter: Centre for Medical History, 2014): http://practitioners.exeter.ac.uk/. 25 Pelling, ‘Occupational Diversity’, 228–9. 26 But see P. Wallis, ‘Medicines for London: The Trade, Regulation and Life-cycle of London Apothecaries, c. 1610–c. 1670’ (D Phil thesis, University of Oxford, 2002), and Wallis’s project on apprenticeship mentioned in note 21 above. 27 S. Rappaport, Worlds within Worlds: Structures of Life in Sixteenth-Century London (Cambridge: Cambridge University Press, 1989); I. W. Archer, The Pursuit of Stability: Social Relations in Elizabethan London (Cambridge: Cambridge University Press, 1991); Ogilvie, ‘Guilds, Efficiency and Social Capital’. Cf. S. R. Epstein and M. Prak, eds, Guilds, Innovation and the European Economy, 1400–1800 (Cambridge: Cambridge University Press, 2008), who argue for the continued economic effectiveness of (some) craft guilds; also B. De Munck, ‘Gilding Golden Ages: Perspectives from Early Modern Antwerp on the Guild Debate, c. 1450–c. 1650’, European Review of Economic History, 2011, 15, 221–53. 28 Pelling, Barber-Surgeons’ Guilds; Pelling, ‘Occupational Diversity’, 210–13. 29 J. Thirsk, Economic Policy and Projects: the Development of a Consumer Society in Early Modern England (Oxford: Oxford University Press, 1978, repr. 1988). 30 For what follows, see Pelling, ‘Occupational Diversity’; P. Rushton, ‘The Matter in Variance: Adolescents and Domestic Conflict in the Pre-industrial Economy of Northeast England, 1660–1800’, Journal of Social History, 1991, 25, 89–107, makes good use of barber-surgeon company records for Newcastle. 31 This was the natural, and indeed desirable state of affairs in customary apprenticeship: Humphries, ‘Rent Seeking or Skill Creating’, 250–1. 32 On the processes of attrition during apprenticeship, with an emphasis on the tendency not to complete, see C. Minns and P. Wallis, ‘The Price of Human Capital in a Pre-industrial Economy: Premiums and Apprenticeship Contracts in 18th Century England’, Explorations in Economic History, 2013, 50, 335–50, esp. 336–40; Wallis, ‘Labor, Law, and Training in Early Modern London: Apprenticeship and the City’s Institutions’, Journal of British Studies, 2012, 51, 791–819, esp. 797. Tracking apprentices after truncation or completion of term presents considerable difficulties, but see I. Krausman Ben-Amos, Adolescence and Youth in Early Modern England (New Haven and London: Yale University Press, 1994), 129–31; G. Hamilton, ‘Enforcement in Apprenticeship Contracts: Were Runaways a Serious Problem? Evidence from Montreal’, Journal of Economic History, 1995, 55, 551–74. 33 But see an early advocacy of the benefits of specialisation in surgery: C. Lawrence, ‘The Edinburgh Medical School and the End of the “old thing” 1790–1830’, History of Universities, 1988, 7, 259–86, esp. 269. On Scottish medical education, see also Lawrence, ‘Ornate Physicians and Learned Artisans: Edinburgh Medical Men, 1726–1776’, in W. F. Bynum and R. Porter, eds, William Hunter and the Eighteenth-Century Medical World (Cambridge: Cambridge University Press, 1985), 153–76; Rosner, Medical Education in the Age of Improvement; Risse, Hospital Life in Enlightenment Scotland. Smith stated of Scotland that he knew of ‘no country in Europe in which corporation laws are so little oppressive’: Wealth of Nations, I, 110. 34 M. Pelling, ‘Corporatism or Individualism: Parliament, the Navy, and the Splitting of the London Barber-Surgeons’ Company in 1745’, in I. Gadd and P. Wallis, eds, Guilds and Association in Europe, 900–-1900 (London: Centre for Metropolitan History, 2007), 57–82. 35 Smith, Wealth of Nations, I, 89, 100. 36 On the flourishing of the surgeon-apothecary in the later eighteenth century, see I. Loudon, Medical Care and the General Practitioner 1750–1850 (Oxford: Clarendon Press, 1986). 37 D. Evenden, The Midwives of Seventeenth-Century London (Cambridge: Cambridge University Press, 2000); A. Giardina Hess, ‘Community Case Studies of Midwives from England and New England, c. 1650–1720’ (PhD, University of Cambridge, 1994); H. King, ‘“As if none understood the art that cannot understand Greek”: The Education of Midwives in Seventeenth-century England’, in Nutton and Porter, eds, History of Medical Education, 184–98. 38 S. C. Lawrence, ‘Anatomy and Address: Creating Medical Gentlemen in Eighteenth-century London’, in Nutton and Porter, eds, History of Medical Education, 199–228, esp. 208. 39 There are certain continuities with the later custom of ‘tramping’: see E. J. Hobsbawm, ‘The Tramping Artisan’, Economic History Review, 1951, 3, 299–320; R. A. Leeson, Travelling Brothers: The Six Centuries’ Road from Craft Fellowship to Trade Unionism (London: Allen and Unwin, 1979), esp. chs 1–3. 40 See, e.g., Siraisi, Medieval and Early Renaissance Medicine, 72; Jones, ‘Reading Medicine’, 156; Pelling, Medical Conflicts, 102. 41 For advice to students of medicine to this effect, and examples of such relationships, see D. Harley, ‘The Good Physician and the Godly Doctor: The Exemplary Life of John Tylston of Chester (1663–99)’, The Seventeenth Century, 1994, 9, 99–101. 42 See Rosner, Medical Education in the Age of Improvement; S. C. Lawrence, ‘Educating the Senses: Students, Teachers and Medical Rhetoric in 18th-century London’, in W. F. Bynum and R. Porter, eds, Medicine and the Five Senses (Cambridge: Cambridge University Press, 1993), 154–78; Loudon, Medical Care and the General Practitioner, ch. 2; J. Lane, ‘The Role of Apprenticeship in 18th-century Medical Education in England’, in Bynum and Porter, eds, William Hunter, 57–104. Lane too easily discounts apprenticeship in the case of physicians, as does Clark, historian of the London College of Physicians: Pelling, The Common Lot, 237–8. 43 Loudon, Medical Care and the General Practitioner, 48. 44 See M. Pelling, ‘Apprenticeship, Health, and Social Cohesion in Early Modern London’, History Workshop Journal, 1994, 37, 33–56. On the later ‘clubbing out’ of apprentices, see Snell, ‘The Apprenticeship System’. 45 Loudon, Medical Care and the General Practitioner, 29–39. 46 I. Loudon, ‘Medical Practitioners 1750–1850 and the Period of Medical Reform in Britain’, in A. Wear, ed., Medicine in Society: Historical Essays (Cambridge: Cambridge University Press, repr. 1994), 219–47. 47 Loudon, Medical Care and the General Practitioner, 152–88, esp. 158–60. 48 Holloway’s remains the most thorough account of the various attempts at medical reform legislation at this period: S. W. F. Holloway, ’The Apothecaries’ Act, 1815: A Reinterpretation. Part I: The Origins of the Act’, Medical History, 1966, 10, 107–29, ‘Part II: The Consequences of the Act’, Medical History, 1966, 10, 221–36, esp. 127–8, 227, 221. For references to apprenticeship in earlier bills, see pp. 111, 113, 116, 120, 121, 123, 125. 49 See T. K. Derry, ‘The Repeal of the Apprenticeship Clauses of the Statute of Apprentices’, Economic History Review, 1931, 3, 67–87; I. J. Prothero, Artisans and Politics in Early Nineteenth-Century London: John Gast and his Times (Folkestone: Dawson, 1979), ch. 3. 50 D. van Zwanenberg, ‘The Training and Careers of those Apprenticed to Apothecaries in Suffolk 1815–1858’, Medical History, 1983, 27, 139–50. 51 Loudon, Medical Care and the General Practitioner, 176–80; Holloway, ‘Pt II: The Consequences of the Act’, 224–8. The excellent study of the Act by M. J. D. Roberts, ‘The Politics of Professionalization: MPs, Medical Men, and the 1858 Medical Act’, Medical History, 2009, 53, 37–56, brings out the shifts between corporate protectionism (abused by opponents as ‘guild-based’) and laissez faire, but does not deal with apprenticeship. 52 Loudon, Medical Care and the General Practitioner, 180; British Medical Journal, 1885, i, 1112, 1299; 1885, ii, 654–6. See also M. J. Peterson, The Medical Profession in Mid-Victorian London (Berkeley: University of California Press, 1978), 165. 53 M. Pelling, ‘Unofficial and Unorthodox Medicine’, in I. Loudon, ed., Western Medicine: An Illustrated History (Oxford: Oxford University Press, 1997), 270; C. Lawrence, ‘Still Incommunicable: Clinical Holists and Medical Knowledge in Interwar Britain’, in Lawrence and G. Weisz, eds, Greater than the Parts: Holism in Biomedicine 1920–1950 (New York: Oxford University Press, 1998), 98, 104–5. 54 Smith, Wealth of Nations, I, 110–11; P. Griffiths, Youth and Authority: Formative Experiences in England 1560–1640 (Oxford: Oxford University Press, 1996), esp. 222–34; Pelling, ‘Apprenticeship, Health and Social Cohesion’, 42–4; Loudon, Medical Care and the General Practitioner, 45–8. 55 A prime example is (Sir) Henry Acland, who was later highly influential in medical education: see J. B. Atlay, Sir Henry Wentworth Acland, Bart … A Memoir (London: Smith, Elder, 1903). In general see K. Waddington, ‘Mayhem and Medical Students: Image, Conduct, and Control in the Victorian and Edwardian Teaching Hospital’, Social History of Medicine, 2002, 15, 45–64; F. Palluault, ‘Medical Students in England and France, 1815–1858: A Comparative Study’ (D. Phil, University of Oxford, 2004). 56 ‘The Introductory Addresses’, British Medical Journal, 1885, ii, 656. Dickens’s novel Pickwick Papers was first issued in 1836–7, when Dickens himself was aged 25, and included as characters two medical students, Bob Sawyer and Benjamin Allen. On the production of the stereotype, see Waddington, ‘Mayhem and Medical Students’, 46–53. 57 'The Introductory Addresses’, British Medical Journal, 1885, ii, 656; letter to editor by N. E. Davies, LRCP of Sherborne, ibid., 1885, ii, 124–5. Davies had had part of his medical education at St Bartholomew’s Hospital, London, for which see Waddington, 'Mayhem and Medical Students’. 58 See for example A. Digby, Making a Medical Living: Doctors and Patients in the English Market for Medicine, 1720–1911 (Cambridge: Cambridge University Press, 1994); Loudon, ‘Medical Practitioners 1750–1850’, esp. 229, 241ff. 59 M. Wiesner, ‘Wandervogels and Women: Journeymen’s Concepts of Masculinity in Early Modern Germany’, Journal of Social History, 1991, 24, 767–82; J. Rule, ‘Employment and Authority: Masters and Men in Eighteenth-century Manufacturing’, in P. Griffiths, A. Fox and S. Hindle, eds, The Experience of Authority in Early Modern England (Houndmills: Palgrave Macmillan, 1996), 286–317. 60 See, e.g., the London surgeon-apothecary William Chamberlaine (1813), quoted in Loudon, Medical Care and the General Practitioner, 48. On eighteenth-century notions of servitude and mastership, see Rule, ‘Employment and Authority’. For later shifts in terminology see Snell, ‘The Apprenticeship System’, 319–20. 61 Pelling, ‘Apprenticeship, Health and Social Cohesion’, 120ff; Loudon, Medical Care and the General Practitioner, 46–7. 62 ‘Medical Education and Apprenticeship’ [Editorial], British Medical Journal, 1885, i, 1299. 63 Loudon, Medical Care and the General Practitioner, 50–1. Cf. Peterson’s pioneering study of metropolitan practitioners, The Medical Profession in Mid-Victorian London, 163, which stresses that this was for the select few. 64 On the persistence into the present century of the ‘psychological’ model of one-to-one transmission (and the need to replace it), see A. Bleakley, ‘Pre-registration House Officers and Ward-based Learning: A “new apprenticeship” Model’, Medical Education, 2002, 36, 9–15. 65 Hammerstein, ‘The Modern World, Sciences, Medicine’, 155ff and authors there discussed. 66 P. Slee, ‘The Oxford Idea of a Liberal Education 1800–1860: The Invention of Tradition and the Manufacture of Practice’, History of Universities, 1988, 7, 61–87. 67 Osler, Aequanimitas, 26, 33; Osler, The Student Life and other Essays (London: Constable, 1928), 6–7, 14. It seems probable that these widely shared ideals contributed to the resistance against women entering medical education, the Greek ideal being one in which women had no part whatever. On the (slow) decay of apprenticeship in America, in which ‘masters’ had become ‘preceptors’, see G. W. Corner, ‘Apprenticed to Aesculapius: The American Medical Student, 1765–1965’, Proceedings of the American Philosophical Society, 1965, 109, 249–58. 68 Osler, The Student Life, 7, 24–5. 69 K. Hodgkin, ‘Thomas Whythorne and the Problems of Mastery’, History Workshop Journal, 1990, 29, 20–41; Pelling, Medical Conflicts; A. Bray, ‘Homosexuality and the Signs of Male Friendship in Elizabethan England’, History Workshop Journal, 1990, 29, 1–19. 70 On the shift from patronage relationships to those of ‘friendship’, and ‘informal middle-class apprenticeship’, see L. Davidoff and C. Hall, Family Fortunes: Men and Women of the English Middle Class, 1780–1850 (Chicago: Chicago University Press, 1987), 199, 216. 222–5. 71 See for example G. H. Brieger, ‘Classics and Character: Medicine and Gentility’, Bulletin of the History of Medicine, 1991, 65, 88–109. 72 For a recent version of the standard account of medicine’s achievement of authority through science, see M. Brown, Performing Medicine: Medical Culture and Identity in Provincial England, c. 1760–1850 (Manchester: Manchester University Press, 2011). 73 W. Osler, Aphorisms from his Bedside Teachings and Writings (New York: H. Schumann, 1950, repr. Springfield, IL: Charles C. Thomas, 1961), 48–9; Osler, The Student Life, 7, 10ff. 74 Smith, Wealth of Nations, I, 111. Seemingly Smith was wrong about this, but given the nature of the surviving evidence, he can hardly be blamed: W. L. Westmann, ‘Apprenticeship Contracts and the Apprentice System in Roman Egypt’, Classical Philology, 1914, 9, 295–315, esp. 305, 315; A. Burford, Craftsmen in Greek and Roman Society (London: Thames and Hudson, 1972), 87–91. Acknowledgements The first version of this paper was given at a ‘Skills and Training’ workshop at King’s College, Cambridge, in 1994. Subsequent versions were presented at the universities of Sheffield, Glasgow, Leeds, Cambridge, Saskatchewan and Exeter. I thank all these audiences for their comments and suggestions, as also Catherine Kelly and those attending the workshop on ‘Physicians, persuasion and politics’ in Southampton in 2015. I am particularly grateful to my collaborators on the Early Modern Medical Practitioners project based at Exeter, and especially to Erica Charters, John Stewart and Patrick Wallis for their helpful comments on a late draft. My thanks are also due to three reviewers for this journal. I should like to dedicate the paper to a very good friend and colleague, John Pickstone, who before his premature death was urging us all not to ignore ‘the big picture’. © The Author 2017. Published by Oxford University Press on behalf of the Society for the Social History of Medicine.
Social History of Medicine – Oxford University Press
Published: Aug 25, 2017
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