Performing Medicine, an exploration of the transformation of the cultures, values and meanings of medicine across the late 18th and early 19th centuries, constitutes a new and welcome contribution to the historiography of medical life and the creation of a modern medical profession. Through a case study of the social and intellectual activities of medical practitioners in the city of York, the book presents a much broader set of arguments around the crucial shifts in the culture of medicine between the 1760s and the 1850s. York, as Brown points out, has particular advantages for a study of this sort: it formed a geographical midway point between two key medical metropolises – London and Edinburgh; it did not experience the transformations associated with the processes of industrialization; yet it was shaped by many of the specific characteristics of the period such as political factionalism, the urban renaissance movement and ideologies of socio-scientific progressivism. A rich archive of minute books, letters, memoirs and newspapers produces a wealth of material covering medical lives and their individual and collective encounters with fellow citizens and medical practitioners across social and political spheres.
The book opens with a brief survey of York’s political, economic and social landscape in the late 18th century which establishes the values attributed to gentility, polite sociability and civic belonging. York’s medical ‘faculty’ was relatively small at the time, consisting of around 20 physicians, surgeons and apothecaries and this heightened the value of interpersonal relationships. (Bristol for example had 230 practitioners at the same period). A vignette of the Doctors Club demonstrates the tight connections between medical culture and identity and the broader values of politeness, gentility and sociability. The Club’s male-only members met weekly from 1781 until the turn of the century and activities were focused on dining, drinking and socializing. Only a small proportion of members were medical practitioners; the majority were local merchants who were amongst the elite of York society. The Club’s rules promoted geniality: ‘no party disputes are to be suffered in the Club in regard to any election of members to represent this City in Parliament’ (p. 26). On marriage, Club members were bound to treat their fellows to supper and punch. After dinner activities included betting and again the rules determined that winnings should be spent in the Club. Notably, Brown’s analysis of the minute book shows that bets pivoted on claims and assertions of knowledge; one example was the speed at which members could find the word ‘mahogany’ in a shilling dictionary. This supports the argument that such fora were crucial spaces in which medical practitioners could cultivate personae as polite and sociable civic gentlemen. Chapter one ends with a discussion of apothecary Oswald Allen’s trajectory from 13-year-old apprentice in 1781 to his establishment in the medical, cultural and social spheres of York. Despite Allen’s inauspicious beginnings and the negative trade associations surrounding the dispensing of medicine, he succeeded in developing networks of patronage which won him the appointment of Apothecary to the York Dispensary and facilitated his marriage to the sister of one of York’s most noted physicians.
The book then explores the ways through which medical practitioners fashioned their identities through public displays of knowledges such as botany, natural history, poetry and literature. Quaker and physician William White submitted papers to the Royal Society in 1778 and 1781 which were published in the Philosophical Transactions. The first gave an account of experiments White had undertaken using a eudiometer to measure the quantity of phlogiston in the atmosphere of the city and its rivers and marshes. Hippocrates had drawn attention to the dangers posed to health by ‘bad’ air from natural environments many centuries earlier but the new gas chemistry of the 1770s had intensified interest in air quality and it was topic of much social and medical interest. His second paper mapped the numbers of births and deaths in York between 1770 and 1776 according to the season and compared them to similar figures compiled between 1728 and 1753. Improvements in the health of the population, he suggested, were principally due to the civic improvements in York such as paving and new drains as well as inoculation and other medical advances. Brown suggests that White’s coupling of his experimental work with some of the prime issues in York polite society and prominent questions in science and medicine helped formulate a social identity which allowed him entrée into civic circles. As a Quaker, White would not have participated in many of the Anglican-dominated civic activities. Importantly for Brown’s thesis, White’s story illuminates the pluralist nature of medical knowledge of the time.
The scandal resulting from public challenges to the conditions and treatments for patients within the York Lunatic Asylum between 1813 and 1815 is the focus for chapter three. The reformers demanded ‘public’ scrutiny of the ‘private’ space of the institution which they claimed was self-regulated by corrupt medical practitioners and local elites. Through the York press which was becoming more radical and politically polarized, they called for new regulations which would permit visitors to monitor the condition of the patients and regulate the conduct of the staff. Brown shows that previous challenges to medical authority over asylums had failed in the 1780s and argues that the success of the 1813–15 campaign illustrated how significantly moral, political and cultural forces had swung towards a reformist agenda. For medical practitioners, these public and visible controversies in the context of wider social and political agitations across York critically undermined medical identities grown from old values of civic gentility and polite association.
The final chapters explore the ways in which a new culture of medicine, hinged on the values of expertise and public service took shape over successive decades. The 1820s in York were a time of profound change with the demise of polite society and political factionalism. Medical practice became increasingly competitive as a consequence of the numbers of practitioners increasing at a time when numbers of private patients were decreasing due to many of York’s wealthy families leaving the city. The formation of the Associated Body of Surgeons and Apothecaries in 1818 was a response to local pressures but also epitomised the shift from medical practitioners’ participation in civil social groups to more vocationally specific associations. The new visions of medical practitioners as experts and public servants devoted to the health and welfare of a new social order are revealed through the intense debates on the practice of body-snatching and the social functions of anatomy. The gradual disaggregation of medical knowledge from other physical sciences is exemplified in the early history of the British Association for the Advancement of Science (BAAS). York was the location for the inaugural meeting of the BAAS in 1831 and numbers of medical practitioners were exceeded only by clergymen. But the relations between medical knowledge and ‘universal science’ were disputed: in 1833 anatomy and physiology were separated from sciences such as zoology and botany; by 1844 medicine was no longer included in the BAAS.
The cholera epidemic of 1832 devastated many localities, and medical practitioners differed vehemently on its causes and treatments. Nevertheless it was a defining moment in the history of professionalisation as it was the first time that medical practitioners held official roles on the state-organised and legally-constituted Boards of Health. At the same time in various centres, including York, medical practitioners established medical societies and in many cases this seems to have been prompted by the desire to create a collective forum in which medical views and opinions about cholera could be debated. Brown draws on the story of Thomas Laycock, son of a Wesleyan minister, who after training in London and Paris was elected apothecary to the York County Hospital in February 1836. Laycock may not have been representative of the rank and file but his visions of ‘political medicine’, a distinct branch and science of medicine with specialist literature and practitioners whose work had the authority of the state, illustrated the remarkable speed at which public health as a medical domain had taken root in society.
The creation of the York Medical Society (1832) and the York Medical School (1834) were followed in 1842 by the establishment of the York District Branch of the Provincial Medical and Surgical Association, founded by Sir Charles Hastings in 1832 and known from 1856 as the British Medical Association. These successive enactments of medical identity and authority set the stage for a new compact between medicine and society in which medical practitioners were nationally cast as experts in medical science with a collective desire and duty to alleviate disease and suffering. The transformations undergone in the culture, values and meanings of medicine since 1760 are underlined by the public’s acceptance of the Medical School’s authority, under the provisions of the Anatomy Act, to dissect the body of a local man who had drowned in the river Ouse in 1835. Only three years earlier, as Brown points out, popular resistance to such activities during the cholera epidemic was high indeed. The epilogue makes a sound case for the relevance of this history to the present dilemmas and controversies over professionalism and medicine and rightly stresses the social and political contingency of medical ideas and values.
Brown takes a cultural historical approach to his enquiries focusing on the transformations around medical culture, identity and performance. He crafts his analysis by grouping together the varied social and intellectual practices of medical practitioners into two categories: knowledge and association. This strategy, he argues, reveals the ways in which medical identity and culture were transformed over the period from the late 18th–century importance of liberal learning and the values of gentility and politeness to the early 19th–century focus on vocationally specific forms of knowledge and association. Throughout, his arguments are well-supported and convincing and each chapter contributes clearly to the wider thesis. Brown succeeds entirely in what he sets out to do and it is particularly welcome that he chooses the provincial setting of York, as this offers a nice corollary to the London-heavy literature around professionalisation.
It may be unfair then to criticize such a well-executed work but I was left wishing that Brown had created a more expansive framework through which to interrogate the transformations in medicine and had included explorations of the practical elements of performance. How were changes in culture and identity enacted in medical practitioners’ encounters with patients in private homes and public medical institutions? Did the disaggregation of medical knowledge from other knowledges impact on routine practices such as correspondence between practitioners and the writing of patient case notes? And how did changes in medical practice and therapeutics over the period link to shifts in the cultural and intellectual aspects of performance? Performing Medicine is a work of sophisticated research which presents a convincing account of the irrevocable changes to the cultures, values and meanings of medicine which occurred between 1760 and 1850. It also leaves vital questions about the relations between these elements and the practice of medicine open for further enquiries.