Sally Wilde

The Elephants in the Doctor-Patient Relationship: Patients' Clinical Interactions and the Changing Surgical Landscape of the 1890s

The phrase 'doctor-patient relationship' obscures the profound differences between clinical interactions in hospital and in private practice. In the 1890s in private practice (whether in Britain, Australia or New Zealand) patients typically encountered doctors in their own homes, while accompanied by friends or relations. In hospital, solitary patients faced a multiplicity of nurses and doctors. At this time, surgery was already moving from homes to hospitals, thereby shifting the clinical encounter from the patient's to the doctor's territory, and the balance of power from the patient to the doctor. The fiction of one doctor interacting with one patient, ignoring the financial and administrative arrangements under which they met, served the interests of inter-doctor etiquette over 'ownership' of patients, and the emerging system of specialist referrals.

When something is very large, but for one reason or another people try to behave as if it is not there, it is customary to draw attention to it by referring to the elephant in the room. The objective of this paper is to draw attention to the multiple elephants in the doctor-patient relationship. There are two major reasons for problematising the phrase 'doctor-patient relationship' in this way. First, focus on the dyad of a single doctor and a single patient is deeply misleading, because it erases from the picture the many other people involved in the process of seeking and providing medical advice. Secondly, using these words obscures, and therefore supports, the false assumption that the content of the clinical encounter is constant, whatever the surrounding institutional and financial circumstances.

There is now a large body of literature that examines the history of the doctor-patient relationship. Work in the 1960s and 1970s tended to focus on changes in the sites for the generation of new medical knowledge, famously encapsulated in Erwin Ackerknecht's tri-partite progression from eighteenth-century bedside medicine to early–nineteenth-century hospital medicine and late–nineteenth-century laboratory medicine.¹ This approach was associated with a great deal of discussion of changes in what doctors believed and how they behaved, and an emphasis on their shifting sources of information and ways of viewing the patient.² During the nineteenth century, doctors began to examine patients using instruments such as stethoscopes and thermometers, and it has been argued that the role of patients became increasingly passive, as the results of instrumental examinations were privileged over patients' narratives.³ In a landmark article, N.D. Jewson argued that the transition from bedside medicine to hospital medicine was accompanied by a novel subordination of the patient to the doctor and further that, 'whereas under Hospital Medicine the direction of the power differential between the sick and medical personnel had been reversed, under Laboratory Medicine the patient was removed from the medical investigator's field of saliency altogether.'⁴ But more recent emphasis on the nature of medical practice, rather than on the ways in which new medical knowledge was produced, has substantially modi.ed this picture. In the 1980s, the work of Roy Porter and others moved the focus away from the doctor's perspective, and towards interest in the patient half of the dyad.⁵ There has also been significant work on the range of options available to patients in the medical marketplace, including alternative medical practitioners of many kinds.⁶ The work of Regina Morantz-Sanchez, Nancy Tomes and Judith Leavitt, among others, has extended a further challenge to the idea of passive and disempowered patients in the nineteenth century, by highlighting the patterns of negotiation and bargaining between doctors and patients in America.⁷ Nancy Theriot's work has broadened the focus to the relationships between doctors, patients and their families.⁸ She argues that female patients in particular cooperated with doctors in the late–nineteenth century, using them as allies in a bid for increased autonomy in relation to their families. Theriot's discussion of 'doctor-patient-family' interactions has broken through some of the limitations of an emphasis on the doctor-patient relationship by highlighting the importance of family and friends in nineteenth-century clinical encounters, but this approach still ignores the significance of the surrounding financial and institutional arrangements.

Figure 1: Punch's view of one patient's reaction to the new methods of diagnosis. (Illustration reproduced by permission of the Wellcome Trust.)

The examples of clinical encounters in the 1890s in Britain, Australia and New Zealand, are used here to highlight some of the limitations of the phrase 'doctor-patient relationship' for conceptualising what went on when people sought the advice of medical practitioners. In what follows, particular emphasis has been placed on the circumstances surrounding surgery. This is because the hospitalisation of surgery—that is to say, the shift from operating in private homes to operating in purpose-built institutional spaces—was an important feature of medicine in the 1890s.⁹ The associated changes in the nature of clinical interactions demonstrate especially clearly the limitations of the concept of a 'doctor-patient relationship.' Whilst the rhetoric of surgery was about the achievements of skilled individuals, the reality was about work performed by teams.

This is an historical essay, but there are pronounced resonances in what follows for the heterogeneity of the current 'doctor-patient relationship,' and the use of the phrase in current practice may well be just as misleading as its use by historians.

Clinical encounters in the 1890s (as in all times and places) did not just involve doctors and patients.¹⁰ Patients might search for medical help alone, or in various combinations of husbands and wives, parents and children, and friends and relations. In their travels across the medical landscape in search of advice, they might encounter multiple doctors, alternative health care practitioners, nurses, hospital administrators and friendly society officials, not to mention well-meaning friends with just the right remedy for their condition. However, despite the variety and complexity of these encounters, each of the financial arrangements under which patients received medical advice was associated with a distinct pattern of interaction. Financial arrangements in medicine mattered, as the following quote demonstrates:

Mrs. P ... is a patient of mine ... she had a uterine polypus and unbeknown to me she was admitted into your hospital and operated upon. Now, I consider this most unfair treatment, as the above is in good circumstances and was quite willing to pay the fee which I told her I should charge for the operation.¹¹

This is an extract from a letter in the complaints files of the Middlesex Hospital, written in 1900 by a Suffolk doctor.¹² Mrs. P's case highlights a number of features of patients' clinical encounters in the 1890s, and the complex ways in which patients made their choices among the various health care options that were then available. Mrs. P's husband also wrote to the Middlesex Hospital about her case, and his letter allows a glimpse of 'doctor-patient relationships' in the 1890s from the viewpoint of someone who was neither the doctor nor the patient. The Suffolk doctor, noted Mr. P, examined his wife and proposed an operation

which he was extremely anxious to perform at once. Having no confidence in him for such a matter I considered it desirable to consult the doctor who had attended my wife in another town for some years and in whom we had implicit confidence. He advised me to obtain her admission to a London Hospital. To this I readily consented for two reasons, first my cottage is unsuitable for the performance of any intricate operation, secondly I desired that my wife should be in the hands of Gentlemen with the utmost experience of similar cases and not in those of a man in whom I had not a particle of confidence and who possibly had not attended a like case before.¹³

Mrs. P's husband appears to have made decisions on her behalf: 'I considered it desirable ...'; 'I readily consented ...'; 'I had not a particle of confidence ....' Mr. P may, of course, have consulted his wife and certainly implies a joint view ('we had implicit confidence'), at least once. But the overall impression is that Mr. P was more involved in making decisions about his wife's treatment than she was. Clearly, Mrs. P and her doctor were not the only people involved in this case. Mr. and Mrs. P consulted the Suffolk doctor and at least one other practitioner privately, in addition to those they saw at the Middlesex Hospital, so that in this series of medical interactions there was a patient, her husband and a multiplicity of doctors. Further, none of the doctors dominated the patient. Mr, and perhaps also Mrs, P were making choices, not only about doctor, but also about diagnosis and treatment and the place where that treatment should take place.

As Irvine Loudon, Anne Digby, Christopher Crenner and others have highlighted, in both Britain and America many patients continued to exercise considerable autonomy until well into the early–twentieth century.¹⁴ In private practice, as Mrs. P's case illustrates, patients and their friends had the freedom to choose their doctor and their treatment. Indeed, M. Jeanne Peterson has argued that nineteenth-century doctors were victims of 'medical powerlessness. At every turn men in medical practice found themselves ruled by their patients, by the governors of hospitals, by the workingmen who ran medical clubs ...'¹⁵ This is an extreme view, but without going that far, it is clear that the Suffolk doctor did not enjoy anything even remotely resembling the 'medical dominance' attributed to doctors two or three generations later by scholars such as David Rothman, Eliot Freidson and Evan Willis.¹⁶ Despite this doctor's wish to perform surgery at once, Mr. P had 'no confidence in him for such a matter' and took his wife elsewhere.

So how common was it for patients and their 'friends' to make conscious choices of this kind as they sought diagnosis and treatment for the causes of their pain?¹⁷ Was it always possible for patients to find 'gentlemen' in whom they had 'confidence'? Or did some patients have more choices than others? In what follows, published case reports have been examined in a search for answers to these questions.¹⁸ There are striking similarities in the style of case reports between Britain, Australia and New Zealand, at least partly because a very large proportion of Australasian doctors in this era had trained in Britain.¹⁹ Published case reports were not representative of practice as a whole.²⁰ They were selected, firstly by the doctors concerned, and secondly by the journal editors, as reports of cases they considered interesting in some way. Almost by definition they omit the mundane 'bronchitis in winter and diarrhoea in summer' of general practice.²¹ Published case reports were essentially advertising by doctors to an audience of their peers, and the general tone is of slightly self-deprecating boasting In this era doctors did not just publish their successes, and deaths were often recorded in case reports, possibly because this was an opportunity to publicly explain (make excuses for?) any failures. Despite these limitations, 1890s published case reports are a valuable source of information This is particularly so for private practice, for which very few unpublished case note series have survived. These reports demonstrate that clinical interactions varied enormously according to the circumstances of the various parties, and that they often involved multiple people, not all of whom were either doctors or patients. There were, however, distinct patterns to clinical interactions, and each pattern was associated with a particular kind of financial basis for the consultation between patients and their 'medical advisers.' Members of friendly society clubs, recipients of Poor Law services and users of charitable dispensaries, for example, each had distinctive ways of interacting with those who provided them with medical advice. From the patient's perspective, the overall experience of a clinical encounter under any of these arrangements was influenced quite as much by issues such as poverty, ideas about their rights, and the problems of negotiating access to means tested services, as by the content of their interaction with a doctor, if and when they eventually got to see one. Two of the most common frameworks within which patients encountered doctors will be examined in some detail in what follows, to demonstrate just how misleading the phrase 'doctor-patient relationship' can be.

Clinical encounters in private practice

In the 1890s, the private practice of most doctors involved a mix of house calls—where they visited their patients—and consultations in their surgeries—where the patients visited them. Published case notes from the early 1890s describe many instances where the 'private' consultation did not involve a solitary doctor and a solitary patient, especially where the encounter took place in the patient's home. Indeed, the idea of a doctor interacting with a group rather than an individual is implicit in the idealised concept of the family doctor, which was already well established by the 1890s.²² Jukes De Styrap, in his 1890 guide book for young doctors setting up in practice, takes it for granted that the usual relationship was between a doctor and a family, rather than between a doctor and a patient as an uncontextualised individual. 'Many a young practitioner,' he wrote, 'secures a good family permanently by simple kindness and assiduous attention in cases of accident, convulsions, colic and the like...'²³

Figure 2: Punch's view of a doctor-family interaction: Doctor: "Well, you got those leeches I sent for your husband, Mrs. Giles!" Mrs. Giles: "Yes, Zur; but what on earth be the good o' sending they little things vur a girt big chap like he! I jes' took an' clapped a ferret on 'un!" (Illustration reproduced by permission of the Wellcome Trust.)

As might be expected, children seldom saw a doctor without the presence of a parent or some other responsible adult, and several people might be present during a medical consultation.²⁴ For instance, in reporting a case of acute intussusception in an infant, Dr. Newmarch of Sydney noted the following: 'Operation was advised, and whilst the parents were hesitating, an old lady who happened to be present remarked that she had seen Dr. Fiaschi invert a patient suffering from a similar complaint with success.' Dr. Newmarch duly shook the child by its feet, which seemed to rectify the problem.²⁵ In this instance, someone who was not the doctor, the patient or a parent suggested the successful treatment. But it is not just children who did not always have a one-to-one relationship with their medical advisers. There were also cases of adults where, for various reasons, someone else spoke and acted on their behalf.²⁶ In the case of a 'poor old maid, living alone in a little house in the neighbourhood of Dunedin,' for instance, the local clergyman's wife and the neighbours were involved, as well as at least two doctors.²⁷ Quite commonly, husbands were involved in decisions about the medical care of their wives and it appears that fathers were sometimes involved in consultations over the health of what we would now consider to be adult daughters.²⁸ With older people, sons and daughters sometimes became involved in consultations over the health of their parents. In the case of a seventy-three-year-old farmer's widow in Lancashire, for instance, a servant, a son, a doctor and a daughter all appear to have been involved in discussions about her hernia.²⁹ It should also be appreciated that treatment very often began before any doctor appeared on the scene. The following example of a case of snakebite in outback New South Wales in the summer of 1892 gives a hint of some of the complexities that might be involved in the interactions affecting the treatment of a patient:

Mr. and Mrs. [Robert] Simson and master John Simson, aged 15 years, son of Mr. Colin Simson of Carmyle, Toorak, were sitting on the lawn at the homestead when the lad was bitten by a young deaf-adder on the forefinger of the right hand. A ligature was promptly placed round the finger, and Mr. Robert Simson injected some drops of the strychnine antidote prepared by Dr. Mueller, of Yackandandah. A messenger was immediately sent to Quirindi for a doctor, and pending his arrival, which did not take place until 9 o'clock next morning, Mr. Simson and one of the station hands kept the patient awake by walking him briskly about the house.³⁰

Was John Simson's primary medical relationship with his uncle, who administered the strychnine, with Dr. Mueller, who devised the treatment that was marketed by L. Bruck of Castlereagh Street, Sydney, or with the local doctor who arrived the morning after Simson was bitten? Or is it more useful to understand this as one of many medical episodes involving interactions between the patient and a range of people?

The involvement of parties other than just the doctor and the patient often becomes evident when the question of consent for surgery is mentioned: 'On being called to see her, I found her pale and anxious-looking,' wrote one doctor. 'The patient and her friends readily consenting, abdominal section was performed without delay.'³¹ The outcome was a happy one in this case, but the doctor concerned reports a less favourable outcome in another case in the same article. 'I urged operation without delay as the only chance of saving her, but the friends would not consent till the patient became moribund.'³² 'Friends' might be involved in decisions over consent for surgery involving men as well as women:

Mr. Pat H ... had the misfortune of having his ankle terribly smashed by a tree falling on it ... two doctors—men of very high attainments—advised amputation; but as the patient and his friends objected to this, and said that he might as well be dead as to lose his leg, they asked me to try and save it for him.³³

It should also be noted that the strictly commercial side of the clinical consultation—who paid the bill—was by no means always a matter of a one-to-one relationship, with the patient paying the doctor. Parents, husbands and employers, for instance, all regularly paid doctor's bills on behalf of someone else, and sometimes they refused to pay, which might bring the matter to the attention of the medical journals. ³⁴ In July 1890, for instance, the Lancet reported from Birmingham:

a successful action by Mr. Hallwright to recover from a gentleman £5 5s., chiefly for obstetric attendance on Mrs.—, which he had agreed to pay. Though neither the husband of the woman nor the father of the child, he had relations with her, and had clearly authorised her engaging Mr. Hallwright, and promised to pay him, undertakings he afterwards, on quarrelling with her, sought to escape from.³⁵

Clinical encounters in hospital practice

The experience of patients in the hospital environment contrasted strongly to the clinical encounter in private practice. However, it still seldom involved a one-to-one relationship between the patient and the doctor who was notionally responsible for their case. In crowded outpatient clinics, patients might see one or more members of the medical hierarchy. These hierarchies varied by hospital and by specialty. The pattern in Australia and New Zealand, especially in the larger hospitals, was modelled on that of the major charitable hospitals in London, such as St Bartholomew's and the Middlesex. At the Melbourne Hospital, for instance, the hierarchy included surgical and medical clinical assistants, resident medical officers (RMOs), registrars, a medical superintendent, and honorary physicians and surgeons to outpatients and to inpatients. In smaller hospitals, the medical hierarchy was less complex. In the Brisbane Hospital in 1900, for instance, it consisted of resident medical officers, a medical superintendent, honorary medical officers to the outpatient department, and honorary visiting surgeons and physicians.³⁶

Whatever the details of the medical hierarchy, except in remote areas anyone going to an outpatient clinic in this era would typically be seen initially by a junior doctor and then passed up the hierarchy, depending on the complexity or interest of the case. Notionally, patients were under the care of the most senior member of the hierarchy, yet they might quite possibly never see this august individual. Alexander Francis gives us a glimpse of this world at St Bartholomew's Hospital in London, where he was appointed to a junior position in 1886. He describes how not only the patients but also the junior doctors seldom saw the senior honorary surgeon in charge of their cases, and the effective senior doctor on duty for most purposes was the House Surgeon, although even him 'we did not like to disturb ... more often than necessary.'³⁷ At the Brisbane Hospital, it was the duty of the Medical Superintendent to: 'inform the member of the Visiting Staff, whose case it is, if it require attendance, and in the event of that officer being unable to attend he shall himself operate ...'³⁸ Here, too, it seems, a member of the Visiting Staff might not actually have seen 'their' patient before an operation was performed.

Figure 3: The Hospital for Sick Children, Brisbane, c. 1899. (Photograph reproduced by permission of the State Library of Queensland, John Oxley neg. 22159.)

Those patients who were admitted to the wards would have had multiple clinical encounters with nurses every day, but they would usually have seen doctors less often. The standard pattern was for the RMOs to visit the ward at least once a day, but the honorary surgeon or physician in charge of the case might only put in an appearance once or twice a week. In teaching hospitals, the appearance of the honorary on the ward was famously a group affair, the great man (never a woman in this era, except in dedicated women's hospitals) accompanied by all the more junior members of his team, plus a varying number of medical students, nurses and possibly also student nurses. Questions were asked and answered at the foot of each bed and the case discussed by members of what could be quite a large group. Even at the Brisbane Hospital in 1900, which was not to become a teaching hospital for doctors until the 1930s, RMOs accompanied 'the Visiting Staff in their going round the wards, bringing under their notice any important particulars concerning the cases under their charge, and reporting to them anything that has been ordered as urgent.'³⁹

Patients who were treated in private hospitals had a rather different experience. Besides better food, more comfortable rooms and greater privacy, they would have had a direct relationship with the doctor that they (or their husband or father or employer) were paying for medical advice and treatment. But their care would still have been provided by teams rather than by a single individual, and this is illustrated especially clearly by the experience of patients who went to hospital for surgical treatment.

The hospitalisation of surgery

Although she was not poor, Mrs. P went to hospital. We would almost certainly be right in assuming that if her case had been categorised as 'medical' rather than 'surgical,' she would have been treated at home. As Charles Rosenberg has noted, the late–nineteenth and early–twentieth centuries saw a revolutionary change in hospitals, which involved both the hospitalisation of surgery and the surgicalisation of hospitals.⁴⁰ The pressures for the hospitalisation of surgery are often mentioned in 1890s case reports. For instance: 'it was almost impossible to form a diagnosis in the small room and amid the inconvenient surroundings of the private residence,' and: 'The surroundings being non-hygienic in the extreme, the patient was brought in to the Sydney Hospital in an ambulance.'⁴¹ By 1900, the focus was often on poor light: 'as the hour was late, the light and the surroundings totally un.t for the performance of a serious operation ... we decided to ... defer operative procedures until the following morning,' wrote an Adelaide doctor.⁴² In 1897, Professor Archibald Watson noted in his diary another case with bad light that would have been better treated in hospital.⁴³ The patient had multiple ovarian cysts and the operation took place in her kitchen. Despite putting blocks under the table legs, the patient was still not in the best position to provide the surgeons with good access. The room was small with 'terribly bad light,' so that it was difficult for them to see what they were doing. There was no electricity in the house and they were 'afraid to use a candle on acct. of ether.' In addition, the silk they were using for sutures kept breaking, and it was difficult to stop the patient bleeding. The overall result was a disaster, and the patient died three days later.⁴⁴

By 1900, basic items of equipment such as rooms of an adequate size with adjustable operating tables and good light were regularly available in hospitals, but were not regularly available in private homes. Photographs from the turn of the century begin to show operating theatre staff wearing gowns and caps, and sometimes even gloves and masks, and using enamel bowls in well-lit, white-tiled spaces.⁴⁵ Meanwhile, behind the scenes, steam sterilisers and laundries were also adding to the cost and complexity of the paraphernalia associated with operations, tipping the balance even further in favour of hospitals as sites for providing 'safe' surgery. However, among the greatest advantages of hospitals were the pooled facilities that drew together teams of appropriately skilled people.

Figure 4: Medical students C. Farrow and R. Johnson, Resident T. Millar, surgeon V. Hurley and two unnamed nurses, Grice Operating Theatre, Melbourne Hospital, c. 1924. (Reproduced by permission of the Royal Melbourne Hospital Archives.)

Also by 1900, many kinds of medical therapy involved the work of multiple people, but this was particularly clear in the case of surgery. Doctors found it very difficult to perform surgery unaided. During the 1890s, considerable publicity was given to deaths under anaesthesia, and they were regularly the subject of coroners' inquests in both Britain and Australia.⁴⁶ Even before this publicity, many surgeons drew the conclusion that it was safer if someone else administered the anaesthetic, and by 1900 all major operations involved a doctor and at least one assistant (often named in published case reports). In private practice, there are reports of a wide range of people providing anaesthesia, including family doctors, medical students and nurses, and in country areas doctors sometimes called on the help of vets, chemists and even 'laymen.'⁴⁷ In hospitals, people experienced in the administration of anaesthetics were more readily available. The Middlesex Hospital, for instance, had both a junior and a senior 'chloroformist' by 1890, although this did not prevent deaths under anaesthesia and, following two embarrassing inquests, regulations for the administration of anaesthetics were tightened in 1892.⁴⁸ However, the surgeon and the anaesthetist were just the core of the team. When operations were performed in hospitals, the procedure regularly involved other people, including one or more nurses and, particularly if the operation was difficult or complex, one or more surgical assistants. Importantly, hospitals also provided pre- and postoperative nursing care, and practitioners trained to make provision for whichever mix of antisepsis, asepsis and cleanliness was favoured by the surgeon.⁴⁹

As a result, the trend toward having their operations in hospitals, which began with those in moderate circumstances who lived in 'cottages,' was increasingly followed by people higher up the social scale.

Private practice versus hospital practice

We have, then, two strongly contrasting pictures of encounters between 'medical advisers' and patients. On the patients' ground— in their homes—doctors encountered patients in the company of varying numbers of friends and relations. In the private practice setting, even when the consultation took place in the doctor's surgery, the patient retained a degree of control over the consultation.⁵⁰ In the hospital, in contrast, the patient may have had various friends and relations with them in outpatients, but on the ward, visiting hours were strictly limited and they were far more likely to encounter nurses and doctors on their own, more or less unsupported by friends and family.⁵¹ In this setting, the model might be of a single patient encountering multiple nurses and doctors at varying levels of the medical hierarchy. To conceptualise clinical interactions as 'doctor-patient relationships,' suggesting as it does the involvement of just one doctor and one patient, is to totally miss this complexity and variation. Further, it should be noted that the phrase also erases nurses and other health professionals from the picture.

As Irvine Loudon expressed it, from the doctor's point of view: 'In hospital practice colleague approval tends to be the dominant factor; in general practice patient approval dominates.'⁵² The balance of power was thus more likely to lie with the patient and their friends and relations when the clinical encounter took place on their ground, and with the medical hierarchy when the clinical encounter took place in hospital. As Irvine Loudon and Anne Digby have shown for Britain, private practice in the nineteenth century continued to be dominated by traditional bedside medicine, where care was related to the wishes of the patient and their family, and where the doctor's behaviour was influenced by the desire to attract and keep a family's custom.⁵³ The movement of patients from their homes to hospitals for surgery thus contributed to a significant shift in the balance of power in the clinical encounter. As patients moved from their homes to spaces controlled by medical considerations, so their range of choices was restricted by members of the medical hierarchy. For surgery, this late–nineteenth- and early–twentieth-century shift in location was largely complete by the 1930s. It was followed by the further trend to restrict private consultations to the doctor's territory of the surgery or office, rather than the patient's home. By the 1950s, the waiting room experience virtually always preceded medical interactions, which took place at the convenience of the doctor, not the patient. This approach to the treatment of not only the poor, but patients at all except possibly the highest social levels, in spaces under medical control, was at least as important to the construction of the medical dominance of the postwar era as the famous late–eighteenth-century introduction of 'hospital medicine' or the 'birth of the clinic' in Paris.

So why, given that the variation in the nature of medical interactions was so marked, has the phrase 'doctor-patient relationship' been so widely adopted? The answer is linked to the fact that doctors were concerned to establish that they had a special relationship with their patients in private practice, because their livelihoods were directly related to that relationship. By the early 1890s, the rules for the encounter were well entrenched in a code of what was sometimes called 'medical ethics,' but often 'medical etiquette.'

Medical etiquette, the ownership of patients and reinforcing the illusion of the 'doctor-patient relationship'

This section does not attempt to make any contribution to the growing historiography of the context for nineteenth-century changes in medical ethics.⁵⁴ Rather the intention is to examine brie.y what a range of late–nineteenth-century doctors wrote about their own and their colleagues' behaviour in regard to each other. In the twenty-first century, the phrase 'medical ethics' conjures up images of relationships between patients, clinicians and scientists. Late–nineteenth-century medical journals are almost entirely silent on this subject, although antivivisectionist views, for instance, were expressed in the contemporary press.⁵⁵ However, late–nineteenth-century medical journals did carry regular items concerning relationships between members of what was called 'the faculty.' These interdoctor disputes were sometimes discussed under the heading 'medical ethics,' and sometimes as 'medical etiquette.'

The pages of the medical journals in the early 1890s indicate that there was an accepted code of behaviour covering interdoctor disputes, and in editorial replies to letters there are multiple references to a Code of Medical Ethics or an Ethical Code.⁵⁶ This was Jukes de Styrap's, Code of Medical Ethics, the third edition of which appeared in 1890.⁵⁷ This, in turn, was based on Thomas Percival's Medical Ethics, published in 1803, and sometimes follows the earlier work word for word.⁵⁸ However, there were significant differences between Styrap and Percival. There has been some disagreement as to whether Percival's Medical Ethics broke new ethical ground, or whether his work is better understood as one of medical etiquette. Historians have emphasised the importance of Percival in the context of the development of hospital medicine. He set out ethical guidelines for group consultation between medical practitioners, especially in hospital practice. ⁵⁹ Sociologists, however, have tended to characterise his work as one of medical etiquette, arguing that Percival's codes of behaviour favoured the interests of medical practitioners as an emerging professional group.⁶⁰ But even if this is acknowledged as a 'presentist' interpretation of Percival, it is an attractive explanation for the popularity of Styrap's code. He modi.ed and adapted Percival's code (as had the American Medical Association before him) to provide a far more detailed guide for behaviour in private (as opposed to hospital) practice in the late–nineteenth century.⁶¹ The essence of Styrap's rules of medical etiquette seems to have been to establish and maintain orderly behaviour over competition for patients within a crowded profession.⁶² Young doctors struggled to earn enough to support the status to which they aspired, particularly during the 1890s depression. Doctors were in direct competition with each other for patients in private practice, and when disputes arose, they appealed to what was clearly a widely accepted code of medical ethics. Many references to Styrap's Code can be found in the monthly sections headed 'Medical Ethics' in the Australasian Medical Gazette and in the similar weekly sections of the British Medical Journal. On 4 January 1890, for instance, under the heading 'Medico-legal and Medico-ethical, Fees for attendance on the families of medical men,' the editors of the British Medical Journal published the following:

We transcribe for the information and guidance of our correspondent the following rule from the Code of Medical Ethics, which was submitted to and cordially approved of by some of the most eminent and representative practitioners of the day, including the late Sir Thomas Watson, the Nestor of the profession.⁶³

There followed a direct quote of chapter II, section 2, rule 1, from Styrap's Code of Medical Ethics.⁶⁴ In Australia, there were also direct references to Styrap, and correspondence over 'medical ethics' was heavily influenced by his work.⁶⁵ In June 1893, for instance, a doctor from Dubbo complained that a colleague had 'kept' one of 'his' cases. He wrote as follows to his colleague:

During my unavoidable absence from home last night, Mrs. G., who had me engaged to attend her during her confinement, sent for me, that event commencing during the night. I called at her house this afternoon and find that you had been desired to assist her during my absence. Of course I quite understand their anxiety; but according to my ideas of the rules of professional etiquette, I now expect you to allow me to continue the attendance, I paying you the agreed fee of £3 3s...⁶⁶

This case makes sense if the aggrieved doctor is understood to expect his rival to abide by chapter II, section 5, rule 12 of Styrap:

When a practitioner is called in or otherwise requested, to attend at an accouchement for another, and completes the delivery ... he is entitled by custom ... to one half of the fee; but on the completion of the delivery, or on the arrival of the pre-engaged accoucheur, he should resign the further management of the case.⁶⁷

Dr. Styrap devoted many pages of his Code of Medical Ethics to the problems arising from interactions with the 'patient of another practitioner,' and over consultations with other practitioners, and much of the correspondence in the pages of the medical journals was devoted to complaints about practitioners who broke these generally accepted (but nonbinding) rules.⁶⁸ Conflicts between doctors over patients were clearly a very real problem for doctors in the 1890s, and they had developed a code of conduct for deciding whether a patient 'belonged' to doctor X or doctor Y. This competition over patients should not be taken to imply that patients did not remain free to consult multiple doctors or other medical practitioners. But doctors were attempting to impose their own order on the way in which patients sought medical advice. Medical control over multiple consultations was facilitated by a code of conduct over either calling in a colleague to consult about a case, or referring the patient to go and see another doctor. In a key passage, Jukes de Styrap wrote:

When a practitioner is called in to, or consulted by a patient who has recently been, or still may be, under the care of another for the same illness, he should on no account interfere in the case, except in emergency, having provided for which, he should request a consultation with the gentleman in previous attendance, and decline further direction of the case except in consultation with him.⁶⁹

Styrap goes on to provide an extended version of the corresponding section of Thomas Percival's 1803 Medical Ethics, where the primary concern is with the good repute of the profession as a whole, and also, perhaps, providing the best treatment for the patient.⁷⁰ But the main thrust of this section of Styrap concerns the regulation of competition:

If the [previous medical attendant] refuse [consultation], or has relinquished the case, or if the patient insist on dispensing with his services, and a communication to that effect be made to him, the practitioner last consulted will be justified in taking charge of the case ...⁷¹

In Britain, Australia and New Zealand, the system of referring patients to specialists was already established in the 1890s, despite the fact that specialisation and specialist hospitals were frowned on by many doctors.⁷² But the system depended on those concerned being able to have faith that the consultant would not 'steal' the referred patient. Medical etiquette required the specialist to keep the referring doctor informed about the patient and, where appropriate, to ask him (or her) to assist during any specialist procedure such as surgery. It was also not uncommon for the referring doctor to be acknowledged in published reports, even of public hospital cases, and some practitioners were scrupulous in setting down the involvement of other doctors when they published cases.⁷³ In a series of reports in 1899, for instance, G. A. Syme, Surgeon to St Vincent's Hospital, Melbourne, acknowledged when the patients were initially admitted under the care of a physician ('admitted... under the care of my colleague Dr. D. Grant...'), when they were seen by another consultant ('Dr. Kenny reported that the left optic disc was pale') and even mentioned the pathologist by name ('Dr. Officer, pathologist to the hospital, examined the growth removed, and pronounced it a glioma.')⁷⁴ In this instance, tracking the involvement of other doctors represented an ideal of collegiality, respect for the rules of etiquette operating in the best interests of the patient, the careers of the doctors concerned, and good relationships between consultants at the hospital.

Overall, doctors were developing a concept of 'ownership' of patients, and of respecting the proprietary interests of fellow practitioners. 'Should the practitioner who has been called in consultation be subsequently requested to take sole charge of the patient, he should courteously but firmly decline,' wrote Dr. Styrap.⁷⁵ 'Ownership' of patients mattered. Keeping track of which individual patient 'belonged' to which individual doctor was important for making a medical living, and it was important for maintaining agreed ethical standards within the profession. This is the context for understanding how the pattern of complex clinical encounters in private practice involving parents, spouses, children, friends and multiple doctors, that has been described above, could emerge as simply 'doctor-patient relationships.' This concept was carried over directly from private practice to hospital practice, where responsibility for patients was divided up between the senior physicians and surgeons. The authority of these elite clinicians over junior staff was reinforced by the fiction that patients 'belonged' to, and were treated by, them, rather than by multiple nurses and doctors.

Figure 5: New Zealand-born plastic surgeon Harold Gillies and unnamed members of his team in their new operating theatre, Queen Mary's Hospital, Sidcup, 1917. (Reproduced by permission of Dr. Andrew Bamji, curator, Gillies Archives, Queen Mary's Hospital, Sidcup, Kent DA14 6LT.)

Conclusion: Not doctor-patient relationships, but patients' clinical interactions

As Mr. P's letter and the many other examples in this paper make clear, doctors were not the only ones making decisions about patients and their treatment. Perhaps it is time for historians to acknowledge this, and conceptualise clinical interactions in a more realistic and complex fashion than just 'doctor-patient relationships.' The term is a simplification, and in some cases an obfuscation of reality, or even an outright fiction, analogous to the pre-1970s convention of using he/him/his when people of both sexes were meant. But like the inaccurate use of masculine pronouns, use of the phrase 'doctor-patient relationship' is both shaped by and actively shapes our conceptualisations of clinical interactions. Focussing on the dyad of a single doctor and a single patient, and assuming that they had a 'relationship,' draws attention away from any others involved in the process of seeking and providing medical advice and care, assumes that the encounter was of the same kind, whatever the financial arrangements involved, and supports the financially and professionally advantageous conceptualisation that allowed an individual doctor to talk about 'my' patient, as if there was some sort of 'ownership' involved.

In the 1890s, it was the custom within the medical profession to refer to the patient and their 'friends' and, at least for the late–nineteenth century, Nancy Theriot's phrase 'doctor-patient-family interactions' has the virtue of evoking something of the complexities of clinical encounters in private practice.⁷⁶ For patients in hospital, 'patient-hospital interactions' might be a useful starting point for consideration. Overall, the phrase 'patient's clinical interactions' is less misleading than the phrase 'doctor-patient relationship,' and might fruitfully replace it in general use. This is not a matter of purely academic historical interest. In a recent article on patient safety in the twenty-first-century hospital, it was noted:

Communication failures are the leading causes of inadvertent patient harm. Although medical care is delivered by multiple team members, medical quality and safety has historically been structured on the performance of expert individual practitioners.⁷⁷

This, the authors argued, was a major cause of the problem. In order to improve communication and thus patient care, cultural change is essential: 'transforming care from the culture of the individual expert physician to a truly collaborative team environment.'⁷⁸

University of Queensland

Notes

^1. Erwin Ackerknecht, Medicine at the Paris Hospital, 1794–1848 (Baltimore: Johns Hopkins Press, 1967); Michel Foucault, The Birth of the Clinic, An Archaeology of Medical Perception (1963) (London: Routledge, 2003); for an overview of the enormous body of literature on the importance of French postrevolutionary medicine see: Caroline Hannaway and Ann La Berge, eds, Constructing Paris Medicine, Clio Medica 50 (Amsterdam: Rodopi, 1998).

^2. See, for example: Edward Shorter, "The History of the Doctor-patient Relationship," in Companion Encyclopedia of the History of Medicine, edited by W. F. Bynum and R. Porter (London: Routledge, 1993), 2: 783—800.

^3. Mary E. Fissell, "The Disappearance of the Patient's Narrative and the Invention of Hospital Medicine," in British Medicine in an Age of Reform, edited by Roger French and Andrew Wear (London: Routledge, 1991), 92—109; Ivan Waddington, "The Role of the Hospital in the Development of Modern Medicine: A Sociological Analysis," Sociology 7 (1973): 211–224; Volker Hess has argued that even in the era of bedside medicine, proletarian patients did not have an effective voice in their own care, and that the introduction of 'objective' measures of their bodies from the 1850s allowed such patients to exert some social control over medical authority: Volker Hess, "Standardizing Body Temperature: Quanti.cation in Hospitals and Daily Life, 1850–1900," in Body Counts, Medical Quanti.cation in Historical and Sociological Perspectives, edited by Gerard Jorland, Annick Opinel and George Weisz (Montreal: McGill-Queen's University press, 2005), 109–26.

^4. N. D. Jewson, "The Disappearance of the Sick-man from Medical Cosmology, 1770–1870," Sociology 10 (1976): 225–44, 237.

^5. Roy Porter, ed., Patients and Practitioners, Lay Perceptions of Medicine in Pre-industrial Society (Cambridge: Cambridge University Press, 1985).

^6. Anne Digby, Making a Medical Living, Doctors and Patients in the English market, 1720–1911 (Cambridge University Press, Cambridge, 1994), 27–8; Dorothy Porter and Roy Porter, Patient's Progress, Doctors and Doctoring in Eighteenth-century England (Stanford: Stanford University Press, 1989); Owen Davies, "Cunning-Folk in the Medical Market-Place During the Nineteenth Century," Medical History 43 (1999): 55–73; Philippa Martyr, Paradise of Quacks, An Alternative History of Medicine in Australia (McLeay Press, Paddington NSW, 2002); Willem de Blecourt and Cornelie Usborne, "Situating 'Alternative Medicine' in the modern period," Medical History 43 (1999): 283–5.

^7. Regina Morantz-Sanchez, "Negotiating Power at the Bedside: Historical Perspectives on Nineteenth-Century Patients and Their Gynaecologists," Feminist Studies 26 (2000): 287–309; Judith Walzer Leavitt, Brought to Bed, Childbearing in America, 1750–1950 (New York: Oxford University Press, 1986); Nancy Tomes, A Generous Confidence, Thomas Story Kirkbride and the Art of Asylum-Keeping, 1840–1883 (New York: Cambridge University Press, 1984).

^8. Nancy M. Theriot, "Negotiating Illness: Doctors, Patients, and Families in the Nineteenth Century," Journal of the History of the Behavioral Sciences 37 (2001): 349–68. The inclusion of the family is also found in work on clinical relationships in China: Ruiping Fan and Julia Tao, "Consent to Medical Treatment: The Complex Interplay of Patients, Families and Physicians," Journal of Medicine and Philosophy 29 (2004): 139–48; Yali Cong, "Doctor-Family-Patient Relationship: The Chinese Paradigm of Informed Consent," Journal of Medicine and Philosophy 29 (2004): 149–78.

^9. For a discussion of the evolution of operating theatre design at one elite institution see: Annmarie Adams and Thomas Schlich, "Design for Control: Surgery, Science and Space at the Royal Victoria Hospital, Montreal, 1893–1956," Medical History 50 (2006): 303–24.

^10. The emphasis in this essay is on the varying numbers of people involved in clinical interactions. But the nature of the clinical encounter is also deeply affected by the age, gender, race, education and social circumstances of the participants.

^11. Complaints files, No 47, 1900, Middlesex Hospital Archives, University College London Hospital.

^12. There are only a small number of complaints files in the archives of the Middlesex Hospital, mainly for the years around 1900. However, they offer a tantalizing glimpse of patient attitudes, and a search of other hospital archives might well be very rewarding.

^13. Middlesex Complaints files.

^14. Irvine Loudon, "The Concept of the Family Doctor," Bulletin of the History of Medicine 58 (1984): 347–62; Digby, Making a Medical Living; Anne Digby, The Evolution of the British General Practitioner 1850–1948 (Oxford: Oxford University Press, 1999); Christopher Crenner, Private Practice in the Early Twentieth-Century Medical Office of Dr. Richard Cabot (Baltimore: Johns Hopkins University Press, 2005); for the negotiated nature of clinical interactions see: Nancy M. Theriot, "Women's Voices in Nineteenth-Century Medical Discourse: A Step Towards Deconstructing Science," Signs 19 (1993): 1–31; Kathleen E. Powderly, "Patient Consent and Negotiation in the Brooklyn Gynecological Practice of Alexander J.C. Skene: 1863–1900," Journal of Medicine and Philosophy 25 (2000):12–27; David G. Schuster, "Personalizing Illness and Modernity: S. Weir Mitchell, Literary Women and Neurasthenia, 1870–1914," Bulletin of the History of Medicine 79 (2005): 695–722.

^15. M. Jeanne Peterson, "Gentlemen and Medical Men, the problem of professional recruitment," Bulletin of the History of Medicine 58 (1984): 457–473, 471.

^16. David J. Rothman, Strangers at the Bedside, A History of How Law and Bioethics Transformed Medical Decision Making (Basic Books, 1991), especially the introduction; Evan Willis, Medical Dominance, The Division of Labour in Australian Health Care (Sydney: Allen & Unwin, 1989); Eliot Freidson, Professional Dominance, The Social Structure of Medical Care (Chicago: Aldine, 1977); Jay Katz, The Silent World of Doctor and Patient (Baltimore: Johns Hopkins University Press, 1984).

^17. For U.S. examples of refusal to consent to surgery see: M.S. Pernick, "The Patient's Role in Medical Decision-making: A Social History of Informed Consent," in Medical Therapy. Making Health Care Decisions, The Ethical and Legal Implications of Informed Consent in the Patient-Practitioner Relationship, vol. 3 (New York: President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioural Research, 1982), Appendices, Studies on the Foundations of Informed Consent: 1–36; R.R. Faden, et al., A History and Theory of Informed Consent (New York: Oxford University Press, 1986).

^18. Journals consulted include the British Medical Journal (BMJ) 1889, 1890 and 1900; Lancet, 1890 and 1900; Australasian Medical Gazette (Aus. Med. Gaz.) 1890, 1891, 1892, 1893, 1895, 1898 and 1900; Intercolonial Medical Journal of Australasia 1898, 1899 and 1900.

^19. Of the 350 doctors on the roll of the Intercolonial Medical Congress of Australasia in 1899, 76 percent had Irish, Scottish or English qualifications. Wilton Love, ed., Intercolonial Medical Congress of Australasia, Transactions of the Fifth Session, Brisbane, September 1899 (Brisbane: 1901), 5–12; Donald Simpson, The Adelaide Medical School 1885–1914: A Study of Anglo-Australian Synergies in Medical Education (MD thesis, University of Adelaide, 2000); Laurence M. Geary, "The Scottish-Australian Connection 1850–1900," in The History of Medical Education in Britain, edited by Vivian Nutton and Roy Porter, (Amsterdam: Rodopi, 1995); Anne Crowther and Marguerite Dupree, "The Invisible General Practitioner: The Careers of Scottish Medical Students in the Late Nineteenth Century," Bulletin of the History of Medicine 70 (1996): 387–413.

^20. Comparisons were made between published case reports and unpublished patient record series from the Middlesex Hospital and St Peter's Hospital for Stone, both held in the Archives of University College London Hospital, and from the Brisbane Hospital, held in the Queensland State Archives.

^21. Theriot, "Negotiating illness"; Steven M. Stowe, "Seeing Themselves at Work: Physicians and the Case Narrative in the Mid-19^th-Century American South," in Sickness and Health in America, edited by Judith Walzer Leavitt and Ronald L. Numbers (Madison: University of Wisconsin Pres, 1978), 161–86; for the use of unpublished case records see: J.H. Warner, "The Uses of Patient Records by Historians—patterns, possibilities and perplexities" and J. McCalman, "Writing the Women's—hospital history with medical records," Health & History 1 (1999): 101–11 & 132–8; Guenter B. Risse and John Harley Warner, "Reconstructing Clinical Activities: Patient Records in Medical History," Social History of Medicine (1992): 183–205.

^22. Loudon, "Family doctor".

^23. Jukes de Styrap, The Young Practitioner, With Practical Hints and Instructive Suggestions as Subsidiary Aids for his Guidance on Entering into Private Practice (London: H.K. Lewis, 1890), 36.

^24. For example: J.M. Creed, "The Treatment of Diphtheria," Aus. Med. Gaz. XI (1891): 71–3; E. Owen, "Selected Subjects in the Surgery of Infancy and Childhood," Lancet 135 (1890): 65–6; see also: Jonathan Gillis, "Taking a Medical History in Childhood Illness: Representations of Parents in Paediatric Texts Since 1850," Bulletin of the History of Medicine 79 (2005): 393–429.

^25. "Case of Acute Intussusception (Death)," Aus. Med. Gaz. X (1890–1): 117.

^26. "The Case of Bellamy Southern," Aus. Med. Gaz. XII (1893): 206–7.

^27. L.E. Barnett, "A Case of Spontaneous Shriveling of a Cancer of the Foot," Intercolonial Medical Congress of Australasia, Transactions of the Fourth Session, Dunedin, February 1896 (Dunedin: Otago Daily Times, 1897), 208–9.

^28. J. Michell Clarke and J. Greig Smith, "Case of Removal of the Vermiform Appendix (During a Quiescent Period) for Recurrent Attacks of Inflamation," Lancet 135 (1890): 956–8.

^29. Henry Pilkington, "A Case of Spontaneous Laceration of an Umbilical Hernia, With Protrusion and Strangulation of Intestine," Lancet 135 (1890): 1008.

^30. Anon, "Strychnine in Snake-bite," Aus. Med. Gaz. XI (1892): 137. Snakebite Antidote Pocket cases were advertised from 1892: 'For Dr. Mueller's successful treatment of Snakebite by the hypodermic injection of strychnine' marketed by L. Bruck, 13 Castlereagh Street, Sydney, who was a 'Medical Agent' and also publisher and editor of the Australasian Medical Gazette.

^31. J. Graham, "Twisting of the Pedicle in Ovarian Tumours," Aus. Med. Gaz. X (1891): 4–6.

^32.Ibid., 6.

^33. E.H.L. Pratt, "Clinical Notes of a Country Surgeon," Aus. Med. Gaz. XII (1893): 288–9

^34. For the eighteenth century see: C. Crawford, "Patients Rights and the Law of Contract in Eighteenth-Century England," Social History of Medicine 13 (2000): 381–410.

^35. "Successful Action for Recovering Medical Charges," Lancet 136 (1890): 191.

^36.Fifty-Second Annual Report of the Brisbane Hospital (Brisbane: 1900), Fryer Collection, University of Queensland, 3.

^37. Alexander Francis, Then and Now, The Story of a Queenslander (London: Chapman and Hall, 1935), 106–7.

^38.Brisbane Hospital By-laws Adopted by the Committee of Management March 28, 1899 (Brisbane: 1899), Fryer Collection, University of Queensland, 3.

^39.Ibid. It was a teaching hospital for nurses, from the 1880s.

^40. Charles Rosenberg, The Care of Strangers, The Rise of America's Hospital System (Baltimore: Johns Hopkins University Press, 1987); Sally Wilde, Practising Surgery, A History of Surgical Training in Australia 1927–1974 (PhD thesis, University of Melbourne, 2003), 58–66.

^41. Dr. Ellis, "A Case of Abdominal Section," Aus. Med. Gaz. X (1890): 54

^42. W. Cavenagh-Mainwaring, "Rupture of the Vaginal Wall," Aus. Med. Gaz. XIX (1900): 146–8.

^4. Archibald Watson, Diaries, Series 64, P1/2/5, 27 August–11 November 1897, Archives of the Royal Australasian College of Surgeons, Melbourne.

^44.Ibid.

^45. Daniel M. Fox and Christopher Lawrence, Photographing Medicine, Images and Power in Britain and America since 1840 (New York: Greenwood Press, 1988); J.D. Howell, Technology in the Hospital, Transforming Patient Care in the Early Twentieth Century (Baltimore: Johns Hopkins University Press, 1995).

^46. Ian Burney, Bodies of Evidence, Medicine and the Politics of the English Inquest, 1830–1926 (Baltimore: Johns Hopkins University Press, 2000).

^47. In 1890, The Hyderabad Chloroform Commission and the prominence given to anaesthetic deaths at the International Medical Congress in Berlin insured that the pages of the BMJ and the Lancet were full of information on the risks of anaesthesia. See: Surgeon Major E. Lawrie, "Hyderabad Chloroform Commission and Professor Wood's Address on Anaesthesia at Berlin," Lancet 136 (1890): 1143–5; See also Spencer Wells' public soul searching about choice of anaesthetic: Sir T. Spencer Wells, "Modern Abdominal Surgery," BMJ 2 (1890): 1413–6. There were multiple reports of inquests into deaths under anaesthetic and by August 1890, the editors of the Lancet appear to have decided that 'no operation requiring an anaesthetic should be undertaken, save under the most urgent circumstances, without the presence of two or more duly qualified surgeons.' (Lancet 136 (1890): 457). See also William S Byrne, "Notes on Four Cases of Syncope During Chloroform Inhalation," Aus. Med. Gaz. XII (1893): 231; Eustace H.L. Pratt, "Clinical Notes of a Country Surgeon," Aus. Med. Gaz. XII (1893): 288 Dr. Jos C. Verco, "Hydronephrosis, Nephrotomy, and Nephrectomy—Recovery," Aus. Med. Gaz. XII (1893): 339–30; A. Jefferis Turner, "Recent Research on Chloroform Anaesthesia," Aus. Med. Gaz. XII (1893): 400; Proceedings of the South Australian Branch of the British Medical Association," Aus. Med. Gaz XIV (1895): 102–3 Dr. L. W. Bickle, "The First Indian Medical Congress," Aus. Med. Gaz XIV (1895): 114–5; B. Poulton, "Cases of Appendicitis," Aus. Med. Gaz XIV (1895): 485; G. Hamilton Rowlands, "A Case of Appendicitis Complicated by Empyema—Operations—Recovery," Aus. Med. Gaz. XX (1901): 325—6

^48. Minutes of Medical Committee, Middlesex Hospital, 7 March 1891–22 October 1892, 92, 134, 149–50, 177, 201–2, Middlesex Hospital Archives, University College London Hospital.

^49. For a recent overview of the complexities of the acceptance of germ theory see: Michael Worboys, Spreading Germs, Disease Theories and Medical Practice in Britain, 1865–1900 (Cambridge: Cambridge University Press, 2000).

^50. Loudon, "Family Doctor," 359.

^51. J.T. Hart, "Going to the Doctor" in Medicine in the Twentieth Century, edited by Roger Cooter and John Pickstone, (Harwood: Harwood Academic, 2000), 543–57.

^52. Loudon, "Family Doctor," 350.

^53.Ibid., 358; Digby, Making a Medical Living; Digby, Evolution of General Practice. See also: Crenner.

^54. Andrew A.G. Morrice, "'Honour and Interests': Medical Ethics and the British Medical Association," in Historical and Philosophical Perspectives on Biomedical Ethics, edited by Andreas-Holger Maehle and Johanna Geyer-Kordesch (Burlington: Ashgate, 2002), 11–35; Lisbeth Haakonssen, Medicine and Morals in the Enlightenment, John Gregory, Thomas Percival and Benjamin Rush, Clio Medica 44 (Amsterdam: Rodopi, 1997); Roger Cooter, "The Resistible Rise of Medical Ethics," review article, Social History of Medicine 8 (1995): 257–270; Roger Cooter, "The Ethical Body," in Medicine in the Twentieth Century, 451–68; Robert Baker, Dorothy Porter and Roy Porter, eds, The Codification of Medical Morality, Historical and Philosophical Studies of the Formalization of Western Medical Morality in the Eighteenth and Nineteenth Centuries, volume One: Medical Ethics and Etiquette in the Eighteenth Century (Dordrecht: Kluwer Academic Publishers, 1993); Albert R. Jonsen, A Short History of Medical Ethics (New York: Oxford University Press, 2000)

^55. Burney, Bodies of Evidence.

^56.BMJ 1 (1890): 1206; see also 48, 509 and 1512.

^57. Jukes de Styrap, A Code of Medical Ethics, With General and Special Rules for the Guidance of the Faculty and the Public in the Complex Relations of Professional Life (1878), 3^rd edition (London: H.K. Lewis, 1890).

^58. Thomas Percival, Medical Ethics, or A Code of Institutes and Precepts Adapted to the Professional Conduct of Physicians and Surgeons (Manchester: J. Johnson, 1803), reprinted Edmund D. Pellegrino, ed. (New York: Classics of Surgery Library, 1997).

^59. Haakonssen; Robert Baker, "The Formalization of Medical Ethics, Introduction," 141–4; Robert Baker, "Deciphering Percival's Code," 179–211; and John Pickstone, "Thomas Percival and the Production of Medical Ethics," 161–178, all in Baker, Porter and Porter, Codification of Medical Morality.

^60. Ivan Waddington, "The Development of Medical Ethics—A Sociological Analysis," Medical History 19 (1975): 36–51; Jeffrey L. Berlant, "Medical Ethics and Professional Monopoly," Annals of the American Academy of Political and Social Science 437 (1978): 49–61.

^61. Styrap noted in the preface to the first edition, 1878, that his code was based on that of the American Medical Association, and that this in turn was based on Percival's code. (Styrap, Code, 285).

^62. For the particularly crowded nature of the profession in the 1890s see: Digby, Making a Medical Living, especially chapter 4; Digby, Evolution of General Practice, chapter 2.

^63.BMJ 1 (1890): 48.

^64. Styrap, Code, 331; see also: BMJ 1 (1890): 509; 867

^65. For example, the editor quotes 'Dr. Jukes de Styrap in his Code of Medical Ethics...' on homeopathy: 'A question of ethics,' Aus. Med. Gaz. XIX (1900): 209.

^66. L. Fitz-Patrick, "Medical Etiquette," Aus. Med. Gaz. XII (1893): 319–20.

^67. Styrap, Code, 347.

^68.Ibid., 333–51; see also: "A Question of Medical Etiquette," Aus. Med. Gaz. XI (1892): 266.

^69. Styrap, Code, 346.

^70. Percival, 33; Styrap, Code, 346.

^71.Ibid.

^72. For a recent contribution and overview of what is now a considerable body of work on specialisation see: George Weisz, Divide and Conquer, A Comparative History of Medical Specialization (Oxford: Oxford University Press, 2006).

^73. E.g. R.A. Stirling, "Surgical Operations at the Melbourne Hospital During the Six Months From April to October 1897," Intercolonial Medical Journal of Australasia III (1898): 17–21.

^74. G.A. Syme, "Some Cases of Operation for Intra-cranial Tumour," Intercolonial Medical Journal of Australasia IV (1899): 320–5.

^75. Styrap, Code, 342.

^76. Theriot, "Negotiating illness," 365.

^77. M. Leonard, S. Graham and D. Bonacum, "The Human Factor: The Critical Importance of Effective Teamwork and Communication in Providing Safe Care," Quality and Safety in Health Care 13 (2004): i85–i90.

^78. Ibid, i90.

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