"Professionalization" is a word whose length and awkwardness wholly befit what it denotes. To "professionalize" is is to submit oneself to a structure of norms and expectations in exchange for formal or informal accreditation. Though the aspiring professional is engaged with abstract institutional powers, the concrete private necessity to make a living creates and sustains the terms of one's engagement. In this regard, professionalization is a type of alienation, in Marx's sense. Unlike the worker, however, the professional is nominally free to choose his or her chains. This choice does not make the chains less confining, though they may be made of nicer stuff.
Professionalization was perhaps nowhere a more awkward process than in Victorian medicine, where it required the organization of a variety of constituents that ranged from apothecaries, herbalists and midwives to anatomists, surgeons and gentlemen physicians. During several decades at mid-century, representatives from all these specialities (and others) struggled to set the terms that would distinguish, once and for all, scientific from from unscientific training, useless nostrums from effective medications, and the real doctors from the quacks. Sylvia M. Pamboukian's Doctoring the Novel: Medicine and Quackery from Shelley to Doyle traces the winding development of this boundary as observed and theorized by Victorian novelists, critics, politicians, and legislators.
Then as now, the state was the authority of first and last resort in cases where it was necessary to distinguish quackery from legitimate practice. Nevertheless, the route from lawmakers to practitioners was never one-way; indeed, practitioners were called upon as experts in the production of legislation. Thus, as much as legislation shaped the process of medical professionalization, it was also, in turn, shaped by it. Of the early legislation, the Anatomy Act of 1832 was perhaps the most sensational as it gave anatomists greater access to unclaimed corpses, particular of those who died in prisons or workhouses where there were few if any relatives to claim an exception for the disposition of the body. Perhaps predictably, Pamboukian's opening chapter uses Mary Shelley's Frankenstein to contextualize this legislation. Although Shelley's novel was first published some fourteen years before the Anatomy Act, the 1831 edition contained a preface that emphasized the wickedness of anatomical dissection, in contrast to earlier editions in which Shelley presented anatomy in a more benign, progressive light. Pamboukian uses this discussion to demonstrate how the worlds of Victorian medicine, literature and the law were surprisingly enmeshed.
As doctors became more closely tied to professional bodies that provided accreditation, patients' expectations for medical care rose apace. While the educated doctor often proved no more effectual against disease than the quack, he was increasingly held to a higher standard. Patients expected more, and their disappointments were correspondingly keener. But professionalizing doctors, as Pamboukian shows, increased the pressure on themselves. Ironically, those advocating professionalization wanted laypeople to hope for more from legitimate physicians who, after all, had modern science on their side. These surplus expectations extended to social life. The Victorian physician was expected to be not only well-trained but also possessing important habits of mind and demeanor. He must be observant, discreet and composed, in order to ensure his objectivity and to provide the best care for all of his patients, regardless of their background or social status. Describing one such paragon in Little Dorrit, Dickens explicitly linked the ideal doctor's equanimity to the implacability of both natural and divine forces:
Few ways of life were hidden from the Physician, and he was oftener in its darkest places than even the Bishop. There were brilliant ladies about London who perfectly doted on him, my dear, as the most charming creature and the most delightful person, who would have been shocked to find themselves so close to him if they could have known on what sights those thoughtful eyes of his had rested within an hour or two, and near to whose beds, and under what roofs, his composed figure had stood. But, Physician was a composed man, who performed neither on his own trumpet, nor on the trumpets of other people. Many wonderful things did he see and hear, and much irreconcileable [sic] moral contradiction did he pass his life among; yet his equality of compassion was no more disturbed than the Divine Master's of all healing was. He went, like the rain, among the just and unjust, doing all the good that he could, and neither proclaiming it in the synagogues nor at the corners of the streets. [Quoted pp. 53-54].
Interestingly, Pamboukian observes, where Dickens notes failures of medical professionalism, he presents them in terms of the failures of professionalism generally. Dickens' doctors are not unprofessional. Rather, they suffer from too much professionalism, from an overfocus on professional role expectations at the expense of authenticity. When Dickens' doctors display inadequacies, their failures are those of tradesmen and lawyers. Bad doctors aren't quacks so much as frauds and social parasites, like the treacherous Skimpole of Bleak House who informs on the ill and destitute Jo rather than helping him.
Of course, this view of the medical profession — as basically good, oriented toward ideals of vocation and service, but suffering from corruption due to an excess of professionalism — was an idealization. In fact, the ubiquity of unreliable practitioners and the questionable character of their interventions stoked anxieties about appropriate medical conduct. If the medical mountebank did not actually exist, his persistent appearance as a stock figure in popular books and broadsides suggested that, at the very least, the possibility of being on the receiving end of fraudulent medical care was a real and significant anxiety. The mountebank threatened as well the burgeoning (and therefore still vulnerable) medical profession. The readers of the Lancet, which drew its audience from establishment physicians, were urged to redress sins against professional reputation as vigorously as they fought disease. In 1858, a correspondent urged doctors to the public relations barricades even when doing so might breach the bounds of propriety:
Now we have no desire to draw down condemnation upon ourselves for letting the guilty escape, simply because the delinquent may belong to our own order. We, who fearlessly, in the discharge of our public duty, mete out no measured castigation to those beyond our pale for their vulgar and unbecoming practices, must not be less fastidious and less sensitive to derelictions against propriety, when the latter are committed within our own professional circuit. (1)
Even the article's title, "The Profession and Its Dignity," suggested that, like a fool and his money, profession and dignity were all too easily parted. One could not yet take for granted the medicine's dignity as a profession. In the meantime, doctors were encouraged to adopt an attitude on Dickens' model, to go "like the rain, among the just and unjust."
No matter how noble their intentions, medical practitioners always had to cover their expenses somehow; as in any other line of work, any service rendered could be counted upon to eventuate in a fee. This fundamental contradiction between a doctor's ideal of service and his or her need, like anyone else, to make a living provided Victorian novelists with a fruitful avenue of exploration of the distance between ideals and reality. In fiction, if not in life, it was sometimes necessary for good doctors to behave badly, for honest doctors to deceive their patients in order to make a living. In Arthur Conan Doyle's The Stark Munro Letters (1895), Doyle explores this conflict by means of his elaboration of Dr. Cullingworth, inviting readers to see the complexities of the medical practitioner's often competing interests and loyalties. Conan Doyle's Cullingworth, a successful doctor who is not always scrupulous, advises Munro to maintain his professional autonomy by subtly and consistently letting his patients know that he holds none of them in very high estimation, lest they perceive how much he needs them, or at least their illnesses, as a source of income:
[Y]ou must never let them see that you want them. It should be pure condescension on your part seeing them at all ... Break your patients in early and keep them well to heel. Never make the fatal mistake of being polite. (Quoted on 128).
Pamboukian's concluding chapter considers her main themes in light of the eventual stabilization of professional medicine in opposition to quackery, which at this later point no longer posed such a threat. The spate of medical legislation that marked the second half of the nineteenth century included the Poisons Act (1857), the Chemists and Druggists Bill (1865), and the Pharmacy Act (1868), all of which differently served to solidify professional identity while progressively excluding other sorts of practitioners from the realm of medical legitimacy. Still, the troubling specter of quackery never quite disappeared; its presence particularly haunted popular literature. Pamboukian's concluding discussion of Vernon Galbray (1875), a popular novel about an incompetent dentist, suggests the extent to which ideological resources external to medicine were increasingly called upon to support the distinction between legitimate and illegitimate medical practice. Galbray, a Dutch Jew opening a dentistry clinic in London, is a threat to legitimate practice not only because he is incompetent but also because he is foreign and Jewish. His assistant Spyk, who is the more competent dentist, is also Jewish, and additionally burdened by his disadvantaged social class. While the novel's anonymous author allows things to end badly for both men, the end is much worse for Spyk, who loses his life in a fire that consumes Galbray's office but leaves him alive to suffer the humiliation of losing his practice. The upshot, Pamboukian says, is that "the author encourages readers to view quackery as an external force that can be recognized and eliminated" (148), a matter of the social and legal patrol of religious belief and class mobility rather than as a parochial production of professional medicine alone. Though Victorian doctors had early needed quacks and quackery — in theory if not in fact — in order to sustain an idealized image of their profession in opposition to devalued quack practitioners, this need was less pressing by the 1880s, when the medical profession became sufficiently autonomous, with its own credible institutions and processes for determining who belonged — and who did not — from one generation to the next.
While readers may fault Pamboukian for her heavy reliance on secondary sources, it is worth remembering that the book's aim — to show how the discourse of medical orthodoxy created and sustained ideas of quack medicine — has required Pamboukian to marshal and present information gleaned from a wide variety of disciplines, including the history of medicine and popular culture. To make links from these fields, she cannot do without the connective tissue that the secondary material provides. Pamboukian has as well the challenge of finding a theoretical framework sufficiently robust to encompass these different kinds of sources, and here she relies on Hayden's White's ideas of language and hegemony, which allow her to include virtually any textual source she pleases but discourage consideration of non-textual sources and limit her considerations to the discursive and the literary.
In several chapters, Pamboukian dilutes her argument by indulging in a kind of prosy list-making at the expense of analysis. So, for instance, while her catalogue of links between money and status in Little Dorrit is exhaustively detailed (56), the details are simply exhausting when they are not routinely tied to fresh insights that develop an argument. The book is further weakened by the author's habit of asking questions rather than offering hypotheses that can be developed and defended. The problem crops up now and then throughout the book, but Pamboukian's chapter on Dickens suffers the most from it, which perhaps reflects an understandable reluctance to say anything too new or original about an author about whom so much has already been said. Pamboukian's reluctance to take a position was, at times, grating. I could have done without her plodding announcement, at the start of the Dickens chapter, that "The ways in which [Dickens'] novels represent physicians raises [sic] questions about professional medicine at a significant moment in its development," a generalization that Pamboukian is pressing into service as a thesis, which she makes even less pointed by immediately barraging the reader with questions: "How did medicine redeploy the language of healing to craft a trustworthy professional ethos? What were the implications of such language for professional medicine's negotiation of financial, scientific and social interests? How was professional trust maintained, and how could the requisite trust be maintained along with a healthy skepticism?" (50) To all of which one might be tempted to retort: Great questions, but how about taking a position? In other words, had Pamboukian dared to offer straightforward claims against which readers might weigh her evidence, Doctoring the Novel would have been a stronger, more satisfying book.
Pamboukian, Sylvia A. Doctoring the Novel: Medicine and Quackery from Shelley to Doyle. Athens, OH: Ohio University Press, 2012.
Last modified 19 September 2012