Doctors often yearn for the good old times when governments didn’t interfere and economic security was matched by an unfettered freedom to practise their skills, but did these times ever exist? Delving into the Australian Medical Journal (AMJ) from 1870 to 1879 suggests that the medicopolitical issues confronting the profession have changed very little. Medicine today is more sophisticated, but the politics is not and has lost a certain character-forming robustness.

Premises of Dr William R Pugh, surgeon and oculist, 131 Collins Street, Melbourne, circa 1865. © State Library of Victoria.

The political issues confronting doctors in the 1870s included:

• The number of doctors entering the colonies with questionable overseas qualifications and uncertain language skills, and the failure of medical boards to control this;1

• Poor remuneration for general practitioners and control of doctors’ remuneration by health funds (lodges and friendly societies);2

• Specialist intrusion replacing general practice;3

• Inadequate funding of the public and charity hospitals;4

• Competition from pharmacists and alternative medicine;5 and

• Litigation, an unfair legal system and poor expert witnesses.6

It sounds familiar!

In 1870, Australia had medical schools in Melbourne and Sydney. A reputable British degree was a prized qualification, and England was fondly referred to as “home”. Medical Acts governed the registration of doctors, a privilege which was jealously guarded. In 1873, there were 469 registered practitioners in Victoria with degrees from 48 universities, “not to speak of 10 who hail from no College at all, but by good luck were practising in the colony before 1853”.7

Valid proof of 3 years of equivalent study was enough to gain entry to the Medical Register, but there was doubt that medical boards were able to adequately check overseas qualifications. Frequent stories appeared of unlicensed medical practitioners being prosecuted, as did editorials calling for better screening of international medical graduates, exemplified by the case of Dr Myers, of the University of Lima, Peru, who rated an entire editorial, as he was accused of “sneaking into the profession”.8

The editorial castigating Dr Myers and the Medical Board was a gentlemen’s tiff compared with a stinging editorial in August 1875 on American degrees:9 “. . . the Americans who do everything in a hurry, educate their doctors in their usual fashion”, implying that a fat fee to an American university could purchase a pass in a fast-tracked medical degree.

This, in turn, was mild compared with the disdain shown towards Chinese degrees and to those of Asian descent who attempted to gain access to the Register. The comments from an 1875 editorial10 would today earn a trip to the Anti-Discrimination Tribunal: “Because they speak in an unwieldy tongue and because any system of medicine they may have studied is at the opposite extreme of intelligence” and “. . . whenever an opportunity has been afforded them of submitting their medical knowledge to a reliable test, they have shown an incompetence . . .”

The failure of the Medical Board of Victoria to protect the public from overseas-trained doctors of dubious quality caused great agitation. Criticism in an editorial using the subtle genre of the time expressed the view that “The Medical Board . . . is, in reality, only the mockery of an authority. They have no option in registering the most objectionable holder of a valid qualification and . . . what they know to be the most insufficient evidence of a proper medical education.” Have these all-too-similar sentiments been more gently expressed in our own medical and popular press of late?

“A person will go to a specialist and joyfully give a guinea . . . while the poor half guinea of the general practitioner is uniformly begrudged”, lamented an AMJ editorial from April 1876.

The standard fee for a GP consultation was 10 shillings, but most GP visits were house calls. This period saw the rise of the medical clubs and friendly societies. GPs were invited to tender a competitive price and were paid by the club, essentially a health insurance fund. To ensure a busy practice, the price competition was fierce. As the price of general practice was driven down to meet the demands of the funds, GPs complained frequently about their poor remuneration.11 There were several attempts to form cartels to stand up to the clubs and bring the prices up, but doctors would always break ranks and offer to undercut their colleagues to ensure the security of their own practices.11 Attempts to improve GP remuneration usually failed because of lack of political unity.

Successive Medical Society presidents expressed great concern about the emphasis on low cost, high volume medicine, which meant that it was “impossible that they [doctors] can devote sufficient time to each individual case. They must hurry along . . . and this continued hurry must lead to a kind of practice unsatisfactory alike to practitioner and patient.”12

State remuneration of “medical men” was considered a “disgrace”. The vaccination fee of 2s 6d “was ludicrously inadequate”,13 and state health officers were “mocked by their paltry salaries”.13

Compassionate discounting in private practice was common, but many GPs felt their charity was abused by the wealthier who could afford to pay. Informed financial consent was the subject of an editorial in November 1875:15 “Patients are often obtuse on the fees for operations and it is better there be no misunderstanding afterwards”.

However, the popular press often made reference to high medical fees. Such a story in The Argus, a Melbourne newspaper, so raised the ire of one GP that he was moved to write In reply:16 “Of the 30 medical men residing there [Collins Street, Melbourne’s equivalent of Harley Street in London] . . . and [who] visit their patients in expensive vehicles, drawn by thoroughbred horses, driven by fat coachmen in gay livery, seven have no carriages at all, and eight drive but one horse, and their coachmen are not in livery . . . albeit I have no carriage and cannot quite make ends meet.” Doctors and their cars in the 1870s!

An 1878 editorial entitled “Special practice” stated: “There is not much left for the General practitioner to do in these days of specialism; at least there is not much the public think he can do. Every organ of the body is appropriated by those who give their attention to regional diseases so that the general practitioner is looked upon as a kind of pathological poacher if he extend his treatment greatly beyond catarrh, colic or fever. In surgery, especially, he is forbidden to meddle, and there are certain instruments which it is a kind of professional crime for the average [GP] surgeon to use.”3

The public (or charity) hospitals were chronically underfunded. Outpatient waiting rooms were crowded with patients waiting many hours to be seen. There was a need for more public hospitals, and the decade saw the completion and opening of the Alfred Hospital in Melbourne. It was initially a free hospital, but it wasn’t long before a debate started about the merits of increasing its income by taking in “pay patients”. As the charity hospitals received minimal government funding, there was continued and strident criticism of those patients who could afford to pay for their hospitalisation but took advantage of the free system.

The question of paying patients in public hospitals was a vexed one, with lessons we could learn from today. The medical profession was divided, as it gave a competitive advantage to the full time clinicians and honorary specialists at the hospital. An editorial entitled “Pay hospitals” in March 1877 summed up the position well: “It is a mistake to endeavour to associate gratis patients and pay patients under the same roof. So far as we know, wherever the experiment has been tried, it has failed . . . the difficulty continually arose, of pay patients complaining they did not receive attention and accommodation sufficient to distinguish them from the gratis patients, while these latter were of the distinct contrary opinion, that the pay patients were unfairly preferred.”17

Melbourne Hospital circa 1870. At that time honorary medical staff were elected every 4 years by the hospital’s subscribers. Doctors expended considerable effort and expense to win these prestigious positions.14 © State Library of Victoria.

Competition for honorary posts was fierce. Appointment was by elections, the voters being the subscribers to the hospital; such ballots were a cause for much angst and legal action after the results became known. Petty jealousies abounded between doctors, and tension existed between the hospital administrators and the medical staff over budget control. The Melbourne Hospital’s budget was saved in the nick of time by a zealous administrator who publicly called the medical staff to account in no uncertain terms for their over-prescribing of meat extracts as dietary supplements, thereby nearly breaking the pharmacy budget.

In May 1878, the whole medical staff of the Sydney Infirmary resigned because of dissatisfaction with the conditions at the hospital: “Week after week it has been found necessary to turn away applicants for admission there, partly for want of room . . . there are many instances in which patients cannot be properly treated at the infirmary at all.”18 Access block in the 1870s!

Three groups provoking the ire of the profession in the 1870s were pharmacists, homoeopaths and quacks, a basket into which all other alternative healthcare providers also fell. The prescribing pharmacist caused the most concern, and some doctors were most rigid in their views. One GP was fined for refusing to attend to a child who had been kicked by a horse because a pharmacist had already applied some sticking plaster to the child’s head!

Pharmacists drew this comment in an 1876 editorial: “They [the public] seem to entertain a belief that a knowledge of drugs implies a knowledge of disease and he who can compound and dispense can also prescribe.”11

How did the medical profession fight this competition? They considered dispensing medicines and charging for their own drugs. Doctors insisted on charging a consultation fee when issuing repeat prescriptions, and this was a source of frequent public complaint. These complaints particularly aggrieved the profession, which felt that there was some intellectual property in the potions and mixtures that they designed to treat various diseases — intellectual property which then stayed profitably with the pharmacist.19

Patent medicines, which promised a cure for everything from alcoholism to scurvy, were also a problem, particularly when promoted by snake oil merchants. However, it was humbling to see one of the major academic tussles of the day was a written war between The Lancet and the AMJ on the benefits of intravenous ammonia for the treatment of snakebite, a cure promoted by a Professor George Halford, one of Melbourne’s leading academics.

Homoeopathy was especially hated by the profession. This hatred was fired by the repeated attempts by homoeopaths to gain admitting rights to the Melbourne Hospital and to set up special homoeopathy units. This was a move as fiercely resisted then as it would be today. Homoeopathy was described in an AMJ editorial in 1877 as “an irrational heresy” and homoeopaths were described as “immoral, dishonest and promoting a system of charlatanry”.20 The homoeopaths were well organised and very adept at answering public criticism and mobilising their supporters. The public seemed to find no shortage of cash to pay their homoeopath or herbalist, but were very reluctant to pay their GP, a source of serious irritation to the profession.21

“Quacks” encompassed a wide range of practitioners, and even included the odd member of the profession whose views did not match the thinking of the day (which seemed rather rigid despite proud claims that it was consistently evidence-based). Certainly, unqualified practitioners abounded, as did cures using cupping, blistering, electricity, patent medicines, chiropractic techniques, and herbal medicines. The disdain of the profession towards all of this was evident, and doctors bemoaned the general public’s support of alternative therapy, as shown in an 1871 editorial: “A sympathetic public would be up in arms to protest against the inhumanity of repressing a benefactor of mankind who got his knowledge of disease from nature and who, like a poet, had not been licensed to practise, but had been born with a diploma.”22

Our profession’s dim view of their legal brethren was not shaped in recent times. Doctors in the 1870s felt hounded by an unfair, biased and poorly administered legal system. Most of the AMJ issue of November 1871 was devoted to the unjust nature of a verdict for malpractice against a doctor who missed a fractured neck of femur.6 The patient was awarded damages of £230. The opinion of the AMJ was: “It is hardly possible to imagine a verdict more unjust, or more directly contrary to all the facts as they were presented.”

A public fund was set up to help the defendant pay the damages, medical defence organisations not being available at the time. The AMJ was scathing about the expert witnesses who testified against their colleagues, especially as they were of the view that the whole unjust action was begun after a doctor consulted for a second opinion implied the treatment by the initial surgeon was defective and so “encourages the belief in the patient’s mind that there has been neglect in her (first) attendant.”

Doctors were frequently in court as witnesses and experts but were also exposed to the rigours of a jury in the Coroner’s Court. Deaths frequently resulted in coroner’s cases, and the outcomes of these cases were extensively reported in the popular press. Manslaughter charges against unfortunate practitioners were not uncommon. An editorial in the May 1875 issue of the AMJ called for coroner’s juries to be replaced by expert panels so medical men could be tried by their peers, who more fairly understood the complexities of medical practice.23

Court fees paid to expert witnesses were low and their experiences were unpalatable: “That a medical man should be kept in attendance for a whole day at a court of justice, and probably bullied into the bargain, and then, for all this trouble and annoyance, get a paltry pound, was monstrous.”13

This was a litigious age and legal actions against medical practitioners reported in the Journal made spicy reading, with actions for slander and libel being not infrequent.

The politics of the time was robust and intemperate, not ruled by genteel Victorian manners. Consider these quotes from the AMJ in 1871:24

“The autocrat who rules Geelong hospital . . .”

“The committee of the Alfred Hospital are a very paltry one” and

“Some opposition can be expected from an unimportant section of the profession which makes up in obstreperousness and bad language what it lacks in numbers and intelligence”.

How better to end than with an obituary in the all-too-plain language of the day, expressing regret at the passing of a Melbourne specialist, who died on holiday in England: “For, although as a contributor to the sum of medical knowledge, Mr Whitcomb cannot be said to have taken a prominent position, he had practised long and successfully in this city . . . and at the Medical Society dinners . . . could be relied upon . . . to take part in the more convivial division of the festivities”.

It seems the secret to successful practice in the 1870s was very similar to today’s — work hard, look after your patients, control your own fees and stay out of court. A little advertising didn’t go astray even in those times, and many speeches deploring medical men appearing in the press to announce their latest breakthroughs and triumphs were disdainfully reported. Ego was never far from the surface, often manifested as professional pride. Doctors tempered their independence with compassion and were more caring than commercial, as well as irascible, difficult to lead and organise, contemptuous of government and very opinionated.

What has changed?

Alfred Hospital circa 1875. Nosocomial infections were never as rife at The Alfred as at Melbourne Hospital. In the 1880s the Herald newspaper advocated that people carry cards reading “If any accident should happen to me do not on any account take me to the Melbourne Hospital”.14 © Alfred Hospital Archives.