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Before a medicine could become an imperial commodity, it first had to be made. This chapter examines the production of medicines by druggists, chemists, and apothecaries in London that together formed the beginnings of an industry. It underscores topics of competition, collaboration, secrecy, investment, regulation, and taxation, while also presenting central figures in the narrative, such as Thomas Corbyn. The laboratories where medicines were manufactured appear as busy, dangerous, and generative workspaces in a distinctive medical marketplace. An attention to chemical, labor, and recordkeeping practices, for example, offer an unprecedented peek inside the early modern pharmacy. Here, those who manufactured medicines began to borrow the tactics of the mercantile house to link their businesses to financial, industrial, and state institutions as the British medicine trade reached a scope and scale unlike ever before.

The changes under way in medical training in the transatlantic world by 1830 owed much to the political and social transformations of the preceding half-century. The political revolutions of the old century, which ushered in a long period of turmoil and conflict, had been followed by a period in the early nineteenth century of reaction and consolidation, new industrial growth and the spread of cities, commercial expansion and rising prosperity, and a high degree of political turbulence in every country. No nation escaped the impact of rapid population changes, of buoyant capitalistic enterprise, of the spreading democratic tide, or of the efforts of reformers to help those most adversely affected by the urban-industrial revolution. The training of doctors was inevitably influenced by the rising power of the middle classes in Europe and America as they demanded more medical services and a higher standard of medical competence. The continued growth of industrial cities, notably in Britain, posed serious problems of public health and the medical care of the poor. By 1831, London’s population was already approaching a million and a half, and nearly half the remaining population were now living in towns of more than five thousand. The doctors most in demand in these conditions were those who joined a skill in practical medicine with a knowledge of the new practical sciences. The new studies of science, it was increasingly believed by laypeople, gave the physician a surer command of diagnosis and a better understanding of the disease process, and his practical skills assured the patient of the best possible treatment. Medicine as a practical science, in short, was seen by the public as an important advance over both the old humanistic medicine of the universities and the crude empiricism of the earlier practical schools. The triumph of the clinic and the rise of the new sciences together created a new confidence in medical education. The schools themselves were becoming more alike.

The years around 1830, as just described, were a turning point in the movement to create a more systematic and uniform approach to the training of doctors. For the next quarter-century, a battle royal raged in the transatlantic countries between those seeking to create a common standard of medical training for all practitioners and those who defended the many-tiered systems of preparing healers that prevailed in most of them. At stake were such important issues as the care of the rural populations, largely unserved by university-trained physicians, the ever larger role claimed for science and academic study in educating doctors, the place of organized medical groups in decision making about professional training, and the role to be played by government in setting standards of medical education. In Great Britain, the conflict over change centered on the efforts of reformers, mainly liberal Whigs, apothecary-surgeons, and Scottish teachers and practitioners, to gain a larger measure of recognition for the rights of general practitioners to ply their trade freely throughout the nation. Ranged against them were the royal colleges, the traditional universities, and other defenders of the status quo. Particularly sensitive in Britain was the entrenched power of the royal colleges of medicine and surgery— “the most conservative bodies in the medical world,” S. W. F. Holloway called them—which continued to defend the importance of a liberal, gentlemanly education for medicine, as well as their right to approve the qualifications for practice of all other practitioners except apothecaries. Members of the Royal College of Physicians of London, the most elite of all the British medical bodies, were divided by class into a small number of fellows, almost all graduates of Oxford and Cambridge, and a larger number of licentiates, who, though permitted to practice, took no part in serious policy discussions and could not even use such college facilities as the library or the museum. “The Fellows,” claimed a petition signed by forty-nine London physicians in 1833, “have usurped all the corporate power, offices, privileges, and emoluments attached to the College.”

There was no more turbulent yet creative time in the history of medical study than the latter years of the eighteenth century. During this troubled era, familiar landmarks in medicine were fast disappearing; new ideas about medical training were gaining favor; the sites of medical education were rapidly expanding; and the variety of healers was growing in every country. Student populations, too, were undergoing important changes; governments were shifting their role in medicine, especially in the continental nations; and national differences in educating doctors were becoming more pronounced. These transformations are the subject of the opening chapters of this book. These changes in medical education were a reflection of the general transformation of European society, education, and politics. By the century’s end, the whole transatlantic world was in the grip of profound social and political movement. Like other institutions, universities and medical schools were caught up in a “period of major institutional restructuring” as new expectations were placed on teachers and students. Contemporaries spoke of an apocalyptic sense of an older order falling and new institutions fighting for birth, and inevitably the practice of healing was also affected. From the middle of the century, the nations of Europe and their New World offspring had undergone a quickening transformation in their economic activity, educational ideas, and political outlook. By 1800, in the island kingdom of Great Britain, the unprecedented advance of agricultural and industrial change had pushed that nation into world leadership in manufacturing, agricultural productivity, trade, and shipping. Its population growth exceeded that of any continental state, and in addition, nearly three-fourths of all new urban growth in Europe was occurring in the British Isles. The effects on higher education were to create a demand for more practical subjects, modern languages, and increased attention to the needs of the thriving middle classes. Although Oxford and Cambridge, the only universities in England, were largely untouched by the currents of change, the Scottish universities, by contrast, were beginning to teach modern subjects, to bring practical experience into the medical curriculum, and to open their doors to a wider spectrum of students.

For the traditional physician of the eighteenth century, medicine was above all a humane study, mastered largely through books and the careful examination of medicine’s past and leavened now by a growing concern to know something firsthand of the feel of the human body in sickness and in health. To be a French or German or British physician in these years was to be a member of a cultural elite who, like other university graduates, found the truth in the rich treasures of ancient Greek and Latin writings. A degree in medicine was a testament of higher learning, not merely a professional qualification, and Latin was the visible symbol of that learning. Medicine was valued not so much for its efficacy in curing patients as for the knowledge it implied about the universe and humankind. Such notable figures as Quesnay, who had a medical degree, and Diderot, Voltaire, and Rousseau studied medicine as an integral part of a broad, humanistic culture. The character of a physician, wrote an English practitioner in 1794, “ought to be that of a gentleman, which cannot be maintained . . . but by a man of literature. He is much in the world, and mixes in society with men of every description.” Students were easily converted to the idea of the centrality of classical study in their lives. A young man in Edinburgh, for example, ridiculed his medical professors in 1797 for their ignorance and that of their students, who “could not translate the easiest passage in Latin.” On the Continent, a Munich professor offered at about the same time to instruct a whole class of medical students in liberal studies, since “their knowledge of the Latin language, philosophy, logic, and other general branches of education” brought “shame” to the faculty. Such complaints were frequent by 1800, revealing the growing tension between the ideal and the real in the classical training of students and professors. What kind of education, then, was suitable for a late-eighteenth-century physician? The mastery of ancient literature and medical texts was still essential to one’s status as a gentleman but was no longer regarded as the sole qualification for success as a physician.

The lives of students in all periods of history are difficult to recapture. Only scattered correspondence and occasional diaries can normally be found to give us a firsthand look at their experiences. Less satisfactory but still useful are the accounts of teachers, often written long after the events they describe, as well as the memoirs of former students, usually composed with nostalgia toward the close of their careers. Enough evidence does exist, however, to provide at least some glimpses into the student culture of past eras. In this chapter, we trace the social origins of medical students from about 1780 to 1820 and describe something of their lives in and out of the classroom as well as give some account of medical teachers and teaching of the same period. No more uncertain time in the life of a medical student can be imagined than the unsettled years after 1780. Both Europe and America were convulsed by war during much of the period and by fears of the spreading revolution in France. Students everywhere were being pressed into military service; academic enrollments dropped on both continents; and demands for military surgeons had become desperate. Deans and directors of medical schools pleaded with governments to spare their students from army service. In 1799, for example, the director of the French school at Montpellier asked his counterpart in Paris to join him in a last effort to save students from the huge call to arms of that year. Some medical schools were suddenly closed during the years of war; others were reorganized; and everywhere standards fell rapidly. Most of the small number of American schools were forced to shut down during the War for Independence and were then slow to reopen. In Great Britain, the hope of recruiting more medical students needed for war service was dashed by “the reality of low pay, lack of respect and the physical dangers facing most recruits.” In revolutionary France, the medical schools were officially closed early in the Revolution; the title of doctor was disdained by equalitarian reformers; and near chaos prevailed in the hospitals.