Decapitation after death by hanging. So directed the judge in sentencing the Cato Street gang who plotted to assassinate Lord Liverpool and his cabinet in February 1820.1 Reporting this gruesome public execution, the Morning Chronicle speculated that the masked man who decapitated the bodies was a young surgeon living at 5 Argyll Street near Oxford Circus.
During the night of 26 August 1820, revengeful supporters of the executed gang went to 5 Argyll Street – the home of Thomas Wakley. They stabbed him, bludgeoned him and set his house ablaze. But despite serious injuries, Wakley escaped the inferno and survived the brutal assault.2 This resilient, determined and principled man then set about reforming medical professionalism.
An irresponsible, unreformed monstrosity
Thomas Wakley (1795–1862), youngest son of a prosperous Devon farmer and his wife, became a member of the Royal College of Surgeons in 1817. He was elected Member of Parliament for Finsbury in 1835 and played a leading role in social reform. In 1839 he became coroner for West Middlesex, as the first medically qualified coroner in England. However, in the medical arena, Wakley is remembered mainly as the founder and inaugural editor of The Lancet, first published in 1823.3
Wakley named his radical journal after the knife used for lancing abscesses and releasing their foul contents, akin to his editorial objectives. The Lancet’s most notorious early achievement was exposing what Wakley regarded as corruption at the core of his profession – the medical royal colleges. His most vitriolic criticism was directed at the Royal College of Surgeons: ‘the Council of the London College of Surgeons remains an irresponsible, unreformed monstrosity in the midst of English institutions – an antediluvian relic, in human institutions, of all that is most despotic and revolting, iniquitous and insulting, on the face of the earth.’4
How did these august professional bodies come to be so despised by Wakley?
Diligently and expertly examined
The earliest proposal for medical regulation in England was in 1421, when physicians petitioned Henry V: ‘that no man… practise in Physic… but he have long time used the Schools of Physic within some University, and be graduated in the same… and that no Woman use the practise of Physic under the same pain [i.e. imprisonment and fine].’5
Although unsuccessful, the petition is revealing. First, this regulatory initiative came from medical men – an early manifestation of their professionalism. Second, the university-based criterion couldn’t apply to surgeons; they trained by apprenticeship (hence ‘Mr’ rather than ‘Dr’). Third, the discrimination against women continued for centuries thereafter. Not until 1909 did the Royal College of Physicians change its byelaws to admit women. Another 20 years elapsed before the first woman was elected to fellowship.
The first statutory medical regulation in England came in 1511. Henry VIII empowered bishops with the authority to license physicians. In London, medical licences were issued by either the Bishop of London or the Dean of St Paul’s.6
The oldest college, the Royal College of Surgeons of Edinburgh, originated in 1505 as the Incorporation of Surgeons and Barbers. The Seal of Cause issued by Edinburgh Town Council stated that no person ‘practise any points of our said craft of surgery… unless he be worthy and expert in all points belonging to the said craft, diligently and expertly examined and admitted by the Masters of the said craft’. Placing the assessment of surgical competence in the hands of experienced practitioners was a key principle adopted thereafter by all medical royal colleges.
Physicians in London led by Thomas Linacre petitioned Henry VIII for a college to issue licences. Thus, in 1518, the Royal College of Physicians (London) was established by royal charter, extending its authority throughout England in 1523. The Royal College of Surgeons (England) emerged in the 18th century from the Company of Barber-Surgeons founded in 1540. Likewise, the Worshipful Society of Apothecaries separated from the Grocers Company in 1617 and was authorised to issue licences by the Apothecaries Act 1815.
Tribalism, elitism and nepotism
Unfortunately, the colleges and their licensing regimes engendered tribalism. The specialties became professional fiefdoms and colleges treated harshly those who trespassed upon them.
In 1700, John Seale, a butcher with syphilis, complained to the Royal College of Physicians because William Rose, an apothecary, had sold him a ‘Balsamic Elixir’ as a remedy, but it proved ineffective.7 The College fined Rose for practising ‘physic’ without a licence, but in 1704 the House of Lords upheld his appeal. Thenceforth, apothecaries were permitted to treat patients directly. The Rose case established apothecaries as an independent specialty from which today’s general practitioners evolved.
Although the Royal College of Physicians issued licences to practise, originally only licentiates who were Oxford or Cambridge graduates could become fellows. In 1767, dissatisfied with exclusion from the senior ranks, a mob of angry licentiates who were graduates of other universities besieged the College (Figure 1) and stormed the building: ‘With inhuman violence they broke into this very senate, like swimming sea monsters in our medical ocean!’, wrote Sir William Browne, the College President. Not until 1835 did non-Oxbridge licentiates become eligible for fellowship.
The Royal College of Surgeons provoked Thomas Wakley’s ire for several reasons. He was appalled by its council’s shameless nepotism. Demitting councillors were replaced often by close clinical colleagues or by surgical relatives – a self-perpetuating cabal. Membership candidates were required to attend lectures for which fees were charged, but only those lectures given by council members were approved, thereby ensuring that they profited from their own policy.
Wakley was appalled also by the colleges’ blithe indifference to quacks and charlatans, purveyors of useless and often dangerous remedies, most notably James Morison. Wakley ensured that inquests on Morison’s patients and prosecutions for manslaughter were publicised in The Lancet.8 In the 19th century, medicine was a profession divided against itself.
Together in perfect unison
Dismayed by the tribalism and disreputable governance of the colleges, Thomas Wakley proposed a new professional body – the London College of Medicine – uniting physicians, surgeons and apothecaries. ‘Here physicians, surgeons and apothecaries… may assemble on the most friendly terms, and act together in perfect unison, promoting their own respectability and enriching their stores of medical knowledge.’9 However, his bold initiative never gained sufficient support. Wakley abandoned the project but not the underlying principle.
In the late 1830s, Wakley, now an independent radical MP, began campaigning to reform medical regulation through legislation. Although illness forced him to resign in 1852, his parliamentary endeavours culminated in the Medical Act 1858, thus creating the General Medical Council (GMC), on which colleges and universities were represented. Importantly, the Act empowered the GMC to scrutinise the colleges’ procedures: ‘The several Colleges and Bodies in the United Kingdom… shall from Time to Time, when required by the General Council, furnish such Council with such Information as they may require as to the Courses of Study and Examinations to be gone through in order to obtain the respective Qualifications’.10
Mirroring increasing specialisation, many new colleges appeared in the 20th century. Some evolved from specialist societies, notably the conversion by royal charter of the British Paediatric Association to the Royal College of Paediatrics and Child Health in 1996. Others issued from an ancient college. A college for pathology specialties, formerly represented in the Royal College of Physicians, emerged in 1962 as the College of Pathologists and received its royal charter in 1970.11
In 1974, the colleges allied to form the Conference of Medical Royal Colleges, later renamed the Academy of Medical Royal Colleges. Currently, this influential body federates 24 colleges and faculties in the UK and Ireland, focusing on generic issues without compromising the sovereignty of its constituents.
All changed, changed utterly
Those words from WB Yeats’ poem Easter, 1916 titled the BMJ editor’s account of the threats to public trust in medical organisations resulting from ‘the Bristol case’.12 Sir Ian Kennedy, who chaired inquiries into paediatric heart surgery and the retention of hearts in Bristol, attributed the latter to ‘an arrogance born of indifference’ (a sentiment promptly rejected by the then President of the Royal College of Pathologists).13 Richard Horton, editor of The Lancet, echoed Wakley: ‘The leaders of the profession – the presidents of the colleges, for instance – exert enormous influence. But the system of patronage in medicine nourishes a malignant conservatism which trickles down through the ranks. Inevitably, these presidents and their institutions foster a feeling of clubbable security which preserves the status quo.’14
Trust relies on professionalism: ‘Medical professionalism signifies a set of values, behaviours, and relationships that underpins the trust the public has in doctors’.15 The royal colleges seek to contribute to professionalism and trust through their training, credentialing and standards. Mindful of Shaw’s dictum that ‘All professions are conspiracies against the laity’,16 it is welcome that since the 1990s the colleges’ ability to earn that trust has been advanced significantly by greater public and patient involvement in their work. Consequently, public trust in the medical profession generally has remained high despite the homicidal GP Harold Shipman, the ‘organ retention scandal’ and serious failings in some clinical services. Surveyed in 2018, 92% of the public trusted doctors to tell the truth; only nurses ranked higher.17
Wakley’s death and legacy
In later life, Thomas Wakley developed tuberculosis and sought better health in Madeira. There, in May 1862, he fell while disembarking a boat, precipitating a massive fatal haemoptysis. His embalmed body enclosed in a simple coffin lies in the catacomb of Kensal Green Cemetery.
Many years earlier, Wakley had been exonerated publicly from any involvement in the execution of the Cato Street gang. Rid of that myth and having survived its potentially lethal consequences, he pursued an unwavering commitment to high standards of medical professionalism by ruthlessly exposing archaic rituals in the royal colleges that were hindering their development. Had he and his likeminded colleagues not done so, the colleges might have declined irretrievably such that they became merely clubs for medical men wealthy enough to maintain them.
Past tense, future perfect?
Formerly, medical royal colleges dominated the British medical landscape unchallenged, but in the 19th century, when medical licensing and regulation transferred to the GMC, their supremacy weakened significantly. Fortunately, however, the Medical Act 1858 assured their continuing role in postgraduate training, although subject to the GMC’s oversight.
The colleges’ prosperity relies now on effective leadership in specialist training and professional standards and in advocacy for the disciplines they represent.18 Colleges must also nurture strong relationships with the public and patients, with their professional memberships and with other organisations and agencies. As befits their charitable status, the colleges come to be respected as independent sources of authoritative advice.
When founded 500 years ago, the Royal College of Physicians had no lawful authority beyond seven miles from London. Now the influence of UK medical royal colleges extends internationally. Nevertheless, even those working in the UK sometimes feel remote from their London-based colleges, and not just because some regard (mistakenly) their institution as a building. The professional membership is the college.
Based on a public lecture given by the author on 5 January 2019 at the Thackray Medical Museum, Leeds.