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This study is concerned with the development of the profession of almoner (renamed medical social worker in the 1960s) in Scotland in the period from the outbreak of the Second World War until the mid-1970s. In addition to primary and secondary documentary sources, it is based on extended interviews with practitioners of different generations, the collected personal records of individuals, and a witness seminar which involved medical social workers, members of parallel professions, and those who carried political responsibility for social work both at the Scottish Office and within the local authorities during the critical years.1 The story of the development of a small, well organized, purposeful, predominantly female, profession would be worth telling for its own sake, but there are wider implications. In the first place this is an example of a profession or, to be more specific, what we shall call an insecure profession, developing initially within one professional jurisdiction, the medical, and then switching to another, social work. As such, it offers an insight into the dynamics of professional politics. Secondly, there are social change issues and their impact on health services; all professions mirror the times in which they operate but the almoners’ experience was particularly interesting because they engaged with issues of poverty, poor housing, abortion, adoption, and domestic violence in a period when popular and professional attitudes were subject to challenge and change. Thirdly, the story carries implications for the NHS as a whole. Currently the social contexts of health and medicine are much debated and often outlined as if they rested on novel insights. In reality, there have always been individuals and organizations arguing passionately for the social dimension. By 1948 politicians and prominent physicians had identified the almoners as a way of advancing social medicine. Over the next twenty years the profession did much to justify such expectations. Almoners, or medical social workers, were never as numerous on the wards and surgeries of the NHS as they would have liked but they became a part of many medical teams and were involved in the “social” education of other health professionals, including doctors. In the late 1960s changes began which would take the profession out of the NHS and into the new social work departments of the local authorities. At the same time, the profession lost its separate identity and became part of the new generic social work profession. The developments, which in Scotland were completed with the reorganization of local government in 1975, represented, in the view of many practitioners, the moment when their profession lost its effectiveness. In discussing why this happened, it is possible to shed light on some of the difficulties of embedding social considerations in the practice of health care. The significance of this debate becomes clear when we note the striking parallel between what have recently been identified as key service weaknesses and what the almoners were trying to promote: an informed social input into clinical decisions on wards and in surgeries, and continuity of care linking primary and secondary, health and welfare, and state and voluntary services. Not for the first time, the intricacies of professional politics appear to have thwarted desirable ends. That the activities of almoners promised not only better but also more cost effective care only adds a degree of mystery.

Le taux eleve de mortalite infantile dans les familles ou la mere ne pouvait allaiter ses enfants a pousse a l'utilisation de laits artificiels. L'amelioration de leur valeur nutritive a ete une grande bataille scientifique

Quels sont les mecanismes qui determinent l'apparition et le developpement d'une decouverte scientifique? Pour repondre a cette question, l'exemple de deux enzymes, la papain et la monoamine oxidase, est analyse

In June and July of 1858, oppressed by one of the hottest summers on record—a summer which, among other things, required parliamentary staff to hang lime-soaked cloths across the riverside windows of the Houses of Parliament to filter out the stench of a 20 per cent concentration of sewage in the Thames1—the United Kingdom parliament agreed to the passage of a Medical Act. The Act gave statutory recognition for the first time to a distinct occupational category of “legally qualified Medical Practitioner” “entitled according to his Qualification to practise … in any Part of Her Majesty's Dominions”. It also set up a general medical council with powers to monitor standards of professional training, to register qualified practitioners, and to de-register practitioners found guilty of criminal acts or of “infamous conduct in any professional respect”.2 The Act fell far short of the hopes of some of its medical promoters, especially those who had campaigned for the criminalization of “quackery”. Yet it was also the first major bill for medical reform to be passed, after sixteen unsuccessful attempts over the previous eighteen years, and it was in large part for that reason that seasoned campaigners for medical reform such as Thomas Wakley were content to argue that half a loaf was better than none. In similar fashion, more recent historians of the nineteenth-century medical profession have been luke-warm in their evaluation of the Act's significance. They tend to point out all the contextualized ways in which the emergence of a unified profession was destined to happen, with or without legislative encouragement, before grudgingly admitting that, if there is a foundation law of state recognition of the modern British medical profession, then the Act of 1858 is it.3 In short, the 1858 Medical Act has generally been presented as a disappointment, both to promoters of medical reform at the time of its passing, and to historians of an emergent British medical profession since. This article approaches the negotiations surrounding the achievement of state recognition of “medical professionalism” from a different perspective. My aim is to argue for the fruitfulness of an approach to the Act of 1858 which begins from the assumption, not that the Act was “defective”, but that what needs investigating and explaining is why it emerged in the shape that it actually took. This approach requires some preliminary clarification of the terms in which the debate was conducted—the rhetoric of “medical reform”. It also requires as much attention to be paid to the mental world of the law-makers as to the expressed and implied goals of advocates (and opponents) of medical reform within the emergent medical profession. Finally, it requires an exploration and evaluation of the nature and underpinnings of medical authority in early and mid-Victorian times. Part of an explanation—a significant part of an explanation for the dismissive historical evaluation of the Act of 1858 it will eventually be seen—lies in the assumptions about the nature of professional authority applied, retrospectively by historians, on the basis of a belief that professionalism denotes a set of ideal characteristics relatively static in meaning over (modern) historical time. As recent historians of science and medicine have reminded us,4 this is a recipe for the involuntary importation of teleology—assumption of end intentions—into historical analysis, as indeed frequently happened over the formative generations of the social history of medicine. The first generation, broadly speaking, assumed that professional status relied on the proof of ever-widening advances achieved by specialist division of labour, and identified the recognition of medical professionalism as an aspect of progress towards modern science-based standards of control over human suffering; a second, Foucault-assisted generation, assuming in professional status a mutation of “knowledge” into “power”, identified this process of recognition as a technique of “social control” by the self-interested over the manipulable.5 In counterpoint to these dominant narratives, there have been, from time to time, those who have recognized that professional authority, however defined, rests on more than professional assertion—that it requires some measure of cultural acceptance as well.6 Such acceptance will be evident in historically specific ways, including a society's views on the nature of health and illness, on the nature, purpose and degree of necessity of suffering, and on the plausibility of medical claims to specialist expertise. The exploration of the Act of 1858 undertaken here attempts to apply these latter insights, aiming to be sensitive to the possibility that in debating, and eventually passing, a distinctive version of medical reform in 1858, MPs were acting to mediate, not just between divergent strands of a still fluidly defined profession, but between professional and lay conceptions of the role of the medical practitioner as well.

A history of accident and emergency medicine, 1948–2004 traces the development in the UK of that specialty. “A&E is a curious specialty” in that whilst most specialties originated out of increasing sub-specialization, A&E was born out of the need to provide immediate and broad coverage of acute disease and injury in all body systems (p. xii). The author, Dr Henry Guly, has been, over the last three decades, a central figure in this developing area of health care, having held a consultancy in A&E since 1983. Drawing on the archives of the Royal Colleges, the British Association for Emergency Medicine, and other involved bodies—and on his own participation in and considerable personal knowledge of events—he meticulously documents the struggles within the NHS, with other specialties, and within the specialty itself, which gave rise to A&E as a medical specialty and the A&E as a health care institution. Guly begins by reviewing the state of casualty services between the 1948 founding of the NHS and the Platt report of 1962. The Report of the Standing Medical Advisory Committee on Accident and Emergency Services by Sir Harry Platt is cited as the crucial point at which “casualty” services began to be reconfigured around a more specific concept of “accident and emergency”. In the 1950s, postings in casualty departments were unpopular, and staffing was through rotas of attending GPs, house surgeons, and casualty officers with joint appointments in other specialties. Throughout the 1960s, orthopaedic surgery, general surgery and anaesthesia vied, often quite robustly, for leadership in this area of health care. However, in 1966, Senior Casualty Officers formed the Casualty Surgeons Association (now the British Association for Emergency Medicine). Familiar with the reality of the A&E, where care involved not only trauma but medical, paediatric, psychiatric and social problems, Senior Casualty Officers recognized that such work required specialist expertise not encompassed by any one of the traditional specialties. They lobbied for the creation of A&E positions within hospitals at the consultant level. Between 1971 and 2001, A&E became the fastest growing specialty in the UK, with consultant positions increasing from an initial 32 to just under 500. However, the battle for control of the specialty by its own members was a long one. Though Edinburgh established an FRCS in A&E in 1981 and, in England, a Faculty of Accident and Emergency Medicine was established in 1993, it was not until 2003 that the specialty gained full control over its own training programmes, exams, and entry requirements. Most of the book is concerned with detailed descriptions of individual battles lost and won in this long process. In the latter chapters of the book, Guly goes on to describe the implications for the specialty of changes in pathology, work patterns, and medical practice over the last thirty years. In particular, he singles out the expanding role of the A&E in primary care, increased acuity of medical problems, a relative decrease in trauma, limited availability of GPs out of hours, and an aging population. As Guly himself points out, his book has a narrow focus. It does not set out to examine the progress of the specialty in other countries, nor is it intended to address the larger questions of relations between health care demand, demographics, economics, technologies, etc. It is not intended as a social history of A&E, nor as a theorization of disciplinary formation. Rather, it is an internalist history dealing specifically with “the battle to get the specialty recognized” (p. xiii). As such, it is a careful documentation of precisely that. It should be of interest to practitioners within the specialty of A&E, and of value to those involved in research on emergency medicine, the NHS, and the development of disciplines in general.