Introduction

The GMC proceeded with redefining how overseas-trained doctors gained access to the register at a moment of political crisis within British medicine. On November 23, 1972, Secretary of State for Health and Social Security Sir Keith Joseph announced in Parliament the appointment of a committee of inquiry into the regulation of the medical profession. The committee, chaired by Sir Alec Merrison, was created to follow up on a pledge by Joseph's predecessor, Richard Crossman, in March 1969, during the continuing dispute between the BMA and the GMC over the retention fee. Crossman had urged the association leadership to find common ground with Lord Cohen to resolve differences over the governance structure and functions of the GMC. Working groups had reached consensus on a host of items—including the centrality of an independent body to regulate the medical profession—prior to Secretary Joseph's announcement. But the hardening of opposition to the fee among a core element within the BMA membership, together with the intention of the GMC to remove nonpayers from the register, effectively doomed compromise. The specter of an apparent breakdown in the regulation of the profession was not without liabilities for the government. While the number of doctors to be potentially removed was not definitively known, even the possibility carried the threat of a contraction in the supply of registered doctors and a possible interruption in the delivery of health care to the public. At a minimum, the appointment of the Merrison Committee was a means to defuse a crisis while grounding any proposed changes to the regulation of the profession in the judgment of a nonpartisan body that represented a cross section of the public and the profession, but neither the GMC nor BMA.

The inquiry was unprecedented in the longer than 150–year history of the GMC. Although the GMC would be subject to prolonged scrutiny, council president Lord Cohen and his successor, Sir Richardson, welcomed the inquiry. This was not simply a matter of putting on a brave face in a difficult situation. However much the GMC and the BMA were at odds about governance and oversight functions, there was broad agreement on at least two principles.

PERFORMED roughly seven years apart, during a period that saw a hierarchically ordered culture undergoing intensely felt alterations, The Revenger's Tragedy (c. 1606) and The Duchess of Malfi (c. 1613) would be hard pressed to place a more pessimistic construction on the relations between the social strata of the societies they dramatize. As early as 1938, L. G. Salingar, focusing on shifts in economic paradigms, argued that The Revenger's Tragedy revealed its author's loathing of nothing less than “the disintegration of a whole social order.” Almost fifty years later, Frank Whigham, focusing on the defensive posture of the aristocracy, made a related but more specific point about The Duchess of Malfi: the play represents “a status-group withdrawal from responsibility to the larger social body.” Clearly a murderous class antagonism lies at the heart of both plays, one that cuts in contrasting ways. In The Revenger's Tragedy, Thomas Middleton portrays the lower-status Vindice as he seeks to protect his family's honor against a predatory aristocracy, wreaking revenge in the most horrific manner that his considerable wit can bring about. In The Duchess of Malfi, John Webster portrays male members of the aristocracy, brothers Ferdinand and the Cardinal, who go to vicious lengths in order to protect their family's purity from the corrupting infiltration of their social inferiors. A search for the mechanisms of class-based violence locates easily the sister as the vulnerable site in both plays. Less obvious, but more crucial to both Middleton's and Webster's diagnosis of this violence, is their relational construction of identity, found most clearly in the relation between brother and sister. This principle works in both plays, first to set the machine in motion and then to define the destruction that follows as suicidal in kind.

Although the plays differ with regard to which class sees itself as subject to the corrupting influence of the other, in both, the sister is portrayed as an extension of the brother, who must guard this shared identity against invasions by another class. In both plays, the brothers' defense of the family, understood to have a communal identity, entails violence aimed not only at the male members of the interloping class, but also at the female members of their own family. Thus they are shown to attack the very means by which they hold their identities.

Introduction

The 1886 Medical Amendment Act reinforced the political nature of British medicine. The extension of reciprocity made possible through part 2 of the 1886 Act provided Britain with a mechanism to protect and project its interests in the world, including securing the right to practice abroad for British registered doctors, ensuring access to British medical services for the well-being of tourists and health restoration of the chronically ill living or traveling abroad, and building and sustaining strategic partnerships with territories inside and countries outside the empire.

Yet for all of the benefits associated with reciprocity, the expansion of the jurisdiction of British medicine was not without tension or conflict between the GMC and the state. Reconciling state interests in the world within the framework of the medical register, whose purpose was to serve the public by privileging British doctors, did not always align due to the uneven division of responsibility concerning the jurisdiction of British medicine. The government extended reciprocity as an act of state, and the GMC recognized the medical degrees awarded in a participating territory or country for purposes of admission to the register. Concerns about opening the domestic market to overseas-trained doctors as well as the equitable treatment of British doctors in reciprocating countries surfaced in deliberations and consultations about extending reciprocity. At the same time, enforcing the rights of doctors on the register to the unrestricted practice within the jurisdiction of British medicine was a constant preoccupation of the council. While the reciprocity agreements that Britain entered into created one of the largest medical markets in the world, participating colonial professions attempted to protect their local markets from the resulting competition by mandating conditions that either privileged local graduates or doctors who qualified or worked in the United Kingdom exclusively.

As I will show in this chapter, these reciprocating relationships proved to be critical to Britain during World War I. By the 1890s, the trend in new domestic admissions to the register settled into a fairly reliable annual average of 1,200. This number replaced total departures due to death or retirement, leaving a slight surplus of 300. The relatively tight supply of doctors contributed to the improved economic rewards of medicine before the outbreak of war in 1914.

Introduction

As the place of overseas doctors became politically contentious within and outside of the medical profession, the liminal place of the GMC between the state and the profession made it highly sensitive to political pressure. To be sure, the council possessed regulatory authority. But the effective power of the GMC was minimized by its constitutional subordination to the Privy Council, not to mention the government's legislative mandates. Its capacity for independent action was diluted further by the autonomy of university and nonuniversity licensing bodies, which comprised the majority of the representatives on the council. Nonuniversity licensing bodies, for example, were able to use their own discretion in determining whether the conditions for requalification had been met by overseas candidates, relying on their expertise in assessing candidates’ professional experience.

Furthermore, the virtual absence of supplementary sources of funding curbed the GMC's capacity for pursuing independent initiatives. Until the establishment of the category of temporary registration for overseas doctors, the GMC had maintained a hand-to-mouth existence. To subsidize its operations, the GMC relied on the one-time fee for life paid by domestic medical graduates who were admitted to the register to subsidize its operations. Fees from overseas doctors proved advantageous in the short run but were not a permanent solution to financial stability as hostility against nonwhite Commonwealth immigration grew. Indeed, one unintended consequence of the 1962 Commonwealth Immigration Act, which mandated work vouchers for all Commonwealth immigrants, was the drop in the number of overseas doctors seeking admission to the register. As costs associated with the operation of the GMC continued to climb, this reduction of revenue spurred the council to look to the domestic medical profession for a more reliable source of support.

The development of a more regular source of revenue would produce a trade-off for the GMC: financial security heightened scrutiny from organized medicine. In 1966 the council proposed a new retention fee. Instead of a one-time fee for life, all doctors would now be required to pay an annual fee to remain on the register and continue to be legally entitled to practice medicine.

Introduction

As the interwar landscape of international politics rapidly shifted from the threat to the reality of a second global war, the influence of British medicine was once again challenged, from the plight of Jewish medical refugees in the United Kingdom before the war to the wartime need to supplement the domestic supply of doctors. The register proved to be a rather flexible instrument in accommodating overseas-trained and refugee doctors, in large part due to the multiple points of entry to the medical market, yet the conditions under which refugee doctors were admitted to the register and legally entitled to practice medicine were not identical. Institutional interests and national needs shaped whether or not the register differentiated overseas doctors from domestic doctors in ways that assimilated or marginalized them in the community of British medicine. As I will show in this chapter, the experience the council gained in internationalizing the register during wartime established a precedent for a new postwar registration category for overseas doctors. Temporary registration, which became available with the passage of the 1948 Medical Act, combined access to medical labor with restrictions on where and how long overseas doctors could practice medicine in the United Kingdom.

More so than any other group, Jewish medical refugees from the early 1930s on were vulnerable to differential treatment. Fleeing brutal persecution in Germany, Austria, and later Italy, Britain only permitted a fraction to enter as aliens. Stateless and subject to Home Office employment restrictions, these doctors and medical students who sought to practice medicine in the United Kingdom had few choices beyond requalification. As Kenneth Collins and other scholars have documented, nonuniversity licensing bodies in England and Ireland were resistant to calls from the government to accommodate more Jewish aliens. At a moment when the economy was struggling to recover from depression, any increase in the number of doctors beyond replacement levels raised competition anxieties. When the refugee crisis appeared to grow rather than decline, accommodation was seen as a precedent that was liable to change the ethnic composition of British medicine.

There's no continuity between the two installments of Don Quijote that were published ten years apart—part 1 in 1605 and part 2 in 1615. Similar episodes appearing in both parts are often distinguished by the radical differences of context and atmosphere. Though in its concluding chapters the mood of part 1 approaches that of part 2, the two installments are separated by a quantum jump that closes off the world and order of the first from those of the second.

Cervantes's attention to the serious problems of life is clearly more intense and unremitting in part 2. By “serious problems” I don't mean pratfalls, broken ribs, and missing teeth, which are scattered throughout part 2 as well as part 1. Rather I mean hurt feelings and insecurity; the failure of trust and communication; the breakdown in human relations occasioned by bad faith, lack of self-control, and loss of respect for self and others. At the sociopolitical level, these serious problems are connected in part 2 with poverty, lawlessness, war, the decadence of a bored and idle aristocracy, and the eviction of the Moors from Spain.

Since the differences between the two parts are compactly illustrated in their respective prologues, I'll begin by comparing them. Most of the first prologue is given over to poking fun at the pedantry and elaborate fanfare with which authors of the time decked out their books: sonnets, epigrams, eulogies; marginal glosses; the liberal citation of biblical and classical texts; the lip service paid to authority; the extravagant display of useless learning. Cervantes pretends that while he's despairing over his inability to write a proper prologue, a friend comes in “unexpectedly” and saves him by suggesting a simple expedient: “If you can't get anyone to write commendatory verses, write them yourself and palm them off on someone else.” Here he cites two outlandish candidates, Prester John and the emperor of Trebizond (C27).

“As for citing in the margins,” he continues, “all you have to do is throw in a few pat phrases or bits of Latin that you know by heart, and someone is sure to take you for a scholar. To make footnotes possible, work some footnote-worthy references into the text. If you want to refer to authors who will lend authority to your work, simply find a book that cites them all from A to Z, beginning, of course, with Aristotle.

Introduction

For critics of the GMC, overseas doctors of color signified the collapse of the historical boundaries of nation and empire that had long restricted the practice of British medicine domestically to a distinct social group. Rather than expanding these boundaries in order to privilege white male doctors in the broader world, the register now facilitated the globalization of the profession within the domestic sphere. In aggregate, overseas doctors accounted for 51 percent of all admits to the full register between 1955 and 1966. Among member states in the Commonwealth, India and Pakistan were the leading exporting countries. In the medical and lay press, Indian and Pakistani doctors were unfavorably compared with doctors from nonreciprocating countries in Europe who practiced medicine under the far more restrictive terms of temporary registration. Their entitlement to full registration was deemed as little more than an obsolete privilege of a bygone imperial era when British doctors controlled the portals to Western medicine in colonial India. Decolonization not only yielded the modern nation-states of India and Pakistan but, it was feared, also diluted British medicine due to the purported national differences in medical education overseas.

Rendering these doctors into a globalized workforce suitable for Britain would involve dismantling their historically constructed access to the register as equals to domestic graduates. The retraction of reciprocity and the withdrawal of recognition would restrict medical graduates of India and Pakistan to the temporary register. Just as political imperatives informed the historical basis for opening the register to them, so too did the decision to narrow it. Even though calls for reforming the system of registration were framed in terms of buttressing the standards of medicine and ensuring patient safety, the GMC and policy makers were mindful of the internal contradictions of postwar British medicine: Britain's dependence on overseas medical labor in the face of growing demands from both the medical profession and the public to control that workforce. Although the respective decisions by the government to retract reciprocity from Pakistan in 1972 and by the GMC to withdraw recognition from Indian medical schools in 1975 were procedurally different, the net effect was the same: channeling access to the temporary register while keeping overseas medical labor under strict control in Britain.

Since the 1950s, the presence of overseas-trained doctors of color in the National Health Service in the United Kingdom has attracted persistent attention. Their numbers, countries of origin, training and credentials, right to practice medicine, and cultural competency have all been featured in the medical and lay press. This attention to overseas doctors, a designation that includes doctors from within and outside of the British Commonwealth or former empire, certainly reflects the unprecedented pace of the globalization of the medical profession since World War II, not to mention the rise of a multiracial, multiethnic postwar society. The meaning of the term overseas doctors is not limited to merely describing visible changes in the diversity of the profession. It also extends to affirming presumed certainties about the identity of British medicine. The undifferentiated description of national origins as “overseas” obscures the historical connection between British medicine and its former empire in South Asia. In highlighting heterogeneity, the term also implicitly renders the domestic profession as a homogenous social unit, bounded by the distinctive experience of the British Isles. In other words, collapsing the place of origin into a single modifier “overseas” reinforces the assumption that membership in the community of British medicine is determined by birth and training in the United Kingdom while masking the influence of the wider world in the making of British medicine.

In this book I examine the ways in which the boundaries of nation and empire have influenced the scope of British medicine in the world and as a social institution domestically. Fit to Practice is an institutional history of the General Council of Medical Education and Registration of the United Kingdom (GMC) and its management of the register between 1858 and 1978. As provided for in the landmark 1858 Medical Act, the register was more than a listing of doctors with approved medical qualifications; it also functioned as a common or national portal of entry into the profession for medical graduates from England, Scotland, and Ireland. The register defined the national and imperial boundaries of the jurisdiction of British medicine and membership within it, not only mediating where British medical graduates could practice medicine in the world, but also who was fit to represent British medicine domestically.

Introduction

Nation and empire defined the boundaries of medicine in the United Kingdom. But these boundaries did not encompass a unified or British jurisdiction until 1858. Instead, there were informal and formal jurisdictions. University medical degrees as well as diplomas and certificates awarded by professional colleges in England, Scotland, and Ireland controlled access to medical markets in the archipelago and state-mandated medical services in the empire. The Medical Act of 1858 altered this landscape. It provided for a unified jurisdiction and a single market through the establishment of a medical register. The register, which comprised a list of practitioners who were deemed “legally qualified,” operated as a common portal of entry into the medical profession for English, Irish, and Scottish medical graduates. This was only possible because university and nonuniversity licensing bodies modified their relationship with each other and the British imperial nationstate. Instead of serving their own narrow interests, they now functioned as equivalent routes to a national register. The rights enjoyed by graduates were one and the same. Their qualifications guaranteed admission to the register and, most importantly, the unrestricted right to practice medicine in the United Kingdom and the territorial empire. Of course, integration did not happen overnight. But the act created a framework for it to develop. Doctors retained their national affiliation with England, Wales, Scotland, or Ireland while adding an imperial or British identity. The combination of a common portal and a demarcated jurisdiction for the practice of medicine created the basis for a liberal imperial profession at midcentury. The scope of the authority of the British medical qualification in the world was based not necessarily on the superiority of domestic medical education per se, but rather on Britain's position as an imperial power. Any registered doctor could practice medicine wherever the Union Jack flew. The national and imperial reach of the newly formed field of British medicine therefore implicated all medical graduates and bodies in the defense and expansion of this jurisdiction.

As I will discuss in this chapter, admission to the register reinforced the social character of the profession as a space for white men.

IT has often been said of late,” observed Arthur Kinney in 1976, “that King Lear is written in the imperative mood, but it is not; its natural mood is the interrogative.” Kinney makes an apt observation, for King Lear has one of the largest proportions of questions in Shakespeare's canon, and like many of Shakespeare's plays, it is preoccupied with the rhetoric of questions and of questioning. In this paper, I argue that the use and abuse of questions in King Lear reveal Shakespeare's profound skepticism about eloquence as a gateway to, or marker of, authority and about the textbook view that rhetoric and early modern methods for teaching it are means to moral improvement. I explore the rhetorical skillfulness of Goneril and Regan and discuss their proficiency in imitation, which Richard Halpern calls the “principle that animates not only humanist stylistics but also humanist pedagogy,” arguing that imitative practices allow Lear's daughters, as students of rhetoric, to create their own voices through the voices of others. As good grammar school students, they borrow the language and styles of their elders, particularly their habits of questioning, and begin to develop patterns of speech that both emulate and transform their models. The speech of Lear's rhetoricians, like Shakespeare's plays themselves, is both imitative and innovative, copied and original. The rhetorical skill of Goneril and Regan that allows them to adopt and manipulate the speech patterns of their father ultimately facilitates their rise to power. The rhetorical education of these characters has produced subjects who are skilled in imitating obedience to authority, able to mask their subversive tendencies with an outward show of deference when such a show is warranted but also able to throw it off when such deference is no longer useful.

King Lear's concern with rhetoric is apparent from its very first scene in which Lear makes of his daughters an unusual request:

Introduction

DIEGO Velázquez (1599–1660) is generally regarded as the greatest painter of seventeenth-century Spain. He is celebrated for elevating the status of art to an honorable endeavor and that of the artist to a nobleman as seen in his extraordinary self-portrait, Las Meninas (The Maids of Honor; fig. 1). While the cultural contexts of Velázquez's formative years in Seville and mature career at Philip IV's court in Madrid have been the subjects of important publications, many questions remain to be addressed about Velázquez's intellectual life. Published documents relating to Velázquez's later years in Madrid primarily pertain to his handling of the logistics of the court in his administrative capacity as aposentador (or court chamberlain) and tell scholars very little about the painter's views on art. The prevailing image of Velázquez in the art historical literature is that of a painter and courtier, whose social climbing paradoxically curtailed his artistic production.

Velázquez's persona as a reader and thinker, however, warrants fuller discussion. Cultural historian José Antonio Maravall placed Velázquez in the intellectual world of the seventeenth century but without much regard to how the artist's style reflected his complex ideas. In reconsidering the erudite aspects of Velázquez's art, the inventory of his library is perhaps the sole document that concretely identifies the varied printed sources that shaped his ideas. On August 18, 1660, twelve days after the artist's death, the Madrilean notary Juan de Burgos drew up an inventory at the request of the nobleman and secretary of the treasury Gaspar de Fuensalida and the painter Juan Bautista Martínez del Mazo, Velázquez's son-in-law. These books were among the possessions that Velázquez kept in his apartment in the Casa del Tesoro within the royal complex of the Alcazár, the interior of which is represented in del Mazo's family portrait, The Artist's Family (1659–60; Oil on canvas, Kunsthistorisches Museum, Vienna).

Currently housed in the Archivo Historico de Protocolos in Madrid, the actual inventory of Velázquez's library was first located by Francisco Marin, an archivist at the Biblioteca Nacional de Madrid, who presented his findings during a lecture on Velázquez's mentor, Francisco Pacheco. Thereafter, it was published in 1925 by art historian Francisco Javier Sánchez Cánton.

Introduction

The influx of foreign doctors into Britain was unprecedented in the post– World War II era. By 1955, overseas doctors—fully and temporarily registered— in aggregate far exceeded the annual production of domestic medical graduates. Their presence was no accident. The register continued to serve the national interest of Britain and British medicine even as the empire rapidly contracted. Technical assistance in the form of medical training constituted a major component in sustaining relations among member countries, including new Commonwealth countries in Africa and Asia that obtained their independence after the war. In addition to government-sponsored exchanges and training schemes abroad, domestic professional colleges and hospitals participated in the delivery of assistance to sponsored and unsponsored doctors. Indeed, overseas doctors who returned home with professional experience or additional qualifications advanced Britain's postwar vision of itself as a postimperial world power.

Besides buffing its image, technical assistance translated into an enormous transfer of wealth to Britain from donor countries. Indeed, the labor of overseas doctors was indispensable to the National Health Service (NHS). Launched in 1948, the NHS fulfilled a wartime pledge of comprehensive social security for all British citizens as outlined in the 1942 Beveridge report. Organizationally, the NHS consisted of a hospital service and a network of private practices that contracted with the government. But the delivery of medical care was ultimately dependent on a steady supply of doctors, especially in the hospital service. Even after mandating a preregistration yearlong hospital rotation for all medical graduates in 1952, growing use of services exposed the structural imbalance between the demand and supply of medical labor. Here overseas doctors supplemented the domestic profession. By 1960 they accounted for nearly 40 percent of the medical staff in the junior or training grades. In accommodating the training aspirations of overseas doctors, temporary registration afforded hospitals with an elastic supply of doctors to deliver health care to the public. These doctors provided care in underserved urban and rural hospitals. Their conditions of registration ensured that they would be under the supervision of a senior British member of the hospital staff and would not compete with domestic medical graduates who pursued career advancement in the service or practiced medicine privately.

IN Antony and Cleopatra, Shakespeare represents the effects of global interconnectedness and mobility, but he also raises the issue of how to sustain a sense of the local and maintain our own “little world” when global forces of empire expand their reach. Lucy R. Lippard defines the “lure of the local” as “the pull of place,” “the need to belong somewhere.” In this essay, I want to explore the extent to which the global meets the local in Shakespeare's Antony and Cleopatra, a “nexus” between the restlessness and mobility of an expanding colonial empire and a desire for permanence and rootedness. In a more specific context, Shakespeare associates the lure of the local with Egypt and grounds it in Egyptian cultural traditions and practice, which resist Rome's global influence and military hegemony. When Cleopatra insists on commanding her own troops, side by side with Antony, into battle, she argues that she bears “a charge” in the war, and that, “as the president of [her] kingdom,” she will appear on the battlefield “for a man” (3.7.19–23). The play raises a fundamental question about what it means to “preside” over and be a “guardian” of such a world.

Immanuel Wallerstein, in his seminal work on global systems theory, argues that “globalism” refers to a period of transition and of processes that initiated around 1450 and extend to the present day. Jyostna Singh describes the early modern period as an age of transition and of paradigm shifts, and situates England's “emerging role in the complex of travel and traffic in diverse regions and nations.” As Barbara Sebek argues, the forces of globalism in the period from 1550 to 1700 met with “cultural ambivalence, if not outright condemnation, prompted by the period's unprecedented commercial expansion.” Like Wallerstein, Sebek argues that “the early processes of globalization must be viewed as intertwined economic and cultural phenomena.” In Antony and Cleopatra, however, Shakespeare does not seem interested in economic phenomena of Rome's expansion into Egypt, although he may be reflecting the anxieties associated with global trade. Rather, in this play, Shakespeare focuses on sites of cross-cultural and transnational encounters through which he localizes and explores a global/local nexus. Throughout the play, Rome, which is intensely preoccupied with global politics, asserts its emerging military power over the entire Mediterranean basin and beyond.