Chapter 20

Now let me add one other word, and that is, that if I were a despot, I would cut down these branches to a very considerable extent. The next thing to be done beyond that which I mentioned just now, is to go back to primary education. The great step towards a thorough medical education is to insist upon the teaching of the elements of the physical sciences in all schools, so that medical students shall not go up to the medical colleges utterly ignorant of that with which they have to deal; to insist on the elements of chemistry, the elements of botany, and the elements of physics being taught in our ordinary and common schools, so that there shall be some preparation for the discipline of medical colleges. And, if this reform were once effected, you might confine the "Institutes of Medicine" to physics as applied to physiology--to chemistry as applied to physiology--to physiology itself, and to anatomy. Afterwards, the student, thoroughly grounded in these matters, might go to any hospital he pleased for the purpose of studying the practical branches of his profession. The practical teaching might be made as local as you like; and you might use to advantage the opportunities afforded by all these local institutions for acquiring a knowledge of the practice of the profession. But you may say: "This is abolishing a great deal; you are getting rid of botany and zoology to begin with." I have not a doubt that they ought to be got rid of, as branches of special medical education; they ought to be put back to an earlier stage, and made branches of general education. Let me say, by way of self-denying ordinance, for which you will, I am sure, give me credit, that I believe that comparative anatomy ought to be absolutely abolished. I say so, not without a certain fear of the Vice-Chancellor of the University of London who sits upon my left. But I do not think the charter gives him very much power over me; moreover, I shall soon come to an end of my examinership, and therefore I am not afraid, but shall go on to say what I was going to say, and that is, that in my belief it is a downright cruelty--I have no other word for it--to require from gentlemen who are engaged in medical studies, the pretence--for it is nothing else, and can be nothing else, than a pretence--of a knowledge of comparative anatomy as part of their medical curriculum. Make it part of their Arts teaching if you like, make it part of their general education if you like, make it part of their qualification for the scientific degree by all means--that is its proper place; but to require that gentlemen whose whole faculties should be bent upon the acquirement of a real knowledge of human physiology should worry themselves with getting up hearsay about the alternation of generations in the Salpae is really monstrous. I cannot characterise it in any other way. And having sacrificed my own pursuit, I am sure I may sacrifice other people's; and I make this remark with all the more willingness because I discovered, on reading the names of your Professors just now, that the Professor of Materia Medica is not present. I must confess, if I had my way I should abolish Materia Medica [1] altogether. I recollect, when I was first under examination at the University of London, Dr. Pereira was the examiner, and you know that Pereira's "Materia Medica" was a book _de omnibus rebus_. I recollect my struggles with that book late at night and early in the morning (I worked very hard in those days), and I do believe that I got that book into my head somehow or other, but then I will undertake to say that I forgot it all a week afterwards. Not one trace of a knowledge of drugs has remained in my memory from that time to this; and really, as a matter of common sense, I cannot understand the arguments for obliging a medical man to know all about drugs and where they come from. Why not make him belong to the Iron and Steel Institute, and learn something about cutlery, because he uses knives?

But do not suppose that, after all these deductions, there would not be ample room for your activity. Let us count up what we have left. I suppose all the time for medical education that can be hoped for is, at the outside, about four years. Well, what have you to master in those four years upon my supposition? Physics applied to physiology; chemistry applied to physiology; physiology; anatomy; surgery; medicine (including therapeutics); obstetrics; hygiene; and medical jurisprudence--nine subjects for four years! And when you consider what those subjects are, and that the acquisition of anything beyond the rudiments of any one of them may tax the energies of a lifetime, I think that even those energies which you young gentlemen have been displaying for the last hour or two might be taxed to keep you thoroughly up to what is wanted for your medical career.

I entertain a very strong conviction that any one who adds to medical education one iota or tittle beyond what is absolutely necessary, is guilty of a very grave offence. Gentlemen, it will depend upon the knowledge that you happen to possess,--upon your means of applying it within your own field of action,--whether the bills of mortality of your district are increased or diminished; and that, gentlemen, is a very serious consideration indeed. And, under those circumstances, the subjects with which you have to deal being so difficult, their extent so enormous, and the time at your disposal so limited, I could not feel my conscience easy if I did not, on such an occasion as this, raise a protest against employing your energies upon the acquisition of any knowledge which may not be absolutely needed in your future career.

* * * * *

[1] It will, I hope, be understood that I do not include Therapeutics under this head.

XIII

THE STATE AND THE MEDICAL PROFESSION

[1884]

At intervals during the last quarter of a century committees of the Houses of the Legislature and specially appointed commissions have occupied themselves with the affairs of the medical profession. Much evidence has been taken, much wrangling has gone on over the reports of these bodies; and sometimes much trouble has been taken to get measures based upon all this work through Parliament, but very little has been achieved.

The Bill introduced last session was not more fortunate than several predecessors. I suppose that it is not right to rejoice in the misfortunes of anything, even a Bill; but I confess that this event afforded me lively satisfaction, for I was a member of the Royal Commission on the report of which the Bill was founded, and I did my best to oppose and nullify that report.

That the question must be taken up again and finally dealt with by the Legislature before long cannot be doubted; but in the meanwhile there is time for reflection, and I think that the non-medical public would be wise if they paid a little attention to a subject which is really of considerable importance to them.

The first question which a plain man is disposed to ask himself is, Why should the State interfere with the profession of medicine any more than it does, say, with the profession of engineering? Anybody who pleases may call himself an engineer, and may practice as such. The State confers no title upon engineers, and does not profess to tell the public that one man is a qualified engineer and that another is not so.

The answers which are given to the question are various, and most of them, I think, are bad. A large number of persons seem to be of opinion that the State is bound no less to take care of the general public, than to see that it is protected against incompetent persons, against quacks and medical impostors in general. I do not take that view of the case. I think it is very much wholesomer for the public to take care of itself in this as in all other matters; and although I am not such a fanatic for the liberty of the subject as to plead that interfering with the way in which a man may choose to be killed is a violation of that liberty, yet I do think that it is far better to let everybody do as he likes. Whether that be so or not, I am perfectly certain that, as a matter of practice, it is absolutely impossible to prohibit the practice of medicine by people who have no special qualification for it. Consider the terrible consequences of attempting to prohibit practice by a very large class of persons who are certainly not technically qualified--I am far from saying a word as to whether they are otherwise qualified or not. The number of Ladies Bountiful--grandmothers, aunts, and mothers-in-law--whose chief delight lies in the administration of their cherished provision of domestic medicine, is past computation, and one shudders to think of what might happen if their energies were turned from this innocuous, if not beneficent channel, by the strong arm of the law. But the thing is impracticable.

Another reason for intervention is propounded, I am sorry to say, by some, though not many, members of the medical profession, and is simply an expression of that trades unionism which tends to infest professions no less than trades.

The general practitioner trying to make both ends meet on a poor practice, whose medical training has cost him a good deal of time and money, finds that many potential patients, whose small fees would be welcome as the little that helps, prefer to go and get their shilling's worth of "doctor's stuff" and advice from the chemist and druggist round the corner, who has not paid sixpence for his medical training, because he has never had any.

The general practitioner thinks this is very hard upon him and ought to be stopped. It is perhaps natural that he should think so, though it would be very difficult for him to justify his opinion on any ground of public policy. But the question is really not worth discussion, as it is obvious that it would be utterly impracticable to stop the practice "over the counter" even it it were desirable.

Is a man who has a sudden attack of pain in tooth or stomach not to be permitted to go to the nearest druggist's shop and ask for something that will relieve him? The notion is preposterous. But if this is to be legal, the whole principle of the permissibility of counter practice is granted.

In my judgment the intervention of the State in the affairs of the medical profession can be justified not upon any pretence of protecting the public, and still less upon that of protecting the medical profession, but simply and solely upon the fact that the State employs medical men for certain purposes, and, as employer, has a right to define the conditions on which it will accept service. It is for the interest of the community that no person shall die without there being some official recognition of the cause of his death. It is a matter of the highest importance to the community that, in civil and criminal cases, the law shall be able to have recourse to persons whose evidence may be taken as that of experts; and it will not be doubted that the State has a right to dictate the conditions under which it will appoint persons to the vast number of naval, military, and civil medical offices held directly or indirectly under the Government. Here, and here only, it appears to me, lies the justification for the intervention of the State in medical affairs. It says, or, in my judgment, should say, to the public, "Practice medicine if you like--go to be practised upon by anybody;" and to the medical practitioner, "Have a qualification, or do not have a qualification if people don't mind it; but if the State is to receive your certificate of death, if the State is to take your evidence as that of an expert, if the State is to give you any kind of civil, or military, or naval appointment, then we can call upon you to comply with our conditions, and to produce evidence that you are, in our sense of the word, qualified. Without that we will not place you in that position." As a matter of fact, that is the relation of the State to the medical profession in this country. For my part, I think it an extremely healthy relation; and it is one that I should be very sorry to see altered, except in so far that it would certainly be better if greater facilities were given for the swift and sharp punishment of those who profess to have the State qualification when, in point of fact, they do not possess it. They are simply cheats and swindlers, like other people who profess to be what they are not, and should be punished as such.

But supposing we are agreed about the justification of State intervention in medical affairs, new questions arise as to the manner in which that intervention should take place and the extent to which it should go, on which the divergence of opinion is even greater than it is on the general question of intervention.

It is now, I am sorry to say, something over forty years since I began my medical studies; and, at that time, the state of affairs was extremely singular. I should think it hardly possible that it could have obtained anywhere but in such a country as England, which cherishes a fine old crusted abuse as much as it does its port wine. At that time there were twenty-one licensing bodies--that is to say, bodies whose certificate was received by the State as evidence that the persons who possessed that certificate were medical experts. How these bodies came to possess these powers is a very curious chapter in history, in which it would be out of place to enlarge. They were partly universities, partly medical guilds and corporations, partly the Archbishop of Canterbury. Those were the three sources from which the licence to practice came in that day. There was no central authority, there was nothing to prevent any one of those licensing authorities from granting a licence to any one upon any conditions it thought fit. The examination might be a sham, the curriculum might be a sham, the certificate might be bought and sold like anything in a shop; or, on the other hand, the examination might be fairly good and the diploma correspondingly valuable; but there was not the smallest guarantee, except the personal character of the people who composed the administration of each of these licensing bodies, as to what might happen. It was possible for a young man to come to London and to spend two years and six months of the time of his compulsory three years "walking the hospitals" in idleness or worse; he could then, by putting himself in the hands of a judicious "grinder" for the remaining six months, pass triumphantly through the ordeal of one hour's _vivâ voce_ examination, which was all that was absolutely necessary, to enable him to be turned loose upon the public, like death on the pale horse, "conquering and to conquer," with the full sanction of the law, as a "qualified practitioner."

It is difficult to imagine, at present, such a state of things, still more difficult to depict the consequences of it, because they would appear like a gross and malignant caricature; but it may be said that there was never a system, or want of system, which was better calculated to ruin the students who came under it, or to degrade the profession as a whole. My memory goes back to a time when models from whom the Bob Sawyer of the _Pickwick Papers_ might have been drawn were anything but rare.

Shortly before my student days, however, the dawn of a better state of things in England began to be visible, in consequence of the establishment of the University of London, and the comparatively very high standard which it placed before its medical graduates.

I say comparatively high standard, for the requirements of the University in those days, and even during the twelve years at a later period, when I was one of the examiners of the medical faculty, were such as would not now be thought more than respectable, and indeed were in many respects very imperfect. But, relatively to the means of learning, the standard was high, and none but the more able and ambitious of the students dreamed of passing the University. Nevertheless, the fact that many men of this stamp did succeed in obtaining their degrees, led others to follow in their steps, and slowly but surely reacted upon the standard of teaching in the better medical schools. Then came the Medical Act of 1858. That Act introduced two immense improvements: one of them was the institution of what is called the Medical Register, upon which the names of all persons recognised by the State as medical practitioners are entered: and the other was the establishment of the Medical Council, which is a kind of Medical Parliament, composed of representatives of the licensing bodies and of leading men in the medical profession nominated by the Crown. The powers given by the Legislature to the Medical Council were found practically to be very limited, but I think that no fair observer of the work will doubt that this much attacked body has excited no small influence in bringing about the great change for the better, which has been effected in the training of men for the medical profession within my recollection.

Another source of improvement must be recognised in the Scottish Universities, and especially in the medical faculty of the University of Edinburgh. The medical education and examinations of this body were for many years the best of their kind in these islands, and I doubt if, at the present moment, the three kingdoms can show a better school of medicine than that of Edinburgh. The vast number of medical students at that University is sufficient evidence of the opinion of those most interested in this subject.

Owing to all those influences, and to the revolution which has taken place in the course of the last twenty years in our conceptions of the proper method of teaching physical science, the training of the medical student in a good school, and the examination test applied by the great majority of the present licensing bodies, reduced now to nineteen, in consequence of the retirement of the Archbishop and the fusion of two of the other licensing bodies, are totally different from what they were even twenty years ago.

I was perfectly astonished, upon one of my sons commencing his medical career the other day, when I contrasted the carefully-watched courses of theoretical and practical instruction, which he is expected to follow with regularity and industry, and the number and nature of the examinations which he will have to pass before he can receive his licence, not only with the monstrous laxity of my own student days, but even with the state of things which obtained when my term of office as examiner in the University of London expired some sixteen years ago.

I have no hesitation in expressing the opinion, which is fully borne out by the evidence taken before the late Royal Commission, that a large proportion of the existing licensing bodies grant their licence on conditions which ensure quite as high a standard as it is practicable or advisable to exact under present circumstances, and that they show every desire to keep pace with the improvements of the times. And I think there can be no doubt that the great majority have so much improved their ways, that their standard is far above that of the ordinary qualification thirty years ago, and I cannot see what excuse there would be for meddling with them if it were not for two other defects which have to be remedied.

Unfortunately there remain two or three black sheep--licensing bodies which simply trade upon their privilege, and sell the cheapest wares they can for shame's sake supply to the bidder. Another defect in the existing system, even where the examination has been so greatly improved as to be good of its kind, is that there are certain licensing bodies which give a qualification for an acquaintance with either medicine or surgery alone, and which more or less ignore obstetrics. This is a revival of the archaic condition of the profession when surgical operations were mostly left to the barbers and obstetrics to the mid-wives, and when the physicians thought themselves, and were considered by the world, the "superior persons" of the profession. I remember a story was current in my young days of a great court physician who was travelling with a friend, like himself, bound on a visit to a country house. The friend fell down in an apoplectic fit, and the physician refused to bleed him because it was contrary to professional etiquette for a physician to perform that operation. Whether the friend died or whether he got better because he was not bled I do not remember, but the moral of the story is the same. On the other hand, a famous surgeon was asked whether he meant to bring up his son to his own calling, "No," he said, "he is such a fool, I mean to make a physician of him."

Nowadays, it is happily recognised that medicine is one and indivisible, and that no one can properly practice one branch who is not familiar with at any rate the principles of all. Thus the two great things that are wanted now are, in the first place, some means of enforcing such a degree of uniformity upon all the examining bodies that none should present a disgracefully low minimum or pass examination; and the second point is that some body or other shall have the power of enforcing upon every candidate for the licence to practice the study of the three branches, what is called the tripartite qualification. All the members of the late commission were agreed that these were the main points to be attended to in any proposals for the further improvement of medical training and qualification.

But such being the ends in view, our notions as to the best way of attaining them were singularly divergent; so that it came about that eleven commissioners made seven reports. There was one main majority report and six minor reports, which differed more or less from it, chiefly as to the best method of attaining these two objects.

The majority report recommended the adoption of what is known as the conjoint scheme. According to this plan the power of granting a licence to practise is to be taken away from all the existing bodies, whether they have done well or ill, and to be placed in the hands of a body of delegates (divisional boards), one for each of the three kingdoms. The licence to practise is to be conferred by passing the delegate examination. The licensee may afterwards, if he pleases, go before any of the existing bodies and indulge in the luxury of another examination and the payment of another fee in order to obtain a title, which does not legally place him in any better position than that which he would occupy without it.

Under these circumstances, of course, the only motive for obtaining the degree of a University or the licence of a medical corporation would be the prestige of these bodies. Hence the "black sheep" would certainly be deserted, while those bodies which have acquired a reputation by doing their duty would suffer less.

But, as the majority report proposes that the existing bodies should be compensated for any loss they might suffer out of the fees of the examiners for the State licence, the curious result would be brought about that the profession of the future would be taxed, for all time, for the purpose of handing over to wholly irresponsible bodies a sum, the amount of which would be large for those who had failed in their duty and small for those who had done it.