Chapter 21
The scheme in fact involved a perpetual endowment of the "black sheep," calculated on the maximum of their ill-gained profits. [1] I confess that I found myself unable to assent to a plan which, in addition to the rewarding the evil doers, proposed to take away the privileges of a number of examining bodies which confessedly were doing their duty well, for the sake of getting rid of a few who had failed. It was too much like the Chinaman's device of burning down his house to obtain a poor dish of roast pig--uncertain whether in the end he might not find a mere mass of cinders. What we do know is that the great majority of the existing licensing bodies have marvellously improved in the course of the last twenty years, and are improving. What we do not know is that the complicated scheme of the divisional boards will ever be got to work at all.
My own belief is that every necessary reform may be effected, without any interference with vested interests, without any unjust interference with the prestige of institutions which have been, and still are, extremely valuable, without any question of compensation arising, and by an extremely simple operation. It is only necessary in fact to add a couple of clauses to the Medical Act to this effect: (1) That from and after such a date no person shall be placed upon the Medical Register unless he possesses the threefold qualification. (2) That from and after this date no examination shall be accepted as satisfactory from any licensing body except such as has been carried on in part by examiners appointed by the licensing body, and in part by coadjutor-examiners of equal authority appointed by the Medical Council or other central authority, and acting under their instructions.
In laying down a rule of this kind the State confiscates nothing, and meddles with nobody, but simply acts within its undoubted right of laying down the conditions under which it will confer certain privileges upon medical practitioners. No one can say that the State has not the right to do this; no one can say that the State interferes with any private enterprise or corporate interest unjustly, in laying down its own conditions for its own service. The plan would have the further advantage that all those corporate bodies which have obtained (as many of them have) a great and just prestige by the admirable way in which they have done their work, would reap their just reward in the thronging of students, thenceforward as formerly, to obtain their qualifications; while those who have neglected their duties, who have in some one or two cases, I am sorry to say, absolutely disgraced themselves, would sink into oblivion, and come to a happy and natural euthanasia, in which their misdeeds and themselves would be entirely forgotten.
Two of my colleagues, Professor Turner and Mr. Bryce, M.P., whose practical familiarity with examinations gave their opinions a high value, expressed their substantial approval of this scheme, and I am unable to see the weight of the objections urged against it. It is urged that the difficulty and expense of adequately inspecting so many examinations and of guaranteeing their efficiency would be great, and the difficulty in the way of a fair adjustment of the representation of existing interests and of the representation of new interests upon the general Medical Council would be almost insuperable.
The latter objection is unintelligible to me. I am not aware that any attempt at such adjustment has been fairly discussed, and until that has been done it may be well not to talk about insuperable difficulties. As to the notion that there is any difficulty in getting the coadjutor-examiners, or that the expense will be overwhelming, we have the experience of Scotland, in which every University does, at the present time, appoint its coadjutor-examiners, who do their work just in the way proposed.
Whether in the way I have proposed, or by the Conjoint Scheme, however, this is perfectly certain: the two things I refer to have to be done: you must have the threefold qualification; you must have the limitation of the minimum qualification also; and any scheme for the improvement of the relations of the State to medicine which does not profess to do these two things thoroughly and well, has no chance of finality.
But when these reforms are witnessed, when there is a Medical Council armed with a more real authority than it at present possesses; when a license to practice cannot be obtained without the threefold qualification; and when an even minimum of qualification is exacted for every licence, is there anything else that remains that any one seriously interested in the welfare of the medical profession, as I may most conscientiously declare myself to be, would like to see done? I think there are three things.
In the first place, even now, when a four years' curriculum is required, the time allotted for medical education is too brief. A young man of eighteen beginning to study medicine is probably absolutely ignorant of the existence of such a thing as anatomy, or physiology, or indeed of any branch of physical science. He comes into an entirely new world; he addresses himself to a kind of work of which he has not the smallest experience. Up to that time his work has been with books; he rushes suddenly into work with things, which is as different from work with books as anything can well be. I am quite sure that a very considerable number of young men spend a very large portion of their first session in simply learning how to learn subjects which are entirely new to them. And yet recollect that in this period of four years they have to acquire a knowledge of all the branches of a great and responsible practical calling of medicine, surgery, obstetrics, general pathology, medical jurisprudence, and so forth. Anybody who knows what these things are, and who knows what is the kind of work which is necessary to give a man the confidence which will enable him to stand at the bedside and say to the satisfaction of his own conscience what shall be done, and what shall not be done, must be aware that if a man has only four years to do all that in he will not have much time to spare. But that is not all. As I have said, the young man comes up, probably ignorant of the existence of science; he has never heard a word of chemistry, he has never heard a word of physics, he has not the smallest conception of the outlines of biological science; and all these things have to be learned as well and crammed into the time which in itself is barely sufficient to acquire a fair amount of that knowledge which is requisite for the satisfactory discharge of his professional duties.
Therefore it is quite clear to me that, somehow or other, the curriculum must be lightened. It is not that any of the subjects which I have mentioned need not to be studied, and may be eliminated. The only alternative therefore is to lengthen the time given to study. Everybody will agree with me that the practical necessities of life in this country are such that, for the average medical practitioner at any rate, it is hopeless to think of extending the period of professional study beyond the age of twenty-two. So that as the period of study cannot be extended forwards, the only thing to be done is to extend it backwards.
The question is how this can be done. My own belief is that if the Medical Council, instead of insisting upon that examination in general education which I am sorry to say I believe to be entirely futile, were to insist upon a knowledge of elementary physics, and chemistry, and biology, they would be taking one of the greatest steps which at present can be made for the improvement of medical education. And the improvement would be this. The great majority of the young men who are going into the profession have practically completed their general education--or they might very well have done so--by the age of sixteen or seventeen. If the interval between this age and that at which they commence their purely medical studies were employed in obtaining a practical acquaintance with elementary physics, chemistry, and biology, in my judgment it would be as good as two years added to the course of medical study. And for two reasons: in the first place, because the subject-matter of that which they would learn is germane to their future studies, and is so much gained; in the second place, because you might clear out of the course of their professional study a great deal which at present occupies time and attention; and last, but not least--probably most--they would then come to their medical studies prepared for that learning from Nature which is what they have to do in the course of becoming skilful medical men, and for which at present they are not in the slightest degree prepared by their previous education.
The second wish I have to express concerns London especially, and I may speak of it briefly as a more economical use of the teaching power in the medical schools. At this present time every great hospital in London--and there are ten or eleven of them--has its complete medical school, in which not only are the branches of practical medicine taught, but also those studies in general science, such as chemistry, elementary physics, general anatomy, and a variety of other topics which are what used to be called (and the term was an extremely useful one) the institutes of medicine. That was all very well half a century ago; it is all very ill now, simply because those general branches of science, such as anatomy, physiology, chemistry, physiological chemistry, physiological physics, and so forth, have now become so large, and the mode of teaching them is so completely altered, that it is absolutely impossible for any man to be a thoroughly competent teacher of them, or for any student to be effectually taught without the devotion of the whole time of the person who is engaged in teaching. I undertake to say that it is hopelessly impossible for any man at the present time to keep abreast with the progress of physiology unless he gives his whole mind to it; and the bigger the mind is, the more scope he will find for its employment. Again, teaching has become, and must become still more, practical, and that also involves a large expenditure of time. But if a man is to give his whole time to my business he must live by it, and the resources of the schools do not permit them to maintain ten or eleven physiological specialists.
If the students in their first one or two years were taught the institutes of medicine, in two or three central institutions, it would be perfectly easy to have those subjects taught thoroughly and effectually by persons who gave their whole mind and attention to the subject; while at the same time the medical schools at the hospitals would remain what they ought to be--great institutions in which the largest possible opportunities are laid open for acquiring practical acquaintance with the phenomena of disease. So that the preliminary or earlier half of medical education would take place in the central institutions, and the final half would be devoted altogether to practical studies in the hospitals.
I happen to know that this conception has been entertained, not only by myself, but by a great many of those persons who are most interested in the improvement of medical study for a considerable number of years. I do not know whether anything will come of it this half-century or not; but the thing has to be done. It is not a speculative notion; it lies patent to everybody who is accustomed to teaching, and knows what the necessities of teaching are; and I should very much like to see the first step taken--people making up their minds that it has to be done somehow or other.
The last point to which I may advert is one which concerns the action of the profession itself more than anything else. We have arrangements for teaching, we have arrangements for the testing of qualifications, we have marvellous aids and appliances for the treatment of disease in all sorts of ways; but I do not find in London at the present time, in this little place of four or five million inhabitants which supports so many things, any organisation or any arrangement for advancing the science of medicine, considered as a pure science. I am quite aware that there are medical societies of various kinds; I am not ignorant of the lectureships at the College of Physicians and the College of Surgeons; there is the Brown Institute; and there is the Society for the Advancement of Medicine by Research, but there is no means, so far as I know, by which any person who has the inborn gifts of the investigator and discoverer of new truth, and who desires to apply that to the improvement of medical science, can carry out his intention. In Paris there is the University of Paris, which gives degrees; but there are also the Sorbonne and the Collége de France, places in which professoriates are established for the express purpose of enabling men who have the power of investigation, the power of advancing knowledge and thereby reacting on practice, to do that which it is their special mission to do. I do not know of anything of the kind in London; and if it should so happen that a Claude Bernard or a Ludwig should turn up in London, I really have not the slightest notion of what we could do with him. We could not turn him to account, and I think we should have to export him to Germany or France. I doubt whether that is a good or a wise condition of things. I do not think it is a condition of things which can exist for any great length of time, now that people are every day becoming more and more awake to the importance of scientific investigation and to the astounding and unexpected manner in which it everywhere reacts upon practical pursuits. I should look upon the establishment of some institution of that kind as a recognition on the part of the medical profession in general, that if their great and beneficent work is to be carried on, they must, like other people who have great and beneficent work to do, contribute to the advancement of knowledge in the only way in which experience shows that it can be advanced.
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Footnotes:
[1]The fees to be paid by candidates for admission to the examinations of the Divisional Board should be of such an amount as will be sufficient to cover the cost of the examinations and the other expenses of the Divisional Board, _and also to provide the sum required to compensate the medical authorities, or such of them as may be entitled to compensation, for any pecuniary losses they may hereafter sustain by reason of the abolition of their privilege of conferring a licence to practise. Report_ 50, p. xii.
XIV
THE CONNECTION OF THE BIOLOGICAL SCIENCES WITH MEDICINE
[1881]
The great body of theoretical and practical knowledge which has been accumulated by the labours of some eighty generations, since the dawn of scientific thought in Europe, has no collective English name to which an objection may not be raised; and I use the term "medicine" as that which is least likely to be misunderstood; though, as every one knows, the name is commonly applied, in a narrower sense, to one of the chief divisions of the totality of medical science.
Taken in this broad sense, "medicine" not merely denotes a kind of knowledge, but it comprehends the various applications of that knowledge to the alleviation of the sufferings, the repair of the injuries, and the conservation of the health, of living beings. In fact, the practical aspect of medicine so far dominates over every other, that the "Healing Art" is one of its most widely-received synonyms. It is so difficult to think of medicine otherwise than as something which is necessarily connected with curative treatment, that we are apt to forget that there must be, and is, such a thing as a pure science of medicine--a "pathology" which has no more necessary subservience to practical ends than has zoology or botany.
The logical connection between this purely scientific doctrine of disease, or pathology, and ordinary biology, is easily traced. Living matter is characterised by its innate tendency to exhibit a definite series of the morphological and physiological phenomena which constitute organisation and life. Given a certain range of conditions, and these phenomena remain the same, within narrow limits, for each kind of living thing. They furnish the normal and typical character of the species, and, as such, they are the subject-matter of ordinary biology.
Outside the range of these conditions, the normal course of the cycle of vital phenomena is disturbed; abnormal structure makes its appearance, or the proper character and mutual adjustment of the functions cease to be preserved. The extent and the importance of these deviations from the typical life may vary indefinitely. They may have no noticeable influence on the general well-being of the economy, or they may favour it. On the other hand, they may be of such a nature as to impede the activities of the organism, or even to involve its destruction.
In the first case, these perturbations are ranged under the wide and somewhat vague category of "variations"; in the second, they are called lesions, states of poisoning, or diseases; and, as morbid states, they lie within the province of pathology. No sharp line of demarcation can be drawn between the two classes of phenomena. No one can say where anatomical variations end and tumours begin, nor where modification of function, which may at first promote health, passes into disease. All that can be said is, that whatever change of structure or function is hurtful belongs to pathology. Hence it is obvious that pathology is a branch of biology; it is the morphology, the physiology, the distribution, the aetiology of abnormal life.
However obvious this conclusion may be now, it was nowise apparent in the infancy of medicine. For it is a peculiarity of the physical sciences that they are independent in proportion as they are imperfect; and it is only as they advance that the bonds which really unite them all become apparent. Astronomy had no manifest connection with terrestrial physics before the publication of the "Principia"; that of chemistry with physics is of still more modern revelation; that of physics and chemistry with physiology, has been stoutly denied within the recollection of most of us, and perhaps still may be.
Or, to take a case which affords a closer parallel with that of medicine. Agriculture has been cultivated from the earliest times, and, from a remote antiquity, men have attained considerable practical skill in the cultivation of the useful plants, and have empirically established many scientific truths concerning the conditions under which they flourish. But, it is within the memory of many of us, that chemistry on the one hand, and vegetable physiology on the other, attained a stage of development such that they were able to furnish a sound basis for scientific agriculture. Similarly, medicine took its rise in the practical needs of mankind. At first, studied without reference to any other branch of knowledge, it long maintained, indeed still to some extent maintains, that independence. Historically, its connection with the biological sciences has been slowly established, and the full extent and intimacy of that connection are only now beginning to be apparent. I trust I have not been mistaken in supposing that an attempt to give a brief sketch of the steps by which a philosophical necessity has become an historical reality, may not be devoid of interest, possibly of instruction, to the members of this great Congress, profoundly interested as all are in the scientific development of medicine.
The history of medicine is more complete and fuller than that of any other science, except, perhaps, astronomy; and, if we follow back the long record as far as clear evidence lights us, we find ourselves taken to the early stages of the civilisation of Greece. The oldest hospitals were the temples of Aesculapius; to these Asclepeia, always erected on healthy sites, hard by fresh springs and surrounded by shady groves, the sick and the maimed resorted to seek the aid of the god of health. Votive tablets or inscriptions recorded the symptoms, no less than the gratitude, of those who were healed; and, from these primitive clinical records, the half-priestly, half-philosophic caste of the Asclepiads compiled the data upon which the earliest generalisations of medicine, as an inductive science, were based.
In this state, pathology, like all the inductive sciences at their origin, was merely natural history; it registered the phenomena of disease, classified them, and ventured upon a prognosis, wherever the observation of constant co-existences and sequences suggested a rational expectation of the like recurrence under similar circumstances.
Further than this it hardly went. In fact, in the then state of knowledge, and in the condition of philosophical speculation at that time, neither the causes of the morbid state, nor the _rationale_ of treatment, were likely to be sought for as we seek for them now. The anger of a god was a sufficient reason for the existence of a malady, and a dream ample warranty for therapeutic measures; that a physical phenomenon must needs have a physical cause was not the implied or expressed axiom that it is to us moderns.
The great man whose name is inseparably connected with the foundation of medicine, Hippocrates, certainly knew very little, indeed practically nothing, of anatomy or physiology; and he would, probably, have been perplexed even to imagine the possibility of a connection between the zoological studies of his contemporary Democritus and medicine. Nevertheless, in so far as he, and those who worked before and after him, in the same spirit, ascertained, as matters of experience, that a wound, or a luxation, or a fever, presented such and such symptoms, and that the return of the patient to health was facilitated by such and such measures, they established laws of nature, and began the construction of the science of pathology. All true science begins with empiricism--though all true science is such exactly, in so far as it strives to pass out of the empirical stage into that of the deduction of empirical from more general truths. Thus, it is not wonderful, that the early physicians had little or nothing to do with the development of biological science; and, on the other hand, that the early biologists did not much concern themselves with medicine. There is nothing to show that the Asclepiads took any prominent share in the work of founding anatomy, physiology, zoology, and botany. Rather do these seem to have sprung from the early philosophers, who were essentially natural philosophers, animated by the characteristically Greek thirst for knowledge as such. Pythagoras, Alcmeon, Democritus, Diogenes of Apollonia, are all credited with anatomical and physiological investigations; and, though Aristotle is said to have belonged to an Asclepiad family, and not improbably owed his taste for anatomical and zoological inquiries to the teachings of his father, the physician Nicomachus, the "Historia Animalium," and the treatise "De Partibus Animalium," are as free from any allusion to medicine as if they had issued from a modern biological laboratory.