bear me out in saying that I have not been exaggerating the evils and
defects which are current--have been current--in a large quantity of
the physiological teaching the results of which come before examiners.
And it becomes a very interesting question to know how all this comes
about, and in what way it can be remedied. How it comes about will be
perfectly obvious to any one who has considered the growth of medicine.
I suppose that medicine and surgery first began by some savage more
intelligent than the rest, discovering that a certain herb was good for
a certain pain, and that a certain pull, somehow or other, set a
dislocated joint right. I suppose all things had their humble
beginnings, and medicine and surgery were in the same condition. People
who wear watches know nothing about watchmaking. A watch goes wrong and
it stops; you see the owner giving it a shake, or, if he is very bold,
he opens the case, and gives the balance-wheel a push. Gentlemen, that
is empirical practice, and you know what are the results upon the
watch. I should think you can divine what are the results of analogous
operations upon the human body. And because men of sense very soon
found that such were the effects of meddling with very complicated
machinery they did not understand, I suppose the first thing, as being
the easiest, was to study the nature of the works of the human watch,
and the next thing was to study the way the parts worked together, and
the way the watch worked. Thus, by degrees, we have had growing up our
body of anatomists, or knowers of the construction of the human watch,
and our physiologists, who know how the machine works. And just as any
sensible man, who has a valuable watch, does not meddle with it
himself, but goes to some one who has studied watchmaking, and
understands what the effect of doing this or that may be; so, I
suppose, the man who, having charge of that valuable machine, his own
body, wants to have it kept in good order, comes to a professor of the
medical art for the purpose of having it set right, believing that, by
deduction from the facts of structure and from the facts of function,
the physician will divine what may be the matter with his bodily watch
at that particular time, and what may be the best means of setting it
right. If that may be taken as a just representation of the relation of
the theoretical branches of medicine--what we may call the institutes
of medicine, to use an old term--to the practical branches, I think it
will be obvious to you that they are of prime and fundamental
importance. Whatever tends to affect the teaching of them injuriously
must tend to destroy and to disorganise the whole fabric of the medical
art. I think every sensible man has seen this long ago; but the
difficulties in the way of attaining good teaching in the different
branches of the theory, or institutes, of medicine are very serious. It
is a comparatively easy matter--pray mark that I use the word
"comparatively "--it is a comparatively easy matter to learn anatomy
and to teach it; it is a very difficult matter to learn physiology and
to teach it. It is a very difficult matter to know and to teach those
branches of physics and those branches of chemistry which bear directly
upon physiology; and hence it is that, as a matter of fact, the
teaching of physiology, and the teaching of the physics and the
chemistry which bear upon it, must necessarily be in a state of
relative imperfection; and there is nothing to be grumbled at in the
fact that this relative imperfection exists. But is the relative
imperfection which exists only such as is necessary, or is it made
worse by our practical arrangements? I believe--and if I did not so
believe I should not have troubled you with these observations--I
believe it is made infinitely worse by our practical arrangements, or
rather, I ought to say, our very unpractical arrangements. Some very
wise man long ago affirmed that every question, in the long run, was a
question of finance; and there is a good deal to be said for that view.
Most assuredly the question of medical teaching is, in a very large and
broad sense, a question of finance. What I mean is this: that in London
the arrangements of the medical schools, and the number of them, are
such as to render it almost impossible that men who confine themselves
to the teaching of the theoretical branches of the profession should be
able to make their bread by that operation; and, you know, if a man
cannot make his bread he cannot teach--at least his teaching comes to a
speedy end. That is a matter of physiology. Anatomy is fairly well
taught, because it lies in the direction of practice, and a man is all
the better surgeon for being a good anatomist. It does not absolutely
interfere with the pursuits of a practical surgeon if he should hold a
Chair of Anatomy--though I do not for one moment say that he would not
be a better teacher if he did not devote himself to practice.
(Applause.) Yes, I know exactly what that cheer means, but I am keeping
as carefully as possible from any sort of allusion to Professor Ellis.
But the fact is, that even human anatomy has now grown to be so large a
matter, that it takes the whole devotion of a man's life to put the
great mass of knowledge upon that subject into such a shape that it can
be teachable to the mind of the ordinary student. What the student
wants in a professor is a man who shall stand between him and the
infinite diversity and variety of human knowledge, and who shall gather
all that together, and extract from it that which is capable of being
assimilated by the mind. That function is a vast and an important one,
and unless, in such subjects as anatomy, a man is wholly free from
other cares, it is almost impossible that he can perform it thoroughly
and well. But if it be hardly possible for a man to pursue anatomy
without actually breaking with his profession, how is it possible for
him to pursue physiology?
I get every year those very elaborate reports of Henle and
Meissner--volumes of, I suppose, 400 pages altogether--and they consist
merely of abstracts of the memoirs and works which have been written on
Anatomy and Physiology--only abstracts of them! How is a man to keep up
his acquaintance with all that is doing in the physiological world--in
a world advancing with enormous strides every day and every hour--if he
has to be distracted with the cares of practice? You know very well it
must be impracticable to do so. Our men of ability join our medical
schools with an eye to the future. They take the Chairs of Anatomy or
of Physiology; and by and by they leave those Chairs for the more
profitable pursuits into which they have drifted by professional
success, and so they become clothed, and physiology is bare. The result
is, that in those schools in which physiology is thus left to the
benevolence, so to speak, of those who have no time to look to it, the
effect of such teaching comes out obviously, and is made manifest in
what I spoke of just now--the unreality, the bookishness of the
knowledge of the taught. And if this is the case in physiology, still
more must it be the case in those branches of physics which are the
foundation of physiology; although it may be less the case in
chemistry, because for an able chemist a certain honourable and
independent career lies in the direction of his work, and he is able,
like the anatomist, to look upon what he may teach to the student as
not absolutely taking him away from his bread-winning pursuits.
But it is of no use to grumble about this state of things unless one is
prepared to indicate some sort of practical remedy. And I believe--and
I venture to make the statement because I am wholly independent of all
sorts of medical schools, and may, therefore, say what I believe
without being supposed to be affected by any personal interest--but I
say I believe that the remedy for this state of things, for that
imperfection of our theoretical knowledge which keeps down the ability
of England at the present time in medical matters, is a mere affair of
mechanical arrangement; that so long as you have a dozen medical
schools scattered about in different parts of the metropolis, and
dividing the students among them, so long, in all the smaller schools
at any rate, it is impossible that any other state of things than that
which I have been depicting should obtain. Professors must live; to
live they must occupy themselves with practice, and if they occupy
themselves with practice, the pursuit of the abstract branches of
science must go to the wall. All this is a plain and obvious matter of
common-sense reasoning. I believe you will never alter this state of
things until, either by consent or by _force majeure_--and I
should be very sorry to see the latter applied--but until there is some
new arrangement, and until all the theoretical branches of the
profession, the institutes of medicine, are taught in London in not
more than one or two, or at the outside three, central institutions, no
good will be effected. If that large body of men, the medical students
of London, were obliged in the first place to get a knowledge of the
theoretical branches of their profession in two or three central
schools, there would be abundant means for maintaining able
professors--not, indeed, for enriching them, as they would be able to
enrich themselves by practice--but for enabling them to make that
choice which such men are so willing to make; namely, the choice
between wealth and a modest competency, when that modest competency is
to be combined with a scientific career, and the means of advancing
knowledge. I do not believe that all the talking about, and tinkering
of, medical education will do the slightest good until the fact is
clearly recognised, that men must be thoroughly grounded in the
theoretical branches of their profession, and that to this end the
teaching of those theoretical branches must be confined to two or three
centres.
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.