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.
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.
* * * * *
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.