Part 26

I presume that the great majority of those whom I address propose to devote themselves to the profession of medicine; and I do not doubt, from the evidences of ability which have been given to-day, that I have before me a number of men who will rise to eminence in that profession, and who will exert a great and deserved influence upon its future. That in which I am interested, and about which I wish to speak, is the subject of medical education, and I venture to speak about it for the purpose, if I can, of influencing you, who may have the power of influencing the medical education of the future. You may ask, by what authority do I venture, being a person not concerned in the practice of medicine, to meddle with that subject? I can only tell you it is a fact, of which a number of you I dare say are aware by experience (and I trust the experience has no painful associations), that I have been for a considerable number of years (twelve or thirteen years to the best of my recollection) one of the examiners in the University of London. You are further aware that the men who come up to the University of London are the picked men of the medical schools of London, and therefore such observations as I may have to make upon the state of knowledge of these gentlemen, if they be justified, in regard to any faults I may have to find, cannot be held to indicate defects in the capacity, or in the power of application of those gentlemen, but must be laid, more or less, to the account of the prevalent system of medical education. I will tell you what has struck me--but in speaking in this frank way, as one always does about the defects of one's friends, I must beg you to disabuse your minds of the notion that I am alluding to any particular school, or to any particular college, or to any particular person; and to believe that if I am silent when I should be glad to speak with high praise, it is because that praise would come too close to this locality. What has struck me, then, in this long experience of the men best instructed in physiology from the medical schools of London is (with the many and brilliant exceptions to which I have referred), taking it as a whole, and broadly, the singular unreality of their knowledge of physiology. Now, I use that word "unreality" advisedly. I do not say "scanty;" on the contrary, there is plenty of it--a great deal too much of it--but it is the quality, the nature of the knowledge, which I quarrel with. I know I used to have--I don't know whether I have now, but I had once upon a time--a bad reputation among students for setting up a very high standard of acquirement, and I dare say you may think that the standard of this old examiner, who happily is now very nearly an extinct examiner, has been pitched too high. Nothing of the kind, I assure you. The defects I have noticed, and the faults I have to find, arise entirely from the circumstance that my standard is pitched too low. This is no paradox, gentlemen, but quite simply the fact. The knowledge I have looked for was a real, precise, thorough, and practical knowledge of fundamentals; whereas that which the best of the candidates, in a large proportion of cases, have had to give me was a large, extensive, and inaccurate knowledge of superstructure; and that is what I mean by saying that my demands went too low and not too high. What I have had to complain of is, that a large proportion of the gentlemen who come up for physiology to the University of London do not know it as they know their anatomy, and have not been taught it as they have been taught their anatomy. Now, I should not wonder at all if I heard a great many "No, noes" here; but I am not talking about University College; as I have told you before, I am talking about the average education of medical schools. What I have found, and found so much reason to lament, is, that while anatomy has been taught as a science ought to be taught, as a matter of autopsy, and observation, and strict discipline; in a very large number of cases, physiology has been taught as if it were a mere matter of books and of hearsay. I declare to you, gentlemen, that I have often expected to be told, when I have asked a question about the circulation of the blood, that Professor Breitkopf is of opinion that it circulates, but that the whole thing is an open question. I assure you that I am hardly exaggerating the state of mind on matters of fundamental importance which I have found over and over again to obtain among gentlemen coming up to that picked examination of the University of London. Now, I do not think that is a desirable state of things. I cannot understand why physiology should not be taught--in fact, you have here abundant evidence that it can be taught--with the same definiteness and the same precision as anatomy is taught. And you may depend upon this, that the only physiology which is to be of any good whatever in medical practice, or in its application to the study of medicine, is that physiology which a man knows of his own knowledge; just as the only anatomy which would be of any good to the surgeon is the anatomy which he knows of his own knowledge. Another peculiarity I have found in the physiology which has been current, and that is, that in the minds of a great many gentlemen it has been supplanted by histology. They have learnt a great deal of histology, and they have fancied that histology and physiology are the same things. I have asked for some knowledge of the physics and the mechanics and the chemistry of the human body, and I have been met by talk about cells. I declare to you I believe it will take me two years, at least, of absolute rest from the business of an examiner to hear the word "cell," "germinal matter," or "carmine," without a sort of inward shudder.

Well, now, gentlemen, I am sure my colleagues in this examination will 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 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.

* * * * *

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

XIII

THE STATE AND THE MEDICAL PROFESSION

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.