MEDICAL REFORM.

BY A MEMBER OF THE PROFESSION.

OUGHT THE QUALIFICATIONS OF MEDICAL PRACTITIONERS TO BE RE- GULATED BY LAW? THE ABSURDITIES OF EXISTING LAWS. THE NECESSITY FOR UNIFORMITY OF QUALIFICATION AND PRIVILEGES IN PRACTITIONERS OF MEDICINE.

THERE has of late years been much agitation in the medical world in regard to what has obtained the title of Medical Reform. The number of pamphlets which have lately issued from the press on this sub- ject, owing their production to men in every department of the pro- fession, and to men, in the majority of cases, of the highest standing— the universal advocacy of change by the medical periodicals, some of which have sprung up in order to aid in the promotion of reformation— and the forming, in all parts of the United Kingdom, of associations, with the express object of seeking for improvement in the institutions affecting their members, among men who work not in classes but • separately, who do not herd in communities but are dispersed over the surface of the country, while their pursuits, from their own nature, are at variance with political turmoil—would all yield prima facie ext- ' dunce of strong grievances. But the evidence is strengthened by the fact that the necessity for some change is universally acknowledged by the profession ; even those members who have risen to affluence and the 'highest honours under the old system (and who may, therefore, aecOrding to a general rule, be considered prone to conservation) ad- mitting the desirableness of a reform. It is time, then, that the import- ance of the subject should be fully understood by the public, who have hitherto been too apt to consider it as something affecting a class merely, and as a matter in which they are but little interested ; and that the public should know that the question involves, or not,.s as is met, an Immense deal of social improvement. Indeed, it is principally on the latter and broader ground that the matter should be argued ; for while it may be shown that the medical profession has just cause to demand a change or rather a new system of law in reference to itself, it may be also established that a large and liberal plan of medical reform might be the instrument of great good to the community. An en- lightened foresight would demonstrate to each individual that be is as necessarily concerned in the question, as in a statistical account of the duration of human life—as much interested as in the mortality of a climate or the prevalence of epidemics.

There ought either to be no laws affecting the practice of medicine,— that is, every one should be allowed to practise it who might think proper to do so,—or there ought to be such laws. It is either for the public good that medical practitioners should be examined as to their com- petency before they deal with matters touching the lives of their fellow- citizens, or it is not. At first sight, one is sometimes apt to suppose that to leave the profession to itself entirely, to allow a perfect freedom of trade in it, so to speak, would be for the best. It would undoubtedly be better to have no system at all than to have such an incongruous, absurd collection of medical laws—a thing of shreds and patches, in- complete and inefficient—as we have now. But nevertheless, legisla- tion might be applied to the practice of medicine with advantage to the public, which is the main object to be kept in view. It might be desir- able to leave a citizen to choose as his attendant in disease the man whom he deemed fittest, or who was most to his liking, irrespectively of all legal qualification, did the mischief rest with the patient himself; but tbe crimes of quacks must be kept under at the expense of indivi- dual likings, for the good of the community, as much as inoculation with small-pox matter is to be suppressed; the lives of the lieges are to be saved from the ravages of empiricism, as much as from the hardly more palpable calamities of a fearfully contagious malady. It can be demonstrated that medicine is a science, which, though it can never arrive at exactness, depends nevertheless, as much as do the exact sciences, on facts and reasonings. " A competent geometrician," says Mr. GREEN, in The Touchstone of Medical Reform, "in the demonstra- tion of any problem or proposition, feels assured, that if all the geome- tricians in Europe were present to contribute their aid, the result would be the same, the evidence no greater. Now, I need not say that this is an advantage that can belong only to the so-called abstract sciences—those which are concerned with the forms of the mind, wholly separate from the changeable materials and objects to which they may be applied. Nevertheless, it remains the ideal standard, however great the difference may be in the comparative distance from the goal, however unapproachable this may be : this is the goal ; and to that which we never reach we may be gradually approximating." A knowledge of medicine is but to be arrived at by a knowledge of principles; and the practice of medicine consists in the ability to apply these principles to varying, variable, and complicated circumstances. Much learning and much patient study are requisite to the attainment of a degree of proficiency in the treatment of disease : few individuals are able of themselves to decide on the comparative merits of different medical practitioners, and very many are unable to judge between the pretensions of an empiric and the qualifications of a scientific man. It would therefore seem that there would be no hardship, but a benefit for the people, in legislation taking care that their interests should be at- tended to in matters of which a great portion of them are necessarily unable to judge for themselves—in taking care that, while they were allowed to select their own medical attendant, they should make their choice from a class of men each of whom had been proved and found fit to be intrusted with the care of life in sickness. The law has as un- doubted a right to prevent the destruction of citizens by the maletreat- ment of their diseases, as it has to see that the lives of her Majesty's subjects are not sacrificed to the ignorance of pilots or of engineers. One ought to argue rather on principle than on mere precedent at all times ; but it may be mentioned, that no enlightened state has existed in modern times, which has not acknowledged the necessity for some supervision of the capabilities of those engaged in the treatment of dis- ease. If only a portion of the people have the ability to choose a medi- cal adviser, even that portion is often placed in circumstances, by sick- ness, or by time or place, incapacitating from a choice, and rendering it desirable that the state should have provided some guarantee of safety in those professing to take on them the serious responsibilities of the physician. But a choice of medical practitioners for the greater part of the community rests with the lesser, whether the latter have the ability to choose safely or not : the physician or surgeon is generally provided by the head of a family; and till we allow to a man the licence of killing his wife, his child, or his domestic, we ought not to concede to him the power to slay any of them through a more indirect process— through his own want of knowledge of scientific principles—through his own superstitious faith in some brandy and salt or some cold-water- care delusion—or through his fanatic faith in the spells of any other sort of empiricism. Men are not to be allowed the liberty of trifling with the lives of their compeers, whether in a ship, in a workhouse, or in a family. The only feasible objection that can be made against restraining persons more or less incapable from practising medicine, is that such restnctions are apt to increase the price of the article medical skill in proportion as they enhance its value ; that if medical men be made better physicians and better surgeons, they may be made so good that some people shall be unable to pay for their medical services. Now, it can be shown that there is a certain amount of knowledge of medical principles necessary for the safe treatment of disease. Nobody can say exactly where the line is to be drawn under which it is unsafe to pre- vent men from treating their fellows in illness ; but it is the business of the low to make an approximation—to fix the qualification required of practitioners in medicine as near the line as possible ; and while it pre- vents them from falling below it, to encourage them to rise as high as Possible above it. Ir. might be demonstrated that the public is to be he- ated by preventing the qualifications of medical practitioners from falling under a certain minimum, even though such an arrangement could only be effected by a higher rate of remuneration. But the poor

man, who could not pay for a practitioner at all who had been educated up to this minimum qualification, what is to be said to his case, when his choice is to be limited to such practitioners ? This : that rather than he should employ a practitioner not possessing the minimum qualifica- tion—that rather than he should employ a quack, or one whom it might be unsafe to trust—who might strike Nature when he levelled blows at Disease—that, rather than do such things, he should leave the

healing powers of Nature to their own efforts. Such an argument can but appear unreasonable to those who are ignorant that it is not the

physician but Nature who cures all disease ; and to those who, putting confidence in yellow pills or pink bottles, are in the habit of employing retailers of drugs to prescribe for their diseases, capriciously overlook- ing the equal claims of their cooks and bakers. After all, this is but supposing the extreme case of an individual being unable from the state of his purse to obtain safe medical advice, for the sake of argu- ment; for as long as professional knowledge is to be increased by ex- perience, so long will the doors of every hospital, every dispensary, every practitioner's private dwelling, be open, and part of the time of every practitioner be ready to be devoted to the relief of disease; so

long will practitioners not only be prepared to administer relief, but be earnest in ferreting out cases for the experience they are to yield. But

were it otherwise, it ought to be considered a duty of the state to pro- vide safe medical aid to such individuals as were unable to pay for it themselves. We live in a community : men's lives are to be protected against the sins of commission, and they must not be sacrificed to errors of omission : people ought not to be let die for the want of medical knowledge.

Let it be supposed, then, that it is granted that there ought to be laws to regulate the medical profession. Now, it is generally allowed that laws, of whatever kind, ought to be as simple and efficient—as wise as it is possible to make them. The laws at present affecting the medical profession are far from being so. On the contrary, they are incon- gruous, and many of them have become obsolete from their sheer

absurdity : and a single statute might simply and speedily remove the sources of the complaints of medical practitioners, while it conferred a

boon on the people at large, did the public but take upon itself to care about the matter. The profession might receive the necessary aid, were it possible for the public to become possessed of the facts of the case, and interested in its merits.

There exist within the United Kingdom eight different medical corpo- rations, besides the nine Universities; and each of these bodies, corpora-

tions and universities, grants some kind of degree, licence, diploma, or

qualification, to exercise the art of healing ; each takes a method of .its own of training its graduates, its members, or its licentiates ; each pro- duces a distinct kind of practitioner. There are, besides, the medical departments of the Army, the Navy, the Ordnance, and the East India Company, each of which prescribes a course of education of its own, and examines the candidates for admission into its own service ; and there exist too, as sources of the highest honours in medicine, the Archbishop of Canterbury, and "the Bishop of the diocese "; such learned ecclesiastics possessing still the power to examine individuals touching their skill in the art of medicine, and to license them to practise accordingly. Now, this body grants certain privileges

of practice in one part of the kingdom, that in another ; the members of one corporation can practise merely in this department of medicine, and the licentiates of another are not allowed to step beyond the boundaries of their province of the science. A licen- tiate of the College of Physicians cannot infringe the privileges of

the Apothecaries Company ; a surgeon cannot act as a physician, that is in medical cases ; and when a physician first joins the London Col- lege, he must renounce all the connexions he may previously have formed with other grades or departments of his profession ; though nobody has been able to draw a line between medical and surgical ' cases—though physicians have a right to treat surgical disease— and though it is well known that some of our most eminent pure sur-

geons have been most excellent physicians, and have had more of a

medical practice, so called, than a surgical. A Scotch surgeon-apothe- cary, who is considered legally qualified to practice medicine in Dum- fries, is incompetent to do so in Carlisle ; an apothecary may treat pati- ents in London, who is quite incapacitated in Dublin ; and if an Irish apothecary were to venture across • the Channel in the hope of being allowed to exercise his calling in the sister island of a United Kingdom, he would find that he had calculated without his host—that the Apo- thecaries Company in Ireland and that in England, not only had each a monopoly of its own, but was besides composed of different sorts

of practitioners, the Irish being nearer to the original character of an apothecary, while the English were not apothecaries at all. Army and

Navy surgeons are not legally qualified to practice, according to the usual mode of general practitioners, in England or Wales ; though the medical charge of the flower of British manhood is intrusted to them

abroad and at home, by land and water. A. medical graduate of a Scotch University, however learned he may be—though he be a Fellow of the Edinburgh College of Physicians, which Dr. GRANT instances

as one of the most amiable and most virtuous of the medical corpora- tions—cannot be admitted among the fellows of the London College, because he has not studied at Oxford or Cambridge, where there are no means afforded for enabling men to become practical physicians : this happens in consequence of a narrow-minded by-law of the London College, at variance with the spirit of the charter obtained from King

HENRY the Eighth in favour of a few metropolitan physicians, most of

whom held degrees from some of the Italian Universities, while many of them were foreigners by birth. (Dr. Kinn.) Though the treat- ment of persons in London, and within seven miles, is confined to Fel- lows of the College of Physicians, and such as they choose to tolerate, any one who buys a degree may practice in the provinces of England,

notwithstanding that it is supposed that the legal right of doing so IS confined to graduates of Oxford and Cambridge and those whom the College of Physicians may approve : in fact, there are very few legal physicians in the provinces, inasmuch as the majority of them practise in consideration of degrees obtained out of England. There is no law in operation to prevent any one, without a degree or qualification of any kind, from practising in England ; and it is not necessary to have a surgeon's diploma either to practise or to charge for the art of ear- gory; though the Poor-law Commissioners have lately, by some crab- like process of their own, discovered that medical practitioners most be members of the Lincoln's Inn Yields College of Surgeons. Of course, it cannot for a moment be supposed that their ignorance has been preyed upon by any representations of interested individuals. It it; only in practising as an apothecary in cases strictly medical, (which it is impossible to define,) that any one without a qualification can be inter.. fere& with ; and then not for dangerous practice, but for selling medi- due. Strange to say, this power has been exercised not so much against quacks as against members of Colleges or Faculties giving better diplomas than the apothecaries themselves. Here, reader, is an entangled skein of legal fictions and absurdities. But, after all, it is but a sample, picked at random, of the endless incon- gruities in the law as it affects the practice of physic. Incongruities ! for what can they be else, when we know that one kind of physiology, or one kind of' pathology, is not peculiar to one country or section of the kingdom—not peculiar to one part of the world—not even peculiar to the human race? when we know that medicine and surgery are one science—that the practice of each is but the application of certain prin- ciples common to both—that the education of the surgeon is the educa- tion of the physician—that a practitioner who knows nothing of external diseases can know but little of internal ones—that topical ailments de- pend on constitutional causes, while general affections of the system are referable to a local origin ? What can the laws at present affecting the medical profession be called but anomalous, when we acknowledge that the lives of her Majesty's subjects are of as much consequence here as there, in London as in the provinces, in Scotland as in Ireland, and are as worthy of safe medical treatment in the Colonies as at home. It seems ridiculous that practitioners of an art which is the same every- where should have geographical limits set to their individual exertions in a single country. It does not seem proper that the public should be deprived of the effects of a free competition ; nor does it appear right that a medical practitioner should not only be deprived of the power of carrying his knowledge to the best market, but actually have his particular part of the United Kingdom assigned him. Yet so it is : he is not free to carry his skill where he would wish ; nor could he be unless by acceding to all the contrary regulations, and passing all the different examining boards of the various uni- versities, colleges, and facultieer—which would be next to impossible. It would be as reasonable to prevent farmers who had been bred in Hampshire from farming in Middlesex, as it is to continue the present anomalies in regard to the "practice of physic." A knowledge of French law does not involve necessarily an intimacy with English jurisprudence, and a good English lawyer might be a bad American one : but science is the same in one country as in others ; if a man is skilful in medicine in Cincinnati, an Englishman may safely be guided by his advice ; if a practitioner be bred in the French hospitals, it will answer the same purpose as if he had "walked" Guy's or Bartholo- mew's. But this would appear a new light, quite at variance with the received hypothesis that there are about a score of different kinds of human constitutions, and consequently about twenty different species of practitioners in these little islands. If every one of the corporate bodies had exercised its peculiar pri- vileges by charter or by act of Parliament, we should have had such a polling at cross-purposes that the evils must have corrected them- selves long ago. This but proves the necessity for abolishing such as still stand out in bold relief to inflict grievances and to do discredit to an enlightened state. If corporate bodies, for the general advantage, had tolerated each other, and the necessity for the possession of one of their diplomas had been left to public opinion, the profession would have been in a much healthier state ; for in Scotland, where one corporation or university does not use its power to put down the licentiates of a differ- ent faculty, (except when the Faculty of Physicians and Surgeons of Glasgow prosecute the C.M.s of the University of the same city, as emanating from a source which has no right, as the faculty thinks, to make surgeons at all,) we do not hear much of grievances. We may mention incidentally, that the holders-up of the old system against a partial reform of it which was proposed by a bill in 1833, called the "Apothecaries Amendment Act," took advantage of the letter of the charters of the different medical bodies in Scotland, to make believe that the privileges conferred by these charters were carried into force by one corporation or university against its neighbours ; while it was not stated that such privileges as had become inconsistent with common sense and the spirit of the age had fallen almost altogether into des- uetude, that the Northern petitioners for reformation had long, in their own country, set the example, voluntarily, of the practical working of a principle which they wished to see carried out in other parts of the empire. But what could be expected of men, one of whom in his evidence before the Parliamentary Committee which sat on medical matters in 1834, objected to medical reformation on the part of the Apothecaries Company, because such a reformation would make Scot- land the thoroughfare to supply England with practitioners? Though the position is a false one, the apothecaries may a forliori, on their own reasoning, cast away all their sea-borne commodities, as not being in- digenous articles, and John Bull may forego for ever his indulgence in figs or plum-pudding. The evil of being "dependent on foreign countries" has been amply insisted on ; but it was not before publicly announced that it was dangerous for one part of the same kingdom to be dependent on another part. Without saying more about the fact enunciated by the witness above alluded to, we may state that we had hoped, in the nineteenth century, to have it generally allowed that the good of the people of England was to be consulted in preference to the private interest of a city corporation of druggists. The reader will allow, that if a medical practitioner is qualified to practise medicine in one part of the United Kingdom, he ought to be qualified in any part, and thereby accede to one of the grand principles of medical reformers. But his argument must be gained to another leading principle of equal importance in the question of a reformation of our medical institutions—that it is absurd to parcel out the practice of medicine into departments by acts of Parliament or old-fashioned charters, which, however well suited in their time for the wants of their age, are now but ill assorted with a state of more advanced intelligence and liberality—that while a medical practitioner is not to be confined within certain geographical boundaries, neither is he to be limited by law to the practice of one part of his profession. Medicine is one science: the physician, the surgeon, the general practitioner, must each be educated in the same way—most each be ac- quainted with the same principles, to be qualified to practice in his own province. The same kind of knowledge, the same amount of 'informa- tion, must be required of each practitioner before he can safely be trusted to visit the sick bedside. External diseases are not always surgical diseases, neither are internal diseases always medical: the treatment of each class comprehends medicines as well as surgical operations and appliances : no line can be drawn between them. Diseases of the skin are considered more particularly the province of the physician, and stone in the bladder is always conceded to the surgeon. No doubt that if one individual, on his groundwork of principles, should devote his practice to one part of science, he may surpass in it: no doubt that a surgeon can amputate a limb better than a physician' or that a physician can excel a surgeon in cases in which the latter hasas had little expe- rience while the former has had much : but if the profession is to be divided by the operation of law on such grounds, why is the principle of division not carried out ? why have we not physicians and surgeons everywhere ? why are Army surgeons and Navy surgeons the Army and Navy physicians ? why have not oculists, aurists, orthoptedists, and other individuals who give all their attention to diseases of one class— of the chest or skin, for example—each of them a faculty as well as the surgeons and the physicians ? An individual may certainly excel, by accumulated experience, in one department of his profession ; but what society should require ought to be that before he practices he should be acquainted with the principles of medicine to an extent which should prove a sufficient guarantee for his practice being safe towards the public. Now if society has to exact, necessarily, from every prac- titioner the same qualification, it follows, in common justice that each practitioner should be left to practice one, or more, or all of the branches of his art, as best suited his own inclination, his talents, his turn of mind, or his local or social position. While such an arrangement would be but just to the practitioner himself, the public would enjoy the benefit of having the talents of each member of the medical profession directed to that kind of practice which most suited his own case. But if the necessity for there being the same qualification required for whatever department of practice, and for individuals possessing such qualification being allowed to exercise their profession in what par- ticular mode they might choose, be made evident by the very nature of medical science the circumstances of society, apart from the philo- sophical view of the subject, point out the same necessity. The bulk of practitioners are "general practitioners," that is, such as combine the practice of all the different departments of their art. Physicians are found in the greater towns : London, the head- quarters of the "higher grades" of all professions, contains something more than two hundred and fifty physicians, while it probably contains about two thousand general prac- titioners. The "pure surgeons" in the Metropolis cannot make up the fifth part of the number of the physicians : there are a few pure surgeons in Edinburgh and in Dublin ; in the other towns it would be difficult to find a single pure surgeon. The reader will be astonished then to learn, that the great opponents of an uniformity of legal qualification to practice are physicians and pure surgeons, especially such as are fel- lows or members of the council of corporate bodies, (but this was to be expected); but he will be more astonished when he considers that such members of the profession as move in the higher walks do so, not in virtue of degrees or diplomas altogether, but on account of success, whatever may have caused it—on account of public esteem ; for many general practitioners are doctors of medicine, and many physicians practice on purchased degrees ; while pure surgeons, so much opposed in general to uniformity, call themselves surgeons in virtue of a diploma possessed, nearly uniformly, by all the younger generation of general practitioners in England, and are actually pures in consequence of hospital practice and public repute. The opposition of the "higher grades" to uniformity of qualification seems the more unreasonable, when we consider their own declaration that "society makes the grades ": of course it does : the "uniform qualification" may be likened to a door, through which, for the advantage of society, each member of the medical profession should have to pass before being left at liberty to follow his own course--to become a physician, a surgeon, or a general practitioner. There must still be physicians, still be surgeons ; while each man in the profession would have the opportunity, by practising in what mode he might choose, of being recompensed for the talent be could claim ; and while the public would reap the ad- vantage of having its bona fide physicians and surgeons gathered from a larger field—shaken up, as it were, like the larger grains in a vessel full of sand when it is agitated. A merchant may increase his business by means of parties hired to conduct it, but a medical man can but carry on his work by his own head and hands : his only reward, then, for increased merit, comes to be the power to demand increase of fees: he ought not to be tied down by law to a certain grade, or to certain con- ventional usages. But alas ! even in the retiring contemplative profession o medicine, whose business is to investigate natural truths, we find men animated by party-spirit and corporation-spirit, and prevented by the jaundice of prejudice and partiality from assenting to propositions the most palpable. When the Apothecaries Amendment Bill was intro- duced in 1833, the different medical communities petitioned each in favour of its own interest in some form, not from an enlightened anxiety for the general good. The Scotch schools of medicine peti- tioned for the abolition of serious grievances affecting themselves; the Irish, that the changes which might be made should contemplate their claims to justice; the College of Surgeons of London put in a word on its own account ; the Apothecaries Company petitioned in favour of things as they were ; and some of its licentiates in different parts of England, while they could not deny the propriety, the liberality, and the justice of the proposed changes, sent petitions from various towns in favour of the old system of monopoly and absurdity. It is to be re- gretted that professional men should have availed themselves of the mere letter of the law to injure an honourable rival who did not happen to be an apothecary, while they tolerated quacks ; for these latter pe- titions, it is to be lamented, seemed to have such an unworthy origin. The profession ought to be one; the law at least should make no grades in it : all that legislation has to do is to ascertain the fitness of indi- viduals to practise, and to leave the rest to themselves and society.

This investigation will be completed in other two papers.]