SIR JAMES CLARK ON MEDICAL REFORM.

WHEN the Physician of the Queen and of her Consort publicly ad- dresses a Secretary of State on Medical Reform, it may be predi- cated without much risk of error that some reformation is needed and that the reform recommended will not exceed the necessities of the case. If, in spite of all courtly precaution, a fear peeps out that the Government plan will be shaped to fall in with the notions of certain fashionable practitioners, and to uphold the interests of existing corporations, rather than to apply a sufficient remedy to a real evil, it furnishes grounds of apprehension that the danger we suspected some years since has come to pass—that in any attempt at changing existing modes, the Parliament men would most pro- bably be earwigged by their medical attendants ; and that the origi- nators, knowing nothing and learning nothing of medical matters, would meddle and unsettle without improving. To understand the necessity for reform, and the nature of Sir JAMES CLARK'S pro- posals, it will be necessary to take a cursory view of the present state of the profession ; which he, not allowing for the public igno- rance, has omitted to do. The number of corporations in the United Kingdom privileged to grant degrees to medical practitioners is upwards of a dozen; to which may be added foreign universities. In England, however, three institutions alone would seem to have the power to convey a legal authority to practise ; though this monopoly as it stands is so in- vidious, the privileges of each body are so difficult to define, their jealousy of each other so great, and so nice a proof is required in legal proceedings, that for all practical purposes their powers are in- operative, or, when set in motion, work injustice : now and then a gra- duate of a Scotch or foreign university, or a member of the College of Surgeons supply ing medicines to his patients, may be annoyed, while practitioners totally unqualified, or downright mountebanks, flourish with impunity. These three privileged corporations are the College of Physicians, the College of Surgeons, and the Apo- thecaries Company; which names pretty accurately define the three classes of practitioners in this country. The Physicians, as a matter of professional etiquette, rank first : to be eligible for ex- amination by the London College, they must have taken the degree of M.D. in some university, though their actual studies are of slender consequence ; they only practice in cases of pure disease, as opposed to injuries from violence, or (visible) morbid changes of structure; they furnish no medicines, and perform no operation, not even bleeding though the patient were in extremis and no other practitioner at hand ; they write a prescription for the medicines to be taken, and order in writing any treatment to be pursued either by the patient himself or inferior practitioners ; and they are paid by a fee, which is not recoverable by law. Many members of the College of Surgeons practice as apothecaries or general practi- tioners; but the higher and more ambitious members are pure surgeons. In strictness, it is their business only to perform opera- tions—such as cutting for the stone ; attend to accidents—as setting a broken limb, or injuries from violence—as gun-shot wounds, or morbid change—as external cancer. But as all such cases are accompanied by constitutional disturbance, which requires con- stitutional treatment—as it is often not easy in practice to separate a physician's from a surgeon's case—and as, moreover, accidents and capital operations are of much rarer occurrence than cases of dis- ease—a pure surgeon prescribes for almost any case that comes be- fore him. As their knowledge of anatomy and physiology is of necessity much greater than that of any physician, and their opportunities of observing disease nearly or quite as great, they regard the Doctors with great contempt, looking upon them as little better than old women. They are paid, like a plusician, by a fee on consultation, which they cannot recover by law ; but they can recover for operations performed, the amount being settled by the jury. The apothecaries, or general; practitioners as they are now called, practice indiscriminately in both branches of the profes- sion; but where capital operations are requisite, they generally send the patieut to a hospital, or call in a pure surgeon ; as, when the patient can afford it, they have a consultation with a physician in critical cases of disease, if the family wishes for "further ad- vice," or they desire to divide responsibility. The tangible dis- tinction between the general practitioner and the higher classes is, that the general practitioner supplies medicines, which the others only write for, leaving the patient to get them from the chemist. The charge for these medicines is the general practitioner's mode of remuneration ; but to be able legally to recover his bill, he must be a member of the Apothecaries Company. Some " very genteel" practitioners sink the price of the medicines, making a charge for their visits ; but this is not recoverable if disputed. The graduates of Scotch and foreign schools practise each branch of the profession according to the bent of their nature or necessities ; but, however professionally eminent they may be, they practice without legal right, and really evade the law. It is not unusual to see So-and-so M.D. with a small "surgeon" added. This word is intended to bar the College of Physicians, who can proceed against a man if he take a fee as a physician, but not as a surgeon. The powers of the College of Surgeons, we have understood, extend to painting over the word "surgeon." The Apothecaries Company can proceed by action against persons attending a patient and making a charge for medicines, unless he is a member of their body ; but the proof of the case is usually so difficult that proceedings are rarely insti- tuted.

The advance of general education, the struggling competition of society, and in many, no doubt, an earnest desire to excel and a conscientious wish to discharge their duties, enable these monstrous anomalies, if not in cant Tory phrase to "work well," to work better than might be expected. Still the public have no security whatsoever against practitioners totally unqualified; and mere licence is per se no proof of sufficient qualification. " In proof of the almost total disregard of preliminary education," says Sir JAMES CLARK in his Second Letter, " the following statement, recently made in a public lecture by Mr. Guthrie, will be admitted as unquestiouable evidence= I regret to say, observes that gentleman, ' that among the student!, who entered the profession some years back, and are only now presentiog themselves for examination under the regulations of 1836, there are many who cannot spell very common words in their native language.' Mr. Guthrie has been long on the Council of the Royal College of Surgeons, and is therefore well acquainted with the acquirements of the candidates for the College diploma. What these were before 1836, Mr. Guthrie dots not inform us; but such, it seems, is the deplorable state of ignorance of a portion of those permitted at the present day to pass the Royal College of Surgeons of London ! Are men Co educated worthy of being intrusted with the important duties attaching to the ordinary medical attendants of the community ? Is it surprising that quackery and quacks should thrive, when such is the education of the regular practitioner ? "

Again- ., No good reason can, I think, be given why the medical practitioners in civil life in this country should have an inferior education to those in the pub- lic service : yet such is the case. The gentlemen placed at the head of the medical departments of the Army and Navy, Sir James M•Grigor and Sir William Burnett, dissatisfied with the regulations of the medical institutions, have long required a more extended and varied course of study of the candi- dates for the medical departments of the Army and Navy than those inatita- lions require of their licentiates. The number of applicants has not been diminished by these regulations ; nor will the number of medical practitioners in private lie be reduced beyond the due proportion by requiring them to possess an equally good and even superior education ; while the character of the profession as a scientific body, and the respectability of its members, will be greatly raised. I repeat my deliberate conviction, that you have only to say that the whole medical practitioners in this country shall in future have a good education, and the call will be readily responded to." For strictly medical purposes, the general plan of Sir JAMES C LA RK for the removal of the above evils is simple, radical, efficient, and safe. He would establish one Board in each of the Three Kingdoms, with the sole power to license medical practitioners. A preliminary examination should be required on general education ; the profession should be divided into two classes, with a minimum and a maximum medical examination—the minimum being neces- sary to authorize a man to practise as a general practitioner, the maximum enabling him to rank as a consulting surgeon or phy- sician, leaving each person so qualified to practise any branch of the profession he pleases : a plan which is, we believe, adopted in every country save England and Ireland.

"As it has been stated, in the evidence to which I have just referred, and which will not he disputed, that to practise any branch of medicine successfully requires a knowledge of the whole science, it necessarily follows, that every me- dical practitioner should pass through the course of medical education deemed necessary for the general practitioner; and that those who desire to confine themselves exclusively to medicine or surgery should first take the degree

which qualifies for general practice, and then devote a certain period in acquir- ing that additional experience and practical knowledge, and that manual dex-

terity, which may qualify them for consulting physicians or operating surgeons.

There will always be a sufficient number of the profession who will possess a more extended general education, and a greater amount of medical instruction

and experience, than could at present be required or expected of the whole body of medical practitioners, and who will consequently take the higher de- gree of Doctor of Medicine. From this class will naturally be selected phy- sicians and surgeons to hospitals, lecturers in the medical schools, examiners, &c.; in short, this class would alone be eligible to such honourable appoint- ments as will prove a sufficient stimulus to insure an abundant supply of highly-educated men as successors to the physicians and surgeons of the pre- sent day. And not only this: the facilities for acquiring instruction in every branch of science are increasing so rapidly, that the proportion of medical men

who will take the higher degree will no doubt augment from year to year ; and, judging from the progress which has been made in our own day, it will not be

considered a very extravagant prediction that in the course of another half century the smaller proportion only of medical graduates will stop at the lower degree. 'The first and most essential step in medical reform is, unquestionably, the establishment of a good and uniform education for the general practitioner;

the second, that every practitioner in medicine, whatever may be the depart- ment for which he is destined, should qualify for the duties of the general prac- titioner—that is, should take the degree of Bachelor of Medicine, or whatever title he may be designated by —as a preliminary step to the higher degree of Doctor of Medicine. "This I consider one of the cardinal points of medical reform; and one against which I have never heard a single sound argument advanced.

" As by this regulation all would pass through the first degree, so all would be eligible for the second or higher degree, by devoting an additional period to acquiring a practical knowledge of their profession, and submitting to the pre-

scribed tests. Such a regulation would at once do away with all just cause of jealousy between the two grades of the profession; while the knowledge that at any future period he might take the higher degree, would prove a powerful stimulus to the general practitioner to keep up his knowledge with the progress of medical science. This relation of the two grades of medical prac- titioners being established, there could he no good reason why men SO closely

connected by education, and so intimately associated in the exercise of their profession, should be ranged in different institutions. It is surely more na-

tural, and would, I think, be infinitely more beneficial to the profession, that the whole should he included in one institution. Make two classes of mem- bers in the united body. Let those who take the higher degree constitute the Fellows, and be alone eligible as officers for conducting the affairs of the cor- poration; while the general practioners, or Bachelors of Medicine, would con- stitute the great body of members, and have, under such regulations as upon consideration might be deemed proper, a vote in the election of the officers. As this rule would apply to all, and the fellowship would be open to every member of the body who chose to qualify himself for it by taking the higher degree, no one could complain of being excluded from the fellowship. " The whole profession would thus be united into one body ; while the pre- sent distinction of physician, surgeon, and general practitioner, would be main- tained. All just cause for the discontent at present existing in the profession. would be removed. The one faculty' and ' representative' system would

be realized, without in the least degree interfering with the present distinc- tions: such distinctions, on the contrary, would be established upon the only legitimate ground—that of more extended acquirements. So far from such an

arrangement being calculated to lower the physician and surgeon to the level of the general practitioner, as Las, I think, been most erroneously urged, both classes would be raised by it. The more the education of the general practi- tioner is raised, the higher, doubtless, will be that of the consulting physician and surgeon."

These extracts contain the germ of the author's plan. The

remainder of his pamphlets is devoted to what, but for the public ignorance of this subject, would be a superfluous defence of the proposal, and to arguments in favour of requiring a good general education from medical candidates, (an approach to which has been made by the lowest existing body, the Apothecaries Company.) In a practical point of view, the publication is perhaps rather wanting in detail. The nature and extent of the examinations may and must be settled by the Boards when appointed ; but it would have been desirable at all events to learn Sir JAMES CLARK'S views as to the schools in which the comae of study might be pursued. Some of the existing English corporations have been charged, whether truly or not, with chalking out a course of study which must be followed in schools where their members teach, and with virtually refusing to receive certificates from other masters. This monopoly of late years is admitted to be somewhat broken down; but it is still said to exist : and, no doubt, a man who had studied in France or Germany might be refused examination in London, without the slightest regard to his learning, but merely with reference to where he bad learned. Does Sir JAMES uphold this limitation, and to what extent ? or would he allow any one to be examined, on proving by his certificates that he had gone through a sufficient course of study, his permission to practise de- pending of course upon his showing under examination that he had profited by that study ? Another omission an the proposal has reference to the public. Oir. Jesus properly denounces, what is said to be a favourite scheme of Sir HENRY HALZORD'S, a very low grade of practi- tioners to practise on the poor. But we see no proposal to pro- tect the public from impostors without any qualification what- soever. We do not so much allude to "quacks," as to chemists. As matters now stand, a chemist is a tradesman, and, like any other trade, any body can follow it. No examination is required, not even an apprenticeship. Yet, practically, there is no means of preventing these persons from acting as medical men, and very fatal accidents often happen from their incompetence : but Sir JAmEs CLARK proposes no direct remedy for this evil. He may indeed say, that his wish to prevent any regular medical man from furnishing medicines to his patients, would meet the case. But we doubt it, without some punishment for irregular practitioners. It might drive very many patients to chemists and druggists; but that would be all. Indeed, we think this view ill-considered, and the blot of the plan. It is true that this division generally obtains in other countries; but, though the practice of other countries is a cogent argument as regards medical requirement, it is no precedent as regards medical remuneration. That must have reference to the state of society, the habits of living, the plenty or scarcity of money, and various other social and economical points. In London, the usual fee of a physician or consulting surgeon is a guinea : in the countries Sir JAmrs alludes to, the fee of the same practitioner is little more than an English chemist charges for making up this guinea prescription ; and the poorer patients, that is the vast bulk of the community, would have to pay the poorer druggists, not in- deed at this rate but at something like this rate. In other words, they would pay double what they now do—once for the prescription, and again for making it up. But in reality, fees, with the bulk of the community, are out of the question. The Queen's Physician may not know it, but a vast majority of the poor are half their time without money. So far from baying fees to pay "Bachelors of Medicine," they cannot even buy bread. The majority, it is to be feared, live from hand to mouth : when sick or out of work, they have to exist upon credit as they can, and pay off their debts as they may. How is it possible for such a class to pay first of all a fee for their prescription, and then to pay the chemist for their medicine ? It is difficult and distressing enough for the general practitioner to deal with such patients at present. Gentlemen by profession and education have to feel their way, even in cases of afflicted humanity, to attend at all hours and in all weathers, for a charge including medicine, which the chemist would probably make fi* compounding the prescription, and to give credit with little chance of ever being paid. That chance, such as it is, would be cut sway under the proposal of Sir JAMES CLARK. There is a notion in this commercial country, and it exists in classes much above the poor, that a professional man, who loses nothing tangible, loses nothing at all. They cannot see that "time is his estate." Those who may now struggle to pay a bill for medicines would never dream of paying a bill for fees. Nor can we see a necessity for the two pro- posed classes, when every man's practice is to be the same ; besides which, much practical difficulty would arise as to the amount of the fees. The nearest approach to Sir JAMES CLARK'S proposal would be, not to allow medical practitioners to be venders of drugs : and this alteration is perhaps attainable. At the same time, be the forthcoming Government measure what it may, we think it highly important that general practitioners should be legally permitted to charge for their visits, if they prefer it, instead of swelling their bills with unnecessary medieines • subject, of course, to a maximum fixed by law, or the decision of a jury, or both. This view we took when discussing the subject in 1838,—for the following reasons ; and all the pamphlets and speeches, and abortive bills brought forward since, have only confirmed our opinion of its prac- tical soundness.

"In some disorders," we said, "the medicines are expensive; but in the ma- jority of cases the value of the curative drug is so small as to be inappre- mibk ; and though it requires a liquid or solid basis to be administered, yet the worth of what sick people in general need take, including phials, boxes, and all appliances, is often not above a few pence a day. This candid mode of practice

would not, however, remunerate a in for one, two or three visite a

tiay, or perhaps foe being called up m the middle of the night He is there- fore compelled to poor in drugs disguised in simple bodies, according to alai endurance and pocket of the patient, so far as observation enables him to vett; at the latter. Hence the degradation of an important profession to a sor- did trade, without the openness with which trade is carried on ; much suspi- cion on the part of the patient as to the uses of his medicine and the motives of his attendant ; with, often, much huckstering as to the charges when all is over, no standard by which they can be fixed, and no means of ascertaining beforehand what they are. Yet if a man were to treat his patients rightly, sending no more medicine than they absolutely required, and charge them for his visits, however moderately,—nay, though in the case of a poor person he lumped the whole out of charity,—he is dependent on their honour, and can recover nothing but the mere medicine, or any manual service. So important do we deem this point, as regards Me public and the bulk of the pro- fession, (the heads, we know, will be averse to the change,) that any reform which does not embrace it will be useless and deceptive.

"And this improvement is practicable, whilst we suspect many others are not. The objects of the Medical Association are all excellent ; but, such is the ignorance and indifference of the public, the power of the corporate bodies whose privileges and monopolies will be destroyed, with their means of earwig- ping Ministers and Senators, who must move in and decide upon medical re- form, that much time most elapse before the question has a probability of suc- ceeding; whereas a short act, requiring chemists and druggists to pass an ex- amination before practising, and to enable a practitioner to recover a maximum fee for visits, might probably pass at once ; for though physicians and pure surgeons would be very averse to it, it is questionable whether they could infuse their views into the Members of Parliament. Besides, the bill might be limited to members of the Company, it would under Sir JAMES CLARK'S plan be the lower degree,] leaving physicians' and surgeons' fees still honorariums... (Spectator, No. 544; let December 1838, page 1139.)