%mm L I B RA RY OF THL U N IVE.RSITY or ILLINOIS SPEECH BY THE Right Hon, Sir LVfll KWE, K,C,B„ MEMBER FOR THE UNIVERSITIES OF EDINBURGH AND ST ANDREWS, ON THE MEDICAL ACT AMENDMENT BILL, DELIVERED ON SECOND READING, IN THE HOUSE OF COMMONS, ON 22D JUNE 1884. 1884. Reprinted frotn The Scotsman of 2 ^d June 1884. SPEECH BY THE RIGHT HON. SIR LYON PLAYFAIR, K.C.B., Member for the Universities of Edinburgh arid St Andrews. I THINK it has been a surprise to most of us that this Bill has been reached to-day, and if I do not discuss it fully it is because I really did not expect that I would be called on to speak on it until a later date. The reason I intervene so early in the debate is that out of 6500 constituents 3000 of them are medical men, and therefore they are deeply interested in a bill which will add very much to the dignity of the profession and to its importance in the future. My right hon. friend the Vice-President of the Council has clearly explained the leading features of this Bill. Since 1870 more than twenty bills for medical reform have been before the House, and have been referred to Select Committees, and ulti- mately to a Royal Commission. This Bill is certainly the best which has been framed, and it is desirable that it should pass, so as to give peace to a long agitated profession. The main object ef the Bill is to secure efficient medical education, and to ensure the possession of adequate knowledge on the part of all persons who receive licence to practise. The present authority which supervises medical education is a General Medical Council, created in 1858, partly nominated by the Crown, and partly representative of the Universities and Medical and Surgical Corporations. This central authority, strengthened by direct representatives from the medical practi- tioners of the United Kingdom, is continued by this Bill. In addition to it, three Divisional Boards, one for each section of [ 4 ] the kingdom, are now created. They are in future to be the sole licensing authorities recognised by the State. Their exami- nations are to be made equally efficient by the General Council, and they are to require from every candidate a knowledge of the three fundamental subjects of the medical profession — medicine, surgery, and midwifery. This is an essential condition of medical reform. At present the public have no security that the general practitioner pos- sesses such knowledge. A College of Surgeons may pass into the profession a man entitled to attend medical cases, such as measles or scarlet fever, although he has not been examined by them in the practice of physic. A College of Physicians may license a man legally entitled to amputate a leg, although he may not have passed in surgery ; while both may send out licentiates without having passed in midwifery. There are now nineteen licensing boards, furnished among them with fifty or sixty titles of all sizes and shapes, out of which an embarrassed public has to judge of efficiency. It is true that the licensing bodies have been lately reforming them- selves, and have in some cases coalesced, in order to pass licentiates with a knowledge of the three fundamental subjects ; but these arrangements are private, and not statutory. The general purpose of this Bill is therefore unassailable, for it pro- vides that every licentiate shall have adequate knowledge of medicine, surgery, and midwifery. Opinions differ as to whether the General Council and the divisional examining boards are properly constituted. I do not propose to discuss this question till we reach the Committee stage of the Bill. At present I confine my remarks to the educational effect of the Bill on the public interests of a great and noble profession. I have said that the General Medical Council is charged with seeing that the three divisional examining boards in England, Scotland, and Ireland shall have a common standard of sufficiency in their examinations. The standard of efficiency must not be placed higher than average candidates can pass, for the waste of the medical pro- fession must be supplied. This waste is about 1600 men yearly. The three doors of admission to a licence must be wide enough to let 1600 men at least pass through them. Suppose that the door were made as narrow as that of the University of London, only forty or fifty licentiates could pass [ 5 ] through annually. Suppose it were merely widened to the size of the Scottish Universities, only 300 men could pass through it. With such higher examinations four-fifths of the medical men annually required by the country would be rejected. The new divisional boards of licence cannot therefore have too pedantic views of their functions, because already the supply of medical men throughout the kingdom does not increase in pro- portion to the population. Between 1851 and 1861 it positively decreased, for the medical men in 185 1 were 15,241, and fell to 14,684 in i86t. In the following decade, ending in 187 1, the medical men increased 2 per cent, while the population did so by 13 per cent. In the census of 1881 the medical men of England increased 3 per cent., while that of the population was 14 per cent. Scotland showed a better proportion, for the increase of doctors was 7 per cent, and that of the population was 1 1 per cent. In Ireland the doctors increased in all to the extent of 50 men, although there was a slight decrease in popu- lation. None of these figures are satisfactory. They show that the present conditions of medical men are not attractive enough to induce students to enrol in sufficient numbers to supply the population. This Bill may provide a remedy, or it may increase the evil, according as it is wisely framed and wisely administered. (Hear, hear.) The conditions of licence must aim at provid- ing a minimum examination for sufficiency, but dare not try for a maximum of efficiency. As Sir William Gull puts it, the licensing divisional boards must only try to give " a better low- est examination than is now given." Of course, that in the future will embrace the three fundamental subjects of medicine, surgery, and midwifery, which all the nineteen licensing autho- rities do not do, and certainly are not bound by statute to do. No doubt, however, a low pass examination has its danger. Candidates will certainly look to the State examination as the main end to be achieved. Its natural tendency will therefore be to produce and often to reduce to a low level of uniformity. In careers barred by examinations, the latter become the motive power, while a desire to attain a higher standard of ex- cellence is limited to the ambitious few. The minimum standard of the State examination will in future govern the teaching of medical schools as surely as the main motive wheel of a factory engine governs the motion of a [ 6 ] thousand bobbins. (Hear, hear.) This has not escaped the attention of the Royal Commission, which was obHged to adapt its recommendations to the varying circumstances of medical education in the three divisions of the kingdom. In England, medical education is chiefly conducted by hos- pital schools, the pupils of which are examined by the London College of Surgeons or of Physicians. The Universities of Eng- land have hitherto contributed only eight per cent, of the licentiates of England ; but I am glad to say that both Cam- bridge and Oxford are rapidly developing their medical schools. In Ireland, the Universities play a more important part, for they graduate one-third of all the licentiates. The Irish Cor- porations also have their own teaching schools, and differ in this respect from the Corporations both of England and Scot- land. In Scotland, the Universities take a very conspicuous part both in medical education and graduation. If we compare double licences in medicine and surgery, the Scottish Univer- sities now license sixty-one per cent, of all the licentiates in Scotland. The students prosecuting medicine at the Univer- sities are 2700 in number, while their annual graduates are 300, or exactly six times more than the medical graduates of the English Universities. A system somewhat less organised than the hospital schools of England prevails in Scotland under the name of extra-mural teachers, who have a considerable number of students, partly preparing for the corporation licences, and partly for University degrees. It will therefore be observed that Scottish and Irish medical education is essentially differ- ent from that in England. Indeed, it more resembles that in Germany, where out of 25,000 University students, 6000 are engaged in the study of medicine. The effect of having medical education within Universities is to associate general culture with technical training. Mere professional schools give length, but they do not give breadth to technical training. In the case of the Universities it is different, for their primary object is to give a cultured educa- tion, and then to make professional training its natural and logical development. (Hear, hear.) The Royal Commission and the Government, acting upon their report, were obliged to adapt any new system of licensing to the varying conditions of medical attendance in the three [ 7 ] divisions of the kingdom. This they have endeavoured to do, by making the representation on the divisional boards in pro- portion to the part which the Corporations and the Universities respectively take in medical education, giving, however, a preponderance to those bodies which both teach and graduate over those which merely influence medical education by systems of examination without teaching. So the divisional boards in the three sections of the kingdoms are differently constituted. In England, where the Universities have in the past only trained fifty graduates yearly, the Corporations and Universities have equal representation on the divisional board. In Ireland, where both the Universities and the Corporations have medical schools, the Universities have a majority of two. In the Scottish divisional board there are eight University representa- tives to five from the corporations. At present I do not desire to discuss whether these are fair proportions between the Universities and Corporations. This is a subsidiary question which had best be considered in Com- mittee. At the same time, I entirely uphold the principle of the Royal Commission, that where teaching Universities do much to promote medical training, they ought to have a preponderating influence over mere examining boards. The reason for this is obvious, — that we desire to promote methodical education, and not mere cram. Unless you encourage Uni- versities to aim at maximum qualifications, the State boards will have the eff"ect of inducing candidates to work down to the minimum of sufficiency, instead of working up to the higher qualifications of Universities. Examination is not education ; it is only a test of what education has achieved, and it is always attended with uncertainties, and very frequently with evils. (Hear, hear.) The Bill abolishes two examining boards, but it adds three, so that twenty will still remain if it were not for the tendency of the Corporations to unite in order to form conjoint examina- tions. Thus the three Scottish Corporations have united, and instead of five means of entering the profession, they will here- after have only one entrance, so that all the candidates must pass in the three subjects — medicine, surgery, and midwifery. The London Colleges of Physicians and Surgeons have a con- joint scheme prepared, which will no doubt be ratified by the Medical Council in October, and they will consolidate their examinations in a like way. [ 8 ] According to the present Bill, all the candidates for Univer- sity honours, or for Corporation licences, must pass a final examination before the State Divisional Board. This was necessary when the Corporations gave licences for single subjects, such as medicine and surgery, or midwifery. But now that some of them have conjoined, and give one final examination for all three subjects, the whole question becomes much simpler. Frequent and repeated examinations on the same subjects are an intolerable oppression on candidates. The Medical Council and the subordinate Divisional Boards have to satisfy the public that the examinations for licence to practise are sufficient. This is the essence of the scheme, and with it I have no intention to interfere. If they can do this without adding to the number of examinations it will be an immense gain no doubt. The whole security for efficiency must be maintained. But this could be done in two ways — either by the Divisional Board instituting a complete new final examination entirely by its own examiners, or by sending its examiners to take part in the final examinations of the Universities, and of the conjoint examinations of the Corporations. Both these plans were under the consideration of the Commissioners, who by a majority recommended new and separate examinations. The two Commissioners of the highest professional authority — Professor Huxley and Professor Turner — dissented, and gave very strong reasons indeed for the second plan of sending examiners from the Divisional Board to the University exa- minations and to the conjoint examinations of the Corporations. This is, in fact, the present system adopted in Germany. The State sends examiners to the Universities, and, associating the Professors with them, conducts the final examination. Germany first tried the other system of having a distinct licensing board, but abandoned it because it was found to lower very materially the medical qualifications of licentiates. I believe that if the majority of the Commissioners had now before them the schemes of conjoint examination since adopted, they would have reported in favour of a combined rather than of a new and separate examination. (Hear, hear.) Let me show how grievous a hardship an additional examina- tion would be in the case of the University of Edinburgh. The final examination there in medicine, surgery, and midwifery occupies the examiners five or six hours daily for three or fotir [ 9 J weeks, and then six weeks more are occupied in clinical exami- nations at the hospitals. Upon that long and searching exami- nation the University grants its degrees. But according to this Bill, the candidate who has been successful at the University has to take his prolonged and harassing examination twice over — once at the University and once at the Divisional Board. Of course the result would be that many men would be content with the minimum examination which will put them on the register, and never take the maximum examination required for a University degree. But that would defeat the purpose of the Bill, which is to promote, and not to deteriorate, medical education. It is quite possible that the Corporations might accept the final examination of the Divisional Board, although it would not add to their dignity or to the permanence of their existence ; but it would be impossible for the Universities to do so unless they lowered their standards f(;r degrees. Another practical difficulty stands in the way, which would not be felt in a large capital like London, but which is fatal to the proposal of the Bill in a city like Edinburgh, which, it must be borne in mind, contains by far the largest school in the country. At present the clinical examinations in its hospitals require all the patients who can be used with safety to them- selves. If a second examination in clinical subjects is enforced by the Divisional Board, one of two things must follow^ — either that the hospitals will refuse to place themselves at the disposal of the examiners of the boards or of the Universities. It must be borne in mind that patients are patients, and that it would be wicked to expose them to the exhausting effects of a double use of their bodies. (Hear, hear.) But this double examination is wholly unnecessary when Universities and conjoint Corporations are wiUing to allow the examiners of the Divisional Board to take part in their final examinations in as full and complete a way as the Divisional Board and the General Medical Council may desire. I can answer for the University of Edinburgh in this respect — indeed, I know it to be the opinion of all the medical authorities in Scotland ; and if there are any Universities or Corporations in England and Ireland who object to the introduction of public examiners into their final examinations, let them remain under the present provision of the bill, which provides for a separate and additional examination. All that I ask is that when [ 10 ] Universities, or Corporations acting under a conjoint scheme, are willing, this simple method of sending public examiners should be adopted, for thus the most complete security of efficiency will be given to the public, and the evils which must follow from an additional examination will be reduced to a minimum. (Cheers.) I know how difficult it is to command the attention of the House to a bill of this character, which includes so many technical and professional points. It is this feeling which pre- vents me from discussing them fully on the second reading. But when the Bill passes into Committee, I hope that we may have ample time to discuss the details. The public interests of a profession which has to deal with the health, and even with the life, of the people, ought not to be hastily considered by the House. The long-continued agitation for amended laws relating to it has prevented the natural growth of the profession. It is essential, therefore, that we should have permanent legislation on a wide basis. This Bill makes an honest attempt to give us it, and I have resisted many efforts to make me an opponent instead of a supporter. But let me warn the House to keep in view that teaching and training, and not examination, make the physician. A distinguished surgeon, Sir James Paget, has lately claimed for the medical man that wdthin a generation he has lengthened human life, decreased pain and suffering, while he has increased the working powers of the people. I could admit this with the qualification that we legislators may claim some part of this result by our sanitary laws. (Hear, hear.) The results, both as regards medicine and law, are primarily due to the advance of science. The microscope, which lately has led to such wonderful discoveries in regard to the small organisms which produce disease; chemistry, which has dis- covered anaesthetics, and enabled us to examine diseased secretions ; the investigations which have led to antiseptic treatment in surgery ; the stethoscope, which enables us by sound to know the working of the internal organs — these we owe to advancing science. It is, then, of extreme importance for the future advance of medicine that medical men should be efficiently trained, especially in those practical means of research which modern laboratories offer to students. Mere examination may promote cram, but will not advance [ " ] science. (Hear, hear.) The Bill recognises this broad truth by encouraging Universities to continue the training of the medical profession. Some of these undoubtedly fear that the Bill will be prejudicial to their higher education, and I admit that it would be in its present form. But I have pointed out how easy it will be to remove this danger either to the Universities, or to the Corporations which have joined together to make a complete examination, without altering in the slightest degree the structure of the Bill, or lessening the powers of the General Council to enact the conditions for licence, and with- out lessening the powers of the Divisional Boards to admit to the register on well-ascertained qualifications. I have pointed to an amendment which might be inserted in three lines enabling those boards to send their examiners to Universities or conjoint Corporations, for the purpose of assuring the Medical Council that the examiners were not only sufficient but efficient. If this were done I think much of the alarm which now prevails would subside. I know that the Scottish Corporations are not at present supporters of the Bill. But their objections are on another ground, and can be fairly considered in Committee. I should deplore as much as they do any prejudice to their prosperity by legislation. They have a useful and important function to perform in promoting the welfare of the medical profession. I am sure that they are sensible, although they are examining boards, that the scientific training of medical students is far more important as a means of education than the mere stimulus of examination. They, therefore, when they under- stand the proposal, will not object to the limitation, instead of to the multiplication of the examinations. As to the fundamental object of this Bill, which is that all medical men in the future should have a sufficient knowledge of the three chief divisions of medicine — medicine, surgery, and midwifery — there is a consensus of opinion in its favour. (Loud cheers.)