MEDICAL REFORM.
BY A MEMBER OF THE PROFESSION.
FEES. THE " DRENCHING SYSTEM." PRESCRIBING DK LATIN. "CUE- MISTS AND DRUGGISTS." PATENT MEDICINES. ELECTION TO PUBLIC OFFICES BY PUBLIC COMPETITION. EDUCATION. ASSISTANTS. AP- PRENTICESHIP.
BEARING in mind the necessity for uniformity of qualification in such as enter the profession, and for identity of privileges among its mem- bers when they have been initiated, as the two grand features in a ra- tional scheme of reorganization, it will be proper, before considering the progress of the question, or the machinery best adapted to work a new system, to dispose of some important though subsidiary matters.
Some of our reformers would ordain that medical practitioners should be paid by uniform fees, fixed by law. This would appear but a foolish arrangement ; for it is hoped that it has been already shown that a me- dical man's charges ought, in justice to himself, to vary according to the demand for his advice. On a uniform system of charges, the future Dr. Bsirrivs and Sir ASTLEY COOPERS of our profession could but earn the same amount of fees as a village practitioner whose hands were full : the same plan, while it thus prevented the deserving from being sufficiently remunerated, would hinder the public from the advice of the younger members of the profession at the cheaper rate at which they, on a more natural method, must commence practice. Fees must be left to circumstances. A practitioner's interest would be a sufficient check on his putting an undue value on his own usefulness; but, in case this preventive should fail, there are juries in the country. Medical charges, on being disputed, must be referred to a jury. By a uniform system of charges, estimating the price of a professional visit at five shillings, a bungler who required to pay ten visits to a case would re- ceive fifty shillings, while a better practitioner, who kept his patient ill but half the time, would be rewarded by half the sum. By such a method, too, a trifling operation would yield the same recompense as a capital one.
The barbarous system prevalent in this country, of charging for drugs instead of for medical services, is productive of much evil. It arose in this way. The London College of Physicians, instead of be- coming a great and useful institution for the benefit of the country—by spreading abroad, on a liberal principle, a sufficiency of proper medical practitioners to guard the health of the community—unfortunately de- generated into a narrow-minded clique of Metropolitan physicians ; and the English Universities, not being fitted originally, and failing to adapt themselves to the circumstances of the profession, have never been able to supply a stock of graduates it medicine suitable to the wants of the country. In consequence of the shortcomings of the Universities and of the College, the druggists (apothecaries) commenced the practice of medicine; putting their charges for their medical skill, such as it was, upon their drugs. Their successors are now the general practitioners of England, who still charge for their medicines ; while the present race of "chemists and druggists" occupy the position originally held by the apothecaries.
The system of charging for drugs is one of the greatest of the evils,— as Dr. JOHNSON agreed before the Committee of the House of Com- mons,—that affect the profession. The peoplelof England swallow more drugs than any other nation ; and have come to attach such a false value to medicines, that the druggist now-a-days, instead of charging the market-price for his wares like other tradesmen, harges after the man- ner of the "apothecary,"—as if the drugs possessed a virtue which exists only in their proper administration. It is evident, too, that the less a practitioner knows of a disease, the more drugs shall he have to admi- nister for it, and consequently the more pay to receive for its treat- ment; for, unless he can remove the cause of it, he will administer some nostrum for each of its symptoms, which nostrums may but tend to complicate and perpetuate the mischief. It would be as proper to pay a practitioner for the gruel his patients drink as to reward him for the medicines they consume. Medicines are substances given in quan- tities necessarily small, and their intrinsic value is generally so trifling that the labour of putting them together is of more account than the materials themselves. Sensible people must submit to the barbarous usages of the apothecaries from custom, not from reason. But how are the evil effects of the "drenching system," as it is called, to be obviated? By preventing medical men from dispensing drugs, as some reformers would have it ? Certainly not : that would be unjust ; for, if others are allowed to dispense medicines, why should the very men whose business it is to direct the administration of them be hindered from dispensing them, especially when it is allowed that it is absolutely necessary for them to do so in many circumstances ? A surgeon is his own apothe- cary in the services, and on board of ship, as well as his own physician ; so must he be in rural situations : but even in great towns it is necessary for him to administer drugs from his own pocket occasionally ; and he must often, everywhere, to insure the exact fulfil- ment of his own intentions, make up his medicines himself, or have them made up under his personal superintendence. When the late Dr. BIRKBECK, whose clear and manly evidence before the Parliamentary Committee is worthy of admiration, was asked if physicians ought to be prohibited in all cases from dispensing medicines, he answered, "Cer- tainly not by legislation." As a remedy, it is submitted that, while medical practitioners cannot be prevented, in common with other citizens' from selling drugs if they choose, they should not be allowed, more than other people, to charge more for drugs than their intrinsic worth, their market value, and that they should be at the same time empowered by law to sue for a fair remuneration for medical care or attendance. The system of charging for medicines instead of for medical skill is, as Dr. BIRKBECK says, a deception ; but it is also a custom of the country, and as such must wear out gradually : legisla- tion cannot suddenly stop the deception, but it can divest it of legal sanction, and thus accelerate its gradual lapse into desuetude. Under the arrangement proposed, general practitioners would coEug to dispense drugs only in such circumstances as rendered it necessary for them to do so ; the people would more rapidly perceive that drugs were not specifics; and, in the main, the mere dispensing of drugs would as a
business become disassociated, as it ought, from the profession of medicine. The druggists, too, on this system, would gradually become less able to sell drugs as if medical skill accompanied them ; and, for this want of emolument from an illegitimate source, they would be recompensed by an increased amount of dispensing. The system, being founded on reason, has the advantage of adapting itself to all the cir- cumstances of the case. Mr. MUNTZ proposed, the session before the last, when Mr. Hawns's bill for better regulating the medical profession was on the tapis, that it should be made necessary for medical prescriptions to be written in English. Mr. MuNTz was right. The French, who have the start of us in many scientific matters—who have divided the profession better than we—who do not regard the dispensers of physicians' prescriptions as doctors of medicine, any more than do we the law-stationers as law- yers—who do not attach so many virtues to blue bottles and red pills— make it necessary that their physicians should prescribe in their own language. The defence of prescribing in a language which not every liedical practitioner can write correctly, and of which the " chemists ' are supposed only to know some conventional contractions, affords a fine illustration of the fact that no social arrangement can exist, however absurd, without being regarded as something particularly worthy of continuance and respect. The writing of prescriptions in English, whether legislation should interfere in the matter or not, would help to disabuse the people of their absurd reliance on the specific virtues of nostrums : it would tend to show them that medicine was a science; and it is only for those who wish to keep up empiricism in practice, and who are afraid to rest their claims to success on knowledge, to defend the custom of prescribing in a language that was written in Italy about the commencement of the Christian tem.
With regard to the question as it affects the "chemists and drug- gists," the most general opinion is, that they should be examined touching their skill in materia medica and pharmacy before being allowed to dispense medicines. The medical practitioner must always neces- sarily be acquainted with chemistry, materia medica, pharmacy, toxi- cology, and therapeutics : it is his business to see that his patients have proper remedies, from whatever quarter these may come—whether from the cook, the baker, the confectioner, the instrument-maker, or the druggist : it is his duty to make up medicines, or to see them dispensed, when that he should do so is for the interest of his patient. " Che- mists and druggists" are merely the sellers of certain commodities, and it does not seem clear why a measure of medical reform ought to inter- fere with them : it ought merely to prevent them, in common with others not possessing a medical qualification, from acting as medical practitioners. The apothecaries were once the druggists ; and as they encroached upon the province of the physicians, the "chemists and druggists" invaded theirs. Is it not to be feared that any licensing of "chemists and druggists" would be apt to create a class of men who might be regarded as having some claims to medical knowledge, and thus to interfere with the groundwork of the plan advocated, of a cer- tain amount of qualification being necessary to the practising of medi- cine in any department or in any modification ? The "chemists and druggists" in the general mass do not necessarily possess chemical knowledge. Difficult operations in the manufacture of medicines are accomplished in modern times by a class of men whose business it is to make "preparations" on a large scale. Our " chemists " do not make their own muriate of morvhia or sulphate of quinine: which of all the salts do they prepare ? they purchase their acids from the manufac- turer, and their spirits from the distiller. The trade is not now an art and a mystery, as when the apothecaries received their charter ; and the prescribing in English would make it still less so. The chemical ope- rations of druggists are confined to the simpler "processes" of the pharmacopceia : the business consists in retailing drugs, and in putting a few together occasionally according to the letter of a recipe. The extensive adulteration of drugs is much to be lamented ; but their quality depends not so much on the knowledge of the dealer as upon his conscientiousness. In a "medical profession bill," it does not appear that there is any necessity for any clause regarding "the trade of chemists and druggists." Patent or secret remedies are absurd: the Government ought neither to countenance nor to tolerate them ; it should not levy halfpence on quack pill-boxes, as it does ; but, rather than thus indirectly encourage empiricism, it ought, with a parental care for the good of the public and the aggrandizement of the poor, to reimpose a small sum upon salt. A capital pamphlet, by a "Member of the College of Physicians," pub- lished in the beginning of the eighteenth century, and entitled "The Present Ill State of the Practice of Physic in this Nation, truly repre- sented, and some remedies thereof humbly proposed to the two Houses of Parliament," exposes the absurdity of specifics in very pithy and quaint language : but it is to be feared that human intellectual progres- sion is slower than sanguine people would wish, for tons of specifics are yet sold in the nation. This old pamphleteer settled the question concerning specifics, about a century and a half ago, when he said- " The bill-quacks give out that they can cure all diseases by one or two medicines, or have a certain remedy for some particular disease. That the first pretence is absurd and vain, every man of sense will ac- knowledge ; and that the second is dangerous, I will demonstrate. Sap- p/big they are masters of a good medicine for someone disease, (which it is odds they are not,) yet it is left to every man's judgment that makes use of it, whether he have that disease ; and how easy and frequent is it for men to mistake ? But suppose he has that very disease for which the medicine is proper, yet how seldom is a disease alone, or how sel- dom accompanied with just the same symptoms ? not to mention the age, the sex, the variety of causes, the late invasion or long standing of the distemper ; all which circumstances it is impossible that one medi- cine should. be suited to. I will instance one disease and one medi- cine that cures it specifically. The disease is an ague, which can hardly be mistaken, and the medicine the jesuits' bark, which seems to be no edge-tool ; and I may affirm there is not any other disease that has so peculiar and certain a remedy. And yet all that have agues, one and another, take this medicine in the same manner ; and I dare say it will kill as many as it cures. Perhaps, indeed, they shall not die presently, nor of the ague, for which it is given, but of ther diseases, that it either introduces or increases. How many asthmatical persons has it suffocated I how many intermitting (as well as remitting) fevers has it made continual, and even malignant I How many
desperate caliche, some ending in palsies, have-I-known caused brit+ with many other grievous distempers ; and all for want of due pre- paration before, a right method in, and proper treatment after the use of it. Of this scandalous sort of practices, therefore, I shall take no further notice, believing they can have no patron, no advocate among, wise men." As there are no specifics for one disease, or for all diseases, there would be no hardship in suppressing secret medicines, andirr making it necessary that the ingredients of all nostrums should be made known upon demand. If a chemist discover a new mode of manatee-. taring a salt, or any other valuable commodity, let him by all means have the advantages which discoverers in any branch of art or manu- factures are entitled to, by patent—that is a totally different affair ; but let us not only not have a Government-office for labelling empirical nostrums, but let the law prevent the propagation of compounds as good for this or for that or for all diseases, as one of the most flagrant kinds of the illicit practice of medicine. But the law has been busy in pre- venting red-cloaked gipsie,s from encouraging poor servant-girls with happy auguries for the future. It would be pleasing to see a British Government taking into consideration the necessity for rewarding the discoverers of principles that cannot be patented—yielding now and then some return for good conferred on the community, to such men as HARVEY, JOHN HUNTER, and JENNER.
It would be desirable to have the road to medical distinction made more public to all the members of the profession. The way to great eminence is often through a connexion with an hospital. Now, though before being elected to a great public charge an individual must possess a considerable degree of merit, yet medical distinction is as often the result of an hospital appointment as the cause of it. The in- fluence of private interest can never be prevented ; but it is desirable that merit should be encouraged in every profession by having as much chance to reward itself as circumstances will allow. The French officers to public medical charities are admitted by concours : were the plan of public competition adopted in this country, while an impetus would be communicated to the cultivation of science, we should sae merit having a chance of reward, and we should know that the oppor- tunities of further self-improvement were held by such as would enjoy them with the greatest advantage to the community. It may be said, that the French Government has more to do than ours with hospitals, which are here governed by their voluntary contributors : ours might, however, take advantage of every opportunity to give an example of liberality to governors, if it did not interfere to direct them. The ma- chinery for introducing a system which would admit individuals to great public appointments by concours could be readily supplied from that which must be instituted in a liberal system of medical reform to decide upon ability to practise.
The education of medical practitioners might be elevated with ad- vantage, especially their general or elementary education. A smatter- ing of Latin has generally been considered necessary. Some know- ledge of the ancient languages must continue to be requisite ; but an acquaintance with modern ones, which is never insisted on, would be much more useful; for a cultivator of science, as such, is a citizen of the world ; as his principles are not confined by geographical limits in their operation, neither is his search after knowledge. The strictly medical part of the education should be made of a more prac- tical nature. Medical examiners would do well to spare no pains, to grudge no time with candidates, to walk with them into dissecting- rooms, to carry them to the bed-side, and thus to make themselves sure that the answers were not the result of parrot-learning, but of real knowledge, capable of practical application. More could be trusted to such examinations than to curricula of education, prescribing a number of lectures to be attended in a certain order.
The qualification to practise medicine should be necessary to assistants as well as to principals. In the professions, an individual is not in- trusted with the full confidence reposed in principals till he has attained a mature and sober age ; and gentlemen would find that their younger years might be well spent in the character of assistants, when the re- spectability of the grade was increased, at the same time that medical men would be with propriety prevented from delegating part of their duty to incompetent hands. Under an improved system, we should have no apprenticeship: youths might, of course, pay a fee, when it suited their interest, to see the private practice of medical practitioners, never- theless. The general practitioners, requiring hands for the making up of their drugs, were anxious for an apprenticeship-clause in the Apothe- caries Act of 1815; and the Bishop of PETERBOROUGH was kind enough to become the means of having such a clause introduced. It has done much harm. The Apothecaries acknowledged the absurdity of it in 1825; when they obtained a temporary amendment of an act having more ridi- culous points than one; and the Company now recommends to its licentiates the partial evasion of the clause. It would have answered very well if the apothecaries had really been such, instead of practitioners in medi- cine: as it is, it has had the effect of confining young men to the mere drudgery of a "surgery," while they might have been more profitably employed in acquiring a general education worthy of a learned profea- sion ; but it has also had the effect of deteriorating the character of the profession, by hurrying into it numbers of young men for whom there was but little room ; for practitioners, to secure the services of appren- tices as dispensers for five years, have taken them with little education and without premium, to be thrown on the world at the expiration of the period to struggle as assistants, or otherwise, as they best might. There ought to be no " apprenticeship-clause " in a measure of medical re- form ; and assistants ought to be qualified and registered as well as other practitioners.
[In the next and concluding paper will be attempted a slight sketch of the history of the question, and some review of the plans which have been proposed.]
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