MEDICAL REFORM.

BY A MEMBER OF THE PROFESSION. [Third and concluding paper.]

THE VIRTUE INHERENT IN MONOPOLISTS, AND THE PROPRIETY OF LOOKING TO THEM FOR REFORM. THE EFFECT OF A MEASURE OF REFORM ON THE UNIVERSITIES, SCHOOLS, AND MEDICAL COLLEGES. SOURCES, IN THE COLLEGE OF PHYSICIANS AND IN THE APOTHECARIES COMPANY, OF DISCONTENT IN THE PROFES- SION. MEDICAL REFORM BILLS. A PLAN PROPOSED.

THE most formidable opponents of medical reform are such as enjoy influence and power from a connexion with corporate bodies ; such as belong to the class of " Fellows " in the College of Physicians, which is composed of about one hundred and fifty individuals ; to the Council of the College of Surgeons, which consists of twenty-one members ; or to the Worshipful Company of Apothecaries, which is made up of a Master, two Wardens, and twenty-one Assistants. These corporations are self-elective. It is not to be wondered at that the men forming them should oppose reformation ; but it does seem strange that legisla- tors should be sometimes simple enough to seek for information as to the changes which are necessary among the very individuals interested in the perpetuation of existing abuses. It is curious to observe how much acts may differ from the professions which have preceded them : when the different corporate bodies petitioned for their charters, they did so, as Dr. GRANT observes, on pretence of some benefit to be con- ferred on the public ; so that, when it is distinctly proved to these bo- dies that the regulation of the profession might be taken out of their hands with advantage to the same public, sincere people might expect that the virtuously-minded corporations would hasten to agree to the new arrangement, and would scorn to set up the paltry interests of in- dividuals against the general good for which these interests were merely held. These confiding mortals would tax poor humanity too much. We are but the mere creatures of selfishness, the best of us : this may give us a clue to the fact, which must be in candour acknowledged, that corporations in Scotland and Ireland have shown much more libe- rality than those of England ; for the reforming corporations of the sister countries do not possess so extensive a power to hug themselves upon, and have bad to depend more on their merits simply, while their influence can only extend itself indirectly or illegitimately into the ter- ritory of the huger monopolies which engross to themselves the most cen- tral, the most populous, and the largest portion of the United Kingdom. Dr. KIDD of Oxford, in urging the necessity fora complete reorgani- zation of the profession, tries to console the possessors of the authority, of which according to his own plan they must be bereft, in these sentences—" With respect to the future condition of existing institu- tions, there appears nothing in the least derogatory to their dignity ; nor, which is of much more consequence, to their professional utility and efficiency, in considering them henceforth as independent scientific societies ; which, retaining all their present members and internal laws, might henceforward admit new members by the same mode as new members are customarily admitted to the Royal, Linnman, and other scientific societies. Each of the existing institutions might still have its own library and museum, and its own lectures ; each might have its own meetings, and publish its own transactions ; and all, vying with each other in a spirit of liberal emulation, might continue to benefit both in- dividuals and the public, quite as effectually as under the present system.

" And, on the same principle, the several Universities which have the right of conferring medical degrees, might still exact a previous public examination of the candidates for those degrees."

But the Universities and great schools of medicine would be benefited by the change. Under a system which would institute a rigid exami- nation of candidates to practise, and which would disregard the local position of schools, such as were already established and capable of yielding the greatest facilities for instruction would reap a direct ad- vantage which would far more than compensate for what some of their professors receive as examining-fees. And as even now degrees from Universities and diplomas from Colleges of Surgeons are taken rather on account of the titles than the privileges they confer, it is not apparent wby such bodies should not continue to be resorted to for such honours : nearly all the general practitioners of England now take the diploma of one of the Colleges of Surgeons, though it merely allows them to call themselves members, or licentiates, without conferring any legal pri- vilege : medical men would still retain a pride in belonging to some of the " scientific societies," if these were worth any thing.

The College of Physicians of London, though advised by Lord Mans- FIELD in 1767 to "review their statutes," as he saw "a source of great dispute and litigation in them," and even pronounced them illegal, failed to act on his Lordship's advice ; and though the medical profes- sion, as Dr. KIDD intimates, now takes a wide view of the question of reform, the germ of the question was developed principally by the ob- stacles thrown capriciously in the way of the admission to the fellow- ship of such as were not graduates of either of the English Universities ; for the class of licentiates has always been considered an inferior one, though it includes, and has included, many of our most eminent physi- cians. It was first of all adopted in the middle of the sixteenth century, to embrace aurists, oculists, dentists, and other practitioners such as these were at that period. About a century and a quarter after the in- stitution of the order of Licentiates, the College, in a "short account" of its own "institution and nature," takes credit to itself as being no monopoly, seeing that foreigners and " holders of degrees beyond the seas" are admissible to the unlimited class of " Honorary Fellows"; and "Licentiates" in the same pamphlet are defined as "such others as are foreigners or do not hold,degrees in our Universities, or by want of learning or by reason of their youth are ineligible to the candidateship, but are yet of use to the King's subjects, at least in some particular dis- eases." If the Licentiates are now a body of most able physicians, that is the very reason why they should not be excluded from the rights, privileges, and honours of an order to which they have as much legal right to belong as have those who compose it. But a greater source of discontent, inasmuch as it affects a larger body of men, is to be found in the monopoly obtained by the City of London Company of Apothecaries through the means of an act to "en- large their charter," in 1815. In the earlier part of the reign of JAMES the First, the apothecaries were incorporated with the grocers, out of his Majesty's "more abundant and special grace, and certain knowledge, and nicer motion," and in order "to the end the art, mystery, or faculty of apothecaries, now of a long time fain and despised," might " the better advance to its beseeming greatness and honour." In the thir- teenth year of JAMES'S reign, the apothecaries were formed into a sepa- rate incorporation. They were the druggists of their day ; and for a very long period the complaints of the physicians were load against the apothecaries for presuming to prescribe : a fierce paper-war was carried on between the two classes in the beginning of the eighteenth century. The apothecaries, however, gradually became confirmed, not only in the Metropolis but all over the country, in their assumed province ; and it would seem that the physicians had to thank themselves for it ; for by having the charter of their order " enlarged " to snit the changes of the times, or even by the powers which it already conferred, they might have made their Col- lege the means of supplying all England with regular physicians in

place of the vendors of drugs who now took possession of the practice.

The present generation of general practitioners in England (and a very respectable body of men they are) are sprung from the Grocers' Com-

pany : it would be gratifying to see their occupation become separated

from a traffic in drugs. The charter of the Apothecaries Company was " enlarged " in 1815, by an act of Parliament which was huddled

through during the last few days of the session—the second and cor- rected edition of a bill which the Commons refused to pass on account of the extensive amendments the Lords had found it necessary to make ; and was, after all, properly described by Earl STANHOPE in his speech at the time, from the report of which speech in Hansard's Parliamentary Debates the following quotation is made---" He had never seen such a bungling bill, even from the bunglers of the House of

Commons. (A laugh.) During the session, a bill had been brought up from the House to their Lordships, in which the pecuniary penalty for

some offence had been changed into transportation for fourteen years. Now, their Lordships knew, that when a fine was levied by way of penalty, it was customary to provide that half the fine should go to the informer, and the other half to the King ; but in this bill they forgot to alter that provision, so that the enactment literally ran thus—that the person committing the offence should be transported for fourteen years, half the penalty to go to the informer and the other half to the King. (A laugh). With respect to the present bill, he was decidedly friendly to its object, because it was an honest one ; but he was an enemy to its clauses, because they were oppressive and incorrect. He objected also to its being made a private instead of a public bill, as it was smuggling the bill through the House in an unfair manner. He wished that it might be postponed for the present, not from any desire that it should be abandoned, but merely that it might be resumed next session in a less imperfect manner; and he should therefore move that it be read a third time on Thursday next." (Parliament was prorogued on the Wednesday.) The Lord Chancellor defended the bill, as calculated to produce much benefit, and stated that it was " a qualification and limitation " of the Apothecaries' charter ; but his Lordship does not appear to have be- stowed his usual deliberation on the matter, for the powers of this City Company were extended to England and Wales, and the worshipful so- ciety itself was, to use the words of Dr. MANN BURROWS, "absolutely

astonished " at the amount of power put into its bands. Well it might, for the " mystery of the art of apothecaries" became a faculty of

medicine, with more real power than was possessed by all the other medical bodies in the kingdom put together. Since the Company ob- tained its act, it has been much more remarkable for prosecuting persons holding medical degrees from Universities or diplomas from Colleges of Surgeons, for sending medicines to their patients, than for suppressing ignorant pretenders to medical skill. To protect the people against impostors it has seldom or never attempted. It is strange that an act to enlarge the charter of a company of druggists, and which makes a five-years apprenticeship in mixing drugs necessary, should regulate the medical profession, and should contain a special provision against the " druggists " being interfered with. Some readers were probably unprepared, even after the other anomalies brought under their notice, to arrive at such a climax as this.

It has been often said that the Apothecaries Company has done much good. So it has—because it could not help it. It was shamed into making its curriculum of education somewhat respectable by the very bodies from whose fingers it filched the power to which it had no title. But if such a corporation as this, with real power in its hands, has been of public service, how much more good might not be expected from a • system which should be wiser in principle, and should exercise a uniform power over the whole empire. The Apothecaries Company of Dublin has not been in the habit of disturbing qualified practitioners in medicine and surgery in dispensing medicines to their patients ; while its licentiates, at the same time that they are considered general practitioners, monopolize the trade of compounding medicines. This company does not seem to have been so much complained of by graduates in medicine, and qualified surgeons, as by its own licentiates, who have frequently petitioned that they might "no longer be subject to the misrule of a trading company, consisting of twenty-nine practising apothecaries, in whose election or pro- ceedings they have no voice, whose interest is perfectly opposed to theirs, and who will neither allow nor make any effort themselves to benefit the public, or rescue the profession from the degradation which their conduct has brought upon it." (See the Journals of the House of Commons.) In 1833, a bill was introduced in the House of Commons to relieve graduates of the Scotch Universities and members of the three Colleges of Surgeons, as well as surgeons on the establishments of the Army, Navy, and East India Company's services, from the grievances which they felt under the Apothecaries Act ; which, in fact, prevented them from practising as general practitioners in England and Wales, unless they complied with its apprenticeship-clause, and submitted to its diverse rules and regulations, besides passing its board. The bill would have passed, had not the examination into medical matters by the Committee on the bill displayed to them in formidable array such anomalies as have already been spoken of, and caused them to report, " that before any bill to amend the laws for regulating the practice of apothecaries through- out England and Wales shall be passed into a law, it is desirable to in- quire more fully into the subject than can effectually be done during the present session of Parliament." The profession has now to regret that it did not get the instalment to begin with, for nine years have passed and not a tittlefurther forward is the question at this moment. A Select Com- mittee was appointed in February 1834, " to inquire into and consider of the Laws, Regulations, and Usages regarding the Education and the Practice of the various branches of the Medical Profession in the

United Kingdom." It published part of the voluminous evidence it

collected—such as referred to the three London incorporations of Phy- sicians, Surgeons, and Apothecaries—and advised the reappointment of a Committee the ensuing session. In the mean time, the Houses of Parliament were burnt, and it is understood that a mass of unpublished evidence and papers were lost in the conflagration : a change of Minis-

try, too, took place in the beginning of 1835 ; so that no more was beard of the subject in Parliament, except through petitions which grew more frequent as the Legislature seemed further to postpone the consideration of the question, till Mr. WARBURTON read a bill, at the end of the session 1840, "for the Registration of Medical Practitioners, and for establishing a College of Medicine, and for enabling the Fellows of that College to practise Medicine in all or any of its branches, and hold any Medical Appointments whatsoever in any part whatsoever of the United Kingdom." From the coldness and in some respects oppo- sition which this bill met with in the professsion, it would appear unjustly, Mr. WARBURTON allowed Mr. HAWES, the session before last, to take up the subject. Mr. WARBURTON meant to check empiricism by a system of registration—by public lists of all medical practitioners; with their qualifications—instead of by penal enactments against the illegal practice of medicine. He wished to govern the profession by a Council elected from the practitioners in each of the Three Kingdoms, a proportion of lay members being infused into each Council; and by a Senate elected from the Councils. The great objection to a purely me- dical Senate is, that the profession might be over-partial to its own in- terests ; though it is well known that, as a body, it has always been characterized by the most philanthropic views, and has always been the first portion of the community to urge the adoption of whatever measures seemed necessary for the physical welfare of the people. Mr. HAWES proposed a tripartite method of governing the profession, similar to Mr. WARBURTON'S ; but be omitted the lay members from his Coun- cils; and thus his scheme met with a warmer reception from the British Medical Association, the provincial associations, and perhaps the pro- fession in general, though they disliked the part of it which taxed them. His first bill, which was to suppress quackery, and to legislate for the "chemists and druggists" as well as medical practitioners, was with- drawn, and a " Medical Profession Bill, No. 2," was introduced, from which Mr. HAWES left out such parts of the first bill as interfered with the trade of the " chemists and druggists," or with quackery. From the partial discontent of the profession at these mutilations as it con- sidered them, though it was still willing to accept the bill as a great improvement, but most of all from an apathy in the House, arising as well from this unsatisfied state of the profession as from the knowledge that the public were apt not to feel a due interest in what they considered a measure for the removal of something like personal disabilities alone, Mr. HAWES failed in his laudable attempts. It is to be hoped, that a question on which a careful Medical Committee sat for a whole session without being able to consummate its task—a question which has been vexatiously delayed, one which affects the nearest interests of a numerous and useful profession, almost unanimous in its desire for change—a question intimately connected with the wellbeing of the whole people—shall not be met again, as it was the session before last, by the House allowing itself to be " counted out." Medical re- formers received no kindly aid, nor aid of any kind, from the Whigs: it remains to be seen what the Tories are capable of doing in a matter which can only be viewed in a spirit of partisanship by such as defend abuses for their own sake.

To enter minutely on the details of the machinery required to work out the changes which have been pointed out as necessary, would but perplex the general reader. Legislation should begin, of course, by in- corporating all the graduates in medicine of the .Universities, all the licentiates or members of Colleges of Surgeons and other chartered medical bodies, all who were in practice in England and Wales before the passing of the Apothecaries Act, and all who had served as medical officers in the public service, as members of the national faculty, and as forming the legalized profession with which to commence the reor- ganization. While Mr. WARBURTON was right in thinking that medical men should not have exclusive power committed to them over affairs which involve public as well as medical interests, the difficulty expe- rienced under this proposition should be obviated, not by an intermix- ture of lay-members in the Councils, but by conjoining with a purely medical Senate like that of Mr. HAWES, and medical reformers in gene- ral, such a Minister of the Crown as is suggested by Dr. GRANT. The public health—the physical welfare of the people—when viewed in all its bearings, is an important subject, and one fit to be intrusted to a public Minister, or at least to a functionary appointed by the Secretary of State for the Home Department ; while a Medical College, Council, or Senate, elected from and by the profession as the only part of the public capable of supplying and choosing it, should cooperate with him : so . that he, as guardian of the public interests, might have the advice and assistance of a body of men, pointed out by the suffrages of the whole profession as the most fitted for the purpose, while medical practitioners would feel secure against the misrule of self-elective bodies. The duty of the Minister and his Senate should be, not so much to make laws as to carry out the spirit of the law—to admi- nister it : but, of course, the management of much detail must be left to himself and the Senate; for example, it should be their province to appoint a Board of Examiners in each division of the kingdom, and to superintend and direct these boards so that they might act in unison. They might also have the power of organizing what they considered the best system of registration. But, on such a plan, much might be accomplished besides supplying ant registering properly qualified me- dical practitioners : other boards than those required for examination might be instituted with advantage ; other means than such as were necessary for registration might be set on foot for the general benefit. Much remains to be done in this country in the matter of medical po- lice : the promotion of greater health in towns by ventilation, cleanli- ness, draining, the removal of nuisances, and whatever other means— the investigation into the causes of epidemics—the means afforded the people for recreation and amusement —might all, instead of being everybody's business as at present, and consequently nobody's, come within the scope of a Minister of Health strengthened with the power of making the whole medical profession, through its Senate, a means of indicating evils and suggesting their remedies. Of late years, the great importance of them dical statistics supplied through reports from the public services, to pitals, and last though not least through the means put in operation by the Registrar-General of England and Wales, has been universally app eciated ; and we have felt indebted to such enthusiastic labourers as Major Trrixocri, W. FARR, and others. But what machinery for the collection of facts and their systematization, as well as for the more ready application of the knowledge thence deducible, might we not possess with an organized profession of medicine! It might be made imperative on every medical practitioner in the empire to return an account of every case of disease occurring in his practice—its history, its treatment, the result—accord- ing to a uniform method prescribed by the Medical Senate. Should the scruples of the little men of the present generation who would be ready to oppose such a scheme be listexed to, when we could recognize in it a spirit worthy of a great country, and of one which has yet to cancel the reproach of having lagged far behind its Continental neighbours in fostering or encouraging science—" a country which has the in- tellect to maintain national museums without a single instructor, universities without a single professor, colleges without a single endowed chair, endowed colleges without a pupil, university di- plomas without a single privilege, twenty totally independent, irre- sponsible, rival, medical-licence shops, hospitals, in the medical appoint- ments of which neither the Government nor the medical community have any share, where the medical superintendence of the poor is sold by auction, where the titles of distinction conferred upon men of genius have nearly all been the rewards of foreign states, and where the most illustrious men, after pining in penury and neglect till aged and ex- hausted, occasionally receive a pittance, to save the national infamy of their dying in the workhouse."—Dr. GRANT.

After all, what reason is thereto look forward to the subject of medical reform being entertained by the Legislature and made a question worthy of the nation ? For when matters have not a party hue, or when they are not forced into prominence by the clamour of multitudes, it is difficult to rouse the Government of this colossal empire to their importance, however great. There are grievances, however, which must soon be redressed. The anomaly must not be continued of a medical practitioner being disqualified in one part of the country while he is legally competent in another; nor the inconsistency of his being authorized to apply his skill in one department of medicine, while in another arbitrary division of it he is prohibited from exercising the same knowledge. These sources of vexation must be removed, whether empiricism be let alone or not—whether the incorporated bodies be mo- lested or not—however trifling a measure is to be vouchsafed. But, rather than that the present or a similar system should be continued— rather, indeed, than that there should be any thing short of a full and satisfactory reorganization of the whole profession, a perfect freedom of trade in medical practice should be sought for as a public boon. That would be the next best plan to a thorough reformation.