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quality of their own food ? It is notorious that,speaking generally, women’s colleges and otherinstitutions governed by women provide food whichis often inadequate in amount, badly chosen, badlycooked, and badly served. All men who have sistersor daughters at college or some similar place becomeaware of this. It is not enough to say that women areless greedy than men. The deficiencies I have inmind often take the diet below the minimum for duenourishment, while bad cooking is at least as wastefuland indefensible as greed itself. I venture myself tothink that the phenomenon I describe, now perhapsbeginning to disappear, was originally due to theintellectual fervour of the movement for women’shigher education, and that in the pursuit of highthinking plain living was allowed to become badliving. Here has been a great opportunity for medicalwomen, and I believe that enlightened a ction from yourprofessional side has still immense potency for helpingthe nation by improving the food and the health ofthe very girls and women upon whom our best hopesfor the national future depend.

CONCLUSION.May I finally touch upon one consideration which

must be borne in mind in all discussions of divergencebetween the medical courses of men and of women ?The high function of marriage rarely takes a man outof the profession ; it must, on the other hand, in mostor many instances, remove a woman from practice.This elementary difference is inevitably a large factorin decisions that have to be made when men andwomen students stand together in competition foreducational facilities within hospitals or elsewhere.Time and money spent upon, say, ten men will go tomake nearly ten future doctors. The same effort Ispent upon ten women must give a far smaller futureeffective output. I hold myself that few, if any,schemes of education are better than a sound medicaleducation as a preparation and equipment for marriage.It should guide and strengthen a woman to perform" justly, skilfully, and magnanimously," all the highand all the lowly tasks of married life. I think a wisestudent will see to it that in the absence of specialreasons she will try to emphasise in her professionaltraining and work those parts of the subject not onlybest fitted for a woman if she remains in professionalpractice, but most likely to be serviceable if and whenmarriage comes to her afterwards.

I know well that I have touched upon several pointsstill the subject of high controversy. Yet it is thosewho are most in earnest about the future of womenin medicine who will be the most desirous that theseproblems should be raised fearlessly, and that theyshould find their discussion and their right solution ata place like this, so rich already in the highest traditionsof work and service.

DOCTORS AND THE PUBLIC.

An Address delivered at the Opening of the WinterSession at St. George’s Hospital on Oct. 1st, 1926,

BY E. GRAHAM LITTLE, M.D., F.R.C.P., M.P.,PHYSICIAN IN CHARGE OF SKIN DEPARTMENT,

ST. MARY’S HOSPITAL.

jar. Graham Little commenced his address with aeulogy of the personal and teaching qualities of Dr.Howship Dickinson, under whom he worked in closecontact at St. George’s Hospital, made the closerbecause the late Lee Dickinson, Howship Dickinson’spromising and only son, lived in Dr. Little’s house.He went on to say that in dealing with his subject,Doctors and the Public, he intended to take as thetext of his address a letter which appeared in the Timesof Oct. 23rd, 1925, written by Mr. Bernard Shaw.He said :-]My illustrious countryman is handicapped, but of

course not deterred, by a complete ignorance of thesubject he criticises, and perhaps for this very reason

is more than ever typical of a great mass of publicopinion which the profession will do well to recogniseis dissatisfied with many of the circumstancesattending the practice of medicine to-day. Mr.Bernard Shaw writes :-

" Unregistered practitioners are at a heavy premiumbecause they have mastered the modern technique of whichregistration guarantees ignorance.... The G.M.C. hasbecome a trade-union of the worst type-namely, the typein which the entry to the trade and the right to remain in itare at the mercy of the union. Not only is the type the worse,but in this particular instance it is at the crude stage ofpreoccupation with professional earnings and sullen defianceof public opinion, which produced the Manchester and Sheffieldoutrages in working-class trade-unionism in the last century."

In condemning the obsolete training maintained bythe G.M.C., Mr. Shaw remarks that-

" There is nothing that the unregistered practitioners dothat cannot be done by registered ones, if only they areapprenticed to the techniques of to-day instead of to those

of a century ago."The implications are : (1) that medical education

of the present day is ill-designed to meet the needsof the public and compares unfavourably with thetraining, if that word can be used in such a connexionof some branches of unqualified practice ; (2) thatthe medical profession is ruled by an obsolete andtyrannical code of ethics, administered by a body,the General Medical Council, which ought in the

public interest to be forthwith scrapped, and thatrulers and ruled are actuated by the most sordidmotives of self-interest.

THE WORK OF THE GENERAL MEDICAL COUNCIL.

[Examining these criticisms in detail, Dr. GrahamLittle pointed out that the General Medical Council,so far from maintaining an obsolete training, hasresolutely marched with the times by keeping in theforefront of medical education the preventive andclinical aspects. He said :-]Although readjustments in teaching both anatomy

and physiology may be necessary, those subjects mustform the basis of all scientific medicine. Again, withthe object of laying greater emphasis upon theultimate end of medicine-namely, the prevention ofdisease rather than its cure-the General MedicalCouncil has wisely placed in the very forefront of itsresolutions adopted in 1922, with regard to profes-sional education and examination the recommenda-tion : " That throughout the whole period of study theattention of the student should be directed by histeachers to the importance of the preventive aspectsof medicine." And with the same object of securingthe maximum period of study for clinical subjects,these resolutions further recommend: "That a

minimum period of three years shall be available forthese studies." This period is much more usually fouryears than three. It is, in fact, in the insistence uponthe importance of clinical training that the EnglishSchool of Medicine has gained its great prestige.....It is precisely in the preposterous neglect of clinicalstudy and the lack of opportunities for pursuing itthat the unqualified practitioners compare so veryunfavourably with orthodox medical schools. Totake one glaring example : The largest osteopathiccollege in the United States, Kirksville, Missouri,which claims 1000 students, is situated in a smallfrontier town, the whole population of which does notexceed 4000 ; one-fourth of this population may beregarded as students of this particular college. TheUniversities of Oxford and Cambridge, each situatedin towns with about 60,000 inhabitants, have wiselyregarded the clinical material afforded by suchpopulations as being entirely inadequate for the studyof clinical medicine, and their medical students areconsequently sent to London for their clinical years.There is no statutory body in the United States com-parable to our General Medical Council, and the lackof such an authority accounts for the success of the

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bluff by which these colleges pretend to be adequateschools of medicine. Our General Medical Councilwould, of course, not recognise any medical schoolas being equipped for clinical study in which theclinical material was limited by a population of3000 persons.

UNQUALIFIED PRACTICE.

[Dealing with the multiplicity of subjects requiredby the medical students of to-day, Dr. Graham Littlethought that medical education must tend to be moreprolonged, it being inconceivable that the time givento the study of the preliminary subjects should becurtailed, while it is impossible to prevent the latersubjects becoming more numerous and complicated insympathy with immense advances in medicine. Hedrew a parallel between the training of qualified menand that which unqualified persons receive, remindinghis audience that in Great Britain alone the legislatureencourages unqualified practice, allowing any man toexercise his skill in any branch of medicine or surgeryand receive payment without legal penalty unless heshould pretend to the position of a registrable quali-fication. He did not consider that there was any dearthof properly educated medical men in this countrymaking unqualified practice a necessity for the public,seeing the proportion of doctors to the population is1 to 1400. He continued :-] IThe following I consider ought to regulate the

attitude of the public towards the medical precession.The words are quoted from a leading article in theTimes of March last.

" The fatal weakness of the.unqualified practitioner isnot his lack of a medical degree, but his lack of that know-ledge of the disease which, however imperfectly, enables aqualified man to interpret the signs presented by his patient,to distinguish one sign from another, and to relate the signsto prognosis and treatment. Diagnosis, in short, must precedetherapy. To contend, then, that the public interest can

possibly be served by exempting anyone who is to enjoythe status of a registered medical practitioner from trainingin those sciences by means of which alone a diagnosis ofdisease can be made is, on the face of it, ridiculous. Therecan be no back-door ’ to the Medical Register. Nor canthe public suffer for a moment any delegation by doctors oftheir right to determine the nature of a patient’s complaint.Once, however, this crucial matter has been settled and aline of treatment laid down the doctor may delegate, undera general medical guidance, the responsibility of treatmentto skilled persons, who do not possess a medicaldiploma."

The Times properly stresses the danger of allowingunqualified and ill-trained persons to undertake thediagnosis of disease. There is another factor than mereignorance which adds very considerably to this dangerand which has not been noticed. At the present dayit is more than ever necessary in any case of unusualdifficulty that the patient should be examined byseveral experts, for no one can combine the knowledgewhich all but the simplest cases require for theirelucidation. The unqualified practitioner is by thenature of things debarred from seeking any helpwhatever. He is afraid to betray his ignorance, or heis met with the real difficulty that reputable persons,quite properly, will not consult with quacks. Theresult often is that the unqualified practitioner is asisolated in his practice as Robinson Crusoe, and thisconsideration alone should enlighten the public uponthe very real risk of relying upon such isolated andinadequate experience. Notwithstanding these veryobvious handicaps to unqualified practice the humanimpulse to believe the printed word leads vast numbersof the public to swallow both medicine and theorieswith an equally absurdly misplaced confidence, and theBritish Isles still enjoy a bad pre-eminence in theconsumption of patent medicines as against all othercountries, with the possible exception of the UnitedStates. Nowhere, indeed, have the quacks morefriends than in the present House of Commons, if onemay judge by the personal experience I had when

bringing in my motion, in February last, for an inquiryinto the whole question of unqualified practice, withthe object of regulating it. In the very interestingdebate which ensued it was amusing to find that speechafter speech expounded the thesis that advances inmedicine had come invariably from extra professionalsources.

The public are, in fact, unaware of the immensestrides made in our science and art during the last30 years, so eloquently described by Prof. Starling.

" When I compare," he writes in his Harveian Oration," our present knowledge of the workings of the body, and

our powers of interfering with and of controlling thoseworkings for the benefit of humanity, with ignorance anddespairing impotence of my student days, I feel that I havehad the good fortune to see the sun rise on a darkened world,and that the life of my contemporaries has coincided, notwith renaissance, but with a new birth of man’s powers overhis environment and his destinies unparalleled in the wholehistory of mankind."

The medical discoveries in that period have beenfar more often made by medical than by non-medicalmen. The great name of Pasteur is the stick mostoften used to beat the medical dog, who is accused ofhaving been blind to the significance to medicine ofPasteur’s discovery of the causes of putrefaction.But it was Lister, a medical man, who saw its fullmeaning for surgery, and without Lister Pasteurmight very well have passed unheeded by medicine.

INDIRECT ADVERTISING AND COVERING.

[Dr. Graham Little, dealing with the subject ofcommunications to the lay press signed by medicalmen, thought that the potent influence of the pressshould be used to disseminate sound expert informa-tion which would be useful to uninstructed persons.He was critical of the work of the New HealthSociety, and in reference to the disciplinary actionsof the General Medical Council he said :—]

There can surely be little question that the professionof medicine has advanced in usefulness and in reputa-tion pari passu with the setting up of the GeneralMedical Council. The vast majority of the professioncheerfully accept the ruling of the Council uponmethods of professional education and discipline.That the Council in its educational policy followsclosely the progress of science is surely very evidentfrom the frequent additions and modification of thecurriculum which it initiates ; indeed, it is perhapstoo ready to accept as gold what is sometimes pinch-beck, and I have hinted at the enormous burden whichthe addition of fresh subjects throws upon the presentstudent. In its prime duty, that of supervision ofmedical education, objections to the Council that itlags behind modern advances in science can hardlybe sustained. In the matter of discipline I submitthat the profession, and not the public, is the bestjudge as to what degree of control medical menwould or should accept-that the control is useful tothe public can again hardly be disputed. In thematter of advertisement the Stock Exchange enactsa self-denying ordinance against its members adver-tising, an ordinance which is clearly of public utility.Medical men should surely enjoy the same privilegeof ordering their affairs in this respect as they will.Open advertisement would probably be resented asmuch by the public as it would be disliked by reputablemedical men. In the matter of covert advertisementit is more difficult to differentiate what is legitimatefrom what is undesirable, but no doubt a via mediacan be found.The activities of the Council in restraining the

association of registered practitioners with unqualifiedpersons are also greatly misunderstood by the public.It should be emphasised that the offence knownas " covering "-that is, the protection which anunqualified man receives from his association with aregistered practitioner-may be actually dangerousto the public, and it is from this standpoint that the

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Council has framed its professional rule against such"covering." The registered man who breaks this ruledoes so with full knowledge of the consequences whichit entails. Indeed, the consequences are quitefrequently desired, inasmuch as a registered man hasvery much more liberty of action after his removalfrom the Register, and he is in no way debarred fromcontinuing his practice. He may advertise to hisheart’s content, and he commonly reaps an enormousadvertisement by the mere removal of his name.The unfortunate phrase foisted upon the Council bythe wording of an Act of Parliament, " infamousconduct in a professional respect," often creates anunmerited sympathy with the removed person, whoseconduct does not appear in the least infamous to thepublic conscience, by which it is often regarded as amere breach of professional rule. But if it be kept inmind that this removal means very little more thanthe omission of the removed person’s name from a listof practitioners who prefer to be bound by rules whichthe removed person wishes to break and does break,much of this misplaced sympathy would be eliminated.It is again to be emphasised that the penal activitiesof the G.M.C. form only a very small part of itsfunctions.

MEDICINE IN PARLIAMENT.The comparison which Mr. Shaw makes of the

G.M.C. with trades-unions plainly springs from theconfusion in his mind between the General MedicalCouncil and the British Medical Association. Thelatter is a private body which has as much right tomake rules for its members as has the committee ofa club, and those who do not like to obey those ruleshave the easy alternative of resigning membership.But the complete inability of the G.M.C. to initiateany disciplinary action is a source of weakness whichclearly puzzles the public mind ; few laymen under-stand that unless a change is made in proper legalform by some person or body of persons prepared totake the considerable risk of bringing what amountsto a legal action against the errant practitioner, theCouncil is powerless to intervene ; it acts only as judge,never as prosecutor. In the interest of the public itwould seem desirable that some machinery should beprovided, such as the institution of a public prosecutor,whose duty it would be to bring the offender to book,and who would be protected from personal loss in thedischarge of this duty.The hostility to the medical profession prevalent

in the House of Commons was evidenced by the debateupon my motion dealing with " unqualified practice."It is inconceivable that a similar motion defendingpractitioners of law from the competition of unqualifiedpractitioners would have met with the same hostility,and of course no practice by unqualified personspretending to be lawyers is allowed. The reason forthis difference of feeling is not far to seek. Thereare no more than 14 doctors in the present House ofCommons ; there are something like 200 lawyers. Itis difficult to say why doctors should be so poorlyrepresented, and especially doctors in active practice.I believe I may claim to be the only medical man inthe House of Commons at present in full and activepractice. It should be no more impossible for doctorsin practice to be Members of Parliament than it isfor lawyers in practice. A man out of practice verysoon loses touch with the profession, or, at any rate,ceases to be as representative of medical interests, asthe man who is constantly in contact with his fellows.And so I would plead for a more general cooperationon the part of my profession in political problems ofto-day, which must, and do, so vitally affect theprofession. A certain monetary sacrifice is entailed,more especially because the profession seem to thinkthat when a man goes into Parliament he cannotremain a doctor, and for a consulting physician thismay mean serious loss of practice.... Action in theHouse of Commons is far more effective than in anyother place, and authoritative information in thatassembly, contributed by men engaged in medicalwork, has never been greater than it is at present.

"EX NIHILO NIHIL FIT."

Abstract of an Address to Students at the MiddlesexHospital on Oct. 1st, 1926,

BY THOMAS YEATES, M.B., C.M., D.P.H.,COURTAULD PROFESSOR OF ANATOMY IN THE UNIVERSITY

OF LONDON.

THE life-history of a successful man, no matterhow great, consists of a prolonged, strenuous struggle.Throughout nature every animal is constantly forcedto fight for its existence and search diligently for food,and work may be looked on as the price paid for life.For the successful study of medicine work is essential,and the logical conclusion is that to serve up know-ledge to a student in a predigested state must paralysehis effort ; mental dyspepsia must be the result.Teaching-or rather cramming-in which the facts ofsubject are presented to the student without anyexplanation how the knowledge has been gainedonly attracts those devoid of ambition, whose onlydesire is to qualify and make a living. The processis fatal to the evolution of intellectual faculties, andteachers guilty of it are sinning against posterity.The easier it is to get anything the less the desireexists for its attainment, and to make the acquirementof knowledge easy is, perhaps, the best way to increaseignorance. Free education is not the boon it issupposed to be, and compulsory education is impossibleand worse than useless. The individual being taughtmust be an active and willing agent, and all medicalstudy, therefore, should be active, not passive.Most small lectures should be relegated to the dust-heap, though occasional lectures should be given asa stimulus by a master in the subject. A studentshould attend the courses prescribed regularly andtry to gain a clear knowledge of the subject in hand ;he comes to a medical school to become an efficientlytrained medical man, not to pass examinations.Work must be purposive and regular if definite

results are to be gained. It is foolish to becomeexhausted by memorising a book so that when anexaminer touches the button the record may beproduced with painful accuracy. This kind of workis slavery. As a contrast, for instance, there is thestudent who carefully models freehand the parts ofhis dissection, building them up to form a solidrepresentation. After an hour’s work he deliberatelydestroys his model, puts the original away, and againattempts to model in freehand. A few days later hetries to model the same part without the originalin front of him. He is slowly developing a solid,concrete, stereoscopic X ray image of the human body,which in time will become permanent, and, like hisshadow, accompany him everywhere. In the wardsand later in his consulting-room it is beside him,at once becoming visible at his command. Diagnosisbecomes a simple matter, for thoroughness of workhas led to the result aimed at-a full appreciationof the structure and working of healthy and diseasedbodies.

It would appear, from which is often said, thatwhen the student reaches his final years of study he isdevoid of all or most of the knowledge he has gainedin previous years ; but obviously he must have learnt a

something. The truth seems to be that the youngfledgeling from a medical school has some knowledgeof every subject, but it is not coordinated. He hasnot been taught in each succeeding stage of hiseducation to make use of the knowledge alreadygained in the school. Although, of course, anyproblem in any subject is useful as a mental exercise.and, if overcome, develops the logical faculties andscientific sense, there are problems in medicine sodiverse and numerous that it is quite unnecessaryand unwise for a student to wander into other fieldsof knowledge to exercise these faculties. His timeis better taken up in coordinating his medical know-ledge. The best way to get coordination in knowledge eis to prolong the early education into the succeeding .