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Had time allowed it I had intended to discuss the modifi-cations of the heart and vessels by the introduction ofremedies into the circulation, the power of drugs to slow orstrengthen, to quicken or weaken, the power of the heart tocontract or relax the arterioles, to raise or lower the bloodpressure, to relieve pain or to remove dropsy, but to do thiswould require time far exceeding that of a single lecture.Moreover, the methods and results were admirably expoundedto the College by Dr. Leech in his Croonian Lecture, and Ihave therefore thought I should be better fulfilling the wishof Harvey that the orator of the year should exhort theFellows and Members of the College to search out the secretsof nature by way of experiment by directing their attentionto fields of research which have received at present littleattention, but promise results of great practical value.Lastly, I have to exhort you to continue in mutual love andaffection among yourselves, and it seems to me that the bestway of doing this is to direct your attention to the examplesof Harvey and of our late President, whose death we deploreto-day. They were beloved by their fellows while they lived,their loss was deplored when they died, and they have leftbehind them an example not only of goodness but of courage.Harvey, seated speechless in his chair, distributing rings andparting gifts to his friends while awaiting the approach ofdeath; and Andrew Clark, steadfastly determining to continueat work and die in harness in spite of the haemoptysis whichseemed to threaten a speedy death, afford us noble exampleswhich ought to encourage us to follow the directions of thevenerable poet, Longfellow, who, taking the organ Harveystudied to symbolise such courage as Harvey and Clarkshowed, says :

" Let us then be up and doingWith a heart for any fate,

Still achieving, still pursuing,Learn to labour and to wait."

The Hunterian LectureON

SOME SUBJECTS OF PUBLIC AND PROFES-SIONAL INTERESTS.

Delivered before the Hunterian Society on Oct. 10th, 1894,BY THOMAS BRYANT, M.CH. R.U.I.,

F.R.C.S. ENG. AND IREL.,CONSULTING SURGEON TO GUY’S HOSPITAL.

WHEN, Mr. President, you kindly invited me in the nameof your Council to deliver one of the lectures recently foundedby your Society, and intimated that some of the topics of theday would be an acceptable subject, my mind almost naturallyreverted to a short address which I delivered on Feb. 8th, 1894,before the South-West London Medical Society on somesubjects of public and professional interest ; and, as I havereason to believe that that imperfect communication proved tobe of some assistance to my professional brethren, I propose onthe present occasion to continue the same line of thought,and to lay before you, for your consideration, the conclusionsto which I have been led upon many matters which seriouslyinvolve the progress and welfare of our profession in its

public relations as well as in its own special interests. In

carrying out this purpose it is probable that I may have touse expressions which will not be in the keynote of generallaudation, and consequently it seems expedient to rememberthat our profession at the present time is well spoken of byleading men, and that our two most prominent, if not greatest,statesmen have recently made some remarkable observationsupon its progress. Thus Mr. Gladstone has said "that theposition of the medical profession in our generation, and insome generations previous, has been continually advancing andcontinually rising. It continually advances in knowledge,credit, and importance." "Men," said Lord Salisbury butthe other day, "may, perhaps, have overrated the progress ofnineteenth century research in opening the secrets of nature;but it is difficult to overrate the brilliant service it has renderedin ministering to the comforts and diminishing the suffer-ings of mankind." 2 These opinions are pleasant reading,

1 THE LANCET, Feb. 10th, 1894.2 Address to the British Association, THE LANCET, Aug. 11th, 1894.

emanating as they do from men of great intellect, wideknowledge, and careful observation. Let us accept them"therefore, with the pleasure such complimentary statementsare calculated to excite, and do our best to demonstrate theirtruth. For my own part I think so highly of the professionI practise with such pleasure that I claim for its members.that they stand before the public as the representatives ofthe whole circle of the arts and sciences as applied fcrthe benefit of mankind: since the public directly or

indirectly reap the benefit of every scientific or proves-sional advance, by the teachers of medicine and surgery,.as students, utilising from all fields of human labour any-thing which can possibly or probably be turned to theadvantage of suffering humanity in the way of the pre-vention, the relief, or the cure of disease. The positiou

i of our profession in its public relations is consequentlyof such bigh importance as to induce me to lay it downas an axiom, that the interests of the profession and cfthe public are identical ; when the profession advances inskill, knowledge, and character, the public prosper with it ;when the profession sleeps or lapses into bad ways, the public.suffer. And the truth of this axiom is as evident when we applyit to the profession and the public in a general sense, as it igwhen we apply it to the smaller public and professional circlesof urban or village communities; indeed, it is in these smallercircles that its truth is the better demonstrated, for the

elevating influence of a clever and good doctor in a smalltown or village is fully and generally recognised, as well asthe unhappy influence of what must be described as theprofessionally indifferent, casual, or trade doctor. I is

important, therefore, for the public to be taught to under-stand that, since it is in their interests that medical menshould maintain a high tone of professional morality, so itis in the same interests that no scheme or custom which iscalculated to lower the position or depreciate the value ofthe medical profession in the person of any one of itsmembers should be encouraged or receive public support.

I would next wish to enforce the truth of the opinionthat for a medical practitioner to prosper in the positionin which he is placed he must do so through his profession.and by no by-ways or crooked paths. He should under all.circumstances raise the standard of medicine high in thecircle in which he practises, and follow it himselfas a painstaking and conscientious disciple ; and heshould do this under the firm conviction that he willpersonally rise both in social status and in pecuniaiy rc-v7ardgas he raises the profession he practises in the estimation ofhis neighbours. He should, moreover, be firmly convincedthat he can rise by no less worthy means, and at a21 timesscout the thought that he can raise himself by lowering inany way the profession of his adoption. As an important, ifnot absolutely essential, means to attain this object I hold itshould be the routine habit of every medical practitioner totreat each patient, whether private, hospital, club, or parish,with equal consideration, and, above all things, in the true"professional spirit," which bids him employ every neces..sary means of investigation which may be available to cn,hlehim to form, if not a correct diagnosis, at any rate a ’’ work-ing diagnosis " of his case before he tieats it. He will thendo so with confidence and probably with success ; and indoing this he will at the same time be doing what must bedesignated as a matter of primary importance to his pro.fession, for he will be giving an object-lesson to the public,and be demonstrating in the most practical way possible theessential difference there is bebween an educated profes&ioE:’.!medical man and an uneducated practitioner, whether calif dan unqualified assistant, a prescribing chemist, a medicaltradesman, or a quack.That such an education is wanted everyone must admit,

and that such should come from the medical profession islikewise clear ; for no other class of men has knowledgeenough to undertake it, or the will to do so if it had. The

way I have sketched out is, moreover, I believe, the only trueway to fulfil the object. Indeed, I believe that if thiu ruieof practice which I have just enunciated had been moregenerally adopted in the past we should not have heard somuch as we now hear of the evils of prescribing chemistsand of the unrestricted practice of lay persons, tor I muchfear that it has been from a neglectful recognition of whatought to have been a standing rule of professional action--and the value of which I am convinced all my bearersfully recognise-that too many of the so-called educated,as well as of the poorly educated classes of societyfail to recognise the difference between a qualified

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medical man and an unqualified one, by whatever namebe may be called. For where both qualified and un-

qualified men prescribe medicine or local applica-tions without attempting to make, or without making,any "working diagnosis " of the disease for which treatmentf.B called for, both classes are on the same level, for bothlead the public to think that the practice of medicine con-sists in mere drug-giving ; and under these circumstancesthe qualified man has no reason to complain of his qualifica-tions not being recognised when the failure to make themrecognised has been mainly his own. Again, let me ask, Hasmot the employment of unqualified assistants by registeredpractitioners tended much to confuse the minds of all classesof patients, and particularly the poorer, as to the distinctionbetween medical men and druggists, and induced them toplace such medical helps on the same level, since both classesof practitioners give stuff" for symptoms without anydiagnosis being made as to the nature or requirements ofthe case they have in hand ? With respect to rank quackery, what hope is there of

seeing it abolished so long as human nature remains as it is ?The educated members of society of all grades, as well as thepoorly educated and uneducated, support, and love to support,bone-setters and illiterate quacks of every kind, but moreparticularly the dogmatic and self-asserting registered prac-titioner ; for a man, whether qualified or not, has only toassert with sufficient emphasis and repetition, and with muchnoise and advertisement, that he can cure any trouble towhich flesh is heir, and do so better than his neighbour,and he will find supporters ; for certain members of theseclasses support quackery and professional quacks for thesame reasons that lead others to oppose vaccination, theContagious Diseases Acts, and vivisection-and that ison account of their lamentable or wilful ignorance of themerits of the practice they, on the one hand, oppose and, onthe other, support, together with their unfortunate ignor-ance of the structure of their own bodies, this ignorancebeing certainly greater than it is of the structure and delicacyof the watches they wear, and which, when out of order,are assuredly not placed in the hands of quacks to restore.With education of the right kind and with some knowledgeof how the human frame is formed and kept in order by naturalprocesses the influence of quackery may be weakened, butsuch a period of education is, I fear, very remote. TheGovernment, it is to be regretted, also encourages quackeryin a way which is not to its credit, and they do this byaccepting money in the form of stamps for patent medicines,which, if good, have no need to be patented to bring theminto use, and, if bad, are helped to do harm by Governmentassistance. For as patents, drugs and mixtures are recom-mended to the ignorant public by having Government stamps,and, in addition, reap all the advantages of a free and, attimes, unscrupulous advertisement, as well as of the pub-lished highly favourable opinions of men who thoughtlesslyailow their names to be employed for trade purposes; thisevil of patent medicines is not lessened with the knowledge that many of them are highly injurious and are annuallythe cause of death to many thousands, more particularlyof infants. The Government, again, encourage quackeryby neither taking action nor giving power to the GeneralMedical Council or great medical corporations to check orput down the practice of surgery or medicine by uneducatedlaymen, although they have not only established at greatexpense a General Medical Council to look after the educationof the medical students through the empire, and to see thatall such should be well and liberally educated before they areallowed to practise upon the public, and at the same timehave sanctioned pains and penalties against qualified menwho from any cause may do harm in the exercise of theirvocation ; whereas, with a strange inconsistency, unqualifiedlaymen of all kinds are left to do what they will withoutcheck or hindrance. But must I not add that the professionitaelf has thoughtlessly, but no less truly, encouragedquackery by too readily taking up every new medicine,whether its nature is known or not, which is freely and loudlyadvertised, and at the same time highly praised, by men who,after the methods of trade, seek to make themselves knowna.s authorities, upon grounds which at the best must too oftenbe described as slender ? 1With these general remarks upon some points connected

with the practice of our profession, which must be regarded:M important, I will now pass on to consider some of thequestions which refer to the education of the medicalstudent, and more particularly to the education it is desirable

he should have before he commences the special professionalprogramme ; and upon this subject. I believe I may say thatthere is in the profession a greater unanimity than it is

customary to find. For I have no hesitation in assertingthat the members of the General Medical Council, as repre-sentatives of all the licensing bodies-with the authorities ofthe Royal medical corporations and all thoughtful medicalpractitioners,-are convinced from experience that youngmen who have enjoyed the broadest and deepest generaleducation are the best fitted to undertake and master, as theyought, the many difficulties with which the student ofmedicine has to grapple. Under these circumstancesI hope the time is not far distant when for all uni-versity men an Arts degree, and for all others an examina-tion of equal standard, will be required before they areallowed to enter the portals of the profession of medi-cine ; although, with the view of giving a helping hand tothe medical student-who, after taking his Arts degree, mustnow have five years for special medical study,-it ought to bearranged that in his Arts curriculum or preliminary scientificexamination the subjects of physics, chemistry, and biologyshould be included. The student of medicine would then,under this arrangement, enter upon his purely professionalwork well equipped and with every prospect of success, andhe would, I trust, with greater probability than can now besaid to exist have unconsciously acquired in his universitytraining a cultured mind, and with it something of the true"professional spirit," so that in years to come he will notonly practise in that spirit, but when the business side of hisprofessional work has to be faced-for there is a businessside, and the questions of emolument and worldlyadvantages have to be considered-he will recognisethe truth of the observations I have made in theearly part of this lecture, and remember that he canonly rise himself by raising his profession in the estimation ofthose who form his circle, and that he can never do either bylowering the position of his profession ever so little, or byallowing the "spirit of trade" to master the "professionalspirit " and by practising it as a medical tradesman. Withthis scheme, therefore, before us, as the one which claimsuniversal support, let me ask, Where is the room for the oldsystem of apprenticeship, for the restoration of which weevery now and then hear a feeble cry ? The answer to thiscry can be but one, and that is, "Too late, too late."Apprenticeship is as dead as Csesar, and dead for ever. Andneed this be a source of regret ? for I am convinced frompersonal experience and much inquiry that where one

apprenticeship has proved useful to the pupil ninety andnine have been not only not useful, but positively injurious ;for by such a system a boy was removed from school beforehis schooling could have been of much value ; he was turnedinto a surgery to dispense in the company of assistantswho were not always desirable companions ; and he, more.over, rarely had a master who had the power or inclina-tion to do anything in the way of teaching beyond dispens-ing and keeping books. Where he was fortunate enough tohave had such a master, the pupil doubtless learned a con-fused something which in after life may have been of use;but reviewing the system all round the master was the onlyone who, as a rule, derived any certain benefit from its

adoption, for he pocketed the premium which wentwith the apprenticeship and at the same time founda dispenser or useful servant in the unfortunate

apprentice who, for five or more years, was bound todo whatever work his master might require of him. Iearnestly hope we may hear no more of this bygone anddead system, which, with the present heavy demands uponthe powers and time of the medical student, is an impos-sibility and an anachronism.With these remarks on the preliminary education of the

medical neophyte, I will now pass on to discuss severalof the various questions he will have to consider when hehas obtained his diploma or licence to practise-and it wouldbe well if his teachers during his last year of study were totake some opportunity of leading his thoughts in this direc-tion, for it is perfectly clear that in business questionsbusiness knowledge is essential, and good advice at this timemust bring forth good fruit. This might probably be doneby means of a post-graduate lecture, this lecture taking theplace with advantage of the old "introductory," which hasbeen nearly given up. For my own part I believe that thebest step for a student to take before he goes into practice isto spend a year as an assistant to a good medical prac-titioner ; for by so doing he would learn the business part of

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his profession in a practical way, and at the same time beacquiring much more if the practitioner happen to be of ahigh class. Medical schools should keep a list of high-classpractitioners in good practice who are willing to acceptqualified students for this purpose, and the practitionerswould doubtless profit by the plan.The subject of professional remuneration must now claim

our attention; it is a difficult one to handle, but it has beenthe cause of no little recent complaining and heartburning.There is, I believe, some reason for this feeling, since muchpublic professional work is notoriously ill paid, and privatework is no less so. But these facts can in a measure beprobably explained by the existence of unwholesome com-petition and under-bidding ; for it would seem to be truethat there is no limit to these destructive processes. Notlong since, when in conversation with an active and thought-ful chairman of a provincial county council, he told me thathe was as chairman ashamed at the smallness of the salarieshis Poor-law medical officers received, and yet, he added, hewas quite alive to the fact that if the present occupiers ofthe posts refused to work for such remuneration others wouldbe readily found to accept the positions. He admitted theparish parsimony as regards payments, but, as he expressedit, with such competition before him, what was he to do 2The same complaints may doubtless be made with referenceto clubs, and more particularly as to the so- called medical aidassociations. Indeed, rising higher in the scale, and with re-spect to honorary appointments, men who would wish to standwell with their confreres are at times too ready to accept posi-tions which others have deemed it right to vacate. We must

suppose that men who do these things do so with the hopeof some personal advantage, but they clearly have littlethought or care of professional dignity or what is due to theirprofessional brethren. In such men the "spirit of trade"has mastered the "professional spirit," and is allowed tohave its way. This conduct all round is bad and sad ; buthow is it to be prevented ? Some men, in their anxiety toput an end to these and other practices, the evils of whichthey see too well,-call out in their excitement or thoughtless-ness, "Let the General Medical Council or Royal Corpora-tions correct these evils "; whilst others, with more self-reliant feelings, look to defence associations, medical associa-tions acting as courts of ethics, to pass judgments and enforcedecisions. But I would wish to point out that in this lookingfor outside aid and longing for some outside power torelieve or cure the maladies which affect the body corporateof our profession we are forgetting that the diseases towhich attention has been drawn, with others, have beenbrought on and are maintained by our own action or wantof action, and that to look for a sound remedy we musttherefore look to ourselves, for "our remedies oft in ourselvesdo lie." To aid us in this direction by all means let medicaldefence unions, local societies, and medical associations beformed, if we have not enough, and more particularly letthese unions, associations, and local societies bring beforethe General Medical Council or Royal Colleges every act ofgrave professional misconduct of registered practitioners, andin so doing support their causes with evidence which mustsatisfy their judges ; for remember, the functions of thesebodies are simply judicial. By so doing the evils of cover-ing, of unqualified assistants, of giving false certificates, ofundue or gross forms of advertising and touting for patients,would speedily be abolished, and with these evils many otherswould succumb which naturally follow such practices; but toput an end to over-competition and under-bidding, with otherethical evils, is another matter, and is one, I fear, which canonly be done by raising the self-respect of the individualmembers of the profession by means of the higher educationto which attention has been already drawn, although it mayprobably be much helped by the establishment of some

"professional medical court of appeal" or "board ofmedical discipline" composed of certain members of thecouncil or comitia of the Royal Colleges, nominated by theColleges, with leading provincial, country, and urban practi-tioners nominated by the profession, to whom all medicalgrievances could by the local societies or associations be sub-mitted for their consideration and decision-the duties ofsuch a board being much the same as those which nowdevolve upon the Censors of the Royal College of Physicianswith respect to their own Members ; and upon the Council ofthe Royal College of Surgeons through its President with theMembers of the College. Such a strong appeal court wouldhave the confidence of the profession and public, and wouldhelp materially to suppress doubtful acts and check many evil

ones before they become grave enough to be pronounced"infamous in a professional respect " and so render theculprit liable to be removed from the Register. The moraleffects upon the profession of this "Board of MedicalDiscipline" would also be very great.3

In the practice of our profession we should never forget orcease to impress upon its younger members that our patient’sinterests are those we should always primarily consider, andthat in all our practical and scientific professional work thepublic good is its ultimate object ; but in doing so let us bearin mind, in order to realise this leading purpose, that it is all-important for the interests of the public as well as for thedue exercise and dignity of our profession that every practi-tioner of medicine should hold an independent but responsibleposition, and that in his professional work he should be left t per-fectly free from lay control, although amenable to lay censure.It is also equally necessary that he should be adequately paidfor his professional services by all classes accordmg to theirmeans. Under these circumstances all measures, whetherunder the guise of charity or called "provident," and allhospitals, general, special, or private, which encourage thepublic to seek professional advice for little or nothing are tobe discouraged as helping to pauperise and degrade thepublic at large. The same may be said of the members ofour profession who induce or tempt the public to do the samething by means of private hospitals, competing private dis-pensaries, touting clubs, and associations, or who are ready toaccept at a reduced figure, over the heads of their neighbours,appointments which have been put up by laymen, as it were,to auction or competition. Medical men by such acts adoptthe surest means within their power to lower the position oftheir profession in general estimation ; and at the same timedo injustice to themselves and the public by not giving to thelatter the best services the profession can supply, whilst theymust, in addition, lose their own self-respect even if theyhappen to gain cash by their unworthy actions. Fcr let meask, How is it possible for a man who is ill paid or overworked,or both, either to give, in the interests of the public, the pro-fessional attention it is essential for him to bestow on everycase he has undertaken to attend; or to maintain, in theinterests of the profession, the position to which he is entitledand his own self-respect ? The questions I propose now briefly to bring before you, and

upon which I would invite your consideration, are the follow-ing : the working of public provident dispensaries; the condi-tions under which private dispensaries should be workedand sanctioned ; the conditions under which country andtown clubs should be worked; the good or evil influencesof medical aid associations worked by laymen for their o-ynprofit ; the duties of unqualified assistants; and how midwives ’or, what seems to be a better term, "nurse midwives, " are to beeducated and utilised for the public good. All these questions,with many others, are well worthy of the attention of yoursociety--one might be taken up each session and well threshedout, for let me say that the solution of most, if not all thesequestions must rest in the hands of the general practitionersof this country ; and I must also express my conviction thatclearly formed opinions upon each and all of these subjects,formulated after due discussion by such societies as this,would do more to mould the minds of the professional andlay public for good, and form a better basis for future cor-porate action, than any opinions emanating from the GeneralMedical Council or the Royal Medical Corporations.

Practical questions of the kind enumerated should be

primarily settled by the great body of the profession in apractical manner, and it is through these local societies thatthe matured and independent opinion of the professionshould be expressed. When the profession has spokenthrough these means, extraneous aid may be sought. The

press is always ready to give help to any movement, butfor the profession to leave important questions such as thesefor the press to solve is a mistake, for remember that whatis called the press is but the product of a handful ofactive men. It is likewise a mistake to look to theGeneral Medical Council or Royal Corporations to give,under existing circumstances, judicial opinions upon theseand other complicated questions, as it is urging these bodiesto seek for powers, since they do not possess them, to enforcetheir views when formed; for these important bodies haveenough to do to carry out their respective registration,

3 This court of appeal or board of medical discipline shouldfinancially be supported by the societies who are represented upon it,the subscriptions of the members of the profession coming through thelocal societies.

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educational, and examination duties, as well as to purge theirregisters of men who have openly and unquestionably offendedagainst the laws of their country or their corporation. Toask these bodies to consider and solve ethical questions con-nected with professional work and professional advancement,and, having solved them, to seek powers to enforce theirviews, is too much to expect, even if it were desirableI would, however, wish to remind you that the GeneralMedical Council has done, and is now doing, good work inputting down the serious public offence of "covering" andof giving false certificates, more particularly of death, byunqualified practitioners. It does good also in expressingdecided opinions upon gross ways of advertising and otherprofessional delinquencies as brought before its notice, and Ifeel sure that the report upon medical aid associations whichwas issued last year will help the public and profession to cometo a definite conclusion as to the merits or demerits of thesenew trading bodies, if it does not lead the General MedicalCouncil to pronounce a definite opinion upon their nature.I would also assure you that my own College-the RoyalCollege of Surgeons of England,-with its present limiteddisciplinary powers, has not been, and is not, idle in the samedirection, for there are few meetings of the council beforewhich some complaint of undue modes of advertising, andof the employment of secret remedies, with other illegiti-mate methods of carrying on the "medical trade," is not

brought ; and if the offence charged is not serious enoughto justify the name of the offender being taken off theCollege books, a serious expression of opinion on the part ofthe council upon the nature of the act complained of, anda decision that the misdemeanour is inconsistent with thedeclaration made by the delinquent when he was admitteda Member of the College "that he would demean himselfhonourably in the practice of his profession and do hisutmost to maintain the dignity and welfare of the College, "are often enough to induce him to mend his ways and adoptmore legitimate means of carrying on his work. At anyrate, of this I am sure, that these expressions of opinionupon the part of the council do great good and tend to I,stop ways which lead downwards; and I likewise believethat if the attention of the council were drawn more fre-

quently by the Members of the College to methods whichweak men adopt from their weakness, and which strongermen know are injurious both to the profession and the public,the action of the council for good would be more frequentlyrepeated, to the great advantage of the profession and the,suppression of bad ways. It might be well for you to con-sider whether duties of this nature should not be part of thework of such societies as your own. A society could well do- what individual men might shrink from. I may, however,- tell you that during the last seven years-besides all Members.of the College who have been convicted of criminal offences-six Members have been removed from the list of Membersfor issuing advertisements or practising secret methods ofcure which the council regarded as "prejudicial to the inter-- ests" and "derogatory to the honour of the College, " as wellas "disgraceful to the profession of surgery " ; and six otherMembers who had offended against our by-laws in the sameway have simply been let off after they had made "dPClara-tions " that they would not so offend again ; whilst one other-Member was removed for being associated with a disreputablemuseum. Thus thirteen Members have been brought beforethe council in seven years for having seriously offendedagainst the by-laws of the College, besides many others whohave been satisfactorily dealt with by the President for minoroffences. But let me beg of you not to rely upon the RoyalCorporations for the help which, to be effective, must comefrom yourselves.Let the great body of the profession pronounce with no un-

,certain voice, through local societies, county asseciations,and private societies, that this, that, and the other method of.seeking or obtaining practice and notoriety ace unprofessional,derogatory to the interests of the profession, and injuriousto those of the public. Let such societies as yours, and allothers like it, exclude men who do such wrongs from theirlists of members if they persist in their bad ways after theyhave been warned, and let the excluded members know thereason why they are so excluded ; and when the professionas a body has spoken, greater powers may be obtained by thecorporations, for I must tell you that seven years ago, whenthe Royal College of Surgeons applied to the Privy Councilfor some enlargements of its disciplinary powers, its requestswere refused-not, however, on account of any objectionswhich were raised by the Privy Council to the powers asked

for, but on account of the opposition of certain Fellows andill-informed Members of our own body, who had placed them-selves in an antagonistic position to the action of their College.and had made a great noise about the matter by means ofthe press and other ways. If this opposition had not takenplace the disciplinary powers of the College would have befnnow enlarged, to the advantage of the profession generallyas well as of the public.With respect to "public provident dispensaries," I believe

that such institutions may be made of great value both to thepublic and the profession : to the public, by helping a largenumber of the wage-earning and poorer members of the com-munity from falling into the pauper class, as well as byencouraging in these classes the spirit of thrift and inde-pendence which is so essential for national prosperity; andto the profession, by enlarging the field of observation forthe local practitioners, and by securing for them reasonableremuneration for their professional services, with manyother secondary advantages. But in order to secure thesedesirable ends it is all-important that only such membersshould be admitted to the advantages of the dispensaryas are of the wage-earning and poorer classes, and thatthe scale of admission charges should be calculated insingle persons as upon a percentage of their wages, andin families upon the aggregate wages of the family or

household and not upon that of the member only inwhose name the dispensary ticket may have been taken out.I should like to see in every district one or more publicprovident dispensaries for the "well-to-do poorer classes"as we now see dispensaries for the pauper class. I wouldhave these dispensaries managed by a committee of laymen,medical men, and possibly representatives of the classes inwhose interests they exist. Their doors should be open t)registered members, but their rules should be such as toallow of any of the "well-to-do poorer classes" being ableto obtain speedy help and relief upon well-defined termsfrom any one of the medical men of the district in theevent of any sudden illness or accident taking place. Everymedical man of the district should, morecver, be admitted amember of the stafE, should he desire to be so, and receiveremuneration from the dispensary for the work he may havedone for it.With parish dispensaries for the very poor, and provident

dispensaries of the kind alluded to for the "well-to-do poor,"the needy classes would be well looked after, and the medicalofficers of both would be fairly treated ; for any applicantto one or other of the dispensaries, if of the wrong class,could be passed over to the right class. Any medical man ina dispensary district who cares to do dispensary work shouldhave the power of placing a poor patient upon his dispensarylist, and of attending him as a dispensary patient; and anypoor patient should have the power of consulting anymedical man of his district who is on the dispensary stafEupon dispensary terms. With the existence of these publicprovident dispensaries, so-called "private dispensaries wouldnot be needed, and consequently should not be allowed ;since such dispensaries are too often the mere speculativeadventures of needy men who trade upon the poor for theirown ends, and certainly not for the poor’s advantage, whilstthey degrade the profession in public estimation anddoubtless degrade the dispensary medical officer to thelevel of a small and unscrupulous tradesman. Again,town and country clubs are institutions to be encouraged,for the same reasons that have been adduced in favour ofpublic provident dispensaries ; but it seems to me that thescale of payments now required should be somewhat higherthan that which has been demanded in past years, for wageshave been much raised, and the medical club charge shouldbe a percentage rate upon wages. With the adoption of thissuggestion I regard club work, when honestly carried out, asbeneficial to the public and valuable to the medical prac-titioner, who not only obtains fair remuneration for his work,but carries out his responsible duties untrammelled by layinterference. As to what are now called " medical aidassociations, " I am at a loss to know where, in most of them,good is to be found ; for it is clearly degrading for anyqualified medical man to do professional work as the paidservant of a committee of illiterate or even educated lay-men, and consequently to work under their control; and it iscertainly injurious both to the public and profession that thismedical servant should be required to look after any numberof members admitted by a lay committee to the supposedadvantages of the association upon terms concerning whichthe medical officer has no voice and when he knows that he

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is often called upon to treat many more patients than can possibly be treated with due care and proper &kil].

It is likewiss a clear wrong both to the public and pro-fession that members should be admitted to these associa-tions who are not of the wage-earning or allied classes, andwho are well able to pay the limited charges of a privatepractitioner. The medical aid association is a developmentof the medical club, but it is a growth of a diseased nature,and it ought to be either brought into line with publicprovident dispensaries or club practice, as sanctioned

by and based upon the Friendly Societies Act, or it

ought to be rooted out of professional public work. Ihave a very strong belief that these medical aid societieshave been wrongly admitted under the Friendly SocietiesAct, and I wish some leading lawyer would take up thequestion.As to the duties of unqualified assistants, I believe all will

agree with me that they should be reserved to home duties, notfar beyond those of a dispensing assistant. No visiting anddispensary or outside club work ought to be entrusted tothem beyond a visit of inquiry, nor ought they to havepower to sign professional certificates of any kind. If theyare employed beyond these limits harm is certain to ensue.And, lastly, let me say a few words upon the burning ques-tion of midwives, for we all must admit that midwives arenecessary, since in some districts they divide the midwiferywork between them, and in all districts they hold an importantposition in the social scale. If, then, midwives are necessary,it is equally evident that they should be efficient, for if theyare not efficient they are dangerous assistants and hadbetter be away, and if they are to be efficient the conclusionis certain that they must not only be made so, but that theirknowledge should be tested by competent examiners beforethey are allowed to embark on the responsible and seriousduties they have undertaken. With respect to the questionof their education, it goes without saying that the teachingmust be practical, although based upon a certain amount ofanatomical knowledge, and that this practical knowledgeis only to be acquired at lying-in hospitals which are

sufficiently well officered to afford a guarantee that theteaching will be enough, but no more than enough, toensure competency to attend a natural labour and to knowwhen true professional assistance is required on accountof the many difficulties and dangers which may arise.For I would wish "midwives," as they are now called, to beregarded as nurse midwives," and even to be named such-and I am pleased to add that this suggestion has been adoptedby the General Medical Council-since the term carries withit the meaning that they are really nothing but skilled nurseseducated for special work, and that they are always actingeither directly under medical supervision or under theclearest instructions that they are to call in medical pro-fessional assistance in every case of suspected or real diffi-culty or danger, and, in the majority of cases, the districtmedical officer is the one to be called in. Finally, let meask, How is this examination work to be conducted, and whois to conduct it? For my own part, I feel strongly that suchimportant public work should not be entrusted to any privatesociety or institution, however eminent, but that it shouldbe placed and left in the hands of some responsible publicbody. I do not mean such a one as a county council orallied body ; but I would wish it to be undertaken underthe direction of the two Royal Medical Colleges of England-the Royal College of Physicians and the Royal College ofSurgeons-by means of examining boards, central or district,composed of either specialists or general practitioners, or ofwhat would be preferable, both combined, as may after fullconsideration be deemed best, the curriculum of study aswell as scope of examination resting entirely with the twoRoyal Colleges.

I must now bring these somewhat desultory remarks to aconclusion. The subjects I have brought before you are allof importance, and my views upon them have not been formedhastily ; for I have been called upon to consider them withcare when President of the Royal College of Surgeons ofEngland and as member of the General Medical Council.Whether these views are right or wrong I leave to you todecide; for their full consideration is well worthy of theattention of this and other allied societies. Whatever solu-tion you may find for the different problems which I havebrought before you, of this I am sure-that the conclusionsyou come to will help the final solution of them all and sotend to the advantage of our profession and the welfare ofthe public.

An AddressON

A RIGHT PERSPECTIVE IN MEDICALTHOUGHT AND PRACTICE.

Delivered before the Torquay Medical Society,Oct. 5th, 1894,

BY R. DOUGLAS POWELL, M.D., F.R.C.P.LOND.,PHYSICIAN TO THE MIDDLESEX HOSPITAL AND CONSULTING

PHYSICIAN TO THE BROMPTON CONSUMPTION HOSPITAL.

MR. PRESIDENT AND GENTLEMEN,-Our sense of pro-portion in things medical, especially with regard to sym-ptomatic phenomena and measures of treatment, is liable todistortion from various causes. The attractiveness of new

discoveries, whether they be pathological or clinical, tendsfor a time-until they have taken their allotted place in theonward march of our science-to loom too largely in ourforeground and to draw off our attention too much from otherand more familiar facts and teachings with which they mayin no way clash. The accurate estimation of the body heatby the clinical thermometer-a great discovery in its applica-tion to medicine in my student days, which has made itsway so thoroughly into our daily practice-tended for a timeto command our too exclusive regard ; the readings of thethermometer were apt to be too exclusively relied upon, andto this day I find it difficult to keep the student’s attentionawake to the importance of careful observations of the pulsein association with those of temperature. Fortunately, the-sphygmograph was invented soon after the thermometercame into common use and before the traditional regard fort

pulse characters had been lost sight of, or the circulationmight have been fairly forgotten or "taken as read." In

febrile illnesses this weapon of precision-the sphygmo-graph,-at first threatening to find a use in everyone’s hands ..

in routine work, was not without a danger of its own to

diagnosis, but, happily, that danger has passed, and itsusefulness as a delicate recording instrument is fully estab-lished. It has had in the hands of experts the great valueof teaching us and delineating for us accurately the im-portant features of the pulse, which we may perceive by oureducated finger touch.

Imperfect readings of thermometric records and an im-perfectly proportional combination of thermometric withother clinical and pathological data seem to me to be stillresponsible for errors both in diagnosis and treatment. Itmust be observed, too, that recent and, as yet, not fullydisclosed pathological researches give a new interpretationto some pyrexial phenomena which the thermometer butfaithfully records, and are shedding a new light upon thenatural history of pyrexial diseases. Thus the interestingstories which-some of them, perhaps, fables-come to usfrom our bacteriological laboratories, of the loves andantipathies, the triumphs and disasters, in the microbeworld assume a new and strange fascination for us

as we come to recognise ourselves, our blood and tissuesas forming more and more largely their playground andbattlefield.We in practice direct our attention too exclusively to,

the higher excursions of the thermometer, as indicating,apart from any corroborative symptoms that may or maynot be present, a condition which per se calls for activeinterference, whilst our tendency is to ignore, or even to,

bring about, low ranges and deep depressions of temperatureas salutary or of no importance. It is probable, however,that these depressions, especially when they occur pre-maturely or are artificially brought about in the course of anacute febrile illness, are fruitful of opportunities for freshmicrobic activity. The results of bacteriological investiga-tions are in favour of this probability, for it is found thatthe bacilli of tubercle, of anthrax, of pneumonia, of=influenza, enteric fever, and probably of rheumatism germi-nate at the lower ranges of temperature, between 97° and