NO. 4696.

AUGUST 30, 1913.

THE LANCET.

LONDON: SATURDAY, AUGUST 30, 1913.

An Address to Students.IN this our annual Students’ Number of THE LANCET we

present to our readers the usual summary of the curriculumwhich must be followed by the medical student before thetermination of the first stage of his studies is reached bywinning a position on the official roll of the medical

profession.ONCE A STUDENT ALWAYS A STUDENT.

To many students it will come as a surprise that we

should allude to the attainment of registrable qualifi-cations as only the end of the first stage of their studies.So important is it for the student to pass out of the range of

compulsory examinations that it is difficult for him not to

regard perpetual freedom from these irksome tests as the

main object of his education. It is for this that he has

undertaken an arduous curriculum, and strained his intelli-

gence to follow and his memory to hold many things of whose

utility he is doubtful; and although he will have been told

inevitably and more than once during his educational careerthat all medical men must remain students for their

lives, and that the gap which separates the man with ,the testamur from the man without one is largely arti-

Ificial, he cannot believe it. But the circumstances of

early= practice, whatever branch of the profession he

may elect to follow, will compel him to recognise that

the more he knows the more he will ascertain the

limits of his knowledge ; and he will find that the tests ofthe qualifying bodies are no harder than those which are setbefore the practitioner daily, and that true conscientiousness,which must be the distinguishing characteristic of the sound

physician and surgeon, is as difficult to satisfy as the mostcritical examiner ever was. This view of medical education

should be inspiriting to the mind of the student, removingvague feelings of diffidence which may arise at any pointin an elaborate course-a course which is legally bound toextend over five years, and which quite usually occupies six ormore of really industrious struggle-and also filling him withadmiration for the calling that he has adopted because the

range of its possibilities are seen to be boundless. In the

beginning he is a learner in the field where his teachers areyet learners ; at all stages of his career he will become awareof his limitations ; and at the end his store of experiences,which have enabled him to deal confidently with a surprisingnumber of practical problems, will be counterbalanced byhis appreciation that the progress of science knows no

confines, and that his journey with truth, though it mayrepresent a life’s companionship for him, has been a verybrief stage in the prolonged march of science.We essay within the contents of this issue of THE LANCET

to give complete information as to the various Universities

and Medical Schools, through the medium of whose pro-fessors, class-rooms, and laboratories the student can obtainthe training necessary to enable him to satisfy the demandsof multifarious examiners; and it is at once apparentthat in this country our medical training, so much

criticised, and in a few directions still so incoherent,is none the less ably planned both to secure for the

public an adequate band of professional men to under-take the private and public duties which fall to those whohave the health of the country in their charge, and at thesame time to allow of a proper development of scientificmedicine along lines which are rapidly multiplying in

number. The critics of our scheme of medical education

in this country would be more convincing if there was anyconsensus of condemnation upon particular points, and if

the remedies put forward by different reformers had thesame shape or purpose. We are well aware that there is no

great reason for complacency as to the curriculum as a

whole, but we also know that we turn out from our medicalschools young men as well equipped as the young men insimilar position in any country, and demonstrably bettereducated than the recently qualified practitioners in mostforeign lands. The recently qualified medical man cannotknow everything and cannot be taught everything. But his

statutory course of education furnishes him in this countrywith a solid beginning to clinical medicine, to which hemust add from his own experiences, and which will keep himin the right line while those experiences are yet small.

THREE POINTS OF VIEW FOR THE MEDICAL

PRACTITIONER.

The students who have joined our schools this year havedone so under interesting circumstances. It is possiblyclear to them, and is certainly clear to most of their parentsand seniors, that the medical profession is undergoing rapidchanges of all sorts. For the most part medical men are

bound to consider their medical career from three points ofview : First, they desire to discharge their duty to the publicin as efficient a manner as possible so as to reduce the

toll of misery exacted from the public by sickness or

injury; secondly, they aspire to assist in the progressof their science and to contribute to the accumulated

store of wisdom and truth on which the world dependsin its combat against disease; and thirdly, they hopeto obtain such material return for their work as will

represent a fair reward for their public and private services.Until quite recently the public knew very little about thefirst of these considerations, was indifferent about the

second, and was wrongly advised about the third. The

student of to-day is joining our ranks when on all sides

there is evidence that the medical profession is becomingbetter understood by the public. Moreover, simultaneouslythe public view is more sympathetically treated by medicalmen, who do not want to shield themselves from scrutinybehind some rampart of mysticism, but who can justifytheir right to speak authoritatively of the things which

appertain to their calling because ot the magnificent practicaloutcome of modern medicine. Medical practice is more

appreciated, its difficulties are more readily recognised andits performances more justly estimated than was formerlythe case, and this satisfactory position is bound to improve

I

n&w tha.t the number of oocasions on which laymen andmedical men must meet to transact public business is so

greatly increased.And while the aims of practice are more readily grasped

the exploits of our scientific workers are acclaimed with

far more sympathy at the present time than they have metwith previously. At the recent International Congress ofMedicine there was no more conspicuous feature than the

attempt on the part of the daily press to supply their

lay readers, who could not be present at what were

purely scientific gatherings, with information concern-

ing the proceedings of the Congress. Doubtless the

subjects selected for particular notice were not alwaysthe really important ones, but the fact remains that

pige after page of several of our best-known lay con-

temporaries were employed, often extremely neatly, in intro-

ducing to the public some of the scientific contributions

to the different sections. We regard these reports of the

proceedings of the International Medical Congress in the laypress as an indication that the claims of scientific medicine to

be accepted as an integral part of the daily life of everyoitizen are now being admitted-in other words, the public isaware that it is the duty of all men to assist medicine

in her forward progress.

And, thirdly, the claim of medical men to be paid for theirservices has been recognised in an unprecedented, if in no

very profuse, manner during the prolonged agitation whichattended the passage of the National Insurance Act throughthe House of Commons. While it was a considerable time

before reasonable pecuniary terms were arrived at, and

while there remain many provisions of the National Insur-ance Act which yet require modification, the outstandingfact remains that the country at large declared againstthe system of sweating the medical profession that had so

largely prevailed under the irregular developments of

contract practice. The medical student who joinsour ranks to-day may feel assured that he is doingso, therefore, under better auspices in many ways

than his predecessors of 50 years ago. There is no

allusion here to the fact that he is the heir to their learning,and that his career will necessarily be a more successfulone because he will succeed to effective weapons against

sepsis and to specific remedies for conditions marked

until recently by high mortality. The sweets of triumphover disease were as great, and the labours of combatingdisease as strenuous when the medical armamentarium

was small as now when it is so varied ; but the recogni-tion of medicine by the public, not as an elaborate art

with something mystical and even something pretentiousabout it, but as a science upon whose ministrations com-munities and nations are peipetually falling back, gives a

security of position to the medical man hitherto unknown,at any rate in this country. Again, the chances of coöpera-tion in the great march forward of medicine are more

rumerous and more obvious than they were even in recent

days. The education of the medical student, however over-

crowded and much criticised the curriculum may be, is now

so good that a large number of students are able, when theyare qualified, to erect upon a firm basis of scientific know-

ledge ’the results of their personal investigations. While

helping their seniors they can make observations upon theirown initiative which may transform them into valuable

cooperators ; and these chances for the young scientific manto do some good and make some mark while at the outsetof his professional career have all arisen out of the simpli-fication of medicine which is so characteristic of the modern

conception of progress. Each new disease discovered, eachnew procedure tested and found good, must bring in itstrain new points for diagnosis and new technique for treat-ment, but the methods both of diagnosis and treatment

grow more orderly and follow more regularly schemes thatare oomprehensible to the duly educated man.

GENERAL PRACTICE AND THE INSURANCE ACT.

The effects, both immediate and remote, of the National

Insurance Act upon the numbers and quality of those enter-

ing the ranks of our profession cannot be estimated with

any certainty, but in our opinion the altered position and

prospects of general medical practice, which constitute areal change in the outlook of the medical student, ought notto prevent the recruiting of the profession adequately andfrom the proper sources. There are no indications as yetthat any marked falling off in the entries at the medical

schools is to be expected this autumn, nor, so far as can be

judged at present, is any appreciable change imminent in theclass of men who are about to join the medical profession.Partly through the operation of the National Insurance Act,and partly from other causes, the conditions of medical

practice in hospital and in private are undergoing changes ;but although the circumstances of hospital administrationare giving great anxiety, it is unlikely that the relationsbetween the student and the clinical teacher or between the

student and the patient will be altered, at any rate for sometime to come. The traditional spirit of loyalty and disciplinethat marks the hospital in its teaching and its practicewill be found strong enough to survive very marked changesin the material affairs of our British hospitals. If, as is

assumed by many authorities, the State must soon playsome part in the management of these institutions, studentswill certainly remain an integral part of hospital life, andthe education which they receive there will still be reflectedin medical practice carried on outside the hospital.While the quality and training of each generation of

students have more effect than anything else in raising or

lowering the standards of general practice, it must be remem-bered that conversely the prospects of general practice at anygiven time have an immediate effect on the popularity orotherwise of medicine as a career ; for general practice is the

goal of the great majority of medical students, and anythingwhich seriously affects the status, methods, or rewards of

general practice must react upon the supply of students.

Although in view of the changes which have already taken

place or are imminent, the future of general practice is some-what uncertain, the prospect is not now as dark as it seemedin the stormy days of last January. The National Insur-

ance Act has not as yet fulfilled the gloomy anticipationswhich were then so freely made, and generally speaking itwould appear that medical practice under the Act is not

proving so irksome or so laborious as was expected.

But it will not be possible for some years to say with any

oertainty how far and in what respects this measure has

609

permanently disturbed the conditions of medical practice or

changed the personnel of the medical profession. One

possible effect of the Act, which we have always foreseenand deprecated, is of special importance when the students’outlook is under consideration. In the course of time it

may come about that in all but rural and purely indus-trial districts a gradual cleavage may appear between the

panel practitioner and the private medical adviser, so

that of its own accord the public may come to distinguishin an invidious way between the " insurance doctor and

the "private doctor." This effect of new legislation may notbe very noticeable as yet, because the Act does not at presentapply to the families of insured persons, but it is con-

fidently stated that before long the attempt will be madeto include all dependents within the scope of the Act andtherefore within the scope of medical benefit. If this comes

to pass and the present medical arrangements are continued,the entire industrial population of the country will be in

the sole medical care of the panel practitioners. This means

that many of those medical men who elected to remain on

the panel would have to give up their hold on private prac-tice altogether, and that in a great many districts the

I"mixed practice " would be swept away. This is an anxious i

position to contemplate.While the dignity and efficiency of general practice will

probably be enhanced by the transfer of dispensing from themedical man to the pharmacist, it must be remembered

that a great many practitioners have resigned this branchof their work with considerable reluctance. Again, the

Act has abolished the former domination of the FriendlySociety officials, but it is unfortunate that it has compelleda large number of medical men to engage in contract practiceagainst their wish. If in the future the extension of

the scope of National Insurance should leave only a

small proportion of openings for private practice, manyyoung men of the class from which the better kind

of medical student is now drawn may look with less

favour on medicine as a career. On the other hand, it

must not be forgotten that general practice is not the

only branch of medical work which is undergoing changesand developments, and that the newly qualified practitionernowadays has an increasingly wide field of choice. The

number of administrative and institutional posts open to the

suitably qualified medical man and woman is growingsteadily. Official medical posts of all sorts are beingcreated, and the student should keep this fact in view fromthe very beginning of his career. While the number of

commissions in the Navy and Military Medical Services

remains fairly constant, the increase in knowledge of

tropical hygiene and the growth of State responsibility for

public healthin Colonies and Dependencies and Protectorates Iare combining to enlarge the other medical services of the

Crown; but it is in the number of public medical appoint-ments at home that the largest increase has occurred andis to be expected in the future.

THE YOUNG MAN’S PROSPECTS.

A gap of 32 years lies between the two International

Medical Congresses which have been held in our capital, anl Iwe have learned from the proceedings of the recent Congress

the steady manner in which medicine is transforming itselfinto an exact science, and the promise which this transforma-tion holds out to young labourers in pathological fields.

This may be said to have been the message of the Congress,for every unconcluded investigation and every unverified

hypothesis brought forward during its deliberations can be

regarded as invitations to new workers. But the care of

mens’ minds and bodies can never be undertaken entirely byrules. The practice of medicine demands more than can be

taught in the ward or acquired in the laboratory, and that

larger numbers of our young men, whose qualities inspirethem to accept the responsibilities either of general practiceor of public medical service in one of its numerous forms, willfind in the altered and altering conditions of to-day manyopenings for a life of the utmost utility to their fellow

men.

Side by side with some decline in the attractions of

family practice there is a steadily growing demand formedical men in posts carrying fixed incomes and pensions,security of tenure and opportunities for scientific enterprise.Medicine will not look in vain to the rising generation forsuitable recruits, and we congratulate upon their choice ofa calling those who have decided to join our ranks this

year.

POST-GRADUATE MEDICAL INSTRUCTION.-AnInternational Conference on Post-Graduate Medical Instruc-tion was held in the Jehangir Hall of the University of Londonon Thursday, August 7th, in connexion with the SeventeenthInternational Medical Congress, We are delaying publica-tion of the article upon Post-Graduate Instruction in. this

Country, which generally finds a place in the Students’Number of THE LANCET, until next week, so that it can

appear at the same time as a note upon the International

Conference.

FOREIGN UNIVERSITY INTELLIGENCE.—.tMSte : -Dr. R. Massini has been recognised as privat-docent of Medi-eine.-Ilerlin : Dr. J. Morgenroth, chief of the bacterio-

gical department of the University Pathological Institute,has been appointed Extraordinary Professor.—.2?ya.M : Dr.F. Landois has been recognised as privat-docent of Sur-gery.—77a.Me Dr. Hans Willige has been recognised as

primt-docent of Neurology and Psychiatry.- Giess&bgr;n :Dr. Hans Koeppe has been appointed ExtraordinaryProfessor of Children’s Diseases.-Gratz : Dr. Otto.Burkhard has been recognised as privat-docent of SocialHygiene.-GI6atemala Medical School : Dr. Wunderlichhas been appointed Professor of Operative Medicine,Dr. Lizarralde has been appointed Professor of Anatomy,in succession to Dr. Wunderlich.—; Dr. R. lemma.professor in Palermo, has been appointed to the chair of

Podiatry.&mdash;.P<M-a.; Dr. Francesco Lasagna, of Turin, hasbeen recognised as privat-dooent of Otology and Laryngo-logy.-Prag1be (German University) : Dr. A. von’l’schermakhas been appointed Professor of Physiology, in successionto Dr. Hofmann.&mdash;-BoNA : Dr. A. Bennecke, privat--docent of gynsecology, has been granted the title ofProfessor.&mdash;<SM Francisco (University of California): Dr.J. Morris Siemens, of Johns Hopkins University, Baltimore,has been appointed Clinical Professor of Gynaecology.Dr. A. H. Morse has been appointed Adjunct Fro-fessor of Midwifery and Gynp3cology. -Stockholm: : Dr.1. Holmgren, docent, has been offered the chair ofClinical Medicine, in succession to Dr. Hensohen.&mdash;

S’trasb2rg : Dr. K. Stolte has been recognised as privcct=docent of Pediatry.-Tienacz : Dr. Constantin Freiherr vonEconomo has been recognised as prirat-docent of Psychiatryand Neurology, Dr. Hans Thaler as privat-docent of Gynre-cology and Midwifery, and Dr. Josef Kyrle as privat-dooentof Dermatology.