No. 2559.

SEPTEMBER 14, 1872.

THE LANCET.

LONDON: SATURDAY, SEPTEMBER 14, 1872.

ADDRESS TO STUDENTS.

IN compliance with a custom honoured by time, andsanctioned by experience, we incorporate with our students’number an Address containing such special reflections asthe circumstances of the time may seem to suggest. In

successive years we have discussed almost every topicbearing upon either the principles or the details of medicaleducation; and although these, if we were to discuss themonce more, would probably be brought to the notice of manynot yet familiar with them it is nevertheless impossible forus so soon to traverse again such beaten ground. We pur-pose this year to deal with an entirely different set of ques-tions, and to consider the present number as addressed

mainly to those who have not yet entered the profession,or who are ignorant of the conditions under which it ispractised. We write for intending students, or for the

parents or guardians of intending students; and we wishthem to ask themselves what it is that they propose or

expect. We wish them fully to realise the nature of thebattle of life as it presents itself to a medical practitioner,and to ascertain whether they, or those dear to them, areprovided with the resources necessary for the strife.Given a fair education, ordinary abilities, and ordinary

industry, the profession of medicine is open to all comers;and there must be absolute deficiency in at least one ofthese requirements on the part of any young man whoexperiences serious difficulty in attaining even its best

qualifications-such as the doctorate of the University ofLondon, or the Fellowship of the College of Surgeons. For

those who do not aspire so high, the path to qualificationis only too broad and easy. In England we have never

recognised a grade corresponding to the officier de santé of

France; but our corporations have nevertheless persistentlymaintained a low minimum standard, and have admittedmen to qualify on very easy terms. For this policy, whichwe think wholly mistaken and disastrous, there is, of course,something to be said; and the main argument in its favouris that it opens a door of access to our calling to industriousyouths of small means, who would be excluded altogetherby a very high standard of either general or professionalexamination, and who, as it is, can only succeed by astruggle against difficulties, the overcoming of which will

justify favourable anticipations of their future conduct.

The practical result has been, in time past, to tempt intothe profession a certain number of men whose selection ofit has been mainly due to their inability to enter any other,whose means have been exhausted in obtaining a qualifi-cation by which they were immediately compelled to striveto live, and who, in the aggregate, have formed the

weak link in that chain of brotherhood by which themembers of every calling should be united. In our own

dav, the facilities for the acquirement of the medical cha-

racter are somewhat less than formerly; but, on the otherhand, we believe it is far more difficult than formerly tause the profession as a means which will enable its

members to assume, at an early age, the position and re-

sponsibilities of citizenship. A student of high charactermay almost always, as soon as he is qualified, obtain a paid.office at some hospital; but such offices do not permit of

marriage, and, in their very nature and essence, are to

be regarded as temporary holdings. The time of their

determination brings before the young practitioner a ques-tion to be answered without delay. It compels him prac-tically to consider, if he has not considered already, whatsort of weapon the fact of being 11 registered" has put intohis hand, and what are the conditions under which he canturn that weapon to good account.The ailing members of the public, who carry their com-

plaints to the waiting-rooms of the leading metropolitanphysicians and surgeons, find those rooms occupied by agreat number of patients, each of whom is supposed torepresent a guinea. It often occurs to the invalid, duringsubsequent periods of home reflection, that there was some-thing in the manner of the doctor which got him out of theaudience chamber sooner than he had intended to go; that he

had entirely forgotten to enlarge upon the odd sensation in hisleft leg, or to describe the effects produced upon his systemby a cup of green tea. It becomes his opinion that the doctor

got his guinea with unnatural and unfair facility; andhence he reaches the conclusion that a calling in which thiscan be done would be an extremely eligible one for his ownson, ward, or nephew. The superstition arises, and is per-petuated, that doctors make money very quickly and easily,

, and that, as they do so with little obvious outlay, their’

business is one in which tact and brains will supply the. place of capital. Once in a generation there may be an; example of the kind, but it is an exception of a character, to prove the rule.. If we glance at the career of even an eminently successful

physican or surgeon, one whose name is familiarly known. both to the public and to the profession, we shall find that! he is, as a rule, not much under from fifty-five to sixty

years of age. Supposing that he had completed his qualifi-l cations at the age of twenty-five, let us inquire how theL intervening period has probably been spent. By the, time he was thirty he would probably obtain assistant. office-that is, the care of out-patients-at some hospital,; and also a lectureship in the attached medical school-a. lectureship determined, not by his own tastes or speciall knowledge, but by the fact that a certain post was vacant,L and that he, as one of the juniors, was expected to fill it.

l In these capacities he would probably receive emoluments, amounting in favourable cases to two or three hundred a) year, but frequently not exceeding a third of the sum. For

! another ten Jears we may imagine him filling the same, position, and working hard both as a teacher and as a

. student, but doing little more. It is not too much to

, say that occupation in private practice during this

, period would be not only antagonistic to but almost

, prohibitory of the eventual attainment of a great re-

L putation; and, as a matter of fact, the practice does. not come. How should it ? - and whence? The phy-

L

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sician or surgeon situated as we have supposed aims atbeing a consultee; and no man is, in the technical sense,consulted until he has given his proofs of aptitude for thecomprehension and solution of the problems of his calling.He does this by his contributions to medical literature andto the work of medical societies, and so comes to be

esteemed as a rising man. His contemporaries as students,who have gone into general practice, begin to call him in

to some of their more obscure and difficult cases, and

notably, in the first instance, to those patients who are ableto afford only a limited remuneration for the benefit theyreceive. By the time that the ten years have passed, andthat our imaginary hero is forty years old, he may be

making six or eight hundred a year if a physician, andperhaps half as much again if a surgeon, on account of thefees accruing from operations. If he has remained single,he is now fairly able to pay his way by his professionalearnings, but hardly to do more. A man who even seeks

practice must live within certain narrow limits of locality,and in a house of a certain aspect and character; so thatthe mere question of rental and local taxation will absorbwhat would be a handsome income in many parts of theworld. If he has married and has a family, his expenseswill still outrun his fees, and he must wait for further pros-perity before he can meet his necessary outlay by his profes-sional earnings. To many the further prosperity does notcome. Many men there are who have ambition enough andenergy enough to enter the race for the great prizes of theircraft, but who, by the time they are forty years old, are seenby their contemporaries to be practically out of the running.They reach a certain point, and do not pass beyond it.

They are safe men-very good opinions-as it is said,-butit is easy to mention others who are better; and so theyfall to the ground between two stools, being disqualifiedfrom general practice by reason of their hospital offices, anddisqualified from great success as consultees by some wantwhich in many cases it is not easy to define. Some of these

comparative failures are men of conspicuous ability, and

yet, for some reason or other, they do not get on in theprofession. Those who have sufficient private means jogon, supplementing their incomes by a pleasant addition inthe way of fees ; or they " retire" from London practice and

carry a respectable metropolitan reputation to some fashion-able health-resort. Those whose means become exhausted

fall out of the ranks after a weary struggle-some to countrypractice, some to emigration, some to become water-curedoctors, or specialists in the various forms of division oflabour that are based upon impecuniosity rather than uponscience. Of the men who may be said to succeed, who goon from the six or eight hundred a year to a secure position,some few do indeed make large incomes, although the in-comes of leading practitioners are usually much exaggeratedby common report. But, as a rule, a man would be called

very successful and fortunate who could pay his way by his

earnings by the time he was forty, and who from forty-five tosixty-five could earn an average of three thousand poundsa year, at a domestic and professional expenditure of twothousand. In other words, it would be a great success tobe able to retire at the age of sixty-five, having originallyspent not more than four or five thousand pounds in esta-

blishing a position, and having invested twenty thousandpounds as the result of a life of unremitting mental appli-cation and constant physical toil.

i If we turn now from what are called the higher branches

of the profession-from hospital and consulting practice,to consider the work and prospects of the family doctor, orU general practitioner," we find a state of things very ana-logous to the foregoing. A young man, of whatever ability,cannot take the public by storm, and when he is ready toput a brass plate upon his door he must be prepared eitherto buy a practice or to wait for one. In provincial townsand rural districts the tie between a family doctor and hispatients is a very close one, and is at least fourfold. It

would be presumed, by many persons, to rest almost en-tirely on confidence in the doctor’s professional skill; but inactual fact this confidence is reinforced by many other con-siderations. If it were presumed that some newcomer werereally more skilful, " more clever in his profession" as it ispopularly said, than any of the old-established men, yetpatients would feel that the latter had the advantage of aclose knowledge of past personal history and of bygoneailments, that they were in possession of certain premisesand data which no stranger could reach. Furthermore,the doctor is often a trusted adviser in family troubles,and knows all about the domestic skeletons of half the

houses in the parish. Besides personal friendship, thesocial combinations of the locality come into play. And,beyond all these things, it often happens that people whowould like to change their doctor are restrained by the re-membrance that they have not paid the last year’s accountof the one with whose services they have a passing fancy todispense. The outcome of all this is, that a young man

may establish himself in a place where he imagines thereis an opening, or where he has perhaps spent a couple ofhundred pounds in the purchase of that very intangiblearticle known to medical agents as

11 a nucleus." His

hospital career and his qualifications may afford proof of

distinguished ability, his nucleus" may yield him pa-tients enough for the display of kindliness and of the

art of managing the sick, and he will probably be con-sulted by some of the hypochondriacs or chronic invalidsof the locality. Among these he will almost certainly findone or two who have so wearied their customary attendantsthat something in their more recent ailments has beenoverlooked, and that a fair opening for a cure is presented.The young doctor will be talked about as a prodigy; andthe practical issue of the talk will be a general determi-nation to employ him-when old Dr. JONES, who has at-tended for twenty years, shall see tit to retire from business.Dr. JONES may not do this for ten years to come; and the

suggested reversion may even then descend to some other

person-in most cases, indeed, to Dr. JONES’s partner andsuccessor. We have seen many instances of this kind,in which young men of great promise, but of small know-ledge of the world, have beaten themselves to death againstthe iron cage of circumstances. Without capital, butfull of hopefulness and ardour, they have relied upon

hospital and academic distinctions as passports to speedypractice; thinking they had only to notify their willing-

ness to heal the sick in order to bring the sick in numbers

363

to be healed. For many the disenchantment of awakingfrom this dream has been a shock greater than they couldbear, and has led to calamitous results in various ways.Some, who had married upon imaginary prospects neverdestined to be realised, have fallen with their families intochronic penury, and, after years of toil as assistants or as

practitioners among the poor, have left widows and orphansdependent upon the charity of others. Some, who haveremained single, have sought relief from the tedium of idle-ness and from the solitude of their homes in companionshipthat has led to dissipation and intemperance. Some, en-dowed with high principle, high courage, and a power of

patient self-denial, have ultimately overcome all difficulties;but these qualities are not possessed universally, and, whenpossessed, they may be put to far better purposes than in

nghting against difficulties which a little foresight wouldhave avoided.

The general practitioner, as a rule, does not make a suf-ficient income to leave money behind him otherwise than

by insurance. If successful, he lives comfortably, insureshis life pretty largely, educates his children respectably,and may perhaps invest a few hundreds in local securitiesor undertakings. A thousand a year takes him much time

to earn, and involves heavy expenses in the way of horse-flesh and establishment. Taking an average of country or

provincial town practitioners at forty years of age, theyprobably do not earn a thousand a year; and, as a rule, Itheir possible incomes are circumscribed within very de-finite limits by local conditions.Now, our object in writing all this has been to dispel

what we conceive to be a popular delusion, and to impressupon our young friends and upon their advisers that the

profession of medicine, in all its branches, is one for which

capital is imperatively required; or, rather, that it is one inwhich success without capital is too exceptional to be reason-

ably anticipated, and can only be brought about by some for-tuitous combination of circumstances, or by the exercise of

powers which would have obtained far greater rewards inother walks of life. Moreover, the difficulties that besetthe path of a poor man, striving to enter into medical prac-tice, are of a kind that tend to lower his self-respect, andto lower also his standard of professional conduct. Theyare such that none who have either experienced or wit-nessed them would willingly subject others to so fiery andfierce an ordeal.

As a rule, in this country, a partnership in an establishedpractice may be purchased for about two years’ income ofthe share required, and a succession, with ample length ofintroduction, for twelve or eighteen months of the averageincome of the seller. In large practices the rate is perhapsa, little higher. A young man who thinks he can beginprofessional life on an income of five hundred a year, oughtto be prepared to invest at least a thousand or twelve hun-dred pounds in his purchase; and, if he buys a succession,he must be prepared for a falling off of income to the

extent of at least one-third of the average on which he

pays. Moreover, as the income of a general practice is

mainly derived from accounts sent in once a year, and eventhen often paid only after some delay, the beginner should ibe prepared to furnish his house, and to live for at least a I

year on resources independent of his practice. When he hasdone this he will be well ahead of the world; and if his healthbe good, if his investment has been judicious, and if hismental and moral qualities are of the right kind, he mayconfidently expect to continue in a career of comfort,

respectability, and usefulness, exempt from the varioustemptations that are the lot of the man who has a deficitat his bankers. For a good commencement in generalpractice it follows that at least two thousand pounds wouldbe required. For consulting practice, five or six thousandwould be not at all too much; and a man with less than

this, unless he is able to make good the deficiency by some

extra-professional resource of equivalent amount, is in greatdanger of swelling the ranks of those whose prospects havebeen excellent, but who are described as having been unableto °°hold their ground."The chief extra-professional resource for earning money

is, of course, literature; and there are many instances,

among men who have afterwards attained very high posi-tion, in which the help afforded by literary earnings hascarried them over the early difficulties of their career, andhas made to them the difference between success and failure.

Few things are more interesting to ourselves than to lookback on the long roll of the names of those who were firstknown to us as workers on this journal, and who have sub-

sequently become known wherever the healing art is studiedand pursued. There is, of course, a certain amount of re-munerative literary work to be done in connexion with the_

profession, apart from medical journalism; such, for in-stance, as the translation of medical books from other lan-

guages, and this has the advantage of running side by sidewith the studies and pursuits proper to our calling. There

is much more for which the calling renders indirect

assistance; and a variety of subjects are now growingin interest with the public concerning which the generalpress must be greatly dependent upon medical writers.

Every young practitioner, therefore, who aims at distinc-tion in the metropolis, and who has any doubt of the ade-

quacy of his pecuniary resources, should early make up hismind to devote a certain portion of every day to the studyand practice of the art of writing, in order that he mayacquire the power of turning this art to account. Litera-

ture, nowadays, is not the work of amateurs, but of a pro-fession ; and success in it is not the result of any peculiargifts or special capabilities, but simply of industry andperseverance. Every man begins his attempts at com-

position by tying up his sentences into knots of almostmiraculous entanglement; and the power to realise CoB-BETT’S description, and to render them " as clear as a

pebbled brook," is gained only by the aid of labour andexperience.We have dwelt thus much upon the pecuniary qualifica-

tions necessary for success in medicine, in the hope thatour words may serve as a timely warning to any who maybe disposed to embrace the calling, and who may look to itas one in which a competence is easily to be secured. The

man of small means, if he has been liberally educated, andif he possesses ability, courage, and patience, may in timeovercome the difficulties in his way. But for the attain-

ment of early success in general practice, or for the attain-

364

ment of eventual success in consulting practice, capitalshould be regarded as absolutely necessary. It is cruel

kindness on the part of our corporations to open the pro-fession at all to poor men; and it would be eminently judi-cious of them to require proofs of a preliminary education

sufficiently liberal and extensive to justify the presumptionthat he who had received it would afterwards have moneyat his command.

It is not the least among the evil results of the delusion

which we have been striving to set aside that the medicalman who is struggling for a bare subsistence is he who isdriven to the shifts which we all concur in considering dis-reputable. Quackery of all sorts within the profession, andthe acceptance of parochial and other offices at inadequatestipends, are the direct results of the fierce competition ofmen who can barely live-a competition in which the finerfeelings and more delicate instincts become blunted, and inwhich the public suffers even more than ourselves. The

medical practitioner is placed in so many and such intimaterelations with his patients that it is eminently to theirinterest that he should be above all temptation to abuse theconfidence which they are compelled to repose in him. We

quote the words of an eminent surgeon of the present dayin saying that it is not enough for a medical man to behonest-it is necessary for him to be chivalrous. There are

not many who will keep their chivalry unstained under the

pressure of privations in the present and of anxiety aboutthe future.

We must yet caution our readers against the belief,erroneous in the opposite direction, that success in the pro-fession can be obtained by money alone, without the aid ofability and industry. We sometimes hear it said of a suc-

cessful practitioner that he has done nothing to justify hissuccess; but it will usually be found, in such cases, thatthe success has justified itself. He has cured his patients,and they value him accordingly. Now a man who cures his

patients is every day engaged in solving successfully someof the most complicated problems that can be submitted tothe human intellect-problems that cannot be solved with-out the aid of minute and accurate observation of facts, norwithout the knowledge and the constant application of

principles. The possession of a little money is rather aptto be a snare to young men, to render them idle, to leadthem to fancy that they have a key which will unlock allthe doors of life. In the profession of medicine, as wehave striven to show, ability and industry have not fair

play without a sufficiency of means; but still, under anydisadvantages, they sometimes conquer at last. For moneywithout ability and industry there is simply no placeamongst our ranks at all, unless it be one for tardy and un-availing repentance.

CHANGES IN THE LONDON MEDICAL SCHOOLS.

As customary on presenting the Students’ Number ofTHE LANCET to our readers, we here enumerate the variouschanges which have occurred during the past medical yearin the staffs of the metropolitan hospitals.

At St. Bartholomew’s death has removed the time-honoured name of Mr. Skey from the list of consultingsurgeons and lecturers on Clinical Surgery. Mr. Coote,

though still on tho F3taff, is, as wo recently announced, pre-cluded from undertaking active duties.At Chnring-Cross Dr. Silver has become physician, and Dr.

Vivian Poore assistant-physicifm and lecturer on ForensicMedicine. Mr. Hancock, on becoming President of the

Royal College of Surgeons, has retired from the office ofsurgeon, retaining, however, the lectureship on Clinical

Surgery. Mr. Barwell succeeds him, ant! thereby a vacantassistant-surgeoncy is made, which is shortly to be filled

np. The post of physician to the Skin Department is alsovacant. Mr. Fairbank has been appointed dentist, and Dr.Mitchell Bruce registrar, and Mr. Cantlie demonstrator ofAnatomy.At St. George’s there are no changes.At Guy’s Sir Wm. Gull has become consulting physician.

Mr. Durham has succeeded the late Mr. Poland as surgeon,Mr. Richard Rendle and Mr. Lucas have been appointedassistant demonstrators of Anatomy; the former gentlemanhas also been made assistant to the lecturers on Practical

Surgery. Mr. G. F. Rodwell is the lecturer on ExperimentalPhilosophy. Dr. Frederick Taylor and Mr. Goodhart havebecome respectively medical and surgictl registrars.At King’s College Dr. Playfair has succeeded Dr. Priestley

as professor of Midwifery and physician-accoucheur. The

post of assistant-physician-accoucheur is not yet filled up.Dr. Ferrier has succeeded Dr. Guy as professor of ForensicMedicine, the latter retaining the professorship of Hygiene.Dr. Urban Pritchard has been appointed demonstrator ofPractical Physiology in the place of Dr. Ferrier.No changes have been made at the London Ho’pital.At St. Mary’s Dr. Shepherd has succeeded Dr. Nunneley

as assistant-physician, and Dr. Wiltshire has been appointedassistant-physician-a,ccoucheur.At Middlesex Dr. Robert Liveing has succeeded Dr. Good-

fellow as physician. Dr. King has been appointed assist-ant-physician, and Mr. H. Morris, and Alr. A. Clark assist-ant-surgeons. Dr. Thorowgood has become lecturer onMateria Medica, and Mr. H. Morris joint-lecturer onAnatomy.At St. Thomas’s the only alteration made is, that Dr.

Pollard and Dr. Saunders have been appointed respectivelymedical and surgical registrars.At University College Dr. John Williams has been appointed,

assistant-physician-accoucheur.At Westminster Dr. AUchin has been appointed to the-

chair of Practical Physiology, and Dr. Sutherland to thatof Psychological Medicine, and Mr. Ramsay has been madeone of the demonstrators of Anatomy.

SESSION 1872-73.

RECOMMENDATIONS AND REGULATIONSOF THE

GENERAL COUNCIL OF MEDICAL EDUCATIONAND REGISTRATION.

Preliminary Eaeamination.-Tbat testimonials of proficiencygranted by the following educational bodies be accepted :-Oxford University: Examination for a degree in Arts; Responsions;Moderations; Local Examinations (senior), certificate to include Latinand Mathcrnaties.

Cambridge University: Examination for a degree in Arts; Previous Ex-amination ; Local Examinations (senior), certificate to include Latinand Mathematics.

Durham University: Examination for a degree in Arts; Examination fort’tudens in their second and first years; Rc"dstration Examination forMedical Students; Local Examinations (senior), certificate to includeLatin and Mathematics.

Loudon University: Examination for a degree in Arts; MatriculationExamination.

Universities of Aberdeen, Edinburgh, Glasgow, and St. Andrews: Exami-nation for a degree m Arts; Preliminary Examination for graduationin Medicine or Surgery.