[BILL 40.] SECOND READING. (Hansard, 30 March 1870)

§ SIR JOHN GRAY
, in rising to move that the Bill be now read a second time, said, its principal object was to amend the Act of 1858, the Preamble of which stated that the main object of the measure was— To enable persons requiring medical aid to distinguish between qualified and unqualified medical practitioners. That Act had grievously failed in effecting its purpose, owing to the existing system of licensing medical practioners. There wore at present nineteen licensing bodies, each empowered to grant medical degrees, exclusive of the degree conferred by the Archbishop of Canterbury, which made the twentieth. The result was that, armed with a bit of parchment, given rather in consideration of so many pounds sterling than of any real qualification in the possessor of it, a man utterly ignorant of his profession might obtain a licence to practice. The object of the Bill he introduced was to insure, in the interest of the public, that no person 963 could receive a licence to practise who had not previously demonstrated to a Board of examiners, not interested in the fees to be paid, that he was practically acquainted with the duties of the profession. The Bill proposed a reconstruction of the Medical Council, giving a representation in it to the profession at large, instead of a mere representation of the licensing bodies, and that members appointed by the Privy Council should have seats in it. The presence in the Council and on the examining Board, but especially on the latter, of skilled men representing and responsible to the public, would have a most salutary influence, and would help very materially to carry out the main object of the Bill—the protecting of the public from licensed ignorance. At present, a complaint was generally made, both in England and in Ireland, that if a man failed to pass the examination at one College he went to another where the examination was easier; and that the licensing bodies competed which should grant the largest number of licences, and, therefore, get the largest amount of fees, instead of competing in raising the standard of knowledge. Memorials had been presented to the Secretary of State for the Home Department and to the Medical Council, signed by 9,600 medical practitioners, some of great eminence, complaining of the want of representation of the profession at large upon the Council; that there was no proper system of admission and licensing; and that the public suffered much through the admission of persons who were not practically tested as to their knowledge of disease, as it presented itself not in books, but in the living subject. It was proposed by the Bill that, instead of allowing a man to be registered on presentation of his licence and the payment of £5, he should be practically examined at the bedside, in the dead-room, and in the laboratory; and the memorials he had referred to declared that proof ought to be given, by the adoption of a practical and high standard of examination, that the applicant for the licence really possessed a competent, scientific, and practical knowledge of medicine and surgery. All the nineteen licensing bodies had different curricula; no two of them had the same system of education and of examination; they did not all require the same amount of attendance at hospital, where alone the symptoms of dis- 964 ease and the mode of curing disease could be learnt—some requiring twelve months, some eighteen and thirty-six months' attendance at hospital. But even attendance at hospital was little more than an unprofitable routine in the majority of instances. Men walked the hospital, but did not study disease, and its cure, or practice even the minor duties of dressing surgical injuries; for, until recently, none of the licensing bodies, when conferring degrees or licences, resorted to the practical test of bringing the candidate to the bedside and asking him to recognize and explain the disease. He was glad to recognize that many of the licensing bodies had lately adopted the bedside test of a candidate's knowledge, notably the University of London. The University of Dublin, in a recent document issued by that body, declared that such a test was desirable and practicable, and the College of Surgeons in Dublin, in reply to the Medical Council, declared that the demonstrative examination was essential. A letter had recently been written by the noble Earl the President of the Council, in which he stated that no new legislation ont his subject could be permanent or satisfactory unless it promised to effect a considerable improvement in the existing system of licensing, and provided adequate and uniform security for the examination of candidates. He (Sir John Gray) admitted that, under the pressure of public opinion, some of the licensing bodies had lately substituted an improved and really practical examination for that which they before required. But, even now, a Dublin surgeon (Mr. Corley), a Fellow of the College, and a teacher of great eminence, wrote to him— I would undertake to pass any candidate of average ability through any of the Colleges which did not require a bedside examination in the space of, at most, six months, oven assuming complete ignorance at the commencement, and that the candidate never had the slightest opportunity of learning anything connected with the profession before. Having asked the President of the College of Surgeons in Dublin whether this could be true, the reply he received was— A man who never entered a hospital or dissecting room, who never held a lancet or a scalpel in his hand, could get a degree from any of the Colleges provided there was no bedside and demonstrative examination. 965 A young man might have gone through his whole three years' hospital course, and yet never have dressed a wound or done any practical work whatever. Since he last pressed this subject on the attention of the House at the close of last Session, he had, during the Recess, an opportunity afforded him, through the courtesy of the Secretary at War, of examining the system adopted by the Army Medical Board. At present no candidate for a medical commission in the Army would be received unless he could produce the two diplomas—one for medicine and one for surgery, and was subjected to a satisfactory test at the bedside. It was recently stated by Dr. Parkes that even of these candidates, doubly licensed and doubly examined though they were—in the course of five or six years no fewer, if his memory was right, than 165, with their double diploma, and some of them with four diplomas, had been rejected for utter incompetence. Some of these gentlemen, when tested, could not recognize the commonest drugs. Some proposed a dose for a man that would kill ten men, and others a dose for a child that would kill a horse. The Army Medical Board felt that if they gave such persons in charge of a patient, the next prescription would probably be an order for a coffin. But so careful were the Army authorities that, notwithstanding the bedside test and the two diplomas, they required that the successful candidates should undergo six months of the most careful tutorial instruction in the Netley hospitals before being allowed to practise on Her Majesty's soldiers. He asked whether it was not absurd that a man who was rejected by the Army Medical Board for the most disgraceful blunders should be allowed, merely because he had purchased his two diplomas, to set up as a doctor and prescribe for the general public? A remarkable illustration of the value of the demonstrative examination recently came under his personal observation, which proved the necessity of its universal adoption, as a means of preventing ignorant men from obtaining licences to practice. In one of the most advanced of the Colleges, he was present at a test examination a few weeks since. The examination was one recently instituted, and was, in fact, a preliminary practical test of the surgical and manipulative skill applied in 966 the dead-room to candidates about to go in for the final licence examination. A young man was asked to describe the operation of trephining. He did so perfectly; Sir Astley Cooper, if he had been alive, could not have done it better. He was then asked to proceed to a table, and select the requisite instruments and appliances for performing the operation on a dead subject; and he was utterly unable to recognize whether the instrument was perfect, and in attempting to perform the operation with an instrument without the handle, he broke the instrument, and, no doubt, he would have done the same if he had been suddenly called on to perform it on a living subject. The examiner, when he saw the candidate take part only of the instrument from the box, with great tact and judgment asked several questions as to the condition of the trephine—asked if he had to travel six or eight miles to operate, would he feel sure of the instrument in its then condition; but he plainly never saw a trephine before, and but for this test, this man might have been licensed on his answering, and proved his ignorance on, perhaps, a valuable life in the hunting field. According to the admission of all the licensing bodies, there was now no sufficient test either of practical instruction or practical knowledge. The Royal College of Surgeons, Edinburgh, in their answer to the admirable letter of the Lord President of the Council, proposed to remedy this defect by obliging the student to spend three months in an hospital as a dresser; but what would be said of a mason or shoemaker who had spent only three months in learning his trade? Now, one of the provisions of the Bill introduced by his hon. Friend the Member for Liverpool (Mr. Graves) and himself, required that every student should be tested at the bedside, not only in the dispensary, where ordinary cases were received, but also in the hospital, where the cases were of a more serious character, and unless he satisfied the examiner that he was fit to be entrusted with the care of health and life, as demonstrated by his acquaintance with disease, he should not be allowed to pass. Another object of the Bill was that the public might have the security which would arise from the State being fully represented at every final examination. At present negotiations were going on between the various 967 licensing bodies, who were trying to have this State examination an ornamental adjunct rather than a reality. But if Parliament was going to deal with the profession it should reorganize it thoroughly. He was glad to see that the Lord President of the Council had already taken vigorous action, and he hoped that the Government would relieve private Members from the necessity of proposing legislation on this all-important subject. It was essential that the Government should be efficiently represented at the Council, and that candidates should satisfy the State examiner, as well as the examiners, representatives of the corporations, before licences to practise were granted to them. The profession itself, under the existing pressure, was anxious to organize itself, and to diminish the number of licensing bodies to something like five or six, or it might be three; but, whatever arrangements might be decided on, he hoped this one idea would pervade the whole, that whatever mode of access to the profession might be open to one man should be open to all, and that no second door should be open to any. If they made three, four, or five licensing bodies, all they would do would be to reduce the present absurd number of nineteen. Let their great object be to secure that whoever was certified to the public under the Seal of the State should be competent in every respect, and that there should be a uniform examination for all, whether they might be students of London, Edinburgh, or Dublin. The present system established high fees, not a high standard of knowledge. The interests of the public required the reverse of all this. The costs should be diminished, and the amount of skill increased. The fees for admission to the noblest of the professions should be sufficient merely to cover the cost to the public of a sufficiently stringent examination, and would not be a barrier to aspiring youth of limited means. He hoped the present high fees would be tolerated no longer, and that fees would be low, sufficient to pay expenses, but leaving no margin for the accumulation of wealth or the creation of sinecure offices. The profession should be open to all who possessed the requisite knowledge—even though their purses were not full—and those who entered it ought to have sufficient practical skill to enable them to do justice to 968 any case entrusted to their care. He begged to move that the Bill be now read a second time.

§ MR. GRAVES
, in seconding the Motion, said, that he did so in deference to a very general wish which had been expressed to him for a radical change in the condition of medical education in this country. The time had arrived when the profession in large non-metropolitan towns bike Liverpool and Manchester wore entitled to be directly represented upon the Medical Council. Last Session, in obedience to strong representations made to him by the community with which he was connected, he placed a Notice on the Paper with the view of calling attention to the constitution of the Council; but he was now prepared to adopt the Bill of the hon. Member (Sir John Gray), as affording a basis for a fair settlement of the question. A reference to the remarkable Petition signed by 10,000 medical men, which had recently been presented to the Secretary of State for the Home Department, was sufficient to show how much a change was needed. He wished to ask what became of the failures before the Army Medical Board to which his hon. Friend had referred. Were men who were held to be unfit to deal with the lives of Her Majesty's soldiers allowed, without further instruction, to go and practise on the civil portion of the community? The mere fact that such a possibility existed was enough to condemn the present system. As far as he understood, what was needed was that no one should be allowed to practise the profession of medicine who was not found to be perfectly competent to discharge all its duties. The Bill proposed to utilize the existing corporations. The competition had hitherto been downward; this Bill aimed at making it an upward competition. All the licentiates, when offering themselves for examination to the central Board, would be required to produce a certificate from some one of the existing corporations, and honour or discredit would redound to those bodies just as their pupils were found to be well-instructed or otherwise. If the same healthy rivalry could be brought about between these corporations as existed among our public schools, a valuable boon would be conferred on the profession and on the public. Another object which it 969 was desirable to attain was the opening to public competition of all the civil appointments of this country. Hitherto those appointments have been given by public patronage or personal influence. The Bill aimed at securing them for merit and capacity, and on this subject he could speak from personal experience. In Liverpool there was an important and increasingly useful medical school, and many of the young men who had passed a distinguished career in it had applied to him to give them assistance in placing their foot on the first rung of the ladder of life. To young men of this kind the throwing open of the medical appointments of the country would be an incentive of the highest kind. By raising the standard of medical education and by having one portal through which all should enter, this Bill would promote the interests of the public, as well as confer a great boon on the profession. He would conclude by apologizing for having taken up a subject outside those with which he was more particularly conversant.

§ MR. BRADY
moved the adjournment of the debate.

§ MR. W. E. FORSTER
said, he hoped his hon. Friend who introduced the Bill (Sir John Gray) would consent to the adjournment. Considering the lateness of the hour, it was advisable to adjourn the debate on this very important question. He thought the hon. Member would agree to this proposal when he stated that he was authorized to announce that his noble Friend Earl De Grey and Ripon intended, on behalf of the Government, to take an early opportunity of bringing forward a Bill in the other House, having for its object the amendment of the several Medical Acts. He thought the House would feel that, under such circumstances, it would be unfair to expect him to follow in detail the able speeches which had been made; and he had no doubt that hon. Members would prefer to postpone further discussion until they knew more of the Government measure.

§ SIR JOHN GRAY
said, he would at once accede to the proposition of his hon. Friend the Vice President of the Council. He would further add that he 970 should feel it to be his duty to withdraw his own Bill if the measure of the Government should be at all framed in the spirit of the letter recently written by the Lord President of the Council, which would enforce a uniform and practical test of knowledge, and leave the licence fee at a moderate figure.