“The Trent and I go wandering by”

Robert George Hogarth


Contents

Aged 80, Robert George Hogarth, 1948

PRESIDENTIAL ADDRESS

BY


ROBERT GEORGE HOGARTH

AS PRESIDENT OF THE BRITISH MEDICAL ASSOCIATION,

AT THEIR 94th ANNUAL MEETING IN NOTTINGHAM,

“JULY 1926”


The Medical Practitioner and the Public


My first duty tonight is strictly personal. It is to express my heartfelt appreciation of the great honour conferred on me. To be President of the British Medical Association is - I hope I speak without bias - to be President of the finest professional association in the world. I can truthfully add that no one in the fast lengthening line of my predecessors in office has entered upon the duties of the Presidency with a greater realization of his own inadequacy to fulfill them as they might be fulfilled, or with a more earnest desire to bring to such fulfillment the very utmost of which he is capable


The Nottingham Meeting of 1892


May I next remind you of the Association’s last visit to Nottingham in 1892 - more than thirty years ago? That was before I came to Nottingham, and certainly had no visions or premonitions that the next time the Association met here I should occupy this exalted position. What made that Nottingham meeting memorable was then, for the first time, the Association, by its vote , admitted women to its full membership. I will not rake over the cold ashes of that dead controversy except to say that no one, as far as I know, regrets that decision today, or if he regrets it, deems it expedient to say so, or wishes that it had been postponed. The wonder now is rather that the prejudice - for time has proved that it was only prejudice - lasted so long.


There is now no degree or diploma, no office, no honour, no post in the medical profession (at any rate on the civil side) which is not open equally to women as to men, and I shall be well satisfied if, in the years to come, the present Nottingham meeting of the Association has as good cause to be remembered with honor and with gratitude, either for some signal reform or some wise and judicious decision, as was the earlier meeting in 1892


Nottingham and its Surroundings


The abundant literature about Nottingham which all of you have doubtless received makes it quite unnecessary for me to sing the praise of a city which has a glorious past, both in fact and legend, a prosperous present, and a future bright with hope. You will be able to judge for yourselves whether the report speaks in terms too flattering or in terms not flattering enough of Nottingham’s varied charms. All I wish to say is that the local members of the Association are immensely proud of the visit of their colleagues from all parts of the Empire, and are deeply grateful to the civic authorities, and indeed to all who have collaborated so generously in the preparatory work necessary to make the visit a success


We who practice our profession in this yet modern city by the Trent invariably find all classes of the population singularly responsive to the many and recurrent humanitarian claims of her medical institutions. You will see the evidence of that in many a fine building, and in none displayed more nobly than in the magnificent Home to Nurses , which is built on the very spot where Charles I raised his standard at the opening of the Civil War. The city which chose that home for a war memorial will be proud to show her famed hospitality to those who practice medicine.


The March of Medical Science


The decrease in the general rate of mortality is one of the most striking proofs of the rapid forward march of medical science. It has fallen by nearly one half in fifty years. Had the birth rate been maintained the Malthusian doctrine would have enjoyed a new lease of life, and we should now be talking in awed tones of the ‘hungry generations’ treading us down. But it has fallen by a larger proportion in the same period, and the net increase is because of the longer life.


It is a great triumph that a large percentage of humanity can now so far outrange the Psalmist’s three score years and ten, and, instead of the added years entailing heaviness and sorrow, can still enjoy the pleasures of a discreetly ordered table and the beneficent exercise of the veteran’s game at golf. By taking thought and following advice we can lengthen out the measure of our days and look forward with some confidence to a green old age. This prolongation of life - active of course I mean, though the pace may slacken - is, I say, a great achievement in itself, especially if we agree with Scipio’s reason for regretting that so few attained old age - namely, that if more attained it life would be lived in better and in wiser fashion.


Yet is there not a real danger of attaching too much importance to the triumphant statistics of mortality without due consideration of their actual content? Mere prolongation of life is of little good in itself, either to the individual or the nation, unless there is a real capacity to enjoy it. All medical men meet with cases where the efforts made to prolong the life of a patient who is far past effective help hardly seems a kindness to the sufferer and often bring those about him to the breaking point. Far more desirable than to make a brave show in the statistical tables and increase the number of nonagenarians and centenarians is to raise the general standard of health among all ages of the community.


The Practitioner’s Duty to the State


Let us look at this question from the point of view of the State, since our duty to the State, according to some people, seems to be reckoned higher than our duty to ourselves. During the war public opinion was shocked to discover that the C3 category was so large in comparison not with A1, but with the B’s and even with the C’s. But it did not surprise the doctors, who knew the long catalogue of disabling ailments which afflict the general mass of the people.


The first sets of figures published by those who medically examined school children in the elementary schools had already given clear warning. If such distressing percentages prevailed among the children between the ages of 5 and 15, what was to be expected when they grew to manhood? Moreover, a swollen C3 category of men between 18 and 45 necessarily means a still larger percentage of the same category between 45 and 65, after which year, presumably, very few of these damaged people contrive to earn a livelihood. What is true of the men applies no less to the women, and so we have throughout the country an enormous mass of bruised and damaged humanity which never enjoys robust health, which is continually ailing, which provides a multitude of victims for every epidemic, and which, regarded from the purely economic standpoint, never approaches full industrial efficiency, because it is never fit and alert.


I would not paint the picture in too sombre colours. Most of the world’s work is routine work, which can be got through more or less satisfactorily at ordinary times, whether for the purpose of the military category, a man is classed C3 or B2. Nevertheless, the C3 man will be oftener on the sick list; he will make more mistakes; he will produce less; he will lose his job sooner; and at any moment of emergency he will be less trustworthy and reliable. His physical deficiencies will increase with the passing years; he will be less able to protect himself and his family; he is more likely to seek support or stimulant from alcohol and then begin to suffer from its cumulative effect. Would it not therefore be better for the State if we took pride, not in rewriting the tables of mortality, but in raising the C3 people to a higher category - not in view of distant military contingencies, but for the immediate purpose of rendering them more efficient citizens, more valuable producers of wealth, parents of a healthier stock, and themselves more contented with their lot?


If we regard the great pool of ill-health and the infinite variety of debilitating ailments, deep-seated and chronic, we are driven to the conclusion that physical inefficiency is at once the most permanent and fruitful cause of individual unhappiness and social discontent. Walt Whitman’s lines are worth recalling in this connection:-


   I think I could turn and live with animals,

   They are so placid and self-contained;

   I stand and look at them, long and long;

   They do not sweat and whine about their condition,

   They do not lie awake in the dark and cry for their sins,

   Not one is dissatisfied, not one is demented with the mania of owing,

   Not one is respectable or unhappy over the whole earth.


Humans are like animals at least in this, that if they are to be happy and contented they must either keep fit or be kept fit; and the honour of being considered the greatest benefactor to mankind belongs not, as is so often said, to him that can make two blades of grass grow where only one grew before, but to him who can add most to the science of health and raise the standard of fitness  throughout the whole community. Surely that would be of more instant value to the State that the preservation of infant life in the first year of existence and the indefinite prolongation of what used to be called the allotted span. If there be any who dislike such a comparison of human values, they may be reassured by the reflection that whatever measures are taken to raise the general standard of life can hardly fail to benefit the infant in the cradle and the aged patient in the Poor Law Infirmary.


The State and the Nation’s Health

  

If these considerations have weight, it must be one of the paramount duties of the State to concern itself more and more intimately with the health of the nation. It can do that by solicitude for those who are sick, and by taking whatever measures are possible to keep them from becoming sick. Its action, in a word, must be both curative and preventative. While the science of medicine was mainly empirical and the causes of disease were either unknown or wrongly attributed, preventative measures by the State were little thought of. Today a long series of Public Health Acts and the still recent creation of a Ministry of Health attest the full recognition and acceptance by the State and of the public authority to invade this particular domain is no longer challenged. It is seen to be for the common good that the sanitary and the factory inspector are armed with the sanction of the public authority; and as the ameliorative possibilities, latent in preventative measures, are better understood, there will be a growing impatience with the obstacles placed in the way of their effective exercise by selfish or interested parties.


The establishment of the Ministry of Health bore witness, not to the sudden discovery of a new truth, but to the proved results of much admirable work which had been done in the previous half century and the need of its more resolute prosecution. We are now accustomed to the blessings of a pure water supply and efficient systems of drainage and sewerage; we have grown intolerant of the most offensive features of a slum; we have a clearly defined standard of, say, the minimum hygienic requirements of a new house. Throughout the wide field of industrial hygiene we know what conditions are desirable and what are dangerous to health. Our knowledge is fairly complete; the practical difficulties are connected with administration - how to deal with the borderline cases, and how to make the best use of the money at disposal, for improvements are always costly and public expenditure can only be met either out of rates or out of taxes.


Public opinion has to be educated continuously all the time. For example, the compulsory notification of diseases is now extended far beyond its original scope to as many as twenty two notifiable diseases, and will probably be extended much further within the near future. The agitation when the National Health Insurance Act was being passed is now remembered with a smile for the broken vows that were registered never to lick Mr. Lloyd George’s new fangled stamps. But even the greatest changes are very soon accepted as if they had always been, provided that on the whole the new institution functions well and promotes, in spite of whatever defects, the general well being.


Preventative Legislation


The scope of preventative legislation is almost limitless, and we are likely to see the State interfering - or shall I say intervening? - more and more in the interests of public health. For example, all the Licensing Acts of the last half century are based in the last instance on the argument that stricter regulation is necessary for the general public health and safety, and it is obvious that that particular field of controversial legislation is by no means exhausted.


Moreover, the State is beginning to assert its regulative powers in departments of social and even of family life from which hitherto it has held aloof, and its justification will always be that the interests of public health override the personal interest of the individual, who, as a member of the community, does not and cannot act to himself alone. We may expect sharp controversy, for example, if and when the State concerns itself directly with eugenics, and asserts its solicitude for a generation not yet born, not by the provision of cradles and nurseries, but even by the very determination of parentage itself. This might have seemed fantastic a few years ago. But now that the idol of state socialism has been set up for our worship we may be sure that sooner or later the theorists will attempt to invest the Ministry of Health with increasingly autocratic powers, and will seek to transform the whole medical service of this country into a State service, with State hospitals, State examinations for degrees, and the state payment of doctors. This would be a perfectly logical development in a socialist State, nor can it be pretended that such a system could not be worked. But whether it would be as efficient as our present system, whether it would be as acceptable to the general body of the people, and whether the vastly increased cost would be repaid by equivalent advancement of a medical knowledge or improvement in the public health, there is room for the very greatest doubts.


Doctor and Patient


The patient’s right to chose his medical advisor - which right is indispensable to the creation of the perfect relationship between them - has contributed largely to the smooth working of the National Health Insurance Act. There are roughly thirteen million insured persons rather than thirteen million medical practitioners on the panels. These are not, as some ill-informed critics of the service would seem to assume, a separate and inferior class of men. They are in every sense of the word general practitioners, and the service they give is a general practitioner’s service.


To each patient on his list the insurance practitioner accepts the relationship of a family doctor, just as he would do if he were called in by a private patient. He gives to each the skill and attention within his power, and he gives them, as a rule, cheerfully and willingly, as he has contracted to do. One sometimes hears general complaints of too rapid and casual diagnosis; but when the waiting room is full the same complaints are not wholly unheard even in the most august thoroughfares of the London specialists. The true test of value of the service given is to be found in the fact that in 1924 only 404 complaints were received by Insurance Companies and investigated by their expert sub-committees, and in only four cases did the more serious charges result in the removal of the practitioners’ names from the Medical List.


It is likely that a better service would be provided if each insurance practitioner were selected for inclusion in the list by some official of the Ministry of Health, and if he were required to give even more detailed and minute account of his practice and submit still more voluminous reports. The panel would still be composed of exactly the same people, and even if the allotted quota of patients were reduced, is it at all certain that the individual patient would receive a greater share of the doctors attention?


We know what happens in all State services. The red tape machine would soon be started; more and more reports would be called for; the doctor might see fewer patients but the volume of his activities would be in no wise lessened; and the cost of the service to the taxpayer would be enormously increased. You will not make the panel doctor a better doctor by making him more of a civil servant and less of a doctor; nor will you make the thirteen million patients more contented with their treatment.


The reform that is most required in connection with the insurance service is one which shall link up the insurance practitioner with the consultant physician and the consultant surgeon, and give the insured patient the benefit of the profession’s specialized, as well as of its general knowledge.


The Voluntary Hospitals


Nowhere is the principle of voluntaryism so well worth maintaining as in connection with the hospitals; nowhere has it been so triumphantly maintained. It is sometimes suggested that the chief virtue of voluntary agencies is to do the rough pioneer work in difficult and intractable places, to create a favourable public opinion, and then, in due process of time, to hand control to some department of State which will carry on the work upon an altogether larger scale. Indeed, I have seen it stated that voluntaryists ought to be proud to merge their small individualities into the larger being of a public department and lose themselves like rivers in the sea. But the enthusiastic friends of the voluntary hospitals are human beings, not mere charitable machines which function altruistically because their well disciplined hearts happen to be set that way. They are proud of their work. They love it. They see results which encourage and inspire them. They do not want to sink themselves, but to express themselves. The gratitude of those who are healed is sweet to their ears. Voluntaryism is the very life and soul of the whole hospital movement.


It is not suggested that the hospitals would wither if the voluntary principle were abandoned. They would still multiply and prosper. Their orderly routines might well show an even more brilliant imposing efficiency. But the rules and regulations would lengthen. The spirit of institution would suffer change and lose something - I fear much - of its geniality and kindliness. Why is it that such a difference exists today between the voluntary hospital and the Poor Law Infirmary, which is often better constructed and much better equipped? If you ask a patient to which he would rather be sent, why does he always say the hospital? To some extent the old hard, unforgettable associations and traditions of the Poor Law still chill the heart. But that is not the whole truth. There is something inherent in officialdom which freezes the genial application of whatever new principles of kindliness and mercy it can never be thawed right out.


Hospitals and the State


Other countries have their State hospitals services. Some of you may remember that certain British delegates who visited the show hospital of the Medical State Services of Soviet Russia were enormously impressed by the freshwater tank in which they saw the live fish they counted, whether so much as the heads and tails reached the patients in the wards, and whether even this agreeable luxury was much compensation for the complete inadequacy of that particular State medical service to cope with a hundredth part of a 1 per cent of the disease and suffering in Russia.


Let us stand by the principle of voluntaryism in the hospitals at whatever cost of energy and patience required for their adequate provision and efficient maintenance. I need not remind this audience that it will take a vast and sustained effort to provide 10,000 additional beds which the Voluntary Hospitals Commission has declared to be necessary. For that effort the friends of the hospitals will soon have to brace themselves, There is to be no financial assistance from the State. The Minister of Health last February very reluctantly came to the conclusion that no subvention was possible, at any rate at the moment, and so the hope that the Government might repeat its unconditional grant of half a million to the hospitals after the war, in recognition of their invaluable war work and of the utter impossibility during the war period of keeping abreast of their requirements, has been cast to the ground.


Unless this second grant had been as unconditional as the first, I do not know that I am altogether sorry at the Government's decision.  If the Ministry had begun to impose conditions of control it might well have marked the beginning of the end of the voluntary system I contend that the work done by the hospitals is of such inestimable value, and the confidence placed in them by the public is so well justified, that the State, if it makes any subvention at all should do so without restrictions, knowing that the money will be judiciously expended. The hospitals should beware of even the mildest beginnings of State control and the relentless, however friendly, grip of any State department.


However, as there is to be no grant these particular anxieties do not arise, and the supporters of the hospitals must shoulder their burden. So large a sum as four or five millions for new capital expenditure will take a very considerable time to raise  for, over and above all this, the maintenance cost has to be found for each new bed provided, and this means an additional recurrent annual cost of £148 per bed. Many of us were disappointed that once again the Chancellor of the Exchequer in the last Budget failed to exempt bequests to hospitals from liability to legacy duty. That is claimed as an act rather of justice than of grace. The toll taken by the State is an interception of charity which is repugnant to good feeling and a sense of fair play to the suffering.


The hospitals, of course, in their turn, owe to their generous supporters the duty of sound economic management, which in turn depends primarily upon the choice of governors. Those which show the best financial balance sheets usually have upon their board of management some outstanding figure of marked ability who has made the local hospital his hobby, his interest, his care, and his pride. However that may be, there must be the undoubted assurance of economic and prudent management if the full support of the public is to be continued. It may well be that a closer co-operation between hospitals - large and small, general and special - is possible and desirable, and that considerable economies might be effected without infringing the real autonomy of each institution, which is so properly and jealously guarded. Charitable effort in this country has always been specially subject to the besetting sin of overlapping and wasteful management. Voluntaryists must be ready to face a searching  criticism of their accounts by business men whom, if they are wise, they will invite and welcome to their councils.


Changing Type of  Hospital Patient


Again, we must not shut our eyes to the rapidly changing character of the personnel of hospital patients. The hospital is no longer the lazar-house of the destitute, the place to which homeless and plague-stricken outcasts crawled to die, or into which they were herded if they seemed too noisome and dangerous to be tolerated at large. Such it was in medieval times;  then came the period, which lasted more or less down to our own day, when the hospital was still exclusively used by such as were too poor to pay for the ministrations of a doctor. Some people still hold that this should be the fundamental function of any hospital which is supported by public subscriptions, and I agree that this primary purpose for which hospitals exist - namely that of taking in and caring for the indigent poor must in no way be shelved or neglected. But we have advanced far beyond that simple conception in these days, and we shall advance much further still, if only because the hospitals, from being mere infirmaries, have become the centres of the best medical and surgical skill in the areas they serve. The best nursing, the latest scientific apparatus, all are concentrated there for the service of the poor, and while the rich and the well-to-do can look after themselves, there remain large intermediary classes of the population who are cut off from the best skill because, on the one hand, they cannot afford the fees, and, on the other, they are not of the class for which the hospitals were intended.  If that were pressed it would indeed be intolerable, especially in view of the increasing expansiveness of any serious operation or illness, the cost of nursing homes, and the palpable unfairness of leaving out in the cold the great body of the middle classes, whose financial betterment has by no means kept pace with that of the superior artisan class, and who have been in the past, according to their means, good and loyal friends of the hospitals.


WARDS FOR PAYING PATIENTS.


It is certain, therefore, in my opinion, that we shall see a steady extension of the principle of the paying ward, and even of the paying hospital, for the use of the patient who pays in accordance with his means.  In many hospitals today all but the very poorest patients are expected to contribute to the cost of their healing, and there is little need to lament the disappearance of the old principle that the hospitals were absolutely free - a principle which, in fact, was often grossly abused.


The interests of the middle classes deserve attention no less than those of any other class. May we not, therefore, look forward to a time when every general hospital will be well equipped with paying wards, or will have a paying hospital in association with it, served by the same staff and the same nurses? A middle-class patient who is a suitable hospital case could be seen by the almoner of the hospital, and, after stating his income and position, terms could be arranged according to means. Naturally that will open up the question of fees for the surgeon or the physician, and some obvious and possibly difficult adjustments would have to be made  but no vital principle that I can see would be endangered by the payment of these special fees, or even by the hospital itself making a substantial profit on such cases which would help towards the maintenance of more beds in the non-paying wards. Such changes are likely to be gradual;  we can carefully note what effect, if any, they have upon the flow of subscriptions. Personally, I do not think that the charitable donor is likely to object to a middle-class paying patient receiving a share of the fruits of his bounty.  He had a much more valid grievance against those who abused the freedom of the hospital and never contributed a penny to its funds.


The medical profession is generous in accommodating its fees according to the patient's income. But every medical man knows cases where the serious illness of the breadwinner or the wife or child has exhausted the saving of a middle-class home or crippled it with a load of debt. The middle-class patient, moreover, is the principal sufferer from the high fees of the nursing home, another institution which has a necessary place in our existing system for dealing with the cure of disease, but which is by no means immune from well justified criticism.  Is it, indeed, too much to say that the extreme expensiveness of nursing homes - I speak, of course, in purely general terms - is contributing as much as anything else to the extension of the system of paying wards in hospitals and the call for its rapid development?


Working Class Contributions To Hospital


There is also another important development in process with regard to the hospitals. More and more in the large cities and industrial areas the hospitals are coming to rely upon the subscriptions of the working classes, contributing through a general Hospital Sunday collection or through a direct trade union levy.  In this district, for example, the Hospital Saturday Committee are very good friends of the hospitals, contributing willingly, cheerfully, and without condition or stipulation as to the hospital service for their members they will receive in return. This trust is not misplaced. They lose nothing by not dealing in terms of contract and demanding the strict recognition of a right.


Many county hospitals are stimulating interest in their work by forming a collecting committee in every village and persuading the cottages to subscribe to its funds, almost in the same way that they subscribe to a sick or benefit club. This will necessarily lead to a great extension of the hospitals, for those who pay will expect to receive hospital treatment as a right in case of serious illness. When the small contributor begins to talk about our hospital,' the vitalizing spirit of voluntaryism is at work. Open the door to State direction and control and the cold east wind of officialism will contrive an entrance too.


The General Medical Council


Another aspect of the relationship of the medical profession to the public has been much discussed of late in connection with certain punitive actions taken by the General Medical Council. This discussion has removed many misconceptions as to the specific purposes for which the Council was created by the legislature - not, as was too often supposed, to serve as the executive of a powerful professional organization protecting the interests of its members, but as a body entrusted with powers, clearly defined first by Parliament and later by the judges, for the protection of the public against the incompetence and the imposture of unqualified medical practitioners. Practically the only criticism directed against the Council arises from the fidelity with which, in these days of growing laxity, it has maintained its jealous regard for the purity of its register of membership. There are really two main questions in which the lay public is interested. The first is: Is it or is it not to the public advantage that the General Medical Council should set its face like flint against  professional self-advertisement?   The second is: Is it or is it not to the public advantage that the Council should show a less uncompromising attitude towards the unqualified practitioner and a greater leniency towards those who transgress its stringent rule against covering?


The rule against professional self-advertisement is unquestionably in the public interest. The publicity agents of the commercial world may sound their slogan as they will about ' Truth in advertising.'  But, as Dr. Johnson once shrewdly observed, the secret of advertising is' large promise; ' and large, limitless, boundless promise is wholly out of place in the practice of the medical art.  Inseparable from quackery, it is the sign manual of the unqualified nostrum-monger.  In my view, this most salutary rule against professional self-advertisement needs to be observed more than ever now that the old reticences are being broken down in so many directions, and in view of the growing disposition to discuss all medical subjects freely in the public press.


Whether we like it or not, that school of thought is prevailing which holds that the open forum is the best of all popular educators, that ignorance is the greatest of all dangers, and that publicity alone can create the new public opinion out of which it is hoped there may issue a higher moral sense and a stronger self-control. The public press will devote more and more space to the problems of public health, and it is obviously desirable that what is written should be written with authority. No anonymous article on a technical or professional subject carries the weight of the signed contribution, and if doctors write for the lay press, as they will be urged to do with an ever-increasing insistence, the opportunities of professional self-advertisement will greatly multiply.


Nevertheless, it is to the common interest of the profession and of the public that these temptations - not, indeed, to inform the public of what is for its good, but to inform it in such a way as to advertise and glorify the writer and conduce to his personal gain - shall be resisted, and that the Medical Council shall still continue to exercise its powerful restraints  In other countries a different practice may be followed, but till it is shown that their method is more conducive than ours, either to the dignity and character of the profession or to the protection of the public from the charlatan and the quack, these restraints should not be weakened. Many borderline cases are bound to occur as they do at present, but I assume that the Council will continue to act with that judicial discretion which has on several occasions received the acknowledgment of the highest legal authorities.


Unqualified Practitioners


As for the unqualified practitioner, I say without hesitation that the Medical Council cannot and must not recognize him, and therefore cannot and must not abate its strong reprobation of covering. To do so would be to stultify itself and the Register, which is its special creation and instrument.  It cannot, to borrow an expression from another profession, recognize any orders but its own. I do not mean that it should seek to induce the State, as is done in some countries, to make unqualified practice illegal. Even if that were desirable, the public would not permit it. Public opinion, if I may say so, has a sporting fancy for the outsider, and outsiders, even the rankest, do sometimes win. But, though rare and exceptional cases may arise, the Council cannot extend either the bow of friendship or the nod of recognition to any unqualified practitioner without placing itself in a false position.  If an unqualified practitioner really discovers a new cure or treatment for one of the ills of humanity, his consulting room will not long remain empty of patients.  If his method is genuine it will endure, and, soon or late, it will win general recognition. But no one can reasonably expect admission to the Medical Register -  or to any appendix thereto - by any except the approved channels.


Admission is not a question of initiation and secret rite. It is a plain question whether the entrant has gone through certain courses of medical training and passed the presented examinations. How can either be abandoned with safety to the public interest? The unqualified practitioner may or may not have sufficient general medical knowledge to enable him to make a diagnosis. A few may have gone through some sort of a medical course; the majority have not. It takes the ordinary medical man five years or more to complete his course; the unqualified man often does not give as many months. He professes to be a specialist without even elementary grounding in the essential rudiments of medical knowledge.  I say nothing against the science of osteopathy or these uses of the manipulative treatment.  I only say that those who practice these arts should have the medical knowledge without which they may do their patients infinite harm.

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The champions of the unqualified practitioner fall into two main classes. One consists of those good people, invincibly credulous and optimistic by nature, who chatter about cures and treatment as others chatter about politics, and on whose ears well-syllabled words like ''osteopathy' and  manipulation' fall with a sweetly modulated cadence of solace and hope. The other class consists of the ingenious rebels against all authority but their own, the sophists of the day, who deride professional etiquette and grimace at professional tradition. Perhaps here and there certain solemn pomposity's do linger even yet in our profession, and an occasional grin at these may do no harm; but the health of the public is no grinning matter. The plain truth remains that behind the rare - the very rare - unqualified practitioners of whose success so much is made, but whose failures pass unrecorded, there are scores of other practitioners of technique ancient and modern, Chaldean and transatlantic, who are eager to take advantage of any momentary opening of the door, which it is the declared policy of the General Medical Council to keep tightly shut.


A selfish obscurantist policy would he totally contrary to the free spirit of Inquiry which animates the medical science of today. But this is neither selfish nor obscurantist. Whatever in any modern technique is tested and proved good is sure of eventual adoption and not even the gates of the General Medical Council will prevail against it. But the tests and the proofs must be such as are recognized by that universal medical science which talks a common language throughout the world and which alone can securely judge.


The public mind was perhaps never more impatient of authority than it is today. Unable to distinguish with certainty where the trained expert alone has any claim to be heard, multitudes of people are still prepared to accept offhand the morning and the evening stunt of their favourite newspapers, which are then forgotten as soon as read. So many romantic impossibilities of yesterday have become the casual scientific commonplaces of today that the very word 'miracle ' itself has shrunk back to its original connotation, and even the wisest have still no effective retort to Hamlet's gibe as to the inadequacy of their philosophy to embrace the content of heaven and earth. Nevertheless Authority remains unshaken on her intellectual throne, though the gusts of change may a little disorder her raiment, and Authority herself acquires a riper wisdom and a larger experience with the passage of the years.


The medical profession is a living profession. It is forever breaking new ground, mapping and charting as it goes, and the necessary correction of a too hasty observation or faulty induction, as well as the need to include new knowledge, requires us from time to time to revise our atlases. And though we may be fairly confident that the older continents are now accurately charted, there is always the need to be prepared for the crash of old-established notions and for restless movements of insurgence along boundaries which once appeared to have been fixed for all time.


It is a sobering reflection that, but for the violent wrench out of its true direction which medical science suffered two thousand years ago, some of our most recent discoveries might well have been among the oldest blessings to suffering humanity. With the abandonment of the one true scientific method of patient observation and careful induction there was also unhappily discarded that sagest of all the medical maxims of ancient Hellas, that the physician is the servant of Nature.


The human race has suffered sorely because medical art and science took so tragically wrong a turning, after making so brilliant a start. Probably the perversity of the patient was largely responsible. Popular demand has always been insistent for the bottle of medicine and the charm. Science, under the lead of Aristotle, had sought to exorcise the potion-monger and the thaumaturgist, but back they came with a rush, and when the ancient scientist candidly admitted that he was uncertain as to the nature or the cure of the complaint the patient soon betook himself to one who promised a safe, quick and pleasant cure.


The great truth that the supernatural and the scientific do not run well in double harness need, I believe, a resonant restatement today. The profession is often blamed for its instinctive repugnance to the introduction of the supernatural into the art of healing. This is attributed to that professional jealousy which is supposed to seize every doctor when an unregistered hand assumes the gold-headed cane which is the symbol of his craft. I do not know that there is more professional jealousy among doctors than there is among lawyers; I doubt if there is as much as among plumbers and bricklayers.


No professional body loves an outsider who usurps its own particular functions, and long experience has shown that the unqualified practitioner of medicine is in double measure an unqualified danger to the public. And yet how clients troop to his door or rain in upon him a shower of post-office orders if he is a shrewd exploiter at once of the foibles and the earnest longings of mankind. So it has ever been; so it will ever be. As the cynic long ago said: ”If the public want to be deceived, let them.” But the obvious fact is that the public want not to be deceived but to be cured, and that is why, if an authorized prescription in our cryptic Latin fails to bring relief, they will cheerfully take a free medical tip in plain English from their Sunday paper’s answers to correspondents, or accept as gospel the large promise of displayed advertisement; or if they are of a more serious and contemplative type, they will haunt the temples of those who say that they possess the secret of permanent good health.


The Religious Healer


With respect to the religious and quasi-religious healer, the medical profession is in a difficult position. It is precluded by the memory of its own empirical past from adorning its robes with the fragile fringes of infallibility. Dedicated to Science and conscious of boundless horizons still beyond its ken, whatever face the profession may present to the outer world, it must display in the intimate presence of Truth the modesty of the neophyte. Nor can it refuse to acknowledge the sincerity of other searchers after truth traveling upon roads other than that on which its own feet are set. Nevertheless, the profession owes to itself and to the public the duty of speaking out.


There is no difficulty, of course, in dealing with the vulgar quack who sells a bottled panacea to the joint benefit of himself and the Inland Revenue, and who leaves the deluded purchaser, if he be lucky, much the same as he was before. But obvious difficulty arises when a new theory and practice of the art of healing is proclaimed and health is taught in terms of religion, and religion in terms of health. In that company the medical scientist has no place. His facts are not theirs. Their terminology is not his. There is no meeting ground in common. He knows what he understands by science; he does not know what they mean. Even if he were willing to join the new cult, its complete refusal to recognize the need of a medical art, such as that which he practices, must effectually keep the door of communication closed. Science has long since framed her own laws of method and proof which are recognized throughout the world, and the medical profession can have no commerce with any newly organized cult which denies the very bases on which these laws are founded.


But this is not to say that no friendly cooperation is possible between doctors and those who are earnestly studying the healing power of the mind. Let there be no contention about names; when we speak of mind or soul, let us freely admit that we cannot take a specimen of either on a slide and put it under a microscope. That there is a certain healing power, a true vis medicatrix, in religion as in nature, few careful observers would, I think, deny. Between religion and nature, between mind and body, there exists not an opposition but a relation. Every medical man of experience must have known cases in which his own scientific skill has seemed to be helped, sometimes most strangely and wonderfully, by some serenity of mind in the patient, some quiet confidence in the ultimate issue, some realization of sure dependence upon a higher power, some tranquilizing influence of the soul upon the physical stress and tumult of the senses-beneficent, soothing, healing activities in which he and his craft have had little or no share.


These facts are not reducible to formulae. Science cannot explain them as she can explain the operation of an anodyne stealing along the passage ways of sense. We do not, indeed, know very much about that mysterious parallel road, which always lies in deep shadow, where the mind or the soul, reacting to a spirit which seems to come from without, influences profoundly in its turn the body which the doctor is trying to heal. There is no place in respect of this region for dogmatic utterance; but there is always room for patient and reverent inquiry. The whole of our profession will await with impartial mind the result of the labours of the joint committee which was appointed some months ago to investigate the phenomena of what is generally called spiritual healing.


Meanwhile, I say with confidence that any systematized creed which professes to dispense with the art of medicine and surgery is false to the Divine. But if any possess the precious gift of ministering to the mind diseased or of imparting to those who walk in the shadow of the valley the courage to move serenely among the phantoms and terrors which haunt that road, let us be sure that so divine a gift can only emanate from a divine source, and let us welcome the help of any unseen wings that stir the air with healing.


In such moments the old tradition is confirmed that the doctor stands in a different relation to his fellow from most other professional men.  I do not claim that the doctor consciously lives, like the priest, what is called a dedicated life - though I have known men to whom that noble phrase might well be applied - but there Is a special nexus between doctor and patient which is independent of, as it is unpurchased by, the fee which passes between them. The public expect much of the doctor and take much for granted.  I like that old story of the woman of Selkirk who, observing her doctor ride by, said to the neighbour with whom she was gossiping, "Aye, there goes the doctor - honest man! He's brought all my ten bairns into the world and never got a rap for one of them."


The national health insurance scheme has at any rate checked the more unconscionable draughts which once used to be made upon the deep well of medical disinterestedness, but the profession still gives much for which it receives no direct return but gratitude, and sometimes even that is left unspoken. That, however, is the penalty of altruism and an established reputation for kindness of heart, and that is partly why the doctor holds his place in the public esteem, despite the satirists, the playwrights, and the novelists who still delight to poke their fun - on the whole not unfriendly - at his etiquette, his bedside manner, his scraps of weird Latinity, and the artifice with which the wild surmise of an impossible diagnosis may still be masked under the grave, slow smile of apparently assumed certainty.


The Real Doctor


But if you want the portrait of the real doctor we go, not to books, but to life. We expect him, not in vain, to combine with knowledge the understanding that springs from intuition till it is most richly reinforced by experience to bear a tranquilizing influence, and to radiate confidence and hope. We expect him to exemplify, like the surgeon of whom Henley wrote:-


 Faultless patience and unyielding will,

    Beautiful gentleness and splendid skill."


caring always for life as a thing most precious, quick-and now happily well able - to spare the sufferer one unnecessary pang, the restorer of health a strong sure help in the more supreme moments:-


  “In many a house of care, when pain has forced a footing there,

  And there's a Darkness on the stair will not be turned away."


Such is the doctor, the family doctor, who is more to the public at large than the most learned and the most wise who dwell in those two long, unlovely, parallel streets of London, where the waters of healing are laid on at the main. He is still the same, even though he is called upon in these days to enter the service - the preventive service - of the Ministry of Health, disarming disease before it strikes, saving the firstborn, not by a smear of blood on the lintel, but by a dash of disinfectant in the drain, and sometimes purchasing the immunity of millions as cheaply as the restoration of a few convalescents to health. The doctor's professional qualifications may change as medical science advances; the qualifications he needs to win him the confidence of his fellows are unchangeable as human nature itself. That confidence it is the policy of this great Association and the desire of every one of its members always to deserve and for ever to retain.


RETURN

The Trent and I go wandering by