No. 4388.

OCT. 5, 1907.

An AddressON

UNIVERSITY COLLEGE AND SOME POINTSIN MEDICAL EDUCATION.

Delivered at the Medical School of University CollegeHospital on Oct. 2nd, 1907,

BY SIR R. DOUGLAS POWELL, BART.,K.C.V.O., M.D. LOND., P.R.C.P. LOND.,

PHYSICIAN IN ORDINARY TO THE KING; CONSULTING PHYSICIAN TOTHE MIDDLESEX HOSPITAL, ETC.

after a few introductory remarks Sir R. Douglas Powellcontinued :]We meet for the tirst time in this magnificent building

and I do not know whom to congratulate most-the pro-fessors or the students-on its completeness. UniversityCollege Hospital and the University of London, of which itis a part, owe their deepest acknowledgments to Sir DonaldCurrie for the splendid and enlightened liberality with whichhe has built and partially endowed as an annex to the hos-pital this great school of medicine. And we must not forgetto recognise the thoughtful and efficient labours of the build-ing committee in formulating and supervising all the require-ments for teaching, laboratory, and research work. Let uspraise, too, the genius with which the architect has

grasped and carried out the wishes of the committeewithin the confines of a very handsome exterior. Butthere is another aspect in which this magnificent gift ofSir Donald Currie is an object-lesson to those whowill recognise it. We have over the way a great hospital, Igreat in its present and its past beneficence, great in itstraditional and its present teaching, which has been entirelyrebuilt and refitted within the past few years by the public-spirited munificence of the late Sir Blundell Maple. No stoneis left of the medical school which seemed so sufficient in mystudent days, but the traditional spirit which " age cannotwither nor custom stale dwells in the old place-a subtleenergy whose infinite variety meets the ever-changingrequirements of advancing science. There is no break withthe old days, only a growth and development which requirerefitments to accommodate them. There has been a tendencyof late to discourage the close connexion that has existedbetween hospitals and their medical schools, an attempt toalienate their sympathies and to regard their interests asdiverse. Sir Donald Currie, by his gift of this magnificentadjunct to University College Hospital, has pointed thelesson that a hospital without a medical school would be anemasculated institution, wanting in inspiration and cerebraldirection, and lacking the stimulus of youthful criticism andappreciation and ardent enthusiasm that it derives from astudent public-a mere infirmary into which the sick arereceived and well treated but without any lesson beinglearned from them for the benefit of others. With a medicalschool, on the other hand, it has life and virility, giving notonly the most enlightened treatment to those within its wallsbut shedding abroad, as from a fountain source, experienceand scientific methods which quicken the advance ofmedicine for the service of mankind. By this handsomeprovision of a new medical school incorporated with thehospital Sir Donald Currie has, I think, demonstrated hisappreciation of the unwisdom of any attempt to weaken thetie between hospitals and medical schools. It is at least amatter of congratulation to this hospital that the difficultquestion is for it thus wisely solved.With the opening of this hospital medical school Univer-

sity College takes part with King’s College in a new

departure in medical teaching which, whether for good orevil-and I believe it to be for good-will probably prove ofgreat and far-reaching importance to the medical educationof the future. It is the separation of the subjects of thesecond period of the students’ curriculum from those of thefirst which are relegated to the control of a collegiate ratherthan a strictly medical council. The separation will be lessfelt here from the proximity of the two institutions, althoughthe principle is the same. The strictly professional subjectsof pathology, bacteriology, medicine, surgery, gynaecology,and therapeutics will be taught here as heretofore by themembers of the hospital staff, with such expert help as theymay require to students in active touch with hosDital work.

- w

And this building is magnificently equipped for the purposewith laboratories and lecture rooms, library, museums,reading rooms, recreation rooms, refectory, and all thingsneedful.

It will be noted on going through the rooms of this buildingdesigned for the different departments of medicine, surgery,and research that another phase in development in modernteaching has been taken into account-viz., the substitution,so far as possible, of working demonstrational courses for theabstract lectures of past days. The lecture rooms are mostlylaboratories with a platform and a blackboard or two for theuse of the professor. This marks a great advance in medicalteaching which has gradually grown in the past 30 years. In

my time there were no recognised tutorial classes and any-thing like tutorial instruction was looked at somewhataskance as adapted rather for the dull and backward studentor for one who has wasted time and needs cramming. Thestudent has thus to worry out things for himself with thehelp of lectures only and acquire the habit of readingwith critical attention and of verifying his reading bydissection and personal observation rather than by de- ,

monstrations at the hands of the professors. The .

advantages of the present system are manifest. Thestudent with the same amount of thoughtful work not

only learns a great deal more but can verify his learn-ing in every detail. Let me make one note of warningthat each student should be careful under these more helpfulconditions to keep his robustness and independence of mind :that he should thoroughly digest for himself the strong solidfood of science rather than absorb without efforts mental"tabloids" and essences peptonised by his professor. Hewill thus avoid acquiring a somewhat forced smartness ofmind which is not enduring strength, and which whilst itmay serve for passing examinations does not develop thestrenuous intellect and solidity of learning which will equiphim for success in the responsible and difficult work of hisprofessional life.

I would urge every student now entering upon his courseto press on with all zeal and thoroughness with the pre-liminary science work and to settle down here and at thehospital to those more advanced studies which will finallyequip him for that struggle against disease in every climateof our vast empire and in every grade of our complexcivilisation which is to be his life’s work. Work hard as hemay, he will scarcely find less than three years sufficient forthe completion of the second part of his curriculum. And ifthe five years’ course is to be maintained, as I think itshould be, this leaves but two years for the first part, whichhas now at this college been relegated, in accordance with along-thought-out scheme, to a separate building and a

separate control.It is with regard to this part of the student’s career that I

wish to say a few further words. By separating the first twoyears’ subjects of anatomy, physiology, chemistry, physics,biology, and materia medica from those of the hospitalmedical curriculum, making them college subjects ratherthan medical school subjects, University College is withKing’s College, I think, but heading the inevitable drift ofevents. For it is only by large classes that the expenses ofequipment for teaching these subjects can even in part bemet. And not only are the subjects of anatomy and physio-logy too large and absorbing nowadays to be taught by menwho are engaged in the arduous work of building up consult-ing practice in medicine or surgery but there is the furtherfact that the duties of the dissecting room and the wardscannot, in the light of modern antiseptic requirements, be

6 regarded as compatible either for teacher or student.5 Neither can the other sciences of chemistry and biology,

which are not open to this latter objection, now be effi-ciently taught by men engaged in hospital work and private

r practice. It is also in connexion with this separation of the, two sections of the curriculum that the question of timeI and scope of work comes in. Five years having been fixed

upon as the period for thecuriiculum for general qualificationto practise, not more than two years of that time can wiselybe afforded for the preliminary science subjects. I am

myself decidedly of opinion that most, if not all, of thechemistry, biology, and physics required for the ordinarypass examination might, and should be, and in time will be,

-

included in the public school science studies, and be clearedoif before the student enters upon the medical curriculum atall; so that the first two years of the student’s time may begiven up almost entirely to anatomy and physiology, in-cluding some comparative anatomy, so far as it may be

0

946

illustrative of human anatomy, and some physiologicalchemistry. For Anatomy and Physiology are the very base!of clinical medicine and surgery, with which through pathology and bacteriology they are in unbroken continuity.Morbid anatomy and pathology, for instance, throw lightupon many points in physiology. Without the teachingeof the symptomatology and pathology of disease many ofthe most important advances in the anatomy and physio.logy of the nervous system would still be dark to us.

Such illustrations which make for that continuity inlearning which is so important to the medical studentcan be better appreciated and insisted upon by an ana-tomical and physiological professor who is himself ofmedical training. Whilst there is much to be said for con.centrating the teaching of the primary sciences in a fewcentres, it is one of the drawbacks of so completelyseparating the primary from the secondary subjects ofmedical education and making them academic subjects thatthe ultimate aim of the education of the average medicalstudent may be forgotten.

In the possibility that under the new regime anatomy,biology, and even physiology, as well as chemistry andphysics, will be taught by professors with no medical know-ledge or special sympathy with the aims of medicine themedical student must guard himself against alienation fromthe application of his teaching to the needs of sufferinghumanity or he will be apt to acquire an impatience withsick people, the problems connected with whose maladieshe may regard as too full of variants and compromise tocommand his interest. Such a man, however good a

scientist, will make a very bad doctor. The old idea of thestudent in the early years of his course being in touch andsympathy with hospital doings by occasionally going roundthe wards or to the out-patient rooms and operating theatreis past and gone. Nor does the student now commencehis formal studies after any experience of apprenticeship.Such remnants of old times have vanished and are notto be regretted, but neither should they be forgotten.Some attempt should be made to preserve the professionalinterest and zeal which they inculcated.There is no finality in learning and the sciences associated

with medicine are especially in a state of progressive changeand discovery almost kaleidoscopic in their rapidity, thedogmatic teaching of to-day being very apt to become only ofhistorical interest to-morrow. The student cannot become anexpert in anatomy or physiology, in biology or chemistry,unless he devotes his whole life’s work to one of thesesciences, but he may learn from the master mind in each ofthem the foundation principles illustrated by abundantexamples selected from within the sphere of his future workin such a manner as to render his mind open to grasp and toappreciate the significance of the changes and developmentsthat will arise from year to year through the whole course ofhis professional life. It is receptivity not the pretension tofinal knowledge that is required, a certain openness toreceive but a disinclination to be obsessed by any newdiscovery or development and the ability to fit it in arightwith the other requirements of sound diagnosis and treat-ment. It was in this view that I ventured just now to urgethe student to preserve his independence of mind in theverification of everything that can be demonstrated. It hasoccurred to me in the course of practice to meet with someludicrous instances of good men obsessed by some newclinical or pathological discovery and for the moment

deprived of their common sense of proportion and perspectivein symptomatology and treatment.The dangers for the student of extending the scope of his

preliminary science work actually in time-I believe two anda half years are already taken up with it-or in difficultymust be safeguarded by wisdom and foresight on the part ofthe ruling councils of the schools, and ultimately by thewatchfulness of the General Medical Council and examiningbodies. I have hitherto been considering the needs of theaverage man-about 90 per cent. of those who come tomedical schools-who requires to qualify for the work of hislife, and I trust it will not be thought that I am in any wayseeking to curtail or to minimise the present sufficiency ofthe qualifying curricula and examinations in London. Theyfurnish an ample and thorough equipment for medical

practice, and it is a matter for regret that the ordinary- Conjoint qualification cannot be signalised by some moredefinite designation than they now carry. I would make

any further work beyond the requirements for the qualifyingexaminations more strictly post-graduate work. When a

1 man has qualified in his first two years’ subjects by passings the required examination he would do well to proceed to a- six months’ or a longer course in those subjectq for the. higher university degrees, and when he has qualified in theb second grade and obtained his Licence to practise he mays proceed to post-graduate clinical, pathological, or otherE research for his final examinations in those degrees or for the- Membership of the Royal College of Physicians or Fellowship. of the Royal College of Surgeons. A university degree andi the higher grades of medicine and surgery should beb regarded as something beyond and in a sense outside a- qualification to practise-as an academic or other distinctionf for the attainment of which a man may take as long as he- pleases, but for which certainly some additional work in eachr grade or period of his studies should be required.r London cannot compete with some other university centresP in the rapidity with which it can turn out graduates inb medicine, but there is no qualification for practice higher inL status and usefulness than the Conjoint Licences of the Royal

Colleges, and the London University degrees in medicine, and surgery should maintain a correspondingly commandingl position and thus continue to attract the best men to its. schools.i To secure this in the future I believe it to be necessaryl to make the work for the higher degrees post-graduate in each grade. And whilst the studies of the first half will be,L I think, best pursued, with due safeguarding, in academicI institutions, those of the second half which are strictly pro-. fessional might be more strenuously conducted in our great, hospitals if they were exempted from the expense andi exhaustion of energies necessary to maintain the teaching ofI the earlier subjects. I cannot but think further that someI affiliative grouping of the great clinical hospitals about the: three university centres would be of great value in point of, view of financial economy and strength of teaching. It is

very possible, too, that special hospitals and infirmaries! might be more utilised than they now are for clinical teach-

ing material and especially for post-graduate teaching. Itwas suggested to me in conversation by a friend of mine, anauthority on the General Medical Council, that there shouldbe some limitation in the numbers of students at the hos-pitals proportionate to the number of beds available forclinical teaching, so that on the one hand each studentshould have a fair proportion of cases for personal study,and on the other that individual hospital patients should notbe subjected to the fatigue of too much examination.

ABSTRACT OF

An Inaugural AddressON

"RES MEDICA, RES PUBLICA": THE PRO-FESSION OF MEDICINE, ITS FUTURE

WORK AND WAGE.Delivered at St. George’s Hospital on Oct. 1st, 1907,

BY WILLIAM EWART, M.D. CANTAB.,F.R.C.P LOND.,

SENIOR PHYSICIAN TO ST. GEORGE’S HOSPITAL AND TO THE BELGRAVEHOSPITAL FOR CHILDREN.

[IN the opening passages of his address Dr. Ewart madeappropriate references to the senior consulting physician, SirHenry Pitman, who is now in his hundredth year, and to therecent deaths of Mr. Timothy Holmes and Dr. Robert Barnes.He then introduced the subject of .. The Profes!’1ion and itsTwentieth Century Crisis" and continued as follows :-]Had a man stepped forth in ancient Greece or Rome equal

in wonders to the youngest of our qualified men he wouldhave been accounted a demigod. We have 30,000 suchin the kingdom, and they pass unnoticed as negligiblequantity. But a body controlling so much power cannotremain a cipher. We need only look back little more than acentury, as the whole change has occurred in that time. Its

wage, its status, and, alas, its routine have remained whatthey were ; but a transformation has been silently accom-plished within it. It held the shadow of knowledge; it now

holds the substance. It had laboured long in hopeless efforts