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First Published in igis 




THERE is in La DMcle a most vivid picture 
of a French peasant ploughing, going 
backwards and forwards, up and dow^n the 
furrows, in the sight of both armies. He is 
outside the Hne of fire and of passionate hate, 
and while two nations contend for the Empire 
of the world, Zola shows him absorbed in the 
peaceful task of ploughing his field. Yet, when 
his own homestead is attacked by the invaders, 
this non-imperialist is seen to be a fierce 

The provincial doctor, and even the metro- 
politan, is like this French peasant, letting the 
world's controversies rage while he attends to 
a hundred daily duties of his practice. Some- 
times he assists at a tragedy that he cannot 
prevent, sometimes at one that he can. He is 
an easy target for the caricaturist, but he does 
not read the caricature ; or, if his attention is 
arrested when Mr Bernard Shaw attacks him 
in a whirlwind of wit, he remembers that in 
the last twenty-four hours he has saved, quite 
possibly, more than one life. Such is the man 



I have wished to portray, but I have only been 
able to give phases of his life : none but a 
Balzac could picture the whole. And while I 
was out trying to paint my picture under a 
grey sky, the thunders of heaven and of the 
Chancellor of the Exchequer turned the grey 
to black, the storm rent my canvas and drove 
me indoors. This was the time when ignorant 
opportunist politicians, direct descendants of the 
falsely sentimental absolutist school of Napoleon 
ni. rather than of the Bismarckian autocracy, 
were making their first assault on medicine ; 
and I now saw the doctor, no longer in his 
quiet moods, but in his angry moments. The 
reader of this book will easily understand how, 
in these circumstances, the chapters dealing 
with contract and midwifery practice and with 
medical reform assumed in my mind greater 
importance, and were correspondingly increased 
in size. 

My remarks on surgeons and surgery have 
both invited and received criticism from my 
friends. The names of Mayo, Crile, Moynihan, 
Stiles, Bland Sutton, Victor Horsley, Mayo 
Robson, and Littlewood were brought forward 
as evidence of the beneficial effect of extreme 
specialism in surgery, the inference being that, 
with such giants in surgery all over the world, 



the world should be content. It seems to me 
that the world should not be content ; and at any 
rate my critics, by the very cases they cited, 
played into my hands and strengthened my 
conviction. It is true that we have such men 
as Mayo and Littlewood, ^nxg^o'sx^ par excellence, 
the one a Carnot of surgery, an organiser of 
victory, the other a veritable Stonewall Jackson, 
a dashing and successful raider of the enemy's 
territory, rapid in diagnosis, rapid in operation. 
But, on the other hand. Bland Sutton is a great 
pathologist with marvellous manual dexterity. 
Stiles is similarly a great anatomist who has 
never ceased to be a medical student. Crile is 
not only a most resourceful surgeon : he is also 
a great laboratory scientist and a student of 
diagnosis, equally unwearied and successful in 
research concerning the subjects which he has 
made his own. Mayo Robson was the leading 
general practitioner of his own city before his 
great inventive power, aided by his imagina- 
tion, made him a chief among the surgeons 
of his country. Sir Victor Horsley still keeps 
two days a week for laboratory research. It 
is no sufficient description of Mr Moynihan to 
say he is a surgeon : he is a profoundly able 
physician, a man of such immense general 
capability as would have placed him in the 


front rank, whatever career he might have 
adopted, and with an exquisite and surpassing 
genius for complex operative work. He has 
also such a power of understanding clearly the 
logical result of other men's observations that he 
leaps at a truth before his competitors are 
ready to stir. Such a man is not a surgeon ; the 
term does not fit him : it is not big enough. 

These men are all, in fact, physicians with 
clever digits. Of course there are many great 
surgeons who are not physicians ; but what 
these men who are both have been able to do 
in a great way, the general practitioner could 
very easily do in a small way, were he given 
the opportunity and training. At present, 
however, his training, while it makes him 
a capable physician, leaves him, in most cases, 
an incapable surgeon. 

My thanks are due to a large number of 
medical men and others whose observations, by 
correspondence and in conversation, have helped 
me to arrive at my present conclusions in re- 
ference to medical, social, and political subjects. 
From Sir Clifford Allbutt, Sir William Osier, 
and Dr Barrs especially I have received much 
encouragement and helpful suggestion. 

H. DE C. W. 



I. The Surgeon, the Physician, and the G.P. i 
II. Professional Training and Hospital 

Appointments . . .19 

III. The Work of the General Practitioner 35 

IV. Specialists and Consultants . . 42 
V. Public Opinion, the Press, and the Doctor 50 

VI. Contract Practice . . . 6p 
VII. Organisation of the Medical Profession 89 

VIII. The Power of Revolt . . .98 

IX. The Working of the Midwives Act . 102 

X. Hospitals and Hospital Patients . 115 

XI. Poor Law Experiences . . .123 

XII. The Poor Law: A Suggestion . . 149 

XIII. Public Health and Inspection . 155 

XIV. Public Health and its Problems . 163 
XV. Tuberculosis — I . . . j^^^ 

XVI. Tuberculosis — II . . . 

XVII. The Treatment of Tuberculosis . 202 
XVIII. The After - Treatment of Town 

Phthisicals . , . .216 
XIX. Post-Graduate Work : London, Edin- 
burgh, AND Elsewhere , . 225 



XX. Edinburgh : The Younger Workers . 236 

XXI. Edinburgh : Lecturers and Personauties 246 

XXII. A Major Operation in Leeds . . 265 

XXIII. Doctors from a Bookshelf — I . .271 

XXIV. Doctors from a Bookshelf — II . 280 
XXV. Doctors from a Bookshelf — III . 298 

Index ..... 307 





npHE medical profession is fed from many 
■'- sources. Sometimes a lad leaves his 
father's counter for the medical school ; some- 
times the young student originates in the 
parsonage or in the school-house. Families 
which are meekly associated with learning 
desire to have one of their number a doctor, 
whilst the doctor's children tend to commerce, 
to the bar, and to the army. Elsewhere I 
speak of the training which those who desire 
to enter the medical profession must undergo 
before they qualify. When this training is 
over, there is still a certain degree of choice 
open as to the particular branch of work which 
is to be taken up. The father, perhaps, who 
is himself a doctor views with approval the 
pleasant plain of the Army Medical Service ; 
the desert of medicine which he has himself 
traversed is often too much in his memory for 


him to see many advantages in it for his son ; 
and he considers that an army career is one 
of good fellowship, not vulgarised by any 
necessity to know much about materia medica. 
Then there is the Indian Medical Service, open 
to all young qualified men. Candidates are 
passed in by competitive examination, and the 
lists show the names of men of high standing, 
who hold the best diplomas. Eastern diseases 
are not single spies, like ours, but battalions ; 
a good man has, therefore, every opportunity 
to learn if he will. But if he prefers to rust, 
he may. 

Most young doctors, however, tend to de- 
velop into one of three types : the surgeon, the 
physician, and the man who is both of these as 
well as accoucheur — the general practitioner. 
These last make up the bulk of the profession. 
Usually, I suppose, circumstances are at least 
as strong as natural bent in deciding the direc- 
tion a man shall take : it is not everyone who 
is fortunate enough to be able to wait for his 
chance. If the young doctor becomes a surgeon 
to a large metropolitan hospital (and I include 
such cities as Liverpool among the metropolitan), 
he may have to wait long years for recognition, 
though he may spring into fame as rapidly as 
did Byron and Macaulay in the profession of 
letters. If he intends to be a consulting physician, 


he will certainly have to wait. A consulting 
physician is grey before his golden period 
arrives ; but, on the other hand, he lasts longer 
than the surgeon. A young or middle-aged 
surgeon is better than an old one. Yes, the 
physician — the man of wide reading, of logic, 
of large clinical experience — certainly lasts 
longer. The surgeon looks to the adventure 
of the future, but the physician is rich in the 
accumulations of the past. 

The surgeon of eminence is a man to be 
envied : his income is large, and his life is free. 
His career has depended upon opportunity. 
Blessed with leisure at the outset, not compelled 
to earn a living at once, he has entered his pro- 
fession through the hospital staff, and has thus 
been admitted into the ring. He has given 
time to his speciality. Recognised by his little 
group of pupils and friends, known to the middle 
class as well as to the poor by his work in the 
hospitals, he is at length, as time goes on, called 
into consultation with increasing frequency at 
the request of the patients ; then a brilliant 
operation or two, and he is a man of mark. 
Eventually his talents compel recognition from 
his colleagues ; he obtains an important senior ' 
position on the staff of his hospital ; his fame 
as a surgeon at last reaches the deafer ears of 
the general practitioner, and he becomes a great 


consultant. Jealousies there are, such jealousies 
as are frequently laid bare by the correspond- 
ence in the medical journals : Who discovered 
this or that surgical bobbin or button ? Who 
first removed the prostate gland partially, who 
last removed it wholly? Who plucked the 
surgical apple and turned it into an apple of 
discord ? And so on.^ 

The surgeon who is well known to the rich 
is himself a rich man ; time alone limits his 
income by limiting his power of continuous 
operation. We are slowly evolving a knight- 
hood of the tourniquet, an aristocracy of the 
scalpel, instead of, as was the case twenty-five 

^ Mr Moynihan strongly objects to this description. He says : — 
" A surgeon's life is never free. It is a life of abstinence : he may 
not smoke, or drink, or sit up with his friends until two or three 
o'clock in the morning, as a solicitor-general may do. To a surgeon, 
a patient is a divine responsibility. A barrister protects the adventitious 
things of life, a surgeon life itself. Wherever a surgeon is careless or 
tired, there is potential man-slaughter. And do you think tHat we 
have no weary moments, no periods of mental pain ? Unless we are 
prepared to face comparative, if not positive failure, we must put into 
our work our best, not two-thirds of our best ; and the strain is some- 
times very great indeed. One of the busiest surgeons of modern times 
gave up work, firstly, because he could afford to retire, and secondly, 
because it was pleasant to do so. But why was it pleasant ? He could 
have made ;f 50,000 the year he retired ; his health was excellent, his 
fame world-wide, his influence paramount. But he did not value the 
vulgar results of frantic effort ; he had borne for many years the strain 
of immense responsibility ; he could not sleep at night for thinking of 
the operation he would have to perform in the morning ; he knew that 
the whole world was looking at him, demanding the absolute co-opera- 
tion of perfect hand and brain. It was, therefore, a pleasure to him 
to cease being the earner of a huge income ; and though he continued 
to work for the public benefit, it was in an obscure and unpaid position." 


years ago, an aristocracy of the stethoscope. 
Many surgeons, indeed, are so wealthy that they 
compete with brewers for their grouse moors 
and with rich Americans for the deer forests of 
Scotland. And their acquaintance with the 
American does not end there; for the latter, 
who for two generations has been told to see 
Paris and die, comes instead to the English 
surgeon professionally that he may live. 

American surgeons borrow much from Europe, 
but in adopting the science they Americanise 
the manner. America reorganises the know- 
ledge, pouring it, not through one of its older 
colleges, but through one of its newer stores, so 
that it comes out with street- car illustrations, 
with newspaper editor lucubrations, and with a 
well arranged index ; and it is the true native- 
born American who arranges the index. The 
American surgeon may even beat his English 
colleague. America turns out surgical Whiteleys, 
under whose auspices disease is treated depart- 
mentally. Thus, if you consult a famous American 
surgeon, you first see his physician, his bacterio- 
logist, his expert on stomach contents ; you may 
even see others. Each one examines you. Dr 
Johnson, or rather a typewriter, is behind a 
screen, and all you say is taken down against 
you. At last a diagnosis is made, and an opera- 
tion is decided upon. You come into a room 


where you are surrounded by figures suggesting 
something as grim as a mediaeval secret society, 
for each attendant is garbed in white linen, 
masked and gloved. You become part of their 
mystic rite ; in their nightmare scene one of the 
mutes gives you ether, and you sink into an 
apoplectic slumber. And not until this moment 
need the surgeon himself come upon the scene. 
In England, while the mystic surroundings are 
the same, he makes an earlier appearance. 

The surgeon need not be, indeed he is not 
generally, what is called an intellectual man, 
and if he becomes a bookman he is a pheno- 
menon ; but he must be keenly intelligent, 
masterful, and able to command respect. The 
smaller virtues make the greater surgeon, and 
he must have the power of taking advantage 
of opportunity. His patients advertise him, 
and he needs no other advertisement. Foppery, 
falsity, and low artifice are no help to him. I 
am not now speaking of the man who confines 
his attention to one small part of surgery, and 
who is deliberately ignorant of all but that small 
part, nor of the man who, if he wishes to increase 
his knowledge, studies the Stock Exchange. I 
am speaking of the general surgeon. The latter, 
if he wishes to widen his sphere, becomes a 
physician ; he is really forced to invade the 
physician's territory, and he even arranges 


chemical reactions in the duodenum. Your 
successful surgeon is seldom puffed up with 
pride ; to tell the truth, his rivals are healthy 
correctives. His work is so simple, depending 
so much upon manual skill, good tools, and good 
eyesight, that there is not much temptation for 
him to be an egoist. There are, of course, 
brilliant exceptions. I n persistency, in acrobatic 
manual dexterity and keen intelligence you have 
the surgeon's outfit ; and the qualities are given 
in their order of importance. 

A surgeon is, as a rule, simple in his dress 
and manner ; the long frock coat and the silk 
hat he leaves to the physician and the sixpenny 
doctor. He may, if he pleases, dress like a 
workhouse boy ; his simplicity may become un- 
couthness ; no one will mind what he looks like 
if only he is quite at home in dealing with the 
abdomen. The success of one surgeon over 
another may depend not at all upon the intel- 
lectual level of the two men, but merely upon 
their comparative aptitude in the tricks of 
surgical toilette. 

The physician is of quite a different breed 
from the surgeon. To begin with, he is a 
poorer man (I of course mean financially) : 
while the surgeon flashes past in the finest of 
motor-cars, the physician may have to blink 
after him from a hansom. Every average 


man is a physician at fifty, and he will not 
readily pay for advice which is often merely 
common sense expressed in technical terms ; 
but he will pay for surgery. The surgeon's 
time is comparatively short. The physician's 
atmosphere is so darkened by prescriptions that 
he does not observe the passage of time; his 
patients believe in his wisdom to the last, and 
cherish his cookery-book recipes when he is as 
obsolete as they ; for a technical book written 
by a doctor may be an honour for a year and a 
reproach for a generation. 

Surgery changes by revolution ; but while 
there are revolutions in medicine, it is rather 
by repeated riots than by revolutions that 
medicine is altered. Audacity in surgery is 
commonplace, and is always admired ; but an 
audacious ph)^sician is harshly judged. Even 
the medical public, although it learnt from Dr 
Barrs to feed in typhoid, and from Sir James 
Barr to treat the same disease in a tank, criticised 
for years and appreciated for months. 

The physician, unlike the surgeon, is often a 
student of letters ; he remembers the saying 
that to learn physic you should read Don 
Quixote. It is worth while paying his fee to 
see his collection of the ballads of his native 
country. He studies the history of his own 
calling ; he knows the old doctors and the old 


remedies, and he often believes in both. While 
a surgeon is apt to remain a worshipper of his 
own brazen image, the fear for the physician is 
that he may become a stale imitation of himself. 
If, however, he continues contemplative and 
keeps some of his primal originality, and if he 
does not dose into dogmatism, he will remain a 
leader all his life, while the surgeon is inclined 
to become a youthful farmer at sixty. 

Among physicians an epidemic of conceit is 
never met with, though the malady is well 
known to occur sporadically — caught, we may 
suppose, by the physician comparing his own 
laboriously-acquired knowledge with the in- 
tellectual attainments of the surgeon. In 
general the doctor is large-hearted, but full of 
unconscious prejudices ; manly rather than 
refined ; capable of anything in the way of 
routine duty, but cautious and even timid of 
the unaccustomed. Acute in his first impres- 
sions, he is seldom long-sighted and never 
philosophical. He is no hair-splitter. An 
unbeliever in what is new, he is nevertheless 
apt, like other illogical men, to be carried along 
by gusts of fashion. He is by no means hectic 
in his sensibility ; he is sagacious rather than 
clever; and unless he is very young and a 
Resident Surgical Officer, or very old and a 
Medical Officer of Health to a small town. 


he does not take up a burlesque attitude of 
omniscience. Unless he wears a rubber glove, 
he has no itching palm ; he is straight in his 
dealings, but never Quixotic ; he may hesitate 
over a generous deed, but he never regrets it 
when once it is performed. Though affectionate 
and sometimes tender, he can be a bitter and 
unforgiving foe. He is moral in his conduct, 
but seldom devout. Occasionally he is soft 
in the evening and adamant when he looks at 
the glass in the morning. If attached to a 
supercilious clique, he is himself supercilious ; 
but he is so by circumstances and not by nature. 
He has a little of a crab-like capacity of 
shedding his medical shell for a society cara- 
pace. In fact, he is an Englishman, worthy of 
respect but not of hero-worship, deserving 
of criticism tempered by large-hearted ap- 

The general practitioner is a physician too, 
a general physician of wide experience. He 
is not a pioneer, and he seldom unearths new 
facts ; but he accepts them. He knows some- 
thing of everything and much of something ; but 
he does not burden himself with too much of the 
new knowledge, and the obsolete he entirely 
neglects. He is cautious in his procedure. 
When Koch brought out tuberculin, no general 
practitioner used it, though the specialist rushed 


after it ; after a while the acid of criticism left 
a residue of valuable treatment, which the 
general practitioner now uses timidly and the 
specialist boldly. Patients go to the G.P., 
not knowing their ailments ; he finds out what 
is wrong and classifies his multitudes. In a 
proportion of cases he seeks the aid of the 
specialist ; but he is himself incomparably the 
biggest man in medicine. He is a safe man to 
entrust your health to ; the specialist is not. 
The latter is sometimes a Saint Dunstan, and 
every new patient is a devil to be treated 
on well-established business principles under 
entirely new management. Second-hand know- 
ledge and middling talents in medicine are of 
more value to the everyday patient than pro- 
found learning which cannot accommodate itself 
to curing an everyday illness. 

The influence of the doctor is shown, not only 
in positive work accomplished, but also in the 
effect he has on the people about his patient, in 
the stimulating of every effort and of every 
feeling but despair. He is not only an actor 
on his stage, but also a critic, sometimes kindly, 
sometimes coarse, getting the best out of his 

Among outward things, the telephone, the 
ambulance and the motor-car have altered 
the practice of medicine much more than has 


the microscope. The general practitioner 
has a larger district to work in and a larger 
armament of medicine to work with. Socially, 
too, there has been a change. In the past the 
rich man employed and paid the doctor ; the 
poor man called him in, but generally did not 
pay ; and the squire, directly or indirectly, helped 
the cottager. The squire does not now always 
have the same doctor as the cottager, and the 
rich city man lives apart from his clerks ; and 
though some practitioners manage by their 
ability to impress more than one class, as a rule 
each circle has its own medical man. Many 
rich men insist upon a consulting specialist for 
every ailment, and the doctors they employ 
as general practitioners are useful guides to the 
specialists consulted. It is the middle class 
and the upper working class, too busy to know 
much of medicine, that keep the G.P., and these 
classes rely upon the family doctor. The poor 
that he attends deplete his pocket, though they 
may add to his experience. 

The hospital takes much work from the G. P. 
and starves him of much valuable experience, 
thus impairing his usefulness as a servant of the 
public. The remedy is to hospitalise the G. P. , to 
put him on the hospital staff ; but of this I shall 
speak in another chapter. Twenty-five to thirty 
years ago the foundries employed the doctor at 


the gates ; but now telephones and ambulances 
have almost ruled the doctor out. It used to be 
the rule first to send for the doctor, and then to 
get the ambulance ; now the am.bulance is first 
telephoned for, and then the nearest doctor is 
summoned. Masters of large works encourage 
the large hospitals, and all their casualties and 
most of their medical cases are bundled off to 
these institutions, where the Out-patients' Rooms 
are crowded to inefficiency. The master does 
not pay the doctor : he finds it much cheaper to 
subscribe to the hospital. A subscription of a 
few guineas forms the cheapest of insurances. 

As to the so-called doctoring of the present 
day, it is in all classes mostly done by the 
wife, the mother, the druggist, or the patent 
medicine vendor ; only when there are signs 
of danger is the doctor sent for. Lodge 
patients form the exception to this rule : they 
appeal to the doctor in the most trivial cases ; 
yet even by them the doctor is never called in 
to prevent disease, but only to relieve it. 

Doctors take to their work in different ways. 
It may be a strange statement to make that 
some of the best men hate their work, but this 
is true ; they find any distraction preferable, 
even carpentry. But these instances are few ; 

^ Once, having been called to see a patient, I found it necessary to 
order a purgative. " Stop, doctor," said the patient's wife ; " that's my 


most men like the work and enjoy its variety. 
A medical practitioner is benefited by constantly 
rubbing- shoulders with other men, especially 
with consultants. A doctor in the country 
without medical neighbours must get all his 
mental friction from laymen ; in this case his 
medical work may be varied in character and 
most valuable, but it is likely to lose in academic 

Whatever opinions a medical man has on 
theology, he must not offend those of his neigh- 
bour. He may surely bare the head, even if he 
does not bow the knee. 

The act of supreme treachery in a general 
practitioner is to deride his brother practitioner 
and betray his apparent or real weaknesses to 
his patients. 

A doctor starts with great ideals ; but marriage 
and children are stern realities. A doctor who 
reaches old age and retains all his ideals of 
youth is not a physician or surgeon merely : he 
is an apostle and a bachelor. 

Women take their place with men in the ranks. 
Beauty and youth are nothing in medicine. 
Fools of either sex are hardly tolerated now in 
the drawing-room, and certainly not (except as 
patients) in the operating theatre. 

The general .practitioner may, though with 
difficulty, become a man of public affairs. He 


may branch out from medicine to lecture on 
temperance, or on botany, or on health, like Dr 
Andrew Wilson, Dr Ewing, and others. His 
training, however, more readily helps him to be 
a temperance orator than a brewery director. 

One sometimes hears laymen speak of surgery 
with immense respect and of medicine with 
immense contempt : surgery, it is said, has 
advanced, while medicine has marked time. 
Since advance in surgery is so well recognised, 
let us think for a few moments of what has been 
accomplished in medicine. 

Three of the most powerful enemies mankind 
has to contend with are tuberculosis, syphilis, 
and cancer. In 1882 Koch discovered the 
tubercle bacillus ; later he also discovered 
tuberculin, a discovery as important as that of 
Jenner. Since 1 882 consumption has been traced 
to its cause ; that cause has been profoundly 
studied and is now well understood, while a 
remedy, which is in most cases a cure, has been 
brought to light. Of this I speak elsewhere. 
Cancer, too, has been rudely treated by the 
investigators ; it has been asked to give up its 
causal secret, and it has, we think, consented. 
Rheumatism is controlled by salicylates ; 
myxoedema is cured by thyroid extract- 
diphtheria is now, if treated promptly by 
antitoxin, a minor ailment. The development 


of electrical and X-ray treatment is known to all. 
The action of drugs is understood as it never 
was before. I might refer to the discoveries 
concerning the function of the brain and spinal 
cord, the causes and treatment of epilepsy, the 
banishment of yellow fever and malaria— in 
short, I might chronicle progress in the treat- 
ment of every disease which afflicts us. In the 
continued improvement of medical science lies 
the chief hope for the future happiness of the 
race; if the brain of the Caucasian is only large 
enough, medical science will make him lord of 
the whole world, 

Down to the present day races have lived by 
the elimination of the weak. For instance, 
when scarlet fever attacked a village, it seized 
upon those who were liable to become infected, 
and with their bodies it filled the death carts. 
Some it could not blast : they were immune. 
Some were attacked, but recovered : they were 
partially immune. Then this malignant plague, 
having killed those who could not resist it, passed 
on ; if it returned, its power over the population 
was found to be lessened, for it had eliminated 
the unfit. By such elimination of the unfit the 
race improves ; that is, it improves in relation to 
a given epidemic disease, such as the one we 
have been considering. But this elimination of 
the unfit only means that certain people liable 


to scarlet fever have died ; it is progress through 
the triumph of the disease. The future will 
witness progress at a less cost through the 
triumph of medicine. In many respects the 
people sacrificed may have been about the 
average ; or they may have had more than the 
usual share of the qualities which go to make 
good citizens. The same remarks apply to other 
diseases. Nature, therefore, works by wholesale 
massacre, and improves the race by murder. 
But if you are so strong in resistant power 
against the action of any disease that you cannot 
catch that disease, even if it accompanies you 
in your daily work, even if you eat and sleep 
with it, then you are immune to it. 

Medical science, too, is, like nature, a wholesale 
dealer, striving to cure, not the few, but the race, 
and to destroy the causes which produce evil 
results. Panama was once the unhealthiest 
place an American could go to ; now the death- 
rate is as low as that of Washington, Here 
medical science has triumphed over Nature ; the 
rapid change is due, not to the eliminations of 
the unfit among mankind, but to the elimination 
of the fit among the mosquitoes who were the 
carriers of the disease. 

The immunity of man to disease is lessened by 

such methods as are seen at Panama, for the 

elimination of the unfit among men ceases ; but 


there are means of inducing an actual artificial 
immunity. It is not my purpose to explain the 
rationale of this ; I need not do more than point 
to the results which follow the application of 
scientific medicine in such diseases as diph- 
theria and plague. Probably in time all diseases 
will in great measure be robbed of their power 
for evil. And if national life is to depend so much 
upon medical science, then the sooner medical 
science is richly endowed, and the more its 
growth is accelerated, the earlier will be the 
advent of the millennium. 



THERE is a story of a medical student who, 
being visited by his parents, took them 
round the city in which he was studying and 
showed them the pubHc buildings ; finally he 
came to the Medical School, which he unfor- 
tunately failed to identify. This type of student, 
however, is now extinct. The medical student 
of to-day is the modern Dick Whittington, and 
his thoughts are to London and honourable posi- 
tion. Gray's Anatomy is his cat : it is always 
with him, and to it he owes his success in his 
professional examinations. Like Dick, he must 
pass through hardship and toil to his reward, for 
in these days very severe work is needed before 
a man, or a woman, can qualify. First, a Pre- 
liminary Arts examination must be passed, to 
show that the student has had a general educa- 
tion of Grammar School standard. After pass- 
ing this examination he can, if over sixteen years 
of age, register his studentship. Next comes a 
year of science akin to medicine, and after that 



four years of purely medical subjects — everyone 
knows what these are. Then, when the curri- 
culum is finished and all the intervening tests 
have been undergone, the final examinations 
are taken. 

You can begin to cure your patients on the 
strength of the L.M.S. London, the L.R.C.P. 
London, and the M.R.C.S. England. The 
L.M.S. is given by the Society of Apothecaries, 
an ancient corporation which ought to be obso- 
lete ; the degree costs little, and the examination 
is easy to pass. The L.R.C.P. and M.R.C.S. 
are difficult ; a man who takes those diplomas 
has worked hard. Edinburgh and Glasgow give 
a joint qualification ; Ireland, too, will make you 
a licentiate. The Edinburgh and Glasgow and 
the Dublin diplomas are similar to the London 
qualification, and are of about equal standard. 
The Universities, too, give degrees in medicine, 
to obtain which one must have studied at the 
conferring university. To obtain a licence it is 
only necessary to study at a recognised medical 
school and hospital, choosing one's own locality. 
We see, then, that there are many ways of 
entering the profession. But it is hoped by 
most medical men that there will be, at no 
distant date, one portal, through which every 
aspirant must come in, special degrees being 
taken later by those who wish to do so. 


It would be difficult to overestimate the value 
of the education that the young doctor receives. 
It is true that his student course is burdened 
with much that, to my mind, is useless, while 
much that he will have to know some day he 
does not learn as a student. Nevertheless, even 
if he were to leave the profession immediately on 
qualification, his is a great training. He is com- 
pelled to observe keenly, to learn accurately, and 
with infinite patience and some tedium to follow 
his guides, to accept the teaching of authority, 
and yet to act promptly and to be ready to take 
independent responsibility with as Httle fear as 
is shown by a junior lieutenant in charge of a 
gunboat. No one can look at the boy who 
begins his studentship and at the serious young 
man who finishes it, without admiring the 
steadying and sobering effect of his curriculum. 
It is a curriculum which deals with mortality, 
his main study being the human body, which 
he must himself have dissected. 

But he has not yet learnt all. He is qualified, 
it is true, in medicine, surgery, and midwifery ; 
he may even have fought his way into the camps 
of specialism ; but he is only beginning to see 
what lies before him. He may step into one of 
the scientific asides of his profession and never 
enter the ranks of the "practitioners." But if 
he elects to enter into practice, how is his further 


training to be provided for ? Well, it is possible 
that he may at once be appointed to some 
hospital as house-surgeon or house-physician. 
It is possible, I say ; but only for some, not for 
all. In making these appointments the medical 
men on the honorary staff have, quite rightly, 
almost the sole power. Medical men do the 
work for the hospital and take the responsibility ; 
upon the medical staff, including the nurses, 
depends the reputation of every hospital ; and 
the public has nothing to complain of with regard 
to the quality of the men who are appointed. 
Students of medicine work their way into the 
profession under the eyes of their seniors ; an 
able student, brilliantly successful in the exam- 
ination room, naturally expects to be appointed 
on the junior hospital staff, and the selection is, 
as a matter of fact, generally from the best men. 
House-surgeons and house-physicians take their 
year of office ; then they either fall into the ranks 
of the medical profession outside, landing in town 
or country practice as general practitioners, or 
they stay on at the hospitals as senior residents. 
From the senior residents are taken the men to 
fill such vacancies as occur on the honorary staff. 
The junior honoraries, as the years go by, become 
the senior honoraries. For a period their work, 
successful or unsuccessful, is known only to their 
colleagues and to the students who attend their 


teaching classes. Then for a further period these 
men are known to the world; their days are taken 
up with outside work, and their attendance at 
hospital is necessarily only given in their spare 
time. Since for all their past service to the 
hospital they get their recompense only in 
prestige and fame, outside practice alone will 
bring them the tangible rewards which they 
have fairly earned. 

This method of selection, however, while it 
makes it easy for the best men to be appointed, 
does not avoid certain disadvantages. It is not 
every young man who can secure a first-class 
hospital appointment, with the chance of further 
training that it brings ; there is not a sufficient 
number of such posts, and even in the case of 
those who receive them there is no tie between 
the hospital and the men who leave it at the end 
of their year of office to become general prac- 
titioners. Young doctors are keen men, inter- 
ested in the game which is just opening for them, 
and anxious to get all the experience that is 
available at the hospital ; but at the same 
time they are also anxious to set about what 
is for all of us a main object in life, the making 
of an income. They are not welcomed in any 
number at the hospitals, to begin with ; and once 
their period of office inside the hospital is at an 
end, their studentship over, their housemanship 


completed, there is no inducement for them to 
stay. After they have sat at the feet of their 
Gamaliels in the wards and in the operating 
theatre, they leave the hospital, and they are now, 
with all their knowledge, of very litde account. 
One of the greatest living surgeons told me that 
after leaving the hospital in which he had served 
as R. S. O., he one day ventured humbly to return 
to look round ; but he found that his standing 
was ludicrously altered. Like a superintendent 
of police who, having retired into private life, 
should again venture on a familiar beat, he found 
no respect shown him, hardly indeed any recog- 
nition. He asserts, and we must believe him, 
that though he was not actually shown the door, 
its position was almost referred to. Really it was 
only human nature that, after such treatment, he 
should set his teeth and determine to hunt, not 
only in the same pack again, but in the foremost 
place in it ; and now his hospital is proud of its 
greatest son, the surgeon of world-wide reputa- 
tion who condescends to be its clinical professor. 

For one man, however, who can thus fight 
his way by sheer skill to the foremost position, 
there are thousands who must step aside ; and 
yet the Out-patients' Room at the hospital is each 
day filled with a crowded, huddled, and clamour- 
ing mob, while surgeons, assistants, and senior 
students are at it like Chicago pork packers. 


One friend of mine saw, in one morning, 197 
patients. This was too much for any man ; he 
had learnt all the routine of that special institu- 
tion, and he; resigned his post. He was not 
invited to remain on as clinical assistant. 

The result of the present method is that the 
surgeons appointed have too much to do, while 
the vast majority of young graduates just quali- 
fied have nothing. These young men are not 
encouraged : if they do attend out-patient de- 
partments, they may be mocked with the name 
of clinical assistant, but they are given no 

This state of things is to be regretted. A 
large number of surgeons is wanted, for there 
is a great deal of surgical work in the world, 
and it cannot all be done in hospital, nor indeed 
should it. A surgeon's work demands some 
dexterity, less indeed than that shown by a 
miniature painter, but still a dexterity that can 
only be maintained by constant practice. The 
work may require to be done at any moment 
and in any emergency, and unless the surgeon 
does keep himself in constant practice, his skill 
will steadily decrease. Yet, given practice, 
there is nothing in surgery more difficult than 
difficult midwifery : a surgeon generally sees 
all he is doing, while a man in attendance upon 
a dangerous and difficult midwifery case does 


not. But midwifery is attended at home, and 
by the general practitioner, who does the most 
difficult of all work with a skill quite equal to 
that shown by the very best of surgeons 
accustomed to operate in the most critical of 
surgical emergencies. Now, the general prac- 
titioner is not in these days as good a surgeon 
as he is a midwife, even though he may take 
up some branch of surgery and excel in it. His 
medical education, however, goes on amazingly 
after he has begun practice, and he becomes a 
better man in many ways than his brother, the 
surgeon pure and simple, who is qualifying so 
sedulously to become the highest kind of artisan. 
The general practitioner meets people at first 
hand ; he knows them in their homes, and he is in 
their confidence, or he would not be their doctor. 
He must mix with misery ; sin taints half his 
patients, and folly and fate share the rest. In 
view, therefore, of the great importance of 
his work, it is a grave mistake to starve his 
surgical training. The result of such starvation 
is, that men who devote their entire time to 
surgery and are on the staff of a hospital be- 
come the only surgeons and do all the surgical 
work outside the hospital. 

Revolution is in the air : but under present 
conditions the best way to turn out young 
surgeons in large numbers would be to attach 


them as clinical assistants to surgical clinics. 
The advantage would be twofold, for not only 
would the young surgeon receive the training 
he needs, but the congestion in the Out-patients' 
Room would be relieved. I have spoken of 
this congestion already. At present there is 
so much to do in the Out-patients' Room that 
the men who are responsible are horribly over- 
worked ; and as for the business itself, well, let 
us say it could be done much better if it were 
done more slowly. Young and recently 
qualified practitioners could do so much of the 
lesser surgical work of the hospital ; and the 
doing of this would ultimately enable them to 
do a large amount of the outside work which 
is now done at high fees by greater men. I 
have known a great surgeon charge twenty 
guineas to open an abscess, and his time was 
worth the fee ; but the work could have been 
done quite as well by his house-surgeon, or by 
the kind of clinical assistant that I have in mind. 
The plan I am suggesting enables the patient 
of moderate means to live within his income, 
instead of dying beyond it. Surgical fees be- 
come very high ; commonplace operations, 
which should be done by the general practitioner 
at a moderate fee, are sent into hospital, where 
work which anyone should be able to do is done 
by picked men, specialists in surgery, experts 


whose fees for outside work are so high as to 
be beyond the means of the patient. It is be- 
cause the general practitioner's surgery is rusty 
that the layman is found entering a hospital to 
undergo an operation which any needlewoman 
could do for him, if only the College of Surgeons 
would allow her. It is quite right that the poor 
patient should enter the hospital, but the man 
of ordinary means and the moderately rich man 
should be treated in their own homes or go to 
a nursing home. If there were many surgeons 
this would be practicable ; with a few mono- 
polists it is impossible. 

Doubtless the matter is very much in the 
hands of the general practitioner, if he will insist 
upon his rights and those of the public. The old 
G.P. has got used to things as they are ; it is for 
the younger generation that I am writing. They 
should do all the minor and much of the major 
surgery outside the hospital walls ; but they can- 
not do it unless they are invited to join the 
hospital staff early in their career. The hospital 
is the only place where the necessary knowledge 
can be gained ; it cannot be acquired in the 
anatomy room. Clinical assistantships in the 
surgical and medical departments should be 
open to all these young men, with opportunities 
for operating — of course under supervision. A 
general practitioner away from a hospital is often 


called upon to operate without skilled help and 
with few instruments. His chauffeur may have 
to help him in the giving of chloroform ; such 
things have often happened. There is all the 
more reason why a man should be trained to 
operate under supervision before he is sent far 
away from any possibility of supervision. It is 
true that these men often become skilled 
operators, but their guides to excellence have 
been the tombs of their early cases. Under 
present conditions, even when a man does at- 
tach himself to a surgical clinic and is recognised 
as a clinical assistant, he has far too little chance 
of doing operations. Years ago I asked one 
such clinical assistant, a most brilliant man, now 
recognised as one of the foremost of living 
anatomists, to do an operation for a patient of 
mine. He replied that he must refuse. He 
was clinical assistant in the clinic which con- 
cerned itself with the special branch required, 
but he was never allowed to operate. It was 
not his chief who objected ; some old rule stood 
in the way. 

Such a state of things is absurd ; it makes for 
the perpetuation of the closed clique of surgeons 
of which I speak elsewhere. I have no objec- 
tion to the high fees of the expert for really 
expert work. The surgeon's day is over while 
the physician is still in his prime. Moreover, 


in the case of a surgeon more depends on the 
absolute success of a moment, and such success 
— or failure, as the case may be — saute aux 
yeux. Add the preceding diagnostic skill to 
the unerring skill of operation, and you get a 
result which may well command the highest 
rewards. But a large band of surgeons ready 
to do ordinary operations at ordinary fees is 
absolutely necessary in the profession. The 
young doctor has acquired medical knowledge 
which will be useful in general practice. He 
will find the ordinary G.P. a shrewd physician, 
especially well up in treatment, and able to hold 
his own even with the medical expert ; yet the 
other branch of the profession, the branch really 
requiring, I think, fewer of the higher intellectual 
qualities than are needed by the physician, is 

What I am here suggesting is in America 
largely an accomplished fact. I am not a 
surgeon — perhaps this admission maybe thought 
by some to weaken my argument — and therefore 
when in America I have given most of my time 
to medicine. In Philadelphia I visited a small 
Tuberculosis Dispensary, of which Dr Francine 
is the superintendent ; fourteen physicians are 
allocated to the clinic and do most of the work, 
each man seeing four patients in one morning. 
In the Phipps Institutes in Philadelphia and 


Baltimore the same method is pursued, many 
physicians working under the supervision of one 
man. A great gain in knowledge is the result : 
each man has his special experience, and on one 
evening in the week they all meet to compare 
notes. If a man wishes to attach himself as 
clinical assistant to the surgical side of the 
hospitals, the same facilities are given to him as 
are given on the medical side. 

It must not, of course, be forgotten that surgery 
has altered much since the days of Dickens. It 
is nowadays an art, and success in the practice 
of it depends upon scrupulous cleanliness. As 
every cavity of the body is opened and every 
organ operated upon, the processes which occur 
when bacteria invade these cavities and orgrans 
must be stopped by every endeavour possible ; 
and surgery has tended to leave the general 
practitioner and to stay with the man who, under 
favourable conditions, can carry out, with the 
same scrupulous care which is seen in every 
operating theatre, the special technique re- 
quired. Now, a G.P. is always a physician, and 
his work in medicine is marvellously varied. The 
hospital never interferes with him in his medical 
practice to the extent of drying up the sources 
of his experience : it is natural that a patient with 
bronchitis, for instance, should stay at home and 
be nursed and treated there. But when surgical 


treatment is in question, the case is different. 
One might beHeve, if one Hstened to some 
surgeons, that the necessary technique could 
only be carried out in special hospitals or in 
special homes. Yet a nurse, if only she is 
allowed, can turn a bedroom, even in a cottage 
home, into a clean operating room ; and there 
is a benefit in a room in a private house, the 
benefit of solitude and quiet, and of the absence 
of sick neighbours troubled with abnormal 
secretions and excretions. It is true that 
surgery often needs, absolutely needs hospital 
treatment, and that a busy surgeon can do his 
operations more swiftly and more conveniently 
in hospitals or in special nursing homes and 
surrounded by his accustomed assistant staff. 
Nevertheless, minor operations may be better 
done in private houses than in hospital, if only 
suitable nursing can be obtained. I say this, 
though with chastened spirit and humbleness I 
admit that the surgeon may say the exact oppo- 
site. These are my own observations, but I have 
heard that great surgeon, Mr Mayo Robson, say 
that his results for operations in private houses 
were even better than for those in hospital. 
It stands to reason that in a modern house a 
room may be made at least as germ-free as the 
ordinary hospital, full from day to day of patho- 
logically abnormal people. 


I wonder if the people who, from motives of 
piety and pity, raise gorgeous edifices for the 
care of the sick have ever reahsed that one result 
has been to produce a narrow surgical monopoly, 
which bears hard on the middle class population, 
is not the only or even the best thing for the 
poor, and makes a surgical operation a most 
inconvenient costly procedure even to the rich. 
Of course, from the point of view of the material 
prosperity of the operating surgeon, nothing can 
be better than the present conditions. 

However, what I want to see, for the benefit 
of the patient and of the profession, is the young 
G.P. taking to himself much of the surgical work 
which has been filched from him by the surgical 
expert. Young doctors should be allocated in 
large numbers to the surgical clinic ; it would 
be much better for the public, it would be much 
better for the doctor. Diagnostic skill in surgical 
cases is of paramount importance to the G.P. 
People fall ill, not in hospital, but at home ; and 
the more the G.P. is interested in surgery, the 
more able he will be in diagnosis. Early diag- 
nosis will save many lives. Therefore, while 
the skill of a few surgeons is of immense benefit 
to the patients with whom they come in contact, 
the manufacture of a large number of surgeons 
is more urgently required. 

Some objection may be felt to the appoint- 


ment of clinical assistants to a hospital, on the 
ground that such assistantships give young 
men a prestige denied to their elders ; but I 
do not know a single man who would publicly 
make use of such a mean argument. The good 
of the patient and of the profession must take 
precedence of all private and selfish considera- 
tions. After all is said, a clinical assistantship 
such as I suggest is a post-graduate course with 
the most beneficent aid of some portion of re- 
sponsibility. However much the number of 
clever surgeons is increased, the great men will 
still be the great men ; only the pyramid will 
have a base as well as an apex. 



OCTORS are, especiallyin these rapid days, 
a most necessary institution. 

Consider how easy it is for both body and 
mind to go wrong. The small lenticular striate 
artery, supplying the very essence of life to a 
vital brain centre, bursts ; and who is then the 
gentleman ? The greatest brain in Christendom 
becomes lower in level of intelligence than that 
of the horse which will drag his hearse. And 
every one of us is imperfect : we are all nervy, 
all short of breath on exertion, all subject to 
palpitation and collapse if the strain is great — 
and it is great, sooner or later. All common- 
place, of course ; all said before, in obituary 
notices and so on. Well, the commonplace is 
true. A great physician is one who can measure 
the patient's strength or weakness, health or 
disease, resistance or non-resistance to the strain 
of his environment. He can order digitalis to 
be continued, or tobacco to be stopped ; he can 
regulate the output of energy and the income of 
fuel : he can, in short, diagnose your condition 



and tell you what you must do, what you must 
not do. He knows how to prevent scurvy 
and tubercle. He knows the value of foods, 
the valuelessness of chemical substitutes for food, 
and he has not in its extreme form that pathetic 
faith in medicine which is possessed by every 
harassed woman who so naturally and so often 
confounds relief with ultimate cure. And yet he 
has an even more passionate faith in treatment 
which gives him the power of snatching life 
from death. This man, behind the red lamp 
and the night-bell, is an educated citizen, with 
social leanings and with the average culture of 
the professional classes. As a boy, he has 
always taken a good place among his fellows, 
though not, perhaps, the foremost place. As 
a medical student trained by his comrades and 
his teachers, as a practitioner bent into rever- 
ence by the suffering in his path, ennobled, as 
a priest is ennobled, by the confidence placed 
in his integrity, comforted by gratitude and 
soured by ingratitude, each in turn, meeting in 
the same day vice, mean cunning, simplicity, 
suspicion, and again absolute trust, affected in 
character by all the incidents of his varied life, 
he has grown into the doctor whom we all 
know. When I look at the men in practice 
around the house in which I write, I see 
some who have the affection of a large 


circle of patients, and I see none who is not 
respected. . 

The scientific men who, from a study chair 
and a laboratory desk, write books on medical 
reform, know little of the profoundly close rela- 
tions between the doctor and his patient's family. 
, He is consulted about the most intimate details 
of life : whether a woman is fit to bear children ; 
whether she is having them too quickly ; how a 
miscarriage can be prevented ; the extent of the 
wreckage of health which so frequently follows 
miscarriage or confinement ; the cause of sterility, 
and its cure. I can only hint at these matters 
in such a book as this, but the reader will imagine 
the almost sacred character of the secrets which 
are entrusted to the doctor, and the mistake of 
forgetting this side of medical work in any wide 
consideration of the medical profession. The 
general practitioner, living among his patients, 
knowing their characteristics, their family and 
personal history, and all the intimate conditions 
of their daily life, is a much more valuable servant 
to the public than if he were obliged to spend his 
day conning statistics. One addition I would 
make to his duties : he should know a man, not 
as a patient only, but also as an employee ; it 
should be part of his duty to know the details of 
his patient's daily work. 

Some wit has said that there is a type of 


general practitioner who leaves the diagnosis of 
the case to the consultant and the treatment to 
the trained nurse. But wit, though always true, 
is always false ; and in the present day the general 
practitioner does more in the way of diagnosis 
and treatment than ever he did in the past. 

Let us consider for a moment what is needed 
from the doctor by the patient who consults him 
for a real ailment. A man feels he is not well ; 
he does not himself understand illness, so he 
sends for the man who does. The doctor comes 
and examines him ; he seeks to know the present 
condition ; and, as it is desirable to compare this 
with the past condition, he inquires into the his- 
tory of health or ill-health in the past. Further, 
in order to find out any possible hereditary 
peculiarity, he tries to trace the history of the 
patient's family. Certain details of examination 
are at once gone into : for example, temperature, 
pulse rate, and breathing rate. Then a detailed 
examination takes place, first as to what the 
patient feels, next of what the doctor detects for 
himself by his own senses of sight, touch, smell 
and hearing. In the days of our grandfathers 
an examination could only be made by the eye, 
the hand, and the ear, with a little help from 
chemistry in the examination of the urine. Now 
many medical appliances help the ordinary senses 
of the doctor ; so do chemical and microscopic 


tests, X-ray photographs, instruments for testing 
blood-pressure, and so on. The doctor may find 
that he needs an examination, minute and accu- 
rate and requiring special skill, of the sputum, or 
of the blood, or of the pressure at which the 
heart is forcing the blood along the vessels. Or 
special tests of another kind may be required, 
such as the tuberculin tests. The faeces are 
examined as a matter of routine, examined 
microscopically and chemically. It is quite a 
common everyday proceeding to wash out the 
stomach and examine the contents. The state 
of the nervous system, too, must be inquired 
into with accuracy and completeness. The eye, 
ear, throat, nose, bladder, etc., are examined by 
general practitioners in a manner which, in the 
near past, even experts would have considered 

All the routine work that I have described 
the general practitioner can and does do quite 
readily ; it is all in his curriculum. It may not 
be necessary in every case, but it is safe to say 
that it is advisable in many, for all the points I 
have mentioned help the doctor to get a clear 
picture of his patient's condition. The examina- 
tion may be made at one sitting, or at more than 
one. In acute cases a very rapid examination 
is perhaps all that is possible ; yet the doctor 
keeps in his head some such plan as has been 


sketched, and his notes, even if scanty, are on 
that plan. 

Having diagnosed the case, the doctor pro- 
ceeds to treatment. The patient's immediate 
needs are attended to ; directions are given, 
often in writing, as to what he requires, and as 
to what is on no account to be left undone. 
Further, a more general view of the treatment 
is taken, and a general plan is decided on, to 
be modified from time to time. The doctor 
keeps in mind also the possibilities or certainty 
of result, and his whole aim is to make his sum 
add up to a total of recovery — if possible, of 
rapid recovery. 

In the case of incurable illness, to say no good 
can be done for the patient is a grave mistake 
in tactics. Apart from the effect of such a 
pronouncement upon the patient, it makes the 
doctor appear as a prophet who may accomplish 
his own prediction. 

Like the trained nurse or the trained police- 
man, the trained medical man (and all these 
remarks apply equally to the trained medical 
woman) does his work to some extent auto- 
matically ; he has not to think out every detail. 
The general plan of treatment, however, must 
be thought out, and the doctor, like the trained 
nurse, should be unable to be lazy or careless 
or not at his best. If he is to perform his task 


efficiently, he must not be worked too hard ; 
and for work such as has been described he is 
entitled to fair pay. 

Most doctors die in harness. A general 
practitioner working at eighty years of age is 
not unknown. Men reckon on living to be 
seventy and working to the end ; they some- 
times miscalculate, finding themselves incapable 
at seventy and unfortunately alive at seventy- 

Let me close this chapter by quoting the 
advice given by an old practitioner to some 
young students who were just beginning prac- 
tice. He said : " Never show surprise at any- 
thing. Never claim merit for your treatment. 
Always do more for your patient than you are 
paid for, if you can ; for you will perforce often 
do less." 



TN the medical profession one understands a 
specialist to be a man who is an authority 
on some one subject. It is hardly correct to 
speak of a general physician or a general 
surgeon as a specialist. Many men, it is true, 
who act as general physicians or surgeons in 
the hospitals are chiefly employed by the public 
for one special disease, and to the public they 
are single-disease Hamiltons ; but they are 
familiar with all branches of medicine, or of 
surgery, as the case may be. 

A very large hospital splits itself up into 
many departments. The eye, the ear, the nose, 
the throat, may have four classes of men, one 
for each subject. In small hospitals a man 
necessarily has to take more than one branch ; 
and apart from eye, ear, and nose work, general 
surgeons often take all surgery to be their 
province. Physicians, in the same way, take 
almost all medicine to be their province, in some 
cases even the treatment of skin diseases. The 
diseases peculiar to women have their special 


surgeons ; but there is much overlapping, and 
it is quite an ordinary state of things to find a 
general surgeon doing all the best gynaecological 
surgical work outside the hospital, while he does 
little or none inside. 

The specialist is, in his early days, a general 
physician and surgeon : he takes a pass in many 
subjects and honours in one. Specialism with- 
out the general training is necessarily quackery, 
for there can be no scientific specialism in 
diagnosis. To diagnose a particular disease of 
a particular organ you must exclude other 
diseases, and you can't exclude them if you don't 
know them. Therefore a scientific specialist, 
though in his operative work he may be ignorant 
of the technique required in operating upon any 
but his special organ or organs, must in diagnosis 
be a widely accomplished physician. But the 
scientific specialist is not too common ; hence, 
when medical advice is needed, the general 
physician or the general practitioner is often the 
best man to consult in the first instance. 

It has been frequently suggested that 
physicians and surgeons should altogether 
cease to be in separate camps. Some one has 
prophesied that the practitioner of the future 
will be a kind of sectional sub-committee, that 
he will be a man who understands all about a 
disease or a limited group of diseases— which is 


the popular conception of a specialist now ; so 
that the same man will be both physician and 
surgeon for his special organ. Thus a man 
who is a specialist for the stomach will be both 
physician and surgeon for the stomach. This 
is quite rational. There are, of course, some 
ailments which require no surgeon. But in 
eye, ear, and throat work it is already the rule 
for the physician to be the surgeon; and the 
physician who specialised on the eye and could 
not use the knife would be at a disadvantage in 
competing with the surgeon who could. The 
public has a direct way of thinking that the man 
who opens the stomach ought to know what 
should be put into it. People demand prescrip- 
tions from the surgeon, and, I might add, they 
get them. 

If you are really very ill and wish to see a 
consultant, you crawl to his rooms ; if you are 
only curious, you walk erect into the sanctum 
where he sits awaiting patients. You are sup- 
posed to take an introductory note from a 
general practitioner ; if you fail to do this, the 
consultant must either write to the general 
practitioner in attendance, or, if there is none, 
hand you over to a fresh one. The consultant 
visits patients outside in consultation with other 
doctors, but he has, strictly speaking, no private 
practice. There are, however, exceptions. 


Patients sometimes refuse to let the consultant 
write to anyone. Or they may not be under a 
general practitioner at all ; they may be under 
a homeopathic text-book, or John Wesley's 
remedies, or Mrs Eddy, or the nearest chemist. 
One might perhaps imagine that those who 
believe in Mrs Eddy do not trouble the con- 
sultants ; but they do. If there is no general 
practitioner, and if the patient refuses to have 
one, the consultant is in a difficulty. Surgeons 
have more latitude : they have their assistants, 
anaesthetists, etc., and it is easy for a great 
surgeon to appoint one of these as general 
practitioner, himself remaining the consultant. 
The rigid rule is, don't steal. You may take 
the patient's guinea, but not the medical practi- 
tioner's patient. Unfairness to the general 
practitioner brings its own obviously certain 

A consultant may be called in to see a patient 
in his own home. The most useless consulta- 
tion is that asked for when a patient is about to 
die, when sentence has been passed and there 
is no possibility of reprieve ; then a consultation 
is always demanded "to satisfy the friends," 
and the doctor in charge is generally asked to 
bring whichever man he thinks most likely to 
know all the arts which help to recovery. He 
may think it best to choose another general 


practitioner, in whose own experience these 
cases so frequently occur ; but as a rule the 
consultant who has no general work is called 
in. He and the man in attendance consult, and 
then give in their joint decision on the diagnosis, 
treatment, and prognosis of the case ; that is to 
say, they declare what is the condition, what is 
to be the treatment, and what is likely to be 
the future of the patient. When the joint 
report is made to the relatives of the patient, it 
is the rule that all the medical men engaged in 
the case should be present. Generally the con- 
sultant speaks for the others ; but sometimes 
the doctor in daily attendance gives the con- 
sultant's opinion, with which he is supposed to 
agree. Where an important difference of 
opinion exists, the relatives of the patient are 
informed of the fact. The general practitioner 
accepts the plan of treatment from the man 
called in, but there is a joint responsibility ; 
and if either wishes to protest against the plan 
of the other, he is expected to do so at the time. 
Sometimes there is little to discuss. The case 
is written out by the general practitioner, pro- 
bably a clever, well-trained man ; the consultant 
goes over the various points with him and finds 
that almost all the work has been done for him, 
and that nothing is left for him but to bless the 
efforts of the other man. Of course, dramatic 


discoveries are sometimes made at consulta- 
tions; cancer of the rectum, I should think, is 
frequently overlooked unless a strict routine 
examination has been made, and such an ex- 
amination is sometimes missed until the surgeon 

When a patient is rich, he always has two 
doctors, the general practitioner and the con- 
sulting physician or surgeon. If he is very 
rich he often has three. But the most useful 
consultations are those which are held when the 
medical practitioner feels that the case is one 
likely to test his abilities to the utmost, and 
when he turns for help to the man who, he 
knows, can give it. Men who are in the habit 
of meeting frequently do most good together. 
A practitioner finds out who is most helpful to 
him ; he learns the methods of his man, and 
friendship arises between them. 

I have known consultations take place when 
the consultant's time was pressingly short. Mr 
F.R.C.S. (it is now years ago, and he has gone 
home) leaped out of his carriage as I burst out 
of my door. We swung round the corner, his 
arm through mine, and as my little legs ran, 
trying to keep up with his long strides, I related 
between gasps the condition of the patient he was 
to see : malignant disease, the very last stage, 
the suffering great, the relief mercifully near. 


In two minutes we reached the patient's 
door. We assumed a decorous attitude and 
entered slowly and silently. We went upstairs. 
Nothing could be suggested. There were 
medicines, said F.R.C.S. with feeling, that Pro- 
vidence had given to us for the relief of the suffer- 
ing, and it was our bounden duty to use them. 
Downstairs : " Everything has been done that 
could be done. . . . Yes, three guineas, thank 
you. . . . Thank you, good morning." Then 
we walked slowly and silently out as if the day 
belonged to us. There, round the corner, was 
the carriage with the side-glancing horses. 
F.R.C.S. became suddenly alive. To me he 
said, " I shall just catch my train " ; and to the 
expectant coachman, " Drive like hell." The 
consultation was over. 

The modern consulting surgeon of high 
eminence must have skill as absolute as an 
axiom, and this his continual practice gives 
him. Audacity and eloquence are equally 
useful, if a man is to have a world-wide re- 
putation. Both Chamberlain and Randolph 
Churchill had some of the qualities which 
make great surgeons ; in surgery, however, it 
does not do to "forget Goschen." 

A medical man in general practice would be 
both surprised and annoyed if, for attendance 
upon a brother doctor or his family, he were 


offered fees. It would, perhaps, be impossible 
for a surgeon in large practice to be in all cases 
equally willing to attend gratuitously the 
doctor's family, or even the doctor himself 
There are certain necessary expenses connected 
with surgical operations : there is the wool, the 
catgut, the bandages, the anaesthetic and the 
man to administer it. Again, if a surgeon has 
attained the height of his ambition, a unique 
reputation and a South African income, he 
might easily be overwhelmed with patients who 
were also practitioners. Many surgeons risk 
the possibility of a plethora of medical patients. 
Some cannot. Their ideals are perhaps very 
high : ;^20,ooo must be made annually, and 
patients who pay no fees take time. A small 
charge is therefore made by the very rich, 
doubtless from the best of motives ; ;^5o is the 
usual thing, or even less if the patient is a 
nurse. But surgeons with a less stern sense 
of duty to their banking accounts are usually 
available, and the highest skill can, if you are 
on the medical register, be at your service for 
nothing. In my own locality the question of 
fees from a brother practitioner has never arisen. 
If it did arise, some doctors would perforce shun 
an appendicectomy until they had paid their 
domestic debts, and such delay would necessarily 
be fatal. 



TT has lately been decided that the medical 
attention received by the poor is far from 
sufficient. Not that this is a new discovery : 
it was made years ago by Charles Dickens, and 
the medical profession agreed with him ; but 
the facts have recently been brought again in- 
to prominence by the appearance of the reports 
of the Royal Commission on the Poor Law, 
which contain a severe condemnation of the 
medical treatment of the extremely poor. 
Many criticisms have been passed on the 
medical service, and some contempt has been 
poured on the doctor giving that service. It is, 
however, admitted by the critics that these 
doctors have repeatedly protested against the 
position in which they are placed, and that the 
evidence against the workhouse system of 
medical relief is in great measure obtained 
from the Medical Officers themselves ; still, the 
impression left upon the public mind is that 
poor people have been given drugs when 
they needed bread, and the prestige of the 



medical profession has not been increased 

At the same time, the Medical Officer of 
Health is a power in the land. The rich are 
particularly well satisfied with him, and he is too 
well satisfied with himself. His authority is 
increasing, and will increase more and more 
year by year. His work, which is complex 
in its details, is in its general results easily 
understood : to reduce the death-rate of a 
city by preventing diseases which clinicists 
may or may not be able to cure is a result 
which all can appreciate. Now, of the men who 
qualify each year a considerable number escape 
general practice by going straight from a general 
hospital into a fever hospital, or by engaging 
in other branches of Public Health work ; and 
these men have little sympathy with the 
general practitioner. Thus there have arisen 
in our midst two camps, one of men in general 
practice, the other of Public Health officials ; 
and each camp is full of critics of the other. 
The two reports of the Royal Commission take 
one side when they represent the Medical 
Officer of Health as impeccable and the 
Medical Officer under the Poor Law as a 
benevolent incapable. 

Now, this is an age of criticism, and criticism 
is not seldom subjective ; moreover, in all cases 


it draws its conclusions from a part only of the 
data. Take, for example, the attitude of 
women toward weakness and suffering. I was 
once present when a procession of nurses came 
before a number of doctors, each nurse bearing 
in her arms a microcephalic idiot. Some of 
these idiots were over twenty years of age ; 
yet each one might have been a babe, and each 
one was carried in, nursed, and coddled, as if its 
age were a couple of years or less. My own 
feeling was one of horror. Why did these 
people live — for by their age they were people ? 
Every care was lavished on the unfortunate 
patients, and the nurses were quite maternal 
in their affection to their charges. Yet, if I had 
wished to prove how callous men and women 
could be towards children, how demoniacally 
cruel they could become, I might have brought 
many examples : the cases investigated by the 
Society for the Prevention of Cruelty to Children 
would serve my purpose abundantly. My 
point is, that there are two sides to every shield. 

It is not otherwise with other questions that 
have recently come to the front, shaking the old 
traditional respect in which the general prac- 
titioner was held by the public. For instance, 
there is the question of vaccination. Although 
this is a subject of great importance, it is, strange 
to say, one with which, under present conditions. 


the majority of general practitioners have little 
to do, and it is no longer necessary as it was 
once necessary. Vaccination is a valuable and 
indispensable aid against epidemics of smallpox. 
At the same time, Public Health methods of 
isolation and compulsory vaccination of contacts 
can keep out smallpox without the absolutely 
wholesale vaccination that was once so essential. 
I must not be taken to disbelieve in vaccination. 
It was once absolutely necessary as a means of 
clearing the country of smallpox, and it may be 
necessary again. But the danger is now less im- 
minent, and at present, as longas the general mass 
of the population undergoes vaccination, isolated 
exceptions do not so much matter. If even a 
doctor sees this, it is quite easy to understand 
the attitude of intelligent laymen, like the 
stipendiary magistrates, on the one hand, and 
unintelligent anti-vaccinators on the other. They 
recognise half the truth: the lowest and the 
highest are therefore united in sympathy with 
each other and in opposition to the whole medical 
profession. Vaccination has caused the doctor 
to be looked upon by one class of the community 
as a bigot, and by the other as a mercenary. 

Vivisection, too, has injured the general prac- 
titioner, for, although he never willingly hurts a 
fly, yet it is on him that the anti-vivisectors 
spend their hatred, since he belongs to that class 


of the profession with which they come in con- 
tact. Thoroughly believing in the necessity for 
vivisection, the general practitioner hates the 
necessity for it ; it is easy to understand whatmust 
be the feeling of those who do not believe in the 
necessity. To these people the medical pro- 
fession is much in the position of a State church, 
hated by zealots for its imaginary privileges and 
suppositious vices. 

Again, medical practice has greatly altered. 
The changes in treatment have been very 
rapid, and the new treatments have needed new 
doctors. The opsonic index, when it was a 
recognised necessity in medicine, demanded 
laboratories and elementary arithmeticians. 
Rontgen ray work demanded its specialists. 
Syphilis is now likely to be in the hands of a 
group of experts. All these special branches of 
medicine have had their adventures, and the 
Press, which has heralded every new remedy 
with acclamation, has announced the failures 
with equally emphatic blame. Diphtheria anti- 
toxin injections have in a few cases ended in 
disaster, and although the causes of the disaster 
have been discovered and overcome, it is of the 
failures that the public hears, not of the discovery 
of the cause. Nay, even one admired professor, 
whose child died, insisted in his agony upon 
publishing his condemnation of the treatment. 


It was a natural action ; for a doctor is less of a 
worldling than is a lawyer, and less of a phil- 
osopher than is a clergyman. 

The public, too, is more on the watch. A 
discharge from the ears after measles was at 
one time not commented on. But now, if an 
abscess supervenes, it is not the will of God, 
but the fault of the doctor. A young doctor 
dies, perhaps, in a cholera camp : a writer for a 
certain class of papers wags his head, saying : 
" He cured others : himself he could not cure." 
Or he suggests sneeringly that he did not even 
cure others. A doctor hates to lose a patient ; 
he is as devoted as ever, sits up all night with 
his pneumonia cases, meets the moment of crisis 
with an injection of strychnine, hurries up the 
oxygen, is head nurse and druggist in one ; 
and one great critic sneers at his oxygen, at his 
strychnine, at his devotion, and points to the 
pecuniary benefit that accrues to the doctor as 
long as the patient is ill. It being admitted 
that a scoundrel in the medical profession is the 
greatest of all scoundrels, it is more than hinted 
that the scoundrels are numerous. The judg- 
ment of the public on the average doctor is 
harsh. It is like the opinion of some people on 
the Founder of our religion : if the doctor is not 
divine, he is an impostor. The critic, however, 
ignores the fact that those members of the 


public who are specially interested, namely, the 
patients, are as clever as anyone else in judging 
character, that they have a keen sense of 
efficiency and straightforwardness, and that 
most doctors are found, on close scrutiny, to 
possess at least these qualities. One is not 
surprised at constantly meeting with unfair 
criticism. In a commercial age, where the 
standard of success is a money standard, and 
where the test universally and impartially applied 
is : " Will it pay ? " one must expect a certain type 
of man to be utterly incredulous when he is 
asked to believe that, in the art of healing, the 
ordinary practitioner is often a self-denying 
exponent of an ideal which is even a higher one 
than that of Art for Art's sake. The doctor's 
ideal is Art for Life's sake : that is, for the sake 
of the life of the patient. 

Again, the fact that doctors differ even in the 
manner of curing diseases is always an excuse 
for criticism ; men who care as much about 
religion as about an old boot bring in Christ 
and the Gospels, Joan of Arc and S. Francis 
of Assisi to disprove our integrity and intelli- 
gence. Yet the treatment of disease is un- 
doubtedly to some extent individual ; each man 
succeeds best by the methods to which he is 
accustomed. But we are supposed to cry all 
together when our craft is set at naught and 


our goddess is said to be an impostor. Nor 
does the critic take any account of different 
varieties of the same disease. The operation 
on King Edward has been a most fortunate 
episode for gentlemen in search of a subject 
for their descriptive powers. Appendicitis is 
a disease particularly fatal in children, less 
dangerous at other ages, and requiring also 
different treatment, both according to the variety 
of the complaint — and the varieties are numer- 
ous — and according to the special stage of the 
disease at which the doctor is called in. Hence 
all kinds of distorted accounts have, as may well 
be imagined, appeared before the public. 

The treatment of disease by drugs gives much 
opportunity to the caricaturist ; yet here also 
there are two sides at least to the question. 
Take the case of a traveller who falls ill in a 
strange city : if he is cursed with a dose of 
dysentery, he is greatly blessed by a dose of 
opium. But if he is ill at home, with every 
opportunity to rest, the opium may not be 
needed; a doctor may, indeed, think twice before 
ordering anything but a non-irritating diet. 
Strong drugs are used both less and more than 
formerly; that is to say, they are used differently. 
The prescription, too, is only one-twelfth part 
of the treatment, whereas it was once the 
fourth part. The clinicist will continue : since 


the human system will probably grow more 
complex as time goes on, more skill will be 
required in keeping the human machine in 
order, the treatment will be more elaborate, 
and the results will be obtained differently. 

At present we are in a stage of transition. 
Criticism is never intermittent and never tolerant, 
past mistakes are magnified, and the general 
practitioner is in danger of losing for a time his 
well-deserved place in the esteem and affection 
of the people. Organisation of medical methods 
is being called for. In the fulness of time the 
prevention and treatment of disease may be 
recognised as the prime beneficent activity of 
the nation ; the doctor may become part of a 
system ; he may tend to disappear as an inde- 
pendent unit and to be replaced by a great pre- 
ventive and healing organisation. But in America 
the tyrannical trust is eating up the lawyers, and 
here one fears the hospital system and the 
contract system will, if in any way stimulated 
by legislation, eat up the individualism of the 

And now I must quote a few paragraphs of 
real criticism from a treatise which was written, 
not on our profession, but on the one which most 
resembles it : I mean, of course, the Church. In 
quoting Bolingbroke I present the supremest of 
critics ; and I am ready to admit that when such 


an acute intellect considers on broad lines the 
position of a great organised profession, he may 
have something to teach us. However, the 
quotation will appeal to those who wish to see how 
any great organised profession may be attacked. 
Bolingbroke says : — " They taught what they 
could not explain, evaded what they could not 
answer ; and he who had the most skill in this 
art might put to silence, when it came into 
general use, the man who was consciously 
certain that he had truth and reason on his side. 
But as soon as real knowledge was enlarged and 
the conduct of the understanding better under- 
stood, it {i.e. authority) fell into contempt. They 
have been obliged to defend in the light what 
was imposed in the dark, and to acquire know- 
ledge to justify ignorance. They were drawn 
to it with reluctance. But learning, that grew 
up among the laity, and controversies with one 
another, made this unavoidable. They have im- 
proved in learning and knowledge ; but this 
improvement has been general, and as remark- 
able at least among the laity as among them- 
selves. A layman who seeks the truth may fall 
into error; but as he can have no interest to 
deceive himself, so he has none of profession to 
bias his private judgment, any more than to 
engage him to deceive others." And these are 
wise words. 



TN writing the obituary notice of the old club 
system one wishes to be fair both to the 
club patient and to the doctor. The artisan who 
in the past has insured against the expenses of 
sickness and the luxuries of death is to be 
respected. The Friendly Societies, standing as 
they have done between the working man and 
pauperism, call forth our admiration, even if they 
deserve our criticism ; and this criticism, so far 
as I am concerned, is the old criticism that they 
do not understand true economy. I am speak- 
ing, of course, as a doctor, and I am here only 
referring to what I have personally observed. 

Friendly Societies, though they only insure 
after medical examination, have been plagued 
with the presence among their members of the 
abnormally sick (that is, of those who become 
chronic cases) and of malingerers.^ There is 
also another class of men which, in consequence 
of the Workmen's Compensation Act, has he- 
come a burden on the finances of these societies : 

1 See Appendix A, p. 83. 



I mean quite honest workmen who, while wait- 
ing for the settlement of their claims, remain 
unemployed, when, if there were no dispute 
between capital and labour, they would return 
to work again either at their old employment or 
at some other. The executives of the Friendly 
Societies were in favour of the sick members 
being sent back to work as quickly as possible, 
and in their eyes the doctor who could keep the 
sick-list small was the best man. But this policy 
of rapidly sending men back to work may some- 
times be carried too far. Stanley tells how his 
doctor would sit among his sick Zanzibaris, 
dressing their wounds day by day, and by con- 
stant and skilled attention getting the men ready 
to march once more. But if the doctor had sent 
the men to march and to carry loads before they 
were fit, relapses would have been incessant, and 
the journey would have been delayed. 

The medical attention that has, during the 
last forty years or so, been given to club or 
lodge patients is often referred to in publications 
dealing with general practice, but the case is 
seldom fairly put. There is a very common 
idea that club doctors were chronically at vari- 
ance with their patients, an idea which is far 
from correct. Most writers fail to understand 
that the old doctor learnt to distinguish rapidly 
between those patients who were really ill and 


those who came simply for the note necessary 
to secure them the few days' rest which, with or 
without homely remedies, would suffice to put 
them right. It is quite true, however, that both 
doctors and patients grumbled ; that the doctor 
knew he was ill paid, and that the patient some- 
times thought he was badly attended. It is true 
also that, because drugs have such a marvellous 
effect in some illnesses, the public want them in 
all ; and this was particularly true in the case of 
contract patients. But it is certainly too often 
assumed that every doctor who received a 
minimum fee scamped his work, putting off with 
a few hasty questions and a bottle of medicine 
patients who really required careful examination 
and systematic attention. In a legal sense he 
would have been justified in scamping his work 
and giving only what he was paid for ; but his 
education generally made this impossible. 

At a conference between the executive mem- 
bers of a Medical Association and the executive 
of an Amalgamated Friendly Societies' Associa- 
tion a feeling of exasperation and dissatisfaction 
on both sides was expressed. The Friendly 
Society men contended that the work done for 
a contract man was not of the same quality as 
that done for a private patient. One critic, 
though he paid for the contract doctor, always 
(he added, " wisely ") called in a private doctor 


himself. Another man allowed the contract 
doctor to attend for trivial ailments, but for 
serious illnesses he submitted his life to the 
care of a doctor who charged 7s. 6d. a visit 
and stayed for at least a quarter of an hour. 
A third speaker said that his lodge paid a 
larger fee than was often given, and employed 
a medical man who was known to be a good 
doctor ; and yet there was no feeling of satisfac- 
tion. At the same time many men admitted that 
their experience had been fortunate; they had not 
a word to say against their doctor, who pleased 
them and pleased their fellow members ; and one 
man said that, though his lodge underpaid their 
doctor, the latter invariably did his duty.^ 

On our side a doctor said that every medical 
man had been trained to use his skill and do his 
utmost for his patient, and that an examination, 
if done properly, was a long affair, while the 
advice consisted of an insistence on numerous 
details of treatment as well as of the prescribing 
of a bottle of medicine ; but the payment was 
inadequate. He pointed out that the modern 
practice of medicine was quite a different thing 
from the practice of our fathers ; that at one 

' Although there is no permanent and invariable division of interests 
between contract patients and contract doctors, yet I can quite readily 
believe that the ordinary contract patient is not able to see eye to eye 
with the doctor and take the latter's point of view. To do this readily 
he must be, or imagine he is, a doctor. 


time, for a man in a small town or in the country, 
where life was simple, requiring little alteration 
in illness, a bottle of medicine might have been 
sufficient ; but the man in the crowded town 
must have attention paid to his environment, 
his habits, his food, his work, his sleeping, his 
awakening ; and methods of treatment were 
more expensive. He also stated that the cost 
of making a first-class doctor was greater now 
than formerly ; at present a doctor's curriculum, 
to fit him for all round practice, lasted from six 
to seven years and cost him more than ;^iooo, 
while the expense of carrying on a practice 
was much greater than it had been twenty-five 
years ago. He spoke as one who had taken a 
high degree in medicine and had educated three 
sons forthe profession. I n large towns, he added, 
the lodges were more numerous now than for- 
merly, and the practice had sprung up of allowing 
men to join who were comparatively well off. At 
one time, he admitted, the nominal fees paid to 
the doctors for this kind of work had not been 
objected to, seeing that Friendly Society work 
had taken up little time and energy ; but 
now a doctor often found that a large part of 
his work was financially unproductive to him, 
and the result of the doctor's dissatisfaction was 
that the contract societies were losing the services 
of many good men. The conditions of service, 


he demanded, should be altered. A medical 
man taking contract practice found that he was 
expected to labour through a lot of routine 
work. He admitted that important cases could 
be sent to the hospitals or the consultants ; this 
method, acquiesced in too readily by the societies, 
was, however, demoralising to the profession. 
A doctor should be expected to do everything 
in medicine or surgery, helped by the consultant 
or the hospital, but not displaced by them ; and 
the work done should be paid for.^ 

More than one Contract Society man, joining 
in this interesting discussion, told us that the 
trouble was due to the competition among 
medical men themselves; that Friendly Societies 
had been able to obtain the services of doctors 
for any fee offered, and that Friendly Society 
work was useful to a medical man even if no 
fee whatever was paid. It was quaintly sug- 
gested that medical men who threw over the 
Friendly Society work as soon as they could 
afford to do so were guilty of some ingratitude. 

We on our part know quite well that the men 
who accepted such work in order to obtain a 
start in a neighbourhood, or to prevent a possible 
rival from making good his footing, were fully 
aware of the miserable inadequacy of the fees 

' This passage, written some time ago, is well supported by Sir Clifford 



paid by many lodges. The fault of our black- 
legs was not ignorance, but treachery. We 
told the Friendly Society men that the number 
of our blacklegs was diminishing as our discipline 
improved, and that the time was not far off 
when doctors would refuse to allow any man on 
the medical register to work for the contract 
fees then paid. 

Let us look at the question again. A contract 
patient, who, being perhaps merely a little seedy, 
wished to cease work for however short a time 
and to receive sick pay, had to see his doctor. 
The rules said that the man who could not work 
must get a note from the doctor to say so ; the 
doctor, therefore, had to see many men who 
only required a few days' rest, men who, if they 
had not been contract patients, would have been 
dosed by their wives with castor oil, rhubarb 
or sweet nitre. The doctor was worried — at 
least, some doctors were — by the very triviality 
of these cases. He did not make long examina- 
tions ; he saw his patients quickly, trusting to 
his long experience and to his marvellous 
detective skill to enable him to pick out severe 
cases from among the trivial. We have heard 
often enough of this intuitive skill. Conan 
Doyle, as is well known, describes Dr Bell of 
Edinburgh, a wizard of keen observation and 
rapid deduction : Dr Bell went into Conan 


Doyle's brain as Bell and came out as Sherlock 
Holmes. The contract doctor had something 
of this Dr Bell-like cleverness, and on the whole 
he did very well, though his way was not a 
modern way. Young doctors fresh from the 
training ward can neither do the work nor 
understand how it was done. 

Here is a redzictio ad absurdtLm of the opposite 
method, A member of a Workpeople's Hospital 
Committee, a man of some importance in his 
own eyes, attended a meeting of this Committee 
at the local hospital. As he afterwards explained 
to me, he had an attack of " belly-ache " while 
at the meeting, and his fellows whimsically in- 
sisted that he was lucky for once : here he was 
in the very place where he could be cured. So 
he was taken to the Casualty Room, where a 
young man, " a mere boy," he said, came to see 
him, and the patient was soon, between his 
groans, giving his family history, his personal 
history, and details as to his good and bad 
habits. In twenty minutes, when this was 
all written down, another young man, not quite 
such a boy, appeared. Mr B. was now subjected 
to a closer investigation. His morality was 
doubted ; he, a teetotaller, who never went out 
at night except to "get his divi," was insulted 
by the most searching and suspicious of question- 
ings. A third man came to look at him. By 


this time B. showed some nervousness and 
readily allowed himself to be taken upstairs and 
put to bed, where, as he said, he was all right, 
though he got nothing but milk and " not a 
drop of medicine." However, next morning a 
young student filled two sheets of paper with 
notes of his case. Then a table " full of syringes 
and things " appeared, and B. trembled. " I 
thought I was very bad," he said, " but I had 
not time to say my prayers, for Dr C. came 
round with his house-physician. They stripped 
me, and the old doctor marked me all over with 
a pen and ink and began torturing me inch by 
inch." (Torturing is a touch of imagination.) 
"That was too much, and I begged to be excused. 
I was neither a smoker nor a drinker nor a 
dissolute character " (B. used a shorter descrip- 
tion), "and the pen and ink work frightened me'; 
so I said, ' I'm off,' and I went home. When 
I got there my missus gave me a dose of castor 
oil, and the next day I was all right." My old 
friend Dr D., to whom I told this, said, " Well, 
if he had come to me as a lodge patient, I 
should have given him a bottle of Mist. Alba, 
opened the door, shouted ' Next,' and had 
another lodge man in." 

Many contract patients objected to the 
thorough and careful examination, requiring 
both time and skill, which the young doctor 


always feels bound to carry out. " I've only a 
cold," a man would say, "and I want a bottle 
for my cough." He did not expect an examina- 
tion at all ; at any rate, the elderly patient did 
not. He knew that he had gone for ages past 
to his old club doctor for minor ailments, and 
thorough examinations startled him ; he believed 
them to be unnecessary. Indeed he rather 
resented a fuss. (In one instance a very valid 
objection was made by a bewildered patient of 
mine : he complained that it was hard on him 
to have to come to me at six in the evening to 
have his stomach washed. He was a very 
poor man, and it was so soon after his tea.) 
But in spite of all objections, the only safe 
way is to have every patient stripped and 
examined. An ordinary routine examination 
does not, after all, take so very long, and 
one gets positive, and, above all, negative, 
evidence as to the presence of disease. 
The diagnosis of the condition is generally 
the all-important part of the treatment. But 
the treatment may require of the doctor 
a skill no less than that demanded by the 
diagnosis, joined to the most minute, the most 
persistent and unremitting care. I was once 
called to see a man with pneumonia ; the case 
was evidently one of extreme seriousness, need- 
ing, as I pointed out to the wife, extraordinary 


attention. Even the non-medical reader will 
understand the significance of a pulse of 1 50, a 
breathing rate of 60 to the minute, and a tempera- 
ture of 104", with implication of both lungs. I 
called in the assistance of other medical men ; it 
was necessary for several to arrange their work 
so that other patients were seen by one or 
another, while one doctor was in almost con- 
stant attendance on the patient. A neighbour- 
ing medical man, a friend of the patient's family, 
was constantly calling, and watched with us for 
the crisis. At the critical moment an injection 
of strychnine and digitalis was given, and owing 
to the successful action of these drugs the patient 
recovered. To bring this man round absolutely 
continuous care had been needed : on one day 
I spent about twelve hours in the sick-room. 
All this attention was required to save a man 
from dying of pneumonia, and without it I am 
certain that he would have died. The man was a 
member of a lodge and paid his lodge doctor per- 
haps 3s. or 4s. a year ; but I am quite sure that no 
lodge doctor couldh?iV& given him the necessary 
attention, — he could not have spared the time, nor 
would the lodge officials have expected it of him. 
If a man has incipient pneumonia or typhoid, it 
matters little whether he has " a bottle" or not ; 
but it makes all the difference in the world that 
he should be sent to bed at once. 


Besides the question of time and care given 
to contract patients, there is the question of 
night calls and emergency work. This is not 
stricdy connected with the question of contract 
practice, but as in both cases we are concerned 
with heavy work done for litde or no remunera- 
tion, and as it was very often the contract patient 
who was readiest to knock the doctor up at night, 
it may be convenient to say a word about it here. 

There are certain poor districts where people 
are taken ill in greater numbers than in more 
flourishing neighbourhoods, but where the 
doctor's private fees are never paid. Apoplexy, 
suicide, murder, assault by poker, knife, or pint 
pot are common enough ; but when, at the 
suggestion of the police, the doctor is called to 
these places, he knows that in these drunken 
quarrels abuse of the doctor is a common 
epilogue to the original play. He cannot be 
expected to go willingly ; he is "out at a con- 
finement" or something of that kind. In one 
instance two brothers quarrelled, and one was 
fatally injured by the other. Though I was out 
when the drunken rabble ran to my door, I for- 
tunately followed them to the human warren. 
I was unable to save a life, but I escaped being 
censured by a coroner's jury. 

To deal first with the question of night calls : 
if there were a central night-call office, managed 


by a local committee or by a police or other 
municipal official, such calls would have immedi- 
ate attention ; and so, of course, would all 
emergencies, whether of the lurid type I have 
sketched, or due, say, to a man returning ill from 
his club or being taken ill in his home. Duty 
would be taken in turn by the different medical 
men volunteering to serve on the rota, and the 
expense should be borne, as the expense of 
police cases is borne now, municipally, and 
recovered from the patient by the municipality. 

Then to return to the question of contract 
practice : contract work should not be paid for 
simply at the rate of so much a head. One 
suggestion would be to give the doctors a 
retaining fee, and beyond that to pay for work 

It was once pointed out to me by an old club 
man that lodges had to compete with insurance 
men or penny-a-week collectors. If i|d. or 2d. 
had had to be paid to the lodge for medical 
benefit, the father and mother would have been 
attracted, say, to the Prudential Insurance 
Company. Of course the contribution for 
children in lodges, as for adults, covered more 
than the doctor's fees. For the few pence which 
an adult paid weekly into his lodge, he obtained 
sick pay when he was ill and death-money at 
the end; for a id. a week for the child he 



obtained the doctor and the death-money. 
There was also the further difficulty that only 
a certain percentage of the adult contributions 
to the lodge were allowed by the Registrar of 
Friendly Societies to be devoted to extras, and 
in the eye of the Registrar the doctor was an 

There is an additional explanation of the low 
fees paid by Friendly Societies in the past, 
which has, so far as I know, never been referred 
to. Until the last few years much of the 
attendance on lodge patients suffering from 
trivial illnesses was done by unqualified senior 
medical students working as assistants in contract 
practices. In towns where there were medical 
schools or large hospitals these assistants were 
able to complete their medical curriculum whilst 
earning some small salary from their employers. 
This kind of post has been abolished. The 
work done for lodge patients during the last few 
years has been done by legally qualified men ; 
but the low fees, which were of less importance 
under the old conditions, are to be perpetuated 
under the new, unless the medical profession 
sees that such a policy can only be suicidal. 

Again, in the past a workman has often paid 
much more than is commonly known. Besides 
his contribution to his club or lodge, of which 
perhaps 3s. or 4s. a year went to the doctor, he 


has often paid something Hke a penny a week 
to the local Infirmary, besides giving a small 
contribution to a sanatorium; so that he has 
paid, it may be, as much a los. a year for medical 

Ordinary patients expect the doctor to be 
familiar with massage, baths, electricity, and the 
laws of hygiene. The doctor must have a 
knowledge of what is called Public Health, i.e. 
he must know in a general way what the sanitary 
expert knows in a particular way. He must 
know how habits affect health, — one could go on 
for ever with the list of things necessary for him 
to know. Now, the club doctor may have had 
this knowledge and may have used it for the 
benefit of the club patient. But the latter was 
very tolerant of ignorance ; he desired excellence 
only in one branch of medicine : the giving of 
drugs and the rapid diagnosis of danger or the 
absence of danger in his illness. 

This chapter, will, it is hoped, convince the 
reader that the mutual complaints of club patients 
and doctors have been due to a belated adher- 
ence to a bad system. The medical profession 
of yesterday, wdth its pitiful individualistic pride 
and incapacity for organisation, has allowed a 
considerable minority of its numbers to sink into 
a position comparable only to that of mean whites 
in another political state ; and the number of 


these mean whites is Hkely to be vastly increased 
by recent legislation. I have shown that in my 
opinion no blame is to be attached to the Friendly 
Societies. The club patient was in an intel- 
lectual twilight as regards medical requirements 
in illness : he was shrewd enough, but he did 
not know what was wanted. When men of his 
stamp see clearly what is needed, they will be 
loud in declaring that the doctor who may have 
to attend them in pneumonia shall be a com- 
petent man and shall be adequately paid. But 
the patient himself will demand more than he 
has had in the past. 

In speaking of the Friendly Societies I have 
had the adults in my mind. To describe the 
system of medical attendance on juvenile lodge 
patients is not a pleasant task. The children 
were not in any true sense attended by the lodge 
doctor at all. If a child was chronically ill, say 
with hip-joint disease, it was taken to the 
hospital. Diseases of the eye and of the ear 
found treatment at the Dispensary. The 
ordinary doctoring of the child was done by 
the mother, whose limitations as a careful 
physician were considerable. The doctor to 
a juvenile lodge ought to have attended every 
child in the society, but some doctors had over 
a thousand children on their lists, which made 
the task impossible. In future ages men will 


look back on this state of things with incredulity. 
It is to be hoped that the time will soon come 
when every child will be seen by the doctor, who 
will advise as to diet, exercise, school tasks 
and recreation. The child's mental and physical 
conditions should be thoroughly understood, 
and lectures to the mothers should be a com- 
pulsory part of the doctor's duties. So, and so 
only, would the child be really "attended." 

Such, however, were not the views of the 
lodge officials. The doctor was expected to 
attend when the mother wished him to do so, 
and this was, as a rule, when the child was 
seriously ill, generally with an acute intestinal 
complaint. The coroner was kept out of the 
house, but tubercle, syphilis and rickets entered 
in. The lodge officials were rosy with content. 
It should be added that in their imbecility they 
paid the doctor a halfpenny a week for each 
child on his list. I feel ashamed to have to 
refer to such fees, but the fee has been the crux 
of the whole question. About twenty years ago 
I was doctor to thirteen lodges, but on going 
into the matter I resigned them all on one day. 

Doctors as a body have in the past regarded 
the interests of their patients, especially of their 
poorer patients, far more than their own. If 
they speak now, when their own interests are 
touched, they speak, of course, in some measure 


to defend those Interests. But the selfish motive 
is not the only one : they are making a stand 
in order that they may be able, in the future as 
in the past, to do their utmost for all those who 
seek the help of their skill A pauperised 
medical service can only be a temporary evil to 
the doctors, for it will warn young ambitious 
men to seek elsewhere for satisfying careers. 
These abstentions of the best must eventually 
direct public attention to the cause and so lead 
to a cure. If such a service were to last, the 
present Herodian system would remain for the 
children ; the wiser nations would shoot out 
their lips and shake their heads at us, and we 
should be the scorn of the whole scientific world. 

I was one of those present when a Chancellor 
met the delegates of the British Medical Associa- 
tion. The bright-eyed, alert, popular politician, 
courageous, ready and good humoured, was a 
glorified example of the witty, business-like 
market practitioner compelling his wares on a 
circle of admiring but doubting critics. He was 
just the man to make us forget that a Cabinet 
Minister in charge of a Bill is a man who 
has to strive strenuously to pass his measure, 
whatever its value. This particular Bill, how- 
ever, was a bad one. Such Bills are business- 
like in one single respect : they must pay their 
way. Those whom this Bill — now an Act — 


most carefully protects are those who need little 
protection ; they are included in its scope be- 
cause they have money in their pockets and can 
always be relied upon to pay their coppers. 
The poor — the very poor — will not be benefited ; 
nay, such schemes damn the poor. Those who 
neglect to pay regularly or are unable to do so 
will not receive benefit. And the stream of 
charity which has in previous times helped the 
friendless is easily dried up when burdensome 
legislation is the order of the day. The teach- 
ing of the Minority and Majority Reports is 
that poverty is caused by sickness and the long 
periods of idleness incidental to casual employ- 
ment. Now, among casual labourers sickness 
is the chief cause of poverty, and these men 
will not benefit by this kind of legislation. 

Many of the schemes one meets with, in 
Parliament and out, neglect these feeble folk 
and curry favour with such bodies as the 
Amalgamated Society of Engineers and the 
Hearts of Oak Benefit Society, in order to 
secure a mass of well-to-do, steady payers who 
are also possessed of great social and political 
power. And because the Government will 
not take the trouble or bear the expense 
necessary to inquire into incomes, the present 
income-tax record is to be the test as to whether 
a man is or is not included in these elaborate 


plans. Now, men with over /^loo a year don't 
need the Chancellor's help, but men with less 
than ;^50 a year do, and they don't get it. 
Men should pay according to scale : say two 
guineas a year for a man with an income of 
;^35o, more for a larger income and less for a 
smaller one. But this can be done and is done 
regularly through ordinary insurance companies : 
men insure against sickness and receive during ill- 
ness a weekly sum proportionate to the premium. 
Thus a man paying /^y. ys. a year will receive 
during sickness something like 5s. a week, 
with which he can pay, and does pay, his 
doctor's bill. But this plan does not give the 
Chancellor any money to play with. A demo- 
cratic (!) Government helps inversely to the 
need of help and directly to the power of the 
applicants. And when it is considered that 
the comparatively wealthy workers have never 
asked for help or for interference with their 
concerns, one can understand the anger and 
suspicion that have lately been aroused in the 
minds of medical men. 

Politicans of all kinds are at present looking 
to the men in the street, the men of the lower 
middle class, and relying on them to coerce 
every other section of society. If societies were 
crystallised and in immovable sections, this would 
assuredly happen; but fortunately society is 


fluid, especially in England. If it were other- 
wise, the independent action of such a body as 
the medical profession would be stamped out 
by the roughest and rudest and strongest among 
the organised trades. Most of the men of these 
trades, taken as individuals, are as good as any ; 
the people they choose to represent them are 
often picked for their truculent qualities of 
aggression and their abnormally thick skins. 
For a learned profession to be controlled by 
such men and by their following, male and 
female, would bring about the worst form of a 
democratic aristocracy, with all the vices and 
none of the virtues of its parents. A man 
like Mr Lloyd George knows the powers of 
organised trades and crafts, but he apparently 
does not reckon with the just pride and the 
love of rational independence which animate 
such a body of men as the doctors. An emo- 
tional man, capable of playing on the emotions 
and passions of others, but incapable of fathom- 
ing the real depths of character, is just the one 
to set such an engine of tyranny going. And 
the Friendly Societies are practically the same 
as the organised workmen. 

What is needed in medicine is to use the 
resources of the nation for prevention, to 
institute a reformed service by which the causes 
of illness will be inquired into. But plans for 


making every doctor into a lodge surgeon, 
weighing him down with work, sweating him 
with low fees, and at the same time filching 
from him the patients who have supported him, 
will not do much to that end. 

The medical profession is at present in 
search of a leader acquainted with its needs 
and possessing the perfect wit required to 
advocate its cause. If such a leader could get 
the profession to speak with one voice, he could 
compel Governments to listen ; only by such 
leadership shall we become individually of equal 
importance with an ignorant Irish peasant. 
Hitherto, our opinions have been voiced by the 
pedagogic men who have been chosen to repre- 
sent the voluntarily inarticulate working class 
doctors. The leader who could lead mip^ht 
easily be a great scientist as well as a man of 
the world, but he must be the latter ; Professor 
Huxley in his day could have combined the 
qualities, and in our day such men as Osier, 
Bland Sutton or Moynihan could speak, if they 
would, with a voice like the blast of a trumpet. 

Medical political meetings in the past have 
been good-humoured gatherings, laughing at 
verbal points; at present it is easy to see a 
change. Wit of the careless, genial character 
has disappeared ; men speak seriously, and, in- 
viting no applause, get the more. Such men 



are in earnest. All those who desire the welfare 
of our profession as a means to its greater use- 
fulness must welcome the changed attitude of 
the doctor upon political questions. Compelled 
by the contempt which politicians of all grades 
have showered upon them, medical men are 
ceasing to be Ishmaelites. In the past, what 
politician has ever feared the doctors? And 
what politician has ever dared to cross the 
lawyers ? 

But the political doctor is now born ; he is 
creeping into our municipal councils, and before 
long he will be sitting in the Cabinet. He must 
insist upon a scheme of national medical service 
which will be to the utmost benefit of the nation, 
and he must see to it that those who are to be 
the ministers of this system are so remunerated 
that the best of our young men may be willing 
to work under it. By such an enlightened 
policy the Indian Government has enlisted in 
its ranks Englishmen of high character and 
ability ; by such an enlightened policy we have 
governed successfully an alien empire ; surely 
it is of equal importance to retain the services 
of men who will lessen suffering in every family, 
who will enable us to check preventable disease 
and premature death, who will help us to pro- 
duce a race fit by equipment in body and in 
brain to keep our position among the nations. 



If you have enough unimaginative courage, you may describe 
many real invalids as malingerers. Valetudinarianism is hardly 
malingering, and yet one merges in the other. I am sure that 
very many sick people — I am inclined to say most — are in this 
sense malingerers : their dramatic instincts make them wish to 
pose. I have no doubt that the picture of John Wesley's death- 
bed has affected many a Wesleyan minister when his time has 
come to start on the final ciixuit. 

If, then, honest people may be malingerers, perceiving their 
pathological symptoms in colours, what of the dishonest i It is 
easy to share the universal feeling in the medical profession 
that the Workmen's Compensation Act is responsible for a 
deterioration of character, a wholesale deterioration of character, 
among artisans. This Act directly incites to malingering. A 
man, perhaps a moulder, has a trivial injury, possibly a slight 
burn on the foot. This would at one time have been covered 
with a not necessarily very clean rag, and the man would have 
worn an old boot to prevent galling ; he would not have stayed 
away from work, and he was seldom any the worse. Now he 
goes home ; he is away from work for a fortnight, the legal 
time — he would not get compensation otherwise ; he gets half 
his wages from his master, he gets club and trade-union pay ; 
and on adding it all up one may find that he is receiving more 
than his wages. In one case which came under my notice the 
excess was sixpence — not a great amount, perhaps, but signi- 
ficant. And in this very case the man kept pigs for profit, and 
his wife had a small shop. It must be remembered that if a 
man is away from work for a week he gets nothing from his 
master. He therefore thinks he may just as well stay away for 
a fortnight and have the extra holiday with the half wages as go 
to work the second week and get exactly the same money — and 
this quite apart from the question of club money, etc. With 
boys the case is even worse : if the wages are less than los 
a week, the whole and not the half must be paid when there 


is a fortnight's absence; the temptation to prolonged idleness 
is therefore still greater. 

And before I leave this question of malingering, let me say 
that the doctor is the only protection society has against the 
malingerer, as many a workmen's club has found out in the past. 
The Workmen's Compensation Act has ruined many of these 
clubs, for when a man has claims against his employer the 
lawyer on the man's side very naturally refuses to let his client 
return to work until the case is settled, and thus a man who has 
really been away from work because he is fighting his employer 
has technically been sick and has been drawing money from his 
club, chiefly, and in some cases entirely, on legal and not on 
medical grounds. 


Two of the great social reformers of the day object to recent 
legislation, because " it does not prevent illness any more than 
the insurance of crops against hailstorms protects the crops." 
(" The Prevention of Destitution," by Sydney and Beatrice 
Webb, p. 1 60.) 

" It is, moreover, not unimportant to remember that, whilst 
insurance does not prevent, it may quite probably (unless very 
carefully safeguarded) actually increase the evil for which it 
purports to provide." {Ide7n, p. 163.) 

" Compulsory insurance, as we see it in the German Empire, 
as it is embodied in the Chancellor of the Exchequer's Scheme 
of 191 1, with its automatic and obligatory deductions from wages, 
entails on the contributor no act of thrift, involves no exercise 
of the quality of foresight, demands no responsibility for ad- 
ministration, and impUes no subordination of present impulses 
to future needs." {ldef?i, p. 169.) 

" Now, regarded as a method of raising revenue, compulsory 
insurance of all the wage-earning population, with its elaborate 
paraphernalia of weekly deductions, its array of cards and 
stamps, its gigantic membership catalogue, its inevitable 
machinery of identification and protection against fraud— in- 
volving not only a vast and perpetual trouble to every employer, 
but also the employment of an extraordinarily extensive Civil 


Service Staff— is, compared with all our other taxes, almost 
ludicrously costly and cumbersome to all concerned. We 
believe that the nation will presently wake up to the fact that it 
will be spending from 20 to 25 per cent, of the whole insurance 
revenue in the cost of its collection, as compared with the 2 
or 3 per cent, for which the Inland Revenue or Customs De- 
partments would actually raise those additional thirty miUions 
through one of the recognised channels of direct or indirect 
taxation. We shall be ■wasiin^ from two to five millions a 
year ! " {Idem, pp. 170-1.) 

" It is interesting to notice that it is exactly the unnecessary 
public provision and unnecessary public expenditure, involved 
in any compulsory insurance of the entire artisan and lower 
middle class, which has stirred to rebellion the whole medical 
profession." {Ide?n, p. 173.) 


From '■'■The Times'''' of January 3rd?, 1912 

The Insurance Act and the Future of Medicine 

To the Editor of " The Times " 

Sir, — Unwilling as I am to swell the flood of letters on your 
table, yet I feel compelled to set forth, or to illustrate, one 
aspect of this matter which has received but little attention ; 
I mean the influence of the Insurance Act upon the develop- 
ment of medicine, upon the very end at which it professes in 
part to aim. In the Houses of Parliament the lawyer is at the 
elbow of every Cabinet Minister, if not inside him ; so in all 
legislation the lawyer is well provided for. The medical man, 
on the contrary, is so hard put to it to get through his round of 
irregular work, and so continually is prevented from attending 
to public affairs— his own and other— that he begins to forget 
them, and he himself to be forgotten. Consequently, while the 
lawyer is, fairly enough, receiving his due, the doctor is re- 
membered only to be ignored. The Cabinet Minister probably 
means well towards the doctor, but knows little or nothing 
either of modern medicine or of its business. 


In his Insurance Bill the Chancellor was thus content — and 
that is the point I would make — was thus content with an 
antiquated notion of medicine and of medical service ; he took for 
granted without inquiry a notion built of some vague knowledge 
of village clubs, and of the old-fashioned vade 7necum way of 
doctoring. This is, "for such and such a disease, such and 
such a drug ; take the mixture, drink it regularly, and get well 
if nature will let you." And if our people have ceased to check 
the doctor's bill by the pill boxes, bottles and pots on the shelf, 
even Cabinet Ministers have not escaped from this ancient 
habit of thought. 

Now the younger men who are passing from the Universities 
in these years are entering upon medicine as into a new calling, 
with new ideas, and with changed views of their portion in it. 
Many of these abler and more accomplished men are now 
passing beyond the large towns into smaller towns and villages, 
some of them preferring a country life. Thus they are mission- 
aries, carrying with them these new ideas of medicine, and 
developing new modes of practice. With these men, if not 
discouraged, lies the future of medicine in its popular sense ; 
and they have chosen medicine as a calling chiefly because of 
its new scientific values, and of its enormously increasing power 
over disease, achievements to which. Sir, you have again 
and again generously testified. Thus the hereditary maxims 
and craft rules of the elder medicine, maximum rules which 
made current practice easy and comparatively irresponsible, 
are dissolving into wider conceptions and a larger scope of 
work which demand a far more arduous and a far more respon- 
sible service. To this service the modern medical student in 
town or country is ready to devote himself. 

The modern physician— for such is the modern practitioner, 
to whatever side of his profession he be given— perceives that 
the treatment of disease, if not independent of certain hereditary 
lore and cleverness of resource, yet is first and last a matter of 
searching diagnosis ; and every day diagnosis is opening out 
as a more and more abstruse and costly affair. In therapeutics 
much may depend upon the precise administration of a drug 
at a cardinal moment, a drug used economically and in a timely 
manner ; but it is no longer a matter of continual pills and 


potions- Therapeutics consists even more in rearrangement 
of life, and the aid of other, often physical, means of an elaborate 
kind, such as specific exercises, baths, climate, rest, massage, 
electricity, and so forth ; means, it is true, not commonly at the 
service of the general practitioner, but of which he brings a full 
knowledge from his schools, and on which he is able to advise 
intelligently. And for a more searching diagnosis he can do 
still better. The man who leaves us for practice is schooled 
in all these methods ; he can examine the blood, counting and 
comparing its corpuscles ; he can perform the ordinary bacterial 
examinations ; he can estimate the chemical values of secretions 
and excretions ; he is skilled in the use of instruments of preci- 
sion, of blood pressure gauges, endoscopes for the eye, the 
larynx, and other internal parts ; he knows something of optics, 
and can indicate precisely where more of this kind of investiga- 
tion can be had, and to what advantage. But all this means 
time and money, and a long and costly technical education. 
Nothing tells in argument like a concrete example ; permit me 
to illustrate my meaning by such an instance. A working man, 
of about the age of forty, complains of hoarseness ; nowadays 
he is not sent off with marsh mallow and tolu, his larynx is 
examined ; one vocal chord is seen to be palsied ; and thus an 
aneurism in the chest is betrayed. A specific cause for this is 
suspected ; and a so-called " Wassermann " test is applied ; 
upon the response to this test depends at least six months of 
continuous and active medication, and at least two years more 
of occasional vigilance. Now, to perform the Wassermann 
test takes at least four hours of continuous attention ; most 
general practitioners no doubt will have it done for them by an 
expert, but will all this be done under contract at a low rate of 
pay ? The test alone, for skill, time, apparatus, etc., cannot be 
put at less than 20s. Are we to say that these proceedings are 
to be denied to the poor countryman who is able to do some 
work and cannot spend all his time in a hospital ? 

Now, if we are to say that the general practitioner is to be but 
a stop-gap, and that every malady of importance is to be sent 
to some central institution, is not this to take the heart out of 
our very efficient students, and to degrade the career of 
medicine? Gloss it as we may, contract practice will stand 


lower in public esteem and will be of lower average efficiency 
and much less humane ; it will damp the aspirations and blot 
the high-minded ideals with which I, who know, say that the 
young physicians of to-day are entering upon our profession ; 
and it will push them back to old-fashioned routine and to ill- 
remunerated and therefore under-valued service. 

But it may be urged — what about club practice as it is? 
Well, it has been felt of late that the system was breaking 
down ; partly because of the niggardly policy of the Friendly 
Societies' conduct, for which they are now reaping their reward. 
1 1 must be admitted that, where clubs made the bulk of a practice, 
it was very perfunctory work, and fell into the hands of per- 
functory men ; but where a club formed no great bulk of a 
practice the work has been done better, often admirably, because 
it has been regarded as hospital work has been regarded by 
consultants, and been done for love of the profession, for good- 
fellowship and humanity, and, it is fair to add, for some advantage 
of status and experience, but not for pecuniary profit. But even 
then such a medical man of a club usually makes his members 
understand that he does not undertake to give them more than 
ordinary attention. 

I appeal then, to the public to ask if this new machinery is 
calculated to develop the backbone of medicine on new and 
growing lines, or if it is to sweep us back upon old methods ? 
Can the answer be doubtful ? The solution is no contract, but 
payment for work done on a standard tariff. 

Once more. It is urged that the local committees will keep 
up the standard. Will they ? A short time ago two intelligent 
members of such a local board urged in Committee that means 
should be taken to get the best possible candidate for a post in 
their service. They met with a silent but sturdy opposition, 
and an obscure person was named for the place. After some 
protest the chairman — no inconsiderable person — somewhat 
shamefacedly admitted, "The truth is, we do not want 'a 
good man ' ; he is sure to make new demands upon us j we 
prefer to elect a quiet man who will give us no trouble."— I am, 
Sir, Your obedient Servant, Clifford Allbutt. 

Cambridge, December jpth. 



DOUGLAS JERROLD once said of a 
friend of his that in his writings he 
always added to the description of the particular 
the philosophy of the general. I wish medical 
men would show something of this spirit and 
view the future in a more thoughtful way than 
is now common among them. 

Take, for example, the suggestions which 
are being made by men in our own ranks that 
the doctor should become a state-paid govern- 
ment official. We are told that on the one 
hand the work he does now is not nearly his 
best, while on the other hours are long and 
the pay poor. Both these defects are to be 
remedied when the doctor is an official drawing 
government pay, and he himself is to occupy 
a position of power, dignity, and comfort. So 
at least think the men who have leanings 
towards a state service. But even if we are 
inclined to accept these conclusions, it will be 
well to examine the conditions, and to see what 
is at present the lot of the state-paid official. 



It is not the cultured professional man now 
writing glibly on state-paid officialdom who 
will put our necks under the yoke : it will be 
our new masters. There is grave reason to 
fear that our conquerors, the people, prefer 
quacks to doctors : they are ready to believe 
without question those who say that a medicine 
or a treatment will do 'what in truth it cannot 
do ; they are ready to accept pills to cure earth- 
quakes, and they have a greater faith than we 
doctors have in medicine as a system of 
drugging. What they want from us is often 
not in reality our best work, and many of them 
do not want to pay for it. If the life of a 
state-paid official is to be the lot of the new 
doctor, it will end in poorer wages for harder 

Consider the payment that is meted out 
by the Education Authority to our best men 
now : a doctor with the most expensive of all 
professional educations behind him, and with 
the best of diplomas, who has been appointed 
in the face of competition to the post of School 
Medical Officer, examines thirty Council School 
children and fills up his report ; and he is paid 
for this the munificent sum of 20s. It is not 
good work that is asked for here : it is rapid 
work, colourless, capable of being embodied in 
reports, accurate or inaccurate. These masters 


of ours are sloppy creatures themselves ; they 
are the so-called practical men, and we all 
know what that appellation means ; we have 
only to think of the ordinary practical plumber, 
or the practical man in a workshop, to know 
that these men do not always understand work 
requiring thought. 

The present state of things is not good. 
What of the future ? What is the threatening 
danger? By what means can we safeguard 
ourselves against it ? 

We may judge of the danger by considering 
the position of a schoolmaster of some inde- 
pendence in thought and word. Such a man is 
a marked man. Above him, in an office, is a 
glutton for power called a secretary, with a 
greater glutton called a chairman, who has 
shown in the past that he understands the 
whole game of petty tyranny. The Education 
Committees in City Councils have very few 
cultured lay members : such men are repelled 
somehow ; and on the professional members 
the committee man looks down. An occasional 
lawyer is put on the committee, and he is 
almost always a good man, for the dregs of his 
profession are too fearful of even the shadiest 
of public careers, and the City Council is too 
public for the pillory. There are also other 
good men on these committees, it is true ; but 


some of the members have in past years been 
heartless mediocrities, ignorant as th^ Beadle in 
"Oliver Twist." For fear of these some school- 
masters and schoolmistresses have been in a 
state of horrible degrading terror ; and many, 
•unless they could use slim cunning to cover up 
their feelings, have been subject to all kinds of 
small annoyances, to slights, even to insults. 
And there is always the likelihood that the 
most powerful man on a public committee is a 
snob. To give a very mild instance : I have 
known a case in which the chairman of an 
Education Committee wished to speak to the 
headmistress of the local High School. It 
did not occur to him to call upon the lady ; he 
did not even ask her to come and see him ; he 
sent a message telling her to do so. There 
was no intentional rudeness here, nothing but 
ignorance of manners and want of good breed- 
ing ; but this instance allows one to guess what 
would be possible where there was a spice of 
ill will and an itch to use power tyrannically. 
Where these have been present, I have known 
highly qualified men, who had innocently made 
themselves obnoxious to their municipal masters, 
kept back in their careers. 

I am glad the School Board has gone, but I 
fear the Council School system is no better : at 
its head we still have Gradgrind, with the same 


spirit, the same principles, and the same voice. 
A similar result is seen in the mercantile marine, 
— in fact, in every branch of work where official- 
dom is powerful, and where a central office is 
the king and the castle, while the worker is the 

Here, then, is the danger. How is it to be 
met ? Without a doubt, by the doctors them- 
selves. If medical men are ever groomed into 
stable steeds as schoolmasters are now, it will 
be their own fault. It is for them to defend 
themselves and to find their own remedy. 
Unless the medical profession is to be more or 
less bureaucratically ruled in the future, as is 
evidently intended, an effective antidote must 
be applied ; and this antidote will be the same 
that the small Sheffield masters might at one 
time have used : combination, a strong, solid 
co-operative society. The British Medical As- 
sociation is the only large body which can be of 
use in this way. It has 20,000 members, each 
of whom pays a guinea a year for the " British 
Medical Journal," and a few shillings more for 
certain other advantages. This^ Association 
has a great task before it, and if it is equal to its 

1 This sentence, first written early in 191 1, originally began thus: 
«' The secretary has a great task before him, and if he is equal to his 
opportunity . . ." But now— he is "like as the children of Ephraim, 
who, being harnessed and carrying bows, turned themselves back in the 
day of battle." 


opportunity, some day the medical man will feel 
that he is in a trade union, with all the cohesive 
power which Kitson's or Fowler's men show in 
trade disputes. The more powerful the British 
Medical Association becomes, the more ready 
will any government be to consult it. 

But at present, individualism in medical men, 
the same individualism which makes them the 
prey of every blackleg sixpenny doctor who sets 
up in any district, prevents their active co-opera- 
tion with the British Medical Association. In 
the past they have bought the admirable "British 
Medical Journal," but they have rejected as too 
uninteresting to be read all the pages dealing 
with the financial and co-operative side of their 
work. The local branches of the British Medical 
Association, besides, are too much in the hands 
of correct and starchy men, dry, long-winded, 
anti-social. (I go myself to the local gatherings 
and sometimes take part in the proceedings, all 
in the most correct and starchy manner.) It is 
not surprising, then, that some large centres have, 
in addition. Medical Practitioners' Associations, 
which have been formed as an expression of 
local needs : somehow the British Medical As- 
sociation cannot get close hold of many of the 
districts, and these local associations can. Some 
day, possibly, a Joshua will appear in the British 
Medical Association, who will lead all the differ- 


ent tribes into the Promised Land ; he will look 
upon the lesser bodies as his allies, and he will 
find some means, without destroying their esprit, 
of affiliating them to the greater one. And as 
it is the fault of many great associations that 
they are run by ledger men, with accurate card- 
systems, but with no intimate personal knowledge 
of, or influence in, the respective localities, the 
looser the tie between the British Medical As- 
sociation and the local bodies the better. It 
should be the business of the British Medical 
Association Executive to carry out the wishes 
of the majority, and the business of the branches 
or affiliated bodies should be to obtain the loyal 
adhesion of every medical man in any and every 
district to the policy of the Association, 

A local association such as has been mentioned 
must, if it is to be of use in an emergency, have 
a very large membership. It is not enough that 
it should be merely representative : it must aim 
at including all the medical men and women of 
the district. The policy of the association should 
be decided upon by a preponderating majority of 
he members, and should be carried out by a 
strong executive, elected in a full meeting, whom 
every man should be pledged to support. Ex- 
clusiveness would be fatal : every local man on 
the registershouldbe summoned to the meetings, 
not omitting the men with grievances, who do 


far less harm in the open than if allowed to sulk 
in their tents. These large general meetings 
would operate against unprofessional conduct and 
against fads. Nothing is so feared as general 
disapproval publicly and openly expressed, and 
many a man would shut his surgical shop of 
sixpenny swindles if he were incurring t\\Qptiblic 
censure of his professional brethren. Faddism 
would never flourish if the faddist had to con- 
vince three-quarters of his fellows before his fads 
were adopted. The great danger which such 
an organisation would have to fear would be 
the appearance of an opposition minority suffi- 
ently large to assure to its members such an 
important degree of moral support as a few 
scattered units cannot possess. 

The British Medical Association, supported 
by a system of loosely affiliated bodies such as I 
have described, with large and popular member- 
ship, would be exceedingly powerful, either in 
council or in dispute with a Government acting 
unfairly towards the general practitioner. By 
expressing the views of its members, by offering 
destructive or constructive criticism, by threaten- 
ing passive resistance, it would either stave off 
or, at least, greatly mitigate the evil of badly 
drawn Bills. It would be able to do much to 
prevent medical servants of the State from being 
choked and strangled by hateful officialdom, 


and it would give the country a medical service 
of far greater value than the one it has at present. 

The medical man who, on general grounds, 
is pleased at the prospect of a socialistic medical 
service cannot forget that the public medical 
services at present in being are dreadfully mis- 
managed. Asylums, for instance, should be 
institutions worked on highly scientific lines, 
with research students and highly paid medical 
assistants working for the amelioration and 
cure of disease. But, with a few brilliant 
exceptions, the lunatic asylums of England are 
prisons with overworked medical warders. 

Great changes are certain to take place in 
medical practice. " We are all socialists now " 
may have been said only half seriously ; but sub- 
stitute "reformers" for " socialists," and most 
of us believe in the melting-pot. You may 
have to make all doctors into officials, and many 
into inquisitors called inspectors. But English 
reform must be on old lines : new schemes must 
be grafted on old methods, or there will be a 
reaction of disgust. We want 

" Not the hasty product of a day, 
But the well-ripened fruit of wise delay." 





{Now or in the Future) 

XITITH all the supposed benefits of modern 
life, the exhaustion of competition is 
greater and nerve degenerations are more fre- 
quent. Youth is more often saved, and phthisis 
is thrown into a later age; but there is more 
cancer, more epilepsy, more lunacy. 

Medical men know this, and like other honest 
people they wish to look forward to a bright 
instead of to a sombre future. This is what 
we are working for. If our feelings were less 
earnest, even the little ones now lisping in 
schools would in twenty years be our accusers. 

We have always taught the reformers : the 
Public Health service, the public hospital ser- 
vice, the Friendly Society service have all been 
fostered by medical men ; and it has long been 
the function of the medical profession to strive, 
by opening up a new world of discovery, to re- 
dress the old world of suffering. The one thing in 

medicine I wish to see unchanged is the character 



of the doctor. It is not likely that the profession 
will be found in opposition to the great co- 
operation of strong and weak for the benefit of 
the weak. 

National Insurance has long been overdue, 
and a State medical church appeals to medical 
men as readily as to other people. But this 
does not involve support of every opportunist 
politician who, ignorant of the complicated 
working and interworking of the profession, and 
neglecting to consult fully and frequently with 
any but one school of medical thought, sets 
himself the task of legislating for a proposed 
change vitally concerning the nation, the pro- 
fession, and the whole practice of medicine. In 
all these legislative changes, affecting as they 
do the status and the complex life of the medical 
profession, it is of the first necessity that our 
leaders should be called into council with the 
politicians. Let us have no iron-bound methods, 
based upon the opinions of but one school. 
Progress needs elasticity of thought as well as 
the mathematical opinions of the sociological 
sciolists who essay to closure the future. 

We have received recent legislation with a 
perhaps natural fear; and the more we have 
looked into it, the more our distrust has deepened. 
When we find that because we have never safe- 
guarded our interests in the past these interests 


are now to be sacrificed, our feeling becomes 
one of acute animosity and resentment of the 
injustice done us — an injustice which leaves the 
profession prejudiced against all socialistic legis- 
lation, whether called for or not. 

When it is remembered that it would take 
seven years to create another medical army such 
as ours, it is plain that the politicians are in 
our hands. They can pass medical bills, the 
peers may confirm them and the King give his 
assent to them ; but without our assistance all 
such legislation is useless. If only a great and 
universal impulse passed through our ranks, 
bidding us act as one man, a battle between the 
doctors and the politicians would be the shortest 
ever fought. That we should be unanimous is 
all in favour of public rights. Medical men are 
slothful in politics, prone to bear unfair treatment 
with just so much grumbling as falls short of 
revolt ; they are not by nature rebels. But our 
weapons are simple. We only need signatures 
and guarantees — financial guarantees, it may be, 
as we ought to be ready to pay and to play our 
part. A strike is unthinkable, but a determina- 
tion to refuse to work with a Government is not 
unthinkable. We should never come even to 
that, unless both the public interest and the 
future of a scientific profession demanded it. 

The doctors have immense power, but tradi- 


tion is against the use of it except in extreme 
circumstances. If, however, the opportunists 
wish, now or in after time, to make the condi- 
tions of practice incompatible with the interests 
of medicine as a great profession, if the condi- 
tions are such as to entice into the ranks none 
but men poor in character and intellect, then 
the power will be exercised. 



"r\URING the last dozen years two important 
' changes have taken place in the treatment 
of midwifery cases. It may be interesting to 
consider for a moment what these changes are, 
how medical men and their patients are affected 
by them, and what further developments may 
be hoped for or desired. 

The first change was in the doctor's assistant. 
At one time, especially in practices with much 
midwifery work, many unqualified men were 
employed ; a doctor with a list, say, of five 
hundred confinements in one year left the 
ordinary cases, or at any rate a fair proportion 
of them, to such an assistant, reserving for 
himself those which were abnormal. Young 
doctors felt aggrieved that their seniors, by 
employing men without a full qualification, 
should prevent younger practitioners from 
getting the work to which they felt they were 
entitled ; the Medical Council took the same 
view and set its face against the employment 
of unqualified assistants. Such unqualified men 


were now only allowed when they were bona 
fide medical students, working under the prin- 
cipal and taking no direct responsibility ; except 
for these the unqualified men had to go, and only 
fully qualified medical men were henceforward 
eligible as assistants. As the qualifications of the 
assistant became higher, so did the salary. But 
a great deal of midwifery work is ill-paid ; it is 
also very trying work, and it means much time 
out of bed for the doctor. In a poor practice it 
was not worth while to employ for such work a 
highly-paid assistant ; consequently these cases 
were left more and more to the midwives. 

The second change was in the nurse. By a 
recent act a large number of women who had 
habitually attended poor mothers in confine- 
ment, with or without a doctor " following " 
them, have received a licence to practise as 
registered midwives. The usual way to obtain 
a diploma in midwifery has been to spend a 
certain period in attendance at a lying-in 
hospital, and then to pass an examination. 
Many fully-trained nurses have taken the 
diploma, but have never practised as indepen- 
dent midwives ; they have only acted as mid- 
wifery nurses, and always in conjunction with 
doctors. Other nurses, however, have had no 
such thorough training. The recent Midwives 
Act has been passed with the object of register- 



ing and placing under inspection all persons 
acting as midwives ; and a large number of the 
old untrained generation, mostly fat and dirty, 
always ignorant, and generally given to imbiba- 
tion, have been placed on the roll. One hears 
of attendance by these women at a few lectures 
given by medical members of the municipality, 
supplemented by instruction from the lady inspec- 
tors under the local Medical Officer of Health. 
Thus the first set of these women consisted of 
the old wine in new bottles, by which I mean 
that the old creatures had new uniforms. 

As time passes, a different race of midwives is 
being evolved. The Medical Officer of Health 
will naturally desire to have efficient women 
on his register. But the position is not one of 
honour and prestige, and the pay is poor ; hence 
the Falstaff army of the first enrolment is only 
slowly being replaced by a more sober and 
efficient class of women. In the meantime 
these midwives are watched by inspectors acting 
under the Medical Officer of Health. (The 
necessity for vigilant supervision of this kind is 
shown by the fact that I once, many years ago, 
sio^ned in one week six death certificates for 
women who had died in childbed in the practice 
of one midwife. Most midwives were unregis- 
tered in those days. Now these women must 
be registered and must not attend abnormal 


cases.) They are compelled by written law to call 
in medical practitioners whenever there is danger 
to mother or child, and an unwritten law compels 
medical practitioners to come to their assistance 
when called upon. Many cases of midwifery are 
abnormal, and in poor districts medical men are 
continually helping midwives. But in the nature 
of things the assistance given is, in the majority 
of cases, not paid for. The people are as a rule too 
poor to pay the doctor's fee without great priva- 
tion to themselves ; consequently he is obliged 
to do a great deal of his work gratuitously. 
Frequently the midwife is not paid either. 
Yet the doctor's assistance is ungrudgingly 
given. The Relieving Officer knows this, and 
he snaps his fingers at the lot. The entire 
system is folly. There is a huge death rate, 
capable of being reduced ; but the whole matter 
is shelved. City Councils and Boards of 
Guardians alike refuse to interfere, trusting to 
philanthropy of the midwives and the doctors. 

It is here that questions arise, first as to 
the mother, then as to the doctor. Who is to 
be responsible for the work entailed by these 
cases ? When the parents are destitute, is the 
burden to be borne by the overworked and 
underpaid? If not, what regulations are to be 
made by the community to ensure necessary 
attention for the mother and child, and suitable 


remuneration for those who undertake the care 
of them ? 

Those couples who, among the classes earn- 
ing the abominably low wages paid to labourers, 
produce many children, are all desperately poor. 
How can a family of six live and put by money 
on a wage of i8s. a week, often with short 
time ? When, however, the patient is fortunately 
so destitute that she has a legal right to poor 
relief, the doctor and the midwife get a fee 
from the Guardians. But the definition of a 
person suitable for poor relief is a very strict 
one, and most families are strained out of it. 
If a family is guilty of penury, it is more than 
likely that it will be left to chance, and that the 
mother and child will get chance care. 

Coroners' courts throw much light upon the 
condition of the poor : inquests are continually 
being held upon children who die at birth for 
want of sufficient attention. Within the last 
few days the Coroner ordered me to make a 
post-mortem examination of the dead body of a 
newly born child, and afterwards to attend the 
inquest. The baby had been born the day 
before without medical attendance at the birth. 

The mother is a hawker, and the man she 
lives with is also a hawker ; they rent one room. 
The bed was tidy enough, and so was the 
woman herself A woman from next door came 


in and, with all kindliness, offered her room and 
table for the examination ; her husband 
volunteered to hold the lamp. 

The Coroner who held the inquiry is a man 
with great knowledge of details concerning 
working people. He is never harsh, but always 
pertinent and tolerant. 

The male hawker said the child was " to him," 
and they had expected it in January ; it had 
come in December, before its time. 

" What is the mother's occupation ? " — " She is 
a hawker, same as me." 

" Where is her husband ? "— " In gaol." 
"When did she tell you of her condition ?" — 
" Six months ago." 

" What did you do? "— " I told her to go to the 
hospital and engage a doctor. She went, but 
they said she would have to go into the Home 
to be confined, and they gave her a ticket." 

" Why did she not go ? "— " She thought she 
would rather be at home." 

" Did you engage anyone to attend her ? " — 
" We were going to, but we had no money, so 
we put it off." 

" Did she say anything to you about not 
caring whether the child lived or died ? "_"No." 

" Did you try to get a doctor?"— "Yes; I went 
to the police station, and Mr Matthews rang up 
the hospital, and they wouldn't come : and he 



rang up" the workhouse doctor, and he was out. 
Thenwesent forMrsCrowther, andshesent word 
she couldn't come unless we sent for a doctor ; 
but when she knew we'd sent for one, she came." 

Mrs Crowther said she attended confinements 
and washed the baby, but she was not certified. 

" When did you see the mother ? " — " After he 
came for me. I told him, sir, that I wouldn't 
come unless he sent for a doctor ; but he said 

he had sent, and he said Mrs S wouldn't 

come either." 

" How was she when you got into the house ? " 
— " She was very bad, kneeling against a chair, 
with the little one's feet coming into the world. 
He said he'd got no money to send for a doctor 
and a midwife, or else he'd have gone for 
someone else." 

" Did you stay with her?" — "Yes, until twelve 
o'clock, and then I had to go home and get my 
children their dinner, because they come out 
then from school." 

" Were there any clothes prepared ? " — " Yes. 
We washed the baby and dressed it, and I left 
it by her side." 

" Did she appear distressed at all?"— "Oh yes ; 
she said, ' Do you think it will live ? Oh, what 
shall I do ? ' I've been with her before, sir, but 
I haven't attended her ; I only washed the baby 
and things, because she had a doctor then." 


" Had she lost other children ? "— " Yes, they 
mostly die when they get on a bit." 

" Did the child make any sound ? " — " It just 
gave a little scream, a moan like. I clapped 
it on the back as the doctors tell you." 

" Where was the man all this time ? " — " He 
had to go out hawking ; he had the living to get." 

The Coroner: " Well, gentlemen, you have 
heard the medical evidence that the child was 
born before its time, and you have heard the 
explanations of the witnesses. I can adjourn 
the case if you wish to hear the mother. You 
see that there has been no wilful neglect : they 
had prepared the clothing for the child, but 
the mother was taken unawares, and they had 
no money and had to do the best they could. 
The man has given his evidence in a straight- 
forward way, and I think you must believe what 
he says. The hospital doctors don't go unless 
the case is on their lists, and the woman had 
been told to go into the Maternity Home. The 
doctor has told you that the child was not wilfully 
ill-used, and that it died because there was no 

The foreman, after talking with the other 
jurymen, said : — 

"We think they couldn't help it, sir; the 
child died because they hadn't any money. It 
wasn't their fault ; it was ' natural causes.' " 


Before the modern antiseptic aseptic methods 
of treating wounds was estabHshed, a major 
operation in a hospital was, in a large propor- 
tion of cases, a sentence of death. It is con- 
tinually being said that the modern methods of 
treatment have revolutionised surgery, not only 
preventing a horrible death rate, but also allow- 
ing surgery to make the miraculous advances 
which have characterised its modern history. 

In the case of midwifery the sickening 
epidemics of puerperal fever in the lying-in 
hospitals have absolutely disappeared ; the 
death-rate there for puerperal fever has come 
to be as low as, or even lower than, that of 
outside cases, being now one per thousand 
confinements ; the death-rate outside hospitals 
is very much as it was in 1855. Dr Haultain 
says : " So far as puerperal fever is concerned, 
the death-rate in England and Wales is very 
similar, viz., in 1855 1.6 per thousand, in 1908 
1.4 " ; and here it must be remembered that the 
great bulk of these cases are attended by mid- 
wives. The statistics from other countries 
show a variable result, but in every instance 
cited there is a marked diminution, till in 
Sweden, Holland, and Italy it is under i per 
thousand. Facts such as these seem to prove 
that the fever death-rate, in spite of antiseptics, 
still remains the same in the United Kingdom. 


It is most unwholesome food for reflection, and 
requires most careful digestion. In general 
practice the strict asepsis found in hospitals is 
in the majority of cases impossible. A mortality 
of even 2 per thousand in practice generally 
may not be considered large. "In fact, when 
we think of the nature of the process of child- 
birth, the extensive raw surfaces, and the area 
in which they occur, it is, in face of our know- 
ledge of the modes of infection, almost incredible 
that it is so low. There can be no doubt that 
nature has conferred a special immunity on 
these parts by the germicidal properties of the 
vaginal secretions. ... If it were not so, no 
one could escape." 

Puerperal fever, a septic infection capable of 
being carried from case to case among all classes 
of women, is a cause of death which one looks 
upon as specially preventable ; but of course at 
or about the period of labour there are others. 
In spite of the efforts of physician, surgeon 
and midwife, "the odds in favour of a woman 
having a family of five without losing her life 
are only forty to one " (Haultain). One mother 
in two hundred dies in the so-called natural 
process of the propagation of the race. The 
death-rate is, as would be expected, greater 
among the poor who live in filthy surroundings 
than among the rich. 


Whichever way one looks at the problem, 
whether one considers the qualifications of the 
midwives who attend the majority of labours, 
or the nature of the maladies incidental to the 
pregnant state and the lying-in period, or the 
attitude of those who are in positions of authority 
and responsibility, one is obliged to be pro- 
foundly dissatisfied. The present state of 
affairs, with a fearful and partly preventable 
perennial death-rate, is appalling. We have, it 
must be conceded, a large number of midwives 
•improving in technical qualifications and likely 
to improve still further. But they are concerned 
with a branch of medical practice calling for a 
knowledge they do not and cannot possess. 
Their patients are liable to be attacked by ill- 
nesses which are fearful in the rapidity of attack, 
and which are only relievable if means are taken 
to relieve almost simultaneously with, the 
moment of onset. 

What are the remedies for this state of things ? 

First, we need a better service of midwives, 
whose examinations, based on practical training, 
should be sufficiently severe to weed out all 
inefficient candidates for the licence. 

Secondly, these midwives should be controlled, 
not by the Medical Officer of Health and his 
subordinates, but by a larger local board, on 
which should sit medical men in general practice. 


together with specialists in midwifery practice. 
The Medical Officer of Health knows nothing 
of midwifery : he is as much a lawyer as a mid- 
wife ; and while he should sit on such a local 
board, he should not be in a position of para- 
mount importance. 

Thirdly, funds should be provided out of the 
public purse to pay the charges of the midwives 
and the medical fees of the doctors called in 
to help them. The question of a curriculum 
which, by providing better teaching for the 
medical student, would produce a better prac- 
titioner is being considered at every medical 
teaching centre and need not be gone into here. 

Recent legislation will not greatly alter the 
conditions I have spoken of in this chapter. It 
is not so necessary to legislate for those women 
who can look after themselves as for those 
of a lower stratum who cannot. It is surely a 
dreadful and dreary satire that a child at its 
innocent birth should, so to speak, be put in the 
dock and have a half-and-half chance of being 
sentenced to extinction, or, if it escapes extinc- 
tion, to suffering, deformity, or other calamity. 
^ As I have said elsewhere, there should be a 
rigorous judicial inquiry into every maternal 
death after confinement; if I were a coroner, 
I would pass no such death without inquiry! 
The coroner prevents many deaths, over-lying 


cases, for instance, and burning cases. These 
deaths would be more common if there were no 
fear of having to face the coroner, an official 
with police powers. It seems impossible to 
believe that a woman in confinement can be 
neglected by her family, her nurse, her mid- 
wife, or her physician ; but if in every case of 
death each attendant had to produce a defence 
of his or her conduct, nothing but good would 
result. There is a high standard of asepsis in 
modern surgical practice, and no one would 
think of returning to the merely common- 
sense methods of twenty years ago ; yet 
how many honest surgeons of the past per- 
suaded themselves that the many details of 
aseptic surgery were the fad of a day ? Lives 
were lost because of this sort of honesty, and 
lives are saved now because the public opinion 
associated with a public hospital demands a 
standard quality of work from every surgeon 
on the staff. The illustrative comparison of 
surgical work with midwifery practice will not, 
I hope, be thought unapt. The point is that 
the certainty of rigorous inquiry in every case 
of mishap would ensure in midwifery cases that 
same attention to minute details of care and 
cleanliness which has in surgical practice pro- 
duced such excellent results. 



'pVERYONE praises our hospital system, 
even the patients ; and popular and un- 
popular churches alike are full on Hospital 
Sunday. If eloquence ordinarily knows not 
the vicar, it visits him on that day. Scorn 
leads in the Levite ; Pathos conducts the sick 
man with the Samaritan, and Prudence is the 
Innkeeper ; and here we have all the characters 
for a miracle play. The Ass is the general 
practitioner, burdened with the sick man, and 
even with the Samaritan. 

But there are hospitals for which Hospital 
Sunday makes no appeal. These are the 
Poor Law hospitals ; though, if you think of 
it, there is every reason why they should be 
prayed for. They are the last resort, or rather 
the last resort but one, of the unsuccessful. 
Standing in a corridor and watching the in- 
mates walk past, I was surprised at the faces 
I knew, men I seemed to have seen daily for 
years— and here they were. This man was an 
innkeeper, broken down with ill health, and 


with ill luck too, if the terms in any way differ in 
meaning ; that man was manager of a brick- 
yard, and at one time a constant companion of 
his present acquaintance the innkeeper; another 
was a groom ; and among the weak and feeble 
there was a broken man who, twenty years 
ago, was noticeable for his courteous manner 
and fine clothes. 

These Poor Law hospitals have been, and 
still are, understaffed ; the nurses have not 
held the highest rank in the nursing world ; the 
doctors have in many cases ceased to be scientific, 
and have become swamped in the small details 
of hospital management. There are notable 
exceptions : Dr Nathan Raw and Dr Allan 
occur to one at once ; and from among the 
nurses have come highly esteemed Matrons 
and Sisters, to work not only in workhouse 
but in special hospitals. 

Most of these workhouse hospitals are, in 
equipment, below the average of the voluntary 
hospitals ; but again there are exceptions, and 
the amount of medical and operative work done 
depends upon the personality of the medical 
officer, his present ambitions, his past exper- 
ience, and his command over his hospital sub- 
committee. The routine of a workhouse in- 
firmary does not stimulate to scientific research 
work. The need of an outside visiting staff to 


help the inside staff has been made evident to 
the pubHc in the pages of the reports of the 
Commission on the Poor Law. 

The attendance of medical students and the 
certainty of a daily battery of ready-witted 
criticism will have an effect, possibly depress- 
ing in some instances, upon the permanent 
staffs of such hospitals ; but the work done in 
them will be brought more into line with the 
work of the voluntary hospitals. One trouble 
with Boards of Guardians in commercial towns 
is that they look upon a scientific medical 
officer as a faddist, to be kept in check, almost 
in custody ; and while they readily spend money 
on architects and builders, they feel that money 
spent on surgical equipment for the treatment 
of broken men and women is wasted, since it 
leaves no standing memorial in brick to their 
public-spirited energies. 

Voluntary hospitals were created to supply 
the medical needs of the very poor, and they 
flourished because at the time there was no 
other accommodation. The Poor Law hospitals 
were used for Poor Law inmates who happened 
to be ill, much as one or more upper rooms at 
a public school are kept for infectious or other 

As surgery advanced, and especially after the 
discovery of anaesthetics, and later of the anti- 


septic and aseptic methods, every organ of the 
human body became subject to the scalpel, and 
special buildings and special nursing arrange- 
ments were soon found to be necessary. The 
voluntary hospitals were already in existence ; 
they were reorganised, their numbers multiplied, 
and their utility increased. Soon the upper 
working class, and later the middle class, 
clamoured for admittance, and the managers 
opened the door to all but the rich. For the 
latter nursing homes sprang up ; but as the 
fees for the performance of a major operation 
were enough to swallow up a small tradesman's 
yearly income, these homes did not lessen the 
strain on the free hospitals. All this time the 
visiting physicians and surgeons to a voluntary 
hospital were working without money payment ; 
some of them would work for years without 
getting a single paying patient.^ Fortunately 
they did in time reach the rich, by aid of the 
loud and laudatory gratitude of the poor. 

An occasional hospital here and there has an 
annexe for paying patients, the arrangement 
being that the patient should pay for the bait- 
and-stable part of the treatment. In English 
hospitals the sum paid is low ; in one at least 
of the American hospitals (Johns Hopkins) it is 

1 One very well-known man told me that until he was about thirty- 
five his professional income did not reach three figures. 


high. The fees go, not to the doctor, but to 
the general funds of the hospital. The medical 
staff have protested against the reception of 
patients who, by their readiness to pay, show 
they do not need gratuitous treatment ; and 
objections have also come from the poorer 
patients, who feel that the paying patients 
are squeezing them out. The management has 
thus found it difficult to accommodate paying 
and free patients in the same institution. 

The general practitioner outside has also 
strong views as to the introduction of well-to-do 
patients into an institution where he, as a 
medical attendant, is refused admittance ; such 
patients, he considers, if they cannot be treated 
in their own houses, should go to nursing 
homes or private hospitals. The general 
practitioner, indeed, has come to give only a 
grudging support to the voluntary hospital, 
which, whilst it refuses admittance to many of 
his poorer patients, sending them if possible 
to the workhouse, relieves him of his better- 
class artisans, and even of his professional 

The present Out-patient Department of a 
hospital is only half believed in by the members 
of the medical profession. Crowds collect in 
these huge waiting halls and picnic on buns, 
oranges, etc., until the medical staff can prescribe. 


As the mass of the patients are suffering from 
minor ailments, these morning and afternoon con- 
versaziones are very popular, and even the babes 
at the breast share in the advantages. The 
work in the Out-patients' Room is done by raw 
youngsters who are sometimes perturbed in 
their afternoon deliberations by their anxiety 
to get their evening cricket edition ; they are 
presided over by erudite seniors, who may or 
may not have the rare talent of dealing with a 
multitude, but who certainly have the capacity, 
so common in educated Englishmen, of doing 
their very best under most trying circumstances. 

Of course I am speaking generally. There are 
many cases of tragedy and misery, and these 
need much of the attention which is wasted on 
trivial gossipers. However, who can keep out 
the trivial gossipers, especially when one [con- 
siders that many a trivial ailment masks a fatal 
illness ? Still, if young and active general 
practitioners, familiar with every detail in the 
life of an out-patient, were asked to join the 
staff, with the erudite consultants as consultants, 
the results would be better ; the crowds would 
be treated by men familiar with such material, 
and even the well-trained boys, dignified as 
house-physician and house-surgeon, would 
benefit by the arrangement. 

There are many absurdities of hospital 


supply : for example, the size of the hospitals 
and their position ; the amount of money spent 
on them ; in some cases their inability to help 
the general population of the district. A city 
like Liverpool has two huge hospitals ; Leeds 
and Bradford have each but one. Hunslet, 
one of the largest manufacturing towns in 
Europe, has none, not even a shed for casualties. 
Some of the large districts in the provinces 
and in London have none, their needs being 
supplied by the Municipality or the Poor Law 
service. It may be said of Hunslet, for instance, 
that it has a magnificent Poor Law hospital, 
the delight of the architect and builder, one of 
the last to be built and the nearest to perfection. 
Alas for the public-spirited but probably un- 
conscious foresight which has lavished wealth 
on a building to be used for the benefit of the 
district by the Hospital Board of the future ! 
This building, with all its modern advantages, 
is limited to the use of the paupers ; it is far 
from the centre of the district, and at present 
it does not even need the services of a resident 
medical officer. 

It is foreshadowed that all hospitals will one 
day be under the control of one Health Service. 
When that welcome state of things arrives, we 
shall doubtless have each district supplied with 
casualty hospitals and with wards for the treat- 


ment of acute and dangerous illnesses; the 
larger hospitals, situated away from the towns, 
will concern themselves with the care of chronic 
and convalescent patients; as at present, 
patients suffering from infectious maladies and 
capable of being moved with safety will be sent 
to an institution far from the city boundary; 
the moribund cases, as well as those in such a 
condition of collapse that movement would be 
dangerous to the sufferer, will be treated in 
hospitals in the district, so built and admini- 
stered that isolation and disinfection can be 
carried out without danger to the inhabitants 
of the locality. Such hospitals should be small 
and often empty. 

As the prevention and the cure of disease 
cannot be separated, the whole question of the 
treatment of the sick and injured should be 
under one powerful authority, and hospitals run 
by subscription and donation should come in 
with the others. If the public has to pay, and 
if the management is undertaken by the more 
enlightened of our citizens, with a central 
Government department to see that the general 
aims and principles of treatment are the same 
all over the land, the great question of preven- 
tion of disease and injury will become a financial 
one, with the burden on the nation, and will have 
due weight by the side of the question of cure, 



n^HE general practitioner comes in contact 
with the poor in very many ways and 
learns their characteristics and their needs. 

For some years I was medical officer under 
the Poor Law, attending to the medical needs 
of the paupers of a division of one union. My 
duties were to visit patients unable to visit me, 
and to meet any others at my house. My tools 
were bottles of medicine, medical extras, such 
as Beef Extract, and any meagre gospelling 
on hygiene to which these poor people could 
be persuaded to listen. A great proportion of 
the patients were weary, worn out, old or pre- 
maturely old people who wanted what physical 
relief I could give them and wished to hear 
nothing about hygiene. It is little use preach- 
ing idealism to ten shillings a week. 

I never disliked the work, special work as it 
was in its own way. I entered the house 
much as the vicar did, and we often met, the 
clergyman being an expurgated edition of the 
Poor Law doctor. We neither of us made 



the beds, nor did we wash our humble clients, 
though such was often the treatment they re- 
quired. And we did not feed them, though 
that was essentially what they needed. During 
my official period a branch of the District 
Nurses' Association was started in the district ; 
then the beds were made, the backs were 
washed, common sense and poultices were 
applied, and my patients were attended to 
much more efficiently than when I had to 
give my orders to someone in the family, or 
to someone over the way. I continued to 
order opium to those in pain, salicylates to 
rheumatic patients, quinine as an appetising 
relish for food which was often scanty and always 
coarse. I do not pretend that these and other 
medicines are not of great value — they have 
their use ; but I felt hampered and ashamed, 
for I could not order solid comfort. 

To attend under the Poor Law to a man or 
woman suffering from consumption was a grim 
job. One got used to the court with its wealth 
of wreckage and filth ; one eventually did not 
see the saturated stairs and passage walls. 
The patient was always in the smaller of the 
two rooms, if there were two; but generally 
there was only one room for the whole family. 
The windows were closed. The patient saw- 
no harm in spitting. He would spit on to a 


newspaper if he had any innate ideas of neat- 
ness ; usually he would hit the bare floor, or 
the awful carpet. Sometimes you were full of 
suspicion that he spat on the walls. Occasion- 
ally you found evidences of the visits of the 
kindly. A visitor had, you noticed, left a 
bottle of a " Consumption Cure." As this 
contained morphia, it was of value, for it eased 
the cough. 

You will see that much could be done to 
improve upon this condition of things, and 
the district nurse made things much better. 
The patients I am describing are those who 
objected to go into the workhouse, and yet 
their position seemed more miserable outside, 
suffering as they were from the most forlorn of 

Cleanliness is impossible with deep poverty ; 
hunger eats up all desire except for food and 
warmth. One reads that it was so even 
among the officers in the Crimea. I have in 
my mind a court that I could cross in three or 
four strides. A consumptive, spitting his way 
to the grave, faced a patient who, over the 
way, was dying of cancer, in filth to which the 
disease contributed. A weak-minded young 
man was in another of these small houses, and 
he would come gibbering to the door when I 
entered his court ; he was, I think, left to look 


after the house, and when the others came 
home he went out to sell papers.^ 

These houses in the courts were back-to- 
back with houses in the open street, the latter 
being inhabited by people who, curiously 
enough, were evidently certain they were of 
another race than the wretches in the court. 
Whilst ill health and virtue often went 
together, yet Drink was the destroying agent 
with most of these poor people. I often met, 
I may say I was continually meeting, with the 
drunken neurotic Englishman, a lower type 
than any other living man. His children 
might be starving, filthy, covered with lice and 
skin eruption; the bed black with excrement, 
bugs the only comfortable inhabitants in the 
house. And though the man himself would be 
showing signs of excess in his appearance, he 
would not seem to suffer as much as one miffht 


have expected. These fellows drink madly, 
and then are obliged by horrible filthy nausea 
to stop. They are often casual labourers 

^ Imbeciles were not taken into The House if they could be taken 
care of at home. A woman with nodding head, falsetto voice, and 
cheerful laugh, was one of those on my list. I reported on her case 
four times a year, and she would call to me in the street and tell me it 
was time I came to report. She seemed comfortable, and her friends 
were kind. The family of which she was a member is one of those on 
the rise. They are showing signs of social improvement, and some ot 
them arc leaving the district. They are church people, and this 
church membership is always a sign that the family is not essentially 
pauperised. Chapel membership is ot even more favourable import. 


receiving excellent pay for interrupted spells 
of hard work. Still, both in their days of 
omission and in their days of commission, the 
filth and the cruelty to children go on ; indeed, 
the wife of such a man is generally also a 

Among these very poor, Drink does not 
meet with real disapproval, although they will 
condemn it in speaking to you. To them it is, 
at the worst, associated with inconvenience, 
but it is not in itself an evil. Often, therefore, 
the wife of a drunken sot is encouraged by her 
neighbours to seek the only possible comfort 
that they can suggest. Parties of women 
capture a public house, on Monday generally, 
and feel prosperous for a time. Even the 
decent ones like beer. They say they cannot 
work without it.~ 

Of the poor old folk an astonishing number 
are insured. It is an easy matter, when there 
is no medical examination, to get a policy. 
On one occasion an agent brought me a death 
certificate on which I had put Cancer and 
Syphilis as the cause of death. He wished 
me, " for the sake of the relatives," to alter the 
certificate to something less drastic. In fact, 
he feared he would get into trouble with his 
company for having insured a person of 
evident unsoundness. 


I remember an old Irish army pensioner 
dying the day before his pension was due. 
His old wife was most piteous in her appeals 
to me to let the husband legally live a few 
more hours, and thus draw his pension. I 
think I should have agreed (one loses all one's 
rigidity in morals), but I feared she would get 
drunk on the money and split on me. 

One of the worst cases of ulcer of the leo- I 


ever attended was a woman who kept a sort of 
shop. Her chief trade was in unsound apples, 
and children were her customers. She once 
gave me an apple. She was a kind-hearted, 
slovenly countrywoman, and always in debt. 

I never did any inside workhouse work, but 
one of my assistants had formerly been a house- 
physician in a large workhouse. I found that 
the syphilitic patients were allowed to leave 
the workhouse whenever they thought fit. 
The women took themselves off as soon as 
their art could be practised. 

Married women among the poor suffer very 
much from sexual diseases. The poor are not 
vicious, but they are careless, and strict morality, 
as a Wesleyan deaconess considers it, is not 
thought of. Many a woman suffers from the 
adventures of her husband, and, apart from 
all such adventures, hygienic sexual life is, as 
a standard, difficult to reach. 


Many cities are moral filth. A young lad of 
twenty came to such a city, and though his life 
had previously been of the purest, a careless, 
thoughtless act brought him into a diseased 
condition which ultimately killed him. I was 
told by the doctor who attended him that the 
poor lad dare not tell his father, and that the 
mother, who was nursing him, only told the 
father when she knew the boy was dying. My 
friend said that he would never forget the meet- 
ing of the lad and the father, and how natural 
affection threw them sobbing into each other's 

I suppose this kind of thing will go on, and 
the carefully reared lad, the best product of the 
land, will be destroyed by the worst product of 
the land. I would lay the iron hand of the 
Medical Officer of Health (with penal powers) 
on this business. No one allows a fever patient 
to spread disease, and this complaint is worse 
than fever — often worse when it doesn't kill 
than when it does ; and we ought to remember 
by this time that an old man respects all the 
commandments but the tenth, his son all but 
the seventh. 

If more nurses could be sent among these 
poor, much might be done to encourage cleanli- 
ness, and there would be less illness requiring 
the attention of the doctor. In fact, increase 


the number of your nurses, even if you lessen 
the number of your doctors, and pay them both 
better. As for the Union doctors, they are paid 
very little in some Unions, more in others. It 
so happened that I realised one day that I could 
live without the appointment, and the next day 
I resigned. 

I seldom came into touch with the Guardians 
officially, though I met many of them socially. 
Those Guardians who had wide interests, 
being employers of labour, members of city 
councils, or men of general culture, were reason- 
able men. It was the poorer Guardians who 
were least sympathetic to the poor. These 
smaller men were, curiously enough, more under 
the influence of the Relieving Officer than were 
the others, and this influence was all in favour 
of harshness. I am speaking, however, of more 
than ten years ago. 

I remember the Relieving Officer also as a 
member of a voluntary society. This society 
commenced in a meeting of clergymen and 
doctors, and its membership was open to any 
interested in social questions ; in fact, we had 
one member who was temporarily receiving 
poor relief. The Relieving Officer was a 
member, but his attitude towards the poor was 
so austere that he found himself out of sympathy 
with the others, and he ceased to attend the 


meetings. His views were shared by the Clerk 
to the Guardians. The poor had impressed 
them as being idle, careless spongers, requiring 
the repressive care of men like themselves. 
Both these officers were men of ability and 
character, and they infected the Guardians with 
their views. 

During part of my time the administration 
of the Poor Law was harsh ; in later years it 
softened. When I spoke lately to a Guardian 
of this changed attitude, he explained it by 
the fact that the public were becoming silly 
and sentimental. 

The Guardians are very easy people to work 
for. Do your routine work, and there will be 
no grumbling. Don't be too zealous. Above 
all, don't order too many medical extras. And 
don't attempt any conceited personal philan- 
thropy on your own account. I got along very 
well with the Guardians. 

The poor that I attended were congregated 
in two districts. From a main road you walked 
into a network of the streets of the hooligans. 
During my time there was an attack on a police- 
man, who was so severely kicked that, although, 
curiously enough, he was able to walk to his 
home, he never walked afterwards. He is now 
permanently paralysed. On another occasion 
I was called to see a man who had been thrown 


down by his own brother. His neck was broken. 
Drunkards, low prostitutes, loafing tram thieves: 
all these were well represented here. Among 
the hooligans were many sick and feeble, who 
had either gone like dying rats into their holes 
or become too old or too weak to work. 

When I became Police Medical Officer, I 
recognised many of my old patients in the 
Stipendiary's court. (You see nothing of the 
Empire in the slums. Their only gospel is the 
Old Testament of the Stipendiary.) Two of 
them were up one day, and an inspector of 
police who was sitting next to me was discuss- 
ing them. " They are not criminals," he said, 
'* they are simply low-down thieves." Burglars 
of any respectability were not found in their 
ranks. Occasionally some strong-jawed adven- 
turer got among them. I attended one such 
when he was dying of pneumonia. He asked 
if he were dying — not that he cared much, he 
said. The police told me that this man once 
got through the bedroom window and escaped 
while they were downstairs. But the brainy 
defiers of the law don't live in the lowest of 
districts; I mean, of course, that I have not 
met them. 

A distance of a few yards further down the 
main street of these slums there was a different 
set of people, almost as poor as the others, but 


altogether less vicious. Life is never a blast of 
a trumpet or a beat of a drum to any of the 
people in these districts, yet I have seen very 
many families dig their way out, not often to 
riches, but quite commonly to respectable and 
comfortable solvency, while a few have reached 
celebrity. To these I shall refer again. Grati- 
tude, or that form of it which is the justice the 
weak show to the strong, these men have, but 
servility they seldom show ; the servile kissing 
of the hand, which an emotional Jew will 
honestly affect, would be silly hypocrisy among 
the poor English. Many of the poor were of 
country breed. Irish were found in all parts of 
these districts. 

Dissenters in the hooligan district there were 
none : the Churches of England and Rome 
divided the poor between them. These very 
poor people nearly all had a church, and the 
Roman Catholics did really attend theirs. I 
have heard a Primitive Methodist minister say 
with pride that his community had very few 
paupers, and with shame that they had a few ; 
and he added that if he had his way, his church 
should supply the needs of those few. 

^ Men and women who are closely associated 
with any religious body do not stay long in 
the slums : they work out. I have in mind a 
militiaman and his wife, an ex-domestic servant. 


They had a two-roomed house and six children. 
Three of the children died early. There was 
one bed for the whole family; drink for the 
man ; work for the woman. She was a good 
woman, and her children were born in worse 
than a stable. Their clothing was scarecrow 
clothing, the cast-off of other poor — a boy wear- 
ing a girl's things, and glad to. Anything else 
would have been pawned. The father provi- 
dentially died, and the mother providentially 
lived ; one of the boys joined the Methodists 
and is now a minister. He has told me of 
his efforts — efforts which would have satisfied 
Smiles — who, by-the-by, lived at one time very 
near to this slum. 

There were many old soldiers among my 
patients, and never once a navy man. Con- 
sumption, helped by malaria and drink, killed 
my soldiers. They were nearly always quiet 
men, and especially civil to the doctor. The 
best of them told me they couldn't get perma- 
nent work ; casual labour was their lot. 

There was quite a colony of racehorse touts 
and the like. Of course they didn't want work, 
if they could escape it. One of these latter had 
been ruined by good fortune : a large sum of 
money had been left to his mother and her 
family, but the family was numerous, and the 
money — ten thousand pounds — slipped away. 


This man sank far below his original station ; 
he died in the workhouse from phthisis. These 
racecourse wastrels were in a sort of way poli- 
ticians, and were all for loyalty and the King. 

Some of the Sanatorium patients obtained 
work in the public parks, but they were not 
always desirable workmen ; and one of them 
told me that the foreman soon said that the 
park was " no bloody sanatorium." The patient 
who told me this came out from the Sanatorium 
looking exceptionally fit ; but he was a heavy 
drinker, and he was soon dead. 

I came across a variety of police unfortun- 
ates, who had gone astray although their 
parents were quite able and willing to keep 
them at home in comfort. Many such women 
are born lustful, and should be treated as insane. 

Most cases of scarlet fever among these 
people escaped any medical attention. When 
the cases are slight — and most cases of scarlet ^ 
fever and diphtheria are slight — the children, 
after two or three days at home, go merrily to 
school. We discover the presence of these 
mild cases when dropsy attacks the patients 
and we are called in. Whilst the middle-class 
parents are perfecdy ready to send to the fever 
hospital their children suffering from fever, it 
is quite common to find the poor resenting 
the sending away of their children, especially 


if the illness is apparently slight. I remember 
one woman with a house full of children send- 
ing round for three doctors, and paying them, 
in the hope that one of the three would say her 
child had not got scarlet fever. 

The vices of these people were, as a rule, an 
imitation of the habits of the rich. Even 
among the shopkeepers one frequently sees 
many who really wish to be refined copy the 
vulgarisms of the rich. A rich man may object 
to work without losing his self-respect ; he may 
drink to excess and he may lavish money on 
his betting agent, and he is not even immoral. 
The poor man who imitates him becomes a 
vicious nuisance. 

The pleasures of these people are not their 
own either : they also are borrowed from the 
rich. The poor man's theatre is — but you 
know all about that ; and generally speak- 
ing they prefer the Isle of Man to the Sea 
of Galilee. They are greatly attracted by 
tragedy, as one sees by the crowd outside the 
house of a suicide, and they will weep at misery. 
The ritual of death and burial also appeal to 
them. A clergyman working in the district 
was struck with the almost ghoulish attraction 
which scenes connected with death have for 
the people of these streets. When a man or a 
woman is dying, relatives and neighbours come 


trooping in and squat round the bed ; the 
women of the house move about among the 
throng, and offer refreshments in response to 
what, though mingled with a grotesque relish 
for dramatic incident, is generally real kind- 
ness. Tradition supports this sort of congrega- 
tional and theatrical gathering, and the clergy- 
man and doctor offer their ministrations to the 
familiar accompaniment of a cheerful but re- 
strained rustle of expectancy. 

In the slums, in the districts where pleasure 
is pinched, the public-house is a great power ; 
it is a Friend's Adult School, where men can 
get some squalid imitation of a liberal education. 
Many clergymen recognise this, and would be 
glad to use the public-house for the benefit of 
the labourer ; but it would be a risky adventure. 
The drink of the poor is a very different thing 
from the drink of the rich ; I have known 
the small brewer send to the chemist regularly 
for his chemicals, saltpetre and grains of Para- 
dise (a kind of haschisch) among them. 

The shopkeepers outside this ring of poverty 
were apparendy comfortably off ; they were 
not in lodges, and they certainly never came 
on the Union list. The pawnbroker was a 
rich man, flourishing physically and with his 
bankers. One draper owned property, another 
an extensive knowledge of Church History. 


There was a postman deserving notice, who 
had suffered greatly from ill health and was 
maimed with rheumatism and heart disease ; he 
is still enjoying a pension of 1 7s. 6d. a week. 
This was a man who, if he had been a draper's 
assistant, or an artisan, would have dropped 
out of work in hard times. He is otherwise 
notable : a Churchworker and interested in 
charities, he collected nearly ^500 in pennies 
for the local Consumption Hospital. When he 
was last ill — it was pneumonia, a severe case 
— I had the pleasure of seeing him, as a neigh- 
bour, for the Post Office doctor. The signifi- 
cant part of this man, however, is that, with all 
his good qualities, and in spite of his connection 
with a church, his physical condition would 
have made him a casual labourer, with a down- 
ward tendency to pauperism. The one happy 
accident in his life was that he was a postman. 

It is, I assume, plain to most that, as a rule, 
the poor are poor, not because they are intrinsi- 
cally, but because they are comparatively weak. 
The others are stronger. 

Another of my patients was a woman dignified 
in manner and pleasant of face. She was a 
widow. I met her first at the houses of other 
patients : when there was a case of illness 
among her neighbours, she seemed to be often 
present as a helper and adviser. This woman 


worked, and earned enough for herself and her 
daughter. Now she is old she has angina 
pectoris ; she is broken down in health, the old 
dignity of manner has gone, and she accepts 
Poor Law relief and medicine, with medical 
extras. I say she does — she did ; I have not 
seen her lately. 

I have visited many other countries, but 
nowhere else have I seen conditions such 
as I have met with here. A comparison of 
my very poor with the Egyptian fellaheen, 
living on their one piastre a day, but favoured 
with an excellent climate and with simple cheap 
food, is all to the advantage of the fellaheen. 

I am of course aware that as Union Medical 
Officer I was working on our rubbish heap ; 
but among its population one came across many 
men of strong character. Out of the artisan 
part of my district you could get any kind of 
man you wanted, from a statesman to a criminal. 
From these narrow streets came one of the most 
famous of our engineers, known almost as well 
in his own country as in others. Our national 
caricaturist was a son of this very soil, and the 
list of men who have obtained celebrity in 
commerce is a long one. 

Perhaps one of the most interesting characters 
belonging to this district was a man of virile 
speech and great organising capacity, who came 


into close contact with the great Prime Minister 
of his day, and whose opinions on one subject, 
as there is every reason to beHeve, had a marked 
influence on the poHcy of a great party. He 
was an elector in the division which returned the 
Prime Minister to parliament, and the evident 
confidence of his fellows, who looked up to 
him as their leader, was one of the factors 
which led the Prime Minister to assume that 
on the subject in question he could carry the 
democracy with him. 

The fact that these artisan families could 
produce such men is of importance to the student 
of eugenics. I have not wished to torture my 
readers unnecessarily by mere sordid details of 
the hooligans of this district. But it is also of 
importance to the student of eugenics to know 
that on one occasion a woman walking with her 
husband was criminally assaulted by a number 
of these same hooligans. The husband was 
knocked down and otherwise brutally assaulted 
first. Both the wife and the husband were seen 
by me soon after the occurrence. 

Dreadful things happen more often in these 
streets than in ordinary neighbourhoods. I 
was once called to one of the few through- 
houses in the district ; the front room was used 
as a shop, the back room as the living house. 
The midwife who sent for me was quite sober 


enough to be useful, but the mother of the 
patient — grey, haggard, bedraggled — was 
pleading, praying, quarrelling with all who 
spoke to her, and shouting defiantly that what- 
ever I did I should be paid for. The girl 
patient was fourteen years of age ; she was in 
dreadful convulsions, and, worse than that, in 
labour. In one of her half-conscious moments 
we tried to get her to swallow a draught ; but 
she struggled and screamed, and our entreaties 
and the mother's expostulations with the mid- 
wife and myself added to the confusion and pain 
of the whole dreadful doings. The midwife, in 
loud altercation with the mother, led her to the 
door and turned the key. Then my work 
began. The poor girl, under chloroform, was 
on one of the filthiest of beds, hurriedly thrown 
on the kitchen floor. There was no chance of 
anything better: the convulsions would allow 
of no delay. An operation, which killed the 
child and did not save the fourteen-year-old 
mother, had to be done, while blows and 
blasphemies were heard at the door. When 
the work was over, the door was opened and 
the parents and older sisters were brought in ; 
the mother quieter by now and even eager to 
talk, the father pale, with dry misery in his 
face, anxious to lift, carry, or do anything we 
needed of him, but forced into a groan when 


he saw his daughter (only a few months from 
school, as the midwife said) lying with limbs 
uncouthly mixed up with the dirt of the bed 
and the floor. The limbs were swollen, and 
the face, too, was swollen into the ugliness 
which always goes with such disaster. A 
woman running in from the other side of the 
road gave us a welcome sight of sobriety and 
cleanness. When I came out of the door and 
got into a tram, I found myself among quiet 
and ordinary people. 

There is one addition to make to this story. 
The mother of the dead girl came up for the 
death-certificate, and she told me that the 
father of her daughter's child was a man forty 
years of age. He had worked in the shop 
until the police had prosecuted. He was 
coming back to this shop, and the family were 
keeping the place ready for him until the time 
of his release. 

There are any number of low class drunken 
town labourers who will not do a full week's 
work, or who, if they do so much, are sure to 
break the next. I knew a man who was 
prosecuted by the National Society for the 
Prevention of Cruelty to Children. The in- 
spector brought the case into court because, 
owing to the man's refusal to work, his children 
did not eat ; and the case was adjourned for six 


months to allow him to get work. The inspector 
went to the manager of the pit at which the 
man had previously been employed, and he 
learned that work would be given him for the 
asking. Yet for seven weeks the man never 
went near the place. Then he had no boots, 
so the inspector got him clogs. But still he 
did not work, and when he was convicted of 
gambling, which happened very soon, he pre- 
ferred to go to prison. 

Among these people there was a painter and 
decorator, out of regular employment because 
he would not give up drink ; he was doing 
piece work. His wife was an imbecile, but she 
accommodated him, and children continued 
to arrive. The father, the mother and five 
children all slept in one bed. 

In B Street was a family in which the 

wife was the drinker. The husband worked 
hard, and 30s. 6d. a week came into the house ; 
but the five children were neglected, and the 
bed, a dirty old straw mattress without any 
flock, was as black as my coat. A coloured 
blanket and a few articles of clothing covered 
the family at night. 

In another family the woman was sent to a 
Home for Inebriates ; the husband took up 
with a common prostitute, as many casual 
labourers do, and his children had to go to live 


with her. When the wife came out she wanted 
the children, and she got them and took them 
to a Roman Catholic Home. When the father 
discovered where the children had gone, his 
religious opinions impelled him to take them 
away and put them with a niece of his. Eventu- 
ally the children reached an Industrial Home. 

Another man supplied neither food nor fire for 
his wife and child ; but he took the child's socks 
to a spiritualist woman, who viewed them and 
said the child would die : " she could actually 
see it passing away before her eyes." Many 
readers will remember the Holy Tree near 
Cairo, with bits of children's clothing tied to 
the branches, in this case to propitiate some 
supposed agent of evil. 

Then there was a rag-gatherer who left his 
wife and lived with a widow. Subsequently 
he relapsed into virtue and returned to his 
wife, and he is now paying 5s. a week and 
2S. for arrears on a bastardy-order. One of 
the children is an epileptic. 

Some years ago a three-roomed house in my 
neighbourhood was inhabited by sixteen people. 
The men and women were all out in the day, 
except one who stayed at home and kept house. 
He also kept cocks and hens in the attic. The 
women, of irregular virtue, worked at a rag 
mill. I stumbled by mistake into their door 


one night; two women eyed me at first with 
favour, then with disdain on perceiving that I 

was a b doctor. Another house in the 

neighbourhood was of a similar horrible kind : 
it seemed to be a common brothel of a pro- 
miscuous nature. I was told by a woman that 
she had casually stayed there all night — the 
details you must guess. Both these houses 
were reported by me to a local " Social and 
Sanitary Association," and the police found in 
one of the houses two coiners, men who had 
been " wanted " for months. 

The working people live in streets. Most of 
them have the right of entry to every other 
house, and so there is a social life and a social 
help for all. But there are some families which 
pride themselves on "making no neighbours," 
on " having nothing to say to anybody." I have 
often found these peculiar people to be secret 
drinkers. Occasionally they have sunk from a 
good position. 

An appeal to the senses is naturally far more 
convincing to these people than any argument. 
Once smallpox broke out in the district, and the 
Medical Officer of Health desired that all the 
contacts should be vaccinated. I took down a 
lurid pamphlet on smallpox, with a photograph 
of a child suffering from virulent smallpox and 
looking as if its face had been burnt black. The 



women looked at the pamphlet and discussed 
the photograph, and they and their families 
were all vaccinated. 

I was called once to a house in a lane off a 
busy part of the district. Entering, I found an 
old man who held in his dead hands a pair of 
bellows ; he was leaning over a charcoal fire 
whose fumes had killed him, and he had died 
in the act of blowing. He left a letter saying 
that he had neither friends nor debt, and that 
the coroner need not trouble to seek the former. 
I was once called out on a dark morning to 

go to C Street ; the police were there when 

I arrived, their lamps shining on the grey wet 
pavement. I went into the house. In the 
kitchen was a dazed mother, a feeble-minded 
woman ; her head was crushed with a blow from 
a poker, and she was saying that her son hadn't 
done it. When I asked her a question, she re- 
cognised my voice and said, " Oh, it's Dr ." 

I went upstairs and found an imbecile boy, 
snoring loudly, with his head crushed in. A 
cripple looked at us and did not know what had 
happened ; his head had been struck too. A 
little . boy hidden under the bed-clothes was mad 
with fear and would not come out ; a blow had 
been aimed at him also, but only his hand was 
hurt. On one of the beds lay a young man, 
dressed to go to work; his throat was cut 


to the spine. The horror of Hving with his 
dreadful feeble-minded mother and the other 
three had suddenly driven him mad. Of all 
the family the little boy alone survived. 

Another time I was called out to visit 

Court. A woman lay there dead. The man 
who had killed her had walked to the Police 
Station and given himself up ; the police, think- 
ing he was drunk, had said something to him 
half chaffiingly, by which he was extraordinarily 
upset and insulted. When I came from the 
house to the Police Station, 1 asked to see him ; 
as he came out of the cell he spoke in angry 
tones to the police about their " improper" way 
of receiving him and his confession. He will- 
ingly allowed me to examine him, and even 
assisted me as I did so. He was a strongly 
built, short-statured man, with a face of a prize- 
fighter or a hero of Rorke's Drift. His state- 
ment was simple and true. When the case was 
tried, I sat below the witness-box and heard him 
give his evidence, every word of which helped 
to convict him. Nor indeed did he seem to 
wish any other result. In the evidence it was 
said that the man, before he gave himself up to 
the police, had given his war medal to one child 
in the court where he lived, and his money to 
another, first taking care to pay some small 


I have noticed among these poor people the 
much greater dramatic capacities on the part of 
the women than of the men : a man on receiving 
any terrific shock simply stands and gapes ; a 
woman acts as if she had prophetically foreseen 
the occurrence and rehearsed the part. 



I SUPPOSE that people who readily and 
frequently write books begin with a plan, 
arrange their chapters, and know where to end. 
This has not been the case with me : these 
chapters have grown, and their growth has 
been stimulated by the ephemeral burst of 
wide-spread interest which has lately been 
taken in the concerns of the doctor. I have 
found my words stumble least in the chapter 
on the Poor Law Medical Officer ; in it experi- 
ence has most easily become articulate. The 
chapters on Tuberculosis are the result of 
observation arising out of work done in con- 
nection with a Tuberculosis Association and 
hospital, and the ideas expressed are often the 
co-operative opinions of my co-workers and 
myself. But whilst I am still a private in the 
army which, under many leaders, is fighting 
phthisis, I am a deserter from the Poor Law 
medical service, and as such I have a pre- 
scriptive right to loquacious description and 
denunciation. The work of a Poor Law 



Medical Officer, as will easily be understood, 
does not show the doctor at his best. It is 
work of a low grade, and it is worth little 
professionally to the aspiring doctor ; it is 
worth still less to the sinking patient, the 
patient, that is, who is sinking in the slough 
of Poverty. 

Consider the advantages which the rich 
obtain from modern medical treatment, includ- 
ing bacteriological research, complicated serum 
therapy, X-ray diagnosis, anaesthetics local and 
general, the products of synthetical chemistry 
and organo-therapy, and all the requisites 
demanded by a life based on hygiene. I have 
said elsewhere that when there is a chance of 
a rich man's existence being prolonged by 
efficient nursing and by expert medical con- 
sultation, the experts and the nurses are 
summoned. The poor out-patient Lazarus is 
shut out from all such advantages, the in-patient 
from many of them. The presence of en- 
lightened and educated men, and especially of 
enlightened and educated women, on our 
Boards of Guardians has had some effect in 
improving matters, and should, now that the 
public conscience has become troubled, have 
more. But reforms must come from without, 
for such boards are elected as executive com- 
mittees, not as philosophical debating societies, 


and the reformer is most in place and has his 
chief power in the editorial chair or in the 
market-place rostrum. Yet, given the more 
elastic powers prophetically shadowed in the 
Royal Commission reports as likely to be 
extended to these local bodies, one would like 
to see on every committee dealing with Poor 
Law institutions not only "first generation" 
men, but second generation men, professional 
men ; and one would like to cajole into the 
chair a man strong even to obstinacy, cautiously 
ready to accept suggestions from the earnest 
colleagues around him, yet with striking 
personality, and feeling within himself a capacity 
and a desire for leadership. I hope the Public 
Health section of the Poor Law will be con- 
trolled locally by such committees ; as to the 
central government control, that is outside my 
range. I should like to see such a Committee 
served by a medical superintendent, acting 
under or co-equal with the general Medical 
Officer of Health. Such a medical superin- 
tendent might occupy the present status of 
the Medical Officer of Health, the latter going 
up another step. He might be held respon- 
sible as the supervisor of the Poor Law medical 
work in his district, subjecting himself to the 
general advice and ultimate veto of the Medical 
Officer of Health, who in time will probably 


be at the head of all the hospitals, voluntary 
or municipal. 

The Medical Superintendent would have full 
control over the medical staffs of all the Poor 
Law Unions of his district, and these staffs 
would include the Poor Law doctors inside and 
outside his hospitals. He should allow medical 
men who attend out-patients to have in-patient 
beds, so that they could follow their patients 
when these were transferred from outside to in- 
side. This plan would place the outside doctor 
in a similar position to that now occupied by 
the assistant physicians to a voluntary general 
hospital. A laboratory should form an essential 
part of every Poor Law hospital. Operating 
surgeons and physicians engaged in special 
departments of medicine should also be on the 
outside staff, and should assist the inside staff. 
To take a suggestion from the large general 
hospitals of America, it might be a wise plan 
to appoint the laboratory physicians on the 
understanding that a position on the clinical 
staff would, as a matter of course, follow ; and 
it might easily and beneficially happen that a 
school especially for post-graduate study, and 
herein especially for surgery, would be fostered 
by the Medical Superintendent. This would 
be an equal benefit to the Poor Law patients 
and to the public, for it would raise the general 


standard of medical education in this country. 
In addition, the staff of nurses serving out- 
patients should be as efficient as that serving 
in-patients ; District Nurses might be subsidised 
to this end. With such an organisation, the 
sick poor would have an incalculably greater 
chance of recovery from illness than is the case 
at present ; the chronic and incurable would 
receive a satisfactory minimum of doctoring and 
the necessary maximum of nursing; and patients 
suffering from acute and dangerous illnesses 
would receive the persistent daily and even 
hourly attention from medical men that their 
cases demand. I think such a service would be 
best undertaken by part-time medical men, with 
the exception of course of the resident medical 
staff. Private practice increases the keenness 
of medical men for their work, since a man's 
position in private practice depends upon his 
professional prestige. I should like the rate of 
pay for such an outside staff to be exactly the 
same for the general practitioner and for the 
specialist ; I believe the work of the former is 
more arduous than, and requires as much ability 
as, that of the other. It must be remembered 
that the general practitioner necessarily sees far 
more patients than does the specialist. 

The general reader is mistaken if he concludes 
that in continually introducing the question of 


adequate payment to medical men my motives 
are in any undue degree mercenary. I merely 
recognise that,- if we are given our daily bread, 
we shall the more piously repeat the rest of the 



I HAVE referred to the importance of the 
general practitioner's work, both as re- 
gards the individual patient and as regards the 
family. Much, however, may yet be done to 
extend his sphere of action and to increase his 
power of usefulness. He should be subsidised 
for public work. This is to some extent done 
already ; the medical man in general practice 
vaccinates a child for the State, he examines 
school children, he attends policemen, he is 
Medical Officer under the Poor Law, all for 
the State, and quite independently of any 
private practice he may have. All this work 
is done in the interests in Public Health, and 
done well, because, and only because, he lives 
among his patients and knows them as none 
but he can know them, and not at all as they 
would be known to the whole-time official 
who may work in Whitechapel and live in 
Kensington. It is doctors in general practice, 
or those who have been in general practice, 
who would make the best school doctors, the 



best health lecturers, and, with the help of 
nurse-visitors, the best inspectors. 

Especially is this plain to me in connection 
with the medical inspection of the public 
elementary schools, which now forms so im- 
portant a part of our educational system. A 
man in general practice knows all about 
children ; he knows the children of the school 
he inspects, or others of the same type ; he is 
familiar with their illnesses ; and he knows also 
the prejudices, good or bad, of the parents. 
It often appears as if there were a scientific 
frontier between medical specialism and common 
sense, but the general practitioner is level- 
headed enough, and he is one of the best of 
men to do ordinary work in an ordinary world. 

As every medical reader is aware, the 
Education authority may appoint one or two 
medical men or women to examine all the 
children attending the elementary schools. 
These medical examiners may give whole-time 
attendance. Sometimes their inspection is 
carried out independently of the Medical 
Officer of Health, sometimes the inspectors are 
subordinated to him and act as his assistants. 
The best plan, and one frequently adopted, is 
that of appointing practitioners to give up to 
school inspection a portion only of their time. 
If the district is a large one, there may be part- 


time men to do most of the actual inspection, 
with a whole-time medical inspector to organise 
the work and correlate the results. It is because 
the part-time man is more closely in touch with 
general practice that he is a good man to appoint. 
As I have already said, he knows all about 
children in their normal home conditions, where- 
as the Medical Officer of Health, who has no 
clinical practice, knows in comparison nothing 
of them. The Medical Officer of Health, 
on the other hand, is trained in methods of 
organisation ; nevertheless his work, valuable 
as it is, is at a disadvantage. It is concerned 
with questions of the highest and most general 
importance ; but it is not directly and particu- 
larly concerned with the many personal details 
which go to make or mar the health of a child. 

Although the time allowed for the inspection 
of children in school is far too short, the results 
are fairly satisfactory. Deformities are dis- 
covered ; the parents are told how, when, and 
where these deformities can be treated ; they 
are also told of constitutional defects. The 
schoolmaster, too, learns the physical condition 
of his pupils. Sooner or later there must be in 
every town school clinics, in which the children 
will be treated by the medical inspector, with 
special expert assistance in difficult cases. And 
as the school inspector will be paid for his 


services, this will be a much better state of 
things than the present, in which so many 
children are sent to hospitals supported by 
money of the charitable. 

As for the important work now done by the 
Medical Officer of Health, I do not suggest for 
a moment that it should be undertaken by a 
man in private practice : the Medical Officer of 
Health will find plenty of bureaucratic work to 
occupy his time ; but if the whole of the medical 
profession, or at any rate the greater part of it, 
were given fuller powers in connection with 
public health, it would be better for the public. 

It is upon the Medical Officer of Health that 
the sanitation of the city depends. He is almost 
a despot ; and if only he can keep the respect 
and confidence of the municipal committee, he 
has the powers of the Inquisition. Should a 
householder harbour a case of scarlet fever with- 
out the knowledge of the Medical Officer of 
Health, both householder and doctor may 
discover that this official has power to inflict 
penalties as well as to promulgate commonplace 
hygienic rules by means of street posters. The 
Medical Officer of Health is served by his 
assistant medical officers and by men and 
women sanitary inspectors, who, with the help 
of notification, track out disease. This notifi- 
cation usually comes from the family doctor ; he 


sends to the Medical Officer of Health a certifi- 
cate giving particulars as to name, age, and re- 
sidence of the patient, and also a diagnosis of 
the disease. Now, I want to see this carried 
one step further; I want to see the family 
doctor undertake laboratory work, so that he 
can efficiently diagnose cases which occur in 
his practice.^ 

The compulsory notification of phthisis has 
been hailed with almost unanimous approval by 
medical men. Phthisis is a chronic illness of 
relatively low infective powers ; the cases which 
chiefly spread infection are to be found in at- 
tendance at special hospitals, and their occur- 
rence is therefore easily discoverable by the 
Medical Officer of Health. To notify every 
early case of non-clinical phthisis would be most 
difficult : there are so many of them which 
never advance beyond the first stage. Almost 
all of us have at some time some tubercular 
disease of the lungs, though in the majority of 
cases only to a slight extent ; and in order to 
notify all the early cases, a doctor might have 
to begin by including half his relatives and 

1 In a certain town possessing a hospital and a good medical staff 
I was told of three separate cases of suspected diphtheria in which the 
medical men in attendance were not prepared to take the responsibility 
of deciding by bacteriological examination whether the microbe was 
present or not. It is not that they cannot do the tests ; they simply 
get out of the way of doing them. Note elsewhere Sir Clifford Allbutt's 
remarks on this point. 


himself into the bargain. But the " carriers " of 
consumption absolutely mzLst be notified. The 
voluntary and the compulsory systems of notifi- 
cation have both been tried ; the voluntary 
system led to the notification of marked cases, 
but it failed to discover the sufferers who were 
at work. A workman would not allow his case 
to be notified, since special attention to his 
complaint would probably have led to his 
dismissal from the workshop. But I have 
referred to him in another place. Now that 
notification is compulsory, every care is taken, 
and must be taken, to avoid such a disastrous 
result ; and when the workman feels safe in this 
respect, he will have no objection to the 
notification of non-clinical cases. 

Everywhere sanitary officials are doing most 
useful work in tracking disease, examining drains, 
and ordering the indignant property owner to 
put his house in order. The duties of these 
inspectors are perhaps too varied,^ but their 

^ May I give an instance showing the variety of the duties and ex- 
periences of these inspectors ? One of them called upon me early one 
morning. As I had been out all night, I wished to sleep ; but I was 
told I must get up at once and come with him to examine a baby- 
newly born, he said— supposed to have been buried alive in a midden 
from which faint cries were heard. While I was dressing, a constable 
called to hurry me up, as a crowd was collecting, he said, in the street 
where the discovery had been made. I therefore hastened my toilet 
and strode off up the road between these two huge men, my own 
physique most shabbily diminutive, but my stride proudly equal to 
theirs. It was true that the crowd was large and indignant : women 


powers are not too autocratic, and they show, 
in the presence of many difficulties and much 
opposition, an admirable inflexibiHty which is 
worthy of our respect and admiration. 

It has seemed to me that sanitary inspectors 
do too much and too little. I have come across 
them while they have been spending hours m 
measuring rooms and noting a hundred com- 
paratively unimportant items, and all because a 
child had died of whooping cough in the house. 
Much better to inspect every house in the 
city, reporting on one or two important details. 
Inspection should be followed by compulsion, 
and every house should be put in order. It is 
true that we now learn where disease is ; but 
only by a method of complete inspection shall 
we know where it is going to be, and only by 
proper alterations and removal of defects can 
we prevent its appearance. 

mainly, with a few men. A crowd like this is always on the side of 
justice ; mercy is never thought of in the face of a recently committed 
crime. One woman said, " Hanging is too good for her," referring to 
the wicked mother of the innocent babe. Way was made for me — 
crowds always make way for a doctor ; I walked down the little avenue 
of people and, after searching myself in the midden, which nobody 
seemed to have investigated, I found the infant, which was wrapped 
up in a newspaper. A common, sordid matter of infanticide. When 
I returned home and sought my bed, I was again disturbed by an officer 
telephoning. I was able to say that, according to the statements of 
the crowd, the identity of the mother was shrewdly guessed at. In 
fact, the babe was a kitten. For years after, the inspector who summoned 
me was hailed in that district with cries of " mew." 


Women sanitary inspectors watch over the 
work of midwives, visiting the lying-in chamber 
and instructing both the patient and the attend- 
ant. All very good, but more is required. The 
infant must be under guardianship. Its life must 
be justly valued, its future guarded, its death, 
if it dies from neglect, avenged by society ; and 
this can only be done if inspection, from birth to 
school age, is carried out by domiciliary visits, 
and if instruction is given by practical nurses 
acting under medical guidance, or by the 
medical practitioner himself or herself. 



ly /TANY recently made plans to improve the 
■^^■^ health of our dense population and to 
relieve their miseries have an air of being cock- 
sure that the last word has now been spoken. 
But whilst the authors of these valuable — and 
valued — plans carry their Tables of the Law 
with a gravity and conviction that Sinai alone 
could justify, there is yet among critics an 
elasticity of opinion and a sceptical attitude 
towards these schemes, though perhaps the 
scepticism has hardly been sufficiently ex- 
pressed. There is still a mass of work for the 
clinical detective: with 38,000 medical prac- 
titioners on the register, there are still 250,000 
or more preventable deaths every year. The 
death-rate among the poor reaches an appalling 
height. The casual labourer dies with twice 
the alacrity shown by the doctor, the clergyman, 
the chemist, or the Clerk to the Board of 
Guardians — which is another way of saying 
that regular work and a regularly expected 
wage may lead to the natural and unlamented 



death from senility ; but apart from regularity 
of employment and sufficiency of recompense, 
there are premature deaths due to alterable 
evils of environment and habit. One out of 
every five children born dies before its fifth 
birthday. Some children could not live, not 
even in a palace of hygiene, but this enor- 
mous death-rate is mainly caused by poverty, 
ignorance, weakness and fatigue in overworked 
mothers. It is found where the poor are ill-fed 
and pinched for air and room. It is least where 
there is least filth and most money. 

Can we bring to the poor the health oppor- 
tunities of the rich ? I suppose we cannot, but 
we can certainly lessen the disparity. If we 
cannot alter the social conditions, we could at 
least, if we had the necessary encouragement, 
lessen the disgraceful death-rate. Let me take 
a case of diphtheria. If we are called in to see 
a child suffering from this disease, we are 
anxious to know the day on which the patient 
began to be ill. We know we can cure 95 per 
cent, of the patients with diphtheria if we are in 
the house on the first day. But we are not 
called in during the first day, and I don't think 
we can expect it. The signs and symptoms 
come on insidiously, and the parents do not 
recognise the gravity of these signs and 
symptoms. But if, whenever diphtheria shows 


itself in a neighbourhood, every house and every 
inmate Hkely to be affected were examined, and 
the dinical and bacteriological signs searched 
for, many cases would be found on the first day 
instead of the fifth, the death-rate in those 
attacked would be a very different affair, and 
the disease could not spread, for the infected 
person would be hurried away into isolation. 

But though we can cure our individual cases 
of diphtheria by antitoxin and prevent the 
spread of the disease, this should not be 
enough. We do not lessen the appearance 
of fresh cases : we hit the bird on the wing, 
but we do not discover the breeding nests. 
We ought to find out what the disease really 
is, its relationship with other diseases, its 
hiding-place when it has no human host, and 
the cause of its habit of rapidly increasing in 
virulence. There is plenty of work for the 
investigators, among whom one of the most 
valuable is the well-trained general practitioner, 
a master of the science needed to detect and 
to fight disease. He should, of course, be 
allowed to call for the services of the various 
experts in bacteriology and other branches 
of research, experts to whom he can apply 
and with whom he can work. ^ 

1 Sir Clifford AUbutt hopes that the time will come when research 
laboratories will be thronged by medical men in general practice, who 


Preventive medicine cannot be separated 
from clinical medicine ; indeed, it depends upon 
it. The Fever Hospitals are in themselves a 
sufficient proof of this. These hospitals, though 
beautifully built, are insufficiently staffed ; the 
medical men are hard at work the whole day 
through and have no time for quiet investiga- 
tion. The result is that we get very little 
original work from these hard-driven men, and 
the advance of medicine is proportionately 
delayed. To make, then, the 38,000 men who 
have been wittily but wickedly named mer- 
cenaries produce from their midst a truly 
national Health Militia, some methods of sub- 
sidy and control will be necessary. Two points 
seem to me to stand out : the first is, to induce 
the best brains of the country to join the medical 
profession ; the second is, to refrain from forcing 
the best brains in the profession to devote their 
abilities to the service of the rich. Hunslet 
needs more doctors than Harrogate, but it 
gets fewer, because Harrogate honours them. 

Life inside and outside the house should 
be subject to scientific investigation, and the 

will be not only admitted but also warmly welcomed. (Lecture at 
Bradford to the Medico-Chirurgical Society.) A colleague of Sir 
Clifford Allbutt's (Dr A. G. Barrs) said on the same occasion: "The 
general practitioner has every opportunity to meet with original work, 
but he cannot test his facts in a laboratorj-, and he therefore does not 
formulate theories." 


principles of public health thus discovered 
should be carried into effect. It is not enough 
to visit and remove any patient with an in- 
fectious illness. More must be known of the 
mysterious agencies of disease, of the inter- 
dependence of the diseases of man and animals, 
and even of plants. The only way to this is 
the establishment of a great and richly endowed 
international commission, always at work and 
having authority to dictate to the politicians. 
A year of study given to the dust of the floors 
and walls of our workrooms would be worth 
more to the human race than would be the 
advent of one great musician or of two new 
Irish poets. 

We are proud of our workshop inspection, 
of our rules as to offensive trades, as to bake- 
houses, as to lodging-houses, cellar dwellings, 
and dwelling-house nuisances. But the Sanitary 
Laws deal only with the elementary and 
obviously common-sense side of the subject, 
the air space for each breather, the height of 
the walls, the periodical painting or white- 
washing of these walls, the trapping of gullies, 
etc. These laws compel the observance of 
rules which should be obeyed without compul- 
sion. The history of the introduction into 
workshops of hygienic reform is a most curious 
case in point, the extraordinary fact coming out 


that workmen at one time objected to any such 
introduction. Especially was this true of 
Sheffield in the time of Mr Roebuck, when a 
grinder was not expected to live after the age 
of thirty. Men would work until the very last, 
and when they could not walk to work they 
went in wheel-barrows. No one objected to 
the wholesale spitting, which went on until the 
spitter gave up spitting altogether. The men 
lived hard, and Death was a joke to be enjoyed 
with whisky. When a man showed signs of 
its inevitable approach, it was a frequent bit of 
comedy to throw tow at him, with some slang 
phrase which meant he was on the steep incline. 
Such imbecile heroism in the workshops needed 
the interference of the inspector — the masters 
were said to be powerless. Grinders in Sheffield 
may now live to be forty, although they still 
have five times as much lung disease as the 
average of our population. But the crude 
inspections and ordering of white-washing, etc., 
will not satisfy the next decade. We must 
know why abnormal deaths occur in particular 
workshops and not in other comparable work- 
shops. Simple scientific rules will have to be 
applied for the solution of the problem. Organic 
excreta, and especially the aerial excreta of the 
workshop, will have to be examined. This 
will mean the employment of trained medical 


observers, skilled in the use of the microscope, 
at home in the laboratory ; but it will also mean 
the partial or complete extinction of disease. 

There are many cases of illness which an 
ordinary inspector knows nothing about. Girls 
working in busy shops are on their feet from 
morning till night, and often for meagre wages 
which do not suffice to buy them necessaries. 
I often come across this kind of thing. On 
Christmas Day of last year I was called to see 
two girls, each suffering from vulval inflamma- 
tion, due in each case to the hard work of 
Christmas week. Chairs are placed in all 
shops, but the girls in the cheap shops and 
bazaars are not allowed to use them, certainly 
not in the busiest weeks. Anyone who has 
been in general practice knows the evil results 
which continuous standing produces in these 
girls, the strain and stress which the internal 
organs are not able to bear. I have often said 
that even a negress should not be expected 
to put up with treatment like this, which our 
women trained and taught in the methods of 
the highest civilisation (!) are bound to endure. 

An instance which comes to mind of failure 
in the Public Health service is concerned not 
with sewage, but with the Navy. The Navy 
is saturated with venereal disease. Syphilis is 
frankly the most disastrous of maladies, and one 


which has no justification for its existence. I 
speak of the Navy, because the Navy holds the 
pick of our young men, selected after severe 
medical examination ; but the Army is equally 
affected by the same disease. In civilian life, at 
least 25 per cent, of males have been contamin- 
ated in this or recent generations. A few words, 
without any special attempt at emphasis, and 
certainly without exaggeration, are sufficient to 
indicate the extent of the evil. The vigorous and 
young and impetuous are those most likely to be 
victims of this disease. It affects more than 
one generation : it causes idiocy in the new-born, 
and it would fill the world with degenerates, but 
that fortunately, in the case of syphilitic parents, 
most conceptions end in miscarriage. As it is, 
it sends crowds through the gates of our lunatic 
asylums, malignantly attacking the brain and 
nerve of the highly intellectual. And yet, 
strange to say, it is of all diseases the most 
readily cured, if the practitioner can get to the 
patient early enough, and if the patient will not 
too soon leave the practitioner. If we can't 
abolish diseases, we ought at least, with our 
present powers even slightly augmented, to 
isolate and immure sufferers during treatment, 
especially those who, owning to ignorance, lack of 
restraint, carelessness, or wickedness, are likely 
to propagate the evil. We shall not be able to 


abolish this scourge until we abolish personal 
liberty and institute an inquisition which would 
offend the innocent ; but, for the sake of both the 
innocent and the unfortunate, we should consider 
how far we can go in the direction of medical 
despotism in order to suppress the anarchy of 
foul disease. In saying this I am not speaking 
as an individual : I am voicing the opinion of 
the whole medical profession. We need an 
international medical commission always sitting, 
a Hague Tribunal of medicine, with national 
and provincial branches and sub-branches, with 
authority mediaeval in power, and with lavish 
financial support, not from the State but from 
civilisation. Such a commission should be 
asked to bring our preventable diseases to 
extinction ; it would probably find most of its 
work in connection with the saving of child life, 
the problems appertaining to the diseases of 
children, the causes of disease, the prevention 
of such causes, and the application of medical 
knowledge in the nursery, in the school, in the 
workshop, and in connection with marriage and 

I have elsewhere considered many conditions 
which lead to a low standard of health among 
our people, and I do not wish to enter again 
into details ; but here I would say that the 
conditions of individual health are very often 


affected as much by the action of the police in 
their capacity of indirect PubHc Health auth- 
orities and promoters of personal decency. I 
foresee that in the future the Health officers 
will need further police powers. There is 
much to be done. For instance, it is not 
widely known that disease is carried about by 
the healthy, and that germs may be at one 
time innocent, at another virulent. In healthy 
people the germs which produce pneumonia 
are in some circumstances harmless inhabitants 
of the mouth. Diphtheria is a condition due 
to the roused activities of a bacillus which 
may have lived and bred in the throat for 
long periods without doing an)^ harm to its 
host. One person in fifteen carries an innocent 
form of the diphtheria bacillus in the throat ; 
one person in five hundred carries a malignant 
form, ready to attack others, though apparently 
harmless in the throat of the carrier. There 
are many instances known of hale people 
carrying about typhoid germs. But under 
certain conditions, as when a man has been 
subjected to great fatigue, to chill, or to 
depression consequent upon excitement, the 
hitherto harmless microbe may take virulent 
qualities and attack its host ; then follows 
pneumonia, or diphtheria, or typhoid, as the 
case may be. One such instance is that of a 


healthy woman, a carrier of typhoid germs, 
who infected family after family with which 
she took service as cook. In the end she 
had to be isolated. 

The great questions of hygiene are not 
yet understood ; the knowledge has not been 
swallowed and certainly not absorbed. Trades 
concerned with the selling of alcohol are known 
to be associated with a high death-rate among 
those engaged in them, and it is often hastily 
settled that all such deaths are due to alcoholism. 
It is doubtless true that in many cases, perhaps 
in most, sellers become alcoholics. But the 
conditions of life, the continued inhalation of 
stale and polluted air, infection from sputum- 
covered floors, hurried meals, long hours of 
work prolonged till late at night, short hours 
of sleep : all these must, equally with alcohol, 
cause morbidity ; indeed, such a mode of life 
has to these people its only consolation in 
alcohol. (Dr Barrs has said that the public- 
house should never harbour the family of the 
publican.) The idea that hygiene is a fad 
favoured by doctors measures, not the intel- 
lectual ability of so many ignorant clever men, 
but their short-sighted indifference. Unless 
you give them enlarged illustrations of the 
bacteriology and chemistry of stale air and of 
organic dust, such illustrations as, you might 


think, were needed only by children, these men 
can't beHeve that certain unhygienic conditions 
cause disease. 

Some schools, again, are scandals as far as 
hygiene is concerned. Ventilation may not 
be entirely neglected, but it is ridiculously 
insufficient. There are congregation diseases, 
spread by volatile infection agents, which will 
give a death-rate even if the children are 
taught in the open ; and in some schools the 
conditions are such that this volatile infection 
is intensified to an extremely dangerous degree. 
In the schools of the present day these congre- 
gation diseases have a curious habit of arriv- 
ing, increasing in virulence, then lessening in 
virulence, and finally departing. They may 
cause a huge death-rate and then tempor- 
arily go into retirement. Scientific papers are 
written, but no stern, truculent and determined 
attack is made on the apparently inevitable 
repeating devastations of such diseases as 
measles, whooping cough, diphtheria, and 
scarlet fever. 

A school is a kind of vaccination station, 
since some schools are never free from in- 
fectious disease. Mild scarlet fever is exceed- 
ingly common in schools. The cases are at 
first so slight that they do not attract immediate 
attention ; then a virulent case occurs, and it is 


discovered that the whole school is widely in- 
fected. Some places favour certain diseases ; 
thus favus is never seen in Yorkshire, but 
there are certain Scottish towns where children 
of school age suffering- from this disease can 
be produced for the benefit of the inquiring 

I once saw a child wrapped up in blankets 
carried through the streets, and I found on 
inquiry that the sick boy was being taken to 
school. It was at a time when great importance 
was attached to a large percentage of attendances 
at the Council Schools, and the headmaster of 
the school in question was ensuring that not a 
single pupil should be absent. It is strange 
that a schoolmaster was able to induce a mother 
to send her child to school ; but these poor 
people have a great respect for the law, even if 
they often break it. 

The little ones toddle off to school far too 
early. Most of them have at least one attack 
of measles, and many have scarlet fever ; and 
these diseases are most dangerous to the 
youngest children. Indeed, the huge death- 
rate among children is partly due to the early 
age at which they are sent to school, partly also 
to the great size of the schools, and to the 
absence of open-air teaching. 

Smaller schools would be a benefit to the 


children for other reasons. The children in 
rural districts of a town have in some cases to 
walk long distances in all weathers to get to 
an infant school ; this is obviously wrong, and 
I have often seen illness follow such, at present, 
inevitable exposure of a child attending school. 
I would also suggest that there should be 
modified teaching for all very delicate children. 
But above all other reforms of this kind we 
need smaller schools and open-air teaching. 

Though the gaols of the country are free 
from many diseases once perennially present — 
typhus, for instance, has vanished, but phthisis 
is not one of the absentees — yet the conditions 
which led to these diseases, now absent from 
the gaols, are not absent from the police 
courts ; and the crowded bundles of rags — men, 
women, and children — turn the corridor of an 
assize court into a densely populated slum. 

I repeat, the Medical Officer of Health and 
his colleagues must be Health magistrates, 
with police powers to deal with any individual 
who is in any way a menace to the public 



IT will Strike every thoughtful observer that 
more attention is now being given to the 
social conditions of life than ever was the case 
in any previous period of our nation's history. 
The time for apoplectic and inflammatory 
Chartist riots over purely political questions has 
passed. We are now concerned with the health 
of the community rather than with its liberty ; 
we are more anxious that the labourer should 
get the reward of his hire than that he should 
deserve it ; we are all more troubled by 
problems of overcrowding and ill-ventilation 
than by the extension of political responsi- 
bilities. Even the episcopal apron has become 
an oriflamme of social reform. And althougrh 
more thought and more oratory are being 
expended on the enlargement of the political 
suffrage than was the case ten years ago, this 
very extension has its advocates in order that 
social questions shall be dealt with by the sex 
which undoubtedly comes into the closest 
contact with the intimacies of social miseries. 

12 177 


As one interested in a liospital which deals 
with sufferers from the ravages of tubercle, it 
has been impossible for me to evade an 
intimate knowledge of tuberculous diseases, 
and I have studied the problem presented more 
from a positivist than from a sentimental point 
of view. 

What is tubercle ? It is a diseased condition 
found in the human being and in the animal ; 
it is due to the invasion of the human and the 
animal frame by the tubercle bacillus, a germ 
which is as microscopic in size as it is gigantic 
in its inimical and devastating action on the 
career of mankind. Tubercle is at present 
found wherever the human race is found. 
Everyone of us has been, or will be, attacked 
by this most persistent enemy. It attacks 
indiscriminately the just and the unjust, and it 
destroys the physically and morally weak. 

What are these germs or bacteria or bacilli, 
which inhabit the world as our companions? 
They are the pigmy chemists of Nature. 
Study the common soil ! You reverently place 
in the earth the remains of those who have 
died. You speak of Mother Earth, and you 
return the children to the parent. Nature 
dissolves the human body — the flesh, the 
bones, the organs, everything— dissolves it into 
its constituent elements. It is as if a temple 


of beauteous structure were taken down stone 
by stone, until the whole became one 
amorphous mass, capable, however, of being 
used again at the command of the Great 

This common soil contains myriads of 
microbes in a millimetre. It is the work of 
these myriads to metamorphose the dead husk 
of the mortal body, until it shall become an 
indistinguishable part of the living soil. In 
common soil is the tomb and the memorial of 
the races who have inhabited the world since 
the beginning of things. It is the same with 
the plant races as with the animal. " As the 
tree falls, so shall it lie," and it lies more 
helpless than .Gulliver chained down by the 
army of Lilliputians, until it sinks into the 
monotonous companionship of the soil. 

Now, as these germs attack the human body 
when it is dead, so there are special tribes 
which attack the human body when it is alive, 
and the tubercle bacillus is the most terrible of 
these. The human body resists. Its powerful 
resistance is its vitality. And so with the 
tubercle germ : it treats the human body as if 
it were dead ; it attacks the living human frame, 
while its alien relative attacks the dead human 

But we find in nature, especially in certain 


grasses, bacilli which are in many respects 
similar in structure and function to the germ of 
consumption. In some remote past these germs 
which inhabited grasses and other plants founded 
colonies in animal life. Possibly they attacked 
other animals before declaring war on man. 
From what we know of disease, we can imagine 
with inevitable truth what must have taken 
place : the long defence of the metropolis of 
life, its slow but certain conquest and final 
capitulation, the arrogant increase in virulence 
on the part of the invader, the Asiatic submis- 
sion of man to the will of God. Verily I can 
believe that Oriental fatalism originated in 
ancient plagues of the dim worlds that have 

We know how a modern disease, such as 
measles, familiar to us and hardly feared, has 
been carried back from Europe to their native 
land by the dark envoys of a savage state, 
and we know that on one occasion whole 
islands were depopulated from this cause, the 
inhabitants being destroyed as grass by a prairie 
fire. Such devastations would occur amonof 
primitive peoples. Then slowly humanity 
would learn to defend itself. The weakest of 
the ancient world would die. The fathers and 
mothers left would produce a race more able to 
resist. The continued presence of the foe would 



prevent the weak from multiplying beyond 

Tubercle was the ancient, even more than 
it is the modern enemy ; but as knowledge and 
the microscope have advanced, we have learnt 
of this foe. We have overlooked his camp ; 
we have discovered what he is like ; we have 
watched him in his home, which is also his 
battlefield. We have learnt to photograph him, 
we know what helps him to flourish, what 
makes him terrible, and what makes him weak 
and helpless. 

Children are seldom born with the disease 
present in their little frames. I remember two 
patients of mine, mothers in the last stage of 
consumption, each giving birth to a baby, and 
each baby dying of inanition soon after birth. 
The mothers had sufficient breath to live until 
the children were born, and no more. A 
scientist injected the fluids from the babies' bodies 
into guinea-pigs. Guinea-pigs as a rule quickly 
become overrun with tubercle, but to these two 
guinea-pigs nothing untoward happened. They 
did not develop tubercle, and therefore we 
can believe that the children were free from 
tubercle. Such experiments have frequently 
been made before. 

Infection of children takes place after birth. 
The child lives in the family of the parents. In 


the ordinary house of the labourer there are 
more mouths than food. There is more work 
for the mother than strength. The children 
come too quickly. They infest the house. 
Filth dwells on the floor. The disease has 
already possibly attacked one of the band ; the 
laws of health, which enjoin cleanliness, ventila- 
tion, good food and plenty of air space, are not 
known and certainly not followed. The child 
is the companion of the filth on the floor, of the 
sputum on the carpet, of the flies in the peopled 
air. Its health is depressed by bad feeding and 
a polluted atmosphere. It may have brought 
with it into the world a projected heritage of 

Again, disease may have its origin in the over- 
crowding of houses where comfort and morality 
are evident. The house may be too small, the 
family too large, too young, too affectionate 
and therefore too " stay-at-home," Disease has 
a chance under these conditions, and one after 
another of the children may die. If the family 
scatters, the disease disappears. As families 
become smaller in labouring men's houses 
disease becomes less. 

But even if the child is born into a luxurious 
home, there may be long trailing dresses and 
heavy curtains ; ill feeding is not unknown in 
the abode of wealth ; fresh air is a nuisance in 


the nursery, and the laws of infection from 
mother, father, brother, sister, nurse or servant 
are not understood. The children of the rich 
and poor frequent the polluted streets, the 
crowded assemblies, the trains and tramways 
common to all. There is as much tubercle in 
a train as in a tavern. 

The advantage of the rich is that there is 
more knowledge in the house, more air, and 
much more food. The possible advantage to 
the poor child is that tubercle may have killed 
off the relatives who were germ-carriers, and 
may thus have left a healthier stock. 

Children at school are always in contact 
with infection. Since the mortality rate from 
consumption shows that more than one out of 
every ten deaths is due to tubercle, and since 
for every one that dies a much larger number 
live and recover, and yet in the presence of 
their own salvation destroy others, it is inevit- 
able that tubercle must be prevalent in the 

Many observers have attempted to find out 
the amount of consumption in our schools. 
Dr Philip found 30 per cent, of the children he 
examined to be infected with tubercle which, 
though of slight intensity, could be clinically 
demonstrated, and which might become open 
disease in the future, the final result depending 


upon the accidental circumstances of life in the 
child concerned. The truth is, no child can 
expect to escape some measure of infection, 
although the amount may be slight. In the 
schools of a large industrial centre, I examined 
most closely several hundred children, taking 
special note of the presence of the tubercle. 
I found quite 25 per cent., of the children 
infected. If these figures are found to be 
unassailable — and they have survived attack 
so far — the question is a very serious one, and 
open air schools should be the rule, not the 

From the school the child goes to the univer- 
sity, the office, the factory, the mill. Adoles- 
cence is the time of danger, in which the human 
plant is easily nipped by the frost of ignorance 
or withered in the hothouse of vice. With more 
liberty there is more license. The sedulous 
cultivation of indoor or outdoor excesses is a 
broad way leading to destruction. Sexual vice 
is one horror ; the alcoholic habit is another ; 
and the two are seldom found apart from 
tubercle. Yet, with all this danger, environ- 
ment from the point of view of hygiene is, in 
the minds of the parents, hardly ever a para- 
mount consideration. 

Legislation has had much to say concerning 
hours of work and overcrowding- of workshops ; 


but it has little to say of physical dirt, and 
nothing of moral dirt. There are signs that 
this transitional period is passing, and that 
future generations will only obtain freedom by 
sacrificing liberty. Public opinion, which is the 
John the Baptist to the State Messiah, demands 
that our youth be not sacrificed. The law 
should be more emphatic than the opinion of 
the man in the street. I hope to see the day 
when tubercle and alcoholism and allied diseases 
will be under rigorous inquisition, and when the 
public health service will be elevated. 

But to return from our wanderings : 

Even if the child is apparently invincible to 
the tubercle germ, the little enemy attacks 
him : in the post-mortem room in Vienna 70 
per cent, of the bodies examined contained 
signs, visible enough to the pathologist, of the 
presence of tubercle. 

Suicides are men who have failed, and are 
more likely than not to be tuberculous. Tubercle 
attacks failures. It attacks the depressed, the 
alcoholic, the lunatic of all degrees. But 
tubercle may attack, and may successfully find 
secure lodging, and yet may apparently not 
injure. I have frequendy seen proof of this. 

Looking at my police notes, I see that an 
old man who fell dead in an Irish quarter 
was found on post-mortem examination to have 


succumbed to heart disease. But in his past 
years one lung had been widely attacked by 
the tubercle germ; the man has carried his 
ancient malady into old age, and had died of 
another ailment. Similarly, in the same week, 
a young English postman fell dead on his 
rounds. He also died from a heart affection, 
but he had carried a double burden of disease : 
the chest had marked signs of apparently cured, 
or at least quiescent, tubercle. 

The drunkards who die in common lodging- 
houses, or who die neglected in the common 
courts, always show tubercle, generally active, 
in some cases so active that you wonder why 
they have dragged along, and also how many 
they have infected. 

To return to the rake's progress : the nose, 
throat, lung, stomach, intestine, brain, bones, 
etc., are all attacked by this persistent yet 
inconsistent lover. It depends upon the heredi- 
tary immunity and upon the present physique 
and environment whether or not the victim 
will succumb. Physique is a factor of great 
importance. The child which inherits a large 
chest and a nose which enables him to be a 
nose-breather has an advantage. The mouth- 
breathers are recruits for the consumption 

The juices of the body contain immunity- 


giving- substances, contain, that is, the arma- 
ments of the invaded. The blood, the secretions 
of the stomach and of the other organs are all 
supplied with chemicals capable of killing 
bacilli. The microbe may be destroyed in the 
nose, in the throat, in the glands, in the lung 
itself. It is generally powerless in the healthy 
stomach and healthy intestine. The blood-cells 
seek it out and devour it, the blood-serum 
saturates it and paralyses it for the maw of 
the leucocyte. Outside the body the germ 
is killed in sunshine very rapidly ; it is 
destroyed even by a diffused daylight, but 
more slowly. It lives for a dangerous time 
on foul dust, which it makes its vehicle, 
sticking until it finds a home, say a gritty 
throat. A dusty bedroom after the sheets 
have been shaken is a danger, whether the 
disease is smallpox or tubercle or scarlet fever. 
In Chest Hospitals nurses generally escape 
infection, and means are necessarily taken 
to minimise the danger to the bedmakers. 

A man who spits on the floor should be 
imprisoned in a field where there are no other 
cattle, for if he is put in an ordinary prison, 
he will infect the police. 

The greatest enemies to tubercle are good 
wages, good food, work without strain, play 
without violence, and plenty of sleep. To 


the patient suffering from tubercle the greatest 
enemy is alcohol. One must remember that 
tubercle kills the weakly. Anything which 
destroys or lessens vitality destroys or lessens 
the power of resisting tubercle. Alcohol lessens 
vitality ; it stimulates the lower sensuous 
activities of man, degrades the reasoning 
powers, and destroys the power of self-restraint. 
The grotesque immediate effect of alcohol is 
dimly mirrored in its permanent action on the 
tissues. The talkative, amusing, quarrelsome 
companion of the night is the nauseated, dull, 
wet-leather individual of the next morning, 
and every alcoholic debauch hardens his arteries 
and degrades his nervous system. The brilliant 
after-dinner speaker of thirty, stimulated by 
his dram, is not seen at sixty ; indeed, alcohol 
spares only the bores, and hardly those. 
Tubercle has its greatest friend in alcohol. 

A man may be a tuberculous athlete ; he 
may be like Dr Johnson, a strong man scarred 
with scrofula. The strong man in modern 
life is the one who will refuse to be conquered 
by his environment. He is surrounded by 
disease, he is sure to be attacked; let him 
resist by anticipation. Of all diseases, tuber- 
culosis can be best fought by sanity, by an 
intelligent foreknowledge of the evils of modern 
life ; and of all man's foes alcohol is the one 


to which the tuberculous most decidedly must 
not surrender. Once he goes under the yoke, 
his condition is one of certain slavery and 
equally certain premature decay. 

A few days ago I was asked to address 
a body of men and women who were members 
of, and in fact representatives from, a number 
of friendly societies. After I had addressed 
them, several questions were put to me, 
questions which indicated the deeply intelligent 
interest my hearers had in these subjects. 

I was asked: "What are the signs of 
tuberculous disease, recognisable by a patient 

" Is it proved beyond doubt that the disease 
is not hereditary, and could I more fully ex- 
plain the supposed immunity of the Jewish 
races ? " 

" Were houses that had been dwelt in by 
consumptives a danger to those who might 
succeed them as tenants ? " 

"To what extent were the rich liable to 
tubercle in comparison with the poor ? Why 
was it advisable to compel notification of all 
tuberculous diseases ? " 

"Was it true that in certain districts of 
France the increase in alcoholism measured the 
increase in tuberculosis in those districts ? " 

"Would it not be more to the benefit of 


the working man if some part of the large 
sums of money spent on the out-patient depart- 
ments of our general hospitals were expended 
on special dispensaries for tuberculosis ? " 

" Is there any danger of infection to Friendly 
Society sick-visitors who visit consumptives ? " 

" If twenty-five per cent, of school children 
were already attacked by tubercle to a demon- 
strable extent, what would be the probable 
effect on their future ? " 

"What form of public health service did I 
consider necessary to prevent such diseases as 
phthisis ? " 

" Could not the doctors of the present day 
do more, and was any attempt being made in 
any quarter to bring the necessary knowledge 
to the homes of the people ? " 

These questions were thrown out spontan- 
eously, one man after another rising and 
speaking on the points to which he wished to 
draw my attention. Some of the questions 
had already been answered in part, but it was 
evident that this body of men and women had 
come to the meeting with the desire to learn 
about tubercle, not only as individuals, but 
also as citizens interested in the wider problem 
of how to drive the pest from the community. 

The question of notification of all cases of 
tuberculosis is a very delicate one, for, accord- 


ing to the morbid anatomists, the deposit ot 
tubercle in some part of the substance of the 
lungs or of their allied glands is in these 
islands almost universal. Therefore, minute 
microscopic infiltration of the lungs, only to 
be discovered by the expert, and hardly by 
him, will not have to be considered as clinical 
phthisis and will not have to be notified. By 
clinical cases of phthisis I mean those which 
are, or which will be, capable of spreading the 
infection, and all such it will be better to notify. 
The prophetic power even of an expert is 
limited : even an expert will not know whether 
a minjute tubercular focus will or will not some 
day become an active centre for the spread of 
disease. It is better, 1 admit, to err on the 
side of notification. Personally, what with 
hospital cases and private practice, I have of 
late years notified some two hundred cases 
annually. But great care will have to be 
exercised ; otherwise a man might notify him- 
self, his friends and all his acquaintances. 
Nobody could deny the justice of his diagnosis ; 
and nobody would be a penny the better for 
the notification of these non-clinical cases of 
slight pulmonary tuberculous infiltration. When 
it is fully understood that the tuberculosis patient 
in his early non-spitting stage is not a danger to 
the public, and that he only becomes one when 


he is spreading the seeds in his sputum, then it 
will be no hardship to notify every clinical case 
that is brought to light, for no hardship, no 
penalty, will follow the notification. In those 
early non-infectious cases which are likely to 
advance to a more acute stage, notification 
should be for the benefit of the patient, and 
should be made with the greatest care and 
secrecy ; otherwise the act will become un- 
popular and will be evaded. Notification 
should be confidential between the patient, 
his medical adviser, and the Medical Officer 
of Health ; and this confidence should not be 
violated. Assistance should, if necessary, be 
given from the public purse, so that the patient 
may be helped to his cure. If possible, suitable 
work should be found for him. 

In these days there is a great horror of the 
disease, almost a panic. This panic has spread 
to the sick-visitors. There is a present danger 
of every sanatorium-treated patient being 
tabooed, and a consequent fear that many con- 
sumptives, in their endeavour to hide the 
knowledge of their ailment, may refuse all 

The infection from tuberculosis patients is 
not the same as from smallpox or scarlet fever 
patients. In the latter cases there is a quick- 
acting volatile poison ; in the case of tubercle 


there is a slow-acting infection requiring that 
many doses shall be absorbed by the recipient 
before the malady obtains foothold. It is not 
the doctor, the nurse, the sick-visitor, who are 
in dano-er, but it is the fellow-dweller in the 
house, the sharer of the pillow, the one m 
intimate and prolonged contact with the invalid, 
who succumbs to the infection of this disease. 
And it must not be forgotten that tuberculosis 
may be intermittently infective and non- 
infective. A patient who has been to a 
sanatorium or a tuberculosis hospital has been 
taught how to prevent infection, how to destroy 
his infective material. 

When it becomes the rule, nay, the law, to 
consult a medical man, to find out the frailties 
of one's frame before active disease begins, then, 
and then only, shall we be able to strangle the 
disease before it strangles the patient. The 
public medical service of the future will, it is 
certain, take on this preventive work. Even 
now our nurses visit the home of the con- 
sumptive patient and bring up to the dispensary 
any suspected inmate of the house, in order 
that he or she also may be examined and, if 
necessary, treated. When the problem is 
understood, the family of a consumptive will 
not be allowed to live on a limited dietary while 
he fattens in a sanatorium. 



There will have to be an organised attempt 
to prevent tuberculous milk from reaching the 
public. A system by which a catechism and 
creed of hygiene was carried into every cottage 
would be of great value. The importance of 
environment and infection, and the much less 
importance of heredity, even in its widest 
sense, will be apparent. 



\ T the Congress of London about ten years 
ago, Koch made what appeared to be a 
most important announcement. His experi- 
ments previous to this date had seemed to 
show that bovine and human tuberculosis were 
identical ; he now, however, declared his belief 
that the two diseases were so dissimilar as not 
to be intercommunicable. Since this statement 
was made, the medical world has given immense 
attention to the subject, and it is found that 
evidence is not with Koch : bovine tubercle 
can attack human beings, and human tubercle 
can attack cattle. The carrying of infection, 
however, is not so easy as was at one time 
thought. In following closely the expressed 
opinions of those who have experimented with 
tubercle, one is irresistibly led to the conclusion 
that bovine and human tubercle bacilli, acting 
as causes of disease, are different types of the 
same thing, that they may both attack human 
beings, and that the bovine tubercle is more 
often found in glandular and abdominal tubercu- 



losis than in phthisis. After all, the object of 
the crusade against human tuberculosis is to 
extirpate tubercle both in animals and in man. 

It may be of interest to say a word or two as 
to the programme and the character of the 
work done at some of these congresses, nearly 
all of which I have attended. 

In the autumn of 1908 a Tuberculosis 
Congress was held in Washington. The 
listeners among us had the opportunity of 
hearing men whose names in science were 
great enough to attract five thousand delegates 
to a five days' course of serious lectures. The 
delegates were scientists. One met the in- 
tellectual and rather intelligent German, the 
very intelligent American, the Englishman 
presenting valuable facts with undecorated 
precision, the Frenchman eloquently grave, the 
Hungarian with all the vivacity and none of 
the gravity of the Frenchman, and the educated 
Russian with no characteristic of his own. 
The time at the disposal of the Congress at 
Washington was too short ; the lectures were 
authoritative, they were luminous, but they 
were seldom brief. Yet there were many 
sections, and the subjects and the celebrities 
were well chosen and well distributed. Every- 
one was pleased ; we all felt we were concerned 
in a great and successful gathering. 


The American Government had directed 
that one of the largest public buildings should 
be used for the Congress, and even then the 
Government had fallen short of the wishes of 
the American people, for the Press showed a 
genuine chagrin that the Capitol itself had not 
been chosen. An exhibition, philanthropic and 
educational, of the modern means for dealing 
with tuberculosis was arranged with marvellous 
attractiveness ; in fact, as far as its attractive- 
ness was concerned, never before had one seen 
anything so well done. Tens of thousands of 
people came into the Washington corridors to 
compare the house of the consumptive, left in 
its original condition as a breeding place for 
the disease, with the same house altered at a 
ridiculously small cost until it was as safe as the 
average Englishman's home ; to inspect models 
of slum houses with ready-made arrangements 
for ventilation and rough verandahs for sleeping 
out in back yards ; to see photographs showing 
vividly the dangers lurking in workshops. A 
creed of hygiene was exposed with Kindergarten 
attractiveness, statistics of disease were shown 
as graphically as the magazines can show them, 
and there were all kinds of dodges to make the 
people understand the danger. The general 
public accepted the invitation to attend, and at 
every corner demonstrators, fluent speakers. 


discoursed in language understood of the 
people concerning the disease which dogs 
civilisation. And in the quieter lecture-rooms 
one met Koch, von Pirquet, Arloing, Calmette, 
Detre, Philip, Newsholme, Sims Woodhead, 
and men of equal stature. The Congress made 
a most serious effort to standardise the know- 
ledge collected during the last years, knowledge 
by which consumption will be lessened and 
some day abolished. 

What were the subjects brought before this 
great gathering? 

Tuberculosis as it strikes at you, at me, at 
everyone, the disease as it rules in the home, 
as it steals into the schoolroom, as it thrusts 
itself into the workshop ; the disease as 
it meets a man in his bedroom, at his 
table, at his desk, in the tramcar, in the rail- 
way train, in the theatre, and even in the 

The disease has been carefully stalked in the 
big cities. In New York, for instance, blocks 
of buildings have been found to be death traps, 
and some are known as " lung blocks " ; others, 
however, have been found to be free from the 
disease. As with blocks, so with districts: 
some are full of disease, others are as free from 
it as " The Saturday Review " from dulness. 
The conditions which lead to this morbidity 


have been or are being discovered; and con- 
cerning these, too, we were able to acquire 
knowledge. We learnt of the disease in cattle 
as well as in man, in the wild animal as well as 
in the tame ; of the possibility of transference 
from one animal to another, or from animal to 
man. We discussed the varying virulence of 
the bacillus towards different races, its deadli- 
ness to the black man, and its mildness to the 
Jew, that everlasting city dweller who has 
earned immunity when forced by necessity to 
live among festering filth. Every lecture-room 
poured learning into you and over you ; every 
corridor tricked you into pupilage. Knowledge 
was there ; anyone could pluck it without fear 
of hierarchical damnation. Every university 
in England seemed to have been induced to 
send specimens illustrating the disease, its 
cause, and its ravages ; demonstrators, even, 
had come with their specimens. Every nation, 
including Germany, was represented officially. 
We discussed the increase in Ireland, the 
decrease in England, the spread of tuberculosis 
in France proportionate to the spread of 

A Secretary of State expressed the signifi- 
cance of all these doings when, addressing the 
foreign delegates, he pictured himself as 
contemplating the desolation ever present in 


every nation, only to be prevented by con- 
gresses such as this, and by the slow, steady, 
ceaseless work for mankind which such a 
congress represented. 

In a campaign of this kind there is room for 
all sorts of volunteers. Even earnestness 
without knowledge is a potential power, so 
that it be guided by knowledge with earnest- 
ness. Business-like methods are needed : our 
forces must be marshalled by men capable of 
managing. For the training of the nation we 
require the best teachers, those who possess, 
not only the gift of eloquence, but also what is 
of more importance, the knowledge, the full 
knowledge, of the subject they are called upon 
to expound. 

In England an immense amount of work has 
been done by the National Association for the 
Prevention of Consumption. Exhibitions have 
been arranged in such important cities as York, 
Edinburgh, and Hull ; lecturers of world-wide 
importance have been induced to attend, and 
audiences have been induced to listen to them. 
Posters have met one in every important 
thoroughfare, and the general populace has 
undoubtedly learnt a great deal from these 
wall picture-galleries. It should be easy now 
to make the work of the Association a national 
charge. It would vivify the whole effort if the 


Government provided that the entire nation 
should bear the cost of the campaign, and that 
the work which a man like Philip has done 
in Edinburgh should be imitated in every 
municipality in the British Isles. ^ 

* That part of the Insurance Act which threatens to perpetuate and 
extend the evils of contract practice has met with severe and well- 
deserved criticism from the whole medical faculty, every member of 
which must resent the unfair treatment meted out to the bulk of a great 
profession. Such legislation, if now or in the future it became effectual, 
might easily lower the standard of medical practice among general 
practitioners. But that side of the Act which attemps to grapple with 
the tuberculosis problem is good — good in itself and in the present, and 
having within it the seeds of even greater good in the future. With 
the spirit of this part of the Act every medical man must sympathise, 
and none more than myself : no one is more anxious for the success of 
this national effort to abolish consumption. I hope that the Govern- 
ment — whichever political party may be in power — will go still further 
in this direction, endowing research, supporting medical experts in 
their attacks upon every kind of disease, and encouraging all high and 
noble effort for the welfare of the nation and of mankind. 



T^HE attitude of the world towards tuber- 
culosis has during the last thirty years 
undergone a great change ; it will, let us hope, 
be still further modified as more people come 
to possess greater knowledge concerning the 
true origin of this scourge. 

The disease is far worse than leprosy ; yet 
people have shrunk from leprosy and smiled at 
tubercle. There are even those who deride 
the efforts made for its cure and for its 
prevention. It has been even treated as 
poetic : the Queen of the May dies of con- 
sumption, and the poet who has himself 
suffered from the disease has secured thereby 
a more certain immortality. 

Now, such a view is absolutely wrong. 
Tubercle is in truth a coarse, common disease, 
bred in foul breath, in dirt, in squalor. It 
beean in nature outside man ; but now the 
saprophyte, the alien body, has become a 
parasite both of animals and of man. The 
beautiful and the rich receive it from the 


unbeautiful poor. The scrofula which deforms 
the already coarsened features of the stunted 
slum dweller is tubercle. Lupus, which affects 
both men and women, though it is more 
noticeable in women, is a horrible disease 
which eats away the face ; and lupus is due to 
tubercle. Tubercle causes disease of the 
spinal bones ; tubercle sets up that inflamma- 
tion of the covering of the brain which 
snatches so many children from life, taking in 
this 'case the best and the brightest ; tubercle 
is consumption as it appears in the lungs and 
the bowels. Tuberculosis has affected our 
whole population ; but it is a disease which, as 
a rule, kills slowly, and which will not kill at 
all unless the dose is large, or unless the mode 
of living is wrong, or unless the patient is 
particularly liable to the infection. With all 
its terrors, it is emphatically a preventable 
disease, and if treated early enough it is 
curable. Cancer hospitals receive munificent 
aid from the generous public, and rightly so : 
the horrors of cancer, if unrelieved by Christian 
care, would be intolerable. But for cancer 
there is no prevention ; cancer comes to any- 
one. One must bow the head : resignation is 
the only attitude. It is otherwise with con- 
sumption. The reasons that are strong for 
the foundation and endowment of cancer 


hospitals are ten times as strong for the treat- 
ment of tuberculosis : not only can we alleviate 
and often cure, but we can also anticipate the 
malady and forestall its onset. 

Peoples and races vary in their powers of 
resistance to disease. If negroes, " fresh from 
their forest bed of leaves," are attacked by 
tubercle, they never recover. For thousands 
of years they have led a life in the open ; now 
they are part of the slum population of 
America. Jews were at one time said to be 
almost free from tubercle : B. Ward Richardson 
thought this was the case ; but he and others 
who held his opinions were mistaken. Zangwill, 
in one of his short stories, makes a Jew say 
that living among Goyahs has induced the 
disease in modern Jews ; surely, however, it is 
not the disease that has been induced in a 
formerly insusceptible race, but the conditions 
making for immunity that have been altered- 
The Jews owe their relative freedom from 
tubercle, compared, say, with the Irish, to 
their long-continued association with bad 
conditions of overcrowding and want of sanita- 
tion. They have got used to these bad 
conditions, and the susceptible families have 
died off. Living in the Ghetto has helped 
them as a race by eliminating the unfit ; the 
survivors are able to stand a large dose of the 


poison without being killed. If a Rothschild 
went to reside in the poor Jewish quarters of 
Manchester or Leeds, he would die of tubercle ; 
his immunity would have worn off, owing to 
his banishment to a temporary Elba of cleanli- 
ness and hygiene. With all this the Jew, if 
put into a bad workshop and an overcrowded 
squalid dwelling, still continues to eliminate 
his unfit. I have seen scores of Jews with 
phthisis. I think, however, that the constitu- 
tion of the Jew makes a fight when that of the 
Englishman, the Scot, or the Irishman would 
more quietly succumb. 

Personal resistance varies no less than racial ; 
great physical powers and muscular prowess 
will not save a man from infection. The finest 
policeman I ever saw died from acute phthisis, 
and a small ward of phthisical patients in a 
hospital with which I am familiar contained a 
few months ago none but men of exceptional 
physique, men who had led adventurous 
roaming lives in America or the colonies. 
With " wanderers " the conditions of living are 
hard, and such men are particularly liable to 
this disease. Privation in the present genera- 
tion always invites phthisis, no matter what 
gain it may be to have had forefathers who have 
earned immunity as the survivors of a 
subject to privation. 



If we are to increase our immunity as the 
oldest civilised nation has done, it will take 
many hundreds of years and many millions of 
lives. We must adopt other means: instead 
of eliminating the unfit by death, or attempting 
to cure symptoms and isolated cases, we must 
deal with the conditions which are at the root 
of the disease. In the old days the mortality 
from phthisis, among those in whom it could be 
recognised by ordinary medical examination, 
amounted to nearly loo per cent, of those 
attacked. The treatment included excessive 
warmth, curtained windows, and close air. 
The new treatment, whether in sanatoria or 
not, is the exact opposite of this : we admit 
light and air as freely as possible, and we aim 
at making the patient more hardy rather than 
more tender. Over and over again I have 
found a poor emaciated wretch in a small 
cell-like room, the window closed, the floor a 
spittoon ; but on the solitary shelf would be 
the invaluable balsam, the cod-liver oil and 
the malt extract. The poor fellow was glad 
enough to have these luxuries, which were 
supplied, as a rule, by some kind sick-visitor 
from a neighbouring church or chapel. Now 
the windows are thrown open, the sanitary 
official mounts the stairs (the older philan- 
thropist comes less often, it is true, but the 


disease is now infectious), and the patient is 
sent, if he will go, either to a sanatorium or to 
a special hospital, or to a workhouse. These 
are all excellent institutions ; from a Public 
Health point of view the workhouse is un- 
doubtedly the best, for if the poor patient is 
very ill, infective and helpless, he may stay 
there until he dies. I feel that in advising the 
workhouse I have written a hard sentence ; but 
my point is that if the poor patient is incurable 
you must remove him permanently. Remove 
him to a better place than the workhouse when 
you have one. Consumption, being an in- 
fectious disease, is more common in crowds ; 
and it is most important not to lose sight of 
the danger to the community when the patient 
is left to his ordinary life among his fellows. 
As Koch has pointed out, hospitalisation is of 
national importance in so far as it limits the 
number of foci of infection. Newsholme has 
proved, in his book on " The Prevention of 
Tuberculosis," that where there is institutional 
treatment of phthisis the death-rate from this 
disease goes down, and that where there is not 
institutional treatment the decline does not take 
place. It may be objected that segregation 
in an institution means for those treated an 
intensified infection, but in properly conducted 
sanatoria this is emphatically not the case. 


When sanatoria were first founded, those in 
charge were very optimistic ; and as these men 
really knew what was to be known about their 
subject, their results were better than those 
sometimes arrived at by their followers and 
imitators, who had not always had the necessary 
training. Every Home for Consumptives was 
soon called a sanatorium ; but it was by no 
means invariably the case that proper sana- 
torium treatment was given in these Homes. 
In a sanatorium a patient is given good food, 
fresh air, light, rest and graduated exercise, in 
a way that would often be wholly impossible in 
his own home. 

Tuberculosis has its tuberculin, which con- 
sists of the sterilised dead bodies of the tubercle 
bacilli or consumption germs made into a 
weak emulsion. In extremely minute doses 
this substance has a most marked effect on 
the course of tuberculous disease in all parts 
of the body. The effect is believed to be 
curative, and my own experience teaches me 
that the remedy is one of great value. The 
advocates of tuberculin treatment have thought 
that they could treat their patients at home 
without sending them to sanatoria; but they 
have never attempted to do without the good 
food, fresh air, light, rest and graduated 
exercise on which sanatorium treatment is 


based. Most medical men combine sanatorium 
and tuberculin treatment. But it must not be 
forgotten that the treatment for tuberculosis is 

Professor Osier, in a striking sentence, 
quotes Bunyan as saying that consumption 
was the captain of disease. " It is now only 
a lieutenant, will soon be a sergeant, and 
should eventually be reduced to the ranks." 
Professor Osier fears that it will never be 
drummed out of the regiment. Well — we shall 
see. In ten years England has gravely and 
carefully taken to the study of the tuberculosis 
problem ; in five years more the treatment of 
the disease will have made greater progress 
than in five previous centuries. Trades which 
are now unhealthy will be followed under more 
healthy conditions. 

Anything which injures the structure of the 
body, and in especial the structure of the 
lung, increases the liability to infection. To 
be fed on infected food, to be ill clad and 
ill housed, to work among dust, especially 
organic dust or hard gritty dust: these are 
causes contributory to infection. At present 
two printers out of seven die of phthisis, and 
almost the same proportion of hairdressers ; 
pattern-makers and makers of earthenware 
suffer badly, and so do tailors, especially tailors 


in crowded shops. Gamekeepers and gardeners, 
on the other hand, are almost free from the 
disease, and of clergymen only one out of 
twenty-seven dies of it. 

Tuberculosis is a disease of poverty ; it is 
also a cause of poverty. Let us consider the 
cases of Brown and Smith, artisans of good 
standing and character, and in equal positions. 
Brown, a healthy man, marries and rears 
children, is comfortably off, lives his allotted 
span. Smith marries too. But he is affected 
with tuberculosis ; he staggers on with his 
work, but eventually he gives in and is sent 
to a special hospital or a sanatorium. In the 
sanatorium he is nursed and watched and 
treated much as if he were in a general 
hospital, save that the treatment is carried 
on, as far as possible, on open air principles. 
In the sanatorium he lives in the open air: 
except for the wooden or stone roof over his 
head, he leads frankly an outdoor life, for 
windows are either entirely removed or always 
open. Smith, of course, improves ; he may look 
ready for the Yeomanry, fat, well and fit. 
But he returns home to find his job filled up. 
He must live, and he is fit to work ; so he 
accepts another job with less money, more 
dust, and harder toil. He may stand it, or 
he may slowly break down. His wife goes 


out to work, if he can spare her. He may 
return to hospital, or he may enter the work- 
house, or he may die at home. What his 
children do, God only knows. They certainly 
seem often to be helped by some good souls. 
Sometimes they reach the workhouse when 
their father is buried. Brown goes to the 

Such is too often the fate of the discharged 
patient who leaves the sanatorium for unhealthy 
surroundings, for poorly paid and unsuitable 
work in unhealthy conditions with an exposure 
to fresh infection. These causes lead to many 
deaths among patients discharged as cured — 
these causes, not the failure of the sanatorium 
treatment. Everyone interested in the people, 
especially in working people, must wish that 
they could, after the stricter treatment in sana- 
toria, be placed in colonies and enabled to earn 
their living in healthy surroundings. It may 
be noted also that results as to survival are 
gradually improving. 

For those poor phthisical patients who are 
struck down by causes, originating in environ- 
ment, which they are helpless to prevent, the 
sanatorium is the main if not the only hope. 
A patient wrote to me asking why he had so 
long to wait for admission, and he used the 
following words: — "When I wrote to you 


before, I wrote from my desk ; now I write 
from my bed." The thought of this man 
waiting for his death with hopeless resignation 
(for the letter appealed for others more than 
for himself) so aroused public opinion that 
nearly ;^iooo was collected and spent on his 
case and those of similar sufferers. 

The difficulty at present is to find the early 
cases : I do not see how this can be done by 
ordinary inspection. When, however, a case 
breaks out in a house, the family will, under 
influence of the fear of infection, permit ex- 
amination by a doctor, and in this way many 
an incipient case is found. We are now becom- 
ing familiar with the compulsory notification 
of phthisis. But a man with incipient phthisis 
who does not suspect the true nature of his 
disease should have every inducement thrown 
in his way to make him see the doctor. The 
incipient phthisical has a cough ; a Dispensary 
for Chest Diseases would attract many such 
patients. The dispensary should, I think, be 
for all chest ailments : the net should be spread 
wide. The phthisical may, for instance, think 
he has a chronic cold ; he will go to a dis- 
pensary which treats colds, while he might 
never think it necessary to attend a tuber- 
culosis dispensary. If upon examination the 
symptoms pointed to the need for such a course, 


the patient could be passed on to a special in- 
stitution. This is the plan followed by Dr 
Philip, of Edinburgh. The central feature of 
his scheme is this dispensary for the collection 
of the patients, who attend to receive medical 
advice. The physician may order medicine 
and extra feeding, rest from work, special treat- 
ment in one hospital for early cases of con- 
sumption, or special treatment in another for 
advanced cases. The dispensary is in touch 
with many agencies which can help the patient. 
Dr Philip draws a diagrammatic picture of his 
system : — 

M. o. H. 

Convalescent Home 

Hospital for Phthisis 
(early cases). 

Samaritan Committee 
(to see after patients' 

Poor Law Infirmary 
or Office. 

Hospital for Phthisis 
(advanced cases). 

Other Charities. 

Preventive treatment for consumption should 
begin in the nursery : all the hygienic rules 
which are now so well known, relating chiefly 
to open windows, cleanliness, good food (and 
especially pure milk), good clothing, and the 



avoidance of strain and fatigue, should be 
followed from the very first. In the schools 
a similar preventive treatment should be ob- 
served : open-air teaching should be the rule, 
and the greatest grant should be given to the 
school with the healthiest children. 

Out of every thousand children born, i6o 
die before the end of their first year of life ; 
in the great majority of cases they die from 
neglect, from ignorance and from want. The 
causes are well known. Certain districts with 
pernicious customs, such, for instance, as the 
employment of married women in the mills, have 
an increased infantile mortality on account of 
these local customs. When we consider these 
facts, we see at once that only a powerful and 
enlightened public opinion, backed up by the 
remedial action of a Public Health service with 
legal powers, will prevent the appalling wastage 
of life which now takes place. If only the 
lives now wantonly thrown away were saved 
and the children brought up in healthier sur- 
roundings, or at least with a greater attention 
to hygiene, there would be little need to trouble 
about a declining birth-rate. 

At present the doctor is only sent for into 
the cottage home out of fear of the registrar 
of births and deaths, or out of fear of the 
coroner. He should be sent for into the 


house before the evils of overcrowding-, of bad 
feeding, and of worse ventilation have had time 
to do their worst. 

Dr Naish's reports on his work in Sheffield, 
where at a kind of municipal Dispensary of 
Hygiene he supplies babies with milk and their 
mothers with advice as to the feeding of 
children, give us some insight into a method 
of dealing with a crying need, a method which 
should be widely copied and made of much 
more value by having the range of its action 
extended. In 1900 the infantile mortality in 
Sheffield was 200 per thousand born ; ten years 
later it was as low as 1 1 9 per thousand. The 
main cause of this diminution has probably 
been the Health Department of the city, aided 
by Dr Naish and his Babies' Dispensary. 



pHTHISIS, a disease with a percentage of 

deaths 2| times as great in the industrial 

as in the middle and upper classes, depends 

largely on three factors : (i) unhealthy trades, 

(2) low wages, (3) infection. The first is a 

direct danger ; the second promotes a physical 

condition affording a fertile soil for the disease, 

while the power of resistance is lessened ; the 

third cause is, apart from the first two, of 

relatively little importance. By this I mean 

that since the standard of comfort among the 

poor has increased, since the masses of the 

population have been able to demand improved 

sanitation, including the provision of open 

spaces and decent dwelling-houses, in other 

words, since the poor have shared some of 

the advanges of the rich, phthisis has declined, 

and infection as a cause of disease has, at any 

rate in this country, lost much of its importance. 

Among the curative agencies I have already 

mentioned consumptive hospitals, sanatoria, 

convalescent homes, and consumptive colonies. 


I do not include general hospitals in this list, 
for such hospitals have had very little curative 
effect upon lung consumption. A surgical 
hospital is a factory working at fever heat ; a 
medical hospital is a museum of rare disease ; 
while, as far as anything but the mere palliation 
of consumption is concerned, an ordinary Out- 
patients' Department is, apart from the use of 
tuberculin, a failure. If there were in every 
city a Home of Rest, a hospital without a 
surgeon (patients requiring the surgeon going 
elsewhere), if there were a hospital for broken- 
down invalids, especially women, in which rest, 
quiet and nursing were obtainable, I should 
bracket such a hospital with the convalescent 
home as a preventive of many acute and 
chronic diseases and of many deaths, especially 
of deaths from tubercular disease. 

To these preventives of death from con- 
sumption (especially from phthisis) we shall 
have in the future to add the effect of wide 
sanatorium treatment, educational as well as 
curative ; and I hope we shall have to add also, 
as the outcome of sanatorium treatment, the 
formation of hygienic consumption colonies to 
allow of the transference of the cured phthisical 
from the town to the country. Such a con- 
sumptive colony consists of a limited number 
of cured consumptives, working in the open air 


under hygienic conditions and subject to medical 
inspection. Every large industrial sanatorium 
should supply a colony with recruits. A sana- 
torium containing one hundred consumptives 
promiscuously chosen would, according to 
statistics, cure absolutely ten to twelve of the 
hundred patients : that is lo to 12 per cent, of 
the patients would on leaving show no clinical 
signs of disease ; and it would also almost cure 
another 25 per cent, of its patients. These figures 
depend on the stage at which patients are re- 
ceived : since they are now admitted earlier than 
was once the case, the results are improving. 
There is no doubt of the advisability of provid- 
ing healthy outdoor work for all of the 37 per 
cent., and certainly there could be no serious 
objection from any quarter to the planting of 
the absolutely cured among the rural population 
of an English village. The only difficulty is 
the finding of suitable employment where there 
would be anything like a living wage ; still, in 
this matter my aim is to be suggestive, not 
exhaustive. In many cases, no doubt, it would 
only be possible to plan out situations for in- 
dividuals. The details as to the formation and 
management of such a colony could be worked 
out by six ordinarily intelligent men, such as 
sit on the sanitary committees of municipal 
corporations ; but they should be assisted by 


medical and agricultural opinion. Arrange- 
ments could be made, in case a patient relapsed, 
for his immediate return to the sanatorium 
whence he came. 

Whether the 2 5 per cent, who were nearly cured 
should be sent to such a colony is a moot point. 
Possibly the villagers might object; at least, 
they might at first. I am convinced, however, 
that time will prove such an experiment not to 
be of a source of danger to the surrounding 
district. Personal inquiry of the medical staff 
at Falkenstein and at Nordrach has convinced 
me that no case of infection has ever been 
traced as coming from these institutions to 
the villages in which they are situated. This 
is peculiarly interesting in the case of the 
Falkenstein sanatorium, which is — or was — 
enclosed on three sides by public roads and 
houses. You could throw a stone from the 
sanatorium grounds into the inn yard, and 
coming out of the sanatorium gates you might 
in two or three strides reach the door of the 
village bootmaker. Dr R. Walters, in his book 
on sanatoria, goes into this subject very care- 
fully, and he mentions, among other facts, that 
the death-rate from phthisis in the village of 
Falkenstein had actually decreased since the 
sanatorium was erected. It is sufficient for 
my point that it has not increased. 


Sanatorium treatment for the working classes 
is hardly yet a complete success, because of its 
expense, because of its tediousness, and because 
of the vast army of consumptives clamouring for 
treatment. A patient costs at least ^65 a year, 
and he should stay in a sanatorium for two 
years. But if a patient, after serving a rigid 
apprenticeship in hygiene, is at the end of six 
months turned out from a sanatorium without 
physical signs of disease, he may, while accept- 
ing suitable employment in a healthy country 
district or in the healthy suburbs of a town, 
carry on the treatment he has already mastered. 

Too much stress cannot be laid on the 
question of suitable work and surroundings. 
Twelve years ago Dr Walther, at Nordrach, 
told me he had little faith in sanatorium treat- 
ment for the working classes, since they gene- 
rally had to return to their old surroundings 
and there was great danger of their relapsing 
into their old condition. One finds all Walther's 
disciples — once his patients — repeating the same 
dirge-like tale, but with more dramatic assur- 
ance than ever their master assumed. In the 
case of the colony system, however, no such 
objections can hold ; indeed, such a system 
puts into the hands of the poor the same 
advantages as are obtained by Walther's richer 


The question as to what measures should be 
adopted in the case of patients who are not fit 
for work in a hygienic colony is an extremely 
difficult one. A very long sanatorium treat- 
ment might place them either among the half- 
cured or among the incurables. We must re- 
cognise that no one has yet, so far as I know, 
exhaustively explained why some cases are 
curable and others are not. A dying consump- 
tive, unless he is rigidly isolated, may easily 
infect many ; a cured consumptive will infect 
none ; a half-cured consumptive should not 
infect any if ordinary precautions are taken. 
And it must be remembered that a consump- 
tive who has passed through a sanatorium 
has, generally speaking, taken a diploma in 

I have seen that six months spent in a 
sanatorium have occasionally been mischievous, 
teaching the patient idleness and even im- 
morality. Transfer your cured patients to a 
hygienic colony, where suitable work is pro- 
vided, and these disadvantages vanish. 

Objection has been seriously made that by 
keeping alive our consumptives we are courting 
disease for future generations. But Herodian 
methods are not permissible in our day, and we 
must remember that comsumptives will not die 
to suit our convenience; that from twenty to 


forty-five years of age is, roughly speaking, the 
dying period ; that during this period con- 
sumptives frequently marry and beget children ; 
and that very many thrive and become com- 
paratively healthy. By making the consumptive 
a healthy man you surely make him a healthy 
parent. Already the doctrine of heredity has 
been given up, and it is common knowledge 
that the consumptive who masters his malady 
may beget children of perfect physique. The 
average child of the consumptive is in a better 
physical condition, both for the present and 
for the future, than is the cured consumptive 

At Kelling in Norfolk, at Dr Fanning's 
sanatorium, I found many things in practice 
that had been pointed out to me at Hadleigh. 
The resident physican lives with his con- 
sumptives in what is justly called a sanatorium 

practically a farm. He spoke enthusiastically 

of his results. All his patients work, even 
those who are unable to leave the shelters ; 
and they work for the sanatorium, for which 
their work is sold. Some carve wood and 
make mats. A dozen men w^ere working in 
the garden, their hours of labour being 
governed by their condition; six hours is the 
maximum and three the average. Cured 
patients are found on the permanent staff of 


the hospital : the gardener and the yardman 
were both cured patients, and the chauffeur 
who drove the sanatorium motor car was 
another. The physician favours poultry farm- 
ing for weakly patients, and the sanatorium, 
or colony as he calls it, does a large business 
in eggs and poultry ; the carpenter is kept 
busy all day making the egg-boxes. 

There is at Kelling an After-care Committee, 
which concerns itself with getting suitable 
situations for discharged patients. This com- 
mittee numbers among its members several 
wealthy local residents who are themselves 
willing to employ cured patients. The doctor 
considers that the patients who work five 
hours a day bring in a profit to the institution 
of 4s. a week each, and that from those 
who work seven hours a day the institution 
gets more than a proportionate return, as 
these are men of longer experience. These 
small profits make it possible for the patients 
to stay longer than the usual four or five 
months, and the work helps their recovery. 
The doctor is not in a hurry to discharge 
them : even when he considers that they are 
cured, he allows them to "rest" until a situa- 
tion is found. He is able to pay small sums 
to his patients. These are all of the working 
class: for instance, in the garden I came 


across a postman, two engineers, a sailor, 
a furrier, an insurance clerk and another clerk. 
I was told by the doctor that he had been 
very successful in getting employment for his 
patients. He circularises employers and offers 
to take back at once any patients who relapse 
whilst in employment. He is not opposed 
to suitable indoor work ; indeed, he includes 
it in a published list of suitable employments. 
In this list he mentions light work about a 
garden, driving, care-taking, agency work such 
as insurance, rent collecting, and some forms 
of travelling ; clerical work, where ventilation 
is good ; estate work, such as carpentering ; 
engine-tending, check-taking and door-keeping. 
At Kelling the workers are not separated 
from the non-workers ; it is considered that 
work is a therapeutic agent, and that idleness 
is the worst of curses to the consumptive. 

Very many other sanatoria have been visited, 
both at home and abroad, and in every case 
cordial agreement has been expressed with the 
scheme for a labour colony for consumptives. 
Readers interested in this work should visit 
the Consumptive Colony at Frimley, near 
Aldershot, where they will see a most perfect 
scheme carried out under the supervision of 
that most original of innovators, Dr Paterson. 



TO survey medical work in hospitals or in 
laboratory, one must observe leisurely 
and with no object in view beyond the seeing 
of things as they are. The man who as a 
student is looking forward to test-examinations 
sees little but that which is directly in his 
straight line of vision : like a private soldier, 
he does his vivid bit of actual fighting, yet he 
sees little of the battle. 

The science of the prevention and cure of 
disease may be said to include all knowledge, 
even of theology and archaeology, of astrology 
or star-gazing, and of the speeches of the last 
Chancellor of the Exchequer, whatever be the 
date. But in this book, and especially in this 
chapter, I am voluntarily shackled. This 
chapter is on hospitals, on certain hospitals 
that I have visited ; and in these pages certain 
partial pictures of work and workers will be 

I have frequently returned to post-graduate 
15 225 


hospital work in many medical centres and in 
several countries ; this is quite the usual 
practice with those medical men who cling 
to studentage as a child to its mother's skirts. 
Whilst all medical men soon purge themselves 
of undergraduate rawness and Smollett-like 
wit, there are but few who cease to be in- 
quisitive inquirers. Although a doctor is 
always sceptical, it is equally true that he is 
always interested in research. It is this task, 
common to all medical men, which makes 
of the medical body such a Roman cohort. 
Many universities and medical schools recog- 
nise the hunger after efficiency so universal 
among practitioners. At the front entrance 
to the Johns Hopkins University I have 
seen a long straggling procession of American 
doctors, mostly spectacled, squat and long, of 
all forms and figures, shapes and sizes, and 
from all parts of the States, filing in to see 
Kelly operate. And what is true of Balti- 
more is true of Bradford, true of every city. 
Liverpool's School of Tropical Medicine is a 
recognition of the importance of the post- 
graduate. Oxford, which from the Creation 
has been ancient and modern, institutes a 
series of lectures, given by lecturers culled from 
wherever they grow, because it recognises the 
existence of the post-graduate student. Cam- 


bridge invites us all to take its Diploma of 
Public Health. London is the greatest post- 
graduate college in the world ; the whole of 
civilisation is mirrored in the advertisement 
columns of its newspapers. The London 
medical journals are full of calls to the faithful 
to enter the London medical mosques, in order 
to the improvement of the individual and the 
extinction of ignorance. As in most things, 
so in medicine, London is the Greenwich of 
the hemispheres ; and by their presence in 
London during these early years of the twentieth 
century, Lister,^ Hughlings Jackson, Jonathan 
Hutchinson, Gower, Victor Horsley, Almroth 
Wright, and, one may add, Allbutt and Osier 
proclaim this fact. Every one in medicine is 
sooner or later in London ; and if London is 
or ever was the modern Babylon, it is certainly 
more truly the modern Alexandria, the native 
home of science and of libraries. London 
attracts research students from every city, 
from every country, from every populous plain 
or sterile desert ; but it is especially the haven 
of the Anglo-Saxon student. 

And up and down the Kingdom there are 
smaller Londons. Edinburgh, for instance, is 
a minor British capital. Glasgow, with Goth- 

1 As these sheets are being corrected for the press, there comes the 
news of the passing of a great man. 



like vigour, is anxious to imitate London as a 
great medical educational centre, and Glasgow 
has brains and population. Aberdeen, though 
sure of its future and characteristically satisfied 
with its present and past, occasionally produces 
a pathologist or a surgeon of genius, and there- 
fore retains a more than local reputation and 
following. Leeds is, as it has been for the past 
century, a robust English medical and surgical 
school, and it is at present the metropolis of 
American surgery in Europe and the home 
of accurate diagnosis.^ Sheffield has all the 
advantages associated with provincialism, and 
Bristol is, in a second-rate way, first-ratQ. 
Belfast produces clever physicians and sur- 
geons, some of whom are recognised, not only 
in more than one country, but in more than 
one of four ecclesiastical cliques. Dublin is 
still the possessor of blazing wit, and Man- 
chester isn't. I had forgotten Birmingham : 

1 One of our greatest surgeons says : " The most authentic feature 
... is the diagnosis. . . . We should be able, because of our experi- 
ence and reason, to predict the things we are going to find, and in nine- 
teen cases out of twenty the diagnosis is right. Surgeons elsewhere 
tell me that they can't do this (of course everybody could who would) 
and that they fear to be wrong before a large assembly. I remind them 
of the perennial example of Saul, who went in search of his father's 
she-asses and found— a kingdom ! We must know the correlation be- 
tween symptoms and the pathological conditions to which they are 
attached. . . . You have no doubt heard from visitors here that 
diagnosis is more insisted on here than anywhere. Cleanliness is the 
physical side, diagnosis the intellectual." 


Birmingham is a very clever but uninspired 
London. Newcastle is a great city for the 
study of villainous trades. Probably to the 
doctor who desires not to throw off the old 
teaching but yet to learn the new, who wishes 
to see the highest level of general medical 
practice, and who has not the time to bury 
himself in the many intricacies of many special 
subjects, Edinburgh is the most useful of the 
modern schools. A man with one speciality, 
however, will be happier bending over his 
special cases in some corner of London. 

Edinburgh deserves some attention because 
of its many races. Men of all colours and 
creeds jostle each other in Edinburgh to learn 
their religio medicinse, and all Edinburgh 
lecturers, without exception, have visited other 
schools in order to increase their competence 
for teaching their own. 

Edinburgh is almost ideal as a medical 
teaching school; it would be quite ideal if it 
kept its present characteristics, and in addition 
had Yorkshire on one side and Lancashire on 
the other. It lacks nothing but population : it 
has been ill-treated by the Atlantic, which has 
given to Glasgow a more important position. 
Still, it has many hospitals, which are all 
conveniently near the medical schools ; and 
they are all, with perhaps one exception, 


available for teaching purposes. The patients 
flock in from all Scotland and from the north 
of England, and thus Edinburgh has become 
a hospital city. 

Turn aside for a few moments to consider 
Edinburgh also as a great University city. 
The Editor of the " Saturday Review " has 
said that in England the separation between 
University life and ordinary life is more 
marked than in Scotland. This may be. To 
a Scottish boy the University, with its bursaries 
and scholarships, is a kind of higher High 
School, to be absolved in the ordinary course. 
And yet the University of Edinburgh has 
seemed to me not to be pre-eminent as a 
teacher of universal knowledge, or of the spirit 
of national Hfe. Save for its connection with 
the city hospitals, Edinburgh University appears 
to me to have little to do with Edinburgh 
city. Sheffield University could be nowhere 
but in Sheffield, unless it were in Pittsburg; 
Leeds, a great railway city, and the centre of 
the West Riding trade, has a University which 
is what it is because of its locality. But the 
locality has not influenced Edinburgh Uni- 
versity, great and useful though this University 
is. Even the history of the city has seldom to 
mention it. The great reviewers were connected 
with a Scottish review, but with English 


Universities. And we associate Scott and 
his contemporaries and compeers, and earlier 
names such as Hume and Robertson, much 
with the city and Htde with the University. 
Wilson was a great name, but only for a short 
time ; and there remain certain irritating philo- 
sophers and Professor Blackie, all of whom, 
had they lived in Oxford, would have been 
lost among their numerous peers. 

But though what has just been written is 
true of Edinburgh University as a whole, yet 
the medical schools of Edinburgh are world- 
famed, and they dwarf the other faculties. 
The University — and I include all the medical 
teaching agencies in this term — is near the 
frontier of every country in which medical 
science is respected. It takes toll of every 
other seat of learning. It collects and distri- 
butes. It does its work supremely well, and it 
is, one may add, distinguished from some other 
schools, in that its eminent men are able. 

The Edinburgh medical schools are hospit- 
able to students from afar. All the year round 
practitioners are welcomed as students, and in 
special months, vacation months, a long post- 
graduate course, a kind of course for the inten- 
sive culture of medicine, is arranged for legally 
qualified medical men. This, by allowing 
doctors to see the work of twenty or thirty 


other highly trained men of their own sort, is 
beneficial to those who wish to increase their 
efficiency ; it also assists anyone who seeks a 
picture of hospital medicine of the present day ; 
and finally, it must be beneficial to the teachers 
themselves, adding to their keenness by bring- 
ing them into contact with minds of a more 
developed type than that of the ordinary learner. 

There are so many students in the Edinburgh 
flock that the hospitals and dispensaries, 
numerous though they be, are none too many, 
and the teaching has come to be done, to some 
extent, in class-rooms. Very much is learnt 
in clinical lectures away from the ward, and 
crowded class-rooms mercifully deplete the 
hospital of students. There is a great deal of 
side-room work ^ ; museum specimens and 
blackboard and lantern illustrations are much 
utilised in teaching. The living patient is not 
the central pivot of the system. 

The newer methods of diagnosis, the arts 
which are handmaidens to science, are highly 
valued in Edinburgh, and may be said to 
constitute the Edinburgh system. Edinburgh 
embraces all auxiliary methods of instruction ; 
delicate instruments which record tracings to 

1 Note for the non-medical reader : side-rooms are rooms outside 
the wards of a hospital, in which clinical lectures on the cases in the 
wards may be given. They are also used by the house-physician and 
students for microscopic examination, etc. 


illustrate vital processes are greatly favoured 
here; such instruments are even invented, 
which is suggestive, as Edinburgh is not an 

In Bradford or Burslem you may pitch a 
medical man into the slums and say : " There 
is your material." In Edinburgh this is not 
so — at any rate, not to the same extent. 
Edinburgh has its slums, its hanging gardens 
of disease, bad enough indeed, but not forming 
a predominant fraction of the town, as in 
Glasgow or London, and not supplying the 
medical schools with the material which is so 
plentiful in these cities. 

The teachers are very numerous, eager 
young men and robust old ones ; in no other 
place that I have visited are the old men so 
juvenile and the young men so mature. The 
seniors are so tenacious of intellectual life and 
of office that the juniors are on the eve of 
grand-parentage before they reach the front 

Edinburgh attracts to her chairs and to her 
benches men as good as any in the Kingdom. 
It is a pleasant testimony to the wide catholicity 
of the University that one finds in places of 
honour so many men who are not Scots. 
Glasgow treats graduates, especially her own 
graduates, with less tenderness than does her 


rival. In some wards they are not welcome. 
The rougher side of Scottish character is not 
repressed in Glasgow, where there are men 
who, while they work like angels, treat their 
juniors with the asperity of Post Office officials. 
In medicine as in law, one has occasion to see 
great men lessen their greatness by belittling 
their younger competitors. There are, how- 
ever, as in all collections of cultivated men, 
others who are as frank and hospitable as 
Americans, and as fastidiously cultured as the 
best men of any of our English Universities. 

To return to Edinburgh. During the 
months of July, August and September quite 
a hundred men and women come to these 
vacation classes in Edinburgh. Most of these 
men come feeling the need of the academic 
teaching which Edinburgh can give as a 
supplement to their own valuable experience 
in ordinary practice. Some who are them- 
selves engaged in teaching attend here for the 
benefit of students elsewhere. There are very 
many of these teachers travelling about, picking 
up learning's crumbs in Vienna, Berlin, London, 
Paris, Edinburgh, Glasgow, Leeds, gathering 
valuable information to be used in Melbourne, 
Washington, Sydney and elsewhere. 

The Americans bring appreciation and keen I 
attention, though they slip incongruously into 


anecdote at times, and a tremendous story from 
the States is sometimes holding a court of 
its own during-, say, a lecture on Auricular 
Fibrillation, The American doctors are great 
talkers ; at the social functions which occur 
during their vacation courses you are some- 
times consulted by an American, before he 
makes the speech of the evening, as to whether, 
say, Doctor Edwin Bramwell is " particular." 
You say " No " ; he smiles, and everyone has, 
what is euphemistically called a good time. 

But let us leave the American making his 
witty speeches and go back to the class-room. 



OU will find our students in the theatre, 

high-roofed, domed with clear glass, its 
benches stretching up and back into shadow, 
each bench carved and hacked, as if locusts 
had sought it for food. Blackboards, diagrams, 
a sheet for the lantern — these are the properties 
of your stage. 

The students are of all ages. Most are 
men who appear to be intellectual workers ; 
occasionally you see the turnip without any 
appearance of the candle which is doubtless 
inside. These practitioners must think much 
of their profession, to give for it one, two or 
three months of a busy year. There are 
women among us, too, gathered into one 
group. Before the months are over these 
men and women have exchanged valuable 
experiences ; and this is one of the most useful 
and charming results of the course. 

Here is a post-graduate student, a young 
one, full of vigour and possessed of many 
varied tastes. He is, for instance, first violin 


in an amateur orchestra; he cycles, he is 
fond of cards, and he is just the man to be 
miserable in the absence of a good dinner. 
I have described a very good British citizen, 
and I must add that, with all these distinctions, 
most of his hours are given over to hard 
"grind." He is twenty-six, has served as 
junior in his hospital, has been a short time 
in general practice, has lately taken his M.D., 
and is now expecting to take his Diploma in 
Public Health. He has managed to interest 
the editors, and he showed me with pardon- 
able pride an article in " La Semaine M^dicale" 
on one of his theses. He wants to see general 
medical work, and he has an idea of becoming 
a candidate for the M.R.C.P. Edinburgh, the 
valued membership of the Royal College of 
Physicians. When he has obtained these 
academic distinctions he will have spent a 
large amount of money on his career, he will 
be twenty-nine years of age, he will have 
served several years in hospital, and he will 
be looking for a suitable fixed appointment. 

Such men are for the future of medicine. 
They give much in time and money, and they 
expect a return. There is no hectic philan- 
thropy about them ; they are very British, 
sensible, able, physically and temperamentally 
fit for a lot of work, and with good useful wits. 


Medicine is fortunately attracting many of 
these men, and if powerful politicians can free 
themselves from the vulgar ignorance of 
medical subjects and medical needs which 
oppresses their constituents, these men will 
be encouraged. A generous English family 
life should be made possible for them ; they 
do not ask for affluence, and yet, if set to 
scrape for guineas in the rubbish heap, like the 
Man with the Muck-rake, they will be of less 
use to medicine. These men will be wanted ; 
they have good brains well trained, and when 
the crusade comes, when the fortunate classes 
march through the world of suffering as an 
army with banners, desiring and determined 
to end preventable misery, including prevent- 
able disease, these men should be their honour- 
able mercenaries. 

In Edinburgh one meets some whose lights 
will go out far too soon. Here is one man, 
back from the Soudan, with a tropical disease 
in his blood, the disease he had been sent out 
to study. Like so many young men who find 
a religion in the profession they adopt, this 
man has suffered for his ideal. ^ 

To one who fears the approach of age, there 
is risk in returning to a city whose pavement 
he has trodden when years were gold unspent. 

1 Obiit. 


Foreheads are now furrowed, temples more 
parchment-like, younger men than you are 
grey. I climbed up to my old rooms, passing 
the doors on the various flats, mysterious doors 
opening suddenly and letting out a head pro- 
jected by the dragon inside, a head with 
inquisitive critical eyes. Youngsters are in my 
old rooms, talking about the old subjects, 
worshipping the new gods, who are the same 
as the old. I was welcomed, but warned not 
to interfere with work. These youngsters had 
mapped out their careers until the next 
examination day ; they had rules for work, 
for sufficient play to help the work, rules to 
prevent eye-strain, rules for bodily hygiene. 
Wise youngsters ! I could see that they 
would go as far as any American or any 
German. Some words of mine, referring to 
the value of deliberately arranged long periods 
of study when one is aiming at the highest 
distinctions, were listened to with interest, but 
were not required. With me, as with all 
elderly men, Hope is a joyous sadness ; with 
these youngsters Hope is a silken banner 
gloriously inscribed and hung on a golden pole. 
Two of the men shook hands in the Bradford 
Nonconformist manner, and startled me into 
wondering what sins were branded on my brow 
and making me a case of interest. But the 


cordiality of grasp and smile only meant that 
these two were not Scots. 

I found that students, both Scots and alien, 
were more intent than in my day on working 
for distinction. The same spirit could be seen 
at the Johns Hopkins University. It seemed 
to me worthy of comment that two of the 
keenest medical schools in the world were 
turning out men who did not passionately love 

Being anxious to compare our native breed 
with the foreign, I inquired on this point of 
men who had spent some time at laboratories 
in Berlin. These men considered that the 
Berlin laboratory student of to-day was not 
so hard a worker as the ordinary Edinburgh 
laboratory student. The Berlin man, they said, 
would only work in the morning ; he would 
spend the afternoon in a Bierhalle and take 
his amusement at night. The impression 
seemed to be that men of the present genera- 
tion in Berlin were not equal to their fathers. 

In Edinburgh one meets many Knights 
Templars of Medicine, who neither marry nor, 
apparently, beget. This somewhat numerous 
body lives in apartments. Those familiar 
with these places will recognise the austere 
front door and the economical window blind, 
the housekeeper grisly or grim or both, very 


quiet and efficient, the whisky coming in without 
applause, the cork having been drawn quietly 
in the kitchen. These Knights Templars, 
young men in medicine, are mostly Scots ; 
they become English in time. All dramatic 
races are liars, and the Scots are truthful. 
There is the settled gravity of actual accuracy 
about these young men. I have met Scots- 
men in England and have thought the extreme 
types had been expelled their own country : 
but this is not so. Even in pleasure these men 
are grave, severely lined as to the face even 
during a social feast, and suggesting the 
Shorter Catechism in their highest ecstasies. 

These young doctors in Edinburgh are a 
numerous band. The number of men required 
for tutorships and lectureships, and as assistants 
to other men at the hospitals and medical 
schools, is very great, and consequently 
Edinburgh has a large medical population. 
The result is that these men, who in other parts 
of the world would set up as consultants, beo-in 
here as general practitioners, and that men who 
without teaching appointments strive to make 
a living from private practice alone have to 
meet the severe competition of the hospital 
men. Therefore as time passes on the Knights 
Templars, the junior hospital men, become 
famous, some more and some less. Their 


advantage is that they are teachers of men who 
spread all over the English world, and who 
send to Edinburgh their patients in need of 
consultations. You remember how Macaulay 
said of Clive that he read deeply when he went 
to Calcutta as a clerk, but that soon, as a 
general, he became too busy, and that when 
he was a statesman he had less time still and 
no desire for reading. Similarly one of the 
great clinicists here told me that his original 
work (and it was great work) was mostly done 
in his obscure days, and that now, when 
compelled to do a large amount of clinical 
teaching, he had little time for original research. 
And from the same causes a man's books may 
be, and often are, obsolete when he is at the 
summit of his fame as a teacher. 

The younger men of the staffs find their 
busiest time in the various hospital out-patient 
rooms or dispensaries. I have elsewhere in 
this book appreciated the difficulty of out- 
patient work among a great crowd, many 
suffering from fatal disease, many from mental 
mimicry. The physician must pick out one 
class from the other ; he must remember that 
his own judgment, under the strain of seeing 
many strangers rapidly, may be sometimes at 
fault ; therefore he must give careful attention 
to all. Many who come as out-patients ought 


to be in warm beds at home, many need to be 
admitted at once to hospital. Many, in fact, 
who attend at the out-patient department are so 
ill that the fatigue induced by their attend- 
ance is in itself a bar to their recovery. The 
difficulties, therefore, which confront a re- 
sponsible medical officer to a dispensary are 
considerable, needing to be met by a clear head 
and a quick power of decision. In Edinburgh 
the out-patient work is done as well as is 
possible within the limitations. Specialism is 
wedded to general knowledge ; each man 
ploughs his own furrow, but the furrow is broad 
and may include (to leave metaphor) almost all 
ordinary medical disease. Each man may take 
all medical knowledge to be his province ; each 
special-department man has been trained in 
general medicine and surgery, and has taken 
either his M.R.C.P. or his F.R.C.S.— perhaps 
both ; and these are the highest diplomas for 
all-round work in medicine and surgery re- 
spectively. The men I have described work 
rapidly. Every morning I went to see the 
work done in the Skin Department, so well 
organised by Mr Norman Walker and his 
colleagues. A score of other doctors were 
present, all bending forward interested. It 
was not that I obtained or even sought for 
a demonstration of deep and intricate know- 


ledge of diseases of the skin : the physicians 
rightly preferred to show us a great variety 
of cases, and to append a few practical words 
concerning each ; but the proof of the inter- 
dependence of one disease on several always 
attracts a general practitioner. A skin disease 
seemed to be a hidden condition exposed, a 
lava, so to speak, from the entrails of a 
burning mountain. 

In no other place that I visit do I see so 
much of human frailty and suffering as in an 
out-patient room ; and these rooms in Edin- 
burgh are no exception. Here is a syphilitic 
patient suffering cruelly for his own mistake, 
or perhaps for his father's criminal folly. 
Here are bucks of former days ; here are 
paralytics hoping for another Bethesda. 
Patients are here with phthisis and all its 
disgusting- attributes. The neurasthenics crowd 
here, men who could if they would ; and near 
them are patients with incurable disseminated 
nervous sclerosis, some showing hysterical 
explosive talkativeness, most evincing that 
curious calm so often seen in those who have 
no chance and no place except by the toler- 
ance of charity. A child is here with a tiny 
spot on its cheek, a spot of venomous disease 
which will be eradicated to-day ; and a woman 
is present with a deforming ulcer of the cheek, 


which began years ago as a spot similar to 
that in the cheek of the child. The presence 
of a melancholiac led a clinicist to say that the 
patient arrived at his delusions because he 
keeps his reason up to a certain point. "He 
says to himself : ' I am most miserable ; I 
feel as if God had deserted me.' This 
thought digs into his brain," said the physician, 
" until at last it comes to the surface again as 
' God has deserted me,' and the melancholiac 
is then very near to suicide." ^ Indecision 
prevents suicide in most melancholiacs. The 
physician I have just mentioned told me that 
in the pockets of one man who drowned him- 
self from a ferry-boat, thirty-four ferry-boat 
tickets were found. He had been undecided 
up to the thirty-fourth. 

^ Weir Mitchell, who was an army surgeon in the Federal-Con- 
federate War, says that after one of its fratricidal battles a Confederate 
captain and a Federal major were in the same hospital ward. The 
captain laughingly said to the major: " Who knows but that it was 
you who shot me?" Afterwards, his wound going wrong and he 
sinking into melancholia, he said: "You did shoot me." And he 
died, expressing hatred of his murderer. 



TN this bed is a man over eighty. He comes 
from the Highlands. He seems very 
happy, and he illustrates the truth that a 
man may be full of death-inviting conditions, 
conditions fatal to you or me, which, how- 
ever, spare Andrew M'Kay. 

Near to him is a middle-aged man with a 
pinkish bluish face, a face I had seen before, 
I thought ; and then I perceived that he had a 
family likeness to my own people. He was 
sitting up in bed, propped with pillows. He 
was dying willingly. Cancer. 

Many of the patients are recovering. They 
are paying so much in the pound towards 
wiping out their physical bankruptcy. Most 
will never be solvent again. The Infirmary is 
for the infirm. 

In this ward there are many instances of the 
disease that we all come to if we are unlucky 
and live long : a general vascular disease, a 
hardening of the blood vessels and of the 
tissues of the heart. It must attack you with 


age, but it should not approach you before 
unless you live fast and do violence to your 
powers. It lays its stress on the heart, the 
kidneys, the lungs. It is bedfellow to emphy- 
sema, to asthma, to dropsy. Occupation 
explains the disease, for physical and mental 
strain induce it, hurry its approach. Lead 
poisoning ends in it — arterio-sclerosis. If a 
hard-drinking, hard-swearing, lustful and lusty 
footpad in the prime of life cocked a pistol one 
night at your great-grandfather's head, and if 
your ancestor had a keen eye and a cool brain, 
he would see at the wrist of the miscreant who 
threatened his life the elongated, tortuous, 
visibly pulsating artery — given, that is, a good 
modern acetylene lamp. All the high-cocka- 
lorum pursuits end in arterio-sclerosis. The 
idle apprentice who abuses life reaches arterio- 
sclerosis before he ends on the gallows. The 
industrious apprentice who works night and day 
to become rich may put a greater strain on his 
heart and arteries than they can bear. No one 
is safe but the phlegmatic : Nelsons certainly 
not. Wellingtons may have the disease in 
chronic form. Old Falstaff, before Mistress 
Quickly did the last offices for him, had become 
thick in the legs, short in the breath, giddy and 
querulous ; he had taken to falling asleep on 
the tavern bench, and he dragged one leg and 


nursed one arm. A man is as old as his 

In the middle of the classroom is the hospital 
bed. The door opens, and you perceive that 
a sick man is being brought in, borne by 
house-physicians. He comes in feet foremost, 
much as he would have done in Galilee. You 
see one foot hanging down ; it is incessantly 
moving with a grotesque, useless, purposeless 
violent motion. The lecturer, one of the 
seniors, notices it and, arranging his glasses, 
begins his clinical lecture. Before the patient 
has reached the red blanket, the lecturer is in 
the midst of his subject. As the speaker 
goes on, he tends to clip his sentences and to 
emphasise various words. "Notice the patient," 
he will say, and standing in front of him he will 
demonstrate the twitchings of the man's eye- 
balls. " Nystag ^ — mus," says the lecturer. 
" Note the arm, leg ; arm shakes, leg shakes. 
Put your finger to your nose, thus," he will 
say to the patient. " Finger shakes, head 
shakes as finger approaches head. Shut your 
eyes, and touch your nose again with your 
fineer. Hand shakes, can't touch nose. Walk ! 
Toe scrapes ground. " And so on. Then follows 
the history of the patient, of the family, of what 
the patient has done and suffered ; remarks as 
to his place of birth, the comparative frequency 


of the disease in this country and elsewhere. 
The story is helped by the narration of con- 
versations with other doctors of other countries. 
Then the examination is continued, all the 
observations being made in abrupt sentences, 
repetitions, however, being never avoided but 
rather, on the important points, invited. While 
' direct observations are so abruptly given, 
the conversational additions are diffuse, even 
verbose, and are all the more valuable on 
that account : for when you are closely follow- 
ing explanations fired at you as from a 
mitrailleuse, you are grateful for a conversa- 
tional interval which allows your brain to 
lessen its speed of absorption. Perhaps during 
the examination the lecturer wishes to measure ; 
he pulls out a steel measuring tape and finds 
it rusty. " Ah, ladies and gentlemen — fishing ! 
Do you know how to find the weight of a 
salmon by measuring its girth .'^ So many 
inches of girth, so many pounds in weight. 
In trout, too, so many inches of girth, so many 
pounds in weight." And with no abatement 
of seriousness he is back with his patient. In 
the end you have assisted at a drama, seen 
the victim come in with shaking foot poking 
first through the door; you have gone into 
the man's house, seen his kin, heard their con- 
fessions, those of his brother, his sister, his 



grandparents. The curtain is up, showing 
Isaac and the executioner, and even a picture 
of the ram. ^ 

Again, the lecturer describes how once he 
stood in church, hymn-book in hand, gazing 
at a man in front of him, a fellow-worshipper, 
also holding a hymn-book. This was the 
picture : " He had the harsh dry skin of this 
particular disease, gentlemen, skin harsh and 
dry, scalp dirty and scaly, hair thin, face 
doughy, unintelligent, passive. Myxoedema, 
gentlemen ! Gentlemen, I left the pew, stepped 
out of the church, and stood in the porch until 
he came out. Gentlemen, myxoedema ! " 

Such is one form of the Edinburgh School 
of teaching, illustrative, dogmatic, direct. The 
students flock to such lectures, they remember 
the words, they associate the teaching with the 
figure of the teacher. He is in love with his 
subject, medicine, and for him to teach is as 
pleasant as to learn. The teaching is his own, 
bone of his bone, flesh of his flesh. They are 
no dry bones, so clothed are they ; and yet he 

^ " Then come all the facts and features of the case : pedigree, birth, 
father and mother, brothers and sisters, education, physiognomy, 
personal habits, dress, mode of speech — nothing escapes him . . . 
It was a criticism of his on one of Miss Martineau's American books 
that the story of the way Daniel Webster used to stand before the 
fire with his hands in his pockets was worth all the philosophy, etc., 
found in other portions of the lady's writings." (Augustine Birrell 
on Carlyle.) 


is a lover of excessive detail. He is that rare 
creation, a humorist who is to be taken liter- 
ally. He has prejudices ; what man is without 
them who is built as Solomon's temple was 
built, stone by stone, and not like an Aladdin's 
Palace } But it is indeed fine to hear him 
denounce heresy, his judgments being given 
slowly and deliberately, the sentences coming 
like minute guns, with a funereal rhythm, as 
at the burial of the man he is denouncing. He 
looks through his own windows at the world, 
and he looks shrewdly, somewhat ironically, 
kindly to all but impostors. If, however, a 
great man is one who can sympathise with 
demonstrable error, then he is not great, 
A truth may not exclude its contradictory 
in some brains : in Dr Byrom Bramwell's it 

Most of these lecturers, especially the elder 
men, have the salt of humour, and Dr Bramwell, 
who is human down to his very boots, will seize 
an illustration that few but he could use with- 
out some loss of dignity. The manner of pull- 
ing his breeches on in the morning is used to 
illustrate the difficulties of a man stricken with 
the nervous disease under discussion. Gravely, 
with Swift-like face, the lecturer will go through 
a pantomimic illustration and lament the fact 
(his face all the time like a mask) that his 


knowledge of such details is limited to the 
habits of his own sex. And while we naturally 
smile, no one laughs, for the illustration is to 
give a picture, to teach a lesson. 

Another lecturer, who is also both a senior 
and a man of vast reputation, is equally inter- 
esting, in that he can draw illustrations from 
literature to help the presentation of his picture 
of disease. Not only does he lay literature 
under contribution, but he draws upon contem- 
porary journalism and everyday knowledge. 
You find him talking to a Washington man 
and teaching him of his own city and people. 
His great medical knowledge is laureatised by 
his acquisitions in wider fields of learning. 
One day he used, to illustrate his lecture on 
Diagnosis, Mrs Quilp, Elsie Venner, one of 
Scott's novels, and the rich old Dublin 
school of physicians, so marvellous in their 
Augustan time. Thanks to this power, as 
charming as it is rare, to listen to him is a 
liberal education. 

There are two phrases used to test patients 
with defects of speech, as there are different 
methods of describing an alcoholic debauch. 
Dr Bramwell will tell a man to say "West 
Registrar Street"; the more rotund phrase 
"The British Constitution" is the favourite 
with Dr Gibson, who describes a drunkard 


as " one who frequently and foolishly 
' applies hot and rebellious liquors in his 

I should love to hear these two men tell a 
lie, Dr Byram Bramwell would tell it as 
Defoe would. All the details would be given 
with absolute precision, the picture would be 
truthful in every line, and unlike the folk in 
Andersen's story, you would really see sturdy 
clothing even if there were nakedness. Gibson 
would give his description with so much wealth 
of illustration, with such charm of fancy and 
rhetoric, that you would neither believe nor 
disbelieve : you would only enjoy. 

Your Edinburgh physician is never a spy on 
his own dignity : the atmosphere of the place 
kills that kind of thing. This is well shown in 
the public and private demeanour of another of 
Edinburgh's brilliant clinicists, Dr Philip. I 
have heard him, as the leading representative 
from Great Britain, address two thousand 
medical men, delegates from all parts of the 
world to the famous Washington Congress on 
Tuberculosis, when the purity of his style and 
the force of his reasoning were noticeable even 
on a platform which held representatives from 
Harvard and from our own Oxford and 
Cambridge. Yet he put on no more airs than 
if he were a farmer at a rent dinner. I have 



never seen him more genuinely pleased than 
when I congratulated him on the fecundity of 
his prize sow at his Workmen's Consumption 
Colony at Hawthornden. I have spoken in 
another chapter of some of his great achieve- 
ments ; my medical readers, however, know all 
about him. 

There is one trait that almost all lecturers 
seem to share : it is the habit of referring to 
their eminent friends or personal intimates, 
"my friends the Mayos," " my friend Rocher," 
"my friend Babinski," " my dear old friend Sir 
William G." Such touches always please me. 

Here are notes of another characteristic 
clinical lecture on an important subject : — 

" Some men are so constituted that they can 
impress people to believe that which they 
themselves do not believe. Such men cure 
nervous functional disease. They may know 
nothing about nervous diseases, but they say : 
'If it is a functional nervous disease, it will 
get well, and if not, no one can cure it.' They 
therefore plunge on the functional disease. If 
they are right, the patient gets better. She 
(it is generally she) sends others to the same 
man, a man with a reputation he does not 
deserve. But perchance the disease you are 
called upon to treat is organic. Some organic 
nervous diseases are quite curable. You know 


of many such. And to cure you must 
diagnose aright, or your treatment may be 
altogether wrong. You remember the con- 
fession of the great speciaHst who, being 
obHged to hurry over a case, prescribed arsenic 
for neuritis, to find at the next consultation 
that he had prescribed arsenic for a patient 
suffering from an overdose of that very 
drug. It had been given before, and 
the patient had gone on too long taking 
the medicine prescribed for him. Satisfy 
yourself by accurate examination and careful 
consideration, and if you are certain that the 
disease you are dealing with is functional, then 
say to the patient : ' There is nothing here 
but what I can cure, and I will cure you.' 
The satisfaction you give is immense. En- 
courage hope ! FolloAv up and build upon 
your first dogmatic assertion : ' I can and will 
cure you.' But be sure that you can perform 
what you promise. 

" For my own part, in cases of the functional 
disease I am thinking of, I give medicines. 
There is a natural craving of the distressed 
human mind for routine measures of treatment. 
Sometimes medicines are useful, sometimes 
absolutely necessary, sometimes of no intrinsic 
value. In all the functional diseases I give 
medicine. I should, ladies and gentlemen, 


if I were treating any one of you for a mentally 
painful functional disease, give you medicine 
as a routine measure, and I should not discuss 
with you whether it were necessary or not. 
The medicine may be quinine, arsenic, 
strychnine, bromides or HgO. I prefer to give 
medicine hypodermically. To some this may 
seem quackery. I absolutely deny it. I 
say with truth that I give the hypodermic 
dose of HgO as a mental tonic. Give these 
injections, and give them at a regularly fixed 

" Some years ago I showed a functional case 
to my class ; she was a young woman, cured. 
I took occasion to mention the hypodermic 
injection of H2O, and I noticed that the patient 
was vastly amused. It turned out that she 
was a pupil teacher, and that she had been in 
the habit of teaching chemistry. Nevertheless 
she was cured. 

" A patient comes in paralysed^ — cannot 
move ; and in from two to three weeks he can 
run down the ward. How many seconds, Dr 
Stewart ? " 

" Ten, sir." 

" No ; perhaps fifteen." 
" No, sir ; eight seconds." 
" Eight seconds, ladies and gentlemen," says 
the lecturer, hastily accepting the number lest 


Dr Stewart should insist on a further re- 

" I now come to the case of a boy whom I 
will show you in a few minutes. Never robust : 
had fair health. Attacked in March ; his 
symptoms : severe headache, temperature 99" 
to 102°, pulse 50; failing vision. Ophthal- 
moscopic examination ; nothing found. Squint 
and double vision. Loss of voice. Loss of 
use of legs. Eighteen months ill. I found 
that the patient was suffering from a functional 
disease. He was isolated, massaged, given 
large quantities of milk and hypodermic doses 
of H2O. The patient felt sure that we knew 
the cause of his illness, and that we could cure 
him. On Sept. ist the patient could raise the 
hand. On Sept. 13th he could run in a jerky 
way. On Oct. ist he was discharged cured. 
(To the boy : ) And you now employ yourself 
in selling fruit. Yesterday you rose at 6.30. 
You went to the station with your pony and 
cart. You returned home to dinner. At night 
you enjoyed yourself and afterwards went to 
bed. You are quite well. And these ladies 
and gentlemen believe you will always re- 
main quite well. You may go. (Approving 

''This is only one case. The important 
point is accurate diagnosis; the treatment- 



milk, isolation, screens. Were these the means 
of cure ? Yes, and yet, no ! Strange nurses, 
strange doctors, strange and unexpected treat- 

Every day we visit the Pathology room : 
post-mortem study alone enables you to verify 
clinical judgment. Here you have the true 
memorials of disease : in this room you learn 
that men die too soon, that curable diseases are 
too often carelessly neglected by the patient 
himself, that warnings are almost always given 
before the final summons. The poor fellow 
who was dying of cancer the other day is 
here now. The examination, the constant 
examination of such cases, has led to the 
piling up of an immense number of records, 
which are always available for reference, and 
which are invaluable to the earnest, able 

One day during a lantern lecture I was 
ooking past the lecturer's white gown, when 
the dim light showed me on the table, 
among the other Egyptian-museum sort of 
specimens, a face pardy hidden by the figure 
of the lecturer. The face was placid, the eyes 
closed : it had been long asleep. 

I was reading this afternoon a lecture by 


one of the Edinburgh physicians. It was on 
a patient suffering from a disease which is due 
to an abnormal development of a glandular 
nervous structure found at the base of the 
brain. The result of this abnormality is a 
series of deformities, and the lecturer illustrated 
these in the person of his patient. Even 
Hood in his most elfish mood could not have 
imagined the appearance of the sufferer. The 
fingers were spade-like, the whole hand 
gigantic, the feet the same, and, worst of all, 
the face and head were like the reflection in 
a grotesque mirror. The lecturer named the 
head the third or cephalic extremity ; if ever 
barbaric scientific expressions are apt, they are 
in this case. A portrait of the woman in her 
original comeliness is given, and you look with 
astonishment, almost with a feeling of fear, 
at the power of nature to convert a jewel into 
a toad. The lecturer is Dantesque in his 
command of detail, and he spares none ; the 
heavy protruding simian jaw, the huge head, 

the gigantic outspread fingers are all given 

and near by this thing is the picture of original 
comeliness. The mental as well as the physical 
degradation is described. These people were 
most probably the original monsters of the 
fairy tales, people not often seen, hiding or 
hidden away. They are still hidden away in 


houses, kept in seclusion and merciful in- 
validism together with the family imbecile, 
who is, however, happier in his ignorance of 
the extent of his degradation and of his 
wart-like existence. There is a hope that 
this disease is curable, at least in its early- 
stages. The cause is discovered, and the 
cure of a similar disease has followed the dis- 
covery of the cause ; there is many a medical 
S. George at work, and many another in 

This brings me back to Edinburgh In- 
firmary. By the master physician's side is 
always the young house-physician, with eyes 
fixed first on the patient, and then on his 
chief. The house-physician is examining a 
patient before us, doing the work rapidly, 
accurately, with a touch. Quickly he shows 
us the signs of disease, deftly bringing out this 
reflex and that ; indicating not only the signs 
of disease in his patient, but also the presence 
of disciples to carry on research and clinical 
work when the present masters are resting. 
He is a S. George of the future. 

As one thought leads to another, there 
comes into my mind the memory of a hospital 
patient, the victim of research. I remember 
seeing him lying in bed, speechless and partly 
paralysed, after a dose of a remedy. This 


remedy had saved innumerable lives ; it had 
saved many patients similar to the patient 
before me ; but this man was one of the 
victims grievously wounded on a day of blessed 
victory to others. A physician lectured on 
the case, lectured grandly, seriously, regret- 
fully ; yet no army could be disbanded because 
of one casualty. I remember with pleasure 
that this patient was expected to recover 

I have brought forward three instances 
(Bramwell, Gibson, and Philip) among the 
teachers of this great medical school, not 
because they stand alone, but because they do 
not. They are typical ; their great clinical 
abilities and their wonderful powers of expres- 
sive teaching are shared by many others, by 
most of their colleagues. Edinburgh is happy 
in its teachers, and with them its fame is secure. 
There is R., an austere librarian of all that 
is worth knowing in medicine, who exercises 
a hypnotic attraction on American medicals. 
There is S., who loves pathology and privacy 
as much as the uncultured plebeian loves 
publicity : W., who, like Gladstone, gives to the 
small among the many medical subjects which 
own him expert the same intense attention that 

he gives to the great. And there is R 1, 

who, saturated with learning, is granite chas- 


tened into marble by the sweet associations of 
his former classroom teaching. There is G., 
who would smoke a cigarette at his own toma- 
hawking, and who, with all his absence of side, 
is what Disraeli so much admired, the best 
man at his own subject. Like all good men, 
these men could be easily caricatured. Very 
good ; but they attract earnest men to their 
great hospital and set all other medical centres 
to the study of the Edinburgh books. There 

are others : there is B d, who investigates 

stomachs like an engineer pumping for paraffin ; 
there is E. B. junior, who looks like an agnostic 
and teaches like a Jesuit — that is, with admir- 
able logical simplicity. And there is G. B., 
whose pleasant lectures prepare you for the 
information that he is also a successful novelist. 
And there is also the well-known editor of an 
encyclopsedia, who lectured to us on prenatal 
pathology and took an almost paternal interest 
in the atrocities he put on his lantern slides. 
All these men are good — I suppose because 
they are selected from a brilliant crowd of 

These great teachers, great in their work, are 
equally great in the laying of it down. To the 
end they never lower their flag. I think of one 
of them who heard from his colleagues that 
he was suffering from a malignant disease, 


necessarily fatal. He still, however, thought 
only of his work and planned how he could 
labour to the end ; but he had utterly mis- 
calculated the time left to him. It was necessary 
that he should be told, and of all his sorrowing 
colleagues the one who more than all others had 
been his closest friend was chosen to break the 
news. There was no shrinking on the part of 
the stricken man. " It is coming quicker than 
I expected," he said, " but there are at least two 
things I will do. I must write a letter for 


Dr to help him in his candidature for the 

appointment he is seeking, and I must write 
the preface to my book. Then I shall be 
satisfied." So, in kindness and in duty, 
he completed his work, and then he was 

What will be the future of this great medical 
school? Who, in these days of revolutionary 
change in medical matters, can say? One 
hopes that these leaders will teach the students, 
whom they send out every year to take a 
considerable place in our profession, that they 
must stand for the honour and dignity of 
that profession and its position in our national 
life, believing that the science of medicine will 
grow slowly but surely, like Heine's Cathedral, 
"reared by the strength of giants and the 
unwearied patience of innumerable dwarfs." If 


such is the influence of the teachers, Edinburgh 
will retain its eminence,^ 

^ The praise given to the medical work done in Edinburgh is equally 
deserved by surgery; so I am told by such competent judges as, for 
instance, Mr Moynihan. 



GOME into the surgical ward. 
The hospital is in a populous part of 
England ; it is, therefore, richly endowed with 
surgical cases, and it has become a great post- 
graduate school of surgery, to which pilgrims 
come from all parts of the world. A house- 
surgeon is preparing a patient for an abdominal 
operation. Now, the surface of the human skin 
is a forest teeming with myriads of microbes — 
nations of them ; and a wound, apart from its 
action in causing shock, is serious or otherwise 
according to its invasion or non-invasion by 
microbes. The Japanese sailors, with a fine 
disdain for ridicule, anointed themselves with 
antiseptics before battle, in order that wounds 
might be less dangerous. The house-surgeon 
is doing the same thing, with the same object. 
He shaves the skin and saturates it with 
cleansing preparations ; antiseptic lotions are 
scrubbed in, first soap spirit, then mercury 
lotion, and finally a potent bactericide, specially 
approved by the surgeon of to-morrow. Then 



the abdomen is covered with an antiseptic 
dressing for twenty-four hours. 

The next day the patient is taken to the 
operation theatre. The ceremony of purifica- 
tion is again gone through by the house- 
surgeon, who is himself scrupulously clean ; 
Japanese-like, he has had a bath before enter- 
ing the theatre, and he is clothed from head to 
foot in sterilised garb, for any possible septic 
condition about the surgeon would certainly be 
communicated to the patient. The operation 
theatre is also thoroughly aseptic, its glazed 
walls having been carefully cleansed. And of 
course the nurses are aseptic ; their face-masks 
bring to mind (as far as appearance goes) the 
veils of the ladies of Islam. Everyone con- 
cerned with the patient wears the aseptic suit, 
and the onlookers in the gallery are all similarly 
covered. Every thing about the patient is 
dead ; even the stool on which the surgeon 
sits (but he rarely sits) is sterilised. Only 
under these conditions will the master genuis, 
the principal surgeon, consent to operate. To 
him, if I may quote his own words, cleanliness 
is the physical side, diagnosis the intellectual. 
The elaboration of the minute for the preven- 
tion of sepsis is astonishing to those who, 
forgetting the lapse of fifteen or twenty years, 
remember Mr , the great man of that day, 


bustling up to the occupants of the gallery as 
if he wanted to sell them gloves. He was just 
too serious for cigars in those days ; portentous 
he must be now, if he carries out the formulae 
of his pupil. 

The operator and his assistants close round 
the patient. Each one has his place : one 
assistant is on the same side as the surgeon, 
another stands opposite. There are two 
nurses, each as scrupulously clean as the 
operator himself; the chief presides over the 
table of dressings, the other fetches and carries, 
picks up and removes an instrument that has 
fallen — hovers about, indeed, like a camp- 
follower. The anaesthetist is barricaded off 
by a linen-covered wire screen ; he is alone 
with the head of the patient and sees nothing 
but that. The patient himself is draped in a 
shroud - like garment, which is slit down the 
middle ; this shroud is soaked in antiseptic 
lotion and lies down on the skin, exposing an 
area of operation which is as carefully guarded 
from intrusion as is a prize-ring. 

The first incision is made. No ! Before 
this is done, the surgeon makes on the skin 
of the abdomen a long scratch with a needle, 
to indicate the position of the incision ; cross- 
scratches, like short streets crossing a main 
thoroughfare, are also made. At once after 


the incision the vessels necessarily cut are 
clipped and tied, or a stitch is passed round 
their open ends. The incision is deepened, 
cut vessels being always secured. The knife 
is now dividing muscle; now it reaches the 
peritoneum. Sterilised " tetra " or cotton cloths 
are folded over the edges and ends of the 
wound and are fastened by clips to the margin 
of the skin. 

A moment ago the area of operation was 
likened to a prize-ring ; it is now a deep ditch. 
At the bottom of this ditch the abdominal con- 
tents are exposed ; over them and among them 
the surgeon's light hand, gloved in rubber, floats, 
glides, and dives in its quest. Not only the eyes 
of the surgeon are in his fingers, but his whole 
intelligence also. Skilled by constant use, these 
fingers discover the damaged organ, which, like 
a person ashamed, is exposed to view and to 
further examination. This examination is done 
tenderly and carefully, and the parts which are 
brought into unaccustomed light are surrounded 
by hot mackintosh covered with gauze, this 
being necessary to prevent chill while the 
organs are outside their human hothouse. 
Possibly the diseased part is sacrificed : an 
appendicectomy, which is a kind of decapita- 
tion, may be performed, or a piece of gan- 
grenous intestine may possibly be confiscated 


and the sound cut ends reunited ; or a per- 
foration may be closed and otherwise dealt 
with. The pride of surgical skill is egoistical ; 
the glory is in the performance and is consistent 
with a splendid record of success, and with that 
alone — that is to say, with the saving of many 

When the work in the abdomen is all done, 
when every drop of blood has been wiped up, 
when every cut vessel has been examined and 
found to be securely tied, then the surgeon 
stitches up. The object of the cross-scratches 
is now apparent, for the parts divided must be 
so accurately re-united that one end of the 
cross-scratch joins on with its twin on the other 
side of the ditch. Dressings are then applied ; 
and now the surgeon may straighten his back, 
or rub his nose, or even adjust his spectacles ; 
for the wound is closed. 

The result of all this magnificent detail is 
that there is no sepsis, and that in a few days 
you may see the patient, who has had a wound 
to which Lancelot's was a mere scratch, sitting 
propped up in bed and reading his newspaper. 

The man who operates according to exact 
method is, by his very method, a great teacher. 
Everything has been done by the surgeon in 
his own way : as he operated yesterday, as he 
has operated to-day, so he will operate to- 


morrow. The assistants always know exactly 
what he will require at each step, and instru- 
ments are handed to him without his having 
uttered a word of request. He and his assistants 
are one machine. Even without his genius, 
imitators may obtain his results ; such a chief 
creates a school and originates a tradition, and 
when he disappears the school still continues. 

I have described an operation superbly per- 
formed. Such work is done by the best men 
inside hospital and out. If men who have been 
trained under such surgeons as Moynihan, Mayo, 
Littlewood, Stiles, Robson, and Thompson are 
appointed to the small hospitals, then the work 
may be done there equally well. If men are 
appointed without skill and without the experi- 
ence given by previous surgical assistantships 
or post-graduate appointments, and if for lack 
of this training complicated operations are 
tediously done, then the vitality of the patients 
is lowered and many lives may be lost. I could 
give instances. 



T^OCTORS of the past — and the men in this 
chapter are mostly of the past — may not 
be too welcome to some of my readers ; the 
problems of to-day are problems of to-day, not 
of the day before yesterday. This I admit, 
but I urge that medical men are a conservative 
race, and that the vivid portrayal of the 
characters and characteristics of the doctors of 
the past, so often found in books of their time, 
is of real importance to us, who, in a somewhat 
different time, are faced by difficulties to be 
met, as were the difficulties of other days, by 
character and characteristics. 

I have always sought for the happy 
opportunity of meeting with my fellow- 
practitioners in the pleasant journeys between 
a preface and a wedding. Even the mutilating 
Dr Slop, even the wild men of Smollett, 
including the indelicate eccentric from 
"Humphrey Clinker," are welcome acquaint- 
ances. Doctors are never saints, at least they 
are never ascetic saints ; they are as humorous 


as they are human, except when they are 
vividly in earnest. Dr Slop, with his peculiar 
ability in two arts (obstetrics and theology), is 
a better man, I warrant, than Sterne is aware 
of. Many a minor character in comedy has 
suffered through following Sancho and that 
other, the medical master of Gil Bias. 

There is an ancient tale of a quarrel between 
a doctor and a painter. They lived in neigh- 
bouring houses, garden to garden, with a door 
between. This door was the cause of the 
quarrel. But after a time peace prevailed. 
" Let him do what he likes with the door save 
paint it," said one. " I'll take anything from 
him except his physic," said the other. Two 
such genial wits couldn't quarrel long. 

Fielding, the novelist's favourite among the 
novelists, knows the doctor familiarly and 
paints him coarsely. The doctor who puts 
into his prescription every suggestion from the 
landlady is as life-like as the lawyer who 
wishes us to see that he is the busiest of 
lawyers, needing to be in twenty places at the 
same time. We meet them both in an inn. In 
"Amelia," in "Tom Jones,"in" Joseph Andrews," 
the surgeon is always attending the dissolute, 
or the virtuous suffering from the attentions of 
the dissolute. It is pleasanter to find Johnson 
writing a beautiful epitaph on one of the lowliest 


of our craft, and allowing the doctor to live 
again for us the lowly life spent in relieving 
the sufferings of the helpless. 

Crabbe 's doctor I have utterly forgotten ; 
but Crabbe is himself a doctor, and John Wesley 
praises him. 

Macaulay can do much more than catalogue 
the harsh remedies which bring back a beloved 
monarch to the caresses of his concubines and 
to a gasping reconciliation with the Church of 
Rome. The great descriptive historian notes 
the progress of remedial medicine, which adds 
to the comfort as well as to the safety of life ; 
and he traces it to the influence of his utilitarian 
philosopher. Strange that Harvey, surveying 
the same philosopher, should dislike the man 
who provokes little but admiration in Macaulay. 
There is no geniality in his phrase : " The 
Lord Chancellor writes on science like a Lord 

Addison treats us with the urbane courtesy 
which he extends to all possessing civic virtues. 

Swift's enormous Gulliver is a surgeon, and 
Swift's most esteemed friend (male) is a 
physician. In the death chamber of the latter 
the dropsical invalid himself is the only one to 
laugh, for all mourn Arbuthnot. 

Lady Mary Wordey Montagu, writing in 
1716, speaks with a shameless want of respect 


of Harrogate or some similar town. She 
prefers horse exercise, she says, to drinking 
filthy spa water and paying filthy doctors' bills. 
I can't find her letter, but I remember it. I 
was struck with the lady's fondness for the 
phrase "filthy." In her famous letter, as 
famous as a Pauline epistle or an arrogant 
Roman letter of three words from Egypt, or a 
" mailed fist " message from Potsdam, or (as 
Ireland must never be forgotten nowadays), 
the " Well done, Condor ! " of a minor naval 
engagement, she says : " The smallpox, so 
fatal and so general among us, is here (Adria- 
nople) entirely harmless by the invention of 
ingrafting ; " and she ends with : " I am patriot 
enough to take pains to bring this useful inven- 
tion into fashion in England, and I should not 
fail to write to some of our doctors very 
particularly about it, if I knew any one of them 
that I thought had virtue enough to wish to 
destroy such a considerable branch of their 
revenue, for the good of mankind. Perhaps," 
adds this wonderful woman, "if I live to 
return, I may have courage to war with them." 
Here's a pretty pickle! In 1716 Lady Mary 
hurls filth at us to compel us to inoculate against 
smallpox, and in 191 1 the Hon. Stephen 
Coleridge and Mr Arnold Lupton bespatter us 
with abuse in order to make us desist from 


vaccination. There is a difference : the lady 
has wit. The wit, restrained in this instance, 
is so pleasantly shown in the following letter 
that in my benevolence of heart I am compelled 
to reproduce it for the reader. It shows, by 
the way, that a lady can be a physician before 
she is fifty. 

" You tell me that our friend Mrs is 

at length blessed with a son, and that her 
husband, who is a great philosopher (if his own 
testimony is to be depended upon), insists on 
her suckling it herself. You ask my advice on 
the matter, and to give it frankly I really think 

that Mr 's demand is unreasonable, as his 

wife's constitution is tender and her temper 
is fretful. A true philosopher would consider 
these circumstances, but a pedant is always 
throwing his system in your face, and applies 
it equally to all things, times, and places, just 
like a tailor who would make a coat out of his 
own head without any regard for the bulk or 
figure of the person that must wear it. All 
those fine-spun arguments that he has drawn 
from Nature to stop your mouths weigh, I 
must own to you, but very little with me. 
Would you like to see your husband let his 
beard grow until he would be obliged to put 
the end of it in his pockets, because his beard 
is the gift of Nature ? I grant that Nature 


has furnished the mother with milk to nourish 
her child, but I maintain that if she can find 
better milk elsewhere she ought to prefer it 

without hesitation. Indeed if Mrs was 

a buxom sturdy woman who lived on plain 
food, took regular exercise and was free from 
violent passions (which you and I know is 
not the case), she might be a good nurse for 
her child ; but, as the matter stands, I verily 
think that the milk of a good comely cow, who 
feeds quietly in her meadow, never devours 
ragouts, nor drinks ratifia, nor frets at quad- 
rille, nor sits up at night till three in the 
morning elated with gain or dejected with 
loss " (what a deal the cow misses !) — " I do 
think that the milk of such a cow, or of a nurse 
that came as near as possible, would be likely 
to nourish the young squire much better than 
hers. If it be true that the child sucks in the 
mother's passions with her milk, this is a 
strong argument in favour of the cow, unless 
you may be afraid that the young squire may 
become a calf ; but how many calves are 
there both in State and Church who have been 
brought up with their mother's milk ? " 

To turn back to an old friend, Gil Bias. 
The witty rogue is a doctor's assistant, who, 
though he knows less of physic than he does 
of an archbishop's sermons, shows us the 


doctors practice. His principal insists on 
tapping the unfortunates of their blood and 
filling them up with hot water. Meanwhile 
the assistant partakes of a much more generous 
liqour and abjures hot water as he does 
honesty. Dickens is in a later age to take 
the same liberties with the characters in his 
Yorkshire school. The doctor in " Gil Bias," 
however, has had his revenge. His practice 
with his bowl of hot water is now quite 
orthodox ; even the lancet is reappearing, 
though not with so sharp a point ; and the 
wine bottle is banished from the bedroom. 
Even our modern humorists don't quote Gil 
Bias against us, for modern humour flourishes 
on austerity, on teetotalism, on vegetarianism, 
and on abstinence from all save gross and 
useful exaggeration. 

Physicians, except in France, and in other 
equally oriental countries, do not flourish in 
political life. Struensee has lost his head, and 
his heart, and again his head, by leaving the 
consulting room and taking to the reception 

Addington is not a physician, but we admit 
him here as the son of one. Whilst he in 
England is living his pompous, dignified, and 
secure life as Speaker, as Premier, and as 
another "man of wood painted to look like 


iron," Lavoisier is being interrupted in his 
investigations by the fall of the guillotine 
knife, and Surgeon Marat is dying in his bath. 
His death, at any rate, is clean. 

Mr Francis Osbaldistone finds us a Scotch 
surgeon who is, of course, a philosopher. 
" There was never button on the foil that 
made this hurt. Ah, young blood ! young 
blood ! but we surgeons are a secret genera- 
tion. If it werena for hot blood and ill blood, 
what would become of twa learned faculties ? " 

Surely it is Lever who sends to a medical 
consultation a young non-medical officer, a 
mere lad masquerading as a learned physician 
and greatly pleasing the family practitioners 
by his assumption of quite senile gravity and 
suave acquiescence in the opinions they have 
already expressed. 

Sydney Smith, whatever the subject of his 
satire, served it up as if it were a salad 
requiring a tasty dressing, and he gives us 
the following : 

"The boldness of enterprise of medical men 
is quite as striking as the courage displayed 
in battle, and evinces how much the power of 
encountering danger depends upon habit. . . . 
Dr White in the year 1801 inoculated himself 
with the pus from a bubo of a plague patient, 
and with more injustice wrapt his Arab servant 


in the bed of a patient just dead of the plague. 
Both departed. We learn that the servant 
ran away. The doctor took a longer journey. 

This is all very modern. The world has 
heard of many similar acts of intense devotion 
to experimental medicine and oblique deviation 
from exact morality, and has always shown its 
sympathy — with the servant who ran away. 
Mr Arnold Lupton, amongst others, has put 
on record his profound regret that such in- 
vestigations do not always end with equally 
happy abruptness to the doctor. The flight 
of the servant reminds us of the measure 
Karshish gave of the distance between Bethany 
and Jerusalem : 

"This Bethany lies scarce the distance thence 
A man with plague-sores at the third degree 
Runs till he drops down dead." 

I conclude this chapter with a quotation 
from Heine : 

" When the son of .^sculapius has exhausted 
his skill upon his patient, he sends him to a 
spa, with a long prescription of treatment 
which is nothing else than an open letter of 
introduction to chance." 



T HAVE in a desultory fashion been moving 
about, in easy slippers and dressing gown, 
among these familiar forms, and without taking 
much notice of chronological order I have 
brought certain characters and characteristics 
on to the page. There are many others of 
these old men, some deserving more than a 
respectful word, some indeed whose features 
have been sharply etched on the plate of one's 

There is an old Arab physician, Rhazes, 
preserved in camphor with his smallpox ; there 
is Dr Mead, his translator, of whom Lessing 
wrote : 

"When Mead reached Styx, Pluto started and said: 
" ' Confound him! He's come to recover the dead.' " 

There is Dr Caius, quarrelling, as is natural, 
with a Welshman. There is Lytton's admir- 
able homeopath at war with allopath, as 
Crusader with Mussulman. There is Holmes 
(Oliver Wendell, of course), much surprised 



when we thank him for his paper on puerperal 
fever ; he is imagining in his modesty that we 
have forgotten Elsie Venner. There is Dr 
Brown, with " Rab and His Friends," and there 
is the operating ward in the old Infirmary, 
where the shepherd and his dog are wailing by 
the bedside. There is "All Sorts and Con- 
ditions of Men," with the doctor who is some 
day to write Health Tracts which are to rouse 
us to thought and eventually to lead to 
Majority and Minority Reports. There are 
many others I must leave, and there are some 
I mustn't. 

What lover of Jane Austen does not 
remember the dependence of Mr Wood- 
house on Mr Ferry, and the apothecary's 
pronouncement on the subject of wedding- 
cake ? 

" Mr Perry was an intelligent, gentlemanlike 
man, whose frequent visits were one of the 
comforts of Mr Woodhouse's life, and upon 
being appHed to, he could not but acknowledge 
(though it seemed rather against the bias of 
inclination) that wedding-cake might certainly 
disagree with many — perhaps with most people 
— unless taken moderately." Afterwards, 
however, "there was a strange rumour in 
Highbury of all the little Perrys being seen 
with a, slice of Mrs Weston's wedding-cake in 


their hands ; but Mr Woodhouse would never 
believe it." 

Then there is the delightful conversation 
between Mr Woodhouse and Isabella, each 
quoting the wise utterances of a trusted 
oracle : 

" ' It was an awkward business, my dear, 
your spending the autumn at Southend instead 
of coming here. I never had much opinion of 
the sea air.' 

" ' Mr Wingfield most strenuously recom- 
mended it, sir — or we should not have gone. 
He recommended it for all the children, but 
particularly for the weakness in little Bella's 
throat, — both sea air and bathing.' 

" ' Ah ! my dear, but Perry had many 
doubts about the sea doing her any good. 
. . . And, my dear, whenever he comes, 
you had better let him look at little Bella's 

" ' Oh ! my dear sir, her throat is so much 
better that 1 have hardly any uneasiness about 
it. Either bathing has been of the greatest 
service to her, or else it is to be attributed to 
an excellent embrocation of Mr Wingfield's 
which we have been applying at times ever 
since August.' 

It is not very likely, my dear, that bathing 
should have been of use to her; and if I had 


known you were wanting an embrocation, I 

would have spoken to 

Isabella is sorry to hear that poor Mrs 
Bates had a bad cold about a month ago. 
" ' But colds were never so prevalent as they 
have been this autumn. Mr Wingfield told 
me he had never known them more general 
or heavy, except when it has been quite an 

" ' That has been a good deal the case, my 
dear ; but not to the degree you mention. 
Perry says that colds have been very general, 
but not so heavy as he has very often known 
them in November. Perry does not call it 
altogether a sickly season.' " 

This is nothing to the point, but it was 
written a hundred years ago, which of itself 
is interesting and does not take away from 
the respect we all have for Mr Perry, or from 
our delight in Miss Austen's picture, delicate 
as exquisite china ware. 

Among the doctors nearer to our own day, 
I can never believe much in Bob Sawyer and 
Ben Allen. The truth is, they have both 
come to a bad end. Bob Sawyer dying of 
delirium tremens, and Ben Allen ending as 
one of the numerous professors in medicine 
at a provincial university. 

Charles Dickens describes so many doctors 


that it might be a future task for some one to find 
out those he omitted. He is deeply interested 
in pathological horrors: spontaneous combus- 
tion ; the mental condition of the hangman 
about to be hanged ; the agony of the mother 
when her son's dead body is brought from 
the scaffold ; the dreadful state of the paralysed 
Mrs Clennam, and her marvellous recovery 
under the exaltation of intense emotion ; or 
the uraemic symptoms which preceded the 
death of the elder Dorrit. One could easily 
multiply these instances: the febrile reveries 
of little Paul, the bloodless apathy of Mrs 
Dombey, the suicide of Jonas in the cab, are 
other examples. The foul, beery drunkard 
who interrupts his swilling to assist at the birth 
of Little Dorrit, and who, although he is 
already half-drunk, assumes his professional 
manner when he reaches the lying-in chamber, 
asserting that "we are as right as we can 
be," is a marvellous etching in acid. The 
large amount of brandy sent out for and 
consumed by this accoucheur is carefully 
noted and narrated by the author, who, I 
verily believe, was a little boy downstairs, 
held in awe by the midwife. 

Another sort of doctor is finely described 
in a few words later on in the same book, 
when the alien is taken to the hospital ; 


" ' It's a serious injury, I suppose/ said 

"'Ye-es,' replied the surgeon, with the 
thoughtful pleasure of an artist contemplating 
the work upon his easel. ' Yes, it's enough. 
There's a compound fracture above the knee 
and a dislocation below (!). They are both 
of a beautiful kind.' 

" He gave the patient a friendly clap on 
the shoulder again, as if he felt that he was 
a very good fellow indeed, and worthy of all 
commendation in having broken his leg in a 
manner interesting to science." Interesting 

Still in the same book, Physician gives 
Dickens an opportunity of describing the 
doctor, with his great responsibilities, almost 
with the power of life and death, conversant 
day by day with tragedy and comedy ; and he 
brings him at the end of the chapter to stand 
beside the body of the most prosperous knave 
of the day. Dickens hangs his Turpin on a 
sordid gallows. 

Sir Parker Peps, who orates as physicians 
do orate, saying consoling commonplaces on 
awful occasions, forms a wonderful picture : 

" Doctor Parker Peps, one of the Court 
Physicians, and a man of immense reputation 
for assisting at the increase of families, was 


walking up and down the drawing-room with 
hands behind him, to the unspeakable admira- 
tion of the family Surgeon, who had regularly 
puffed the case for the last six weeks, among 
all his patients, friends, and acquaintances, as 
one to which he was in hourly expectation day 
and night of being summoned, in conjunction 
with Doctor Parker Peps. 

'"Well, Sir/ said Doctor Parker Peps in a 
round, deep, sonorous voice, muffled for the 
occasion, like the knocker ; ' do you find that 
your dear lady is at all roused by your visit ? ' 

"'Stimulated, as it were?' said the family 
practitioner faintly : bowing at the same time 
to the Doctor, as much as to say, ' Excuse 
my putting in a word, but this is a valuable 

" Mr Dombey was quite discomfited by the 
question. He had thought so little of the 
patient, that he was not in a condition to 
answer it. He said that it would be a satisfac- 
tion to him, if Doctor Parker Peps would walk 
upstairs again. 

. " ' Good ! We must not disguise from you, 
Sir,' said Doctor Parker Peps, ' that there is a 
want of power in Her Grace the Duchess — 
I beg your pardon ; I confound names ; I 
should say your amiable lady. That there 
is a certain degree of languor, and a general 


absence of elasticity, which he would rather — 
not ' 

" ' See,' interposed the family practitioner, 
with another inclination of the head. 

" ' Quite so,' said Doctor Parker Peps, 'which 
we would rather not see. It would appear 
that the system of Lady Cankaby — excuse me : 
I should say Mrs Dombey : I confuse the names 
of cases ' 

" ' So very numerous,' murmured the family 
practitioner — ' can't be expected, I'm sure — 
quite wonderful if otherwise — Doctor Parker 
Peps's West End practice ' 

'"Thank you,' said the Doctor, 'quite so. 
It would appear, I was observing, that the 
system of our patient has sustained a shock, 
from which it can only hope to rally by a great 
and strong ' 

" ' And vigorous,' murmured the family 

" ' Quite so,' assented the Doctor — ' and 
vigorous effort. Mr Pilkins here, who, from 
his position of medical adviser in this family — 
no one better qualified to fill the position, I 
am sure ' 

" ' Oh ! ' murmured the family practitioner. 
' Praise from Sir Hubert Stanley ! ' 

'"You are good enough,' returned Doctor 
Parker Peps, 'to say so. Mr Pilkins, who, 


from his position, is best acquainted with the 
patient's constitution in its normal state (an 
acquaintance very valuable to us in forming our 
opinions on these occasions), is of opinion, with 
me, that Nature must be called upon to make a 
vigorous effort in this instance ; and that if our 
interesting friend, the Countess of Dombey — 
I beg your pardon : Mrs Dombey — should not 
be ' 

" ' Able,' said the family practitioner. 

" ' To make that effort successfully,' said 
Doctor Parker Peps, ' then a crisis might arise 
which we should both sincerely deplore.' 

" With that they stood for a few seconds 
looking at the ground. Then, on the motion 
— made in dumb show — of Doctor Parker Peps, 
they went upstairs ; the family practitioner 
opening the room door for that distinguished 
professional, and following him out, with the 
most obsequious politeness." 

At the time that Dickens was writing, Dr 
Lombe Atthill was working as unpaid physician 
to a town dispensary. The following quotation 
is from his book of " Recollections" : 

" On another occasion I was sent to visit a 
woman residing in a lane, the house having no 
basement. It was late on a winter day, and 
twilight. Arrived at the house, I pushed the 
outer door in and knocked on that of the first 


room I came to. Hearing no answer, I opened 
it and asked : ' Is there anyone here ? ' The 
room was pitch dark. I could see nothing, 
but a voice from the far corner said, 'Yes.' 

Asking was she Mrs , the answer was 

'Yes.' So I crept cautiously in the direction 
from whence the voice came. I could not see 
the patient, but, stooping down, felt the out- 
line of a human form stretched on a little straw. 
There was no fire, no candle, not a scrap of 
furniture. I asked her to raise her hand, and 
I felt the pulse : it was that of fever. I told 
her to put out her tongue : it was as dry as a 
coarse file. I knew that it must be a case of 
typhus, alone, friendless, untended, without 
light, without fire, without food. Such scenes 
come in the daily experience of the physician." 

A description like this, not from a novelist, 
but from an every-day physician who also wrote 
dry books on his special subject, will have a 
different effect on various readers. My thoughts, 
which are often coloured by incongruity, lead 
me to another picture. I was at one time 
walking in the underbridge streets of Edin- 
burgh when I saw two women take hold of a 
man helplessly drunk and lead him from the 
road to a safe step in a doorway. One of 
them, in a voice of excuse for her kindness, 
said : "He's somebody's body." These two 


tales insisted upon accompanying each other 
in my thoughts, one a tale of horror, the 
other not altogether to be separated from 

Thackeray appreciates doctors much as he 
appreciates a glass of wine, criticising the 
vintage, but allowing in a general way that 
gratitude is due to the grape. The elder 
Firmin comes off more easily than he deserves, 
and Pendennis pere is worthy of our respect. 
Dr Goodenough pervades the pages of " Pen- 
dennis," of " The Newcomes," and of " The 
Adventures of Philip " ; he is shown as a large- 
hearted man, kindly and capable of self- 
sacrifice, and he is never so eager as when he 
runs up a poor man's stairs. Thackerary is 
good to his doctor, fond of endowing him with 
guineas, and pleased when he sees the spanking 
greys champing and fretting outside the patient's 
door. But he never describes the doctor as a 
scientist, though he makes some use of the 
introduction of chloroform. It was ether that 
was first employed in America, but it is chloro- 
form that is sent over by the elder Firmin to 
Nurse Brandon and tried by Dr Goodenough. 
Nurse Brandon uses it herself in the scene with 
Tufton Hunt. 

Then there is old Dr Huxter. Let us read 
how he was called in to prescribe for Lady 


Rockminster. We shall laugh, but after all it 
will be a kindly laughter. 

" Pen said he would go and call at that 
moment upon Mr Huxter, and see what might 
be done. Huxter junior would lurk outside 
whilst that awful interview took place. The 
coronet on the carriage inspired his soul also 
with wonder ; and old Mr Huxter himself be- 
held it with delight as he looked from the 
coffee-house window on that Strand which it 
was always a treat to him to survey. . . . 

"'I hope you don't intend to grow rich and 
give up practice,' said Pen. ' We can't lose 
you at Clavering, Mr Huxter ; though I hear 
very good accounts of your son. My friend, 
Dr Goodenough, speaks most highly of his 
talents. It is hard that a man of your eminence, 
though, should be kept in a country town.' 

" ' The metropolis would have been my sphere 
of action, sir,' said Mr Huxter, surveying the 
Strand. * But a man takes his business where 
he finds it ; and I succeeded to that of my 

"'It was my father's, too,' said Pen. 'I 
sometimes wish I had followed it.' 

' You, sir, have taken a more lofty career,' 
said the old gentleman. 'You aspire to the 
senate : and to literary honours. You wield 
the poet's pen, sir, and move in the circles of 



fashion. We keep an eye upon you at Claver- 
ing. We read your name in the lists of the 
select parties of the nobility. Why, it was only 
the other day that my wife was remarking how 
odd it was that at a party at the Earl of Kiddi- 
minster's your name was not mentioned. To 
what member of the aristocracy, may - 1 ask, 
does that equipage belong from which I saw 
you descend ? The Countess Dowager of 
Rockminster ? How is her ladyship ? ' 

' " Her ladyship is not very well ; and when 
I heard that you were coming to town, I 
strongly urged her to see you, Mr Huxter,' 
Pen said. Old Huxter felt, if he had a 
hundred votes for Clavering, he would give 
them all to Pen. 

" * There is an old friend of yours in the 
carriage — a Clavering lady, too — will you come 
out and speak to her ? ' asked Pen. The old 
surgeon was delighted to speak to a coroneted 
carriage in the midst of the full Strand : he 
ran out bowing and smiling. Huxter junior, 
dodging about the district, beheld the meeting 
between his father and Laura, saw the latter 
put out her hand, and presently, after a little 
colloquy with Pen, beheld his father actually 
jump into the carriage, and drive away with 
Miss Bell. 

" There was no room for Arthur, who came 


back, laughing, to the young surgeon, and 
told him whither his parent was bound. 
During the whole of the journey, that artful 
Laura coaxed, and wheedled, and cajoled him 
so adroidy, that the old gendeman would have 
granted her anything ; and Lady Rockminster 
achieved the victory over him by compliment- 
ing him on his skill, and professing her 
anxiety to consult him. What were her lady- 
ship's symptoms ? Should he meet her lady- 
ship's usual medical attendant? Mr Jones 
was called out of town ? He should be de- 
lighted to devote his very best energies and 
experience to her ladyship's service. 

" He was so charmed with his patient, that 
he wrote home about her to his wife and 
family ; he talked of nothing but Lady 
Rockminster to Samuel, when that youth came 
to partake of beef-steak and oyster-sauce, and 
accompany his parent to the play. There was 
a simple grandeur, a polite urbanity, a high- 
bred grace about her ladyship, which he had 
never witnessed in any woman. Her symptoms 
did not seem alarming ; he had prescribed — 
Spir : Ammon : Aromat : with a little Spir : 
Menth : Pip : and orange flower, which would 
be all that was necessary. 

" ' Miss Bell seemed to be on the most con- 
fidential and affectionate footing with her 


ladyship. She was about to form a matri- 
monial connection. All young people ought 
to marry. Such were her ladyship's words ; 
and the Countess condescended to ask respect- 
ing my own family, and I mentioned you by 
name to her ladyship, Sam, my boy. I shall 
look in to-morrow, when, if the remedies which 
I have prescribed for her ladyship have had 
the effect which I anticipate, I shall probably 
follow them up by a little Spir : Lavend : 
Comp : — and so set my noble patient up.' " 

I must ask Dr Thorne in. We all know 
Dr Thorne, who, although he has "a hundred 
and thirty proved descents from Macadam," is 
most pleased when he is rubbing up rhubarb in 
a mortar, or curing an old wife's troubles. He 
is the upright, courageous English gentleman, 
kindly as well as fearless, and — surely this 
is great praise — beloved of Trollope. Both 
Trollope and Ian Maclaren paint old doctors 
(Thorne is old at thirty), stern in their integrity, 
shrewd in the knowledge of their kind. Both 
these doctors (and better have never been 
described) are financially unsuccessful. 

That Trollope knows doctors of another 
stamp is evident when Sir Omicron Pie, Dr 
Fillgrave, Dr Century, and Mr Rerechild come 
into the picture. Dr Fillgrave, port-wine- 
pompous, present as part of a ceremonial when 


church dignitaries are dying, is a great tribute 
to Trollope's brilliant ability. Trollope is 
obliged to concede some ability to Dr Fillgrave, 
but he does it with reluctance. I, however, 
cannot help liking Fillgrave : his dislike of Dr 
Thorne is so frank, and his abuse so quaintly 
expressed. " Much as he hated Dr Thorne, 
full sure as he felt of that man's utter ignor- 
ance, of his incapacity to administer even a 
black dose, of his murdering propensities, and 
his low, mean, unprofessional style of practice ; 
nevertheless," etc. etc. And I must give his 
shrieks of annoyance when he thinks that his 
wicked opponent, who is waxing fat and 
prosperous, is trying to keep him out when he 
is at last called to Boxall Hill. " I'll publish 
the whole of the transaction to the medical 
world, Dr Thorne, the whole of it ; and if that 
has not the effect of rescuing the people of 
Greshamsbury out of your hands, then — then 
— then, I don't know what will." Dr Fillgrave 
is still publishing. — He appears under a much 
more sounding title in "The Doctor's Dilemma"; 
but he has fallen off. 

Sir Clifford Allbutt, once of Dewsbury, now 
of two hemispheres, could write delightfully of 
doctors if he would. Those who dare to judge 
say that no hand holds a more graceful pen. I 
have heard him describe the old doctors whom 


he had known, and the description made us 
sigh and smile and share his pride in his 
ancient friends. The good men in the old 
days were excellent, he says, and the duffers 
were dreadful duffers. The good men were 
full of a knowledge which we shall never equal : 
it depended so much on unassisted eye, ear, 
touch, and smell. Microscopes were not used 
by them, neither were they needed. These old 
men of the past, old men in Allbutt's early 
days, knew when to give powerful drugs, opium 
for instance, and when not to give them. Very 
important this, for struggling life may depend 
upon sleep, and yet there are many dangers in 
a narcotic. These old doctors, Allbutt found, 
could always tell when their patients were 
started on the way to recovery ; they also had 
the other complementary knowledge : they 
knew when their patient was going to die. 

Sir Clifford pleasantly says that he was occa- 
sionally called into consultation because, as one 
doctor put it to him, " I sometimes want a 
philosopher, and I'm not a philosopher." All 
these clever old fellows were " fond of horses," 
and knew, like a vet., the points of a horse. 
This is one of those statements that I suppose 
we can call whimsical. 

Carlyle is not complimentary to doctors. 
Sir Richard Quain, one of them, says that the 


great writer was a miserable patient, and that 
he spoilt his digestion, not by struggling with 
the spirit, but by eating common gingerbread. 

A book written the other day gives us a 
most interesting example of the conventional 
opinion of a medical man's work. There is 
just a hint of modernity in a mild censure of 
too much drugging, and there is the prayerful 
and thankful attitude toward modern bacterio- 
logical research. But the medical platitudes 
might have been written by a rector or a 
rector's daughter. It is intended that we 
should admire the conventional young surgeon, 
handsome, athletic, full of vigour and honesty ; 
and there is a sympathetic reference to the 
miracles at Lourdes. We are introduced to 
the pilgrims, one of whom — an American — only 
partially relies on the miraculous, assisting his 
halting faith with a well advertised drug. ("A 
Corner of Harley Street.") 



npHE ability of the social reformer of the 
present year (191 1) fills me with astonish- 
ment The reading of the Minority Report 
makes me say this ; the earnest, vivid pages, 
full as they are of groans, and starvings, and 
statistics, might have been written by Kinglake. 

Such books by the reformers put them and 
the wits in one camp. Most reformers are 
illiterate in thought, intolerant in action. I 
suppose this is obvious : a Luther cannot easily 
be an Erasmus. But the Minority Report 
shows Mrs Sydney Webb and her friends as 
both Luther and Erasmus. 

The Minority Report deserves the most care- 
ful and earnest study from all who wish for a 
better medical service. The strictures passed 
on the Poor Law Medical Service are all more 
or less true of all poorly paid medical work, 
and medical men have for years been protesting 
against such conditions of service. This the 
Minority and the Majority Reports both allow, 

and justice is done to the doctors, who are 


described as men who, on the whole, have done 
good work with ridiculously inadequate tools. 

A powerful health service is advocated to 
take the place of the present profession. Every 
preventive means is to be taken, and then the 
cure of illness is to be assigned to the antiquary. 
We medical men meet these theories often in 
medical journal correspondence columns ; they 
are, perhaps, best expressed among doctors in 
the amiable writings of Dr Moore. We know 
that much that these teachers teach will come 
to pass. The public health will improve ; there 
will be progressive measures carried into law 
from year to year, interrupted, as is inevitable, 
by reactionary movements induced by ill- 
considered measures, zealous mistakes. 

Mr Bernard Shaw has with much condescen- 
sion adopted the reformers. St Shaw is one 
of those preachers who adopt the grotesquely 
serious style, and whose hearers listen to a 
sermon given in the guise of elaborate farce. 
Some hasten to him to hear his wit, a few to 
meet their own crude opinions put into epigram. 
Most of the sermon consists of extravagant 
over-statement, street corner eloquence, made 
artistic, and intended to arrest the moving 
mob. At times he becomes even ecclesiastical, 
and when he shows his motley you imagine a 
surplice, so fine is his unction. Not that he is 


even reverent. He loves to shock the few 
who are ; he paints what he calls " God " as 
utterly godless, and lately he has boastfully put 
an electric light on the Cross. He is no less 
intolerant to humanity itself : original sin is 
the one truth he finds in all the religions, and 
every man is a more than potential rogue. 

After that it is easy to paint any man as Anti- 
christ, and as Mr Shaw has read the Minority 
and Majority Reports, the first man he meets 
is the doctor. Shaw proclaims his absolute 
freedom from bias, for have not these defrauders 
always healed him personally with the most 
Christian kindness, attending to his needs as 
readily when he has been unable to recompense 
them as when, on the contrary, he has added dis- 
tinction to a palace adorning the Embankment ? 

But the indictment must go forth : a new 
order of things must take the place of the old ; 
George Eliot is dead, and Bernard Shaw is 
the pontiff. Nay, pontiff is hardly the word : 
he is the angel with the flaming sword, the 
sword which, having dazzled everyone for so 
many years, is now to prick and scorch us. 
And we so richly deserve it ; our crime is 
that we have not sought the tree of knowledge, 
that we have not read prefaces, that we have 
misled our generation. We must hasten to 
read " The Doctor's Dilemma" and admit our 


worthlessness and ignorance. This enemy to 
pretence will himself guide us, helped, in some 
limited degree, by S. Luke, by S. Francis of 
Assisi, and by the Founder of Christianity ; and 
we may, if we are sensible, become a minor 
branch of the Civil Service. Anyhow, we are 
a dull lot, and Luke Fildes is no artist. 

Has Bernard Shaw a play on lawyers ? If 
so, I know the preface. His method of pro- 
paganda will be to describe the legal profession 
as an organised, Avasteful, selfish rabble, too 
bad to be saved, though (and here is the subtle 
touch) too good to be utterly damned. 

The judge in this preface is (or will be when 
it is written) hopelessly corrupt. He cannot be 
anything else, for "his honor (I adopt Mr 
Shaw's spelling) rooted in dishonor stands." 
Irish judges alone are tolerable — not that they 
are more honest, indeed they are more dishonest 
than the English ; but they are not liable to 
cant, they are incapable of deception, and every 
Irishman is an accomplished comedian, even 
when sentencing a poor wretch to the gallows. 
But English judges are worse than corrupt : 
they are platitudinising bores, making fatuous 
remarks supposed by the ignorant and venal 
to be gems of wit, and to each of these 
judges we pay ;^50oo a year. And we keep 
obsolete coaches, obsolete coachmen, obsolete 


trumpets for the judges, and appropriate gar- 
ments, for we dress them as old women. 

We choose our judges as lunatics alone 
would ; for what sane person is there who, 
if he were not obsessed by an imbecile respect 
for customs, would take men trained to lie for 
fees, and place them in the seats of Truth and 
Justice? And our judges are taken from men 
not only permeated by the degrading effects 
of evil custom, but they are in the decline of 
life, subject to those minor ailments, brought 
on by bar customs, which render them peevish 
and partial. And to these men a country 
prostrate and perspiring with reverence leaves 
the issues of life and death. Shaw will then, 
in his usual way, allow that he likes them 
personally, dines with them, sits on charity 
committees with them, and, except as judges, 
finds them full of kindly mercy. 

An Irish anecdote and an appeal to Ecclesi- 
astes, and then, though the play is on lawyers, 
the preface will take up the Church. 

Shaw has already described Christ as a 
punster, and we shall be told that He knew 
well that every woman who entered the married 
state was in her heart an adulteress. But we 
shall have earnest statements (reading as solemn 
facts) that Voltaire was an Anglican, too strictly 
orthodox for his time, or he would have taken 


Anglican orders when in England ; and that if 
he had restrained his tendency to joke about 
Habakkuk, he might easily have become Arch- 
bishop of Canterbury without the slightest 
alteration in his principles. 

A friend of mine recently told me that 
alcoholics did not die from too much drink 
but from too little. I attempted to translate 
this into sense, and I think I have succeeded ; 
I may, therefore, be one of those who will 
benefit by the reading of " The Doctor's 

Shaw's doctors are not doctors. He can't 
draw character, but he can preach and vivify 
witticisms. His Englishman in "John Bull's 
Other Island" is a galvanised clod, as little 
like an Englishman as is Byron's Constant- 
inople Johnson. Even his Irishman is a 
melancholy Scot deprived of his whisky. 

If it were not that this book is far too long, 
I should like to extract some scenes from a 
medical novel called " The New Religion," 
which I invite medical men to read. It is of 
pathological interest. The writer introduces us 
to many dishonest medical men. There is also 
one honest doctor, but he is, of course, a fool. 
In contrast to our western quackery, there is a 
Mohammedan saint who cures disease with all 
the alarming success of a Boston prophetess. 


Maarten Maartens, who gives us this rubbish, 
is another would-be reformer of medicine. Alas, 
there is much to reform, — and these men mean 
to crucify somebody. As blunderers are some- 
times lucky, let us hope they will fall upon 
someone of little importance. 

The possibility of evil doing in a profession 
restrained mainly by traditions of righteousness 
continually attracts the attention of the satirist. 
Captain Whitefeather may speak for them all. 

" Is it otherwise with the physician who 
sells guesses as truth, and doubts and doubts 
a patient into the grave whilst his medicinal 
palm is open to the guinea ? When the 
apothecary vends cinnamon water and pepper- 
mint for Elixir Vitse, doth he practise a noble 
art ? 

But a gentler satirist addresses the young 
members of the medical profession in a different 
strain. "Don't be downcast," he writes, "if 
you don't receive recognition, praise, gratitude 
from men ; and look with a critical and careful 
eye at the laurel wreath placed on your brow 
by women. If recognition from your patients 
eventually comes, don't be ashamed to show 
that you are pleased. Remember, only one 
leper returned to give thanks, and that is 
above the average. The important thing is 
to go out and cleanse more lepers." 


I have but one more quotation from the 

"Of all the great branches of human 
knowledge, medicine is that in which the 
accomplished results are most obviously im- 
perfect and provisional, in which the field of 
unrealised possibilities is most extensive, and 
from which, if the human mind were directed 
to it, as it has been during the past century 
to locomotive and other industrial inventions, 
the most splendid results might be expected." 
(Lecky, " History of European Morals.") 



Aberdeen, 228 
Acromegaly, 259 
Addington, 277 
Addison, 273 

Alcoholism, 126-7, I34) 136, 
143, 145, 173, 184-5, 188-9, 
199, 252-3, 303 

Allan, Dr, 116 

Allbutt, Sir Clifford, x,, 65, 85-8, 

159, 165, 227, 295-6 
Amelia 272 

American dispensaries, etc., 
30, 152 

American doctors, 226, 234-5 

patients, 5 

surgery, 5-6, 228 

(U.S.) Government and 

tuberculosis, 197 
Anaesthetics, 117, 290 
Antiseptics, 110, n8, 265-6 
Antitoxins, 15, 54, 165 
Appendicectomy, 268 
Appendicitis, 57 
Arbuthnot, 273 
Arloing, Dr, 198 
Army, diseases in the, 246-8 

Medical Service, i 

Arterio-sclerosis, 246-8 
Asepsis, no, 114, 118, 266 
Assistants, unqualified, 73, 102-3 
Asylums, 97 

Atthill, Dr Lombe, 288-9 
Austen, Jane, 281-3 

Bacillus, see Bacteria 
Bacon, Francis, 273 
Bacteria, 31, 150, 172, 179, 187, 

Bacteriology, 159, 165 

Baltimore, 31, 226 

Barr, Sir James, 8 

Barrs, Dr A. G., x., 8, 166, 

Belfast, 228 
Bell, Dr, 66-7 
Berlin students, 239-40 
Besant, Sir W., 281 
Birmingham, 228 
Birrell, Augustine, 250 
Blackie, Professor, 231 
Bland Sutton, viii., 81 
Boards of Guardians, 104, 117, 

130, 131, 150 
Bolingbroke quoted, 58-9 
Bovine tuberculosis, 195 
Bradford, 121, 226, 233 
Bramwell, Dr B., 248, 251-3, 


Dr E., 235, 262 

Bristol, 228 

British Medical Association, 

77, 93-6 
British Medical Journal, 93-4 
Brown, Dr, 281 
Bunyan, John, 209 
Burslem, 233 
Byron, 2, 303 

Calmette, 198 
Caius, Dr, 280 
Cambridge, 226 
Cancer, 15, 203, 246 
Carlyle, 250, 296-7 
Children, and Friendly Socie- 
ties, 75 -6 




Children, death-rate among, 

164, 214-5 
inspection of, 155-7 ; see 


protection of, 162 

Cleanliness in surgery, 31, 228, 


Clinical assistants, 25-9, 33-4 
Clinics, school, 157-8 
Clive, 242 

Club doctors, see Contract 

Coleridge, The Hon. Stephen, 


Congresses : London, 195 ; 

Washington, 196, 253 
Consultants, 45-8 
Consumption, see Tuberculosis 
Colonies, 217-9, 222-4, 


Contract practice, 13, 60-82 
Corner of Harley Street^ A, 297 
Coroner, 113, 214 
Coroner's Courts, 106 
Council Schools, 175 
County Schools, 90, 92 
Crabbe, 273 
Crile, viii., ix. 
Criticism, 51-9 

Death-rate, Infantile, 164, 

from phthisis, 183, 206, 


from phthisis near 

sanatoria, 219 
from puerperal fever, 


preventable, 163 

Defoe, 153 
Degrees, 20 
Detrd, Dr, 198 

Diagnosis, 33, 38, 69, 159, 228, 

232, 266 
Dickens, Charles, 31, 50, 277, 


Diphtheria, 15, 54, 135, 159, 

164-5, 172, 174 
Dispensaries for chest diseases, 

— ; — in America, 30, 152 
Disseminated sclerosis, 243 
District Nurses, 124, 153 
Doyle, Conan, 66-7 
Drink, see Alcoholism 
Dropsy, 135, 247 
Drugs, 57 
Dublin, 228 

Education, Authorities, 90-93 
Edinburgh, 20, 200-1, 227, 

Elimination of the Unfit, 16-17 
Elsie Venner, 281 
Eiiwm, 281-3 

Environment, 204, 209, 211, 

Epilepsy, 16, 144 
Ether, 290 
Eugenics, 140 
Ewing, Dr, 15 

Falkenstein, 219 
FalstafF, 247 

Family history, 38, 249-50 

Fanning, Dr, 222 

Favus, 175 

Fees, surgical, 27, 49 

contract, see Contract 


— • — for school inspection, 90 

Fever Hospitals, 166 

Fielding, Henry, 272 

France, tuberculosis and al- 
coholism in, 189, 199 

Francine, Dr, 30 

Friendly Societies, 60-6, 72-5, 
78, 98 

Frimley, 224 

Gaols, 176 

General practitioner, the. 



10-15, 26, 28, 30, 33, 35-41, 
45-7, 119, 153. 155, 165 

George, Mr D. Lloyd, 77, 

Germ carriers, 172-3, 183 
Gibson, Dr, 252-3, 261 
Gil Bias, 272, 276-7 
Gowers, 227 

Guardians, see Boards of 

Gulliver, 273 

Hadleigh, 222 
Harrogate, 166, 274 
Harvey quoted, 273 
Haultain, Dr, no- 11 
Hawker's child, inquest on, 

Hawthomden, 254 
Heine quoted, 263, 279 
Heredity, 181-2, 189, 221-2 
History of European Morals, 


Holmes, Oliver Wendell, 280-1 
Holmes, Sherlock, 66-7 
Holy Tree, the, Cairo, 144 
Horsley, Sir Victor, viii., ix., 

Hospital Appointments, 22-34 

training, 20-7 

Hospitals, 42, 115-22, 242-50, 

258-61, 265-70 
Hughlings Jackson, 227 
Hume, 231 

Humphrey Clinker, 271 
Hunslet, 166 ; hospital, 121 
Hutchinson, Jonathan, 227 
Huxley, 81 

Hygiene, 167, 173-4, 184, 213 
Idiots, 52 

Imbeciles, 126, 143, 146 
Immunity, 16-18, 204-6 
Indian Medical Service, 2 
Infection (phthisis), 179, 216 
at school, 183-93 

Infectious diseases, 13S-6, 

158-9, 174, 179 
Infirmaries, see Poor Law 

Inoculation, 274; for plague, 


Inquest on hawker's child, 

Inspection, 155-62, 167, 212 

of schools, 90, 156-8 

Insurance Act (191 1), 77> 85, 


Jackson, Hughlings, 227 

Japanese and antiseptics, 265-6 

Jenner, 15 

Jerrold, Douglas, 89 

Jews, immunity from tuber- 
culosis, 189, 199, 204-5 

Johns Hopkins University, 
1 18-19, 226, 240 

Johnson, Dr, 188, 272-3 

Joseph Andrews, 272 

Kelling, 222-4 
Kelly, 226 

Karshish, Epistle of, quoted, 

Koch, 10, 15, 195, 198, 207 

Lavoisier, 278 

Lead poisoning, 247 

Lecky, W. E. H., 305 

Lecturers, 248-64, 

Leeds 121, 228, 230, 265-70 

Lessing, 280 

Lever, Charles, 278 

Lister, 227 

Littlewood, viii., 270 

Liverpool, 121 ; School of 

Tropical Medicine, 226 
London, 227, 229, 233 

Congress of, 195 

Lupton, Arnold, 274, 279 
Lupus, 203, 244-5 
Lytton, Bulwer, 280 



MACAULAY, 2, 242, 273 
Maclaren, Ian, 294 
Majority Report, 78, 281, 298, 

Malingering, 83 
Manchester, 228 
Marat, 278 
Mayo, viii., 270 
Mead, Dr, 280 
Measles, 174 

Medical Officer of Health, 51, 
104, 112-13, 129, 151, 157-9, 

Medical patients, 48-9 
Practitioners' Associa- 
tion, 94 

science, improvements in, 

15-16, 54, 150 

superintendents, sugges- 
tion concerning, 150-4, 176 

women, 14 

Medico - Chirurgical Society, 

Melancholiacs, 245 
Meningitis, 203 
Microbes, see Bacteria 
Midwifery, 25-6, 102-14, 141, 

Midwives Act, 103-4 
Milk and tuberculosis, 194 
Minor operations at home, 32 
Minority Report, 78, 281, 298, 

Mitchell, Weir, 245 
Montagu, Lady M. Wortley, 

Moore, Dr, 299 
Moynihan, Mr, viii., ix., 81, 

264, 270 
Myxoedema, 15, 250 

Naish, Dr, 215 

National Association for Pre- 
vention of Consumption, 

Insurance, 99 

National Societyfor Prevention 
of Cruelty to Children, 52, 142 
Navy, diseases in the, 169-70 
Negroes and Tubercle, 204 
Nervous diseases, 244-254 
New Religion, The, 303-4 
Newcastle, 228-9 
Newsholme, 198, 207 
Night calls, 71-2 
Nordrach, 219-20 
Notification of diseases, 158 

phthisis, 160, 189-92, 


Operating, see Surgery 
Opsonic Index, 54 
Organo-therapy, 150 
Osbaldistone, Francis, 278 
Osier, Professor, x., 81, 209, 

Out-patients, 24, 119-20, 242 
Overcrowding, 124, 142, 182 
Oxford, 226 

Panama, 17 
Paterson, Dr, 224 
Pathology, 258 
Paying patients, 118-9 
Phihp, Dr, 183, 198, 201, 213, 

253, 261 
Phipps Institute, 30-1 
Phthisis, see Tuberculosis 
Physician, the, 7-10, 42-44 
Physique, 186, 205 
Pirquet, von, 198 
Pneumonia, 55, 69, 172 
Police Courts, condition of, 176 
Police Medical Officer, the, 132 
Political doctor, the, 82 
Poor districts, 131 

Law experiences, 123-48 

: a suggestion, 149- 

54, 176 

hospitals, 115-7 

medical service, 



Poor Law, Royal Commission 

on, 50, 52, 78, 117, 151, 281, 

298, 300 
Post-graduate student, the, 

225-7, 234-5, 236-9 
Prevention, 80, 193, 209, 213, 


Prevention of Destitution^ The, 

= of Tuberculosis, The, 207 

Prisons, condition of, 176 
Professional training, 19 
Progress in medical science, 

15-16, 54, ISO 
Psycho-therapy, 254-8 
Public Health, 51-3, 74, 155, 


Public-house, the, 137, 173 
Puerperal fever, iio-ii, 281 

QUAIN, Sir Richard, 296-7 

Rab and His Friends, 281 
Raw, Dr Nathan, 116 
Relieving Officer, the, 104, 130 
Resistance to disease, 179, 205, 

Rhazes, 280 

Richardson, B. Ward, 204 
Robertson, 231 

Robson, Mayo, viii., ix., 32, 270 

Roebuck, Mr, 168 

Rontgen ray work, 16, 39, 150 

Sanatoria, 206-10, 216-24 
Sanatorium patients, 135, 221 
Sancho, 272 

Sanitary Inspectors, 160-2, 

Saturday Review quoted, 230 
Scarlet fever, 135-6, 174, 175 
School clinics, 157-8 
Schools, iSS-8, 174-6, 183-4, 

Scott, 230, 278 
Scrofula, 203 

Sects, 133 

Serum therapy, 150 

Sexual diseases, 54, 127, 128-9, 

169, 184, 244 
Shaw, G. B., 295, 299-303 
Sheffield, 168, 215, 228, 230 
Shop assistants, 169 
Sims Woodhead, 198 
Skin diseases, 244-5 

microbes, 265 

Slop, Dr, 271-2 

Slum work, see Poor Law ex- 
Smallpox, 145-6, 274 
Smith, Sydney, 278-9 
Smollett, 271 

Social and Sanitary Associa- 
tion, 145 
Specialism, 156, 243 

in surgery, viii. 

Specialist, the, 42-7 
Spitting, 187, 191-2 
Stanley, Sir H. M., 61 
State doctors, question of, 

89-90, 93-7, 99 
Sterne, 272 
Stiles, viii., 270 
Struensee, 277 
Suffrage, extension of, 177 
Suggestion, 254-8 
Suicides, 185, 245 
Surgeon, the, 34-7, 42-4 
Surgery, improvements in, 31 
Surgical experience required, 


fees, 27, 49 

operations, 32, 265 

Sutton, Bland, viii., 81 
Swift, Dean, 273 
Syphilis, 54, 127, 128-9, 169, 

Thackeray, 290-4 
Thompson, Sir H., 270 
Tom fones, 272 
Trades, unhealthy, 209, 216 


Troll ope, Anthony, 294-5 
Tropical Medicine, School of, 

Tubercle bacillus, discovery of, 

Tuberculin, 10, 15, 39, 208 
Tuberculosis, 15, 124-5, i34-5> 
149, 159-60, 176-224 

clinic in Philadelphia, 30 

Typhoid, 8, 172-3 
Typhus, 176 

Universities, the, 20, 230-1 

Vaccination, 52-3, 145-6, 

Vivisection, 53-4 

von Pirquet, Dr, 198 

Wages, 106, 210-16, 218 
Walker, Norman, 243 
Walters, Dr R., 219 
Walther, Dr, 220 

Wanderers, 205 

Ward Richardson, B., 204 

Washington, Congress at, 196- 

200, 253 
Webb, Mr and Mrs Sydney, 

84, 298 
Weir Mitchell, 245 
Wesley, John, 45, 83, 273 
White, Dr, 278 
Whitefeather, Captain, 304 
Wilson, Dr Andrew, 15 

John, 231 

Woodhead, Sims, 198 
Workhouse Hospitals, see Poor 

Law Hospitals 
Workmen's Compensation Act, 

60, 83-8 
Workshops, 167-9, 1^4 
Wright, Almroth, 227 

X-ray work, 16, 39, 150 

Zangwill, Israel, 204 


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