1179

THE LANCET.

LONDON: SATTJRDAP,DFCEMBER 5, 1925.

MEDICINE AND MONOPOLY.Sir DONALD MACALISTER’S presidential address to

the General Medical Council1 usefully re-published oneelementary fact with which the medical profession ismore familiar than is the lay public. Whatever elseit may be, the medical profession is not a rigidlyprotected trade-union. There is a register of medicalpractitioners who, after certain years of prescribedtraining, have passed certain examinations and whomay be said to have pledged themselves to maintaincertain standards. In 1858, when the various branchesof the profession were united under one governingbody, Parliament created this system of registrationbecause it was " expedient that persons requiringmedical aid should be enabled to distinguish qualifiedfrom unqualified practitioners." But, with the twoexceptions of dentistry and midwifery, which SirDONALD MAcALiSTER mentioned, there is no

monopoly of practice in any of the healing services.We make no apology for elaborating this simplestatement of the legal position. No woman may,habitually and for gain, attend women in childbirth(except, of course, under the direction of a qualifiedmedical practitioner or in emergency) unless certifiedand enrolled under the Midwives Ace the prohibitionis backed by a fine of £10. No person (save forcertain obviously necessary exceptions) may practise,dentistry, unless registered under the Dentists Act;the prohibition is backed by a fine of £100. Butin creating the machinery of registration for medicalpractitioners Parliament has never said that no oneis to give medical or surgical treatment unless hisname is on the Register maintained by the GeneralMedical Council. The registered medical practitioner-has no more monopoly than the registered veterinarysurgeon. Exclusion from the Medical Register is notexclusion from practice.

Hence in the present state of the law, as SirDONALD MACALISTER reminded us, the man whosename is taken off the Register is as free to practiseas if he had not been registered and the publicis as free to employ him if they think fit. He

escapes the jurisdiction of the Council and, if hehas previously found difficulty in balancing himselfupon the border-line of the recognised professionalstandards which the Council exists to maintain, heis happier if that feat is no longer required of him.There are, it is true, certain limited privileges which theunregistered practitioner docs not enjoy. He cannot-hold a medical appointment in the Army or Navy orin public institutions. He cannot give a medicalcertificate of illness, injury, or death ; and he cannotprescribe a dangerous drug. If our countrymen thinkthese restrictions are unfair to the unregistered,Parliament can abolish them. Meanwhile we canonly repeat that, though a penalty awaits anyunauthorised person who extracts a tooth or attendsa woman in childbirth, nevertheless, in all other fieldsof medicine or surgery any person, whether registeredor not, may perform any sort of operation upon thehuman body without liability, provided that his

1 THE LANCET, Nov. 28th p. 1133.

ministrations do not result in such untoward conse-quences as to give rise to a charge of culpablenegligence. Even at this point, in the domain ofcivil and criminal liability for negligence, the lawmakes no difference whatever between the registeredand the unregistered practitioner, the qualified andthe unqualified. Probably judge and jury are morelikely to find that treatment has been unskilful ifadministered by an unqualified person ; to thatextent a plaintiff brings his action against an

unqualified person with better prospect of success

than against qualified doctors and surgeons ; butthis bias, for what it is worth, arises from an inferenceof fact and not from a principle of law.

Let it not be said, then, that the medical professionis a jealously preserved trade-union. Do other

! professions have to tolerate like liberty of competitionfrom unregistered practitioners 1 What opportunitiesof practice has the solicitor whose name is removedfrom the rolls of the Law Society What right ofaudience has the barrister who is disbarred by theInn which called him ? There must be many membersof the public who realise that more and not less

protection is needed in the sphere of medicine andsurgery. There must be many medical practitionerswho, when they see their practice invaded by theunqualified, marvel more at the impotence of theGeneral Medical Council than at the occasionalexercise of its power of removal from the Register.

THE MUSCULAR DYSTROPHIES.THE neurologist, perhaps more than any other

specialist in the profession, is often called on to dealwith diseased conditions not attributable to extrinsicmorbid action but to intrinsic, possibly congenital,defect. Among the groups with which he is concernednone is at once more simple of recognition and moredifficult of treatment than that of the muscular

dystrophies. Clinical classification and descriptionare doubtless essential as a step towards the problemof aetiology and of treatment, but in respect of thisparticular class of case they have not taken us veryfar. The essential clinical features of the majorityof the dystrophies have been familiar for half a

century, and although difference of opinion stillexists as regards their interrelation we are not likelyto reach any rational conception for treatment, fromclinical considerations alone. Nor, regrettably, canwe rely with confidence solely on the observations ofthe histo-pathologist, for he handles dead material,muscular cicatrices from investigation of which itis well-nigh hopeless to expect the deduction of anydata concerning incipient morbid action. The end-results of the myopathies and of the myelopathies,as far as the histological picture of the muscle substanceis concerned, are for practical purposes not to be

distinguished. Even when recourse is made to biopsy,microscopical examination reveals a pathological statebut not a morbid process, while the interpretation ofthe actual tissue findings is not a little difficult.

It is not to be wondered at, therefore, that dis-satisfaction with mere clinical description and withthe limitations of morbid anatomy should lead theneurologist who has imaginative curiosity to tacklethe problem of the muscular dystrophies from otherviewpoints. Prof. EDWIN BRAMWELL, whose Bradshawlecture on this subject appeared in our columns lastweek, is to be congratulated on breaking away fromneurological commonplaces and on his ingenious andsuggestive endeavour to find an aetiological basis forthese myopathic degenerations in disorder of the