The Development of the London Hospital System,
1823 - 2015
"Good education is amongst the rarest things going; difficult to buy at any price"
The Lancet, 1886
The medical schools which developed in London did so in close alliance with the great voluntary hospitals. Private schools attached to the larger hospitals also existed in the provinces, but outside London medical education tended to become an integral part of multi-faculty universities as soon as these developed, in close association with their science departments. In Europe the medical schools also developed within a university milieu. In London, however, the schools were firmly established before the creation of the University of London in 1836. In most cases the school was established after the hospital, and it always had a closer relationship with its allied hospital than with the University.
Medical training in London evolved from informal arrangements between the physicians and surgeons of the hospitals and potential students, occasional courses which had been held for many years in the endowed hospitals, and private anatomy schools which grew up near the hospitals towards the end of the eighteenth century. The Medical Calendar or Students’ Guide to the Medical Schools, published in 1828, said that the ‘medical schools of London are collected around the Public Hospitals. The lecturers are the Physicians and Surgeons of those Hospitals, and the Private Lecturers who have established theatres in the vicinity.1 Since William Hunter’s day it had been accepted that the education of a well-trained doctor should include a course of lectures on anatomy and dissection.2 More extensive instruction was required following the passage of the Apothecaries Act (1815) and those who did not hold a university degree were bound by law to take the licence of Apothecaries Hall if they wished to practice as a general practitioner or apothecary. The Society of Apothecaries laid down conditions of entry to its examinations and as well as having undergone an apprenticeship to an apothecary the student had to produce certificates of attendance at courses on anatomy, physiology, medicine, chemistry and materia medica. Surgery was not part of the examination. Private schools, established outside the walls of the hospitals, benefited from the subsequent demand for instruction and eminent men, or those rising in the profession, frequently held positions in them. Private schools were sited near one or other of the great hospitals. Thus the Graingers ran the Webb Street School near St Thomas’s and Guy’s, the Aldersgate School was near St Bartholomew’s, and the Windmill Street School was near the Middlesex. The schools’ reputations rose or fell as men like the Bells, the Hunters, the Graingers, Baillie or Marshall Hall joined or left the staff. The demand for bodies for dissection was considerable and until the Anatomy Act (1832) created a better and more equitable supply, the resurrection men plied a busy trade in central London cemeteries.
Increasingly, hospital governors allowed their own staff to take pupils and later assisted them by building dissecting rooms so that anatomy could be taught. The Charity Commissioners noted the use of the endowments for educational purposes, but thought on balance that the sick benefited from the presence of the school. The hospitals’ own schools were also private concerns. Students’ fees were often pooled and after expenses had been deducted the residue would be divided into shares of varying size and divided amongst the staff. The profit made up in some measure for the time the staff gave to their clinical duties, and in the case of the more renowned teachers the rewards could be considerable. The money also helped more junior staff to subsist until they had established their reputation.
By 1830 students were obtaining clinical experience in one or other of seven large hospitals which were open to students on payment of fees. From east to west they were The London, St Thomas’s, Guy’s, St Bartholomew’s, the Middlesex, the Westminster and St George’s. Lectures had been given at St Bartholomew’s and St Thomas’s for many years and their schools date from the middle of the seventeenth and eighteenth centuries. Gradually clinicians like William Blizard of The London came to recognise that a hospital with a medical school attached not only provided a better education but also increased in fame. The schools of The London and St George’s came into existence at the end of the eighteenth century. The Borough hospitals of St Thomas’s and Guy’s cooperated for many years as the ‘United Hospitals’ until an academic dispute in 1826 led them to go their separate ways. The Westminster established its school in 1834. The Middlesex, which had drawn its pupils mainly from the celebrated Windmill Street School, accepted students from University College when it was established in 1832 and the Windmill Street School closed. Finding itself unable to secure a permanent link with the Middlesex Hospital, University College set to work to build its own hospital, donating the ground required. Staff were recruited to the new hospital on the principle that the best man should win, and there was a considerable infusion of talent from other hospitals and other cities.
The supply of pupils at the Middlesex Hospital diminished and Sir Charles Bell, who was on the staff of both hospitals, petitioned the governors to allow the establishment of a medical school at the Middlesex, which opened in 1836. Charing Cross Medical School opened in 1834, when the hospital of which it was an integral part was rebuilt. King’s College, a religious antidote to University College training youth to revere ‘all that was great and good and solid in Church and State’, created its own medical faculty in 1832. Lacking a hospital at a time when Charing Cross was being rebuilt, King’s proposed an association in 1832, 1836 and again in 1837. Each time King’s was rebuffed because of the difficulties in reaching agreement between the various interested parties. Charing Cross would have benefited financially, for it would have gained the pupils’ fee and avoided a competitive institution in the Strand. However Charing Cross maintained that to unite two such youthful institutions would be a hazard to both, and that it would be a premature and dangerous experiment. The governors could see no benefit from an amalgamation which might have rendered it subservient to the objectives of another institution.3 An opportunity was therefore lost, at its very outset, to identify Charing Cross with university-based medical education, not from any lack of goodwill but from practical considerations. An alternative scheme, to transport students from King’s by steamer from Waterloo stairs to St Thomas’s also failed.4 King’s College, like University College, established its own hospital and chose staff from all quarters, although with some sectarian bias. Relationships with Charing Cross remained surprisingly good and several members of staff moved between the two institutions.
The older hospitals like Guy’s, St Bartholomew’s and St George’s were less inclined to appoint men who had trained elsewhere, and a family feeling was cultivated. Promotion was made easier for their own students, while at the new schools men could expect nothing more than a first-rate education and a fight to maintain their position against allcomers.5 Competition led to a rise in standards and the old order began to change. The hospital schools, ‘where science and practice are imparted under the same roof’6 improved in efficiency. In spite of their lower fees the private schools were slowly eclipsed, partly as a result of discriminatory regulations. The Royal College of Surgeons prohibited dissection in the summer term, a traditional time for attendance at private schools. R D Grainger, who ran Webb Street School, closed his establishment and moved to St Thomas’s as Dean. The changes in the medical schools were often announced in the introductory addresses at the beginning of the academic year.7 St Thomas’s, having experienced a catastrophic decline in the number of students registering in 1842, which led to a mass resignation of the staff, established paid lectureships and a hall of residence, ‘so that the hospital might not be behind any of the metropolitan schools.8 The introductory lecturer at St Bartholomew’s in 1847 pointed out that because of the improved state of medical education more labour was required of students than had previously been the case. Nevertheless, although the private schools were giving place to schools within the hospitals themselves, these were just as ‘private’ in finance and management as the institutions they were supplanting. The profit motive was equally evident amongst their staff.
The medical course
Until the establishment of the General Medical Council in 1858 the pattern of medical education was largely determined by the Society of Apothecaries and the Royal College of Surgeons - ‘College and Hall’. Students usually began their studies as apprentices to local practitioners, and most then came to London to attach themselves at moderate cost as pupils, or for a higher fee as dressers or ‘cubs’ to leading surgeons. On the wards, students picked up what they could in a practical way. Those who could afford the larger fee to be apprenticed to a hospital surgeon might assist the chief when he operated, see new patients first when he was out of the hospital and be on call for patients under the supervision of the resident medical officer or apothecary. The Lancet published an annual students’ guide each September and advised students not to select a school on the basis of its low fees or its imposing appearance. The earlier editions did not shrink from naming hospitals students would do well to avoid and made candid comments on the ability and the time-keeping of the lecturers. In 1834 The Lancet recommended St Thomas’s as a good choice, for ‘students were treated with the utmost liberality and clinical observations constantly heard in the wards were numerous and valuable'.9 Such information must have been most useful to students new to London, for their attention was drawn to new developments like the opening of University College’s North London Hospital, where for a time comparatively low fees were charged. To reduce the problem of travelling The Lancet advised students first to select a hospital and then attend lectures and a dissection room nearby, either one within the walls of the hospital chosen, or an adjacent private school where the fees would invariably be lower. It was a constant complaint that the medical staff of the London hospitals were not prompt for their rounds and extorted immense sums of money from students in the form of fees. Lecturers appointed by the Royal College of Surgeons benefited financially from the requirement for certificates of attendance at their lectures before examinations might be taken. Finals could consist of four viva voce examinations each lasting a quarter of an hour, a somewhat crude test of academic achievement.10 The College’s examiners were usually the ten oldest members of the Council, who received a major part of the fee of £22 paid by each candidate.11
There was a growing disenchantment during the 1820s about the powers enjoyed by the Royal Colleges and the Society of Apothecaries, which culminated in 1833 in a petition to the House of Commons. ‘Forty nine physicians of known reputation practicing in London including the heads of most of the medical schools of the metropolis’ asked for an enquiry into the state of the profession throughout the country with a view ‘to framing laws to remove existing evils and place the medical institutions of the country on a more liberal and equitable basis.’ The issue being raised concerned standards of medical education, by whom they should be laid down, what subjects students should be taught, who should teach them and how they should be examined. The absence of a degree-giving body for London, and dissatisfaction with the Royal Colleges and the older universities, led to a demand for reform. The reform movement affected the colleges, the medical schools, and after 30 years, led to the establishment of the General Medical Council in 1858.
The inquiry was established in 1833 as a Select Committee under the chairmanship of Mr Warburton* to inquire into the regulations and usages governing medical education and the practice of the various branches of the profession. Wakley saw the committee as an opportunity to put on public record the restrictive practices which placed control of teaching in a few hands, raised the cost of obtaining a medical education and militated against the interest of students, patients and the wider community. The medical establishment probably did not relish the publicity which resulted from the detailed and careful questioning of the committee. Still less could they be enthusiastic about the possibility of new legislation. However Wakley had been campaigning for ten years for reform and he relished the possibility that Parliament would abolish the privileges of ‘the monopolists’ of College and Hall.
The evidence revealed the influence of the three great ‘orders’ of the medical profession - the surgeons, the apothecaries, who combined the dispensing of medicine with the diagnosis of disease, and the physicians who, having been educated at Oxford or Cambridge, belonged to the learned world of the day.12 Senior members of each order were united in their resolve to maintain London’s pre-eminent place in medical education, but sometimes their power was used to exclude doctors of talent from positions of influence. Much of the evidence to Warburton’s committee was concerned with the detrimental effect of the division of the profession and the exclusive claims and rights of each group, but some witnesses were more worried about educational standards. They wished to see careful checks on the attendance of students at lectures and more adequate facilities like museums in the schools of anatomy. The witnesses were concerned about the clinical material available for teaching and while a few believed that with careful selection of patients only a few beds were required, most agreed with the President of the Royal College of Surgeons, Mr Guthrie, that schools needed at least a hundred beds. The recognition of the Westminster Hospital by the College had been questioned at one time as it was below this size but its excellent reputation in surgery and its status as the oldest subscription hospital in the country led to an exception being made. Nevertheless on its reconstruction in 1834 in Broad Sanctuary the hospital was enlarged. Charing Cross also had difficulty in obtaining recognition and was accused of filling its wards with invalids from the local workhouses on the day of inspection, it being too expensive to admit true patients.4 Dr James Clark, a Licentiate of the College of Physicians, felt that student education would be improved if there were more teaching rounds and more medical staff he also wished to see better patient records and statistical analyses of the hospitals’ work. Other witnesses suggested improvements in the preliminary scientific education of students, less emphasis on pharmacy and longer clinical attachments.13
The reform party had high hopes that Parliament would move to end abuses in the hospitals, the schools and the examination system, perhaps by establishing a central body to conduct a national examination. Their hopes were dashed. The government fell and the evidence, though it was published, did not lead to legislation. The exposure of the weaknesses of the system nevertheless provided fuel for the campaign and Warburton was himself the author of another medical reform bill in 1840.
There was great pride in the London medical schools. When Syme, after a brief and unhappy period as Professor of Surgery at University College Hospital, attacked the standards of the London teaching hospitals, a leading article in the Medical Times and Gazette pointed out that they brought to focus the great variety of cases which had baffled provincial doctors, and provided all the advantages which come from the association of clever men with each other. Students were attracted to London not by ancient universities ‘but by the practical opportunities which her charitable institutions afforded, and the experience which her esteemed practitioners had accumulated’. It was this experience which invested the private lecturer with the dignity of public professor.14 A German visitor, comparing London medical education with the schools in his own country, said it was ‘much more incomplete, far less intellectual, but nevertheless much more true and practical’.15
The Lancet continued to campaign for improvements in the educational system, for better clinical teaching, examinations at intervals throughout the course and for free admission to the practice of the hospitals.16 Matters began to improve and the University of London demanded proof of basic education before a student could begin to read for its degrees. The requirements for matriculation included chemistry, mathematics, a foreign language and English. The Society of Apothecaries also instituted a preliminary examination and ‘even’ the College of Surgeons introduced a test of classics and mathematics. 17 The establishment of the General Medical Council in 1858, on which the major professional organisations were represented, made it easier to modify the curriculum, but the new trends were already well established. The time spent on basic studies of doubtful relevance was cut and The Lancet rejoiced that students no longer had to study the dentition of the mastodon. More time was left for clinical work but The Lancet frequently criticised aspects of the syllabus. It disliked the emphasis on botany, a result of the influence of the Apothecaries, and rebuked the General Medical Council in 1863 when it was suggested that students should no longer be apprenticed to a general practitioner before starting their hospital work. The Lancet supported the claims of science and specialisation. ‘No case of illness is now admitted to a medical ward which does
not demand the careful use of the stethoscope, microscope and test tube in its investigation.’18 Later, in discussing the special hospitals, The Lancet proposed the establishment in the teaching hospitals of special departments in orthopaedics, ophthalmology and ear, nose and throat disease to ensure that the students’ education was complete.19
In an article of 1867, revealing new attitudes to scientific education, The Lancet contrasted methods of instruction based upon ‘questions arising out of the cause of disease’ with those relating to methods of cure. The English system placed the emphasis on the second approach. Students were called upon to ‘act’ before they ‘had been taught to know’. More attention was required to the laws of physical science, anatomy and chemistry, structure and function. Students should understand scientific principles; unfortunately ‘young men often aimed at being practical and were contemptuous of a more basic approach’, adopting the attitudes of some of their seniors. The Lancet epitomised the aim of continental education as the production of a ‘capable inquirer’, while the English system produced ‘a capable practitioner’. Neither alone was sufficient.20 It was a criticism to be repeated later by Flexner and the Haldane Commission.21,22,23 As chemistry and biology developed it became increasingly difficult for doctors waiting for a position on the staff to teach scientific subjects effectively. Schools began to employ permanent staff to undertake this duty, which increased their costs.
Although the hospital schools had emerged as the unchallenged centres of medical education they were not beyond criticism. In 1867 the Medical Teachers Association was formed by representatives of all but two of the London schools and John Simon became its first president and chairman. On taking office he delivered a stinging attack on the examination boards as then composed and the quality of the scientific work undertaken by the schools. The report he subsequently wrote on the present state and future needs of medical education in London showed him to be an educationalist of considerable stature. He urged the licensing bodies to bring their regulations into line with each other and to make them less minutely detailed and stringent. He did not believe it necessary to insist on attendance at systematic courses of lectures, ignoring other methods of study by which information might be gained. He believed that students’ progress should be assessed at regular intervals, subject by subject, to prevent last minute cramming. The schools themselves should be free to design the course best suited to their resources. Subjects ‘taught separately’ should be examined separately; examiners should not attempt to cover the whole range of medicine, but restrict themselves to subjects of which they had special knowledge. Finally John Simon drew attention to the incalculable importance of continuing education ‘far beyond the comparatively low point at which a standard of minimum qualification must be placed’.11
The formation of the Association stimulated debate about the improvement of the education system. John Simon’s advocacy of a better examination system was countered by Professor Richard Quain, Emeritus Professor of Anatomy at University College, who believed that improvements had to come from the colleges instead, because it was from leading teachers that improvements had always come and would always proceed. Dr Parkes, a member of the General Medical Council, published a detailed syllabus which he believed would improve the state of affairs.24 Introductory addresses at the beginning of the academic year also contained references to educational policy. Speaking at St Mary’s in 1870 the Dean commented on the waste of time, money and energy, which resulted from the attempt to teach pre-clinical sciences at so many medical schools. He advocated their amalgamation into two medical colleges with well-paid professors. Clinical instruction would continue at the great hospitals as customary.25 The Lancet believed that the Medical Teachers Association should consider such amalgamations because of ‘the absurdity and practical impossibility of carrying out scientific education in eleven establishments.’ Amalgamation would make it possible to teach the pre-clinical subjects better, providing chairs worthy of competition. Leaving aside Guy’s and St Bartholomew’s large schools which had refused to join the Medical Teachers Association and ‘had prejudices of long standing which would probably interfere with any scheme which might be proposed’, and The London which was too far to the east to fall into an easy relationship with any other hospital, The Lancet said there were eight schools to consider. They fell into northern and southern groupings. The northern group might include University College and the Middlesex which were half a mile apart and had already made coy overtures, St Mary’s which might be ready for change, augmented by the Royal Free Hospital (Gray’s Inn Road) and the Great Northern (Euston Road). The southern grouping would be more difficult because of the rival claims to pre-eminence of King’s College and St Thomas’s. St Thomas’s would be more convenient for the students of St George’s as it would be easier to get to the embankment than to the Strand.25
Increasingly the medical schools were having an effect on the clinical work of the hospitals to which they were attached. An anonymous correspondent in the 1840s protested that cases were abruptly rejected and dismissed by the great hospitals if they were not suited to the instruction of pupils.26 Bristowe and Holmes drew attention to the effects on the case-mix of ‘the desire of medical men educated at the school to place cases of interest, doubt or danger under the care of their former teachers; the desire of patients to come into a hospital served by men of celebrity; and the desire of able men to obtain cases which will afford an opportunity for the exercise of their skill, and will be a source of instruction for their pupils’. When a hospital had a large school the wards were more likely to be full and the cases more acute. Indeed wards in some hospitals might actually be shut during vacations for reasons of economy. Even the design of the hospital might reflect teaching needs. ‘So long as instruction is supposed to be afforded to students, and diagnosis and treatment not hindered by the medical officer making his visit to the patient at the head of a struggling crowd of from 50-100 students, it is necessary on this account alone that wards should be larger and beds widely removed. Fortunately so far the requirements of the school coincide with the requisites for healthiness' 27
The quality of the clinical experience London medical students enjoyed was a traditional source of pride. In his farewell address at St George’s, Timothy Holmes said that hospital practice should be the basis of all studies. To provide living illustrations was one of the chief functions of the great hospitals, and one of their most important benefits to the public’ ‘I had almost said their greatest’, he added as an afterthought.28
The complex relationship of the hospital and its medical school was summarised by Burdett who said:
‘Not only are the hospitals placed at the disposal of the authorities of the medical school for the clinical instruction of their pupils, but the two institutions are very largely manned by the same individuals, an appointment on the staff of the hospital very often carrying with it, by custom if not by by-law, some definite status in the medical school, and similarly the junior appointments in the medical school being very sure stepping stones to the medical and surgical staff of the hospital. The control and management of the medical school is often vested in the governing body of the hospital, and in nearly all cases in this country the financial relations between the hospital and the school are very close. The hospital is called upon to provide the proper facilities for the carrying on of the clinical teaching within its walls, involving the provision of larger out-patient rooms, operating theatre, lecture rooms and laboratory; and the other school buildings - theatre, classrooms, library, museum, laboratories etc., are either provided by the hospital authorities or built with money advanced to the school by the hospital.’ 29
This interaction was mutually beneficial. Although the prime object of the governors might be the care of the sick poor and of the medical school the instruction of pupils, the blending of interests was of great advantage to both. A teaching appointment attracted able men to the hospital and kept them there in spite of the increasing demands of private practice. Students acted as unpaid assistants and they would remain as junior staff, without pay, after qualification. Honorary staff might be more punctual for their rounds if students were waiting, and the time spent by students taking histories led to thorough care of patients and kept the senior staff on their toes.
It was customary to divide the voluntary hospitals into those with schools and those without. There was no doubt which was the first division. Hospital and school looked to each other. The University of London, examining only a few of the students, and teaching none, had little place in the close association of the hospital and its school.
*Henry Warburton (1787—1858), philosophical radical, MP 1826—1841. Selected by medical reformers as their advocate, he chaired the Parliamentary committee on the study of anatomy in 1828.
Peterson M Jeanne. The medical profession in mid-Victorian London. Berkeley, University of California Press, 1978.
Young Professor F G. The origin and development of the University of London, with particular reference to medical education. Appendix 14, Royal Commission on Medical Education 1965—8. Report. London, HMSO, 1968.Cmnd 3569.