2. Sources

Few records of English postgraduate study in the years before the First World War have survived. The best ways to examine postgraduate study are through articles published in the medical press, testimony given before official enquiries and small collections of surviving archival material pertaining to various postgraduate institutions.

The RCVD and the RCUEL contain valuable information about postgraduate study that is not available from other sources. As with accounts of postgraduate teaching published in journals such as the British Medical Journal, testimony given before these commissions contextualises the knowledge claims disseminated among postgraduates at the MGC. Yet witnesses also offered contradictory testimony about the structure, availability, popularity and professional benefits of postgraduate study. When asked about the educational opportunities available to older practitioners, Dr J.S.R. Russell of University College Hospital and Representative of the Royal College of Physicians asserted that there were ‘so many postgraduate courses now … [that] they are only too glad to avail themselves of them’.Footnote ¹⁹ By contrast, D’Arcy Power, surgeon to St Bartholomew’s Hospital, testified that older practitioners who were not abreast of current medical knowledge had little opportunity to undertake postgraduate study.Footnote ²⁰ Both witnesses were lecturers at the MGC and would have appreciated the popularity and effectiveness of postgraduate education. Their divergent opinions are reflective of the fact that postgraduate study was an embryonic and experimental addition to the landscape of medical education and practice.

The structure of the MGC was based upon the London Postgraduate Course (LPC) but apart from a few references in the medical press there appear to be no surviving records of this earlier institution. There are similarly few records of the postgraduate work offered at special institutions such as the London School of Clinical Medicine (LSCM) or St Paul’s Hospital as well as larger general hospitals such as the London Hospital.Footnote ²¹ Other postgraduate institutions also offered comprehensive schemes of study but unlike the MGC few records of this teaching appear to have survived.Footnote ²² These smaller collections of sources supplement discussion here of the work conducted at the MGC.

The MGC was unique among postgraduate institutions in its monthly publication of a journal that was intended as a record of its extensive series of clinical consultations and lectures. This record of teaching extends up to the First World War. As Claire Jones observes, historians have given little attention to how practitioners used medical publications as a means of refreshing or expanding their knowledge.Footnote ²³ Prominent medical men regularly published accounts of interesting and instructive venereal cases brought before postgraduates. The Polyclinic is an invaluable source for understanding the MGC’s organisational structure and teaching objectives as well as the structure and development of postgraduate education more broadly. Its extensive collection of venereological articles offers historians valuable information about the ways that orthodox and innovative knowledge claims were disseminated.

However, surviving records do not offer breakdowns of attendance at individual lectures and demonstrations. We cannot accurately chart the popularity of classes devoted to the study of venereal diseases. The frequency with which articles pertaining to venereal diseases appeared in the Polyclinic suggests that large numbers of venereal cases were brought for examination and demonstration. That venereological lectures and demonstrations continued to be held suggests that there was ongoing demand for such instruction. Unfortunately, the expense of postgraduate study and the fact that it was primarily based in London meant that many general practitioners elsewhere in Britain would not have been able to afford to attend in person. The Polyclinic therefore functioned as a supplementary educational tool for subscribers who attended courses, or as a total educational substitute to actual attendance. As helpful as it may have been, the Polyclinic could not wholly compensate for the absence of practical instruction.

It is also difficult to determine how general practitioners were able to apply the knowledge acquired from postgraduate study in the diagnosis and treatment of their patients. Although practitioners paid fees to attend courses, there was little compulsion to persist with such training. Nor were practitioners required to demonstrate a level of attained knowledge upon the completion of these courses. We may know the types of knowledge claims disseminated among general practitioners but, in the absence of formal examinations, it is difficult to determine whether they retained and utilised this knowledge.

3. Structure and Facilities of the MGC

Premises for the MGC were secured close to University College Hospital, the London School of Tropical Medicine, and the Royal Society of Medicine and included consultation rooms as well as facilities for demonstrations, lectures and practical classes.Footnote ²⁴ A subscription also gave practitioners access to the MGC’s reading room, library and museum. The latter housed Jonathan Hutchinson’s extensive collection of medical prints, anatomical models, photographs, instruments and specimens, much of which pertained to his special interest in venereology.Footnote ²⁵ For an additional fee, practitioners could also utilise the MGC’s clinical and pathological laboratory.

The MGC offered facilities for practitioners to perform their own tests as well as a limited number of diagnostic services. Practitioners could send samples for analysis. Gonococcal testing at 3s.6d. was modest compared to other pathological services, such as that for the bacteriological diagnosis of diphtheria at a cost of 5s.Footnote ²⁶ By 1914 laboratory services at the MGC also included the serodiagnostic Wassermann reaction at a cost of £2.2s., as well as urine analysis to determine the ‘presence of arsenic’ resulting from salvarsan treatment for syphilis. Accompanying this updated list of diagnostic services were instructions for the collection of samples: when performing the Wassermann reaction ‘much more blood is necessary. Half fill a Wright’s capsule or collect about thirty drops in [a] narrow test tube (Special tubes supplied on application.)’ and for subscribers unable to attend the MGC ‘containers for the dispatch of specimens through the post [could] be obtained on application’.Footnote ²⁷ Having been introduced in lectures to the theory and effectiveness of Gram staining and the Wassermann reaction, it was hoped that general practitioners would embrace these new technologies and utilise the MGC’s diagnostic services. However, as observed by Michael Worboys and argued by L.W. Harrison in his testimony before the RCVD, bacteriological testing was often prohibitively expensive.Footnote ²⁸ It is unclear how frequently the MGC’s diagnostic services were utilised but the expense, in addition to subscription fees, probably made these services unaffordable, especially for use on a regular basis.

The seven founders of the MGC held posts at various hospitals and were considered authorities in their different specialisms. Most had venereological experience even if it was not their primary discipline. The President, Sir William Broadbent, brought several cases of locomotor ataxia and general paralysis before postgraduates at the MGC. James Cantlie held posts at the Seamen’s Hospital Society, the London School of Tropical Medicine, and Charing Cross Hospital, all of which would have brought him into contact with venereal diseases. He lectured to student-practitioners on venereal diseases and was appointed to the MGC’s standing committee of investigation to examine any potential aetiological relationship between yaws and syphilis. Malcolm Morris was a respected consulting surgeon and dermatologist at St Mary’s Hospital who worked closely with Hutchinson and also lectured on venereal diseases at the MGC. He campaigned strongly for an inquiry into venereal diseases and was a commissioner to the RCVD. Arguably the most influential of the college founders was Hutchinson, who was also one of England’s leading venereologists. As co-founder, council member, chairman, editor of the Polyclinic, one-time president, regular lecturer and significant financial benefactor, he was instrumental in the MGC’s establishment, organisation and teaching. His involvement certainly influenced the level of attention given to venereal diseases in various courses at the MGC and in the pages of the Polyclinic. Venereology continued to figure prominently after his resignation as editor in 1903, and even after his death in 1913, suggesting that venereal diseases were of ongoing concern and interest to a wide cross-section of lecturers and postgraduates.

By the 1890s the majority of medical staff belonging to London general hospitals also held appointments at various special hospitals and postgraduate colleges where their specialist knowledge could be developed and employed in the treatment of patients and the teaching of students.Footnote ²⁹ The MGC enjoyed the support and scholarly contributions of many elite medical figures. They were respected authorities in their different fields and would have brought prestige to the fledgling college. Between 1899 and 1905 at least thirty-three practitioners with specialist interests in dermatology, laryngology, ophthalmology, pathology, psychiatry, neurology, and obstetrics and gynaecology lectured at the MGC on the subject of venereal diseases. Among these men were William Osler, the Regius Professor of Medicine in Oxford, who wrote authoritatively on a variety of medical and social issues relating to venereal diseases. Neuropathologist, Sir Frederick Mott, and psychiatrist, George Henry Savage (physician superintendent and later governor of Bethlem Royal Hospital), both lectured on neurological conditions associated with tertiary-stage syphilis. Ophthalmologists, Marcus Gunn and Sydney Stephenson, lectured on syphilitic conditions of the eye. Gunn was a surgeon at Moorfields and Stephenson was an authority on gonorrhoeal ophthalmia neonatorum. James Sequeria was an authority on the dermatological manifestations of syphilis and James Ernest Lane was surgeon to the London Lock Hospital. When delivering lectures at the MGC these practitioners drew heavily upon their own extensive experience and knowledge as well as the research of medical contemporaries. Their diverse collection of specialisms indicates an understanding of venereology as multifaceted and best addressed not as a self-contained specialism, but within a variety of associated disciplines.

Many who lectured at the MGC were also involved with the teaching of undergraduate medical students at their respective hospitals. They would have appreciated the limitations of undergraduate venereological training. The content of most lectures given at the MGC assumed a working knowledge of common symptoms, modes of transmission and methods of treatment. Chancres, rashes, discharges, genital sores and the Hutchinsonian triad of interstitial keratitis, notched teeth and middle ear deafness were among the common symptoms of acquired and congenital infection.Footnote ³⁰ Lecturers built upon this knowledge by offering detailed study of specific venereal conditions such as tabes dorsalis. They emphasised the obscurity and multiplicity of symptoms and conceptualised these symptoms within a wider theoretical framework. Although lecturers assumed a certain degree of knowledge among postgraduates, they were also aware of the gaps in their knowledge. Conditions such as tabes dorsalis were difficult to diagnose accurately and link aetiologically to an underlying syphilitic infection.Footnote ³¹ These were the types of challenging venereal cases that occupied lectures and demonstrations at the MGC and filled the pages of the Polyclinic. That greater attention was given in the pages of the Polyclinic to more uncommon or ambiguous symptoms and conditions suggests that these were more likely to have been overlooked or misdiagnosed and therefore required further clinical study.

4. Consultations at the MGC

Subscribers with instructive cases under their medical supervision were encouraged to contact the Medical Superintendent in order to arrange for these cases to be presented for consultation. Letters of recommendation were required from the family practitioner, as was a declaration that the patient in question was suitably ill and impoverished, and therefore deserving of gratis consultation. In September 1900 the MGC offered 17 consultations at which 87 patients were ‘presented for advice’.Footnote ³² By the end of that year 1027 patients had been received for consultation.Footnote ³³ The MGC’s system of referral reflected a wider trend in professional practice. Stevens argues that a system of referral was well established among practitioners by the turn of the twentieth century. General practitioners who had insufficient knowledge or experience to treat particular cases could seek a second opinion. One contributor to the Polyclinic lamented that for most poor patients where ‘further assistance is desired the home practitioner can but say, “you had better go to a hospital”; and he knows … that he must forego all further interest in his patient’.Footnote ³⁴ This account reflected long-standing concerns among general practitioners that they were losing patients to the hospitals.Footnote ³⁵ The MGC’s system of referral, although based on this wider model, allowed general practitioners to retain their cases. It allowed them to receive information about the nature of a patient’s condition whilst giving consultants access to difficult or interesting cases that fell within their field of special interest.Footnote ³⁶

There is little indication of any pattern in the referral or acceptance of patients for consultation. Articles and abstracts in the Polyclinic suggest that there was a steady supply of venereal cases. Some patients were referred because their illness was suitably interesting and edifying to postgraduates. In other cases the referring practitioner sought a second opinion or wanted to improve their knowledge in a particular field. Fletcher Little explained during the first meeting of governors ‘that a patient would be simply seen, examined, and demonstrated, but the diagnosis and scheme of treatment would be supplied only to the medical man’.Footnote ³⁷ The patient was presented to attending postgraduates who, guided by the lecturer, discussed the nature of the patient’s history and symptoms, the method of diagnosis, and the most effective means of treatment. Some of the more perplexing or unusual cases warranted return visits to allow postgraduates to chart either the patient’s deterioration (in untreatable and degenerative cases such as locomotor ataxia) or their improvement under a prescribed treatment regime.Footnote ³⁸ According to Theodore Williams, the value of the MGC was not only in the volume of cases seen each year but also the manner in which these cases and accompanying medical knowledge were conveyed. The postgraduate was able to ‘ask questions and examine the patients for himself’.Footnote ³⁹ The open discussion that often followed offered postgraduates an opportunity to seek clarification or elucidation on various aspects of the case.

Historians and sociologists of medicine have written extensively upon the use and importance of case histories in the development and dissemination of knowledge.Footnote ⁴⁰ As Ivan Crozier observes, case histories transformed subjective experiences of illness into statistically regular and medically comprehensible data.Footnote ⁴¹ Practitioners at the MGC sought to make venereal conditions understandable through the presentation of cases and the keeping of case histories in which they described and categorised symptoms. However, such practices have been criticised for their objectification and subjugation of the patient in favour of a reductionist approach to the disease process.Footnote ⁴²

Despite such problems, case histories have long been central to the study and practice of medicine. They exposed students to common and uncommon symptoms, as well as the most appropriate diagnostic and therapeutic practices. These cases were both contextualised by, and instrumental in developing medical knowledge.Footnote ⁴³ Cases presented for consultation at the MGC conformed to this theoretical and educational framework. They offer important insight into the knowledge and values of postgraduates and the practitioners who lectured to them.

5. Cross-Institutional Co-operation and Hospital Affiliation

Postgraduate colleges did much to refresh their students’ knowledge and introduce them to new ideas and practices but they were nonetheless faced with a constant shortage of instructive clinical material.Footnote ⁴⁴ The MGC was not equipped to accommodate inpatients or provide ongoing medical care and supervision. The Polyclinic was normally optimistic in its estimation of the popularity and efficacy of clinical classes. Yet the editor was aware that the supply of cases upon which these classes relied was in turn dependent upon the co-operation and enthusiasm of subscribers. Unlike the WLH, which offered inpatient care and, by extension, a steady supply of clinical material for the practical instruction to its postgraduates, most cases brought for consultation at the MGC were drawn from the private practices and hospital work of its lecturers and postgraduates. The majority of lectures, clinical demonstrations, practical classes and laboratory work was conducted on the MGC’s own premises and with little cross-institutional co-operation.

The MGC was therefore eager to establish professional links with metropolitan hospitals and medical schools, thereby making available to its postgraduates the wealth of clinical cases in wards and outpatient departments. Unfortunately, several of the larger teaching hospitals declined the MGC’s offer of affiliation. This reluctance was, according to the Polyclinic, due to the fact that these hospitals already accepted undergraduate students and could not adequately accommodate postgraduate study.Footnote ⁴⁵ As George Weisz correctly observes, the comparative lack of teaching staff and resources in English medical schools meant that opportunities for specialist study, particularly specialist postgraduate study, were scarce.Footnote ⁴⁶ In 1906 Hutchinson, in his capacity as a member of the Medical Council of the London Hospital, recommended that ‘formal teaching to postgraduates on patients in the wards or in the outpatient department to the exclusion of [the hospital’s] own students [to be] … undesirable’. A ‘system of supervision over … extra students attending any of the departments of the hospital’ was established but even Hutchinson, despite his competing interests in the MGC, continued to privilege the educational needs of undergraduates above those of qualified practitioners.Footnote ⁴⁷

Various practitioners involved with postgraduate teaching stressed the need for specially tailored classes that were separate from those of undergraduates but the practicalities of such arrangements in teaching hospitals were often problematic.Footnote ⁴⁸ The MGC’s demand that prospective affiliates provide separate and specially tailored classes undoubtedly contributed to the reluctance of institutions to accommodate postgraduates. This lack of co-operation raises questions about the efficacy of the teaching programme offered by the MGC. Although the Polyclinic remained optimistic about the MGC’s ability to maintain a steady supply of clinical material, the majority of venereally diseased patients whose circumstances would have entitled them to gratis consultation continued to gravitate towards hospital outpatient departments and Poor Law infirmaries. Although the MGC continued to offer important opportunities for clinical instruction, postgraduates at the MGC were unlikely to have enjoyed access to the larger selection of clinical material available at established teaching hospitals.

Co-operation was sought from hospitals that were not affiliated with medical schools – an approach that Bidwell considered more appropriate for postgraduate teaching.Footnote ⁴⁹ At a Council meeting in July 1900, the Seamen’s Hospital Society was added to the list of potential affiliates.Footnote ⁵⁰ In October Guthrie Rankin proposed that the Metropolitan Asylums Board Hospitals, the West London Hospital, the Lock Hospital Soho and Bethlem Royal Hospital be included in the MGC’s ‘scheme of Hospital Association’.Footnote ⁵¹ Nevertheless, as Newman argues, special hospitals continued to have a minimal role in postgraduate education.Footnote ⁵² It appears that the London Lock, Bethlem and the Asylum Hospitals declined the invitation to affiliate. The Seamen’s Hospital Society was already affiliated with the LSCM and the WLH offered its own ‘well-organised and successful postgraduate scheme’.Footnote ⁵³

It was hoped that other institutions would prove more amenable thereby securing ‘very excellent opportunities for clinical observation to all postgraduates who may join us’.Footnote ⁵⁴ By the end of 1900, ten general and special hospitals including the Dreadnought Hospital Greenwich, Victoria and Albert Dock Hospital, the Evelina Hospital, the Westminster Ophthalmic Hospital and Blackfriars Hospitals that specialised in skin diseases had ‘expressed a favourable compliance with the broad outlines of [the MGC’s] scheme’ and by January of the following year it had begun to take effect.Footnote ⁵⁵ The Polyclinic advised its readers that ‘gentlemen … waiting for hospital opportunities can be put in touch with whatever class of bedside work they require by applying at the Superintendent’s office’ where a list of these affiliated institutions could be obtained.Footnote ⁵⁶

6. Subscriptions, Attendance and the College Journal

The MGC published annual subscription numbers and monthly attendance figures that probably recorded multiple attendances by some subscribers whilst others did not attend at all. The total number of original members was quoted as 535 in 1899.Footnote ⁵⁷ Subscriptions fluctuated over the following decade with 731 subscribers in 1903, 712 in 1906, 637 in 1909 and 681 in 1912.Footnote ⁵⁸ In January and February of 1900 the MGC recorded average weekly attendances of 230 practitioners.Footnote ⁵⁹

Although total monthly attendances continued to increase, successive fee reductions throughout 1900 suggest that the College did not attract the levels of professional interest initially anticipated. Annual subscriptions for non-resident practitioners were reduced to one guinea (compared to the two guineas charged to those ‘as reside in the London division of Churchill’s Directory’).Footnote ⁶⁰ Most subscribers were drawn from the greater London area but a sizable minority were based in other English cities and as far away as Bombay and New South Wales.Footnote ⁶¹ Fees were soon changed again in order to equalise resident and non-resident subscriptions at one guinea. The Council was ‘doubtful whether in reality [the London practitioner had] actually taken anything like such full advantage of his opportunities as it was thought he might do’. It was hoped that such a reduction would alleviate financial pressures by increasing subscriptions among those who had hesitated ‘to commit themselves to an annual burden of two guineas’.Footnote ⁶² Yet several years after the equalisation of fees (which were described as ‘too indiscriminately low’) contributors to the Polyclinic still lamented that ‘the advantages and opportunities offered … [were] far from … widely known’.Footnote ⁶³ These respectable but comparatively small subscription numbers reflected the fact that postgraduate study, although gaining popularity, had yet to become a fully integrated stage in English medical education and professional advancement.

Terms of subscription included free monthly delivery of the Polyclinic. For subscribers who attended classes, the journal acted as a record of, and supplement to, practical venereological study. For those who could not attend classes, the write-up of select lectures and unusual cases was intended to provide some exposure to contemporary medical knowledge and practice. The journal functioned as a substitutional, rather than supplementary educational tool and as such its efficacy was limited. The fact that non-resident practitioners were unable to examine patients, engage in professional discussion or make regular use of the MGC’s laboratory significantly hindered attempts to improve their venereological knowledge.

The Polyclinic offered contradictory estimations of the quality of its own articles. According to Rankin, the journal was

Hutchinson similarly asserted that articles were intended as ‘instructive commentary upon [the College’s] consultation work’ which, it was hoped, would ‘afford to those … who may not be able to attend regularly or perhaps not at all, as good a substitute as printed material can be for actual observation’.Footnote ⁶⁵ Yet despite his editorial enthusiasm, even Hutchinson acknowledged the educational limitations inherent in a reliance upon written information as a total or even substantial substitute for practical study. Of the large volume of patients presented at the MGC each month, only ‘the more important cases’ were written up for publication. Many of these articles were considered to be ‘mere fragments of narratives without endings’.Footnote ⁶⁶ As early as 1901, it was regretted that only ‘a small portion’ of the cases presented for consultation ‘found adequate record’ in the pages of the Polyclinic.

Even detailed write-ups of cases and lectures were limited in their didacticism by the simple fact that they lacked the visual stimulus and stimulating discussion that accompanied clinical classes. They provide a good indication of common misdiagnoses and forms of treatment prescribed to venereally diseased patients. However, given the potential for the misdiagnosis of uncommon or obscure symptoms, a lack of practical experience placed the absentee student at a significant disadvantage.

Despite its limitations as a substitute for practical instruction, much can be gained from considering the Polyclinic as a means of disseminating venereological knowledge. Practitioners could write to the editor for advice on difficult cases. The Polyclinic was a valuable forum through which readers could correspond and receive answers to clinical conundrums. In 1900 one correspondent delivered an apparently healthy child of a woman with a clear indurated syphilitic chancre. He asked if he should also treat the child with mercury. The correspondent was advised to ‘better wait events’ since ‘the child may not improbably have escaped’. They were also reminded to ‘forbid the mother to nurse her child and in warning her as to the danger of infecting it’.Footnote ⁶⁸

The Polyclinic regularly included articles and editorial correspondence on the subject of venereal diseases. Cases recorded in the Polyclinic often adhered to the same schematic format. The lecturer or writer offered an overview of the patient’s medical history and occasionally brief reference was made to the patient’s own account of illness. Symptoms were documented and the difficulties of diagnosis were raised. A final diagnosis was made and the case concluded with a discussion of the most efficacious form of treatment. The Polyclinic was not unique in its write-up of instructive cases. Articles were regularly published in the wider medical press on cases presenting various manifestations of venereal diseases. What made the Polyclinic unique was the regularity and detail with which accounts of venereal cases were published and the fact that these accounts were regularly accompanied by practical instruction. Most articles on the subject of venereal diseases dealt with only one or two specific symptoms. Yet when considered collectively, the great volume of material published between 1899 and 1914 offers an overview of important developments in venereology. Rankin described the extensive series of cases of tabes dorsalis presented to postgraduates and written up for publication as ‘a valuable clinical exhibition of the various aspects in which the disease may present itself to the physician’.Footnote ⁶⁹ These cases offered important clinical experience and provided a holistic framework thorough which to consider orthodox understandings and new ideas regarding the aetiology, diagnosis and treatment of venereal diseases as manifested through different morbid conditions.

7. Teaching at the MGC

As outlined in the first issue of the Polyclinic, the MGC’s timetable of clinical demonstrations, lectures and practical classes were intended to facilitate the dissemination of current medical knowledge and practice and to stimulate discussion of various subjects of special interest. Specialists drew upon their own experience and specialist knowledge as well as such research as that conducted by Mott at the London County Council Pathological Laboratory at Claybury Asylum.Footnote ⁷⁰ By 1903 the MGC also offered annual courses of composite lectures that, unlike normal lecture series, were designed to encapsulate current medical orthodoxies.

Accounts in the Polyclinic suggest that venereological instruction remained popular. In 1900 Hutchinson’s lecture on ‘The Present-Day Treatment of Syphilis’, had ‘proved so attractive that it had been found necessary to call into acquisition the larger accommodation of the combined library and consultation rooms’.Footnote ⁷¹ The initial decision to offer classes in the diagnosis and treatment of venereal diseases represented an attempt to fill a perceived gap in medical knowledge. That each volume of the Polyclinic contained a comparatively high proportion of articles devoted to the various aspects of venereal diseases suggests that the MGC was responding to healthy attendance rates and an ongoing desire among practitioners to receive venereological training.

Demand was sufficiently high to warrant the introduction in 1914 of a special course of practical classes devoted to the diagnosis and treatment of venereal diseases.Footnote ⁷² The identification of the spirochaete in 1905, and the development of the Wassermann reaction in 1906 and salvarsan in 1909 had revolutionised venereology during the preceding decade. These rapid diagnostic and therapeutic developments, along with the establishment of the RCVD in 1913, probably influenced the decision to run what appears to have been the first systematised pedagogic approach to venereological instruction among postgraduates. However, it is difficult to draw definite conclusions about the educational benefit derived from these courses and to determine how postgraduates applied their newfound venereological knowledge in clinical practice.

Compared to the fragmented treatment of venereology at an undergraduate level, the MGC provided a more systematised, if not an entirely coherent, theoretical approach to venereology. Venereal cases were regularly brought before postgraduates as examples of ophthalmic, dermatological, neurological, antenatal or genito-urinary conditions. In the years following the establishment of the MGC, a course of six clinical lectures in ‘General Ophthalmology’ frequently included an entire lecture on ‘syphilitic affections of the eye’. The course in ‘Comparative Pathology’ included a lecture on ‘Diseases of the Genito-Urinary Organs’ in which syphilis often figured prominently. The course of lectures in ‘Practical Biology’ held in association with King’s College offered practical laboratory-based experience in the diagnosis of diseases including syphilis.

Teaching at the MGC reflected a transitional period in the conceptualisation of conditions such as venereal diseases. Its approach remained, in some respects, pre-theoretical. As in undergraduate study, symptoms were conceptually and diagnostically compartmentalised within specialist disciplines such as dermatology and ophthalmology. Lecturers relied upon traditional observational, diagnostic and therapeutic practices that delineated symptoms according to the bodily structure or function affected. As at an undergraduate level, venereology did not constitute a single field of study. Yet despite such apparent compartmentalisation, the specialist study of conditions such tabes dorsalis suggests that postgraduates at the MGC were slowly being encouraged to consider individual cases or specific symptoms within a wider theoretical and pathological framework.

In 1900 the Polyclinic claimed that practitioners commonly made the mistake of expecting the ‘full roll [sic] of phenomena’ to be present in every case. Chancres may escape observation and characteristic secondary-stage ulceration of the tonsils may never appear. Characteristic sores and rashes might be so faint as to avoid accurate diagnosis.Footnote ⁷³ If this was indeed the case then large numbers of practitioners were potentially misdiagnosing those patients whose symptoms did not correlate to the full list of characteristic indicators. Reliance upon the presence of all common symptoms in order to make a diagnosis of syphilis demonstrated a fundamental lack of venereological knowledge. Lecturers at the MGC emphasised the importance of not expecting an assortment of common symptoms and attempted to teach practitioners to make accurate diagnoses based on what might be only one or two obscure symptoms such as ocular paralysis.

The objective was to diagnose, treat and alleviate the discomfort caused by specific morbid conditions such as ocular paralysis that was identified as a symptom of tabes dorsalis. Yet lecturers also stressed the importance of such symptoms as indicators of a current or past venereal infection. Practitioners needed to be able to distinguish between a localised ophthalmic condition and an early indicator of tertiary-stage syphilis. Tabetics experienced slow deterioration of the spinal cord nerves that carried sensory information to the brain. Apart from the visual impairment brought on by ocular paralysis, symptoms could also include diminished reflexes, inco-ordination and unsteady gait, sporadic sharp pains throughout the body, personality changes, dementia, deafness, rectal crises and sexual dysfunction. These symptoms were demonstrated in the cases brought for consultation at the MGC. As Gayle Davis observes, many of the symptoms characteristic of neurosyphilis were not unique to venereal infections and could have been easily misdiagnosed when relying upon observational practices.Footnote ⁷⁴ Nor could these symptoms often be easily linked to syphilis. There was normally an extended interval between an identifiable syphilitic infection and the manifestation of tabetic symptoms. Furthermore, not all syphilitics appeared to develop tertiary-stage infection and those who did may have presented symptoms such as cutaneous gummas that were seemingly not linked to, or accompanied by, neurological dysfunction.Footnote ⁷⁵ As early as 1889 the respected neurologist, William Gowers, observed that mercury was unable to reverse the tissue damage brought on by tabes dorsalis and common syphilitic treatments therefore had little diagnostic significance.Footnote ⁷⁶ Tabes dorsalis was therefore of particular interest to postgraduates because it was diagnostically and therapeutically challenging and because, in the years before use of the Wassermann reaction became widespread, its venereal aetiology remained a subject of debate.

As Mott observed in his lecture, ‘On the Early Signs and Symptoms of Tabes and General Paralysis’, a person in the early stages of either disease would present themselves for the treatment of one of many otherwise obscure symptoms.

Harry Campbell similarly stressed the challenging nature of tabes by bringing before postgraduates two cases in which diagnoses were hampered by the fact that optic atrophy was the only symptom experienced by each patient.Footnote ⁷⁸ As Gowers reminded postgraduates, ‘almost every common symptom of a morbid state is sometimes absent’.Footnote ⁷⁹ Postgraduates were therefore encouraged to familiarise themselves with diagnostically challenging physiological ‘modes of onset’ so that they might recognise an underlying venereal infection.

The rise of germ theory and laboratory-based medicine gave currency to the idea of micrococcal specificity. However, as Davis observes, before the identification of the spirochaete and the development of the Wassermann reaction it was difficult to identify the exact pathological cause of tabes dorsalis.Footnote ⁸⁰ It may have been identified as a specific disease entity but practitioners spoke with varying degrees of certainty about its aetiology. Discussion instead focused upon symptomatology. Throughout the 1880s suspected cases of tabes dorsalis were discussed in the medical press in terms of their characteristic, unique or diagnostically challenging symptoms. Practitioners had begun to discuss the pathology of tabes dorsalis but this discussion rarely extended beyond the post-mortem identification of irregularities such as sclerosis of the posterior columns of the spinal cord. During the final decades of the nineteenth century a conclusive diagnosis was only thought to be obtainable through post-mortem examinations that allowed clinicians to identify a series of internal physical changes that correlated with physiological changes observed in the living patient.Footnote ⁸¹ The micrococcal aetiology of these changes was rarely addressed with any certainty or in any detail. In 1889 Gowers conceded that, although he strongly suspected the role of a causative syphilitic micro-organism in the development of tabes dorsalis, he could not draw any definite conclusions.Footnote ⁸² In his 1903 lecture on ‘Syphilis of the Nervous System’, delivered at the MGC, he continued to focus upon pathological changes without speculating upon the micrococcal cause of such changes.Footnote ⁸³

The MGC provided practitioners with a forum in which to discuss difficult aetiological, diagnostic and therapeutic questions surrounding conditions such as tabes dorsalis. Although lectures given at hospitals and at institutions such as the Medical Society of London also acted as channels through which to disseminate specialist knowledge, there is little indication that general practitioners were frequently in attendance.Footnote ⁸⁴ Similar lectures given at the MGC were important not only for their detailed and specialised content but also for the fact that they catered primarily to the educational needs of general practitioners.

Among the diagnostic practices regularly taught to postgraduates at the MGC was the examination for, and identification of, ocular paralysis. In 1900 Hawthorne presented three cases of ocular paralysis and gave detailed demonstrations of the examination process through which to arrive at an early and conclusive diagnosis. The size and shape of both pupils must be examined. The light response in each eye should be tested and the contraction of each pupil noted in order to determine whether the patient had developed the characteristic Argyll-Robertson pupil. ‘In order to secure an accurate conclusion as to the condition of each pupil light reflex, each pupil must be alternately shaded and exposed to light, the other eye during the examination remaining covered.’Footnote ⁸⁵ Hawthorne argued that the ‘existence of ocular paralysis … must always give rise to a suspicion of syphilis’ and be considered ‘very frequently the first evidence of serious organic disease of the central nervous system’.Footnote ⁸⁶ Such lectures offered postgraduates opportunities for detailed study of a single but diagnostically significant symptom of tabes dorsalis. They laid out in great detail the clinical process through which practitioners could confidently arrive at a correct diagnosis of ocular paralysis that could in turn indicate the onset of tabes dorsalis.

In January 1910 J.E.R. McDonagh, surgeon to the Lock Hospital, delivered a lecture at the MGC on the serum diagnosis of syphilis. Although general practitioners were not in a position to perform the highly specialised Wassermann reaction themselves, such a lecture demonstrated that it was thought necessary for them to understand the nature and effectiveness of the reaction. Such an appreciation might in turn make them more likely to send samples for analysis. The information conveyed by McDonagh was highly specialised. For practitioners who had qualified before the development of this technology, such lectures, along with articles in the medical press, provided important channels through which up-to-date diagnostic information could be disseminated. McDonagh not only introduced postgraduates to the theory of the Wassermann reaction but also explained when the test should be performed and what physiological conditions (such as recently finishing a course of mercury) might produce a false negative. According to McDonagh, the ‘blood [must be] examined not less than one month after last taking mercury’.Footnote ⁸⁷ This information was potentially of great assistance to general practitioners in determining when to take a sample for analysis. Despite extolling the benefits of the Wassermann reaction, he also warned practitioners against relying too heavily upon its results which, he claimed, should always be accompanied by a thorough physical examination. Practitioners therefore had to be as knowledgeable as possible of the various physical and neurological manifestations of syphilis.

Such lectures were at the frontier of venereological knowledge. Lecturers were expected to be au fait with the diagnostic and therapeutic innovations that informed clinical practice. They drew upon this knowledge in the teaching of postgraduates and in so doing helped to define the MGC as a centre of expertise. The MGC provided general practitioners with detailed instruction on medical orthodoxies whilst also introducing them to new and sometimes controversial knowledge claims. They gave clarity to symptoms that might have otherwise been misdiagnosed and provided general practitioners with the knowledge necessary to conceptualise these symptoms within a more holistic theoretical and pathological framework.

In 1903 the MGC announced the commencement of a series of ‘composite lectures’:

Given that, in 1903, the College experienced one of its many financial crises, it is possible that ‘composite lectures’ that propounded medical orthodoxy were not only viewed as a pedagogic necessity but also constituted a calculated commercial venture. This may have been a clever attempt to compensate for areas of medical uncertainty by tempting fee-paying practitioners with the appealing prospect of medical certainties. However, that such a course of lectures was designed to supplement a focus on the symptoms of individual patients suggests that practitioners were beginning to move away from complete reliance upon empirical and opportunistic observation. A focus on the ‘present state of knowledge’ suggests that practitioners had begun to contextualise their clinical practice and the symptoms of individual patients within a more coherent and holistic theoretical framework.

Composite lectures were forums in which to clearly state the accepted knowledge and practice pertaining to the clinical subject under discussion.Footnote ⁸⁹ In 1904 these lectures included ‘Gonorrhoea in Women’, ‘What is Syphilitic?’ and two lectures on the ‘The Relationship of Syphilis to Insanity’.Footnote ⁹⁰ Lectures given in January of 1906 included ‘Some Unusual Manifestations of Syphilis in the Upper Air Passages’, while the December series included ‘Syphilis of the Nervous System’ and ‘The Prophylaxis of Venereal Diseases’.Footnote ⁹¹ The mandate of the composite lecture series suggests that the content covered was representative of venereological orthodoxy. Yet with the exception of Lane’s lecture on prophylaxis, for which there is a surviving transcript, there is little to indicate either the content of composite venereological lectures or their influence upon the clinical practices of postgraduates.Footnote ⁹²

Lane’s lecture on venereal prophylaxis was both an overview of venereological orthodoxy and an account of some of the prevailing social attitudes towards venereal diseases. The subject matter was drawn from his involvement in the 1901 Brussels Congress which also addressed venereal prophylaxis. His lecture documented venereolo-gical research and outlined a broad proposal for curtailing the spread of infection. He stressed the need for practitioners to be familiar with the ‘trustworthy methods of treatment’ and to impress upon their patients the seriousness of their condition and the availability of those treatments.Footnote ⁹³ He viewed greater education as a more effective means of prevention than the regulationism employed under the Contagious Diseases Acts. His criticism of regulationism and the accompanying unscientific practices employed in the hurried and inadequate examinations of suspected prostitutes reflected growing understandings of micrococcal causation and disease progression.Footnote ⁹⁴ These empirical practices did not, according to Lane, take adequate account of the possibility that the patient had entered a latent stage of infection or that their symptoms were so obscure as to be overlooked. Lane mentioned the spirochaete only in passing, suggesting that he assumed his postgraduate audience to be familiar with this very recent development. With the identification of the spirochaete and the development of the Wassermann reaction, practitioners such as Lane stressed the need to avoid what they viewed as a fundamentally flawed and unscientific process by placing greater emphasis upon laboratory-based practices. Although Lane’s lecture offered a sweeping account of venereological knowledge and practice it was nonetheless well informed and disseminated the most up-to-date information.

That the MGC marketed its composite lecture series in terms of medical orthodoxy suggests that the content of normal clinical lectures was, to some extent, the product of each lecturer’s unique professional experience. Clinical lectures at the MGC served as forums for raising new ideas in the diagnosis and treatment of venereal diseases. According to the Polyclinic, the MGC enjoyed the services of ‘men of undoubted authority who have made certain subjects their own’.Footnote ⁹⁵ However, inconsistencies in the medical knowledge disseminated to postgraduates suggest that these subjects were not always epistemologically cohesive. In some instances there was little certainty to be imparted.

8. Recommended Therapeutic Practices

Contradictions in espoused knowledge were not only evidenced in discussion of conditions such as tabes dorsalis but also in debates over the most effective therapeutic practices to adopt. Salvarsan was a very recent development and not widely used beyond the confines of a select number of hospitals. It is unsurprising therefore that its therapeutic benefits and mode of administration were not discussed as frequently among postgraduates as the more traditional mercurial treatments. Mercurial injections, and the absorption of mercury through the skin by inunction were advocated by some practitioners but dismissed as ineffective, inconvenient or dangerous by others. Mercury needed to be administered slowly lest the patient suffer mercury poisoning. The question, therefore, was how best to administer safe but sufficient dosages. In his testimony before the RCVD Russell argued that inunction was preferable because practitioners could exercise greater control over the dosage.

Hawthorne, Gowers and Thomas St Clair also recommended inunction as the best method of administration. By contrast, Lane attempted to dissuade postgraduates from using inunction in most cases because he considered it to be unreliable, imprecise and ‘dirty’, making it ‘difficult … to conceal the nature of the disease from the family’.Footnote ⁹⁷ Although C.R.B. Keetley, senior surgeon to the WLH, stressed that hypodermic injections were generally ‘to be discountenanced’, he nonetheless advocated their use in cases where ‘more usual’ forms of treatment were ineffective. In such cases, he advised that the injections ‘must be intramuscular’.Footnote ⁹⁸ Keetley’s cautious advocacy contrasted markedly with Lane’s enthusiasm for intramuscular injection, which the latter believed to be the most efficacious means of combatting ‘malignant’ syphilitic cases. In his testimony before the RCVD, Sir Clifford Allbut, Regius Professor of Medicine at Cambridge, claimed that the subcutaneous administration of mercury through intramuscular injections was only a recent development which may explain why practitioners appear to have differed so greatly in their attitudes towards this method of administration.Footnote ⁹⁹ Some practitioners chose to commence treatment immediately upon the identification of syphilitic symptoms whereas others such as Lane recommended caution until the patient developed secondary-stage symptoms that could better confirm the presence of syphilis.Footnote ¹⁰⁰ Such caution reflected a degree of diagnostic uncertainty as well as an awareness of the therapeutic limitations and potential harms of mercury. Yet before the development of salvarsan in 1909 practitioners had few therapeutic alternatives.

The MGC did not administer treatment but instead recommended treatments to be administered by the attending practitioner. With a few notable exceptions, patients rarely returned for follow-up consultations at the MGC and consequently the course of their illness and the efficacy of prescribed treatment regimes went unmonitored. There was often an implicit assumption that the prescribed treatment would be effective or at the very least an understanding that the efficacy of treatment was variable. Little reference was made to the ineffectiveness of treatment or to the inability or unwillingness of a patient to persist with treatment.Footnote ¹⁰¹ For one of Hawthorne’s patients – a woman with acquired syphilis – the normal ‘authoritative dose’ of mercury produced extreme salivation and extensive ulceration of the lips, tongue and fauces. This case, although described as ‘extreme’, nonetheless illustrated ‘that doses must be selected not as a matter of routine but in accordance with what experience shows to be the requirements of the individual’.Footnote ¹⁰²

The unpredictability of patient reactions to mercurial treatments was linked to discussion about the need for greater experience among practitioners who were required ‘to judge in each case when a suitable dose had been administered’.Footnote ¹⁰³ In 1904 Lane admitted that

Such caution reflected uncertainties regarding the epidemiology of syphilis and its responsiveness to available treatments. Gowers had also reminded postgraduates in 1903 that

Before the identification of the spirochaete in 1905 there was little appreciation of the effect of treatment at a microbial level or of the need to standardise treatments according to their optimal effect upon a causative micro-organism. That each patient seemingly had a different physical response meant that practitioners could not rely upon standardised doses. Tailoring treatment regimes highlighted the importance of developing sensitivity to the therapeutic needs of individual patients. It was a sensitivity based upon extensive clinical experience and a thorough understanding of the different methods of treatment. Lane assumed that his postgraduate audience were ‘all perfectly familiar with the customary methods of administering’ mercury and instead focused upon the circumstances under which each method should ideally be applied.Footnote ¹⁰⁶

Inconsistencies in advice given by these practitioners, although unintentional, were indicative of an under-defined syllabus as well as a fundamental lack of coherent knowledge and agreement regarding standard clinical practices. The content of lectures was not determined by, or reflective of an institutionally agreed-upon knowledge base but rather upon the professional experiences of individual lecturers. Just as there were discrepancies in the types and duration of treatments prescribed, so too venereological teaching was limited in its cohesion and regulation.