The Welsh National School of Medicine, 1893–1931: The Cardiff Years
Book review – by Keith Williams
There has been a growing awareness of the importance to medical education of the developments in the late 19th and early 20th centuries. It was during this period that the essential framework of the present medical curriculum was defined, that research began to be embraced by the medical community, and that new relationships were formed between universities and their associated hospitals. Surprisingly, this is an area that has tended to be neglected somewhat by medical historians, and Alun Roberts’ book is an authoritative and welcome addition to the literature on the subject.
Roberts has provided a fascinating account of the Cardiff medical school during the first four decades of its existence, from its foundation as part of the University College of South Wales and Monmouthshire (‘the College’) in 1893 until it became a separate and independent entity within the University of Wales in 1931. As is befitting what Roberts describes as being “a biography of an institution”, the book is largely a chronological narrative, focusing mainly on the events leading up to and surrounding the three major milestones in the school’s history in this period: its foundation, its development as a full medical school in 1921 and its establishment as a discrete entity in 1931. This is a story that is full of paradoxes, for while the school was often at the vanguard of medical educational developments, it was often shaken, and at one point nearly destroyed, by various conflicts arising from the involvement of combatant and dominant personalities. This feature was to lead Sir George Newman, the chief medical officer at the Ministry of Health, to remark that “agreement is a very rare quality in South Wales”. Empire building, turf wars, bureaucratic encumbrances, petty jealousies, personal enmities, financial anxieties, and the impact of local and national politics are all to be found in Roberts’ narrative. Indeed, it is a work that is as much a case study in organisational misbehaviour as it is a story about the development of Welsh medical education.
The first few chapters of the work provide a useful background in terms of the development of medical education in the UK in the 19th century, the foundation of the University of Wales, and the Cardiff College. It then goes on to discuss the events leading to the founding of the medical school, which for its first 25 years was limited to preclinical courses in areas such as anatomy and physiology; students had to move to another institution for their clinical training. There didn’t appear to be a particular reason for the establishment of the medical school in Cardiff, but of those put forward at the time, the idea that no self-respecting university would wish to be without a medical school seems far more convincing than, for example, the argument that residing near their own homes offered Welsh students material and moral advantages. But nationalism undoubtedly played a part; the school was seen as an expression of Welsh national pride. So, too, did the role played by leading local personalities, many of whom made generous financial donations to the setting up of the school, which continued as the school expanded. Even so, finance remained a concern for the whole of the period covered by the book.
Although turf wars, as various departments within the College and within its medical school vied for finance for accommodation and equipment, were often evident during this period (as were personality clashes and resentments over professorial appointments), these would have hardly marked out the school as being any different from any other university, then or now. What placed the school at the forefront of medical schools at this time were progressive moves such as the founding of the first Chair of Preventative Medicine in the UK and a Chair of Tuberculosis, the only other one in the UK at the time being at Edinburgh. The school admitted women medical students from the very start, and it is of note that of the 64 medical graduates of the University of Wales in the period 1916–1931, 22 were women. By contrast, many of the London medical schools still did not admit women at this time or were terminating their policies of admitting women.
The problems for the school, which were to culminate in 1928 in “a crisis unparalleled in the modern history of medical education in the UK”, stemmed from two interrelated issues. The first was the desire to develop it as a full medical school, the Welsh National School of Medicine, offering both preclinical and clinical instruction. This was achieved in 1921 when facilities for clinical teaching and research were provided at the Cardiff Royal Infirmary, which ipso facto became a teaching hospital. However, the agreement reached between the hospital and the College was hasty and ill conceived: the College retained administrative control, and the school remained a constituent part of the College. Tensions between the hospital staff and the school staff and students were apparent from the start, and the introduction of the avant-garde clinical unit system, whereby a department was under the complete control of the medical school, or at least jointly controlled by the school and the teaching hospital, was deeply resented by many of the hospital staff, despite the fact that its establishment led to funding from the important Rockefeller Foundation. The failure to give hospital staff, especially the recognised clinical teachers, representation on the Faculty of Medicine (the medical school’s supreme academic authority) proved to be another source of disquiet. Much of the problem, as Roberts so ably describes, emanated from the school taking as its partner an old-style voluntary hospital and failing to manage its transition into a teaching hospital, and in particular in its failure to understand, let alone cater for, the views of the hospital staff. Consequently, the differences between the school and hospital staff, and the resultant tensions, grew to the point where relations finally broke down altogether during the spring and summer of 1928. By the summer of 1928, one-third of the recognised clinical teachers were refusing to participate in the teaching programme. In June of that year, the hospital gave the school notice to quit the hospital premises, and in September instituted a ‘lock-out’ of school students and staff following a student fracas. This resulted in existing clinical students having to enrol elsewhere to complete their studies and the school having no clinical students at all in 1928/29.
The second issue was that of the school being independent of the College, a move that had been recommended by the Haldane Report in 1918 but successfully opposed by the College, which in this seemed to have the support of the Welsh public. However, this was an issue that was to continue to be raised, particularly by those who wished to see an independent and truly national medical school, with an all-Wales remit, not affiliated to any of the existing University of Wales colleges. With the problems that surfaced at the school in 1928 this idea came to the fore as part of their solution, along with the resolution of many of the problems that caused so much tension at the hospital. Despite the bitter opposition of the College, which had invested heavily in founding and developing the school, independence was finally achieved in 1931. However, what emerged was an example of good old-fashioned British compromise, with the school being split into two: the preclinical departments, such as anatomy and physiology, remaining with the College, and the remainder being transferred to the new entity, which became an independent college within the University of Wales. While Roberts’ account ends at this point, it is not the end of the story for, as is often the case, the wheel turned full circle and in 2004 the school, by then the University of Wales College of Medicine, merged with its one-time parent to become Cardiff University.
No review such as this can ever convey adequately the degree of complexity involved in the story unveiled by Roberts, and he is to be congratulated on disentangling the issues so that they become more understandable to the reader. While Roberts takes us deftly through the twists and turns of the drama, neatly unfolding the various arguments, he also usefully discusses the broader perspectives, briefly examining developments in medical education as a whole, and comparing developments at Cardiff with those at other UK medical schools. Finally, the inclusion of vignettes of the characters involved and of students at the school within each chapter helps to make the story come alive, as well as providing a useful insight as to why some of the combatants behaved in the way they did. Undoubtedly this well-researched book, and its comprehensive bibliography, will be of interest to a wide audience, whether the main focus is the history of medical education, the history of Welsh life and politics in the first few decades of the 20th century, or organisational behaviour. In the preface, Dr Roberts hints that there may be another volume under consideration, taking the story to 2004. This reviewer, for one, looks forward to its publication.
Roberts A. The Welsh National School of Medicine, 1893–1931: The Cardiff years. University of Wales Press; 2008.
Dr Keith Williams is a Research Associate of the Department of History at the University of York.