THE MEDICAL CIRCULAR.

WEDNESDAY, SEPTEMBER 2, 1863.

THE DEARTH OF MEDICAL PUPILS IN THE
PROVINCES.

During the sitting of the General Council of Medical Education, in the early part of the present summer, several questions were mooted as to the educational position of the Profession, in connexion with the relations existing between the teachers and the taught, between the senior and junior departments of our common calling. In consequence of the pressure then existing upon our columns, we were compelled to postpone the consideration of those questions, but we believe that the present time, when another Winter Session is about to open, is a convenient opportunity for laying before the Profession some of the matters to which we refer, and which we had not time then to discuss. We publish in another part of our impression a letter addressed to the Medical Officers of Hospitals by Dr. Shapter, the Senior Physician, and Mr. P. C. De la Garde, Senior Surgeon, of the Devon and Exeter Hospital; and also a memorial from the whole of the Physicians and Surgeons of that Hospital to the General Medical Council.

The complaints made by the memorialists, and the remedies they propose for the existing evils, will be sufficiently manifest from a perusal of the documents themselves, but we may state generally that there is a prevalent feeling of dissatisfaction, especially in the provinces, at the recent recommendations of the Medical Council in reference to the education of Medical | pupils, those recommendations having the tendency to draw away all Medical Students into the Metropolitan Schools of Medicine, and to destroy altogether that relationship between the General Practitioners and their pupils which has so long existed for the mutual benefit of both, and for the advancement of sound practical information in Medicine, Surgery, and Midwifery. The observations of the memorialists do not apply to those students who intend to practise what are called the higher branches of the Profession, and who will, as heretofore, prepare themselves by a long attendance at large hospitals for the special pursuits to which they are led by their tastes, their inclinations, or their pecuniary means; but they apply very forcibly to that very large class, who are destined to become the General Practitioners of the British Empire, and who are to be qualified, at a comparatively early age, and at a moderate expenditure of time and of money, for the multitudinous duties which devolve on this most important and most useful class of the Medical community.

It appears to us that the members of the Medical Council have taken anything but a practical view of the question, for their recommendations are founded rather upon Utopian ideas of what the Profession might become, that of what it really is, and what the public require it to be. This tendency in the Medical Council is hardly a matter of surprise, when we consider the constitution of that body, the members of which are, in the language of the Devonshire memorialists, "by their high position, social and professional, too far removed from the great body of Medical Practitioners to be intimately acquainted with their habits of life and mode of practice, whilst we (the memorialists), who are largely consulted throughout a very extensive and varied district, presenting every conceivable condition of practice, are intimately acquainted with our Medical brethren at their own homes, and in the houses of our patients."

Here we conceive that the right nail has been hit on the head, and that it is to the want of knowledge of the condition of the General Practitioners on the part of the Medical Council that their very impracticable recommendations are chiefly attributable. In fact, we have only to cast our eye over the list of members of the Council to understand their ignorance and want of sympathy in this respect, for the great majority of them are the avowed representatives of the Collegiate and Corporate bodies, while the nominees of the Crown, who, it was at first supposed, would advocate the claims of the General Practitioners, are for the most part little else than thick and thin supporters of the same Colleges and Corporations. Thus the great bulk of the Profession have no chance except in the way of presenting memorials, and in combining with one another, and we may add, in making their wants and wishes known through the medium of an independent Medical Press.

Now the points at present in question are these:-The education of the Student of Medicine has hitherto been twofold: first, his education under some competent private practitioner, and secondly, under the Surgeons and Physicians of the recognised Hospitals and Schools of Medicine. In the early part of the present century, the first method was very generally and very often exclusively adopted, but in later years the attendance on Lectures and Hospital practice was made compulsory on all, and hence the two kinds of tuition, which might be termed the domestic and the public, were blended together: and with what good results the present enlightened condition of the General Practitioners can abundantly testify. That the apprenticeship system, as it is called, is liable to abuse, no one can deny; but on the other hand, few will be bold enough to assert that a young man receives any injury from being placed for a short period under the domestic guidance of a person older than himself, and who, even if he be a man of no extraordinary abilities or pretensions, is at least able to initiate the pupil into the groundwork of his Profession, and is moreover invested with the power of superintending his moral conduct. tending his moral conduct. If any person is so foolish or so ignorant as to believe that an apprenticeship means a slavery of five years or more behind a counter, rolling up pills and mixing draughts, he is of course beyond the reach of argument; but on the other hand, if it is desired to bring up a race of practitioners who know nothing of the practical manipulations of their art, and who are to begin learning them of the chemist and druggist after they have entered into practice, then all we can say is that we pity the patients who may fall into their hands.

The obvious and avowed object of the Medical Council is to abolish all private tuition, to deprive the General Practitioners of the emoluments hitherto derived from taking pupils, to drive the latter into the Metropolitan Schools and Universities, and to drain the Provincial Hospitals and Dispensaries of hundreds of young men who have hitherto derived immense benefit from the clinical teaching afforded in those institutions, and who, by their services as clinical clerks and dressers repay in some measure the advantages they receive.

In place of this wholesome preparatory training, the Medical Council would send the youth straight from school, or from his parental roof, at once into a Medical School in a large city.

Supposing him to be conscientious and diligent, he will be seated in a large lecture-room, amidst a crowd of students, listening to a Professor discoursing on a science of which the new-comer knows nothing, and the very technical terms of

which he is unable to comprehend: or he rushes through the wards of an hospital among hundreds of others, vainly trying to catch the words that fall from the lips of the Clinical Teacher, or if he does catch them, he does not understand what they mean; or he witnesses operations on structures, of the nature and properties of which he is wholly ignorant, performed with instruments which he has never before either seen or handled. As for pharmacy, contemptible as it may seem in some eyes, all he can know about this branch of his art, if he ever knows anything at all, consists perhaps in seeing the Hospital Dispenser ladling out mixtures and lotions by gallons, and pills and powders by hundreds at a time, to thousands of out-patients; but the greater probability is that he never troubles himself to enter the Dispenser's department at all.

We may, however, state that the transparent absurdity of such a scheme has already excited such a feeling of discontent among the Profession generally, and among the Examining Bodies, that it will not be carried into effect. The preposterous proposition of compelling all students to pass four years at a Medical School, to the enormous increase of expense to the parents, and without any corresponding benefit to the pupils, has called forth remonstrances from all quarters, and we are happy to announce that the Medical Council themselves have passed a resolution, practically abrogating their own previous recommendations, and that the term of three years, namely, three Winters and two Summer Sessions, as heretofore, will be deemed a sufficient course of Medical study, leaving any extra time which the student may have to spare to be spent under the tuition of some general practitioner having a dispensary or union practice, or in some provincial hospital.

SUMMARY OF THE WEEK.

THE BRITISH ASSOCIATION FOR THE ADVANCEMENT OF
SCIENCE.

has hitherto proyed a very great success, although the weather at the early part of the time was exceedingly unpropitious.

RECOVERY OF PHYSICIANS' CHARGES.

It is with infinite regret that we allude to some cases which have lately been tried at the Croydon Assizes, where certain members of our Profession have brought actions for the recovery of their fees for Medical attendance. It has always been our pride and our duty to uphold the just rights of the members of our body, and to defend them when unjustly treated at the hands of the law; and we regret that we have nothing to urge in behalf of Dr. Snow Beck or of Dr. Freund for the part they took in the proceedings to which we refer. The former gentleman, who is a man of considerable eminence in his Profession, being a Fellow of the Royal Society, a member of the Royal College of Physicians, and distinguished besides by some original anatomical investigations, has been advised to bring two actions against certain persons, formerly his friends, for large sums of money on account of professional attendance on them and their families. One claim of 957. 15s. has been accorded to him, and therefore there is nothing to be said on that matter; but the other, being for the large sum of 5917. for alleged attendance during four years has been refused, and we think on very proper grounds. It appears that Dr. Beck was in the habit of dining with the defendant every Sunday and spending the evening at his house, and that in the course of his visits he made occasional inquiries as to the health of the family, and probably made suggestions as to the treatment they should adopt for such ailments as had befallen them. But the family, as it was admitted, was regularly attended by a medical gentleman, whom Dr. Beck never met, and who was in all probability regarded as the family practitioner. Again, whether Dr. Beck's visits were professional or merely social, it does not appear that he ever made any charge for them, or indeed ever mentioned the subject of remuneration, until he had quarrelled with the defendant, and then he preferred the enormous claim which was the subject of the action. It does not appear, moreover, that Dr. Beck made any definite notes of the professional visits for which he claimed payment, nor did he bring any evidence, as far as we are aware, that his professional attendance was solicited. The judge and jury would not hear the case for the defence, but at once returned a verdict for the defendant, and we cannot blame them. The other case, that of Dr. Freund, a German practitioner in the neighbourhood of Finsbury square, is not so bad as Dr. Beck's, but still it presents some unpleasant features. Dr. Freund claimed the sum of 1317. from the executors of a person, now deceased, whom he had attended during his life, and from whom he had received no payment, but from whom it does not appear that he ever personally demanded any. No books were kept, no notes made of the visits paid or of the medicines prescribed, and the only evidence of the medical attendance was that of the plaintiff himself, and of the chemist who had dispensed the drugs. It was admitted by the defendants that something was due, and they therefore paid 257. into court; and at the termination of the case, after a very impartial summing up by the judge, the jury gave the plaintiff 257. more.

The Meeting of the British Association for the Advancement of Science commenced at Newcastle-on-Tyne on Wednesday last, with an inaugural address from the President, Sir William Armstrong, who gave a luminous retrospect of the advances made in science of late years, and especially adverted to the great extension of the system of railroads since the former meeting of the Association at Newcastle-on-Tyne, twenty-five years ago. The proceedings of the Association appear to have been very attractive, as more than 2,000 associates had enrolled their names on the first day. The sciences of Chemistry, Physiology, and Ethnology were all adequately represented in the different lectures, and we have published abstracts of some of the papers read on those subjects; but the chief attractions were of course held out to the votaries of Geology, applied Chemistry, and Manufactures, for the practical illustration of which, Newcastle and its vicinity offer peculiar advantages. The immense quantities of coal found in the neighbourhood, and its practical application in the arts, have mainly contributed to the greatness of the British Empire, and Newcastle is, therefore, a most appropriate spot for the assembly of the Association. When we use the word "immense," however, in reference to the coal mines of North-With one or two remarks we must dismiss these very umberland and Durham, we are reminded by the address of Sir W. Armstrong, that the term is not strictly applicable, inasmuch as the quantity, though very large, is limited, and the duration of the supply will be limited likewise. Altogether the Meeting of the British Association at Newcastle

unpleasant cases. In the case of Dr. Beck we regret to find that two medical gentlemen, Dr. Rogers and Dr. Shorthouse, gave evidence that the charge of 5917., under the cir cumstance we have described, was a fair and reasonable one: and in the other case we equally regret to learn that the

near the full term. Mr. W. GAYTON contributes a short paper on a
"New Mode of Securing the Handles of the Forceps during
Delivery." The plan consists in a modification of the practice,
sometimes adopted, of tying the handles with a piece of tape, so
as to secure firm adaptation. In Mr. Gayton's forceps, a rack and
spring are placed on one handle, and the other handle is flattened
and tapered so as to be received into the furrows made for it. Dr.
J. W. OGLE continues the relation of some "Cases of Epilepsy,
Convulsions, Giddiness, &c." The cases which are recorded were
those of children attacked with various forms of convulsive dis-
ease, sometimes attributable to mal-nutrition, sometimes to the
irritation of worms, sometimes of unknown origin. Many were
relieved by appropriate treatment, some were partially relieved,
and some died. In one of the fatal cases, a post-mortem examina-
tion revealed no important appearances which could explain the
result.

"
THE BRITISH MEDICAL JOURNAL.'

Mr. HENRY LEE, of St. George's Hospital, contributes some Clinical Records, the two subjects at present selected being "Lithotomy," and "Unhealthy Ulceration after Vaccination." He gives a case of lithotomy, which, although successfully operated upon, affords no remarkable feature for comment. On the second subject, Dr. Lee observes that he has undertaken microscopic examination of the lymph of the vaccine vesicle, in consequence of several severe cases of unhealthy ulceration arising from vaccination having presented themselves at St. George's. In all the specimens he examined, from the vesicle on the eighth day, when no admixture of the matters had taken place, the lymph was found to be perfectly transparent, no globules or cells of any kind being discernible. But when care was not taken in collecting the lymph, blood-globules and portions of epithelium were occasionally found, On the ninth day after vaccination, a few round granular or puscells are found, and on the tenth day the vesicle is full of a milky fluid, which, on examination, is found to contain numerous puscells. Mr. Lee draws the following practical conclusions from his

own observations and those of others :

1. The ordinary vaccine vesicle yields a fluid, from the fifth to the eighth day, free from any cells allied to pus-cells. The only evidence of any organised products at all in the fluid, at these dates, is the occasional appearance of a few granules, nuclei, or cell-like particles; although, as a rule, even these are entirely absent.

2. Upon the ninth and tenth days, cells may generally be detected; few in number upon the former, but very numerous upon the last named day. These cells possess the characters of pus-cells. 3. When the vaccinated spot, however, has been or is attended with the phenomena of inflammation-heat, redness, and painsuch as it frequently is if the parts have been irritated, then puscells can be discovered in the vaccine fluid at earlier dates than the ninth day.

In reference to the practice of vaccination, Mr. Lee suggests that the lymph is the purest which is taken from the sixth to the end of the eighth day, and that the detection of pus-cells should decide the practitioner against using it for the purpose of vaccination. These precepts have long been known and acted upon by all careful vaccinators, but they cannot be too often taught and inculcated. Dr. EDWARD MERYON continues his "Pathological and Practical Researches on the various Forms of Paralysis," his present subject being paralysis from tabes dorsalis, an affection which arises generally from masturbation practised in early life. This vice is not confined to the male sex, and although Dr. Meryon does not endorse the opinion of Deslandes that out of twenty cases of leucorrhoea, from fifteen to eighteen result from this cause, yet he has seen one unequivocal case of the kind in the female. Dr. THOMAS J. WATSON contributes a paper on the "Laryngoscope and its Clinical Application," in which he describes the healthy appearance of the structures in the larynx and in the nose, when viewed by means of the instrument.

REVIEW OF BOOKS.

On the Diseases, Injuries and Malformations of the Rectum and
Anus; with Remarks on Habitual Constipation. By T. J. Ash-
ton. Fourth Edition. London: John Churchill and Sons, New
Burlington street. 1863. Pp. 411.

There are two most important qualifications essential to a good author; First, That he should have enjoyed a large experience of the subject on which he writes; Secondly, That he should be able and willing to communicate what he knows.

Now, both these necessities have been admirably fulfilled in the production before us. Hence we accord high praise at the outset to this work as eminently practical, clear, comprehensive and based on a large and well observed experience. Partly, then, to corroborate this statement, it need there be of such a step, but much more to inform our readers on points of interest, we shall present a very brief analysis of some portions of the volume, the fourth edition, let it be added, since its first appearance in 1854.

After some judicious remarks introductory to the whole subject, some valuable hints will be found in the first chapter on that always troublesome and often obstinate affection, Irritation about the Anus. This naturally leads, through a subsequent chapter on Excoriation, a third on External Excrescences, and a fourth on Contraction of the Anus, to a consideration of that distressing complaint, Fissure of the Anus. The external pathognomonic sign of its presence is pointed out at once, rendering as it does, the use of the speculum scarcely necessary for diagnosis. The use of local applications is not lost sight of, but the frequent necessity for the little operation of Boyer, so valuable in this condition is recognised; and in passing it may be said, that that modification of the proceeding which consists in dividing the mucous membrane or the base of the fissure simply, and not the sphincter muscle itself as originally practised, is correctly attributed to Brodie, who published it in his lectures in 1836, and who is stated to have derived it from the veteran Copeland.

Passing over three chapters devoted to Neuralgia, Inflammation, and Ulceration of the Rectum, the subject of Hæmorrhoids receives a long and careful examination in the eleventh. Of Internal hæmorrhoids our author recognises three varieties, based on their structural anatomy, and he adopts them as the foundation for the treatment of each respectively. The causes, the symptoms, the complications and results are all considered at length. The questions of diagnosis and treatment follow; and the latter relates to the management of the pile in each stage of development, from the earliest condition, in which it is completely amenable to medicine and local appliances, up to the large masses of mixed external and internal tumours, which require the knife and ligature. The best modes of employing these are fully demonstrated, while the value of nitric acid (the method of Cusack and Houston), and of the nitrate of mercury, in a few cases which are distinctly specified, is pointed out. Numerous illustrations in the form of detailed cases, support the dicta of the text.

The eleventh chapter brings the reader to Prolapsus recti. No previous author has so fully pointed out the two distinct conditions under which this disease occurs in the adult. Its pathology is discussed, and the two opposed states of the bowel described, which require different modes of treatment. The form which appears so commonly in children receives corresponding attention.

Passing by rectal abscess, we arrive at the thirteenth chapter devoted to Fistula in ano. The author cites the opinions of Brodie, Syme and Ribes, in relation to the once much vexed question of the formation of the internal orifice of the fistulous passage, and he writes

"With all due deference and respect for the eminent authorities just quoted, I am yet compelled to differ from them as to the internal opening being always formed, either in the one way or the other. In my practice, having had the opportunity of closely observing the progress of many cases, I do not hesitate to affirm that the intestine is both primarily and secondarily implicated, perforation taking place as often from the external surface of the intestine, as commencing on the mucous surface and proceeding outwards," (p. 239.)

Our readers must refer to the volume itself for the further discussion of this matter.

It is sound practical tact, and a possession of the true surgical sense (a kind of sixth sense we have sometimes thought, without which the most erudite and the most self-possessed individual can never become a surgeon) which calls attention to the right mode of using a probe in the exploration of fistula, and, it may be added, of every other passage for which a probe may be required. The whole art lies in using it as "an instrument not to be directed with absolute control, but one from which we are to gather information; it is to guide and instruct us," (p. 245.)

Does our reader think this a slight matter to be remarked? If so, he lacks, we fear, the one thing needful; he may indeed make a butcher, pardon us, but never can be a surgeon. All that follows partakes of the same spirit; thus among similar directions let us particularly indicate the admonitions not to cram the wound with