2
198 some provisional callus, not yet removed. Had this poor fel- low not met with the injury to the upper extremity, he would have left his bed during the first week, as a patient now under care of Mr. Quain, and treated in this place, had done. It has been urged against this system of treatment, that when swelling comes on, you will get serious consequences. I would submit that the passive compression of the starched bandage differs from the acute strangulation of an inelastic ligature ; provided the rollers are applied evenly from toes to hip, and not too tight at first, you may rest assured that no mortification will take place under your bandage. To support this statement, I will bring forward one point in the preceding case. At the fold of the groin, where the bandage ceased, a patch of ecchymosis appeared after a few days ; under the bandage there was not the least discoloration of the skin, proving that effusion, and, consequently, swelling, had been prevented by the bandage. Of the greater comfort to the patient there cannot be a doubt. A man came in yesterday morning, with fracture of the femur, below the trochanters. I immediately applied the starched apparatus, and, last night, on visiting him, I found him turned over on the uninjured side, quite free from pain and uneasiness. Could such a thing have occurred with the long splint? One more remark, and I have done. It is a great object to fix the hip-joint in these cases; this is most efficiently done by the double spiker, described by Mr. Gamgee in his book, pp. 21--23; no other plan will do so satisfactorily. With many apologies for having intruded so largely on your valuable space, I remain. Sir. vour obedient servant. HENRY KIALLMARK, House-surgeon to University College Hospital. Feb. 4th, 1855. CLINICAL INSTRUCTION. To the Editor of THE LANCET. SIR,—Allow me to remind "A Third-Year’s Student at Guy’s" that my remarks were " calculated to reflect" not on individuals, but on public bodies; not on "many estimable lecturers," but on the system of compulsory attendance on lectures. The error in time pointed out arose from reckoning three winter and two summer sessions as three years. But granting the time should have been stated as two years and three months, the argument is in no way affected. I can still as forcibly ask, if our brave defenders are to wait that time for the aid they so much need ? After all, I have rather under than over-rated the time; for "A Third-Year’s Student" must know that the College requires a "certificate that the candi- date has been engaged during four years in the acquirement of professional knowledge. " Now, I would ask was this certi- ficate dispensed with at the special examination? If so, and gentlemen were really admitted who had only been engaged in professional study " a little more than two years," why, in the name of equity, am I excluded who have been thus engaged more than double the time? Because, Sir, I have only passed one year at a " recognised hospital," as if these were the only storehouses of medical knowledge! That such is not the case, is clearly shown in your leaders on " Clinical Teaching," in which, after pointing out something like a rational mode of professional education, you state that many gentlemen who have seen practice in unions, clubs, &c., need not adopt the plan. Is it going so very much farther, then, to say, that very little, if any, hospital attendance is absolutely necessary to qualify for general practice? In your very last Students’ Number, you, Sir,-untrammelled by a rigid adhe- rence to ancient regulations, and unscathed by the powers of corporate bodies,-have pointed out that the present system "accepts a proof of study (or rather a means of study) in lieu of a proof of knowledge," and that our very intelligent examin- ing boards conclude " by a curious kind of logic," that lie who has had the " means" has necessarily obtained the" ends. Why not make the examination what it professes to be-a "proof of knowledge," and when and where that knowledge is obtained it matters not. If I have the knowledge, and am able to pass, why ask me whether I purchased my knowledge at the established mart? Is disease different in hospital to private practice? And if so, will hospital attendance teach private practice ? The present system is evidently intended to keep up a number of sinecures at the expense of the student. Why, there are not a few persons who cannot learn from lec- tures. I openly told a professor, at the conclusion of his course, I had gained nothing by attendance. He smiled, and owned that "many could not ;’’ and yet the student is com- pelled not only to pay the fees, but to waste his weary hours in listening to that which is useless, and they who seek more useful modes of study are excluded from the privilege of prac- tising their profession ! I would by no means prevent these ’’ estimable" men from lecturing, but I would prevent them from claiming a monopoly to which they have no right—from setting themselves up as the only fountains of knowledge, and from declaring none capable of practising who have not listened to their oracles. " Walking the hospitals"-expressive phrase!-is to many not only tedious, but useless. Who cannot endorse the state- ment of THE LANCET, that London graduates had never seen a case of measles or scarlatina? I have frequently heard the highest authorities state that they learned comparatively little during their hospital career which afterwards proved of any value. I look upon the year I spent as lost time. What did I see there? To be sure, I followed the surgeons on their rounds, and saw scores of fractures, &c.; but they were all so neatly and nicely "put up," that they afforded no opportunity of instruction. Things most common in general practice I saw none of. In the physicians’ wards I never saw an example of the order " Febris, nor of the " Exanthemata." There were very rare and curious cases-treasures for the acute and accom- plished investigator—but none of the every-day practice the student needs to learn. There were very nice points of dia- gnosis solved-very faint sounds heard through the stethoscope - very novel views and theories expounded; but to look for anything which would be of daily service in after life was like " searching for a needle in a load of hay. " An hospital may be a fine field for learning, but as at present carried on, I believe general practice and a well-assorted library infinitely superior. Surely the graphic descriptions of " Wat- son" will supply the place of the lecturer; and he who has diligently studied the practical works of Rigby, Robert Lee, and Ramsbotham, will be as well prepared for the practice of midwifery as he who has heard a course of lectures. Bed-side observation is the same within and without the walls of an hospital, and in general practice the student will be furnished with the cases he most requires. How is it that those who receive their whole professional education in an hospital are at such a loss when thrown on their own resources ? Such a person I once saw commence practice, and though armed with his diplomas and degrees, he daily asked my assistance in the diagnosis, and my advice in the treatment of his patients! "A Third-Year’s Student " thinks that those who will not "waste their energies in the dissecting-room" are not to be trustecl with the lives of our soldiers in the Crimea ? Why not ? *? Is a minute knowledge of anatomy essential for their practice ? If so, how is it that at the end of the first session the student is proverbially "better up" in anatomy than at any subsequent period ? Do you imagine that the surgeons at the seat of war could pass a stringent examination in anatomy? Certainly not. There are a few broad facts to be kept in the eye, and these may be learned zvithout three years’ dissections. Another point: the great duty of our surgeons is not to operate at all. While the sword slays its tens, pestilence is destroying its thousands ; and those brave fellows, who are dying by hun- dreds, of cholera, dysentery, and fevers, would be thankful indeed for the assistance of many gentlemen conversant with those diseases, but who are so unjustly excluded by our Col- leges and Universities. That there is need of surgeons is noborious, or why did the 9th Regiment march up to Sebas- topol "without a surgeon?" and why did the cholera and dysentery the very next day carry off so many ? We are told they " died by dozens," and this because our corporate bodies exclude those who have a moral right to practise. It matters not that the students at Guy’s do not "complain of the tedium;" this one thing is clear, the length of time re- quired prevents many from qualifying, and thus our Colleges are responsible for the want of surgeons for our army. They are responsible, too, for the illegal practice they continue to foster; for I believe I have shown that many are thus driven to act illegally, believing it is not immorally. Thirdly, they are responsible for the frauds consequent on their laws, and for their own corruptions. To show that they are corrupt would not be difficult, but would require more space than you can spare now for Your obedient servant, Feb. 1855. V. T. B. To the Editor of THE LANCET. SIR,—I am as much surprised at the daring views put for- ward by your correspondent" V. T. B." as at the style in

CLINICAL INSTRUCTION

Embed Size (px)

Citation preview

198

some provisional callus, not yet removed. Had this poor fel-low not met with the injury to the upper extremity, he wouldhave left his bed during the first week, as a patient now undercare of Mr. Quain, and treated in this place, had done.

It has been urged against this system of treatment, thatwhen swelling comes on, you will get serious consequences. Iwould submit that the passive compression of the starchedbandage differs from the acute strangulation of an inelasticligature ; provided the rollers are applied evenly from toes tohip, and not too tight at first, you may rest assured that nomortification will take place under your bandage. To supportthis statement, I will bring forward one point in the precedingcase. At the fold of the groin, where the bandage ceased, apatch of ecchymosis appeared after a few days ; under thebandage there was not the least discoloration of the skin,proving that effusion, and, consequently, swelling, had beenprevented by the bandage.Of the greater comfort to the patient there cannot be a

doubt. A man came in yesterday morning, with fracture ofthe femur, below the trochanters. I immediately applied thestarched apparatus, and, last night, on visiting him, I foundhim turned over on the uninjured side, quite free from painand uneasiness. Could such a thing have occurred with thelong splint?One more remark, and I have done. It is a great object to

fix the hip-joint in these cases; this is most efficiently done bythe double spiker, described by Mr. Gamgee in his book,pp. 21--23; no other plan will do so satisfactorily.With many apologies for having intruded so largely on your

valuable space,I remain. Sir. vour obedient servant.

HENRY KIALLMARK,House-surgeon to University College Hospital.Feb. 4th, 1855.

CLINICAL INSTRUCTION.To the Editor of THE LANCET.

SIR,—Allow me to remind "A Third-Year’s Student at

Guy’s" that my remarks were " calculated to reflect" not onindividuals, but on public bodies; not on "many estimablelecturers," but on the system of compulsory attendance onlectures. The error in time pointed out arose from reckoningthree winter and two summer sessions as three years. But

granting the time should have been stated as two years andthree months, the argument is in no way affected. I can stillas forcibly ask, if our brave defenders are to wait that time forthe aid they so much need ? After all, I have rather underthan over-rated the time; for "A Third-Year’s Student" mustknow that the College requires a "certificate that the candi-date has been engaged during four years in the acquirement ofprofessional knowledge. " Now, I would ask was this certi-ficate dispensed with at the special examination? If so, andgentlemen were really admitted who had only been engaged inprofessional study " a little more than two years," why, in thename of equity, am I excluded who have been thus engagedmore than double the time? Because, Sir, I have only passedone year at a " recognised hospital," as if these were theonly storehouses of medical knowledge! That such isnot the case, is clearly shown in your leaders on " ClinicalTeaching," in which, after pointing out something like a

rational mode of professional education, you state that manygentlemen who have seen practice in unions, clubs, &c., neednot adopt the plan. Is it going so very much farther, then, tosay, that very little, if any, hospital attendance is absolutelynecessary to qualify for general practice? In your very lastStudents’ Number, you, Sir,-untrammelled by a rigid adhe-rence to ancient regulations, and unscathed by the powers ofcorporate bodies,-have pointed out that the present system"accepts a proof of study (or rather a means of study) in lieuof a proof of knowledge," and that our very intelligent examin-ing boards conclude " by a curious kind of logic," that lie whohas had the " means" has necessarily obtained the" ends.Why not make the examination what it professes to be-a"proof of knowledge," and when and where that knowledge isobtained it matters not. If I have the knowledge, and amable to pass, why ask me whether I purchased my knowledgeat the established mart? Is disease different in hospital toprivate practice? And if so, will hospital attendance teachprivate practice ? The present system is evidently intended tokeep up a number of sinecures at the expense of the student.Why, there are not a few persons who cannot learn from lec-tures. I openly told a professor, at the conclusion of hiscourse, I had gained nothing by attendance. He smiled, andowned that "many could not ;’’ and yet the student is com-

pelled not only to pay the fees, but to waste his weary hoursin listening to that which is useless, and they who seek moreuseful modes of study are excluded from the privilege of prac-tising their profession ! I would by no means prevent these’’ estimable" men from lecturing, but I would prevent themfrom claiming a monopoly to which they have no right—fromsetting themselves up as the only fountains of knowledge, andfrom declaring none capable of practising who have not listenedto their oracles.

" Walking the hospitals"-expressive phrase!-is to manynot only tedious, but useless. Who cannot endorse the state-ment of THE LANCET, that London graduates had never seen acase of measles or scarlatina? I have frequently heard thehighest authorities state that they learned comparatively littleduring their hospital career which afterwards proved of anyvalue. I look upon the year I spent as lost time. What didI see there? To be sure, I followed the surgeons on theirrounds, and saw scores of fractures, &c.; but they were all soneatly and nicely "put up," that they afforded no opportunityof instruction. Things most common in general practice I sawnone of. In the physicians’ wards I never saw an example ofthe order " Febris, nor of the " Exanthemata." There werevery rare and curious cases-treasures for the acute and accom-plished investigator—but none of the every-day practice thestudent needs to learn. There were very nice points of dia-gnosis solved-very faint sounds heard through the stethoscope- very novel views and theories expounded; but to look foranything which would be of daily service in after life was like" searching for a needle in a load of hay. "An hospital may be a fine field for learning, but as at present

carried on, I believe general practice and a well-assorted libraryinfinitely superior. Surely the graphic descriptions of " Wat-son" will supply the place of the lecturer; and he who has

diligently studied the practical works of Rigby, Robert Lee,and Ramsbotham, will be as well prepared for the practice ofmidwifery as he who has heard a course of lectures. Bed-sideobservation is the same within and without the walls of anhospital, and in general practice the student will be furnishedwith the cases he most requires. How is it that those whoreceive their whole professional education in an hospital areat such a loss when thrown on their own resources ? Such aperson I once saw commence practice, and though armed withhis diplomas and degrees, he daily asked my assistance in thediagnosis, and my advice in the treatment of his patients!"A Third-Year’s Student " thinks that those who will not

"waste their energies in the dissecting-room" are not to betrustecl with the lives of our soldiers in the Crimea ? Whynot ? *? Is a minute knowledge of anatomy essential for theirpractice ? If so, how is it that at the end of the first sessionthe student is proverbially "better up" in anatomy than atany subsequent period ? Do you imagine that the surgeons atthe seat of war could pass a stringent examination in anatomy?Certainly not. There are a few broad facts to be kept in theeye, and these may be learned zvithout three years’ dissections.Another point: the great duty of our surgeons is not to operateat all. While the sword slays its tens, pestilence is destroyingits thousands ; and those brave fellows, who are dying by hun-dreds, of cholera, dysentery, and fevers, would be thankfulindeed for the assistance of many gentlemen conversant withthose diseases, but who are so unjustly excluded by our Col-leges and Universities. That there is need of surgeons isnoborious, or why did the 9th Regiment march up to Sebas-topol "without a surgeon?" and why did the cholera anddysentery the very next day carry off so many ? We are toldthey " died by dozens," and this because our corporate bodiesexclude those who have a moral right to practise.

It matters not that the students at Guy’s do not "complainof the tedium;" this one thing is clear, the length of time re-quired prevents many from qualifying, and thus our Collegesare responsible for the want of surgeons for our army. Theyare responsible, too, for the illegal practice they continue tofoster; for I believe I have shown that many are thus drivento act illegally, believing it is not immorally. Thirdly, they areresponsible for the frauds consequent on their laws, and fortheir own corruptions. To show that they are corrupt wouldnot be difficult, but would require more space than you canspare now for

Your obedient servant,Feb. 1855. V. T. B.

To the Editor of THE LANCET.SIR,—I am as much surprised at the daring views put for-

ward by your correspondent" V. T. B." as at the style in

199

which they are delivered. So well, indeed, does he advocatehis cause that I, who have never entered into the matter withany interest, cannot pretend to emulate either his matteror his manner; indeed, my thoughts on the subject are

"few and far between." Yet I cannot help asking, Haveour privileged medical nobs all the power in their hands tofashion the laws regulating the power of physic, and do notour legislators share it with them ? I know the bye-laws areof College and Hall formation, and come out in fresh andstringent forms every few months, throwing obstacle afterobstacle in the road of those quick aspirants who would getinto practice some shorter or " other way " than through thedoor of that degree of experience and labour which wouldqualify them efficiently for that great line of duty which liesbefore the medical man. Hinc illæ lachrynace, and the frettingand champing of bit in the case of those precocious individualswho are conscious of possessing memoriter power enough toenable them to prepare, in a very brief period, for any sort ofexamination which may be required.

I am, Sir, your obedient servant,Feb. 1855. OCTA.

SURGERY OF THE WAR.

THE contrast between our various surgical and medical

arrangements for the troops in the hospital tents before Sebas-topol and the French hospitals at Pera continues very mani-fest. We do not willingly dwell on this contrast, but that itmay prove of advantage in the various changes now submittedto Parliament with respect to the army. We do not yet de-spair of the latter. Balancing the contending opinions ofvarious writers, though we find, as a figure of rhetoric, in TheTimes, 11,000 in hospital at one time, yet, perhaps, half thesewill return to camp duty again; and if, in London, we canbe brought, under Lord Palmerston’s sway, to do more for thesick and wounded, and talk less, much ultimate good willaccrue. We have inherited a bad military system, and wemust change it, but change it slowly. The " civil element "

will come too late, and we will not do our military surgeons theinjustice to say, if they had been properly {assisted by Parlia-ment, such men as our present surgeons (worthy to workalongside Thompson, Mackenzie, and Wilson) would not besufficient for all emergencies. The chief French hospital, the"Mejidieh," at Pera, we find, is now a complete school ofmilitary surgery. Our hospital at Scutari, on the contrary, isa pest-house, filled with some 5000 or 6000 starved and ill-fedsoldiers, dying of dysentery, scurvy, rheumatic fever, andother medical diseases, the result of exposure to climate anddeficient commissariat arrangements; while, as to our opera-tive surgery, the appalling fact has been stated that, from thesame causes, out of sixty secondary amputations, only one re-covered. If this be true, every hospital surgeon will agreewith us, that the entire records of the world furnish nothinglike it. The average mortality for some time amongst ourtroops, from the same sporadic causes, also, as compared withthat of the French, is calculated at 1 in 88 of the English, and1 in 360 of the French troops. We have some reason to be-lieve these accounts are overdrawn, and though we may wishto arrive at the truth, and nothing but the truth, it is quitepossible to have too much one-sided truth, while the variouscounteracting causes may be held in abeyance. Our surgeons,at least, in camp and hospital, have nobly distinguished them-selves, so that the civil element" may be a little misplacedjust at present.The Mejidieh is represented, by a correspondent who has

visited it lately, as in no way inferior to Guy’s, St. George’s,or the best of our London hospitals. It is described as themost complete and perfect building in Constantinople, and wafconferred on our allies as an especial favour by the Sultan, itcompliment to French military surgery. Our so-called hos.pital at Scutari is only the ordinary pile of buildings used as !barracks for 5000 soldiers. When the expeditionary arm3first arrived in Constantinople, and moved up to Varna, various tiers of corridors and wards were run round an immens!

quadrangle, something like that of St. Bartholomew’s Hospitalthe centre being filled with wooden huts, put up hastily to accommodate the still swelling stream of sickness from BalaklavaAt the latter, also, surgeons and nurses just arrived (February

from England, had found plenty of work to perform; but, inthe French hospitals, the military system was in itself perfect.The Mejidieh is situated in the most beautiful suburb of Con-stantinople, on the side of a sloping hill, immediately adjoiningthe newest of the palaces of the Sultan, and quite easy ofaccess for the wounded arriving from the trenches of theFrench lines. The building was originally intended for amedical college, so that it is complete in every way, and cannow accommodate 1500 patients. We give these particularsas showing that the superior hospital ambulances, and establish-ments of the French, transplanted from Paris to Pera, mustultimately have a great influence on the result of our surgicaland medical statistics. The wards of the hospital at Pera areclean and spacious; our own hospitals at Scutari are now alsoimproved; but we need not bring back to recollection thehorrid scenes described by Mr. Stafford and Mr. Layard in theHouse of Commons, as witnessed by them when they visitedScutari after the battles of Alma and Inkermann. If we doso, it is only as a lesson, in the fervent hope such scenes may,under a new Ministry of War, never occur again; and, if wehave gained little from the present war, we shall have gained,at least_ a knowledge of French militarv surgery.

At Scutari, we are told by this same correspondent who de-scribes the hospitals at Pera, (though he had visited the latter-early in the morning, before there was proper time for cleaningit thoroughly,) the bed-rooms or wards were, many of them,filthy in the extreme, utterly fetid and foul; no facilities of a.sanitary kind thought of. The dreadful necessity of explainingsuch things alone forces one to speak of them. Cartouch-boxesand even bottles were found only half supplying the horriblenecessities of water-closets to the diarrhoea patients, for whom,even in the country of opium also, on the principle of not sup-plying coals to Newcastle, we must presume there was actually,even up to the last accounts of the present month, no opiumor other medicines supplied to check diarrhoea or dysentery.Contrast this with Pera, the beds in which hospital are

said to be perfectly clean and white, in two layers round thewards, raised on a dais, each separated from the other by awhite stone pavement, so agreeable in the heat of summer, allthat the sick soldiers could require in a Paris hospital is pro-cured. We spoke also before of various other French hospitalsin Turkey-that of Batche Serai. for instance, a palace re-markable for its beauty, of "Arabian Nights" celfbntv- andnot more remarkable for its beauty than its internal complete-ness and cleanness. We have now also four hospitals at Con-stantinople, three at Kulubee, one at Rhodes and Smyrna.Amongst the latest facts of our own and other correspondents,

we find that frost-bites of a bad kind had been very frequentamongst the sick and wounded, not from the severity of thewinter so much, (which has not been equal to that of England,)but from the depressed vital powers of the soldiers, owing tothe defective supply of rations. A complete dearth of surgeonsalso had been experienced for a few days, from the numberssick, and the vast amount of labour falling on those engaged.The weather at Sebastopol, by our last accounts, had become

quite mild and warm-milder, indeed, than London. Wespoke six weeks ago of the winter at Sebastopol as, on an

average of ten years, being two degrees, (a large amount in aquestion of climate,) according to Humboldt, warmer thanLondon. We said then, and now again repeat, that we havethe hot south winds, with night chills and agues, of this partof Europe to dread more than frost-the diseases peculiar tothe Crimea, plague, cholera, dysentery, and ague, presentingthe characters more of tropical than of northern regions. Thesummer bursts, it is said, at once, without any intermediatespring, on all the southern parts of Europe adjoining theMediterranean. During these southern winds, all gun-shotwounds and previously granulating stumps of limbs just ampu-tated stop healing. Cholera and ague make their appearance;the latter caused by the vast quantities of land at the embou-chure of the Danube, or more southerly lands along the Dar-danelles, left dry and marshy; even at present cholera seemskept only in abeyance by some curious physiological law notunderstood. "The 39th Regiment has just arrived at Balak-lava," says a newspaper correspondent; "but though no

cholera was in the regiment on arriving, and no. cholera knownat Balaklava since Christmas, cholera began at once in theregiment;" and he adds, "how strange it is that this penaltymust be undergone by every new regiment which arrives inthe Bosphorus’." We have several times alluded to this

singular proclivity to cholera and intermittent fevers amongstrecently arrived reinforcements. The number of deaths in the

present month of February, from this alone, is describedas almost incredible, and exhibiting the necessity, if the war