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On the Medical Profession and Its Reform (Concluded)Author(s): J. BlackSource: Provincial Medical and Surgical Journal (1840-1842), Vol. 1, No. 10 (Dec. 5, 1840), pp.161-163Published by: BMJStable URL: http://www.jstor.org/stable/25489977 .

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PROVINCIAL

MEDICAL & SURGICAL JOURNAL.

EDITED BY DR. HENNIS GREEN AND DR. STREETEN.

NO. 10. VOL. I.] LONDON, SATURDAY, DECEMBER 5, 1840. [STAYPRD Eu,T.Or SIVXPENCE. PAGE

Dr. Black on Medical Reform .161 NEWCASTLE;-O-TYNB INFIRMARY

Cases by Mr. Baird and Mr. Heath ....................................... 163 WORCuaTER INFIRMARY

Cases by Dr. Hastings ........................................... 164 Gus's HosPITAL

Aneurism mistaken for Rheumatism ....................................I ]'5 Fatal case of Chorea ............................................ ib.

PROVINCIAL MEDICAL AND SURGICAL AssoCIATION Report of Council on the Poor-law Question ........................... 166

MR. WARBURTON's BILL .................. 168

PAGE College of Surgeons-Mr. Lawrence and Mr. Liston ..................... 170 'Apothecaries' Hall ........................ ib.

Mr. Carter on Medical Reform. i. REVI. WS OF WORK -

Dr. Arnold on Yellow Fever ...................................... 172 Guy's Hospital Reports .174 Mr. Lucas on the Origin of the Aqueous Humour .ib. Thie Colic of Madrid. ib. Physiology of the Nerves ................. , 175 Squint Quackery .ib. Varying Effects of Remedies ...................................................... ib.

ON THE MEDICAL PROFESSION AND ITS REFORM.

By J. BLACK, M.D., MANCHESTER, Member of the Royal College of Physicians, London.

TO THE EDITORS OF THE PROVINCIAL MEDICAL AND SURGICAL JOURNAL.

(Concluded from page 149.)

Ix the midst of all this professional plethora, dismem berment, and degrading competition, the cry for medical reform is becoming louder and more urgent among all the

working menmbers of the profession, though the medical corporations have shown no awakening sympathy on the engrossing subject-judging, it issupposed, that they have sufficiently guarded the interests of the profession and the public, by raising the standard of education, and by in creasing its expense to the aspirants for membership. Such, moreover, is our unfortunate destiny, that the just and ingenuous complaints of our grievanices never reach the ears of our natural and constituted guardians and pro tectors, but only excite the gratuitous sympathy and in terest of some extra-professional patron), who, to extract golden opinions from a clamorous and expectant coin

munity, most disinterestedly volunteers ani inquiry into our wants and grievances, and holds out the hope of long-de ferred amelioration and sound reform, at lengtlh to present us, out of the abundance of legislative investigation and

wisdom, with only a species of King Log, to reign over us. Such, I conceive, is the nature and beariings of the bill

now before the profession, and wlhichi, after several years' incubation, was brought to light on the last days of the late session of parliament. Agitated, depressed, and, if possi ble, degraded, as was the previous condition of the pro fession, this fresh legislative boon appearstheunkindest cut of all to the dignity of the profession, notwitlhstanding its just and commendable recogflnition of the great and neces sary principle of an equalized scale of education and of a community of privilege to practise to all entering on the threshold of professional life, not forgetting its useful re strictions as to druggists, "et hoc genus omne."

But like the acts which have preceded it, and relate to the profession, as we have noticed, its concocters have con trived, seemingly with studious insult, to present, in the cup of general alnelioration, a few bitter and riepulsive drops to the inembers of the profession,-apparently alwa3 s for the purpose of cooling, if not of quenching, their clamour and zeal for obtruding their grievainces, real or imaginary, so often, as of late they have been alleged to do, before the public eye, and for venturing to bring the nauseous subject of physic before the patricians of the legislature. It was surely enough for poor-law surgeons and parish vaccina

tors to subject their talents and time to a Dutch auction, and to suibmit their surgical and medical administration of vaccination to the wisdom and scienice of operative farmers and slopsellers, in the absence of any medical board of appeal, without inflicting upon the whole body of the pro fession the still deeper degrading measure of registering their name, address, and qualifications, annually, with the common sub-registrars of births and deaths, loaded with the clharge of a fee, as if they were a community of licensed

beersellers and pawnbrokers, who required an annual re vision of their conduct and pretensions, before they were again allowed to serve the public.

Such beinig some of the principal causes which have

slowly and accumulatively, led the profession to its present state of redundant supply of practitioners, and to the agi

tation, compulsory competition, and the humiliating griev ances that exist among a great majority of its menmbers, it

remains, in the second place, to consider in vhat manner all these suibjects of complaint and of unwholesome polity

may be inore or less alleviated, if they cannot be vholly

removed. From wlhat lhas been stated, it may be seen, that seve

ral of the injurious circumstances under which the pro fession labours, cannot be remedied by any extraneous aid or interference, fiscal, academic, or legislative-such as the redundant supply of medical anid surgical talent above the

demand required for the public health. This excess is already beginiiiic to correct itself, from internal reaction, as all other disposable commodities do, wlhen they exceed the demanid. Notwithstaniding the rapid increase of popu lation, all the schools of late years are remarked to be

attended by a diminished niumber of pupils; and in the

provinces to the north of England, and, it is believed, in other parts of the kinigdom, practitioners of late find great difficulties in getting apprentices, wlho are diministhed to one half in many of our large towns, and their place is

more or less supplied by salaried assistanits. This paucity of young aspirants does not arise altogether from the in creased expense of education, nor fromi the fear of the

examining ordeals for a diploma or license, but from parental and other calculations of the prospective bad re turii for the money anid time that must be expenided on

their clhildren or wards' education. It is, moreover, to be expected that this discouraging sentiment will prevail for some time, as young, men now will perceive that the

avenues to profitable employment are becominig more and more less easy of access, from the inicreasing numiiber of

inedical cliarities, and the monopolies of early practice

being forestalled by poor-law surgeonis and vacciniators, wlhose election more ofteni depends on the party politics of the place than upon any other claims.

N

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162 D)R. BLACK ON MIEDICAL REFORM. I

To similar internal means of remedy must be referred all that relates to the dissensions, unfair competition, and selfish jealousies that exist among the members of the pro fession itself. These are past all external surgery, and the patienits muist adminiister to themselves.

We come now to the external means by which some of the evils which we have pointed out as bearing on the pro fession may be ameliorated and cured, as far as can prac tically and to all reasonable puirposes be accomplislhed by legislative enactment and initerference. These may be held to be confined to a measure of public recognition or registration of all qualified practitioners of every degree to one conferring an equalization anid community of privi leges to all regular diplomatists and licenitiates to practise all and every branch of the profession in any part of the three kingdoms, without let or hiindrance-and, lastly, to one regulating the trade of druggists and chemhists, by the granting of licenses after an examination of their skill in chemistry and the materia medica, by appointed phar

maceutists. 1st. The measure of registration of all qualified prac

titioners may be readily accomplished, and without any disparagement to the just dignity of the profession, by the practitioner, on his commencing practice in any county or city, exhibiting for once his diploma or license, with his address, to the clerk of the peace for the county, or corpo ration of the city, with the payment of a small fee for the trouble of enrolment; this registration not to be repeated, cxcept the practitioner removes to anotlier county or city,

when it is to be renewed in the new field of his practice. This is a mode very similar to what is adopted in the States of America, and is found to work usefully, as the name of every legal and qualified practitioner in the bounds

may be known by inspectioni of the public register. In fractions of this registration will of course subject the de linquent to penalties.

2d. We now arrive at the most difficult measure to be adopted, namely, the equialization and community of acade

mic honours and privileges; for, whatever many tlhink, nothing of this kind can be allowed and enacted, wvithout the concurrence of the medical corporations who have at present the authority to grant honouirs and qualifications. All, then, that a public enactment can do, is to lay down a minimum curriculum of education, which all the present and future constituted corporations must adopt before the admission of any candidate for examination; to which, it is presumed, there would be little or no objection. The reputation and reveenues of the several schools and colleges will, notwithstanding, be enhlanced by the talents, fame, and acquirements of the several teachers attached to them, and these seminaries will conitinue to be attended during the subsequent progress of study for hiiglher lhonolurs than

will be required for the first noviciate for practice. This equalized mininmum being instituited, the wlhole system is easily put into operation by a declaratoiy enactment, that every practitioner, of whatsoever degree, is at freedom to practise all or any branch of the profession according to his pleasure, in any county, town, or city in the three kingdoms, with the restriction that he can only recover at law for his fees or professional remuncration, according to the grade of the diploma or license wlhiclh lie actually possesses at the time his clharges were incurred. This national. privilege is to be peremptorilv claimed and allowed, witliout let or hinidrance, in any county or mtinici pal corporation, on the exhiibition and registration of thie diplonma or license with the auithorities abovementioned. The principal difficulty to be overcome in this measure is the equalizzing the culrricultum of education throughout the three kingdoms; but it miglit be easilv remiioved, by eitlher reducing the period of apprenticeship ifor the apotliecaries' license in England, or by insistinig oni an extended couwrse

of attendance on lectuires anid practical plharinacy fiom those wlho were eduicated in Ireland and Scotland, or who did not choose to serve the five years' appreniticeship in Englaiid.

The third measuire required to be enacted by the legis lature is the regulation and licensing of druiggists and chemists. For this ptirpose, a regular apprenticeship- of at least three years to a licensed druoggist or chemist should be required, with the ordeal of an examination before the Apothecaries' Company in London, or three of their dele gated licentiates in the country, as to the person's conipe tenit knowledge in materia medica and chemical pharmacy.

This certificate lhaving been obtained, its exlhibition to the supervisor of excise of the district will enititle the lholder to open business for the sale and dispensing of medicine. This license not to be transferable, and to be yearly re newed, similar to the licenses granted to tea-dealers, tobac conists, and spirit-dealers, from whom it is not more necessary to require an annual pledge and guarantee for intelligence and carefulness, than it is from those who deal in articles more directly affecting the health anid lives of our fellow subjects. The institution of this measure may be said to go so far as to legally recognize druggists and chemists as an integral part of the profession, anid to raise them out of the class of tradesmen. It is true, it would in some degree; but the public requirements demand it for the public benefit, since the old class of apothecaries is niow virtually almost extinct, from the elevation in the scale of society which the increased states of edtucation and its attendant expenses lave given to the inferior grade of the regular profession, by whichl a great void must be supplied by some new creation of administrators to the public health. It need not be remarked that the proposed classs of licensed chemists have their representatives in tlle pharmaciens of France.

Such are the three sin7ple measures submitted to youir notice, and that of your readers, as requiring the inter ference and sanction of the legislature, and to wliichl the

medical corporations now existing can hlave little objection, if they, one and all, would not lendl their aid and concur rence to accomplish them; for they profess to deniude them of no riglhts, privileges, or revenues; and the late proceedings of many of theni hold out assurarnce, that they are desircus to uplhold a course of sound and ample education for all entering the profession, lhowever tenacious

many of them may be oni the subject of exclusive governi ment and election of their corporate officers.

The measures which I lhave proposed contain notling that can be held to be derogatory to any grade of our pro fession, either in the inatter of a single registration witlh an

already constituted and respectable officer, nor yet in jurious to their separate dignities, or to their emoluments, in per

mitting the free exercise of all branches of the profession to whomsoever, of qualified practitioners, it may suiit, thereby leaving the success and fame of every one to de

pend on hiis talent, worth, and industry. Besides, the measures proposed wsill require no new

machinery of boards and commissioners to Le erected, at the expense of the professioni, to exert over its members anl official repulsiveness or a supercilious condescension; nior enmployes, whose situations will likely become the reward or the sale of political influence, and the medium by whichl the profession may be put under the fiscal inquisition and centralized surveillance of the state. Sulch a predica

menit is, by all means, to be avoided, as muclh as it is to be

feared, by every medical reformer, w ho has a respect for the liberty and progress of science, and for the htonour an(d inidependence of the profession; for assuiredly, if such boards for eitlher registration or licensinig be institurted, nieitlher he nor any of hiis bretlhren vill enjoy the beniefits of office nor its salaries.

The subject of quackery lhas niot beenl formallv embraced in the three principal measures lhere propounded, becauise it is presumed that, if government were to give uip the

license-duty on quack medicines, and so withdraw their

punblic counitenianice from-l tlhem, the system of puiblic regis tration of all qjualified practitioners, and the anniual licen sing of druggists and chenmists, would in time puit the qtuack anid hedge-doctor out of tlse pale of public repute,

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NEWCASTLE-ON-TYNE, DURHIANI, AND NORTHUNJBERLAND INFIRMARY. 1G3

as he would be out of that of the law. To instituite any

positive restrictions or penalties beyond tlhis, would never be tolerated by the public, the rich as well as the poor, aind would amounit to an encroachmenit on the liberty of the

subject, who has an undoubted right to call in the services of any person who, lbe may be pleased to tlhink, may benie fit him, either bodily or spirtitally.

Manchester, Nor'. 5, 1840.

NEWCASTLE-ON-TYNE, DURHAM, AND NORTIIUMBERLAND INFIR-MARY.

PRACTICE OF MR. BAI1;D.

CALCULUTS VESICAX-OPERATION-RECOVERY.

(Reported I)y Mr. Taylor, House Sur,geon.)

RFkNNY JOHNSON, at. 4 years anid 9 monithls, Newcastle, admitted Oct. 29, 1810, uinder the care of AIr. Baird, the senior sturgeon. He is a stouit, healthy-lookingr boy, witl flori(d complexion, his mother states that he hias been affected witlh pain and difficulty of voiding turine for two years. There is great irritability of the bladder; frequient desire to pass urine, attended witlh pain and tenesmuiiis urine clear, pale, anid acid, is never tinged with blood elongation of prepuice, from frequent p)llling to relieve the uneasy sensation there ; secretion of bowvels ver y uni healthy, being of a dirty clayey appearanice. A sound was passed into the bladder, and a stone immediately de tected, apparently very small, and glidiing from the point of the sounid ; very little irritation was cauised by the souind ing, which the child bore without complaining. Ordered

mercutry and clialk, five grains; castor oil, twvo drachlms, in the morninig; and a cominon enema every evening.

Nov. 1. Child much easier; stools more healthy; appe tite good ; sleeps well.

3. The lateral operation was performed this inorning at half-past nine, by Alr. Baird, in the usuial way, except that the whole of the operation was performed with a conmmoni scalpel. Little more than a minute elapsed from the coimi

mencing the external incision to the extractioni of the cal culus, wlhich was seized immediately on introducinig the forceps, and extracted ; it is a lithic acid calculus, and

weighs twenity grains. The clhild bore the operation witlh extraordinar-y for titude, and was in great spirits after it was

over; the wouniid was dressed witlh oiled linit, the knees bound togetlher, anid child put to bed.

4. 'fhe uirine passes fr-eely by the wounid; hias lhad a good

night, is quiite easy. Bowels moved once this morning; skin cool, no thirst; lhe continues to do well, never having a bad symptom.

The urinie passed by the urethra on tlhe fifth day, and has continuied to do so more or less ever since; nonie lhas passed by the wound for imiore than a week; it contintues acid. The chil(l is in good spirits; appetite good; sleeps well ; voids his urine freely, and withotut painl ; wouniid very healthy, anid cicatrizinig rapidly, and lhe will be dis charged next week.

PRACTICE OF MIR. IIEATIT.

CALCULUS VESIC^E-oPErCATIoN-RErCo'ERY.

(Reporte(d by Mr. Taylor, Itoulse Surgeoni.)

CHARLES NEVi3Y, et. 3 years, Newcastle, a fine biut delicate-lookiing child, became a lpatiemit of Mlr. Ileath ten weeks ago, labouring ilnider symptonms of stone in the bladder; he suffered trom retentioni of urine and pain in

emptyiing the bladder soon after he was borni, and has been affected ever since with frequent desire to pass Urine, accompanied by great paini; constatnt dribbling, keeping, his clothles wet ; teniesmnius and frequent evacuation of thle bowels; urine occasmonally tinged with blood, otherwise limpidl, acid, and depositinig mnucus; preputial elongatioll, and other symnptoms of stone; lias prolapsus aiu to a con siderable extent, mnuclh increased by tattempts to void urine, with which he lhas been affected the last 12 months: stools

pale and unhealthy. He is of a scrofulous family, some of them are affected witlh scrofulous abscesses and diseased joints. His father suffered from symptoms of stone for many years, but would Inot allowI himself to be sounded; he died in St. George's Hospital two years ago, when, on an examination being made, a stone was found in the bladder. A sound was passed into the bladder, and caused great pain and irritation, with forcible ejection of the urine; no calculus was discovered, but ani indistinct sensation com

municated by the instrument, as if some foreign body was felt of less density, and not producing any sound. It not beinig convenient for his mother to come into the institution at that time with hiim, he was made an out-patient, and his

mother was directed to bringf him frequently to be sounded; somie medicines were ordered, vith the view of allaying the irritation of the bladder and rectum, and improving the secretions. He was frequently sounded at intervals of a few days or a week, sometimes witliout beinig able to detect

a calculus; the child still suffering muclh from the irrita tioIl, a consultation of the surgeons to the institution'was called, and the child again carefully sounded, without being able to detect anly more than the feeling communicated as on the first sounding.

Oct. 24. Mr. Heath sounded the child this morning, and felt a calcuilus distinctly. The child was now brought into the house for the purpose of operation, and some medicines given to regulate the bowels; the child improved in health anid appearance.

Nov. 3. At half-past nine in the morning Mr. Heatl

performed the lateral operationi; the stonle, wlvich was readily extracted, is composed of lithic acid, and weighs 80 grains; a little delay was caused by the tr-ansvserse

artery being larger thani usual, and bleeding so freely as to

require a ligature; muchl inconveenience was also expe rienced from the rectuim, wlhicli was protruided much more

thani usuial. The child was perfectly easy anid clheerful after the operation; the wound was dressed with lint and

oiled silk, and lie was put to bed; the urine passed freely

th1roughl the wound; he continued quiet and easy, and slept

well; boxvels moved gently next morning. 5. Breathing panting and short; troublesome coulgh,

wlhiclh lhe had been affected slightly witlh some time before the operation ; skini hot; pulse frequent; is restless; urine clear, and passes freely by the wound; no uneasiness of

abdomeni. Ordered saline diaphlitis and antimoniials, de niulcents and gentle aperient; but the cough and dyspnoea

continuing, a blister was applied to the chest with great

relief; he conitintued the meidicines a few days, and these

Symp)toms soon subsided ; the urinie passed by the uretlhra

oni the fifth day, but ceased againi and conitinued to flow by

the wouind, w hich has ha1d a little inflammatory blush

airouind the edges, othlerwise lookitngf healthy. 18. Urine las passed fieely by the uirethra for several

days, none passing tlhrouiglh the wound, whlich is lookinig -well and filling up fast. The clhild is daily gaining strength and improviing in appearance; no cou0gh or dyspncea; pulse

regular and natural; appetite good, sleeps well, &c., and

will be fit to be discharged in a few days.

[In Guy's Hospital Reports (lst vol. 1837) Mr. Aston Key publislhed a memoir otn the comparative merits of

lithotoniy anid lithotrity, in whiclh he concluides that, al

though the latter operation is, under certaini circumstances, danlgerous, it is preferable to lithotomy "1 in the majority of

patienits effected with caleuluis." A paper on the subject

of lithlotritv, from the pen of Professor Fergusson, Kinig's

College, appeared in the Edinburgh AMedical and Surgical

Journal for October, 1838. Professor Ferguisson takes a

much more unfavourable view of the operation of lithotrity,

believinig that a great nuimber of those ulpoII whom it is

performed are subsequenitly carried off by chlronlic inflam

mation of the uirinary organs. Some cases of this kind have

recently come under our notice. and otlhers have been N 2

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