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On the Medical Profession and Its ReformAuthor(s): J. BlackSource: Provincial Medical and Surgical Journal (1840-1842), Vol. 1, No. 9 (Nov. 28, 1840), pp.147-149Published by: BMJStable URL: http://www.jstor.org/stable/25489962 .

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tR. BLACK 09 MEDICAL REFORM. 147

symptoms continue, you proceed to trephine. I might, perhaps, have just supposed the more simple case, where the site of the extravasation and of the injury correspond; but under either circumstance you make your incision, and finding some separation of the pericraniuln, gladlyfeel that all is right. You then apply the trephine, and remove a portion of bone. You have, perhaps, come upon the very spot, and then you have merely to removethe clot. Even if you are at some little distance from it, the serum which has been separated from the clot escapes, and the brain is, iu a measure, relieved from the compression under which it has laboured. Trephine, then, as soon as you have any tolerably certain guide to the situation of the extravasation.

WVhen you have no such guide, and there is bleeding from the mouth, nose, or ears, the case is a very forlorn one, as there is in all probability fracture of the bas of the skull; but still you endeavour to stop further effusion of blood by bleeding and purging, and do what you can to obviate in flammation aTid its consequences by mercury.

You would trephine, then, in case of depressed bone, accompanied by symptoms of compression, or where these symptoms were owing to extravasation of blood, of the situation of which you w&re tolerably certain. There is also another case leading to this necessity, I mean when the formation of matter witlhin the cranium causes pressure, and all its dangerous symptoms. 'This cannot of course occur very soon after an accident, as it must have been preceded by inflammatory action. You would probably have severe pain in the head, hard and rapid puLlse, inito lerance of light and sound, constipation, and perhaps vomitifg. With these symptoms delirium or convulsions may be combined, and then a severe fit of shivering indi cates the formation of matter. The dilated pupil stertorous breathing, and coma, then show that the pressure is aug menting; and if you have any guide to the situatiotn of the matter, the sooner you trephine the better. Perhaps yOu lhave the puffiness of the scalp; for anything which presse on the dura-mater so as to obstruct the nutrient vessels passing into the bone, will lead to separation of the peri cranium, and the exudation of a thin fluid between it and the outer surface of the bone. This it is which causes the piffy tumor, and you can desire no better sign to lead you to perforin the operations which we have several times done in tbis hospital; and though it has not always proved successful, yet the symptoms in all were very considerably alleviated, in one in a very remarkable degree.

I had intended, gentlemen, to have read the account of some of my cases to you, but it is now so late that I must defer it till Saturday, whea I hope they will riot prove less inistructive from the hasty. sketch I have given to-day, of theK general principles of these importanit injuries.

ON THE MEDICAL PROFESSION AND ITS REFORM.

BY 3. BLACK, M.D., MArCHZEaTZR, Member of the Royal College of Physicians, London.

TO THE EDITORS OF THE PROVINCIAL MEDICAL AND SURGICAL JOURNAL.

GENTLMigN,- A9 the question of reconstructing the whlole fabric of the medical profession in the three king doms is still continuing to agitate the minds of a majority of its members, and beginning to excite the sympathetic attention of several others, who have hitherto been either inidifferent to its general interests, or despairing of any beneficial reform ever occurring during their advanced career of practice, I take the liberty of addressing to you a few observations on this subject, which seems now to be approaching a point which will either serve to ennoble the profession and beniefit its followers, or consign its mem bers to renewed grievances and disesteem.

To treat the subject in some methodical manner, and with a practical application, I shall, in the first place, take notice of the present condition of the great body of the profession, with the causes which have of late been ope

rating against its prosperity and unanimit ; and, secondly, I shall propowud what may be considered the most prac ticable mode of promotinig its welfare and peace.

First, one of the principal causes which have tended to bring the profession into its present disjointed and unpro fitable condition, is the overstocked state of its members,

which, like every other serviceable and disposable article, suffers depreciation according to the surplus of the supply, however much the article in question may be of more in trinsic value. That the article of medical and surgical talent, with the power to cure the afflicted and injured, has increased both in value and usefulness, with the in creased relative nulmbers of medical practitionen, is un doubted, and which the enjoined curricula of modern study and the high nature and extent of the examinations of the candidates in all grades of the profession, do satisfactorily testify.

The causes of this overstocking of the profession beyond the demand of the public, are but too evident to its mem bers, and to many of the parents and guardians of young practitioners, and they remotely consist in the demand for medical men being very greatly diminished with the cessa tion of the general war in 1815, during the latter years of

wlhich not fewer than 300 younig practitioners were annually absorbed into the public services of the army and navy alone ! Though the sudden cessation of this demand was immedistely felt among the oeminaries and sources of medi. cal education, and its effects became still more agravated by many of the practitioners discharged from active duty in the public service having thrown themselves into the field of private practice, still tlhe onward culrrent of medical education was not correspondently stopped or regulated, because it had its initial impulse in early youth aad family arrangement; so that its course miglht afterwards be di verted, but it could not be arrested. Medical education, therefore, at first, suffered but.little decrease in the num ber of its followers, even though the Apothec.ries' Act, which was passed in 1815, began to regulate the polity of the profession, by restricting its exercise thenceforth to per sons qualified by their examinations, and also raising, by little and little, the standard of study and of examination, uintil these have now reached a point in the scale beyond which it would seem to be injurious, both for the public and the young practitioner, to advance a step farther, when we consider the ordinary circumstances of the publia health, and the means which the great majority of the people have of remunerating the private practitioner.

Notwithstanding this cessation of the public demand for medical officers, and the legal restrictions placed upon Pll entering the profession in England, young aspirants for medical honours and subsequent practice still continued to crowd into the profession, not only from the stream being diverted from the public services, but also from the in creased intelligence and wealth of the middle class, who became more desirous to give some of the sons of their families a more liberal education than heretofore, and of devoting them afterwards to the professions. The increased expense of education was no check; it was rather an in ducement with many parents to bring their sons up for the medical profession; as it promised corresponding respect ability, especially since the avenues to practice were now

more guarded than formerly, when the profession wasopen to all who had the wiU to bleed, purge, or potion make.

The standard of education was, from time to time, stiU more increased in all our seminaries, with, for several years, a corresponding influx of students, when their num bers became nearly stationary, until they have at the pre sent period rather retrograded; owing not so much to the increased expense and the difficulties of passing through the ordeals of examination, as to the prospect of the most inadequate return, for either outlay of money or expendi ture of time and study, to the great body of young men

when they have embarked in the exercise of the profession, as a means of livelihood

and-of respectable appearance in

society. m 2

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148 DR. BLACK ON MEDICAL REFORM.

In addition to these causes, which have acted to diminish the supply, there are several which have also tended to lessen the demand for medical labour and aid, among the ranks of those already in the profession. The principal of these are, the continuedly improving lhealth of the people, owing greatly to their increased intelligence, and better habits of living and cleanliness,, with less intemperance among the upper and middle classes of society-the greatly increased niumber and well-endowed and supported medical charities, which afford advice and medicine, besides board and lodging, to the destitute, to many thousands of artisans and operatives, who could, otherwise, easily find means to remunerate fairly a private practitioner. The erection of dispensaries in many of our towns has tended practically to abridge the receipts of many a resident practitioner, and the case of one, whose emoluments were reduced by 2001. the first year after a public dispensary was opened in the town in which he practised, is well known to me. It is also notorious that applicants occasionally come to these institutions for eleemosynary relief in hackney coaches, and -with gold watches by their sides. A third cause, which

has. nmoreover, tended to diminish the demand for regular professional aid, is the increased nulmber, and, I may say, the improved ability and importanice of thie class of drug gists and chenmists, who now walk beyond the limits of the mere tradesman, prescribe without hesitation over the counter, and not unfrequently usurp the phlysician's place at the bedside, though they are more tender in invading the surgeon's province-leaving that to the more hardy bone-setter and tooth-drawer.

- This usurpation, on the part of the druggists, of the office and emolument of the apothecary, has arisen, not from any positive or concerted scheme ohi their part to supplant the regular apothecary, but solely from the spontaneous wants of the people, who naturally forsook the regular practitioner, wbhen he exchanged his open shop or surgery for his silver plate and "ring of bells" on hisshutdoor-all betokening an increased charge to his patients-and sought the chemist's shop, open as noon-day, and where all the principal doc tors' prescriptions of the town are filed up in public view, denoting a great amount of medical knowledge in the com ponnder of the articles prescribed.

TIle retail druggists and chemists have thus slowly acquired an increasing importance in pharmacy, and a sphere of usefulness to the public, in proportion to the fs creasing expenses of a regular medical education, and the enlhanced degree and extent of enjoined medical study and examinations, far beyond what the worshipful society of apothecaries ever calculated. '1'heir alumni have now become talented physicianis, while the chemists and drug gists have stepped forward to supply the void that was each year obtaining in the lower walks of the profession; for the public will grant their arbitrary diplomas to those

who will serve them best and cheapest, and besides, "nihil mnajis cegris prodest, quam ab eo curari, a quo volunt."

Suclh are some of the chief causes which lhave served and are still acting to the prejudice of those wlho have of late years embarked in the practice of the profession-tending to contract the demand for, and to lower the emoluments of regular medical skill, and dispensation of medicine, lhowever much the acquirements and respectability of the meembers of the profession have generally increased. It is also not to be overlooked, that such a redundant and, it may be said, congested state of medical supply, has led to an injturious anid degrading competition in many in stances. 'I'he economic spirit of many benefit and other afliliated societies, even among classes in decent circum stances, lhave led them to contract for medical advice and

medicinie with professional men who, in the eagerness to get introduced to a circle of famiilies belonginig to two or three hundred members, have forgotten their own dignity, and engaged to afford professional attendance anid medi cines at rates varying from 2s. 4d. down to 2d. per head

per annum. To this species of self-inflicted inijtury and professional

degradation, has lately been imposed upon the general prac titioner, the public injustice and contempt that have been inflicted by the adminiistrators of the new poor-law. Seenm ingly taking advantage of the immense redundancy of medi cal talent runninty to seed throughout the kingdom, and of the little value the members of the profession tlhemselves placed upon it, by tlheir ardent ambitioii to be so gratuitotus of their time and advice on the most indifferent vacancy occurring in any medical charity, and their contending over the living bodies of lher majesty's economical subjects for an assuranice of health at two shillings per lhead, the commissioners had less hesitation in offering up the pau pers, subject to their tender care and mercies, to the lowest bidder, at so much per annum for attendance and medicine. Howeverlmuch the res angusta domi was pressing on many practitioners, and however much they had spontaneously l owered their backs to the burden, and sold their jewels at a low price, this public treatnment of the profession was universally felt as an insult, and as an attempt to lead them to a step of humiliation and degradation, of which the most necessitous had not previously dreamed. The indignant recoil of the profession has, in some degree, mitigated the first load of infliction; but even if the system of tender

were entirely abolished, the blow which the dignity and honourable bearing of the profession has received will long rankle in its bosom, and stands a chance of never being effiaced, as long as poor-law surgeons are subjected, not only to the fiscal but to the medical revision of men in the condition of society of the generality of poor-law guardians.

It does seem strange, that in the improving condition of society, in the advancement of intellectual knowledge, and in the increasing respect paid to real acquirements in science and art, our profession should be repeatedly sub jected to disesteem and depreciation. No section of the public has been so ardent and so truly industrious in establishing the great benefits of vaccination; and it may justly be said, that it was owing to the exertions of the embodied voice of the provincial practitioners of Eiiglhnd, that the recent vaccination act was made the law of the land. But, it may be asked, not how it has benefited the profession, but how have they been treated by its eniact ments? Here is a subject which has required the most recondite research of experiment and philosophy fromn

medical mep, before its great truths have been established, and yet its administration is consigned to the superinten dence of poor-law guardians, who, without any disparage

menit of their hlonesty or virtue, are, in many places, guiltless of the least worldly knowledge bevond the value of a heifer, or a boll of wheat. One of this honoured fraternity for examining the returns and superintending the administration of vaccination, a most honest and worthy man, is the regular carter of household coals in my neigh bourlhood-having been elected a guardian, through the influence of hiis lanidlord, to have political weight at the

board. Such stopgaps and make-weights form the staple of many of these oflshoots of Somerset House.

The tender system, under a modified form, has, also in this new arranigement of professional employment, met the practitioner on his first attempt to lend hiis services to put into execution the great measure of philanthropy and bene ficence which, but for him and his brethren, would not yet have become a legal eniactment. He is forbidden to come on the ground whichi he had conquered, except on the degrading condition of bowing to a guardian of the poor, and accepting at his hands the small pittance of at most eighteen-pence, anid in many places, one shilling only, for each perfect and well-assured administration of the ines timable discovery of Jenner to all and each parishioner that may apply for hiis services; besides the additional absurdity ai-d degradation of statedly submitting his scien tific returns to this parish officer, whose duties would be

more appropriately restricted to superiintending the beef bones and gruel of a workhouse. 'The act itself contaias in the last clause a sting sufficient to make the highly.

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MERCURY IN PHTHISIS.-STRANGULATED HERNIA. 149

sensitive practitioner recoil from taking an active part in its operations, from its treating his possible infringement of its letter as a felony, punishable only by imprisonment and hard labour, when circumstances may so arise, that it would be a solemn and conscientious duty, on principles of undoubted science and experience, for himn to inoculate, on an emergency, with small-pox virus. I need not here enlarge on the collateral effects which the exclusive public administration of vaccination will have on the general members of the profession. As all, rich as well as poor, may bave their children vaccinated at the public expense, by the hianids of the contracting vaccinators of the parish, and 'as these gentlemIen will naturally be supposed to hiave the choice of the best lymph always at their command, this preference will as naturally create something like a

monopoly in private practice, in favour of these privileged practitioners. Other practitioners who may still be called upon to vaccinate in the families of their patients, will, tberefore, have some difficulty in getting a guinea, or half that sum, as heretofore, for what may be done as teniderly and as effectually for one shilling by others equally talented and respectable. But the profession must not complain, for "Salus populi suprema lex. "

(To be concluded in our next.)

MERCURY IN INCIPIENT PHTHISIS. By RICHARD CHAMBERS, M.D.

(Continued from page 134.)

TO THE EDITORS OF THE PROVINCIAL MEDICAL AND SURGICAL JOURNAL.

GENTLEMEN,-As a detail of the rules necessary to be observed in, or the circumstances most favourable for, the adoption of the mercurial treatment in cases of incipient plhthisis, would be nothing more than a reiteration of wlhat is already written on the subject, I beg to refer my readers to those sources, and shall proceed to an examination of the two cases I have detailed. That there was every proba bility of their terminating in phthisis, we have strong grounds for supposing, botb from an examination of the symptoms, and the collateral circumstances attending them: it is not to be expected that I can positively affirm that they would have had such a termination; but if we (as we all must) daily see cases, presenting the same essential characters, terminating in confirmed phthisis, it would be equally unjust and unpliilosophic to witlhhold from the remedy its meed of praise, because recovery happened unider its administration.*

Thle boy Edwards, exclusive of a family predisposition to plithisis, had been for some months prior to his illness reduced to a state of extreme cachexy, by the unhealthy nature of his trade, and an insufficient quanitity of food. About a fortniglht before I saw him, he had been seized with pyrexial symptoms, accompanied with a severe cough, for which he was attended by a medical man up to the period of iny visit; but it appeared that saline aperients, and a blister to the chest, were the sole measures that had been adoped. On visiting him, I found that, in addition to pec toral symptoms of great urgency, he was nearly exhausted by bypercatbarsis; and I must acknowledge, that the

mercuirial treatment was begun, more with the view of calming the intestinal tube, than controlling the chest affection; and it was with much pleasure that I witnessed the improval of both, pari passu; leeches anid blisters (necessary adjuvants in most cases) were, at the same time, applied over the affected portion of the lung.

That it differed from ordinary bronchitis and pneumo nia, its locality is sufficient to point out; but what I wish chiefly to call the attention of my readers to, is the fact of its aggravation by general antiphlogistic measures, (if the system of superpurgation will be considered as such,) and I eel satisfied, that if scrofulous inflammation pos

* Vide Graves' Clinial Lectures, Medicil Gazseie, 183?; Stokes on Diseses of the Chest.

sesses one distinguishing feature, it is that of its not being amenable to the usual antiphlogistic regimen; and that although local antiphlogistics or depletory measures may be imperatively demanded, we will find them aided by a generouis yet unstimulating regimen.

It may be naturally supposed, that from the favourable results which ensued in the case of Edwards, I would have no hesitation in employing the mercurial treatment in Mrs. -'s case; yet my early prejudices against the mineral were so strong, that I was compelled to resort to it as an alternative; and few cases could have presented a more unfavourable aspect for its adoption. That this will be readily admitted, I doubt not, when it is recollected that one of the patient's sisters had died of phthisis ; that she herself had had the influenza some months previously, from which she but slowlY recovered; some irritation re

maining in the lungs, as evidenced by the cough; and lastly, the locality of the disease, and purulent character of the expectoration. When we consider the little success that attends the autimonial treatment in suispected cases of tubercular disease, are not the cases successfully treated by mercury that are on record, though few; sufficient to inspire us with the hope, that, in addition to its power of controlling inflammatory action, it also exerts some specific action over tubercle ? In the case of

'Irs. -, although it was in consequence of a recent attack my assistance was requested, I am disposed to believe that there were tubercles in the lungs; and the character of the expectoration led me to think that it proceeded froman abscess, an opinion not at all diminislhed by the physical signs, but whtich they were not adequate to decide. It

muist be allowed, that more extended observation is needed, to enable us to discover the truie value of the treatment ntider consideration; but I think we have sufficient evi

dence to induce us to look uupon it as a valuable auxiliary in a disease that has hitherto baffled human ingenuity.

It may be said, that a sufficient lapse of time has not occurred to test the stability of those cases I have detailed: as far as they have gone I have no reason to doubt their per

manency. The first patient has been for some months em ployed in various out-door occupations, and is at this

moment in the enjoyment of excellenit health. I hope to resume the subject at a future period; and should any change occur in either, I shall not fail to mention it.

.

CASE OF STRANGULATED HERNIA IN A CHILD TEN MONTHS OLD.

Br JOOHN VALENTINE, ESQ. M.R.C.S.L.

A RECORD of unsuccessful cases is not very gratifying to the feelings of the practitioner to whom they occur, but yet, if faithfully pourtrayed, may not only be beneficial to himself, but also to his professional brethren. For my part, I am truly thankful for the publication of the PRO VINCIAL MEDICAL JOURNAL, which, being especially in tended for the country practitioner, opens a channel through

which he may preserve from oblivion many an interesting fact, which might otherwise be irretrievably lost. With these feelings 1 am desirous of contributing, through its

medium, my mite to the general stock. Charles Gibbs, the subject of three hernia, (an umbilical,

a right and left inguinal,) all of which were observed a few days after birth, was seen by me on Wednesday, May 17th, 1837, at 2 P.u.t The hernia of the left side was irredu cible, about the size of a large ben's egg, very tense and painful to the touch, the testicle plainly felt at its posterior and inferior portion. The mother says, that on her return home the preceding day, she found the hernia down, and

made several attempts to return it, but they were ineffec tual. The bowels have not been moved since 8 A.M. of

Tuesday. There is now frequent vomiting and fever. The warm bath, taxis, bleeding, application of cold to the

t The father, uncle, and brother are all affected with hernia.

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