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purely gratuitous machinery, and the whole sum subscribedhas been applied to the purposes intended. The medical gen-tlemen who kindly became almoners in their respective districtswere in a position only too completely to become personallycognizant of the nature and extent of distress, and were able toselect the most deserving cases. The total sum received and

expended is X362 3s. 7d.

MEDICAL EDUCATION.

No. I.

WE cannot better preface the analysis of this importantsubject than by the following observations, which are from the

pen of an accomplished physiologist and teacher of very greatexperience:-Having been for many years engaged in teaching an impor-

tant branch of medical science in London, I am glad to availmyself of the widely diffused columns of THE LANCET to submitsome remarks on the subject of Medical Education, to whichthe attention of the London teachers was invited in that

journal for February 20th.I have carefully read Mr. Syme’s " Observations on the pre-

sent state of Medical Education;" and, with the highest respectfor that distinguished surgeon, I must confess that he appearsto me, on the one hand, to have altogether undervalued themarvellous advance of all the higher branches of medical sci-ence, and the great improvements that have been during thelast thirty years introduced into the curricula of the licensingbodies; whilst, on the other hand, in some most fundamentalpoints he has enunciated principles which, if they should beadopted, would throw back our science into something like amere handicraft pursuit. In expressing this opinion, it is notintended to be denied that there are still many defects in the

existing system, both as to teaching, and especially as to thesystem of examination, which we may hope will be rectifiedby the Medical Council; and Mr. Syme has rendered a greatservice by forcibly directing the attention of the profession tothis important question.A careful and candid consideration of the existing regulations

of the several examining bodies of London* will, it is conceived,convince any unprejudiced person that they are admirablyadapted to ensure a sound scientific and practical knowledgeof medicine and surgery; that they embody all the leadingprinciples which, for years, those who are interested in thisgreat professional and social question have laboured to secure;and that therefore they ought not to be lightly yielded up atthe bidding of querulous objectors or of the admirers of anantiquated and effete system of teaching. For one, havingclosely watched the successive development of the educationalsystem, I would offer my humble tribute of respect to thelicensing bodies of London for their enlightened and most suc-cessful endeavours to raise medical education to that highstandard by which it has at length been placed in harmonywith the advanced state of modern science, and with the re-quirements of enlightened public opinion.The great complaints against the existing system relate-

1st, to the multiplied courses of lectures ; 2nd, to the extensionof their respective subjects; 3rd, to the frequency of examina-tions. In regard to these allegations, Mr. Syme remarks, thatwhen, some forty years since, he was a student, chemistry wasa science which lay within the limits of a moderate compass,whilst it is now of such boundless extent as to require the mostcomplete devotion of time and talent for its successful cultiva.tion ; that botany in his day was nothing but an agreeable recreation, "touching flowers and fruit," instead of being as atpresent, with its terminology and microscopy, " one of themost oppressive weights on the student’s mind;" that moderr

* I quote those contained in the Medical Directories for 1863.

anatomists, "by means of their microscopes, have opened upan entirely new field of inquiry, and have thus extended theirresearches far beyond what the wildest imagination could haveanticipated ;" whilst as regards practical subjects there hasbeen a corresponding development, as an illustration of whichhe states that one of his colleagues "had placed in the handsof his pupils a printed list of no fewer than 800 fevers."* Thisis rather an alarming summary ; but it seems this redundanceof lectures " shrinks into insignificance when compared withthe inconvenience caused by the present system of examina-tion." " Mr. Syme says-" After thirty years’ experience as anexaminer, I feel quite satisfied that these means of ascertainingthe extent of qualification are productive of little good and verygreat harm, since they afford no trustworthy criterion of realknowledge, and most seriously interfere with the concentrationof mind requisite for obtaining a firm grasp of it." (Obs., p. 10.)The result of all this lecturing and examining is, according

to Mr. Syme, that the student has little time for practical studyin the dissecting-room and the wards of the hospital; that thesubjects to be inquired into are now so numerous that they arenecessarily divided and taken at different times of the student’sprogress, so that he is never free from the dread of a comingtrial; and that thus distracted, and with all the looming horrorof examination before his eyes, he is professing to study onething while he is thinking of another.

If all this were to be accepted as a true delineation of thoexisting condition of medical science, teaching, study, andexamination, the outside public might well inquire whether itwould not be better for their interests that the whole machineryof instruction should be laid aside, and every professor of thehealing art be left to qualify himself after his own devices. Itmay well excite surprise to hear a distinguished professor of arenowned University lament over the development of theseveral branches of medical science ; to see him cast a longingeye to those good old times when chemistry was only on alevel with ordinary intelligence-when a knowledge of medi-cine was considered by the pure hospital surgeon to be a need-less if not a rather contemptible incumbrance - and whenanatomy consisted of a coarse process of manipulation, whicha sharp butcher-boy, by substituting a scalpel for his knife,would pretty well master in six months.Having had a tolerably large experience of the old and the

new systems, I am, however, willing to admit that practicalstudy has, from some cause or other, declined, and especiallythat the practice of dissection has greatly diminished in lateryears ; and as this knowledge lies at the very basis of all medi-cal and surgical science, the source of this great evil deservesthe most searching scrutiny. The result of a careful inquiryleads me to conclude that the neglect of practical anatomy de-pends on several concurrent but distinct causes :-

1. The entire change introduced by the Anatomy Act of thelate Mr. Warburton into the mode of supplying the anatomicalschools with subjects. Formerly it was a great object-as allwho were then engaged in teaching well know-with everyschool to secure by the opening of the winter session a largesupply; the young men, coming to town full of zeal, set towork with a will; the dissecting-rooms were crowded; and animpetus was thus given which never flagged in a well-managedschool. Under the new system it is very difficult, owing towell-known causes, to obtain in the commencement of the sea-son a good supply ; and the pupils, having so much idle timein the intervals of lectures, grow indifferent and discontented.As the cold weather approaches things amend, and for a timethere is some sign of action ; then comes that fatal interruptionof the eight or ten days’ Christmas holiday; after which, sofar as I know, there is great difficulty in restoring anythinglike vigour in the dissecting-room. Again, formerly the medicalsession did not end till the beginning of May-now it termi-

, nates in March ; but, according to my experience, April is oftena suitable month in all respects as to temperature and supplyfor practical anatomy. The abolition of the Christmas vacation,

’ and the extension of the anatomical session to the end of April,would, it is conceived, give a considerable impetus to dissection.

2. According to the regulations of the College of Surgeons,; the student can, at his option, go up to the primary,,examina-

tion, comprising Anatomy and Physiology, at the termination* Observations," p. 7. In a note the number is reduced to 500 or 600. It

is said there are 800 varieties in the forms of the crystals of carbonate of limebut 800 fevers !

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of the second winter session. The result is, that first year’smen, having before them " the looming horror" of their firstexamination, instead of confining their studies, as they should,to dissection and practical anatomy, the only true introductionto physiology, occupy a considerable part of their time withthe latter. The Apothecaries’ Company avoid this error, buttheir curriculum is defective by omitting" Dissections" fromthe requirements of the first year, whilst they entirely banishphysiology from the third and fourth year.

It is further conceived, that to allow the student to set aside,as it were, all concern for anatomy and physiology oa passingthe primary examination at the College of Surgeons, at thetermination of the second winter session, is a fundamentalerror: the last, or "Pass Examination," ought surely to testthe whole knowledge of the student, or what is the good of theextended period of study, four years.

3. As to the much-complained-of examinations, all who areacquainted with the practical working of the present systemmust agree with Mr, Syme, that what with the four examina-tions of the College of Surgeons and of the Apothecaries’Society, and the School examinations at the end of eachsession, the student is liable to be somewhat " distracted,"and is further withdrawn from practical studies. To this- essential point I shall again revert, inasmuch as it would seemthat the existing examining system is not only objectionable as- to its multiplicity, but in the equally essential point regarding’the mode in which it is conducted.

The second great charge is the neglect of " hospital instruc-tion," the supreme importance of which it is impossible tooverrate, being in very deed " the first and the last." Andhere, again, notwithstanding the zealous and persistent effortsof the ruling powers, it is to be confessed that there is muchrequiring amendment. We have plenty of clinical lectures,medical and surgical; but formal discourses, differing but littlefrom the regular lectures, and often, it must be confessed, morecalculated, as indeed they are frequently designed, for themedical journals than for young students, will not give thatpractical, and, so to say, technical familiarity with the multi-tudinous and involved phenomena of medical and surgicaldiseases which is indispensable to successful practice. It isthorough, repeated, and real instruction by the bedside whichis demanded, where the student can freely question his teacher,and compare the oral description with the physical objectsand indications before his eyes ; thus combining the evidenceof the senses with the reflections of the mind, by which alonedurable impressions are made.

It is rather delicate ground to tread on, but somehow orother, either owing to haste, indifference, or manner on thepart of the teacher, our students do not seem to get that insightinto the indications and discrimination of disease which theample means of illustration afforded by our great hospitalsought to secure. A gentleman, now himself a metropolitanteacher, and who had a most distinguished career as a student,writes : " I have known clinical clerks, and attentive ones too,after six months of case-taking, know next to nothing of thephysical diagnosis of cnest affections." Of course a great dealmust in all teaching depend on the teacher himself; and uponthis point the observations of Mr. Syme are well deserving ofattention.* * Where so much depends on personal qualifications,it is difficult for the authorities to prescribe a remedy ; but allwho are familiar with the system of practical instruction in.some of the continental schools must be aware that there is inthe English system room for great improvement, and it is im-possible to doubt that an enlightened review of the whole of- this department would produce a successful result.

Having thus noticed the main points of complaint advancedagainst the existing system of medical teaching, I propose tooffer some remarks in the next number of THE LANCET on theremedies suggested.

THE DISTRIBUTION OF MORTALITY INENGLAND.

A RETURN has just been laid before the House of Commons,the importance of which can hardly be duly estimated whilethe sheets are still scarcely dry from the press. It appearswithout preliminary comment, and is simply headed " AReturn of the Average Annual Proportion of Deaths from

Specified Causes, at Specified Ages, in England generally, and

* Observations, p. 14.

in each Registration Division and Registration District of

England during the Decennial Period 1851-61." Thirty-fivefolio pages of closely printed figures compose this paper; andwe may well be pardoned attempting to pioneer our readersthrough the bristling thicket of numerals within twenty-fourhours after they have sprung into type. There is, however, ahistory attached to this Return which may usefully occupy atten.tion for the present, and which will serve in some measure toindicate the unusual importance of the document which hasthus unobtrusively been given to the public. It was preparedat the instance of Mr. Simon, and forms (to use the wordsof that gentleman, when referring to its compilation in hisfourth Report to the Privy Council), "a digest of all the

mortuary returns elating to the intercensual period 1851-1861,with such distinction of age and sex, and such classification ofcauses of death, as would enable the student to estimate, atleast with approximate precision, how far each district of

England is affected by the several sorts of morbific influence."The extraordinary value of a digest of this character must beobvious on a moment’s consideration. It will furnish at a

glance a knowledge, more or less perfect, of the health-conditionof every district of the kingdom. It will give coherence anduniformity to those investigations which must of necessity pre.cede all sound and comprehensive measures of sanitary improve.ment. It will supply a trustworthy basis for comparing thevarying conditions of health in different localities at differentperiods, and thus will afford an invaluable guide to local health.government. It vitalizes, so to speak, the periodical reportsof the Registrar-General, by yielding that standard of com-parison for the want of which those reports have hitherto failedlargely in immediate utility. Finally, it offers for the firsttime a satisfactory substratum for research into the epi.demiology of the kingdom -into the localization and diffusion ofthe great epidemic disorders. The publication of this digestconstitutes a new epoch for sanitary studies in England. Sucha digest should accompany, and it is to be presumed will infuture accompany, every Census. It is the legitimate, andindeed, it may be said necessary, complement of a Census.The great value we assign to this return is no fanciful or

strained deduction. What the return effects for the whole ofEngland, Dr. E. Headlam Greenhow had already effected forseveral districts, in a paper on the different prevalence of cer-tain diseases in England and Wales, laid by Mr. Simon beforethe General Board of Health in 1858." This paper, togetherwith Mr. Simon’s report upon it, and the reports of the localinvestigations to which, under the directions of the PrivyCouncil, it gave rise, constitute probably the most valuablecontributions to the sanitary and social history of a people inrecent times. They taught the vast excess of severity where-with certain habitual disorders press upon certain parts of thepopulation. They taught that " certain diseases, which amongstthem make up fully half of our annual mortality, are fatal inwidely different degrees in different districts of England."They taught, in fact, with a precision never before approached,the frightful waste of life, and more particularly of adult life,which was constantly occurring in many districts; and howthis waste was largely to be attributed, if it were not entirelydependent upon, local and removable causes.

The form of the present return is at once simple yet compre-hensive. It has been especially devised to meet public needs.It aims at setting before the reader, in the briefest space andclearest manner, the most fatal diseases of infancy and adultlife, classified in the least complex fashion. To have donemore would doubtless, to speak paradoxically, have been todo less. Highly elaborated classifications and a profusionof figures repel most men. It is important that in a workessentially practical in its nature, in which the scientificelement is subordinate to the public want, and which at thebest must present a formidable array of numerals, the arrange-ment should be of the least repulsive character. This has beenmost happily achieved. But it must not be imagined for amoment that, in adapting the return to the public need, it hasbeen thus divested of a strictly scientific character. That thisis not the case will become apparent when we proceed to ana-lyze its contents.

* See " Papers relating to the Sanitary State of England."