702

THE LANCET.

LONDON: SATURDAY, OCTOBER 30, 1880.

WHAT WILL THE GUY’S STAFF DO NOW ?

THE "nursing department" at Guy’s Hospital has-beenagain brought prominently before the public, and the" system ., which the unhappy experience of the last fewmonths has shown to be "in every respect mischievous," iE

apparently as mischievous as ever. On this occasion a

nurse in the surgery ward attended to a " scalp wound," andsent the patient away from the hospital. The next day hereturned, and on examination by a surgeon it became knownthat he had also a fracture of the skull. It is reassuring tobe informed as a "deliberate opinion " that the lapse of timebetween his being sent away and his return the next after-noon did not in any way accelerate the death of this patient;but the fact remains that for a man who had been knocked

down by a cart and sustained a fracture of the cranium tohave his wounds dressed with a lotion and be sent away from

a hospital, particularly when he was" not sober, but smeltof beer," was "not advisable." The nurse herself admits,looking back on the case, that the treatment adopted was notadvisable, and we have it on the authority of a member of thestaff that it was not. The nurse, however, did her best. She

even seems to have taken considerable pains with the case.She made an examination round the wound as far as she

could, and " came to the conclusion that none of the boneswere broken! " Could any policeman have done more ? Thenurse of the surgery ward is clearly entitled to as much sym-pathy as we are accustomed to extend to the police when theyblunder in their discrimination between the drunk and the

dying. It may even strike the public that we are wont tobe a little hard on the police for their blundering, seeing thata trained nurse specially retained on the "nursing depart-ment " of a large metropolitan hospital, and placed in chargeof its "surgery ward, may fall into the same error.The only fault in this case would seem to have been the

effect of an omission to instruct the nurses that in cases of

difficulty they might call in "further advice," and so dis-tribute the responsibility; and that there would be nothingderogatory to the dignity of a representative of the "nursingdepartment" in "consulting the surgeon." He would,in this instance, have coincided in the opinion thatit none of the bones were broken," and then the surgeon’s

evidence would have been available to support the nurse’sevidence, and no possible unpleasantness could have ensued.At the risk of offending the Governors of Guy’s Hospital,we venture to suggest that some arrangement of this natureshould be embodied in a formal rule. The nurse concerned in

the present case said, " As to directions with regard to con-sitlting the surgeons, I have had none directly." We cannotthink the Treasurer, or even the Matron, could seriously objectto giving such directions. There is nothing in itself humiliat-ing in consulting a surgeon, and considering that, afterall, Guy’s Hospital was intended to be a comfort to the poor,it might be well to make this small concession. It would

probably be deemed a pity to do anything which might

seem to imply that the institution could not be carried on bythe Governors independently of the staff, but a mere formalconsultation with one of the surgeons, or even a physician,in a case of obscurity should be gracefully tolerated. The

only persons who could be reasonably expected to object tosuch an arrangement would be the medical officers. There

used to be a feeling prevalent in the minds of medical menattached to hospitals that unless a patient applying forrelief were at once seen by themselves, or one of their pro.fessional representatives, they would rather not have any-

. thing to do with the case. At some of the institutions withinour knowledge-neither small nor unsuccessful in their

, way-the regulations were so definitive and exacting that.

if a nurse had presumed to uncover a wound or apply a! piece of lint or sticking plaster, her zeal without knowledgewould have been recognised and rewarded with instant dis-missal. That was under the old system, when the dressers of a

hospital acquired a practical knowledge of their art by them-selves doing the whole of the dressing, and when every casualtywas attended by an experienced student, in all cases of theleast gravity under the personal superintendence of a qualifiedhouse-surgeon’ ! In those days "nursing " was not a clepart-ment, and nurses did not speak of "consulting " surgeon,but simply acted as servants doing a master’s bidding.What will the Medical Faculty do under the circum.

stances ? They have been told in no ambiguous terms thatthey must accept the system which makes the lay govern-ment supreme in all hospital arrangements. This is part ofthat system. Probably some new " directions" may be issuedfor the guidance of nurses, and in future these persons will

" consult" the surgeon ; but is the profession, and is thecommunity, are the sick poor, to understand that the

physicians and surgeons attached to Guy’s Hospital agreeto administer the charity on such terms ? Is this a satis-

factory discharge of public duty ? Let personal interestsand recondite considerations as to the school and the

hospital be set aside, and the simple question receive a

plain answer-can any staff, humiliated and subordinatedas this medical staff has been humiliated and is subordinated,discharge its duty to the sick poor with credit to itself and theprofession to which it belongs, or with a sincere feeling of self-respect, not to speak of dignity ? We think not, and the

profession thinks not. Already the staff at Guy’s Hospitalhas "withdrawn" and "conceded" until the position it

occupies is logically untenable and altogether incompre-hensible. It is time the patient’s standpoint was takenin this unhappy controversy. No medical man can be

justified in lending his name and the authority of his statusas a practitioner to a system of treatment by nurses,under the control of a treasurer, and matron, and governorswho are all lay persons, doing, or affecting to do, medicalwork. The staff of a hospital cannot take the place of help-meets to the lay authorities. The institution is a medical

charity, and all that relates to the treatment of patientsmust be directly under medical control. The existence of a

"nursing department,"—Which it seems is also a surgicaldepartment,-is fatal to the medical discipline of a hospital.The staff should pluck up courage to tell the Governors thatthey " must " accept the system public prudence and the in-terests of the sick poor require. If the Governors of Guy’s Hos-pital are not prepared to accept the position to which common-

703NEPHRO-LITHOTOMY.

smse and public safety point, let the medical staff retire,anlleave the future of this deplorably discredited hospitalto mfold itself.

Tie announcement that at a meeting of the medical andsurgieal staff, and the lecturers, held last week, a resolutionwas passed earnestly begging Dr. HABERSHON and Mr.CoorE2 FORSTER "not to carry out their intention of re-

signing their appointments," will not fail to stir the pro-fession with a feeling anything but sympathetic. There is

no sufficient excuse or apology for the course pursued. The

possible closing of the hospital and school might cause someprivate loss and a trifling public inconvenience, but what aresuch contingencies as these to the crying evil of a surrender ofprinciple, and the creation of a grave scandal ? It is time

to tell the medical staff of Guy’s Hospital that its policy isout of harmony with the conscience of the great body ofpractitioners to which it belongs. If the physicians andsurgeons of this important institution are animated with adesire to uphold the honour of their profession, they mustclear their position and revise their policy. We have no wishto ignore the efforts they have made, or to undervalue anysuccesses they may have gained. It is much to have pre-vented the introduction of a sacerdotal system and sister-hood ; but more remains to be done, and, rather than accepta position which must needs cripple them, they should resign.

THE operative measure brought before the notice of theClinical Society at its last meeting by Mr. HENRY MORRIS issure to attract attention and to receive criticism. It is one

more instance added to the increasing list of cases where thepropriety of surgical interference in the treatment of diseaseaffecting an internal organ is to be duly considered. The

time has gone by when such interference was regarded withmistrust and met with unflinching opposition; for it wouldseem that the fear nowadays is lest surgery should be too ven- -turesome and should attempt too much. The justifiabilityof excising a calculus from the kidney in the earlier stages ofits formation has, indeed, been often questioned, only to besternly discountenanced. It was held to be a rash, absurd,and even a dangerous procedure by Sir BENJAMIN BRODIEand many writers on calculous disease, both before and sincehis time. And it must be confessed that there were groundsfor this condemnation, not, however, those which made themeasure a dangerous one in itself, for these have been shownto be of slight account ; but those which argued from thefacts of the known history of renal calculus-its frequentencystation or passage down the ureter into the bladder."Nephrotomy," as distinguished from" nephro-lithotomy

"

(which Mr. MORRIS has termed the operation of excision of astone from an undistended kidney) falls under quite a dis-tinct category. For nephrotomy is applied to the incision ofan organ already so diseased as to be past functional re-covery. Nephrotomy has been long practised ; nephro-lithotomy is quite a novel procedure. The objects of theoperation are at least twofold-the one immediate, theother indirect. By nephro-lithotomy the surgeon seeks torelieve the patient from the more or less prolonged suffer.ing entailed by the presence of so irritating a body as aconcretion in the kidney. He also desires by the removalof this source of irritation to forestall those structural

changes which so frequently ensue if a calculus re-

main in the organ. It is almost inconceivable that

a stone should be lodged in the kidney without

setting up such changes. They may be comparativelytrifling ; the stone becomes encysted in a calyx, and thesecreting substance around it becomes atrophied and

indurated. But at any time this calculus may be dislodged,and, if it be not small enough to traverse the ureter, may bearrested there or in the pelvis, and thus become the sourceof hydronephritic disorganisation ; or by its presence it mayexcite pyelitis, with its long train of destructive disease. In

either case the organ is rendered a useless encumbrance, if itbe not an actual source of danger to life. Even where the

stone traverses the ureter it enters the bladder, and after itspassage from the kidney it may have to be removed bylithotrity or lithotomy from that viscus. It is obvious that

much suffering and danger to life would be obviated were itpossible always to remove the primary calculus or calculifrom the kidney itself. This is what nephro-lithotomy isintended to do. Before, however, it can be regarded as anessential operation, it must be shown that other measuresfor relief are inadequate.These measures are those which medicine affords, and it

must be confessed that attempts at the solution of calculi bythe long-continued administration of alkaline remedies are

not so efficacious as might be inferred from their knownaction upon the urine. Many a case submitted to a mostprolonged treatment has been apparently uninfluenced by it,and in the case of oxalic calculi no " solvent " administered

by the mouth has ever had the least effect. Without wish-

ing to take too pessimist a view of the medicinal treatmentof calculus, it must still be admitted that the improvementis very slow, and the actual solution of the calculus probablyvery slight under any method of treatment. The partassigned to medicine lies really more in the prophylaxis ofcalculus than in its cure.

If, then, it ’came to be clearly recognised that a renalcalculus, when formed, tends to increase, or at any rate toremain uninfluenced by remedies, that its very presence isa source of grave destructive disease of the kidney, as wellas a continual cause of suffering, it will be more and moreadmitted that an operation for the removal of the calculusat the seat of its formation, instead of being absurd andrash, is rational and wise. Whether opportunities for suchan operation will be frequent is doubtful, but it is probablethat those cases where the early symptoms are most markedare just those where the calculus is most readily removed.The operation itself, except in the case of large branchingcalculi, as related by Mr. BARKER, should not be considered

dangerous; and even the persistence of a urinary fistulamay be set off as a very minor trouble compared with the

great relief afforded by the removal of the stone. We feel

then assured that the operation is a justifiable one, and areof opinion that it will become established in surgery;and it is not too much to hope it will, in course of time,almost supersede nephrotomy or nephrectomy, which arebeing had recourse to in more advanced stages of renalcalculous disorder than " nephro-lithotomy."

THE approach of November terminates a most gratefullull in the strife of political parties, and calls Ministers toconsider the complexion of their duty in regard to legislative

704 THE ENSUING SESSION AND MEDICAL LEGISLATION.

measures for the ensuing session. Superficial observers andkeen partisans are apt to think that two or three greatduties of the Ministry will swallow up all lesser ones. To

promote the observance of the Berlin Treaty, and to preservepeace in Ireland, according to such critics, is work enoughfor any government. We do not think so disparagingly ofthe present Ministry. And amongst the minor pieces oflegislation which we expect from them is a Bill for the

Amendment of the Medical Acts. This kind of work is

not sensational, and it does not appeal to the passions ofpartisans. But these are reasons rather for undertaking itthan for declining it. The medical profession is expect-ing such legislation, and so are the medical schools andthe licensing boards, in spite of a few indications of an

attempt to believe that the change from a Conservative to aLiberal Ministry has brought some indefinable prospect of anew lease to old and thoroughly indefensible arrangements,and to a General Medical Council which has all the vices of

an old body without the excuse of age.We cannot bring ourselves to believe that the President

and Vice-president of Council will be content with any slightexcuses that may occur to them for neglecting a piece of

reform that was in a fair way of being executed by a Con-servative Ministry, and that contemplates improvement inboth the process and the tests of medical education. It will

be a heartless thing to allow successive generations of

medical students to go on passing increasingly difficult ex-aminations only to procure half diplomas. For ten yearsand more this system of half diplomas has been condemnedby the Government and by public opinion, and by theopinion of the profession. The statesmen forming theexisting Government, when last in power, framed a Bill inalmost every way good, but defective in one respect. It

contained no recognition of the gross faults of the Medical

Council as a Council of Medical Education and Registration,and no provision for remedying them. But for this defect it

must have passed triumphantly. A similar Bill broughtforward now, with clauses amending the constitution of theCouncil, would be heartily supported by the profession,whose interests are not different from those of the public.Very plain facts have been adduced before a Select Com-mittee showing the inefficiency and the costliness of thepresent Council, and that it is framed so as to do the

greatest amount of talking and the least amount of work.All that the friends of reform ask the Ministry at present isto reappoint the Select Committee, granted by the last

Government, which was dissolved with the Parliament, inthe very middle of its work, and to give a fair hearing tothose who wish to see medical schools and boards broughtinto harmony with existing opinion. It is known that some

of the most eminent members of the profession were on thepoint of giving evidence before the dissolution. Is there

anything in the dissolution to make their opinions less

valuable, or the question of medical reform less urgent?Certainly not. We earnestly trust then that Ministers willinclude in their plans of work for the session of 1881 a

Select Committee to be appointed early enough to report intime for legislation. There are no insuperable difficulties inthe way. The profession is very unanimous in its demandfor such a measure. Both parties in the State are committedto it. There can be no rest in the profession or in the

schools till it is passed. And the passing of it will lead toimproved modes of teaching and examining medical studentsby which the public will be the gainers. There is oppositionof course, but it is the kind of opposition that we expect andrather like. It is the opposition of interested and, in someinstances, effete bodies. There could not be a greater libel

upon the existing Ministry than to say that it waited for thesupport of such bodies before proposing measures of reform.

IN a paper in the St. Thomas’s Hospital Reports, 1880,Mr. WAGSTAFFE records the results of careful measurements

of the femur and tibia in twenty-five cases of chronic diseaseof the knee-joint in young persons in whom the union of theepiphyses to the diaphyses may be presumed not to haveoccuired. The fact that lengthening of the femur may occurin such cases has been noted before, but this was an inquiryinto its frequency or constancy, and whether it bears anydistinct and definite relations to the position and kind ofarticular disease. In six of the patients only were thetibia and femur found unaltered in length, the sound

limb being taken as the standard; but in two of thesethe disease commenced after the age of twenty, and

they should, therefore, be excluded. In the nineteen

cases in which alteration in length was found, the femurwas lengthened in fourteen and shortened in one; the

tibia was lengthened in four and shortened in six. In

explanation of these facts, it is pointed out that the femur ismuch oftener the seat of disease than the tibia, and that the

shortening of the tibia may be a part of the general malnu-trition of the limb arising from interference with the circu-lation from enlarged glands in the groin. The manner in

which disease of a bone may be supposed to increase itsgrowth is by keeping up a chronic hyperæmia at the line ofjunction of the epiphysis and diaphysis, where the growth inlength takes place; while a necrosis of the whole epiphysis,or extending to this line of ossifying cartilage, will causeshortening of the bone. Where the disease is purely synovial,or the articular surfaces are only quite superficiallyaffected, there is not likely to be any effect produced on thelength of the bone. In confirmation of these surmises it

was found, on excising the joint in four of these patients,that in two, where no change in length of either bone wasnoted, the disease was purely synovial, or only affecting thebones superficially. In the two others, in each of which thefemur was 2! cm. longer than its fellow, and the tibia normal,the disease "affected the femur with peculiar exclusive-ness." In one of them there was noted acute congestionof the bone, not opposite to the tibial articular surface, butmore deeply along the line of the epiphysis. The increase

in the length of the femur was found to vary from ’6 to

3’1 em., and the average was nearly 2 cm. The practicaldeductions from these observations are, that by a carefulmeasurement of the bones entering into a diseased joint theseat of that disease may be localised ; if when long-standingno abnormality in length is found, it may be decided thatthe disease is synovial ; if one bone is found lengthened itpoints to disease in it with hypersemia along the epiphysialline, while shortening may be due to secondary generalwasting of the limb, or to destructive disease of the bonereaching to the same line.

705THE TREATMENT OF WHOOPING-COUGH IN GAS-WORKS.

Annotations."Ne quid nimis."

THE SEAMEN’S HOSPITAL SOCIETY.

THE policy of the managers of the Seamen’s HospitalSociety is already beginning to bear fruit, and the with-holding of a grant by the Common Council of the City ofLondon shows that at length public criticism is beingbrought to bear on the conduct of the institution. It appearsthat the Seamen’s Hospital Society holds an invested capitalof £112,000, besides the use of the hospital premises rent-free from Government. The hospital is situated in Green-wich, on the side of the river opposite to the docks,and therefore inconveniently placed for the reception ofsick sailors, who on their arrival in port have to be tran-

sported some way round or across the river before they areable to enjoy the rest and comfort which ought to be waitingfor them close at hand. To maintain a hospital for sicksailors at a spot where no sick sailors land, is as absurd asit would be to place a casualty Hospital like St. Bar-

tholomew’s, for instance, on the top of Highgate-hill.The committee have partly seen this, and have so farcondescended to stretch the assistance at their command,as to establish a dispensary where out-patients can

obtain medicine without coming an afternoon’s journeyfor it. But this dispensary does not touch the evil of havingto transport sailors suffering from acute disease across theriver. No wonder that increasing numbers of sailors seizedwith sudden and severe illness apply for admission at thehospitals on the side of the river on which the docks aresituated. Moreover, it is difficult to see why the com-

mittee cling so fondly to their present building, seeing it isanything but fitted for a general hospital. Owing to thesmallness of the wards, the expense of management andthe difficulties of nursing must be in excess of whatwould be the case in wards of better construction,whilst there can be no doubt of their being less wholesome.The committee of the Seamen’s Hospital love to pose as thefriends of " poor Jack "; but really if they had his interestsat heart they would provide him with a hospital better suitedfor his accommodation, and also place that accommodationnear him, so that he might at once find refuge insteadof having to seek for it in his hour of need. With a hospitalbuilding rent-free, accumulated funds of £112,000, and anobstinate adherence to a position which cannot be of the leastvalue to the sick sailor, we do not think the Committee canmake a very serious claim on private charity.

THE TREATMENT OF WHOOPING-COUGH INGAS-WORKS.

A SERIES of recommendations on the treatment of

whooping-cough in gas-works has been made to the Académiede Médecine. A commission was appointed some time agoconsisting of three members, of whom M. H. Roger, thePresident of the Académie, i’3 the sole survivor. He has

presented a report to the Académie which is of some interest.Before considering the communication, he described the

arrangement of the chambers for the purification of gas, andthe chemical products which patients would breathe in them.The purifying chamber is a large room, with doors andwindows freely open. Each contains twenty-four vessels,holding five cubic metres of depurating substance-lime and sulphate of iron, mixed with sawdust,-through which the gas has to pass. When the workmen are

emptying and refilling one of these vessels the children withwhooping-cough are placed around it, and inhale the vapourswhich escape. They are in an atmosphere containingammonium sulphide, carbolic acid, and tarry products. The

statements made regarding the efficacy of this treatment arethe following. M. Commenge records 169 cases in whichthe treatment was persevered with. In 20 the treatmentfailed completely, in 48 improvement was obtained, and 101were cured. M. Bertholle merely states that, of 341 cases,122 were improved and 219 were cured. Failures or deathsare not mentioned. 1B1. Roger points out that these figuresare too good to be quite satisfactory. A method of treat-ment which gives, of 510 cases, 490 ameliorations, and nodeath, would be indeed an admirable result. Buthesidesthe 490 cases improved there were, it appears, 671 cases notincluded because the treatment was not persevered in, andthese probably include a large number of total failures.Moreover, the cases alleged to be cured were not carefullyfollowed up. Evidently also slight and uncomplicated casesonly can be treated in this manner. The remote situation ofmost gas-works, and the exposure involved in the treatmentin winter, limit the application of this method. M. Rogerthinks that it acts only upon one element of whooping-cough-the catarrh,-and that it is contra-indicated in febrileattacks of the disease, and would be positively dangerous incomplicated cases. The method is, however, easy of use insome localities and in summer, and seems worthy of furthertrial in suitable cases, but it is desirable that its effectsshould be more exactly noted.

HOMŒOPATHIC PRACTITIONERS.

THE line of demarcation between homoeopathic and regularpractitioners continues sharply limited, in spite of the effortsof some homceopaths to break it down. Indeed, that itshould be so is for the benefit of the follower of Hahne-mann. He depends for his practice on the crotchets of hispatients, who would not come to him were it not that they"believed (!) in homoeopathy." This being so, the charac-ter of the practitioner is well known to his patients, and insuburban and country districts is well known also to the

neighbouring medical practitioners. They can, and happily,as a rule, do decline professional intercourse with one whosetheories and practice are, as they believe, either foolish or

dishonest, or both, and in any case fraught with peril tothe sick. But medical men at a distance may know nothingof the character of any given practitioner, and, what isworse, they have no means of ascertaining. Homoeopathsconstantly endeavour, as every consultant can prove, to ob-tain consultations without declaring their mode of practice.Many a physician has been summoned by telegraph to adistance to find to his annoyance when he got to his desti-nation that he was called to meet a homœopath. If hehas his suspicions he may telegraph for information on thispoint, but if there is nothing to raise his doubts, he canscarcely do so, and has no means of learning the character ofan unknown practitioner. Every qualified medical man’sname appears in the Medical Directory. The list includesthe names of probably hundreds of homoeopathic practitioners,but in not a single instance is there any indication of thefact. The authorities of the Homoeopathic Hospital latelysent, with characteristic audacity, to many medical men,-to all those connected with medical schools,-a circular

descriptive of the arrangements of their hospital, and

containing a list of the lectures, prizemen, &c. All ofthese are presumably practising hoanmopatliy, but in not asingle case is any intimation of the fact given in the

Directory, nor, in the case of the physicians to the Homœo-pathic Hospital, is their appointment mentioned. We donot know whether this reticence is due to the fact that theEditor of the Directory declines to insert these appoint-ments, or whether it is an indication that homoeopathicpractitioners are ashamed of their sect. Every medical manis assumed to be an orthodox (or, as we would prefer to say,a rational) practitioner, unless he is known to be a homœo-