333

THE LANCET.

LONDON: SATURDAY, SEPTEMBER 27, 1862.

THE COLLEGE OF SURGEONS AND THE MEDICAL COUNCIL.

THE extension of the Medical Sciences, and the stimulatinginfluence of competitive examinations, acting in every directionupon students, medical schools, and examining bodies, havewithin the last twenty years wrought one change in the schemeof medical education which deserves earnest attention. Pre-

cipitate Reform may be more mischievous than lagging Conser-vatism. The great mass of the present generation of medical

practitioners have received, in addition to the ordinary schoolcurriculum, a kind of training which it is now proposed to denyto their successors. It is probable, notwithstanding, that themajority of the large body of young men who will enter thehospital schools next week will, like their predecessors, com-mence their collegiate career not altogether unprepared. The

custom has long held sway, of making the medical tyro takehis first steps under the guidance of a surgeon in general prac-tice. During this first stage the pupil, or apprentice, is initiatedinto all the routine of medical practice. He becomes conversantwith drugs, acquires skill in compounding and dispensing them,trains his eye in the faculty of observing the physiognomy ofdisease, learns the habits and aspects of the sick and injured,acquires tact in addressing them and in dealing with them, istaught by daily repetition the arts of minor surgery, assists,perhaps, at many major operations, and, in fine, becomes sofamiliar with the general duties of the medical practitioner,that when he enters upon the more meLhodical studies of an hos-

pital school he is necessarily better prepared to profit by thenew course of instruction to which he is advanced than can be

the lad coming direct from the schoolmaster. Not only is thispreparation for systematic study of serious importance, butthere are other advantages attendant upon apprenticeshipwhich ought not to be overlooked. There is a business elementin every profession. No surgeon, however great his scientific

devotion, can afford to neglect the meaner duties of requiringpayment for his services, of keeping accounts, of learning theprices of drugs and of surgical appliances, of regulating theeconomy of his surgery, and of mastering numberless otherdetails of conduct essential to his comfort and success in life.

For all this, the new theory of education, which would cut off

everything but the formal teaching of lecturers and hospitalphysicians and surgeons, offers no substitute. Let any man whohas had some years’ experience in medical practice considerwhat are the elements of his professional knowledge which hefinds most useful in his vocation. Will he not readily avowthat much of that knowledge, and certainly much of thatsavoir-faire which he is constantly called upon to exercise, wasacquired in his early days ? The schools cannot teach this.

Through all the rage for multiplying courses of lectures, it hasnot yet been proposed to found a professorship of medical book-keeping and the management of the surgery. Yet this kind oj

knowledge must be mastered at some time. The new order oj

doctrinaires, in their ignorance of the nature and exigencies oj

general practice, may affirm that the proper time for the acqui-sition of this knowledge is after, not before, passing througt

the curriculum of registering tickets, attending lectures, andpassing examinations. In this case the newly accepted anddiplomatized surgeon would be compelled, before commencingpractice on his own account, to enter the service of an esta-blished practitioner for a year or two in the character of anassistant. After passing through a long scientific training-after obtaining knowledge and qualifications which he has been

taught to believe are of the highest order, and testify abso-lutely to his fitness to undertake all the responsibilities ofprivate practice, he must stoop to the humble position of asubordinate-perhaps to a man whose professional acquire-ments he may regard as inferior to his own. This position ishardly likely to be agreeable to either party. The old prac-titioner will scarcely look with favour upon this highly-edu-cated assistant whom he might possibly be nursing into a

formidable rival. There can, in short, be no doubt that the

present system of taking all this technical work at the firststep in the training of the future medical practitioner is infi-

nitely preferable. During this novitiate, the student has theinestimable opportunity of trying the scope and tendency ofhis physical and mental powers ; he can then, before he is toodeeply committed to his new career, ascertain how far he isfitted for it, and can abandon it with less sacrifice of time,money, and character than would be possible at a later

period. Nor is the argument of those who contend that

it is beginning at the wrong end to set a young man to

aid in the treatment of disease before he has been to the

schools to learn anatomy and physiology, so logical as it

may at first sight appear. There is no more useful, or indeedmore necessary, preparation for the intelligent study of theapplied sciences than some familiarity with the arts to whichthose sciences are applied. It is this previous knowledgewhich gives life and purpose to systematic and abstract study.Nor is it possible for a young man, of such education as will fithim to study Medicine, to spend a year or two in the routineof a country practice without picking up a considerable amountof elementary scientific information. He may, for example,acquire a fair knowledge of human osteology, and learn some-thing of botany and other branches of Natural History. Aboveall perhaps in practical advantage, he is sure to undergo a

thorough training in that free use of his eyes and hands whichis the distinguishing attribute of the dexterous surgeon.Another argument which it is necessary to urge upon the

attention of the thorough going advocates of the new systemis, that rigidly-constructed, exclusive schemes of education areas a rule bad: bad, because they are sure to omit or neglectsomething important; and also bad through the excess of pre-cision inherent in such schemes, which is apt to foster a con-

. tracted and conceited turn of mind. No one who has had

much experience or success in practice or in teaching will, wethink, dispute the proposition that it would be an absurd mis-

. take to throw away as valueless all that immense field of in-! struction which our country hospitals, infirmaries, and work-

houses supply. Much may be learned there that cannot be

seen in a metropolitan hospital. It is a monstrous and mis-

chievous fallacy to assume, as the General Medical Council

. have done, that a complete medical education can be obtainedF in the recognised schools, and that all knowledge obtainedP elsewhere, or in any other manner than that presoribed in’ their regulations, is useless, and ought to be disoouraged. The

common sense and experience of the profession are against the

334 BRIGHTON DRAINAGE.

Medical Council in this matter. The error into which they the western end of the esplanade. Now the sea-way at Brightonhave fallen is even more prejudicial to their authority than is runs strongly eastward, as is well known, and maybe observedthe open defiance of it exhibited by the Council of the College by anyone who takes a cursory glance at the trending of theof Surgeons ; for unless they had erred in substance, the College shingle and sand between the timber groins on the shore, erected.would not have ventured to disregard their injunctions. The to oppose the eastward shifting of the surface. Hence the

conduct of the College, in thus contemning the authority of a sewage of the whole of the Hove district will under the present.State Board on which it is largely represented, cannot be com- management inevitably float past the front of the esplanade,mended. But the Medical Council have committed the blunder and be carried in the current in a direction parallel with theof paralysing their own power by seeking to exert it in a bad King’s-road. Thus no part of the sea in front of Brighton willcause. The best thing to be done is for the Medical Council escape this unutterable defilement. Granting that the sewageto reconsider the whole question on its intrinsic merits in a will be so largely diluted with the sea-water as to cause nocandid spirit, entering upon the inquiry with a humble con- noisome exhalation, which we have excellent practical andviction that they may possibly be wrong, and that the great scientific reasons for disbelieving, there will still be for the

mass of the general practitioners of England may be right in large class of bathers the disgusting conviction that they are

supposing that they can usefully guide the first steps of the bathing in sewage-water, and close to the mouths of large out-medical student. fall drains; while everyone will have the agreeable conscious-

- -- ness that the " bright blue sea" before them is the receptacleWITH a due regard to the wholesome maxim of CERVANTES, of the abominations of the town. All this is no way mys-

we are disinclined to stir up unnecessarily the unsavoury ques- terious or difficult of comprehension ; and even if the emedytion of Brighton drainage; but recent efforts at local drainage were very difficult and very costly, we should not hesitate toon the Hove side of the town are bringing matters to a crisis state the unpleasant truth, and require an effectual change.by greatly increasing the defilement of the sea, and it must soon Although town councillors may growl and lodging-house keepersbe decided whether Brighton shall cleanse herself, or be for ever gnash their teeth at the exposition of their infirmity, yetdirty. Naturally this favoured seaport has the highest advan- they may rest assured that their best friends are not those who

tages: placed in a sheltered valley between the open sea and cry peace where there is no peace, or proclaim cleanliness

wide-stretching Downs, accessible to London within a space of where filth exists, which may serve as a focus for disease. Thetime which is not greater than that which separates the suburbs plan which muniuipal wisdom has discussed for improving theof London from its centre, Brighton has found in the gifts of drainage is simply futile : to carry the pipes a few score yardsNature a source of unexampled prosperity. But that source has further out to sea is only to delay the return of the sewage to- been tainted, the sea is befouled, and the air of the Downs is the shore, not to prevent it, and only to dilute the sewage with

polluted ; and in present symptoms of a declining prosperity more sea-water, not to keep the sea clean. The Hove drainage,may be traced the results of a neglect of those principles of nuisance will still exist, and Brighton will be irrevocablysanitary government which the crowd of visitors seeking health, ruined by the completion of thit fatal system. But there is

and the physicians who direct them, have the right and feel it an excellent, cheap, and perfect remedy, and we have greata duty to insist upon. hope that, one way or other, sufficient pressure may, at thisThe question is very simple, and everyone may easily under- opportune moment, be put upon the Brighton Town Council

stand the existing state of things. At present Brighton is to induce them to adopt it. It is by tunnelling throughdrained in great part on the old and abominable cesspool the chalk, and carrying an underground sewer land-ways,system. This refers mainly to the worst houses. The rest parallel to the sea, to Saltdean, three miles eastward of

are drained into a sewer which empties itself into the sea oppo- Brighton. We may say at once that this is pronounced bysite to the Old Steyne, and a little to the west of the Chain able engineers to be a most efficient and cheap operation:Pier. Here everyone may see a long iron pipe discharging indeed, it is estimated at only £30,000--a sum which is, wefloods of black abomination into the waves, discolouring them fear, too small; but it happens that all the present systemfar and wide, and often floating on the surface and spreading of pipes may be brought into that main conduit, and the

an oily smoothness which extends beyond the extremity of the sewage may be thus carried off three miles to the east, where

pier. Here everyone may smell, especially on a warm day arrangements may be made for utilizing it for agricultural pur-with a gentle south-westerly wind,-which should be the most poses; or, if the Brighton people will have it so, they may castdelicious weather at Brighton,—a noisome stench, which is it into the sea without damage to any local population. The

strongest and most sickening at the bottom of the Old Steyne, Hove Commissioners arc willing to frll into this scheme. Theyand along the Marine Parade, are willing to connect their system with this main conduit,A second outfall has just been created-is, in fact, in pro- instead of continuing their pipes into the sea; but if the reso-

cess of completion ; and thia is why the question presses now. lution be not pretty quickly taken they will carry on their

The western extremity of Brighton, known as Hove, and in- sea-pipes at a cost of some £5000, and then it will be idle to

eluding some of the most fashionable and costly residences, is expect them to incur expense in retracing their steps. It must

under the separate jurisdiction of Commissioners. Until lately be earnestly hoped, then, that the people of Brighton wilthis part was especially ill drained; but since the recent discus- adopt the scheme for carrying off their own and the Hovesion of this dangerous nuisance, the Hove Commissioners re- sewage to Saltdean. We have given strong reasons enoughsolved to cleanse their part of the town, and they have done for adopting this determination : we will add another reasonso by draining rapidly, and on a very complete scale, into the why they should not foolishly resolve to be content with

sea at the line of junction of their district with Brighton proper " standing in the old ways" and draining through the old pipe.- that is to say, opposite to the end of Waterloo-street, and at That great out-fall sewer which poisons the sea opposite to the

335

Old Steyne was actually never built or intended for a sewer;it was built as a watercourse some years ago, to carry off storm

water, and to prevent the overflow of the Preston brook, whichused to inundate the old London road opposite to the " Hareand Hounds." Inhabitants were expressly forbidden to draininto this watercourse, and heavy fines were imposed on anyonewho should violate this regulation. But one after another

of the householders found it convenient to drain into the

watercourse, and the authorities winked at the practice, asthe day of cesspools began to wane and the system of main-drainage became popular, until at present a very large part ofBrighton discharges its sewage into the sea immediately underthe eyes and noses of the dwellers on the Marine Parade andof all who pass along that part of the seaport. As we have

said, the Hove Commissioners now threaten to make mattersworse by draining the western end of the town into the sea

opposite Waterloo-street, and fouling that part of the sea whichis most used by bathers. The plan which we have described,and which is authenticated by excellent engineers and hailedwith delight by a large section of the inhabitants, offers a

speedy and effectual release from these evils. There is no reasonwhy Brighton should not be as healthy as Eastbourne, or anyother marine resort. The inhabitants may be assured that

they will consult their best interests by strenuously endeavour-

ing to make it so ; and, meanwhile, they are under greatobligations to Dr. ALFRED HALL for having the moral courageagain to bring the notorious grievance before the public.

Medical Annotations.

THE REOPENING OF ST. THOMAS’S HOSPITAL.

"Ne quid nimis."

ON the 15th instant, the new hospital of St. Thomas was

opened for the reception of patients at Surrey Gardens. The

rapid and complete conversion and adaptation of the old build-ings to their new and beneficent uses is one of the many sur-prising illustrations of the power of modern organization andskill. The main building is replete with every contrivance forthe convenience and cure of the sick; whilst the most efficientarrangements have been made for the school, with its appur.tenances in the shape of museums, libraries, and dissecting-rooms, in detached buildings on the grounds. The gardens, ex-tending over more than twelve acres, have been carefully re-stored, and will present a feature novel amongst metropolitanhospitals. The student will here, in modern academic groves,pursue his duties in a little oasis of quiet and beauty, includingevery appliance for health, comfort, and relaxation, situated inthe centre of an enormous population, such as can alone requirea large hospital, and supply the elements of medical, surgical,and obstetrical education. The patients themselves will enjoythe advantages of free air, repose, pleasant prospects, and exer.cise to an extent unknown in other London hospitals. Thesituation and capabilities of the place are felt to be so excellent,that the eccentric idea of building a new St. Thomas’s in somedistant rural spot must be abandoned.

THE HABITUAL USE OF ALCOHOL.

THERE is an apparent discrepancy-which will surprise nonebut intemperate teetotalers-between the deliverance of merechemists or physiologists on the subject of alcohol and that ofpractical physicians. There is a great difference between a

purely chemical or physiological view of man and his wants,and the view which physicians in actual practice have presentedto them of man in hard and matter-of-fact conflict with thingsas they are. It is admitted that for a man whose object is todo an occasional feat of mind or body-e. g., the chess-playeror the prizefighter-the right thing is to abstain entirely fromalcohol. But for most people, whose business is not to do featsoccasionally, but common work constantly and cheerfully andfor the longest possible time, the right thing may be to take amoderate quantity. This has not yet been proved, but it isquite conceivable, and we are ready to pay as much heed tothe opinion of serious and unbiassed physicians in this matteras to that of chemists and physiologists. Whatever the truthon this point, it is matter of satisfaction that there is an

important concurrence of weighty opinion in favour of extrememoderation; that whereas the question used to be betweenmuch alcohol and little, the question now is between a verylittle and none at all. There is no medical man now with a

reputation to lose who would venture an apology for thehabitual use of more than a very little alcohol, and this in avery diluted form. If there are any representatives of that oldrace of convivial monsters who could imbibe three bottles ofwine or a score of glasses of punch or toddy, who thought noshame of falling under the dinner-table and needing to have theircravats loosed and their necks adjusted by the attendant page,let them know that their habits involve as great a violation ofall sense and science as of manners and fashion. Such practicesare as unfashionable in our day as bucklcd shoes and short-clothes ; and, so far from being considered conducive to health,are associated only with insanity or disease. The injuriousnessof the habitual use of alcohol in any but the smallest quantities,and these well diluted, is a point on which chemists, physio-logists, and physicians are all agreed. It is to be inferred fromwhat the chemists have already established, that the greatthing that the system does with alcohol is to effect its removalas soon as possible. If the quantity is not excessive, its re-moval is probably complete ; if it is excessive, some is left inthe substance of the brain, the liver, the kidneys, &c. The

physiologists, again, tell us that the smallest quantity of alcoholtakes somewhat from the strength of the muscles, from the abilityto endure extremes of temperature, from the clearness of thehead and the activity of the mind. And, as physicians, weknow how soon the immoderate use of alcohol tells against thebody, encasing it with a layer of fat or lard, destructive of allfineness of outline, either of feature or figure; and, worse thanthis, causing the deposit of fat or oil in the fine structures ofthe internal organs--the tubes of the kidney, the fibres of theheart, the cells of the brain and liver-those organs, be it ob-served, in which chemists have detected the residue of thealcohol not removed by the excretory organs. We think ita most significant fact, one that has not been sufficiently con-sidered, that the organs in which alcohol is found, after beingtaken in large quantities and only partially eliminated, arethe very organs whose structure is known to suffer from the useof it, and the impairment of which lands so many drinkers inBright’s disease, heart disease, delirium tremens, paralysis, andhob-nail liver. The conversion of fine structures, such as gland-cells or muscular fibres, into fat, seems to be one of the naturalways in which, in process of time, organization deteriorates, andlife declines. It is a change which we properly associate with age,but it is strikingly favoured in many persons by what would beregarded as a very moderate use of our stronger beers or ofardent spirits. Alcohol seems to do the work of time.

All these facts indicate the wisdom of using alcohol in anyform with extreme caution, and of preferring the milder pre-parations of it. They go far to justify the strong language em-ployed by Dr. Paris many years ago in reference to ardentspirits : " The art of extracting alcoholic liquors by distillationfrom vinous liquors must be regarded as the greatest curseever inflicted upon human nature ;" and they seem to show

N 2

THE REOPENING OF ST. THOMAS’S HOSPITAL.