No. 3185.

SEPTEMBER 13, 1884.

THE LANCET.

LONDON: SATURDAY, SEPTEMBER 13, 1884.

ADDRESS’TO STUDENTS.As we show elsewhere, the hope for legislation in the

interest of medical education is not merely deferred, it is

killed; and the student who is now about to join our schoolsis little likely to see any change during his pupilage. We

shall therefore make a few practical remarks, which maybe useful in guiding him through the mazes of the differentsystems laid down by the twenty examining boards atpresent in existence.Every medical student must pass a Preliminary Examina-

tion in Arts before he can register the commencement of hisprofessional studies. This Preliminary Examination varies inseverity from the Special Examinations held by 1he Collegeef Preceptors and by some of the medical corporations, suchas the Society of Apothecaries, to the Matriculation andPrevious Examinations of the Universities; that of the

University of London being pre-eminent for severity andextent of range. In all cases, English language, Englishhistory, geography, Latin, elementary mathematics and

elementary mechanics are compulsory, and an option is

allowed between Greek, a modern language, logic, and therudiments of one of the natural sciences, as botany orchemistry. In many modern schools these subjects are

selected for the Local Examinations held by the Universitiesof Cmbtidge and Oxford, and by this means a boy may passa sufficient preliminary during his ordinary school course.Such an examination could easily be passed, one wouldsuppose, by any average schoolboy; but the rejections at theleast exacting of the examining boards are still very nume-

rous, and average considerably more than 25 per cent. Thatthe standard is not unnecessarily high is the testimony ofevery medical teacher, and becomes obvious at every

aubsequent technical examination at which the student

has to appear. Practice in English composition and accu-racy in spelling would seem to be passed over by manyschoolmasters as of little consequence, while other subjectsof less importance are cultivated to excess. Whatever

opinion may be held respecting the relative merits of

Classics versus Science, in the preliminary or general educa-tion, it must not be forgotten that the methods of Medicineare for the most part identical with those of so-called

Natural Science, and hence an accurate training in

mathematics and the education of the observing facul-ties in some branch of natural science are essential to

the future medical student and practitioner. Perhapsthe ideal education for a medical student would be, first

,of all, a good literary and classical education, and thenat least a year’s training in those branches of natural

science that are most intimately connected with medicine-namely, Physics, Chemistry, and Biology. If, however,a boy, intended for the medical profession, gives promiseof good literary attainments and has a gift for the

rapid acquisition of languages, we should strongly re-

commend his being taught Greek instead of the now

fashionable German. Latin is of course a necessity to

every student of medicine. We need not here enter into

any controversy as to the superiority of Greek over Germanliterature, but would merely point out that unless a know-ledge of the former language is obtained at school, it will

rarely be acquired afterwards; whilst German, like French,is best learnt where it is spoken; and a year or two’s studyin foreign schools of medicine is a most valuable means ofenlarging one’s views on the nature, and improving oneselfin many details in the treatment of medical and surgicalaffections. Medicine is cosmopolitan, and ignorance of

the methods and theories of our continental neighbours willsoon be considered a disgrace to us, rather than the badgeof a boasted superiority.Medical studies may be commenced either by attendance

on lectures at a recognised medical school, by attending thepractice of a recognised hospital, or by becoming the pupilof a legally qualified medical practitioner holding the appoint-ment of surgeon to a hospital, general dispensary, or unionworkhouse, or having some similar opportunities of affordingpractical instruction. In all cases a certificate must be

forwarded to the General Medical Council within fifteen

days from such commencement. Most students now godirect from school to the medical lecture-room and hospital,and by doing so no break takes place in their education, andtheir habits of discipline are maintained. Technical instruc-

tion is at once engrafted on their general culture, and thestudent merely passes from one course of study to another ;and great advantages may b9 urged for this plan. TheBOB SAWYERS, BEXJAMIN ALLENS, and RODERICK

RANDOMS of fiction were largely the outcome of the indolentand vicious habits which the old apprenticeship systemso rigorously insisled on in former days did Eo much.

to foster. Five years of more or less idleness in the

country were ill calculated to provoke hard work and

industry when the apprentice was transformed into the

student "walking the hospitals" without supervision orguidance. A year in a provincial hospital, or with a

general practitioner who can devote some time to instructinghis pupil in some of the scientific branches as well as inthe practical routine work of the ptofession, would be wellspent. In most towns teachers of the various sciences

can now be obtained, and in this way a year can

be profitably spent in the country in the study of the

preliminary sciences of physics, botany, inorganic chemistry,and general biology before the more technical medical studiesbe bagun. Moreover, for securing the due familiarity withmedical daily work (the need of which is often felt mostsorely by many a fully, qualified practitioner fresh from thewards of a hospital, when called to his first cases of measles,chicken-pox, or scarlatina), and the tact which is so usefuland necessary in visiting the ick, a year’s pupilageor assistancy is advisable; but in our opinion this

should be deferred to either ju’t before or just after thestudent is qualified. In repeating this advice, we are atvariance with many good authorities on medical education,who argue that acquaintance with minor surgery and

pharmacy cannot be made too early in the career of

the medical student, and so urge an apprenticeship byevery student to a general practitioner as a first step.On the whole, probably a pupilage for a year with the house-

L .

444 ADDRESS TO STUDENTS.

surgeon of a county hospital or provincial infirmary, in

addition to some honest work in chemistry, physics, andbiology, is the best plan of commencing medical studies.Entrance into the profession is thus made more gradual,and it can be more readily abandoned, with less sacrifice oftime and money, should the pupil form a matured disliketo the necessary studies and work, or be incapable of pur-suing them with advantage.Every medical student should obtain an adequate

acquaintance with the various departments of general scienceafter he has passed his examination in Arts, and beforehe commences his purely technical studies. The natural

sciences are so closely interwoven with medical progressthat no student can now be considered well educated who

does not possess an acquaintance with them. It is better

if such a knowledge be gained before entrance at a medicalschool; but if this has not been done, a large part of thestudent’s first year’s study must be devoted to this object.The superiority of a university career is mainly due to theinsistence of the authorities on this desideratum, and manyof the corporations-notably the Royal College of Phy-sicians of London-now make it a prominent feature of theirfirst professional qualification; whilst those bodies who do noturge its importance are sure to suffer in public esteem andprofessional reputation for their lukewarmness in this respect.Chemistry, physics, and biological science are graduallybeing removed from the list of strictly professional to thatof preliminary subjects ; and every qualifying body is draw-ing nearer and nearer to this ideal, so that the work of

the student will be proportionately lightened, and his after-success rendered more certain. A student who cannot

grasp the chief principles of these sciences will but seldommaster the theories and practice of the exclusively medicalsciences and technics, and is at a corresponding disadvantagethroughout his course of study and in his subsequent career asa physician or surgeon. Passing a preliminary examinationin Arts should therefore be followed as soon as possible bypassing the examination in Science which may be appointedby the examining body before which the student intends topresent himself for a qualification or degree.The next step is the commencement of his purely technical

education. Anatomy and physiology should occupy eighteenmonths at least, and a summer session must be devotedt3 materia medica. It is a question of some difficultyas to whether a student should devote any of his time

at this period to hospital work, and if so how much.

There can be no hesitation as to his unfitness for any ward

duties; and we are inclined to think that he will be

better employed in the dissecting-room and in the class

of practical physiology than in the out-patient rooms ofthe hospital. The practical hints gained by attendanceon the out-patient surgeons-for the student at this

stage of his career can learn nothing useful in medicalpractice-are easily acquired at a later period, and too muchtime cannot be spent in the attainment of a thoroughknowledge of the two great sciences of anatomy and

physiology, on which his future art and practice must bebased. Practical anatomy, so far as the grosser structuresare concerned, has long been well taught, and now inevery well-equipped medical school a thorough instructionis imparted in practical histology, in the use of the in-

struments employed in physiological experiment and

research, and in physiological chemistry. The methods

by which the great principles of the laws of healthy actionhave been determined must be clearly understood, and

it is only in late years that such an expression as "prac-tical teaching in physiology has had for the student anydefinite meaning. The coarser anatomical dissections, whichwere alone known to the student of fifteen years ago, have been

supplemented by the finer histological methods and prepara.tions, and the advance in this direction has been so great thata student is now expected to prepare and describe tissueswhich were then seen only as museum specimens prepared byan industrious and expert demonstrator or anatomical assist-ant. The length of time devoted to practical anatomy variesat the different boards, but less than two winter sessions areuseless ; and for the acquirement of the details, a thirdwinter session, when practicable, is of great advantage.Many students return to the dissecting-room after theyhave had some hospital work, and are then well able tosuperadd a knowledge of anatomical detail to their medicaland surgical experiences. Practical work in physiology is notinsisted on by some examining bodies, but this will soon bealtered if these corporations be animated by any desire thattheir qualifications should be held in esteem by future studentsand teachers. It is generally at this period of the curriculumthat the medical student complains of being overworked,and is almost in despair of eventual success. This is largelydue to the manner in which the various licensing bodies haveframed their regulations. Every authority has laid downits own regulations in total disregard of those requiredby other boards. Whilst the student is endeavouring tomaster his anatomy, physiology, and materia medica,he finds that attendances on courses of lectures on che.

mistry and botany are still enforced even by bodies

which do not examine in these subjects, whilst other

bodies which examine stringently in them are contented

with certificates merely showing that the candidate has

received some instruction therein, and that such a certi-ficate may be signed by any capable teacher. If a pre-

liminary examination in Science were made compulsory, asthe examination in Arts now is, all these contradictory andvexatious regulations might be swept away, and the studentcould then obtain his scientific training in any provincialtown; for good teachers in those subjects are no longerlimited to recognised medical schools. There is no reason

whatever but the existence of these regulations for theattachment of science teachers to the smaller medical

schools, which are thereby hindered in developing theclinical side of their teaching. Again, whilst some authori.ties insist on two years’ attendance on clinical lectures

in medicine and surgery, others are content with nine

or even six months, and one body-the Royal College ofPhysicians of Edinburgh-only insists on clinical surgeryL for three months. One of the greatest benefits to the studentL of a one-portal system would have been the reduction

I of these chaotic regulations to a definite and weu-con., sidered scheme of medical education. The regulations of mostI of the examining boards are no longer in proper relation withL modern scientific and practical teaching, and require revision.i They are, in the main, relics of a bygone age, to which, in- some instances, a little modern patching has been added;

445ADDRESS TO STUDENTS.

in others they remain as they existed twenty or thirtyyears ago.

By the end of the second academical year the student shouldhave passed his first professional examination in anatomy, phy-siology, and materia medica. When this is accomplished heshould devote himself wholly to the real object of his study-a good knowledge of the principles of medicine, surgery, andtherapeutics, and every care should be taken to secure a facileexpertness in the use of the various instruments used forthe detection and treatment of diseases in the daily practiceof medicine, surgery, and midwifery. A student should nowspend the greater part of his time in the wards, and shouldalways strive to obtain in-patient dresserships and clerkshipsand similar offices. The more numerous and varied of these

appointments he can hold, the better for his subsequentpractice. At this period of his career it is usual for the

student to attend lectures on medical jurisprudence, patho-logy, and hygiene. The two former subjects are compulsory,whilst the latter is made optional by most bodies. We have

never been able to see the necessity of a course of lectures onsuch an ollcc podrida as forensic medicine ; whilst pathology, tobe of any value, should be essentially practical, and istbepropercontinuation of the course of practical physiology. In the

best schools practical courses of pathology are given on theseUnes, but until the regulations of the examining bodies arealtered the student must still attend the theoretical lectures,although he need have no practical instruction. Coarse

morbid anatomy must be studied in the post-mortem theatreand the pathological museum, and the necessity of embracingevery opportunity of increasing his knowledge in this branchis the more urgent, as the occasions which are presented tothe general practitioner to revive his acquaintancewith post-mortem appearances are necessarily very few.Moreover, it is only by a thorough conversance with themorbid processes and the changes effected by disease that ascientific and proper treatment can be established and

carried out. In the last years of a student’s career he shouldmake every endeavour to secure a resident appointment at ahospital, for this will enable him to gain a familiarity withthe immediate treatment of accidents and emergencies, andgive him a sense of responsibility which such an experiencealone can furnish. The readiness of resource and the calm

discretion which never desert the able physician and surgeonhave usually been acquired by filling one of these appoint-ments. The study of mind disease is important, and attend-ance on the practice at a lunatic asylum is also of greatvalue.

In tracing this outline of the proper course of study fora medical practitioner we have referred to no specialties, forwe are strongly of opinion that every student should becomeas familiar with the diagnosis and treatment of the ordinaryforms of disease affecting the eye, ear, throat, and skin aswith those affecting the lungs, heart, or digestive organs.He should be as well able to use an ophthalmoscope, ear-speculum, and laryngoscope as a catheter or a clinical thermo-meter. No hospital staff discharges its duties to the studentsefficiently unless proper teaching in these subjects is secured

I

for them, and an important xeform would be effected if more ]care were taken to prevent students becoming qualified who i

had neglected these branches. After the student has

obtained his qualification, it would be of lasting service and

a source of much pleasure to him in after life if he

could spare a year for increasing his acquaintance withthese more special departments of our art, and, if pos-

sible, this year should be spent abroad. Paris and Vienna

give greater facilities for studying many forms of dis-

ease, and for obtaining short courses of instruction in

specialties, than perhaps any other cities in Europe orAmerica. By this means, too, a fair knowledge of Frenchand German may be acquired, and the importance of beingable to converse and read in these languages is dailybecoming more and more evident to the practitioner whodesires to keep abreast of medical discoveries and to be

acquainted with the theories on which the progress of medi-cine and surgery are dependent. The names of KoCH,PASTEUR, and LISTER prove that advances in medical

science belong to no one country, and that the relations

of our art and science are less insular now than at anyother period in their history.Before concluding this address on medical education, we

would add a few remarks on our medical qualifications anddegrees. The layman, and even the student, is often hope-lessly ignorant of their meaning and relative value. At the

University of Oxford a degree in Arts must be, and at Cam -bridge usually is, taken as a preliminary to the medical degree,but as this can be obtained by passing a previous examina-tion in classics and mathematics, and then going out inNatural Science (some of the subjects being part of the seriesin the medical curriculum), there is very little difference inmethod or even in time between these universities and thosewhich have separate preliminary examinations in Arts andScience, as the University of London, the Victoria Univer-

sity, and the Scotch Universities. The examination in Arts

at the London University is spread over a most extensiverange, and the Scientific Examination is unnecessarily severe.The papers in physics are especially open to this criticism ;and as under the new regulations this examination must bepassed previous to the commencement of medical studies,and is only held once a year, a candidate should do all inhis power to minimise the possibility of rejection even inone subject, for this will probably act as an effectual barrierto his again presenting himself at this university, and allopportunity of obtaining the degree be lost through thismischance. The U niven:ity of Durham and the Irish

Universities have no separate examinations in science;chemistry and botany are included in their first professionalexamination, but they should be kept distinct. Higherexaminations in Arts and Science are the essential differencesbetween the degree-giving and the mere qualifying bodies, thestandard in technical subjects being quite as high in some ofthe examining boards as at some universities, whilst theenforced curriculum is practically the same. The proposedfusion for examination purposes of the Colleges of Physiciansand Surgeons of London will probably lead to their conjoinedqualifications being considered the general qualifications ofthe modern English practitioner; and they will graduallysupplant the older M.R.C.S. and L.S.A. qualifications.The well-known severity of the examinations in anatomy,physiology, and surgery at the College of Surgeon", andin chemistry, materia medica, midwifery, and medicine atthe College of Physicians, affords an ample guarantee thateveryone who obtains this double qualification - has a

446 MEDICAL STUDENTS AND LEGISLATION.

thoroughly good knowledge of his profession; indeed, from Ià practical standpoint it is quite equal if not superior ito the degrees of some of the universities. The facilitiesfor obtaining degrees in Scotland are so abundant thatstudents who merely obtain qualifications in that countrylay themselves open to some suspicion of idleness or wantof ability to attain the higher hononr. The amount of

practical work insisted on by these bodies is very insuffi-

cient, and contrasts badly with the English and Irish

regulations. A practical injustice is experienced by themetropolitan student in the fact that the same amount ofindustry and intelligence applied to the same course of studywill only give him a qualification in London, which in thenorth of England (Durham) and in Scotland would obtainfor him a degree. Tha University of London does not

concern itself with the average medical student.

Diligence, properly trained intelligence, and health

are the only essentials for the successful pursuit of medi-cine ; but it must always be remembered that they areessentials, and that without them a satisfactory pro-

gress in medical studies is unattainable. The sage

aphorism of the Greek master-" Life is short; art is

long"-is even truer in our day than it was in his.a

- MEDIC 1L STUDENTS AND LEGISLATION.

IN our Address to Students last year we were temptedto say, "Fortunately, the days )f single and incompletequalifications are now numbered; the Legislature itself

deems the evil one to b3 crushed." At that time every-

thing seemed most promising for the passing of a MedicalAct which would secure a one-portal admission to our pro-fession, and we had hoped that this year we should havebeen able to congratulate those who were entering theprofession on a change which would have simplified theircurriculum of study and made it uniform in the three

divisions of the kingdom. We also hoped that we shouldhave had to point out the alterations in the method of

study which the new departure would have caused, andthe modifications which would have been necessary for

those who were desirous of higher qualifications. But all suchanticipations have been cruelly disappointed ; the press ofpolitical questions, the cumbrous working of the parlia-mentary machine, and the opposition of some of our owncorporate bodies, have effectually destroyed a well conceived ischeme for getting rid of our present confusion in medicalqualifications.Where are we now?" medical students may be ready to

ask as regards the prospects of medical legislation. " What

are we to do ? By whit body shall we be examined whenour curriculum is complete? Is there any chance of gettinga complete diploma, the respectability of which shall bsabove dispute?" In answer to the fundamental question"where are we now?" our answer would be, " Very muchwhere your predecessors were ten years ago." It is true

that a Royal Commission has condemned utterly the existingsystem, and that the action of certain bodies as examining

. boards has been severely noticed in the Report of the Commis-sioners. But it is not less true that, except to sanguine minds,there is no immediate prospect of any satisfactory legis-lation to enforce what is so much needed-viz., completeness Iof diplomas, a reduction of the number of licensing autho-

rities from twenty to three, and a fair guarantee of equalityin corresponding examinations in England, Scotland, andIreland. What Sir DOMINIC CORRIGAN called the "Battleof Shops" is suspended when the " shops" are about to bereformed. They then stand shoulder to shoulder, and in Par.liament at the last moment advantage is taken of the periodof the session, or the obstructive forms of the House, toraise new questions, and often petty questions, which

simply strangle the Bill or compel the Government to yieldon vital principles. This is the more easy nowadayswhen nothing excites the interest of the House of Commonsbut a big Franchise Bill or a strong party question. A mereMedical Bill that aims at giving the public better doctors,and students fairer examination and complete diplomas, istoo unsensational to be interesting.Another unfortunate feature in the situation is the deter.

mination of Scotland and Ireland to override England inthis matter, to refuse guarantees to England such as inthe opinion of the Royal Commission are necessary for

securing fairness and equality in the examinations of thedifferent divisions of the country. Medical education andthe granting of diplomas and degrees are to Scotland a

matter of pounds, shillings, and pence ; and in the recentsession, even the Scottish Universities, under the unfortunateguidance of Sir LyoN PLAYFAIR, receded from their dignifiedsupport of the fundamental principle of the Government Bill.There seems little immediate prospect of any effective

legislation. The glass houses will help to hold each

other up. They will effect voluntary combinations in

each division of the kingdom, which will be satisfactoryonly to those having their " interests " in the status quo inthat division. Mere voluntary conjoint boards, dictated byinterest and " trade considerations, afford no securityagainst that degrading. competition which has brought dis-credit on certain bodies, which we need not name. Meantime

we advise students to aim steadily at taking their diplomas and

degrees in that division of the kingdom in which they meantc’practise. While all attempts to gain international guaranteesare foiled, it is safest and most honourable to hold the rightof practice from that division in which one has to work,In this way only is disparagement to be refuted, and abetter and fairer state of the law to be gained. "

0

THE CHOICE OF A TEXT-BOOK.THE question which the student is always asking, and

naturally, is what book will best serve his purpose in pre-paring for such or such examinations. The answer to thisquestion is one which becomes every year more difficult,.The number of medical text-books of a high class is nowvery great ; therefore to select a few from amongst them

may seem invidious. At the same time a list, which by no-means pretends to be exhaustive, can be drawn up that

may prove of value as a guide to the student in his choice.As representing all the various examining bodies, we maytake for this purpose the three London centres-the Collegeof Surgeons, College of Physicians, and the University of.London.

COLLEGE OF SURGEONS EXAMINATIONS.

For the Primary Membership Examination at the Collegeof Surgeons the subject of Anatomy may be well studied in, GRY’s Anatomy, ELLIS’S Demonstrations, or HEATH’S

447CHOICE OF A TEXT-BOOK.—POOR-LAW MEDICAL SERVICE.

Practical Anatomy; and in osteology specially may be men-tioned the works of WARD and HOLDEN. The anatomical

plates of ELLIS and those of GODLEE are very useful in sup-plementing practical work. In Physiology the books mostto be recommended are KIRKES’ Handbook, G. YEO’S

Text-book, and H. POWER’S Elements; and Histology, apartfrom the sections devoted to it in the works of GRAY and

KIRKES, may be read in KLEIN’S Elements. For the PrimaryFellowship there may be read in addition (especially its his-tologieal and embryological sections) QuAlN’s Anatomy,which is the most complete and comprehensive in our lan- ’,guage, FOSTER’S Text-book of Physiology, and GEGENBAUR’s ’IComparative Anatomy. Professor FLOWER’S Osteology ofthe Mammalia might also be read. For the Pass Examina-

tion (Membership) in the subjects of Surgery and SurgicalAnatomy there are the text-books of BRYANT, HOLMES, andERICHSEN’s work, so ably and learnedly edited by MARCUSBECK, the Practical Handbooks of BERKELEY HILL, CHRIS-TOPHER HEATH, and TREVES’ Applied Surgical Anatomy.For Surgical Pathology PEPPER or BILLROTH may be recom-mended ; in Diseases of the Eye, LAV/SON or NETTLESHIP.For Medicine and llTid2viferJ, vide College of Physicians,2nfrc. For the Pass Examination (Fellowship) wider read-ing will be useful, and ERICHSEN’S work may be supple-mented by chapters in the System of Surgery edited byHOLMES and HuLKE. In Operative and Practical Surgerythere are works by STIMSON, FERGUSSON, and S. SMITH,and HEATH’S Atlas. PAGET’S or BILLROTH’S SurgicalPathology and ZIEGLER’S Pathology may be profitably readin connexion with works mentioned under the MembershipExamination. !

COLLEGE OF PHYSICIANS EXAMINATIONS. !The subjects included in the various examinations for the

licence of the College of Physicians, in addition to those Iwhich are also required by the College of Surgeons, com-prise the following:-Chemistry: RoscoE’s ElementaryChemistry, and ATTFIELD’S work. Chemical P7aysics :FOWNES’ Inorganic Chemistry, edited by WATTS..Botany .’OLIVER’S Elementary Botany; BALFOUR’S, or BENTLEY’S, orTHOME’S book. llTateria Medica and Therapeutics: Theworks of MITCHELL BRUCE, GARROD, FARQUHARSON, andRINGER. ]yledicalJurispruclence: Those of GUYand TAYLOR.Public Health: WILSON. Medicine: ROBERTS, BRISTOWE,CARTER, and CHARTERIS. Clinical Medicine: FENWICK,FINLAYSON, and GRAHAM BROWN. Pathology : GREEN,COATS, and ZIEGLER (MACALISTER’S translation), and

WOODHEAD’S practical work.UNIVERSITY OF LONDON EXAMINATIONS.

For the Intermediate M.B. Examination of the Universityof London, the subject of Organic Chemistry may be studiedin the text-books of WILLIAMSON and of FowNES. Materia

Medica, besides the books above mentioned, is more fullytreated in the works of PHILLIPS, BARTHOLOW, and H. C.WOOD. Physiology, as for the Primary F. R. C. S., with perhapsthe addition of such books as that of POWER and HARRIS for

practical work, and of SCHAFER for practical histology. The

anatomical text-books are those recommended for the Collegeof Surgeons. For the M.B. Examination, the subject of

Medicine may profitably be further studied in NIEMEYER’SText-book, in that of AUSTIN FLINT, in some of the articlesof QUAIN’s Dictionary or REYNOLDS’S System of Medicine,

and in TROUSSEAU’S Lectures. Special monographs (seeM.D.) may also be consulted. Pathology, which should beworked at practically, may be studied in GREEN’S, COATS’,or ZIEGLER’S text-books; and also in the works of WILhs

and MOXON, and CORNIL and RANVIER. Midwifery, in thewritings of PLAYFAIR, LEISHMAN, LUSK, and BARNES; Gynae-cology, in those of GALABIN, LOJILE ATTHILL, EDIS, andBARNES. Dermatology, in the text-books of TILBURY Fox,LIVEING, DUHRING, and M. MORRIS. Oledical Electricity,in DE WATTEVILLE or POORE. Medical Ophthalmoscopy,in GOWERS’ handbook. For the M.D. Examination the

candidate will do well to extend his reading to the betterknown monographs, such MURCHISON on Continued Feversand on Diseases of the Liver; Ross, CHARCOT, and WILKSon Diseases of the Nervous System; BALFOUR, BYROM

BRAMWELL, and WALSHE on Diseases of the Heart ;PowELL and WALSHE on Diseases of the Lungs; W.ROBERTS and DICKINSON on Diseases of the Kidney.He will also have to dip into the works of BAIN, MILL, andJEVONS to prepare for the subjects of Logic and Mental

Philosophy, included in this examination.In the foregoing lists we have mostly indicated more than

one work upon a subject; but it is, of coarse, impossible toindicate precisely a single work when so many exist. Acertain amount of choice must be left to the student himself,who will do well to be guided in his final selection by theopinion of his teacher in the particular subject.

0

THE POOR-LAW MEDICAL SERVICE.

CAN we recommend the Poor-law Medical Service as a

field for newly-fledged medical men? Before answering

this question, using a phrase of the schools, " we must dis-tinguish."

" The Poor-law Medical Service may be divided

into two branches: (1) The workhouses and dispensaries,conducted on sound principles. (2) The Pcor-law appoint-ments, held under the old régime, which violate even thelaws of justice. The first c1ass finds examples in suchinfirmaries as Marylebone (London), Crumpsall (Manchester),and in the public dispensaries established in London, Bir-mingham, and other large cities and towns. At these largeinfirmaries an honest attempt is made to carry out fullyhospital principles. There are resident surgeons, assistant

surgeons, dispensers, paid nurses, and a co:nplete hospitalpersonnel. Besides Marylebone and Crumpsall, there are manyother Poor-law infirmaries, which may be placed on a levelwith our subscription hospitals. What are the emoluments

enjoyed by the medical superintendents of these institu-

tions? The honoraria vary, for principal medical officers,from i200 to £500 a year. Marylebone is put down in theMedical Directory at £500 ; Shot’editch at £300, with apart-’ments, rations, and washing; Leeds at £300, with residence ;Birmingham at £250; and Greenwich at £250, with resi-

dence and rations. The assistant medical officers have

usually salaries of £100 a year, with residence and rations.

The opportunities for studying all branches of medicine ina large workhouse are unrivalled. Every form of disease,and especially rare diseases, are therein to be found. Weuse the word medicine in its widest sense, necessarily in-

cluding surgery, so that surgical experience is equally to begained. We have only to point to the work done byALEXANDER at the Liverpool workhouse to impress this

448 ARMY, NAVY, AND INDIAN MEDICAL SERVICES.

truth on our young readers. Any young qualified prac-

titioner, fond of his profession and devoted to scientific

pursuits, will find in these hitherto neglected institutions afield which, if he has ambition and talent, may enable himto rival CHARCOT and PASTEUR. The Salpétrière at Parisis only a large workhouse. What CHARCOT has done there

is now matter of history, and should be known to everymedical student. We therefore mu-<t recommend such ap-

pointment?. They possess another advantage-the disciplineof life may be there learnt. Habits of command, and ofdealing with a large number of persons, are acquired. There

is room for the display of tact, kindness, and skill. There

is a necessary degree of friction in such establishments, andsuch friction has a certain beneficial influence on character.The young practitioner must not expect to find therein a bedof roses, nor will he find life one ; but if gifted with a mode-rate share of common sense, he will be able to pass a few

pleasant and useful years in this official occupation, and inafter-life turn to good account the various lessons learnttherein. There are also workhouses which have non-resident

medical officers, whose salaries vary from &pound;50 to f200 a year,all drugs and medical appliances being found, These

appointments are very numerous, and are sought for becauseprivate practice is at the same time allowed. We need

hardly say that we would advise any young qualified medicalman to accept such an appointment if he can obtain it.

They are thrown open to competition, and though personalconsiderations occasionally influence such appointments, asa rule, in England, the elections are blsed on the candidates’merits and qualifications. All appointments are only worthwhat the man himself can make out of them, and it entirelydepends on a workhouse medical officer as to what positionhe will hold with his own profession, the guardians, and thepublic. This is an axiom we cannot too strongly impress onyoung practitioners.

Besides the union infirmaries there are dispensaries, thesalaries of which vary from 9100 to .6130, all medicine and

appliances being found by the authorities. These appoint-ments are very useful to young practitioners who have noprivate means. They form a nucleus for the building up ofprivate practice, though there are certain drawbacks in con-nexion with them. The dwellings of the poor are not veryattractive ; for men who are very fastidious, the noisomeccu’t, the foulsome alley, the overcrowded, broken-downtenement, do not present a pleasant picture; and the windthat comes between their nose and their nobility is not

always scented with the perfumes of Arabia.The training of medical men renders them familiar with

unpleasant scenes and odours. Their mission is to cure

and relieve disease wherever found, and it is unfortunatelyamongst the poor that we have the maximum of disease. For

those who are prepared to work, the Poor-law dispensariesoffer a wide field for activity, and those who work honestlyand conscientiously amongst the poor will be sure to reaptheir reward. Medical men are submitted to a rigid censor-ship by the public, and this censorship is exercised withouttheir knowledge, so that the men who are devoted to theirduties are noticed and their work appreciated. Respecta-bility is a word often mieapplied. Some young practitionersmay imagine that it is more respectable to be connectedwith a voluntary dispensary, where medical services are

unpaid. The class of work in institutions of this kind very

closely resembles what is done in the Poor-law dispen.saries. Respectability was once defined by a witness in acourt of law in this wise. A counsel asked whether a certain

person was respectable. The answer came that he was.

"But how do you know this," retorted the counsel. "Why,he keeps a gig." The same kind of reasoning makes thedifference between the honorary surgeon of a voluntary dis.pensary and the paid surgeon of the State dispensary. Re.

spectability does not consist either in keeping a gig or hold.ing any class of appointment. Something more is required; sothat our young friends must not be deterred by a shibbolethfrom entering into a service in which they can gain bothpecuniarily and scientifically.We must now briefly allude to the second class of Poor-law

appointments. Under the old tender system surgeons con.tracted for the treatment of the sick poor. Remnants ofthis custom still exist, though the tender systems has beenabolished. Excessive competition has effected in many partsof England such a reduction of salaries that the worst evilsof the tender system are preserved and the sick poor as muchneglected. There are numerous Poor-law appointments, thesalaries of which vary from &pound;12 to &pound;50 a year, and out of

such salaries the medical officers have to find all drugs,medical appliances, &c. We have so often spoken of the in.j astice to the sick in such arrangements that we need notagain repeat our strictures. It is a moot question as to whois the most to blame-the Local Government Board, the guar-dians, or the medical officers. It is known to the authorities

that under such circumstances the sick poor cannot receiveadequate medical attendance. The medical officer cannot

afford to give away medicine. He cannot discharge his dutiesconscientiously, and such a system is a mere farce. These

appointments may be taken by very needy men, and the-poorer the men the worse is it for the sick poor. We need

hardly say, then, that we would not counsel any youngpractitioner to accept an appointment the duties of which hecould not conscientiously perform.We trust that with the progress of the educational influences

now being brought to bear upon those who are connectedwith hospitals and other public charities, the proper andefficient treatment of the sick poor will be embraced in a

comprehensive scheme, which will place union infirmariesand dispensaries in their proper position as State-supportedinstitutions of the utmost importance to the well-being of

society, and therefore worthy of taking rank with oar volun-tary hospitals and dispensaries.

ARMY, NAVY, AND INDIAN MEDICALSERVICES.

THERE are three branches of the public service in whichthe appointments are open to the profession by competitiveexamination-the Army, the Navy/and the Indian Services.The examinations take place twice a year, in February andAugust; the number of appointments to be made variesaccording to the requirements of the service, but is statedin the advertisements notifying the date on which theexaminations are to be held. To be eligible to competecandidates must hold the double qualification to practisemedicine and surgery, must be registered under theMedical Act, and must not be under twenty-one nor above