241

THE LANCET.

LONDON : SATURDAY, SEPTEMBER 16, 1854.

ADDRESS TO STUDENTS.

FOR more than thirty successive years it has been our annualcustom to address, to those who are about to embark in the

profession of Medicine, such advice as may serve to guide themin their first and most important steps. A false step at theoutset is not easily retrieved. It may exert a lasting andinjurious influence upon the whole future career of the student.He who deliberates well and determines wisely before com-mencing his journey, will travel pleasantly along the road, andmay reasonably expect to attain the goal with safety andsuccess. The necessity of serious deliberation before enteringupon any career is a general and obvious truth; but it is pre-

eminently necessary before adopting the profession of Medi-cine. Whosoever shall survey the requirements demanded of

aspirants to the honours and emoluments that belong to the various professions, whether of Theology, of Law, of Medicine,of Commerce, or of Arms, will not fail to observe that, whilstthe education and mental accomplishments demanded of themedical practitioner are of the highest order, and tested most

rigorously, the honours and emoluments to which he can lookforward are infinitely below those to which the priest, thelawyer, the merchant, or the soldier may attain. He there-

fore who in after-life would escape the bitter but unavailingregret that he had chosen a profession in which the toil is

great and the worldly reward is small, should ponder wellbefore embracing the profession of Medicine. He whose

ambition leads him to aspire to great wealth, social distinction,high place, and an honourable and peaceful retirement, mustseek some other career. The physician lives and dies in

harness. A large and an oppressive share of his time and skill isa free offering to charity-a voluntary and unrequited con-tribution to the public service. But for the man who can

enter upon it in a spirit of humility,-who regards that as thenoblest ambition which aspires to benefit mankind,-whosefaith is expressed in the maxim of BACON, "Efficaciter operariad sublevanda vitse humanae incommoda,"-such a man mayfearlessly and trustfully consecrate his life and his energies tothe practice of Medicine.The science of Medicine, as we have always contended, and

as it is now beginning to be understood, is a science that has afar wider application and a far nobler mission than the limitedduty of leading the sick back to health. In the present age,more than at any previous epoch of the history of the world,men are brought together into immense masses, under a varietyof conditions powerfully and variously affecting the health ofindividuals and of communities. Thousands of human beingsare closely congregated in factories; emigrants and sailors nowcrowd our transports and men-of-war in numbers unheard ofin former times; armies encamp or move about in giganticmasses. The great problem of Medicine now is, not so muchhow to cure a particular case of pneumonia or of fever, but

how to prevent the outbreak of pestilence; to discover and toavert all the causes of epidemic and endemic disease ; in oneword, how to increase the sum of human happiness, to removethe most terrible and the most oppressive incubus upon phy-

sical and intellectual activity, by preserving the health of

communities. Regarded in this light, the profession of Medi-cine acquires an importance which it has never yet challenged.When it is considered how many great enterprises by sea andland, of peace and war, may terminate disastrously, if the

health of those who are charged with their execution fail,surely the physician, thus necessarily brought into intimaterelation with the planners and administrative chiefs, mustrise to a conspicuous place in the public esteem. Thus, not

only is the mission of the medical practitioner enlarged,but in proportion as he is found more and more essential to thesuccess of enterprises of moment, it may be hoped that a largermeasure of public honours and rewards will accrue to the pro.fession of Medicine.

We have thought it not unsuitable, as an introduction to theimmediate purpose of this Address, to lay before our youngreaders this comprehensive view of the duties and scope of theprofession we will now suppose them to have selected. To be

qualified for success in a calling having such vast and difficultduties to discharge, demands, we need scarcely say, in the firstplace, a sound and liberal general education. The example setby the University of London, of demanding ample proof ofgeneral knowledge as the condition of initiation into the specialstudy of Medicine, is now generally followed. The matri-

culation examination of the Metropolitan University requires ofthe candidate a competent knowledge of Arithmetic, Algebra,Geometry, Natural Philosophy, and Chemistry; of Greek andLatin classics; of the English language; of History and

Geography; and of either French or German. The Apothe-caries’ Society has also instituted a preliminary examinationframed upon a similar plan. The College of Surgeons has inlike manner caught a partial glimpse of truth. A classical andmathematical examination now precedes the examinations forthe Fellowship. This is something. Hereafter, possibly,another beam of light may break through the heavy portalof Lincoln’s-inn-fields-or as that has a northern aspect, the

light may steal in by the back-way-and the candidate for theMembership, the "ordinary-emergency man," may also be re-quired to show that he can write his native language correctly,and that he possesses the education of a gentleman. But in

any case it behoves the student who aspires to take an

honourable position in a " learned" profession, not to frame hisestimate of the character of the medical practitioner upon theworn-out standard of slow-moving corporations. We therefore

earnestly exnort tnose wno may unnappny nave neuiectecl their

general education, to make the best speed to repair their neglect.We strongly advise those who may feel themselves equal to theordeal, to take the classical and mathematical examinations ofthe University of London, and of the Apothecaries’ Society, asearly as possible. The University examination takes place inJuly. Since the first examination for the degree of Bachelorof Medicine cannot be passed until two years from the date ofthe matriculation, it is the more important not to delay. The

preliminary examination of the Apothecaries’ Society takesplace twice in the year.The preparation and acquirements necessary for passing the

examinations of both these institutions, though varying some-what in extent and degree, are of the same kind. It will be

found most convenient to pass both as nearly as possible at thesame time.

We will now consider the course the student should adopt

242 ADDRESS TO STUDENTS.

in the pursuit of the special knowledge of Medicine. One of of students to all the hospitals in London. This facility shouldthe first questions that will arise, is the choice of a school. It be afforded to third and fourth year’s men, who, having pre-is not our custom to point to any one school in preference to viously acquired the necessary information to enable them tothe rest. In this number of our Journal-a number specially observe profitably, would derive the highest benefit from

devoted to the object of placing before the student every infor- that mental correction which more enlarged experiencemation that can be of use or interest-we have gathered never fails to bring. By the course we suggest, the incon.together under one view the educational capabilities and parti- venience and disappointment that now not unfrequently re-cular advantages of all the Schools and Hospitals in the sult from being tied down within a narrow circle of observa.Metropolis. tion, would be avoided. The individual student would gainIn all of them we believe the student will find adequate much. Science in the aggregate would gain no less. In Paris,

schemes of instruction and competent teachers; and, what is where the hospitals are all under one general management,of greater value, fertile fields for observation, in which he may where no pecuniary impediments obstruct the freest inter-

cultivate his mental faculties, and reap the full harvest of change of scientific knowledge, the student enjoys the advan-knowledge. In stating this opinion, however, we cannot miss tages we have pointed out to the fullest extent. We stronglythe opportunity of adding a remark upon what we have long advise those who are able to do so, to carry the principle yetfelt to be a serious defect in the system of medical education further, and, before they settle down in practice, to enlargein this country. It is a defect which it is very much in the their knowledge of disease, and to extend their mastery overpower of the student to remedy. It is for that reason that we the ills that flesh is heir to, by comparing the practice of ourare the more desirous to refer to it in this place. There is a Continental brethren with our own.

vulgar phrase which describes the medical student in London But even with or without this opportunity of enlarged obser-as "walking the hospitals." The phrase conveys a very false vation, we still do not think the choice of an hospital a matternotion of the reality. The student does not "walk the hospitals." of the first importance. He who brings to the study of hisHis studies are for the most part limited to one hospital-the profession the spirit of independent inquiry; of industry thatparticular institution to which he enters-and to which he pays will not be daunted; and the inestimable quality of self-reliance,his fees. All the rest are practically closed to him. The bound- will not fail to discover in any hospital ample means of instruc-less materials for medical instruction congregated in this vast tion. He who does not feel within him the impulse to learn,metropolis are subdivided into small sections, each entering, to the necessity to work,-who waits to be taught, to have aa very limited extent, the advantages which free access to the contracted-for amount of Anatomy, Physiology, Materiawhole might afford. Should the hospital assigned to him by Medica, Medicine, and Surgery served out to him and packedchoice or accident prove deficient in any branch of Medicine; up for him, as a patient mule waits for the load to be laid uponshould it, as is the case in some, exclude certain diseases, the his back,-will find one hospital as good as another, and allstudent cannot, without great inconvenience and often con- equally useless. Knowledge is for him that seeks it.siderable expense, supply the deficiency by complementary The student, then, has made his choice of an hospital. Howstudy in other hospitals. or in what order shall he prosecute his studies? Upon thisIn addition to this, there is another evil attending the plan point we have little to offer. The curricula prescribed by the

of confining one’s education to the wards of a single hospital. College of Surgeons and the Apothecaries’ Society, define theThe student hears the opinions and sees the practice of a small order in which the several departments of professional educa.set of men. Opinions and practices so taught and repeated tion shall be studied with so much minuteness, that the studentbefore a limited and unchanging audience are apt to become has no alternative but to follow that order. Upon the whole,dogmatic and routine in their character. The reaction upon we will admit that the order laid down is a natural and reason-

the school and the teacher is pernicious. The effect upon the able one. But we are inclined to question the general utilitystudent is to narrow his mind, to check the spirit of free in- of prescribing an uniform course of study that shall in all casesquiry, to foster the slavish and dangerous tendency, "jurare be rigorously and undeviatingly pursued. It may be doubted

in verba magistri. " To counteract this tendency, we counsel whether the adoption of the stringent curricula referred to wasthe student to seize every fair opportunity of extending the not dictated, in a great measure, by a false and unhealthysphere of his observation beyond the hospital to which he is principle of accepting a conventional proof of study, in sub-especially attached. Let him pay an occasional visit to the stitution of proof of knowledge. In our system, certificates ofwards of other hospitals. Let him compare the views and the attendance upon lectures are largely received as equivalentspractice of the physicians and surgeons of different hospitals. for examinations. We could wish that our Colleges and Hall.He will find in this pursuit a most valuable guide in THE would rely a little more upon examination, and be less pune-LANCET " Mirror of the London Practice of Medicine and tilious about certificates. The University of London, which

Surgery." By this course he will shake off many prejudices; exhibits the greatest liberality in the matter of certificates,acquire a more extensive and accurate appreciation of the and leaves the student the utmost freedom in his course of

various modes of treating disease; he- will learn many truths study, institutes the most rigid of examinations. We think it

in pathology that would otherwise escape him; the different will not be disputed that by this policy the University takesand often seemingly opposite modes of treating the same dis- the best security for the knowledge of their candidates.

ease, ending perhaps in the same-result, which he will witness, Attendance upon lectures and hospitals are amongst thecannot fail to give him a more correct insight into the processes means of obtaining knowledge and skill. But knowledge and-of nature, and to enlarge his knowledge of his art. We will skill is the end and aim of study. Our Colleges adopt, verygo a step further. We would suggest that some liberal and rigorously and very absurdly, a sort of police-espionage tesystematic arrangement may-be adopted to facilitate the visits ascertain that the student avails-himself of the means. By a

243DANGER OF TREATING CHOLERA BY CASTOR OIL.

eurious kind of logic they conclude that he has acquired theend because he possessed the means !While, however, we counsel a general adherence to the

course of study prescribed by the Examining and Certificate-receiving Boards, we would caution our young friends againstfollowing it in too literal and servile a spirit. The youngstudent should undoubtedly dissect diligently ; he should

attend regularly the lectures on Anatomy and Physiology;but he should not defer his visits to the bedside to a late

period of study. The observation of disease-of the manifold

appliances of modern surgery and medicine-he should com-mence as early as possible. We will not assent unreservedly tothe maxim of BAGLivi, that, " Ars mediose est tota in. ob- ’,servationibus;" but to a great extent it is undoubtedly true.Books should be used, we will not say sparingly, but discreetly;as guides to clinical observation and original research, not asauthorities to satisfy the mind with the false notion that theycan impart true knowledge, or enable the student to dispensewith personal labour. The reader is not necessarily a worker.For the same reason we would warn the student against

voluminous note-taking. Let him beware of heaping up un-digested masses of extracts or lectures. The man who does

not study out for himself the relations of things, who does notassimilate them, as it were, with his own mental organizationby reflection, profits little by accumulating detached scraps ofwisdom and alien experience in note-books, or even in hismemory. "Memory is not wisdom; idiots can rote volumes.The grafted stock-should that be proud of apples not its own ?"It is by meditation, corrected by experiment, putting to thetest of reason and practice, that we learn to estimate the truthand value of the writings or dicta of others. When we shall

have subjected them to this process, we shall have acquiredknowledge that will never desert us, that will be part of our-selves. The best qualities of the mind, the faculties of com-paring, of judging, and of prompt and accurate decision, willbe thus trained and improved. Intellectual power, often more

valuable than mere knowledge, will be possessed. It has been

well observed by that acute thinker, SYDNEY SMITH, that The" desirable and useful thing is, that we should carry our know-

" ledge about with us as we carry our health about with us;that the one should be exhibited in the alacrity of our’’ actions, and the other proved by the vigor of our thoughts." I would as soon call a man healthy who had a physician’s" prescription in his pocket, which he could take and recover" from, as I would say that a man had knowledge who had no" other proof of it to afford than a pile of closely-writtencommonplace books."In what we have said we have been less solicitous to point

out a precise and definite track to be servilely followed, thanto impress upon our young friends the importance of cultivatinga habit of diligent practical research, of self-reliance, and of ’,

independent inquiry. Promptitude of decision, vigor in action,are the great and indispensable qualities of the practitioner.To acquire these inestimable qualities, study, long and patientobservation, and experience are necessary.

If labour be now more essential than ever before to master

the actual forces of Medicine, there are not wanting otherincentives of a more obvious and immediate kind. The prin-ciple of competition is now largely recognised. Superior meritis every day becoming more and more the acknowledged title topreferment and confidence. The valuable appointments of the

East India Company are now held out as prizes for the mostable. The system will certainly be extended. We are not

without hope that something like the co7icours will be adoptedas the test of qualification for hospital appointments. The daymay yet arrive when men of science and worth will not be com-

pelled to sue for the most sweet voices of brewers, bakers, andgrocers. The advent of this much-to-be-desired epoch, theemancipation of an honourable profession from this degradingservitude, will be hastened, if each one of those whom we

’ are now addressing-the rising generation of students-willzealously and honestly strive, not only to make himself anable practitioner, but to make himself worthy of the professionhe has chosen. Let him remember that he has a duty to

perform, not to himself alone, but to the body to which he

belongs. Let him earnestly strive to maintain and to elevate.the social and political position of his profession. If he do

this in a right and manly spirit, he will not only obtainhonour for himself, but take the surest course to promote the

great end of the noble science of Medicine-the alleviation ofhuman suffering-the welfare of his fellow-men.

IN reply to a vast number of questions which have beenaddressed to us on the subject, and in consequence of commu-nications we have received from numerous practitioners, we donot hesitate to express the opinion, that hundreds of lives havefallen sacrifices, within the last few days, to the treatment ofCholera by castor oil. All experience has hitherto shown that-in nearly every instance, if the diarrhcea and vomiting bestopped at the commencement, a cure is effected. The result

of the mass of facts which have reached us, enables us to say

emphatically, that we consider the treatment of choleraic

diarrhoea by castor oil, and a reliance upon that purgative asthe chief anti-choleraic medicine, to be prolific sources of dangerand death. It would probably not be erroneous to allege thatthe whole of the 2,362,236 persons, which are mentioned as

constituting the population of London in the last week’s Reportof the Registrar-General, are every one-man, woman, and

child-affected at the present moment by the agencies whichproduce Cholera; and that in many thousands of them a fewdoses of castor oil, or of any other active purgative, would besufficient to excite the disease in its most virulent form. In our

next we shall refer to this subject at greater length.

IN the crowded state of our columns this week, we have onlyspace to briefly, but emphatically, urge upon our brethren thevalue and importance of filling up the " Returns of CholeraicDisease" just issued by the General Board of Health. It is

only by the cordial co-operation of medical practitioners insuch a praiseworthy work, that anything like accurate data,can be arrived at for determining the laws which regulatethe fatal disease known as Cholera. We feel confident that the

President of the Board of Health will not be disappointedin the assistance which he will receive in this inquiry from themembers of the medical profession.

MEDICAL BENEVOLENT COLLEGE.-The first legacy of.ei00, bequeathed by the late Mrs. Barr, has just been handed-to the treasurer, by the executor, J. R. Unwin, Esq., surgeon,.of Brixton, at whose suggestion it was bequeathed. As it isdoubtless in the power of many members of the profession-tobenefit the College in like manner, we trust that this is only*the precursor of many such benefactions.

244

THE PROGRESS OF CHOLERAIN THE

HOSPITALS OF LONDON.

THE rapid and fearful spread of the epidemic, in the earlypart of this month, has been especially felt in those hospitalssituated in the vicinity of the principal foci. Guy’s and St.Thomas’s, on the south side of the Thames, receive a gre3,tmany cholera patients, owing to the great prevalence of thedisease in the south districts; and the Middlesex and Uni-versity College Hospitals have also had a large influx, in con-sequence of the sudden and appalling concentration of thecholeraic miasm in a certain portion of the western sub-district:,called St. James’s, Westminster, (Berwick-street, Golden-square, &c. &c.)When we made inquiries at the Middlesex Hospital, on

September 4th, which were kindly and readily answered byMr. Sibley, the house-physician, we found that on that daythere were no less than sixty cholera patients in the house,even the surgical wards having been invaded by them. Mr.Sibley considers that on September 1st, at eight in themorning, (the disease generally appearing, as is well known,a few hours after midnight,) a sudden outburst of cholera tookplace in the neighbourhood above-mentioned; and in thespace of three days no less than 120 patients were brought tothe Middlesex Hospital, a great number being, besides, sent toUniversity College Hospital, for want of room. Most of the caseswere in the last stage, and it may therefore be easily imaginedhow great the mortality must have been. It is reckoned thatabout two-thirds of the patients have sunk. The treatment

mostly used at the Middlesex Hospital has been the saline,with the addition of small doses of calomel, and moderatestimulation.

It will be perceived, that owing to the large number ofcholera patients admitted into this hospital, no separateaccommodation could be thought of; but the wards are keptthoroughly ventilated, and in each of them we remarked largedishes, containing a mixture of manganese, sulphuric acid, andcommon salt. In fact, so plentifully is chlorine evolved, thatthe smell of this gas is readily observed on entering thehospital.At University College there were about eleven cholera

patients in the house on September 8th, the number of admis-sions since September 2nd having been about twenty-five.The proportion of deaths has been nearly one-half, the line oftreatment consisting of small doses of calomel, according to Dr.Ayre’s plan.At Guy’s the same rapid increase noticed in some of the

western districts was observed, and more than twenty-fivepatients were admitted between the 1st and 4th of September;of these, up to the latter date, about seven had died; and onthe day of our visit to the hospital, injections into the veins werebeing tried, but with no evident success. Several cases, (aboutfive or six,) have occurred in the medical wards amongstpatients admitted for other diseases, but no seizures havebeen observed on the surgical side.At St. Thomas’s, on September 5th, there were twelve

cholera patients in the house; and since September 1st nomore than about twenty had been admitted. The mortalityhas been comparatively small, as only one-third have sunk.Of course, all depends on the stage in which patients are

admitted; but we may add, that at this hospital care is takenthat the means used be extremely few, the over-medicating ofpatients being sedulously avoided.At Charing-cross Hospital, up to September 5th, about four-

teen cases have been admitted; this being a great increase,as in our last report this hospital was stated to have receivedbut one cholera patient. The treatment adopted is the sameas we mentioned in the account above alluded to-viz., dilutesulphuric acid and artificial heat.The German Hospital, Dalston, had, up to a recent date,

been remarkably free from cholera cases, but the renewedoutbreak has also been felt here. The sudden influx tookplace on September 3rd, and hardly had the first patient beenadmitted, than a man, already an inmate, and under treatmentfor another disease, was seized with cholera. On Septemberthe 6th, there were nine cases in the house; the deaths up tot’iat date having been only two. Some of the patients wereb ’ought in by the police as accidents, the individuals, amongstw Iiom was an Italian organ boy, having been stricken in thepublic thoroughfares. The treatment adopted by Drs. Sutro

and Weber, in this hospital, consists of small doses of calomeland opium, with moderate stimulation, in the shape of port-wine, &c.At St. Mary’s Hospital, Paddington, we were informed, by

Mr. Ormerod, one of the resident medical officers to the insti-tution, that only one new case was admitted on Septemberllth, and no cholera patients had been brought in for the previousfour or five days. Since the beginning of the epidemic, abouttwenty-four cases of cholera have been treated; the number ofdeaths having been a little above half that number. It willbe perceived that the disease is in this district rapidly de-creasing. Dr. Chambers prescribes calomel when the vomitingis severe and there is but little purging; but when the alvine de-jections are very numerous, he gives sulphuric acid. Thislatter medicine has been found very efficacious; but when thelooseness is not controlled by the administration of the acid,injections of a scruple of acetate of lead to six ounces ofwater have been extremely serviceable. When sickness waspresent without purging, castor oil has been tried, with nosatisfactory results. In the secondary fever, when there wascongestion about the head, Dr. Chambers has ordered leechesto the anus.At the Westminster Hospital eight cases were in the house

on September llth, and it was computed that about eightycases had been admitted since the outbreak of the epidemic.Of these about half had died ; but it should be observed that agreat many were brought into the house in a hopeless stateof collapse. The treatment is still the same as mentioned inour former report-viz., calomel and opium, stimulants, warmbaths, &c. There have been noticed at this hospital severaldistinct outbursts of the disease, when the influx was verylarge, and Dr. Fincham, who has the care of many of thecases, suspects, with some reason, that these outbursts are

owing to a sudden concentration of the virus upon one locality.The patients seized with the disease seem to have inhaled alarge proportion of the miasm, and, indeed, so large, that theorganism soon sunk under its effects.At St. Bartholomew’s there were, on September llth,

twelve patients in Bentley ward, (male,) and about the samein Lucas ward (female.) Since the outbreak, seventy-fourwomen and 120 men have been admitted. Mr. Wood, the residentmedical officer, who answered our inquiries with great readi-ness and courtesy, considers that many of these cases presentedsymptoms which would justify the name of choleraic diarrhoea;these were benefited in a remarkable degree by calomel andopium, (in doses of five grains of the former and one of thelatter,) given more or less frequently according to circum-stances. The number of deaths has been twenty-three femalesand twenty-nine males. Dr. Black has given a trial to coldwater; and some cases have also been treated with castor oiland capsicum, but the results have not been peculiar. Onefact, however, has been clearly elicited-viz., the revivingeffect of the injection of a saline solution into the venoussystem. The proportions have been so regulated as toimitate the saline constituents of the serum of the blood.Mr. Wood has used the following quantities :-Common salt,three ounces; phosphate of soda, one ounce; bicarbonate ofsoda, one ounce and a half; sulphate of soda, half-a-drachm;water, as much as is sufficient, at 98° Fahr., to get a solutionof a specific gravity of 1030. Of this fluid about thirty ounceswere injected in two cases. Both patients were remarkablyrevived by the operation, but died some hours afterwards.At the Royal Free Hospital the epidemic is on the decrease,

as on September 11th there were only twelve cases in thehospital. The deaths have been more than half, and it wasstated that some patients had had no premonitory symptoms.The treatment has been the same as described in our formercholera report, (see THE LANCET, vol. ii. 1854, p. 192,) andcastor oil has been tried, but with no success.At King’s College Hospital there were seven patients in the

house on September llth. Dr. Johnson is still pursuing thecastor oil plan. It is reported that he obtains favourableresults, and that a large majority of the patients have re-covered.At St. George’s Hospital about twelve patients were under

treatment on September 11th, the cases admitted for the lastthree days being about seven, five, and two. Amongst theinmates of the house, the surgery-man and one nurse have died,the latter having had the care of a ward where numerouscholera patients were placed. These are here distributedthrough the ordinary medical wards. At the present timelarge doses of sal volatile are being tried.At the London Hospital seven cases were under treatment

on September 12th, three having been admitted on that