« AnteriorContinuar »
not distended; the urine was pale, not albuminous, over acid, depositing uric acid in plenty spontaneously. A great variety of treatment was tried without effect, until the right hand became affected by gouty in-' flammation, whereupon the vesical disorder immediately ceased. Several interesting cases of sacculated, pus-secreting kidneys, conclude Lecture XIV.
Lectures XV. and XVI. treat of gout. Dr. Todd cruelly destroys the solace of those who are thus afflicted, by tracing the origin of gout chiefly to beer— "that ignoble source!" Alas! that Sydenham's goodly list of " magni reges, dynastae, exercituum, classiumque duces, philosophi, aliique his similes," should come to be put in the same category with "coalheavers, bakers, brewer's-draymen, house-painters, and others of the working classes." Verily gout, like " Pallida mors, aequo pulsat pede pauperum tabernas, regumque turres." This at least in England; but it seems that in non-beer-drinking countries the lower classes escape. The features of distinction between gout and rheumatism are delineated in a masterly manner; we would, however, that Dr. Todd had dwelt rather more on the means of distinguishing between the more obscure and chronic forms of these diseases, than between the more strongly marked and febrile. We cordially agree with Dr. Todd in his condemnation of active antiphlogistic treatment of gouty affections—at least in Londoners; it creates, says he, asthenia, and "asthenia gives to both rheumatic fever and gout what I may call the shifting character, which in both diseases is most perilous, but in the latter especially so." With regard to treatment, it is rather refreshing to find some novelty in the proceeding recommended by one of so much experience, even though we may hesitate to agree with it. Dr. Todd is decidedly opposed to the use of colchicum; not that he doubts its power, "in sthenic cases in young subjects," of relieving pain and hastening the removal of the paroxysm, "but at the same time experience leads him to subscribe to a belief very popular among gouty patients, that if it shortens the duration of the attacks, it likewise shortens the interval between the attacks." Wo are far from believing that colchicum acts in any way of neutralizing the gouty poison, any more than quinine the paludal. The latter tones and fortifies the nervous system, so that it can resist the malarious influence; and the former acts as a contra-stimulant on the articulations, nullifying acute inflammatory afflux when set up in them by rheumatism or gout. At the same time, colchicum tends to increase the bile-flow and the intestinal secretion, and if judiciously combined with purgatives, it seems to us highly reasonable to expect good results from its use. These, however, more particularly relate to its use in the paroxysms, the averting of which must depend on the kidneys and other excreting glands being aroused to funetion properly. Small local blisters are the best means, according to our author, of relieving the articular inflammations, and they may be used even during the height of the disorder. Nothing is said of the application of pure spirits of wine to the parts in the acute paroxysm, as practised byDr. Goolden, or of the old remedy, soda poultices, in the more chronic form.
Lecture XVI. relates a ca-e of chronic and asthenic gout, with chalk-stone deposit in the joints, and bronchial and gastric gouty affections. This needs no particular observation, except that we should like to have heard if Dr. Todd had verified the observations of Dr. Budd relative to the conversion in many cases of uric acid into urea in the vicinity of the inflamed joints. The alcoholic extract of blister serum was found to become a solid mass of nitrate of urea when treated with nitric acid.*
Having passed the lectures in review, we would now return to the consideration of the preface. The remarks contained in it are most sound, manly, and needed. They are the voice of a man who has strong sense, and the courage to speak out. They relate to the very defective manner in which clinical teaching is given in the majority of the London hospitals, and point out the chief causes of this short* coming. The period of the day is ill chosen; the student's time is absorbed, as well as his attention, by unnecessary lectures; and the visits of physicians and surgeons are so arranged that unless a student could be in two places at once, like Sir B. Roche's bird, he must omit attendance upon one or the other. Dr. Todd proposes a morning clinic (he has established one at King's College Hospital, medical and surgical on alternate days), and the curtailment of the courses of lectures required. With regard to the latter point, we do thoroughly agree with him that long courses of lectures are unnecessary "on any subject not requiring demonstration and experiment." What does a student want with lectures on physiology, when he can read, and must read, Carpenter and Todd-Bowman, or Kirkesi Must he not leani his osteology with the bone in his hand, and Ward before him; and his auatomy in the like way? How much more knowledge, even in chemistry, would a student acquire who worked, with a good textbook to guide him, in a laboratory, performing various experiments himself, testing, weighing, measuring, &c.1 Would not a student get a far better knowledge of materia medica by being put into a wellarranged museum, and set to read Pereira there, than by listening to the best course of lectures that were ever given 1 We doubt that the mode of teaching by lectures is the best calculated to impart sound knowledge. The professor is obliged to pass over so much ground, to go from one subject to another so quickly, that no time is afforded for careful* digesting thought. Suppose any of us to go and hear Faraday lecture on a subject quite new to us, or nearly so, how much real knowledge should we have acquired, unless we studied the subject carefully afterwards? And if the subjects must be thus studied, and if, moreover, there are excellent treatises in our bands, is not the time given to lectures so much lost? One very useful aid the student might have, not alluded to by Dr. Todd, is the assistance of younger men, who should act as tutors in the several branches of study. In dissecting-rooms the presence of such men is found essential; but we feel sure the same aid would be of great use in other departments. At the Universities, the private tutor is the real essential help to the • 8cc Medico-Chiiurgical Transactions, vol. xxxviii. p. 241.
working man, and the public college lectures are, or used to be, felt rather as an hindrance and interruption. Some plan of the following .kind it appears to us would be a most material improvement on the present system. Let all lectures, except those on chemistry, aud clinical, be abolished. Let text-books on the various subjects be assigned to the student Let him have tutors, men a little above his own standing, to refer to for explanations, for assistance in dissection, and demonstration of specimens contained in well-stocked museums. Let there be yearly examinations instead of one, as at present; and let the subjects for the first be the more elementary and collateral sciences, aud those for the last such as more exclusively relate to practice. Let each student in the fiual examination be required to examine and prescribe for cases of disease. The junior students should be discouraged from running after operations, which they cannot observe in any manner that will do them the least good. The outpatients at hospitals and dispensaries might with the greatest advantage be attended by some of the more advanced students, under the inspection of the medical officers. To something of this commonsense kind we shall in due time, no doubt, come, but the sooner the better.
1. Report from the Select Committee on Medical Department (Army);
together with tlte Proceedings oftlis Committee, Minutes of Evidence, Appendix, and Index. Ordered by the House of Commons to be printed.—London, 185G. Folio, pp. 379.
2. Tlve Crimean Commission and the Clielsea Board; being a Review oj Ute Proceedings and Report of th< Board. By Col. TcixocH, late Commissioner in the Crimea.—London, 1857. 8vo, pp. 189.
Public attention having been directed to the organization of the Medical Department of the Army, by the reports of the disgraceful condition of the hospital at Scutari in the winter of 1854-5, and of the inadequate supplies of medicines and medical comforts furnished to the army in Bulgaria and in the Crimea, the House of Commons ordered, on the 15th of April, 1856, " That a Select Committee be appointed on the Medical Department of the Army," with power to send for persons, papers, and records. It would probably be difficult to find a tribunal less qualified to conduct a searching inquiry into the working of a professional department,—its defects, its requirements, and the changes necessary to render it efficient,—than a Committee of the House of Commons. The members, with very few exceptions, do not bring to the investigation a practical knowledge of the duties required of the department, of the qualifications essential to their discharge, and of the difficulties which the officers have to encounter in the varied spheres in which they must labour. They aro consequently left in a great measure at the mercy of private, and therefore irresponsible, advisers, who, it is to be feared, often lead the inquiry towards details in which they are personally interested, instead of pointing to great measures which would benefit the whole profession, and tend to raise it to that position in the army which it undoubtedly deserves, and by which its services to the soldier would be greatly enhanced. Such a Committee also carries on its labours without any instructions as to the nature of the investigation, its objects, or its limits. It has, in fact, a roving commission to inquire' de omnibus rebus et quib'usdam aliis, and this power is not unfrequently abused.
The Report before ns is not free from the faults adverted to. "With the exception of Mr. Stafford and Colonel Boldero, it is not too much to say that the Committee was not conversant with the subject into which it was to inquire. In the course of its proceedings, too, the object for which it had been appointed was more than once forgotten, —questions were put as to matters wholly foreign to it,—and the examinations assumed a personal character, neither very edifying nor very creditable to the good taste of the members by whom they were conducted.
Dr. Andrew Smith appears to have been the individual upon whom the heavy artillery of irrelevant questions was chiefly brought to bear. He was examined, somewhat unfairly, as to his own previous services, and the circumstances under which he was appointed DirectorGeneral; as to his refusal to employ Dr. Davy, a retired InspectorGeneral, as chief of the department in the Crimea; his reasons for appointing Dr. Hall to supersede Dr. Burrell in the East; the grounds on which he appointed Dr. Menzies to the medical charge of the camp at ShornclifFe, and the reasons he assigned for the subsequent removal of that officer,—all of which questions, it appears to ns, were irrelevant to the subject on which the Committee was to report. With the siugle exception of the case of Dr. Menzies, the explanations of Dr. Smith were, upon the whole, satisfactory; but we regret to say. that he did not assign any good reason for having placed in so responsible a situation an officer who, though zealous and hard-working, had signally failed at Scutari from want of administrative talent, and who in the present case laboured under the very serious disadvantage of not understanding the language of the German officers, whose hospitals he was to superintend. Of his own unfitness, Dr. Menzies seems to have been fully sensible, and repeatedly applied to be relieved from the charge, but was refused; and when at length he was removed, he appears to have been treated with harshness by Dr. Smith, whose explanations on this subject before the Committee were far from satisfactory. We deeply regret this, because in other respects the DirectorGeneral appears to have acted throughout with energy and honesty, and to have been animated by a desire to promote the welfare of the soldier, and the interests of the Medical Department.
It would be impossible, in the space which we can afford, to give a summary of the evidence taken before the Committee, because of its very discursive character, and the great variety of opinions expressed by the different witnesses on many of the subjects. We shall therefore content ourselves with adverting to what appear, from the Report, to be the principal grievances complained of, and the remedies suggested.
A memorial to Lord Panmuxe, from the Military Medical Officers serving with the British Army in the East, is printed in the Appendix, with observations by Dr. Smith, to whom it was referred by .his lordship. These are well deserving of careful perusal, and so clearly point out the injustice with which the department is in many respects treated, that we are sure Dr. Smith cannot but feel uncomfortable that he has so long neglected to inquire into these matters, and to advocate the claims of the officers who are under his jurisdiction, and of whom he may be fairly deemed the official representative.
The first subject in the memorial to which we shall advert is The Bates of Pay. These were admitted by all the witnesses examined to be msufficient to secure the services of the best class of men, and there seemed to be a unanimous feeling that they must be increased. We have said this was the opinion of all, the witnesses; but perhaps we ought to have excepted the Earl of Cardigan, for though his Lordship had, as he informed the Committee, commanded a regiment for eighteen years, he professed that he "did not know anything about the pay" of the assistant-surgeons! But the whole of the noble lord's evidence was pretty much of the same stamp—characterized by ignorance even of the organization of the department, and by supreme indifference to the feelings and claims of. the; officers. For instance, although Lord Cardigan commanded the Light Cavalry Brigade in the Crimea, and ought to have been fully cognizant of the mode in which the sick are supplied with their diets and hospital comforts, and to have ascertained that this very important duty was satisfactorily and efficiently perforated in his brigade, he stated to the Committee, "I never heard of a man called a purveyor, and I never saw one in my life." Again, his lordship's enlightened views, and liberal, kindly feelings towards the medical officers, are well exemplified in the following answers to questions put by Colonel Boldero:
"Q. 4120. It appears that the Medical Department of the Army have no full pay retirement; do you think that it would be for the benefit of the service, as well as beneficial to the gentlemen themselves, if, after twenty-five or thirty years' service, tliey were allowed to retire upon full pay ?—A. Arc they not allowed to retire now on full pay after any service?
"Q. 1121. They get half pay, but they are not allowed to retire, as every other braneh of the service is, upon full pay after a given period?—A. Of course it would be advantageous to them; but I cannot say that I could give my opinion in the recommendation of it, because if one is to begin to recommend about the increase of pay, there is no saying where it will end."
Truly, the noble lord's rule of action is not "Fiat justitia, mat coelum." To those who are curious in the study of character, we cannot recommend anything more amusing or instructive than a perusal of bis evidence.