806

THE LANCET.

LONDON: SATURDAY, MAY 2, 1885.

THE MEDICAL COUNCIL AND MEDICAL STUDENTS.—THE LUNACY BILL.

THE meeting of the General Medical Council approaches,and is likely to be one of more than usual importance tomedical students of the future. There is one consideration

which may tend to liberate the Council in its discussion

of proposed alterations in its Recommendations, whetheras regards Preliminary Education or the Final Exami-

nation of medical students-namely, this: the supply of

medical students is so ample, so much in excess of what isrequired to meet vacancies in the profession, that the regu-lations affecting both education and examination will bearto be much strengthened before any risk is run of starvingthe profession or leaving the public in that plight feared bySir LYON PLAYFAIR, when the sick will not be able to havea physician on account of the scarcity of that craft. We

have before us the Medical Students’ Register for 1885, andamongst its multifarious contents of interest to those con-cerned in medical education is a table giving the number.of medical students registered last year, and for every pre-.ceding year since, and inclusive of, 1864. We may explain,for the benefit of our older readers, that no medical studentcan be registered as such until he has passed a PreliminaryExamination, as required by the General Medical Council,and has produced evidence that he has commenced medical,study. The numbers, therefore, which we are about to

give are of those who have succeeded in passing one of thePreliminary Examinations of the fifty or sixty bodies

recognised by the General Medical Council. We mayremind our readers that the natural waste of the professionby death is under 600. If to this we add another hundred

as representing those whose deaths have not been reportedto the Registrar, or who, not having died, have retired or insome way dropped out of the Register, we may have someidea of the numbers required to keep up the present supplyof medical men.

The number of medical students registered in 1884 was1957, as against 1783 in 1883, and 1862 in 1882. If we

divide the period of twenty years into four periods of five e

years each, we get the following as the average number ofmedical students annually beginning their curriculum:

from 1865 to 1869 inclusive there was an annual registra-tion of 908 students; from 1870 to 1874 inclusive, of 1263

students; from 1875 to 1879 inclusive, of 1643 ; from 1880 to1884 inclusive, of 1975. Thus it appears that there is s.n

increasing rush towards the medical profession. The rush

is not quite steady and regular. Three or four years ago the

annual number for two or three years was a little more than

it was last year. But, dividing the periods quinquennially, itis clear that a great increasing number of youths look towardsthe profession as a calling. No doubt many of them never

succeed in getting a qualification. From failure in examina-

tions or in fortune, from defective ability, or, much morecommonly, defective industry, they do not reach the goal forwhich they set out, and they either fall out of the profession

altogether, or hang on to its skirts in the unsatisfactory formof unqualified assistants. The point of this interestingtable, carefully made up by Mr. MILLER, is that the Councilhas 1975 students a year to legislate for, and that it doesnot need half that number of students to be qualifiedannually in order to keep up the waste of the profession,We do not approve of the favourite pastime of the Council-that of always considering and altering the regulations ofpreliminary and medical education. It is exceedinglyharassing to students and inconvenient to schools and

teachers of medicine. Moreover, it does not tend to raisethe Council in the respect of either students or teachers.But as there seems an intention to deal at the approachingmeeting in some radical and serious way with fundamental

principles in regard to preliminary and medical education,it is well to know that without any risk both the prelimi-nary and final tests can be made more severe. If men are to

be arrested in the process of entering the profession, thesooner the better. " Had it been early, it had been kind,"might many a man say who is allowed to advance only so farin a medical career as to discover his unfitness and incom-

petency when it is too late. If the preliminary tests wereof a thoroughly satisfactory kind they would tend greatlyto diminish the subsequent rejections. We repeat, if ;.

man is to be rejected, the sooner the better, and better in thepreliminary stages than in the advanced ones. There is so

much competition nowadays for students, such a rivalry ofschools and examining boards, that there is constant

danger of the Medical Council, in which school and

examining board "interests" are so excessively repre-

sented, forgetting the great interests of the public and ofthe profession. We have shown by the Students’ Registerthat there is no excuse for laxness of examinations on the

score of defective supply of students, but, on the con-

trary, every encouragement to carry higher the standardof preliminary and medical education.

IT is much to be regretted that the Earl of SHAFTESBURY,whose name can never be mentioned in connexion with

lunacy without the highest respect, has not found it possibleto accept the principle of magisterial authority for the in-c3,reera,tion of a " lunatic " in an asylum, and rather thando so has resigned his position as Chairman of the Board ofCommissioners. We attach the greatest moment to this newmode of procedure, and believe it will be found to afford a

better safeguard against abuses than even its promotersanticipate. Altogether the Bill before the Lords is an

admirable measure. The Earl of MILLTOWN, who has

already done so much real service in this matter, and towhose efforts we mainly owe the fact that the subjecthas been seriously taken in hand by the Government,did not speak too warmly when he complimented the LordChancellor on "the ample way in which he had fulfilledthe promise he had made last session." If the Earl ofSELBORNE will only consent to modify a few of the minorpoints in the scheme as drawn-for example, shorteningthe period during which an alleged lunatic may be con-fined on an emergency certificate, and compelling the

Commissioners to carry out their examination before theychance to find it "convenient" to do so, the reform

effected will be such as to render the law of lunacy in the

807MEDICAL EDUCATION IN THE UNITED STATES.

main satisfactory. As to the piivate asylums, we thinkmatters will adjust themselves before long. Those houses

which are actually needed will be maintained ; but the

provision made by the county authorities will soon besufficiently great to meet all ordinary demands, and thecheaper sort of "licensed house" will cease to be a profitablespeculation. It is a most satisfactory feature of the reformto be effected by this Bill, that committees of publicasylums will be able to ease the burden on the rate-

payers by receiving private patients. This provision willtend greatly to encourage the gradual replacement of

private by public asylums, which is so much desired. At,

the same time, it must not be forgotten by the LordChancellor, and we are sure the Earl of MILLTOWN will notlose sight of the fact, that as soon as they begin to take inpaying patients, the committees of public asylums willthemselves become " keepers of private asylums." This is

a very important consideration. It must not be assumed

that committees are immaculate. At this moment some of

the larger private asylums are managed by committees com-posed of men whose social position is such as to inspirethe highest confidence, and yet, in spite of this, the

allegations of undue detention in these very asylums are

fully as many and as damaging as any which have beenbrought against the proprietors of the smaller licensed

houses. We are not making this statement without reason.it follows that the provisions of the Bill should be strengthenedin regard to the reception of lunatics under emergency certifi-eates. It was stated in evidence before the Select Committee

of 1876, and we are still prepared to maintain the statementthen made, that even forty-eight hours in a lunatic asylummay suffice to convert excitement in a neurotic subject intoactual mental derangement which may afterwards resist

all remedial efforts. Therefore we contend that the follyof allowing a patient to remain a month or more, or even-seven days, without examination by a competent and im-

partial authority stands confessed on the face of the

proposal. The next stage of the Bill is fixed for a fortnighthence. Let us hope that in the meanwhile the Lord

Chancellor will see the wisdom of amending the faultydetails of a measure which in principle, and as far as itgoes, is as satisfactory as could be expected or desired.

OUR readers are well aware of two things in reference to Imedical education in the United States. First, that it

has hitherto been conducted on very free and easy

principles ; and, secondly, that earnest efforts are beingmade by good men and true in all the States to abate thescandals of medical education, and to bring it under somepublic and responsible authorities comparable with thosewhich regulate it in all other civilised communities. An

instructive prospectus on this subject has just been issuedby the Illinois State Board of Health, with the help ofwhich we shall try to elucidate for the benefit of our

readers the real condition of things in the States, not so muchwith the view of finding fault as of supporting and helpingthose who endeavour to bring about a better state of things.The Illinois Board of Health proceeds under an act of theState called the Medical Practice Act, and publishes a schedule Iof minimum requirements. Diplomas from colleges whichgive evidence of an actual and bonci-fade compliance with I

this schedule are accepted unconditionally. Diplomas fromthose which do not are required to be supplemented byan examination before the Board on the branches or sub-

jects of the schedule omitted by the colleges in question.The schedule requires-1. Certificates of moral standing.Diplomas of graduation from a good literary and scientificcollege or high school; failing this, a thorough examinationmust be passed in mathematics, English composition, andelementary physics or natural philosophy. 2. Instruction

in ten subjects or branches of medical science. 3. The

length of regular or graduating courses or sessions to be

five months, or twenty weeks, each; and two full courses oflectures, not within one and the same year, are requiredfor graduation with the degree of Doctor of Medicine.

4. Regular examinations are to be made by each lecturer

daily, or twice a week at least, and final examinations,where practicable, by competent examiners other than theprofessors in each branch. 5. Dissections and hospitalpractice during two terms. 6. The time of professionalstudies to be not less than three full years before graduation.7. Each college must show that it has a sufficient and

competent corps of instructors and facilities for teaching.Such is the standard of medical education in one of the

States which have confided the regulation of medical

study to a Board of Health. It will not be thoughtexacting in its demands. But of 47 colleges which haveclaimed to have their diplomas recognised by the Board,only 26 were found to have regulations satisfying its

requirements. The state of medical education in the United

States is one of the illustrations of the disadvantage of astrong central government. Each State is a law to itself,and in many States it seems possible for any group of needyor adventurous physicians to form themselves into a medicalschool-otherwise a diploma-mill. The extent to which thisevil has attained may be gathered from the fact that a totalof 234 different medical institutions are given in a list inthis pamphlet, dating from the year 1765. There are now

in existence no less than 128 such bodies. Excluding 12 inCanada, there remain 116 in the United States, which for38 States gives 3 per State. Among the extinct schools thereare 54 out of 153 regular, 7 out of 20 homoeopathic, 12 outof 24 eclectic, and 6 out of 10 physio-medical and miscel-laneous. Out of 18 fraudulent institutes, 17 happily arenow extinct. The "Boston Bellevue" is the only one ofthis class remaining. These figures are very significant.They show the mushroom-like growth and death of these" colleges." The harm done by them is incalculable. The

competition engendered makes it very difficult for the more

organised and recognised schools to maintain a high standard.The most absurd particulars are given of the devices resortedto for catching students. Personal solicitations, low fees orno fees, and the certainty that a diploma may be obtained ona minimum of knowledge and education, general or medical,are all enlisted. We are threatened in this country with aform of Parliamentary government where freedom may be

prized above knowledge and efficiency ; but we have not

yet reached this depth, and we can only wish our Americanfriends a speedy curtailment of that form of liberty whichpermits the creation of an indefinite number of schools toissue diplomas legalising the ignorant practice of an art inwhich a little knowledge is verily a dangerous thing. There

808 ACTINOMYCOSIS IN ENGLAND.

is some hope of this consummation on two grounds. First,the public is deeply interested in the suppression of merediploma-mills, and in the quality of work done at medicalschools; and, secondly, the evil now felt by the medicalprofession was formerly rampant in the legal profession inNew York. Idle and incompetent young men were admittedto the bar in excess of legal business and the legitimateincrease of the profession. The Higher Courts took measuresto restrict the supply, and ordered that only graduates ofcertain specified law schools should be eligible for examina-tion after a certain date. The other law schools closed

their doors. The profession upheld the courts, and the endwas gained. Let medicine take a hint from law. It is onlyfair to say that there are signs of improvement in thestandard and methods of medical education in the States, ofwhich the following are the most important : 102 collegesnow exact a matriculation examination, as against 45 in thefirst Conspectus of the Board of Health; more colleges arerequiring longer courses of lectures, and making provisionfor what are called "graded" courses -i.e., courses whichare not mere repetitions of previous courses, but develop-ments of them. We must leave this subject with everyexpression of sympathy with those who are seeking to

abolish fraudulent medical schools and diplomas.

SOME incidental remarks made at a recent meeting of thePathological Society revealed the existence of the first

genuine instance of Actinomycosis in this country. The

case occurred, we believe, in the practice of Dr. HARLEY

at St. Thomas’s Hospital, the post-mortem examination

being made by Dr. SHARKEY, and the microscopicalexamination by Mr. S. G. SHATTOCK, curator of the

museum. As the disease in man has only been recognisedwithin the past decade, and as no cases have hitherto

been recorded in this country, it is not surprising thatbut few members of the profession in England should beacquainted with it. A valuable clinical contribution to

our knowledge of the affection in man has recentlyappeared from the pen of Dr. J. ISRAEL.1 In 1882 Professor

PONFICK published an almost exhaustive monograph on thedisease, in which most of the facts then known were

embodied. From questions which have been addressed tous, we believe that a brief account of the elemental features

of the affection will be welcomed by the majority of theprofession, to whom the malady is unknown.The affection is presumably one which is dependent on

the presence and activity of a micro-organism. The micro-

parasite is a member of the fungoid class, and consistschiefly of a mycelium which divides in a dichotomous

fashion, and gives rise by its spread from a centre to aradiate appearance, whence its name-actinomyces-isderived. The circumferential ends of the mycelial sproutshave a flask-shaped swelling. The little masses of felted

mycelium may be recognised by the naked eye as sulphur-yellow bodies of about the size of a hemp-seed. The disease

which this parasite is supposed to cause may develop in

many parts of the body. The most common site appears to bethe jaw and parts bounding the mouth. The affection in

animals has long been known in this situation under various

1 Klinische Beiträge zur Kenntniss der Actinomycose des Menschen.Berlin: A. Hirschwald.

names, and has been regarded as a form of scrofula and as

a new growth. It is believed that the parasite gains anentrance through the medium of a carious tooth or somewound of the gum leading to the jaw-bone. There is but

little to be said of the morbid anatomy of the disease. A

swelling forms in the jaw, and gradually increases in size.This tumour in it; earliest stages may be punctured without

any matter being let out, although it generally has anelastic and semi-fluctuating consistence. A section made

into a tumour in the early stage of its existence shows

a reddish - white area sprinkled in places with gold-coloured granules. Later on abscesses and fistulæ form,in the discharge from which the sulplmr-coloured bodies

may be seen. Broadly speaking, the tissue of the morbidnew growth, which must be regarded as inflammatoryrather than sarcomatous, has very much the characters

of ordinary granulation tissue. Actinomycosis may occurprimarily in the respiratory tract proper, and Dr. ISRAELmakes this class of cases his second group. He narrates

a case in which the disease was localised to the bronchial

mucous membrane. The patient was a girl aged fifteen,who suffered from the signs and symptoms of chronic

bronchitis, with fetid expectoration, in which the acti-

nomyces were readily discovered. Another case of a man,

aged twenty, is given, in which the primary localisationof the disease was in the parenchyma of the lung; it wasafterwards propagated to the pleura and to the prævertebraltissues. Some of the cases have many of the clinical

characters of empyema with discharging sinuses, and insuch cases a complex system of fistulæ not unfrequentlyundermines the morbid tissues. The structures in the posteriormediastinum and prævertebral regions are often affected,and the bodies of the vertebrae may become carious. Dr.

ISRAEL makes his third group of cases include those in

which the disease begins primarily in the intestinal canal.In some of the cases the foci of the disease are widely dis-seminated. The liver, spleen, muscles of the back, andmuscular substance of the heart have been shown on post-mortem examination to have numerous centres of actino-

mycosis. Large abscess cavities may form behind the

peritoneum as well as behind the pleura, and these maycommunicate by many perforations of the diaphragm. The

symptoms necessarily depend chiefly on the localisations ofthe disease as well as on its rate of progress, and presenttherefore extremely varied clinical pictures. Dr. ISRAEL’S

work contains an account of thirty-eight cases, whichnumber includes all that have hitherto been recorded.

A MEETING of graduates of the Royal University of Ireland,including members of the Parliamentary Committee of theSenate and of the Council of the Graduates’ Association, washeld last week in the Westminster Palace Hotel, presidedover by Sir William Mac Cormac. It was resolved that stepsshould be taken to press the claim of the University toParliamentary representation, and a special committee wasappointed to carry out the necessary arrangements. Thiscommittee will include Sir William Mac Cormac, and Drs.Knight, Jones, Purcell, MacKellan, Henry, Huggard, andWheeler.

DR. MAPOTHER has resigned his seat on the Council ofthe Royal College of Surgeons, Irelanj, and most probablywill be succeeded by Dr. Hamilton.