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brethren are excluded. It is indeed true that only a small numerical proportion would be contributed by the Universities to the ranks of the medical profession, even if the wishes of the most sanguine adherents of the new régime were to be fulfilled. But there is another channel opened, by which the University influence is being very widely, and, as we think, judiciously, diffused, and by which no profession will profit more immediately than our own. The recently enacted statutes for the examination of those qui non sunt de corpore Universitatis, are already beginning to attract crowds of candidates for the certificate of proficiency in all the large towns. To no class of young men will such a testimonial be so really valuable-by none, as we hope, will it be more energetically striven after-than by those who purpose commencing their career as medical students. For, in the first place, it is fixed at a period of life which very accurately marks off a division between the general educational course and the commencement of more specific professional studies. If, by so doing, it in a measure tends to cut short that most unprofitable portion of the ordinary student's career, which is represented by the apprenticeship in a country town, preliminary to attending hospital lectures in London, it will at least have done a negative good; and will, in return, have entailed some positive advantage, by raising the standard of acquirement in the ordinary branches of liberal education. We would willingly exchange, in the great majority of cases, the scanty, imperfect, and purely empirical information of a private practitioner's surgery, for some better mental training and more intimate knowledge of the great writers of ancient and modern times, for the prominent facts of history, and the higher branches of mathematics. In the second place, these examinations may be made useful as a first winnowing-a preliminary classification of the examinees, which will tend to guide the judgment of friends and relations in determining a young man's future path in life. Medicine is the last of all occupations not absolutely mechanical on which a youth should be thrust hap-hazard, and because, as often happens, his father followed it before him. It needs more definite bias and predilection than any other for its satisfactory pursuit, and it presents more points of distaste and discouragement to an ill-matched aspirant. The mercantile man and the government employé can give certain hours of the day to their business, and these over, devote their energies without scruple to other more congenial studies and amusements. Even the barrister, who is probably more called on for severe and continuous mental exertion at times than any other professional man, has usually abundant intervals to recruit his strength; and, except in the case of an overwhelming practice, can throw aside business for a while without damage to himself or his clients. But the medical man must keep himself always in readiness; no time is free from the possibility of calls on his assistance; his practical knowledge, extending as it does over one of the largest areas occupied by any science, must be ever fresh, clear, and ready at hand. Books are but an inefficient auxiliary. His whole life should be one of preparation for emergencies, his temper of mind that of a sentinel on guard.
Is it not of the last importance that requirements so exceptional should, if possible, be founded on special gifts and predilections? It is our earnest hope that these newlyorganized examinations, which we owe to another member of the Acland family,* in some degree supply this test. They present, indeed, sufficient provision for examination and reward in the domain of science and natural history to enable a fair estimate to be formed of the candidate's fitness for the demands of his proposed profession. In this way much good may be done, not only by the early exclusion of the incompetent and unsuitable candidates, but also by the discovery of latent capacity, and by the means afforded for distinguishing a mere sciolistic whim and fancy for mechanical and physical amusement, so common among intelligent lads, from that steady preference and election of a certain class of subjects, which commences in faculties and bodily endowments adapted for their pursuit, is fostered by friendships and opportunities not the less powerful for being often overlooked, and terminates by developing into a temper which is almost always able to command success for its highest aspirations.
It is perhaps not unreasonable to hope that an extension of the University brotherhood, a dependence more or less intimate from the same ancient Alma Mater, may
*T. D. Acland, Esq., of Spreydencote.
tend to draw closer together the bonds uniting different members of the same profession. Any means which should effect this would be an incalculable boon to our whole body; for if there be a mark of inferiority more painfully characteristic of medical men than any other, it is an utter lack of corporate feeling. Every man for himself" is almost the motto of many practitioners, and though some may rise above this shortsighted and suicidal selfishness, hardly any attain that measure of esprit de corps and of unanimity which ensures esteem. The ordinary hospital connexion seems in most cases utterly insufficient for its production. There is, as a rule, little or none of that legitimate pride of clique among pupils of the same medical school which is so apparent in our best public schools or in members of the same college at either University. And its absence gives just ground for regret, for probably no security is so good against attacks from without and schisms from within. It is not indeed inconsistent with much personal difference of opinion; it necessitates little or no interchange of overt acts of friendship, but it produces nevertheless a closer union, a more conciliatory tone, and a larger share of that tacit freemasonry of thought by which each individual member is a support and helper to the others.
Our earnest wish is for the establishment and increase of this good understanding among the scattered disciples of the healing art. It would more tend to raise them than any legislative enactments against quackery, or any mere examination-test, however stringent. And while we see with pleasure faint glimmerings on the horizon of a better and brighter day, it is the bounden duty of every individual among us to gird himself up to help forward the good work which that day is bringing to light. Conspicuous as physicians are and have always been beyond all others for personal earnestness and self-devotion, there is still room for a higher conception of their social responsibilities and of their mutual inter-dependence as members of a world-wide guild and confederation. Let us aim at the attainment of our forefathers' standard, for there is none higher or more worthy, and let each accept the obligation of the oath so nobly tendered by the Father of Medicine himself.*
"To reckon him who taught me this art equally dear to me as my parents, to share my substance with him, and relieve his necessities if required, to look upon his offspring on the same footing as my own brothers, and to teach them this art if they shall wish to learn it, without fee or stipulation, and that by precept, lecture, and every other mode of instruction, I will impart a knowledge of the art to my own sons and those of my teachers, and to disciples bound by a stipulation and oath according to the law of medicine, but to none others. I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous. With purity and with holiness will I pass my life and practise my art. Into whatever houses I enter, I will go into them for the benefit of the sick, and will abstain from every voluntary act of mischief and corruption. Whatever in connexion with my professional practice or not I see or hear in the life of men, which ought not to be spoken abroad, I will not divulge, reckoning that all such things should be kept secret. While I continue to keep this oath unviolated, may it be granted to me to enjoy life and the practice of the art respected by all men in all times. But should I trespass and violate this oath, may the reverse be my lot."
* Hippocrates, "Opкos, Sydenham Society's translation, vol. ii. p. 780
The Diseases of the Stomach, with an Introduction on its Anatomy and Physiology; being Lectures delivered at St. Thomas's Hospital. By WILLIAM BRINTON, M.D., Fellow of the Royal College of Physicians; Lecturer on Physiology and on Forensic Medicine in St. Thomas's Hospital; Physician to the Royal Free Hospital. London, 1859. 8vo, pp. 406.
THIS book can hardly be said to require a very formal introduction to our readers. A great deal of the elaborate material of which it is composed has been contributed to our own pages in the form of Original Communications; and we had formerly the pleasure of reviewing the collected pages of the author on the important subject of the simple gastric ulcer. The present work is the complement and consequence of these former contributions to scientific inquiry; it is the substance of a course of lectures addressed "to the more advanced students of St. Thomas's Hospital;" and professing, as it does, to give a more systematic, as well as a more condensed, view of the author's researches than was consistent with his former plan, it now takes the shape of a treatise addressed to the whole of the medical public. Certainly, no better guarantee could possibly be given for the faithful discharge of the duties implied in writing such a treatise, than the previous career of Dr. Brinton. His book is not, perhaps, one which occupies the entire field implied in the title; but it is one everywhere inspired by the spirit of truth, and is comprehensive enough to prove useful and suggestive. It hardly aims at being brilliant or amusing, bnt it is everywhere readable, and, without tediousness, it is earnest, solid, and instructive. Among the numerous works which have of late years issued from the press upon gastric pathology, it yields to none in importance; and we feel assured that it will be found to supply a want, even in this crowded region of medical literature.
What has the stomach done to attract to its delinquencies and misfortunes so large a share of public and professional attention? This is a question we often ask ourselves; and it is one easier to ask than fully to answer. In one way, indeed, it is easily enough answered. The poor man has no time to think about his stomach-the rich man makes an idol of it; all its whims and caprices, all its abilities and disabilities must be studied, in obedience to the demands of a luxurious age, with the same solicitude about small matters which Fashion demands of her votaries in everything else. The "diseases of the stomach are, under this view of the matter, a little field of fantastic sufferings struck out of chaos, to meet the wants of an advanced civilization, and, especially, to attract money into the pocket of the doctor. That respectable gentleman, the fashionable stomach-physician, is, to a great extent, the necessary complement, or rather aide-de-camp of the cook; and, like him, does not come from the same quarter which sends us "good meat," but from a decidedly lower and warmer region than even the kitchen. And so, in more senses than one, that love of money, which we are told is the root of all evil, is the source of innumerable woes to the stomach. A comfortable balance at the banker's counts, not only for a multitude of good things, but for so much gastric misery and so many doctor's fees. Dyspepsia and oxide of silver wait upon our luxurious modern life like the "Memento Mori" at a Roman festival. The rich man soon languishes; he is sick, "not unto death," but only to the extent to require a little delicate attention. The doctor prospers; the cook has his box at the opera; Mammon smiles on the game; and the patient, soothed and flattered with so much attention, is gracefully handed over from the doctor to the cook, and back again from the cook to the doctor, till he becomes a confirmed valetudinarian. And of his endless tales of little errors and little miseries, one half fanciful and the other half exaggerated, the record goes forth, under professional auspices, dignified with the name of "diseases of the stomach," which have the same resemblance to real diseases that the modern expanse of crinoline has to the primeval garment of the first mother.
To any one who has arrived, by dint of much reading (or much physicking), at conclusions like these, we would recommend Dr. Brinton's book, and especially its final chapter, on "Dyspepsia," as an example how much the spirit of truth and soberness can do for a subject which has been twisted and tortured into such an immense variety of forms. This chapter is indeed short-far too short, indeed, if the frequency of the disease, and its importance in practice, be considered, as compared with those devoted to the organic diseases of the organ; and we strongly recommend to the author to keep in view the necessity of a considerable expansion of his ideas on the functional disorders of digestion in any future edition of the book. In the meanwhile, however, we are happy to find in this chapter, and in Chapters I. and II., which may be regarded as the key to the author's pathology of dyspepsia, a pretty distinct recognition of truths which are often present to our own mind, when dealing with, or speaking of, the diseases of the stomach in general. Some of these truths are well expressed in the following sentences:
"The liability of the digestive organs to functional derangement is a kind of provision of nature against graver and more deeply-seated disease, a provision such as has considerable analogy to the protective function of pain, and to that mechanism of common sensibility of which it forms a part. The position of the alimentary canal (and especially of the stomach) relatively to the food, enables its disturbances to forestall and prevent the mischief that might (and in persons of powerful digestion actually does) gain access to the blood, and through this fluid invade other organs. Unchecked dyspepsia is doubtless not devoid of danger, both by what it thus foreshadows, and by what it can itself produce; just as physiology must own that—in and per se-pain is an evil. But it stands (as it were) midway between certain deleterious agents and bad habits on the one hand, and the penetration of the constitution on the other; and, if its warnings are attended to, is often the means of rescuing its victims from the slower and more dangerous consequences of these errors. The sufferings of indigestion often call attention to some of these errors of nutrition which, if persisted in, inflict serious or irreparable mischief in the form of tubercle, rheumatism, gout, or calculus; and they thus increase (rather than diminish) the longevity of those whose prudence does not allow this epigastric monitor to warn them altogether in vain." (p. 380.)
We cannot afford space to extract the remarks, condensed as they are, which contain the exposition of the causes of dyspepsia. They are in harmony with the view of its nature embraced in the sentences quoted above. In few words, the causes of this disease are not to be sought in the stomach, unless in the very common case of their being directly put into it in the shape of improper food; in the majority of instances they are complex, and bear far less directly upon the stomach than upon the other functions, and especially upon the nervous system. Thus intellectual exertion, ill-regulated, or producing an excessive strain upon particular faculties; mental anxiety, joy, grief, laziness, apathy, over-fatigue, and under-fatigue of body, may all become causes of dyspepsia, because they may all derange the mechanism of that vivida vis animi, which is the centre and culminating point of the animal functions, and with which the vegetative life is brought into relation chiefly through the stomach. Hence, as Dr. Brinton well remarks:
"Our very forms of speech, which, with little exaggeration, represent a person as 'sick' of any person, thing, or topic, show how the chemistry of the stomach is subjected to the least material and palpable agents of our life, to that world of thought and emotion which works within every one of us.'
If we are not greatly mistaken, this idea will bear to be pushed further yet; and we commend it to Dr. Brinton as worthy of more elaborate development than he has bestowed upon it. We are disposed to regard the stomach as one of the most ill-used of organs―ill-used, not in the mere material sense that much is put into it which ought not to go there, and much of what is fitting, at unfitting times and seasons- -but in the more exalted sense, that of all the organs of the body it bears the greatest burden of sins not its own, and bears them, on the whole, with an equanimity (so to speak) and power of endurance alike admirable and entitled to our gratitude. We are entirely
convinced that the nervous system is responsible for the immense majority, we had almost said the whole, of the cases of dyspepsia which do not depend upon errors of diet, or on organic disease; and, further, that in most cases of the latter kind, the stomach is not the real seat of the malady, but only the recording apparatus or dangersignal, as it were, of disorder existing elsewhere. Most thoroughly do we participate in Dr. Brinton's views on this subject, as expressed in the paragraph quoted above; only we desire to see them pushed fairly to their consequences in detail. The course of his researches has led him in this volume to insist at great, almost disproportionate length, on the organic diseases of the stomach. The immense field of its functional derangements demands no less his exact and careful analysis; and it will amply repay the labour. The recent work of Chomel on the subject is, to our apprehension, among the least satisfactory of his contributions to medicine; and among the British authorities, we know not one who has not left ample room and verge enough for a new and enlarged consideration of the subject. The single topic of hypochondriasis and its connexion with gastric symptoms would of itself form material for a chapter of some length. Yet so little have our recent authorities on diseases of the stomach found it to be within the somewhat narrow range they have prescribed to themselves, that there is hardly a hint to be found in any of them upon the subject. So important a morbid relation should not be given over to the quacks.
And here we are tempted to make one remark tending to a less inglorious view of the connexion of dyspepsia with an advancing civilization than that we have put forth, half in jest, at the beginning of this article. May it not be that, with the growth of man in intelligence and moral elevation-in proportion as spirit rises supreme over matter—the sensibility of the whole nervous system is exalted, and its diseases, or functional derangements, are rendered proportionately important? It is the characteristic of an intellectual age to suffer the penalties of an over-worked or ill-worked brain. But among these penalties a restricted digestive faculty is perhaps first in rank and in frequency. It is the inexorable fate which binds the intellectual workman to the earth, and reminds him that he must not follow his aspirations to the neglect of the machinery that controls the very power of thought. The lowest of his appetites holds him in check, as if to remind him that true wisdom is not in rising above human nature, but in submitting gracefully to all its limitations.
But we must not linger on this subject. Suffice it to say that the entire sketch of dyspepsia, considering it only as a sketch, is excellent; the analysis of its multiform symptoms and of their combinations being at once simple and comprehensive, and the treatment equally judicious and clearly stated. In the general description of the symptoms of gastric disease, the author is not less successful in producing a trustworthy picture of a difficult subject; and the ideas, even if not absolutely novel, are often so strikingly enunciated as to have the effect of novelty. The following passage on gastric pain is important. After showing that a high degree of tactile sensibility is "unnecessary" (he might say "would be positively injurious") to the stomach in the discharge of its function, and that therefore no such sensibility has been accorded, the author proceeds:
"But we are not, therefore, to imagine this important organ really insensible to stimulation, or to suppose that, because it is not every moment arousing the brain of its master, and demanding his forethought or exertion, it remains unimpressed and inactive. On the contrary, we must rather conclude that it has a special sensibility of its own, not one whit less marvellous (but surely more so) for possessing a certain independence of the cerebro-spinal centre. Closely related to this centre by the feelings of hunger and satiety-nay more, dictating to it (so to speak) those exertions which the proper alternative of these two states imperiously demands from the mass of mankind-it has a sphere of action altogether its own. And the study of digestion has shown us how admirably and silently the stomach fulfils its various and complex tasks; and how, incidentally to these, the unfelt particle of food no sooner touches its mucous surface than it excites the flow of a variety of secretions, both far and near, and provokes movements in the muscular substance of its walls and vessels, as well as in the analogous structures of neighbouring parts. To these acts, which respectively constitute the sensation and motion of the healthy stomach, its morbid states afford an instructive parallel. And just as the kind of sensibility specific to a healthy muscle-the feel