386

THE LANCET.LONDON, SATURDAY, JUNE 15TH, 1844.

ORGANISATION OF THE PROFESSION IN GERMANY.

THE organisation of the medical profession in GreatBritain is universally allowed to be inferior to that whichexists in several of the principal continental states,

although few persons possess any real information re-

specting the condition of things amongst our neighbours.This is the more remarkable, as one would have thoughtthat an acquaintance with the systems pursued in other

countries, renowned for their intellectual eminence,would have been considered indispensable by all who

take an active interest in the important question of medi-cal reform. In order, therefore, that our readers may

be able to compare the medical institutions of the coun-

try in which we live with those of other nations, and thusform a correct estimate of their comparative value, weintend to lay before them, in a series of leading articles, asketch of the medical organisation of some of the princi-pal European nations, beginning with Germany.With regard to that country our task will be compara-

tively easy, owing to the late publication of Dr. HOEFER’Sreport. Dr. HOEFER is a French physician, who wasdeputed by the Minister of Public Instruction, at thelatter end of last year, to make a scientific journey toGermany, with a view to obtaining documents on the

.teaching and practice of medicine in the principal statesof Germany. Dr. HOEFER’S journey lasted four months,and during that time he collected much information,which he has given in his report under the three followingheads:ņtst, public medical functionaries ; 2nd, systemand duration of medical studies in the German medical

faculties; 3rd, various grades of civil and militarypractitioners; their duties and obligations to the state.Prussia is, as it were, the model for the secondary statesof the Germanic confederation, with the exception of

Bavaria, the institutions of which are rather different.An account of the medical organisation of Prussia andBavaria is, therefore, according to Dr. HOEFER, alone

necessary to convey a correct idea of the condition of

the medical profession in Germany. Any important

points in which the kingdoms of Saxony, Wurtemberg,and Hanover, the duchies of Saxony, the Grand Duchyof Baden, and Electorate of Hesse, differ from the Prus-sian or Bavarian system, being noticed afterwards, will

complete the sketch.

Owing to the existence of public medical function-aries, the medical profession in Prussia presents a

kind of military hierarchy, which is totally unknownin England, and even in France. To the ministry or

department of public instruction is attached a 1* Supe-rior Medical Board" (wissellschriftliche Deputation) whichhas the direction of all the medical affairs of the king-dom. It is before a committee chosen by this boardthat takes place the state examination (Staais examen),which alone confers the right of practising. All the

members who compose the board are medical men, with

the exception of the president and secretary. It is byno means a recent institution. Established under the

name of 11 Collegium Medicum," by FREDERIC WiL-LIAM, Elector of Brandebourg, it has existed, slightlymodified, since 1685. From the date of its origin the" collegium," was intrusted with the duty of grantinglicences to practise to the physicians, surgeons, ac-

coucheurs, and apothecaries, who had fulfilled the

conditions prescribed by law. In disputes between pa-tients and their medical attendants it was referred to,and its decrees had the weight of judicial decisions. In

1724 a medical college was created in each province, andthat of Berlin received the appellation of " SupremeMedical College" (Obel’ Collegiunz Medicum). Accordingto the decree of 1724, the Supreme Medical College of

Berlin was composed of the medical men of the court,of the oldest practitioners of Berlin, and of two addi-

tional members, one for surgery, another for medicine.a minister of state was the president. In 1808 the

direction of medical affairs was comprised in the depart-ment of the Minister of the Interior. In the followingyear the 11 Supreme Medical College" was dissolved, anda medical section was formed in the Ministry of the

Interior, which was united to the Section of Police.

Lastly, after many oscillations, occasioned, in a greatmeasure, by political events and by financial crises, thedecrees of 1815 and 1817 appeared. These are the de-

crees which at present regulate the hierarchy of themedical functionaries.

In pursuance of the regulations which they enforce,there is, in the principal town of each province, a Medical

College (IJ:fedecinal Collegium), presided over by the go-vernor of the province, or, in his absence, by the firstcouncillor of the Medical College. Each " Provincial

Medical College" is composed of six members-two phy-sicians, an accoucheur, an apothecary, and a veterinarysurgeon. The colleges are not administrative bodies.

They are called upon to give to the provincial governmentadvice as to the questions of legal medicine, and of medi-cal police, which may occur; to watch over the publicmedical establishments; to revise the pharmaceuticaltariffs ; to constitute a committee of examination for theadmission of practitioners of an inferior class ; to appre-ciate doubtful cases of legal medicine; to ratify medical

certificates ; to prescribe sanatory measures in epidemicsor epizootics ; to analyse mineral waters ; lastly, to ad-dress to the " Superior Medical Board" of Berlin periodi-cal reports on the medical affairs of the province.Each province is subdivided into from fifteen to twenty-

five districts, and each district into cantons. In each of

these there are secondary and tertiary classes of medicalfunctionaries, all subordinate to the provincial eollege.The " Medical Councillors" (Medicinabraetlie) are the

immediate subalterns of the provincial college, whoeach reside in the chief town of their district, in the same

way as the members of the medical college reside in the

capital of the province. They are immediately superiorto the" medical and surgical inspectors of cantons"

387RUPTURE OF THE BLADDER.-ULCER OF THE DUODENUM.

(kreisphysici and kreiswundaerzte), who occupy the

lowest grade of the heirarchy of the medical function-aries. The cantonnal inspectors are more especiallycalled upon to exercise an active scrutiny over the con-duct of the practitioners of their cantons, and are underthe orders of the judicial authorities in all cases of

legal medicine.Thus, the heirarchy of the public medical functionaries

in Prussia, as also in the rest of Germany, is based onthe political division of the country. In the capital thereis a superior medical board, forming a part of the

ministry of public instruction. In the capital of each

province there is a " provincial medical college." In the

capital of each district there is a " medical councillor,"and in each canton there is a 11 medical and surgicalinspector."

All these functionaries are paid by the state, the salaryvarying, according to rank and length of service, from501. or 60!., the amount received by the cantonnal in-

spectors, to 4001. or 5001., the amount received by themembers of the central board.

These appointments are not given by concours, but noone can become even a candidate for them unless he has

undergone a special examination prescribed by the regu-lations, which we shall hereafter record. The publicmedical functionaries are quite distinct from the teachingbody of the faculties. The faculties confer academical

gra.des, but the state alone, represented by the committeeof the superior medical board, can give the licence topractise.

HOSPITAL REPORTS.

LONDON HOSPITAL.

RUPTURE OF THE BLADDER.

THOMAS WALTERS, a stout-built creole, setat. 27, ad-mitted under Mr. Scott, Wednesday afternoon, Dec. 13,for the relief of retention of urine. He stated that he

had, on the same morning, while walking hurriedly,accidentally tripped over a log of wood, and fell withconsiderable violence with his abdomen upon it. Onfurther inquiry, which, however, was not instituted tillafter his death, it appears that on Sunday evening,during a fight with another man, he fell down on his

back, and received the entire weight of the body of hisantagonist upon him. Immediately on the receipt of theinjury he was conveyed to a neighbouring union, and,on admission, complained only of hypogastric pain,which, however, was not urgent enough to deprive himof sound sleep during the night. On the following morn-ing three pints of urine were drawn off by the catheter,a purgative was exhibited, and, as symptoms of peri-tonitis appeared to be advancing, calomel and opium wasprescribed every second hour. This treatment was con-tinued till he left the poor-house on Wednesday, the ca-theter also being occasionally introduced. No blood wasobserved in the urine that was drawn off.When he came into the hospital he appeared barely

capable of supporting himself, was excessively languid,with cold extremities, and slight perspiration on the fore- Ihead. He was incapable of emptying the bladder, andcomplained of great abdominal pain, referred chiefly tothe hypogastrium, which was tense, and pressure upon itcaused an expression of great distress. An instrumentwas passed, and fifty-two ounces of brownish fluid, MM-mixed with blood, and of the odour of urine, came away.

This caused an immediate relaxation of the abdominalpain. He was sent, directly afterwards, to bed; winewas ordered to be administered at intervals, and fomen-tations to be applied to the abdomen. Excessive languorcontinued throughout the day. The wine, however, hadcaused slight reaction, evidenced only in the pulse,which was just perceptible, being quick, and very small.The extremities were perfectly cold, although he con-stantly complained of the excessive heat, to remedywhich inconvenience he several times endeavoured tothrow off the bed-clothes. He appeared to sleep duringthe night, wine being administered at intervals.- On the following morning the pulse was imperceptible,

the abdominal pain had increased, but instead of beingreferred principally to the hypogastrium, was referred tothe left of the epigastric region. He died at eleven, a.m.,eighteen hours after admission, and three days and seven-teen hours subsequent to the occurrence of the injury.

Inspection.-Viscera agglutinated by thin films of softfibrin ; free surface of the intestines injected ; opposedsurfaces being pale. About a quart and a half of san-guineous fluid in the peritoneal cavity. The bladder pre-sented, at the upper part of its posterior aspect, a rupture,slightly oblique in direction, from above downwards andto the right side. The aperture was an inch and a quarterin length, and irregularly oval; the serous covering wasmore extensively lacerated than the muscular and mucoustunics. The latter had slightly protruded from the open-ing in a pouting manner, being raised by the apparentretraction of the former, appeared smooth, and, as itwere, moulded into the circumference of the rent, thevessels of which circumference were in a state of greatcongestion.

Remarks.—The absence of bloody urine is no proofthat the bladder is not ruptured, which was evident inthis case, from the inability to evacuate it, the urethrabeing pervious, and the spine uninjured; and also fromthe irremediable collapse that directly succeeded the

injury, attended with immediate abdominal pain andtenderness. The remarkable circumstance is that the

patient should have survived the accident three days andseventeen hours.

ULCER IN THE DUODENUM CONSEQUENT ON A BURN.

Emily Ward, aetat. 15, admitted under Mr. Luke,March 16, having received a burn over the anterior partof the chest, back, neck, and left upper extremity. Theskin in several parts was completely destroyed.On the establishment of reaction, considerable amount

of fever supervened. It lasted about five days, andcaused much exhaustion of the system. At the end ofthis period she complained of great pain, referred to theparts implicated in the burn, and to remedy this opiumwas given, in small repeated doses, with beneficial result.One or two days subsequently she was troubled withgreat pain, referred to the epigastrium and bowels. Lau-danum afforded only temporary relief. The pain, how-ever, was not of a continued character, but came on atintervals. It continued to the day of her death, March30, fourteen days after the occurrence of the accident.Twelve hours prior to death she vomited a large quantityof black fluid, of a tarry appearance, and passed also a:similar quantity of the same material by stool. After theoccurrence of the vomiting and purging, she sank veryrapidly, and appeared to die from collapse induced byinternal haemorrhage.

Inspection. - General surface of the body pallid, heartflabby, a small quantity of blood only in the cavities.The stomach and intestines were preternaturally dis-tended, and contained a dusky, blackish fluid, resemblingin appearance a dark liquid holding in suspension irregu-lar particles of pitch, and analogous to that vomitedduring life. At the posterior part of the duodenum ex-isted an ulcer about the size of a shilling, which had in-volved all the coats of the gut. It was situate about athird of an inch from the pylorus. The circumference ofthe ulcer was represented by a margin about a line and ahalf in breadth, bevelled off at one part from withouttowards the centre. The inner border of the margin lostitself in the anterior aspect of the pancreas, which had