THE LANCET. A Journal of British and Foreign Medicine, Physiology, Surgery, Chemistry, MDCCC LXVII. IN TWO VOLUMES ANNUALLY. VOLUME I. LONDON: PUBLISHED BY GEORGE FALL, AT THE OFFICE OF "THE LANCET," 423, STRAND, Lecture INTRODUCTORY TO LINICAL MEDICINE, Delivered on the 8th of October, 1866. Br JAMES ALDERSON, M.D., F.R.S., $10 PHYSICIAN TO, AND CLINICAL LECTURER AT THE SCHOOL OF, ST. MARY'S HOSPITAL. of you can try to recall how many symptoms of each case and how many observations on them remain fixed distinctly in the memory, and we cannot doubt that whoever has the largest amount of these acts of memory in his possession at the end of the session will be the most advanced towards becoming a good practitioner. Genius is a great gift, but honest industry is a more valuable quality. There are innumerable ways in which the art of memory has been cultivated, different professors giving each their system of mnemonics; but I believe that one of the best plans that can be adopted is, after having had subjects presented to the mind, to interrogate the memory as soon as possible, to see how much has been retained, and how much has been merely vaguely seized, and therefore sure to pass away unprofitably. ENTLEMEN, -I am always glad to use the opening lecture the youth of our time from all classical attainments, I cannot Notwithstanding the idle innovation which tends to excuse e session by inviting the attention of the students to some help believing that there are some Ciceronian readers amongst rules for their guidance in the course of the studies you. Those who have not that advantage may like to hear we commence to-day. St. Mary's School is now grow- the incident about Simonides to which the origin of artificial nto a large institution, which may be expected to bear-memory is referred. The story goes, that whilst Simonides does not already do so-a sensible influence on the chawas at Crannon, in Thessaly, with one Scopas, he was suddenly called out; returning quickly to the room he found the roof er of the rising generation of the profession. had fallen in and all the guests were buried in the ruins. The The first great lesson which I should desire to be deeply bodies were so mutilated that they were not to be distinguished read by all of you is to cultivate a sense of the immense re- from each other. In the eagerness to afford rights of sepulture sponsibility of the work you undertake. I rejoice to believe to each there was great rejoicing that Simonides was able to that St. Mary's School has already been prominent in reforming picture in his memory the exact scene which he had left, the frivolous and larky habits which have been too often attri-realising in his mind the order in which the guests had sat, thus indicating where each body would be found. This is bated to the character of medical students; and whilst so many said to be the origin of artificial memory by means of impresefforts have been made to improve the education, and thereby sions on the sight. Fifty years ago Von Feneigle's plan, which the efficiency and social status of the great class of general practi- caused great excitement, was based on the same principle. But the fact is that all our senses ought to be engaged in one tioners, it is gratifying to think that those who are taking their irst step towards that career are doing it with a serious convic-great act of attention when we wish the cultivation of our tion of their obligations. There is something beyond your own memory. You will not only have to make a vast collection of symptoms, and of inferences deduced from those symptoms, but you will in this hospital be furnished with the most valuable of all opportunities-viz., the dead-house, which affords the solution of so many mysteries. It will require the exertion of a great act of memory to reproduce all that has to turn this final revelation to its full account. Post-mortem before in the way of symptoms and reasoning, in order gone examinations are, in fact, your greatest, most invaluable opportunities, unless you should become hospital surgeons or physicians, they are opportunities which you will never have again; and every case that you examine ought to be fixed in your memory, clearly reflected there, in order to explain and illustrate a hundred difficulties which will continually arise In the work of self-improvement the first point to be aimed in practice on to the end of your lives. No one had a more at is to establish a habit of concentrated observation. A half vivid sense of the value of the mortuary than one whom I conattention and a divided mind will help no one to seize the insider to have been one of the greatest, if not the greatest, of numerable and minute particulars which together make up a modern pathologists. Dr. Bright felt that, towards the end ene knowledge of those most difficult of all sciences-Patho- of his life, his practice required to be guided and enlightened logy and Therapeutics. They are difficult, because the mass by continual revelations of results of disease. After giving up of evidence on which they are founded is almost unlimited, his hospital, he once said to me, whilst considering an obscure because no exact general rules can be laid down for the adap- case, "I envy you, who have still the advantage of the deadtation of all those minute particulars, and because cool judg-house; if anybody would give me my income I would gladly ment and highly cultivated memory must be applied to that go back to it." And we may observe from this exclamation, alaptation in every single instance. Your first object there- not only the value of that line of study, but the indomitable sure will be to teach yourselves to observe closely, and to de- industry with which this successful physician had used it. I conTote every possible effort towards the improvement of the ceive that it was industry and a clear unprejudiced intelligence, emory. Acute observation is, in fact, the very foundation rather than any particular genius, which made him what he of memory. I have often quoted the well-known instance of was. Before leaving the subject of the mortuary I should like the manner in which conjurors educate themselves for their to notice that your work in learning practical anatomy has a business. By degrees they learn to fix in their minds at a tendency to detract from the sacred respect which ought to be rapid glance as many objects which are placed before them as felt by human beings towards the remains of fellow-men. It they possibly can. It is done by a highly concentrated atten- is our especial duty, who belong to the medical profession, to tion, and the power they arrive at is so far beyond what the respect the human frame-as well our own as that of other eye believes to be possible, that at last that power persons: a respect not to be neglected even when the spirit appears to be a marvel which is merely the result of educated has been withdrawn from it. We should remember that the banities. This education is pursued by artists, who learn not Creator has made it in his image, and that its future destiny only to see form and colour which common observers are not able is still a mystery. to perceive, but they can take in at a glance all minute details of sonas and pictures, which remain with them for their professonal use. The mere hieroglyphics which Turner jotted down, reproduced to his mind not only the grand effect of a mag sificent scene, but a thousand minutie which toet of a was a wonder that he could ever have perceived in his transient e of cultivating this faculty of close and rapid observation, We might instance in almost every art and calling the sad here, in pernity of beginning such a course of self-improvement. Estening to the observations of the clinical teacher, every one er the brief visits to each patient in the wards, and after No. 2262. uneducated I am now going for a few minutes to pass from the subject of intellectual training to that of conduct and manners. The general bearing towards authorities and mutual intercourse amongst yourselves are, perhaps, beyond my legitimate topics. These, however, are most valuable themes of exhortation on the opening of a school, commended by considerations of the deepest interest to yourselves and to the profession. I rejoice to know that the students of St. Mary's have hitherto presented a good example of gentlemanly manners, and that aniform good conduct, prompted, as I believe, by good feeling, has marked their time of pupilage; and I'equally rejoice to know that the career of after-life has opened with a promise of success which may well be attributed to beginnings so auspicious. That, however, which most concerns me now to dilate upon is proper conduct to the sick, especially of those who are now entering on their studies in the wards. I should like to insist on the almost solemn obligation which young men, with youth and health and high spirits, are under, to adopt manners courteous, I might almost say reverential, towards the suffering inmates; especially to cultivate the great virtue of modest treatment in all personal examinations. Many of you will hardly conceive to what extent the sense of delicacy is keen amongst persons who might be called, comparatively, of the lower orders. There are a hundred little ways in which this delieacy may be considered, and many rough, incautious acts may de avoided without the least approach to anything like effeminate prudery: which last fault is, perhaps, as oppressive to a patient as a want of proper delicacy. True feeling and acquired tact will point out the proper medium; and the value of perfect manners towards the sick, which may be obtained in the wards of an hospital, will be felt by you continually in after-life, contributing in no small degree to your success in practice. Not only in the mode of examining, but the very language used, especially in the female wards, ought to be studied and nicely adapted to each particular case. To learn in your time of pupilage the nice distinction between coarseness and affectation will be well worthy of your serious attention. It is due to your character as gentlemen, and to your principles of humanity. It will also be of great consequence to you as to your future popularity. I remember long ago an instance in which a most worthy practitioner lost the attendance for ever of one of the most important families in his neighbourhood by a single vulgar and abrupt expression. I may mention, as a minor inducement to you to adopt that upright and pure line of conduct, joined with that polished manner which ought to distinguish the medical above all other professions, that these are the qualities that will first bear fruit in your future course of life. A reputation for scientific knowledge and for successful practice must be gained by degrees whilst you are actually at work-its acquisition must be a work of time; whilst your first acceptance by the public must depend chiefly on personal qualifications of which all can judge. I have adverted only, so far, to your conduct towards the patients. There is another class towards whom a very strict and well-regulated tone of manners is imperatively necessary. It is a difficulty peculiar to the wards of an hospital, and one that is altogether unavoidable, that young men have to work in conjunction with young persons of the other sex; and it rather increases the difficulty that the young men are, in most cases, in a superior social position to the nurses, so that a certain amount of respect and reticence is gracefully appropriate to regulate the conduct of the superior towards the inferior class. It is impossible to lay down minute rules for the communication between pupil and nurse, but I trust the hint may not be unavailing to you, and that a habit of gentlemanly selfrestraint will be cultivated by all of you, especially by those who are as yet strangers to the customs and manners of a great hospital. I am not myself by any means the advocate of taking the great and useful work of nursing out of the hands of the class of women by whom it has always been supplied. Employment is wanted by that class; they can sympathise more, they can understand better the wants and feelings of the sick, who belong more nearly to their own condition; and it is my opinion that we are doing better in educating these people to a more complete knowledge of their duty, than in encouraging members of a higher class to accept work which does not naturally belong to them. In the wards of St. Mary's you meet chiefly the genuine hired nurse; and you will consult not only the formation of your own manners, but the improvement of the nurse, by avoiding any possible approach to levity or familiarity. The observations with which I began this lecture, as to the value of intensely concentrated observation, cannot find more important topic than that which the unhappy epidemic now present immediately affords. You are called at the very outset to the study of the gravest and most difficult of all diseases, a disease which is still the humiliation of medical science, the most earnest study of which has as yet been baffled in trying to discover the cause and in applying remedies. One thing is certain, that mere tentative remedies have all failed equally, It is also certain that we have arrived at a few facts in regard to the morbid change, and to a knowledge of many of the elements which favour the development of the disease; whilst speculations as to the exciting cause in each locality have proved, in their turns, to be signal failures. All that can be made out is, that that which depresses the system, which induces a low state of vitality, affords liability to attack, and even this, when we come closely to investigate it, requires some modification. I think we are in a position, in regard to this difficult subject, to attempt some further plans of treatment, based, not as heretofore on the poor system of "trying plans," but upon reasoning drawn from the few facts which we have been able to realise. I shall continue this subject at my next lecture. In the meantime we have only, both students and teachers, to go on in the course of investigation. There has been a painful uniformity in the symptoms, but still some new lights may be afforded by very keen observation. So far as to the morbid changes as seen after death there has been a similar uniformity in all cases, as I shall hope to prove to you on the next occasion. It is into this source of information that we must be especially anxious to inquire. The two inspections which I have already had with you have been full of interest, and before we meet again possibly some further evidence may be afforded to us, which we may hope to turn to good account. ON COMPENSATION FOR RAILWAY INJURIES. BY JAMES SYME, Esq., F.R.S.E., PROFESSOR OF CLINICAL SURGERY IN THE UNIVERSITY OF EDINBURGH, SINCE the passing of Lord Campbell's Act-a most unjust piece of legislation as it has always seemed to me, which established the principle of regulating the amount of damages for personal injuries in accordance with the value of individuals to society and to their families,-claims of this kind have become very frequent, under circumstances which seriously call for consideration. For instance, at this time last year a trial took place at Guildhall in the Court of Common Pleas, on the part of a commercial traveller, who prosecuted the Great Northern Railway Company for compensation on account of an injury alleged to have been sustained from a collision on their line. In this case Sir Wm. Fergusson, Mr. Erichsen, and Dr. Russell Reynolds declared that there was organic disease of the spine, which in all probability would soon prove fatal; while, on the other hand, Mr. Borlase Childs, Mr. Pollock, of St. George's Hospital, Mr. Cock, of Guy's Hospital, Dr. Risdon Bennett, of St. Thomas's Hospital, Dr. Dunsmure, President of the Edinburgh College of Surgeons, and myself, no less confidently expressed the conviction that there was no organic disease whatever, and no reason why the claimant should not enjoy good health. The jury, instead of the £12,000 asked, gave £4700 of damages; and before the end of many months, the plaintiff, who had been rapidly recovering, admitted that he was quite well, as he still continues to be. The truth is, that when juries find the medical evidence so conflicting, not being able to judge for themselves as to the merits of the case, they almost always decide in favour of the claimant, so that there is thus great encouragement afforded to unfounded or exaggerated demands for redress. Indeed any man who travels by railway may easily obtain a competency by stumbling on the platform after the door of his carriage has been opened by a servant of the company, but before the train has ceased to move. He has then merely to go to bed, call in a couple of sympathizing doctors, diligently peruse Mr. Erichsen's lately published work on Railway Injuries, go into court on crutches, and give a doleful account of the distress experienced by his wife and children through his personal sufferings, which have resulted from the culpable negligence that allowed him to leave his seat prematurely. Who can doubt that in such circumstances the jury would give large damages. This system ought certainly to be put down, and as one means of doing so, I beg to suggest the publication of cases exhibiting an entire discrepancy between the medical evidence, in order that regard for professional character may tend to check the reckless advocacy of one-sided views. The results of such cases in regard to the claimant's speedy recovery of health would also be worthy of attention for the same purpose; and, having given one of these, I may add a case of medical diversity that has just occurred here. On the 27th of April last a commercial traveller drove out in the evening to my residence in the neighbourhood of Edinburgh, and informed me that he had been shaken the night before in a railway collision near Berwick-on-Tweed. He had walked immediately afterwards a mile and a half to see Dr. Maclagan, of Berwick, and having been assured by him that there was no local injury or occasion for confinement, had come on to Edinburgh. Finding that there was no local complaint, I desired him to call next morning at my house in Rutlandstreet, and tell me if he felt anything wrong. He accordingly did so, and then exhibiting the most perfect freedom in all his movements, without any sign of local injury, I concluded that if he felt any uneasiness, it must be more mental than bodily. Having expressed my opinion to this effect, I was rather surprised by being asked to recommend a law-agent, and, it is hardly necessary to say, declined to do so. On the same day, the 28th of April, it appears that this person, having procured an accomplished agent, applied to a surgeon of experience in cases like his own, who discovered that he had sustained a "severe wrench of the spine and sacroliac synchondrosis," put him to bed, called in a trustworthy coadjutor, and visited his interesting patient at least once a day for months. On the 12th of June Dr. Dunsmure requested me to see the claimant, as he had now become. We and him lying upon a sofa, from which he rose and walked with vigour and flexibility of body. There was not the slight st swelling, discoloration, or rigidity of the spine, and, on the ntrary, every appearance of good health so far as we could judge from our own observation. On the 29th of July, the trial being about to take place, the daimant desired to be examined by a commission; and his ordinary attendant having given a certificate on "soul and onscience" that he was unable to appear in the witness-box Fithout serious injury to his health, I was requested along with Dr. Dunsmure to report as to this for the information of the Court. We found the claimant lying, or rather lolling, on wo chairs in a garden, to and from which he walked in leaving and returning to his room, which was up a stair on the drawing-room floor. He told us that he sat at his meals, and, on the whole, he had no appearance whatever of bad health. We reported our opinion that he could safely appear in Court, and the trial was ordered to proceed. But the claimant's legal advisers applied for delay. On the 14th of December Dr. Dunsmure and I were again requested to see the claimant, as the trial was to take place on the 24th. We found that he was not at home, but after a ttle while saw him walking stoutly along the street from a public bathing establishment, which it appeared he had frequented for several months. He walked up the stair of his residence before me, and neither then nor afterwards, when zare particularly examined, showed any sign of spinal or ether disease. At the trial, after the plaintiff had been examined, sitting in a chair, as he was not able to go into the Fitness-box! his counsel agreed to accept £1000, instead of the £3000 which had been demanded. I deem it unnecessary to offer any observations on this but would suggest the following questions : 1. Could anyone who had sustained a severe wrench of the sine and sacro-iliac synchondrosis immediately afterwards valk a mile and a half, or on the two following days travel axty miles by railway, drive about in cabs, and make visits without local complaint? 2. Could serious disease of the spine resulting from external violence exist for eight months without presenting some sign of its presence in the patient's gait, flexibility of trunk, or general appearance? Edinburgh, Dec. 26th, 1866. THE BRITISH WORKMAN. -A most seasonable addition to the funds of St. Mary's Hospital was made a few days ago, when a deputation of working men waited on the committee and handed in a cheque for £327 198. 94d. to the chairman, as the contribution from the various lodges of Foresters of the district. Altogether £1500 have been subscribed and presented to the hospital by the Foresters. LONGEVITY.On Tuesday last the obituary of The Times contained the deaths of four ladies and two gentleDen whose united ages amounted to 517 years, giving an The ladies, as usual, took the lead; the oldest being ninety-six, Theage of exactly eighty-six years and two months to each. and the youngest seventy-nine. Our contemporary of Wednes day recorded similar illustrations of longevity. In the Medical Times and Gazette of Dec. 30th, 1865, p. 717, Mr. John Dix, of Hull, refers, in a short note, to a case of carotid aneurism which he had treated successfully by a temporary wire-compress, the wire being withdrawn on the sixth day, as soon as the aneurism had become solid, and all pulsation had ceased-that is, as soon as the objects aimed at by compression of the artery were obtained. Through the kindness of Mr. Dix I had the opportunity of examining his patient a few months ago, at the annual meeting, in Hull, of the East York Branch of the British Medical Association. The case was perfect. The result of this operation, and the prospect thereby held out of somewhat diminishing the risk of secondary hemorrhage after ligature of the larger arteries, prompted me to adopt this plan in treating the following case of popliteal aneurism. Although my own case did not terminate successfully, it will, nevertheless, contribute some evidence which may assist us in forming a judgment as to the value of the operation. For the notes of the case I am indebted to my dresser, Mr. George Fisher. Frederick W, a collier, aged thirty-four, was admitted into the Leeds Infirmary on Dec. 29th, 1865. In the right ham there was a pulsating tumour, of the size of a small orange, very soft (especially on the inner side), and without any evidence of consolidation of its contents. He suffered also from severe neuralgic pains in the leg. He first noticed the tumour two weeks before admission, but he had been for three months laid up with rheumatism, brought on by working a whole day in wet clothes. The rheumatism affected all his joints, and had disabled him during the whole three months, with the exception of one week. The only history of accident was, that four years ago he fell down a cellar when drunk and sprained the right knee, returning to his work in a fortnight, not any worse for the accident. Treatment by flexion. Dec. 30th. The ankle was firmly bound to the thigh until the pulsation in the tumour became almost imperceptible. During the rest of the day the neuralgic pains in the leg were considerably relieved. Jan. 2nd, 1866 (fourth day of flexion). The leg was unbound, in order to ascertain whether any improvement was taking place in the aneurism, and to relieve him from the discomfort of the constrained position. There was no sign of consolidation. Flexion was resumed in the evening. 4th (sixth day).-Treatment by flexion was abandoned, as there was no appearance of improvement, and the circumfer ence of the knee had increased from 16 in. to 16 in. The pulsation was quite as distinct as before the employment of Hexion. Treatment by wire compress. (First period.) Jan. 4th. The femoral artery having been reached in the usual way at the apex of Scarpa's triangle, a silver wire was passed behind the vessel, instead of the ordinary ligature of silk or hemp. Each end of the wire was then threaded on a needle, and by this means carried obliquely outwards throngh distance of an inch and a half from the wound. The two ends the sartorius until it was brought out through the skin at the of the wire, being about one-third of an inch apart, were then tied over a small piece of cork, and were tightened so as to compress the artery and stop the pulsation of the aneurism. Thus the wire formed a bridle passing from the skin round the artery, which could be made tight or slack at pleasure, and could eventually be withdrawn when no longer needed for compressing the artery. The pulsation of the aneurism having been completely arrested, the wire was fixed over the cork, and the wound was closed by wire sutures. The operation was followed by great diminution of the neuralgia of the leg. Second day. Slight pulsation in the aneurism. Third day.-Pulsation arrested by the insertion of a small |