Madam A—, aged 40 years, had been harrassed with violent pains, of a lancinating character, shooting from the pelvis along the thigh, in the direction of the sciatic nerve, and down even to the foot, ever since the month of February, 1826. The pains were increased by the slightest movement, and they were unaccompanied by any visible change in the colour, size, or temperature of the parts. The respiratory and digestive functions were healthy; but an evening access of fever obtained, and terminated in a profuse perspiration in the night. The pains were exasperated during the evening accession. This series of symptoms continued for six months, and resisted the various means that were employed by her physicians. She came under M. Piorry's care on the 6th August. He applied forty leeches in the line of the sciatic nerve-the part was enveloped in a large cataplasm-and baths were afterwards administered. Diluent drinks and low diet were enjoined. A slight amelioration ensued, and the leeches were twice repeated. Still the amendment was very inconsiderable, and, indeed, the third application of the leeches exasperated, rather than soothed the pains. The extract of lettuce was then employed, in full doses, but with only temporary benefit. On the 1st September a large blister was applied, which caused the pain to cease entirely for a time, again to be renewed with equal violence. The oil of turpentine, in the dose of one drachm thrice a day, was given, suspended in syrup and water, by means of yolk of egg. The medicine produced heat at the epigastrium, but no vomiting the first day. The second day it vomited the patient, and the dose was given only twice a day. The patient could feel that the turpentine remained long on the stomach, and it took away the appetite. On the third day the neuralgia was mitigated, and in four days it was quite dissipated, there only remaining a sense of formication, which also disappeared in a day or two more. The patient thought herself cured-began to walk about her room—and left off the medicine. The pains returned, though in a slight degree, and the turpentine was resumed for a few days more, when the recovery was complete.

It appears, from M. Piorry's account, that this medicine is becoming very popular in Paris. If its taste could be disguised, it would prove a valuable addition to our list of therapeutical agents. In our own practice, the pa tients have complained more of the terebinthinate eructations than of the mere deglutition of the medicine.

We are not informed whether the carbonate of iron was employed in the above case, prior to M. Piorry's attendance. We suspect that it would have cured the disease as speedily as the turpentine, and with much less inconvenience.

We were recently in attendance on a young gentleman who had long been afflicted with violent accessions of palpitation, pain in the region of the heart, in the upper part of the sternum, in the throat, and down along the left arm, as far as the elbow. He had read several medical books, and was convinced that he had aneurism of the heart or some of the large vessels. He, therefore, nearly starved himself, and certainly was a most deplorable looking object, being afraid of walking across his room, lest the aneurism should burst. By this system, and by the purgation and other depletive measures which he pursued, the disease was evidently exasperated. It usually came on in the afternoon, and would sometimes last the whole night, during which the action of the heart could be heard by the bye-standers. When we first saw him the heart was nearly quiet. The chest sounded well in all directions-the action of the heart was heard over only a very moderate space and no unusual noise accompanied the ventricular or auricular contractions. As he had had no previous illness of any consequence as he never had rheumatism-and as he had experienced some severe moral affictions, we were convinced that the disease was of a nervous character.

His stomach was very much out of order, in consequence of the vegetable and fruit diet to which he confined himself, from apprehension of aneurism. The diet was changed-and tonics were given. The symptoms were mitigated, but the paroxysms of palpitation continued to return daily. We then ordered him a drachm of carbonate of iron in some compound confection of senna, (which, by the way, is a very convenient vehicle) twice a day. In three or four days the paroxysms became trifling in degree. The dose was increased to three drachms daily, and he was soon well.

7. AXILLARY ANEURISM.

Mr. Liston has detailed some cases of Aneurism in our elder brother of the North, the Edinburgh Journal for January, from which we shall notice one, where the subclavian artery was tied, but unsuccessfully.

Case. J. M. J. æt. 43, after travelling from 150 miles in the Highlands, applied, Sept. 12th, 1826, with an aneurismal tumour, the size of a football, in the right axilla. It passed upwards beneath the clavicle, raising it considerably, and downwards to below the border of the axilla, pressing in the ribs and flattening the chest. Limb of the natural temperature, but paralysed its upper part hard-the lower oedematous, as was the side of the chest. It appears that about Christmas, 1825, he had fallen on the ice with his arm stretched out; that this was followed by violent pains, which were thought to be rheumatic, and that it was only ten weeks previously that he was made aware of the nature of his complaint. On the 14th, Mr. Liston proceeded to tie the subclavian, assisted by Mr. Mackenzie, and in the presence of Dr. Monro, Dr. Sanders, Dr. Malcolm, and other gentlemen. On exposing the artery, it was found to be much enlarged, and on withdrawing the aneurismal needle, a gush of blood followed, which was restrained by pressure with the finger, and soon stopped. The ligature was tightened, and pulsation in the tumour ceased. Apprehending, however, a return of the hæmorrhage, Mr. L. tied the vessel again three-fourths of an inch nearer the heart, and close to the edge of the scalenus anticus. Here the arterial coats were found, if possible, still more diseased.

All went on well for some days, but on the fifth evening the pulse rose from 90 to 120, with increase of pain in the tumour and arm. V. S. ad 3viij.-anodyne. On the morning of the thirteenth day, some oozing from the wound; in the evening, oozing again, with relief to the pain and throbbing at the root of the neck, and diminution of the tumour. Next day, oozing of putrid blood again, and the patient sank.

Sectio Cadaveris. The tumour was diminished nearly one half in size, but still was of enormous extent. The vessel had given way just below the origin of the thoracica humeraria, and from that point to the edge of the scalenus, it was firmly attached to the tumour, and, in fact, contributed to the formation of its coats. The wound was filled with coagula, and the upper ligature was found detached, embracing a slough, and lying loose among them. The under ligature was still attached, though ulceration had occurred here also, to a considerable extent. This ligature lay in the sac behind the subclavian, and from this perforation had proceeded the hæmorrhage, which occurred on withdrawing the needle until the opening in the sac had in all probability been plugged up by coagulum. At neither of the points of deligation was there much appearance of attempt at reparation. There was no clot in the artery, except at the upper opening, which was soft and bloody; and though the vessel was a good deal contracted, the adhesions were slight; the axillary vein also necessarily passed over the inner part of the sac, adhering firmly to it, and obliterated about three inches below the clavicle. The tumour extended, by a process two

inches in diameter, down to the bend of the arm in the substance of the biceps. The brachial artery below was filled by a firm coagulum; the anastomosing vessels much enlarged; the aorta and innominata were double their original size, and their coats thick and pulpy. Adhesions between the pleuræ on both sides.

Remarks. The fatal event was evidently owing to the morbid state of the artery; and from several cases of axillary aneurism which we have seen, where the coats of the artery were, as here, much diseased, we fear that operations on the subclavian can never be attended with general success. Indeed, looking to the anatomical and pathological difficulties which harass the operator, our only wonder is, that he has been so successful as he has. Mr. Liston doubts the accuracy of Mr. Wardrop's operation on the carotid. He says, "I should think it would puzzle Mr. W., and those who put faith in the efficacy of deligation beyond the sac, to say what effect would have been produced on this aneurism, by including the contracted and obstructed humeral artery in a ligature." But the parallel is hardly a fair In Mr. W.'s case, the disease was in its commencement-in this it was far advanced. From the carotid no branches are given off, there is nothing to keep up the current-in the axillary artery it is the reverse. The principle of Mr. W.'s operation is to check the circulation through the sac, but tying an obstructed humeral artery could not do this, for the anastomosing vessels were all enlarged; and to bring the case quite into the same circumstances as the carotid, it would be necessary to tie them. Again, the objection to the new operation, of its inefficacy in this case, would apply equally to the common operation, for it really was inefficacious.

one.

To the paper of Mr. Liston a plate is appended, which shews the morbid appearances clearly and satisfactorily; and, from the details of the case, we are sure, that if dexterity on the part of the operator could have saved the patient, this would not have been recorded amongst the fatal instances of axillary aneurism.

8. CLINICAL MEDICINE.

The subject of medical education has lately excited, and deservedly so, great attention in this country. The clinical education of the student is one of the most important portions of medical education, because on it will greatly depend the future success and reputation of the practitioner. Dr. Clark, whom we have often introduced to the notice of our readers, is well calculated to offer suggestions for the improvement of clinical instruction in this country, in consequence of his long residence in Italy, and his travels on the continent, with the professed view of gleaning useful information on this interesting subject. We hope the patrons and professors of the Edinburgh University will give an attentive perusal and consideration to the suggestions here thrown out, and that they will not allow themselves to be " compelled to follow in the march of improvement, when they should have led." If they permit private interest and cabal to drown the voice of honour and renown, that famous university may live" to see her halls deserted in the department of science to which she has been indebted for her

Observations on the System of Teaching Clinical Medicine in the University of Edinburgh, with Suggestions for its Improvement, &c. By James Clark, M.D. Svo. pp. 30, sewed. 1827.

most extended celebrity." She may, indeed, exultingly point to the increased, or increasing number of her medical students; but numerical calculations are dangerous documents to build upon in such cases. Circumstances may render it convenient or necessary to frequent a market for some time after its goods have been deteriorated in value; but other markets may ultimately spring up to rival the old.

Dr. Clark has confined himself, in this pamphlet, to the subject of Clinical Instruction, and begins by portraying some of the best plans pursued on the continent, where the greatest attention is paid to this important item of medical education.

Two methods of teaching clinical medicine are adopted in the continental schools-the Hospital Clinic-and the Poly-clinic, or Ambulatory Clinic. The latter corresponds exactly with our dispensaries. In both these institutions, however, the system differs in some very material points from that in use at Edinburgh, or indeed in London. The chief difference consists, 1st, in the more advanced pupils having a part in the treatment of the patients; 2dly, in the greater length of time required of pupils to attend clinical medicine; 3dly, in the manner of appointing the clinical professors. In the Hospital Clinic, the elder pupils are entrusted to attend to certain patients, of whom they may be said to have the charge, under the immediate inspection of the professor. These pupils draw up the histories of the cases, and are examined on the nature of the disease by the professor, in the presence of the other pupils. They are also required to point out the symptoms which more especially characterize the disease, and serve to distinguish it from others which it most nearly resembles, and with which it might be confounded; and, finally, to give the prognosis and method of treatment. Those pupils continue to attend the same patients; and at every succeeding visit they examine, under the eye of the professor, the state of the symptoms, inquire into the effects of the remedies prescribed, &c. Of the whole case they keep a faithful record. If the disease should prove fatal, the attending pupil is further required to state, previously to the examination of the body (a thing which is never omitted), the morbid conditions which he expects to find, and what he considers to have been the cause of death." 6.

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There can be but one opinion as to the great advantage which the pupil must derive from such a discipline; but we fear the temper of John Bull, who subscribes to, and becomes a governor of, an English or Scotch hospital, will not permit such delegation of treatment to the pupil, except on emergencies, when the physician or surgeon is out of the way. We have little hope, therefore, that this clinical regulation will be introduced into our English hospitals, at least for the present.

The Poly-clinic, or dispensary practice, is very general over Germany; and at some of the universities, it is the only source of clinical instruction. Those patients who can attend the Dispensary are prescribed for there; acute diseases are attended at the patient's houses.

"The pupil is first exercised in examining the patients that come to the Clinic, under the observation of the professor, and is required to state the nature of the disease, its treatment, &c., as in the Hospital Clinic. The treatment being agreed upon, the pupil writes the prescription, which is examined, modified if necessary, and signed by the professor. After a time, the pupil is intrusted with the care of the out-patients. He is required to draw up an accurate history of each disease under his care, which is submitted to the inspection of the professor, as are also the reports of the progress and treatment of the case. Moreover, when he finds himself in difficulty, or the case appears to the professor to require it, the clinical assist

ant accompanies him to see the patient, and assists him with his advice. In urgent cases, I believe, the professor also visits the patient; and where the disease proves fatal, he superintends the examination of the body, a practice to which, on the continent, objections are very rarely made." 8.

We are acquainted with some officers of public dispensaries, in this metropolis, who closely approximate to the foregoing plan, and who consequently are of more real utility to the pupil, than any officer of a public hospital can possibly be under existing regulations.

"Let us now compare the Edinburgh Clinic with those described. The patients in the wards are here visited once a day by the professor and pupils. The cases are carefully drawn up by the physician's clerks, and the pupils are permitted to copy them into their own case books. The successive daily reports may be added at each visit, as they are dictated at the bedside of the patient by the professor. To see and hear the professor examine and prescribe for the patients is all that the pupil, generally speaking, has to do with them*; and it is not always an easy matter for him to attain this limited and second-hand communication; the crowd being frequently so great as to deprive a considerable proportion of the pupils of the benefit of seeing and hearing distinctly, either the professor or his patient. There are two clinical lectures given each week, in which the professor explains the nature of the cases, the treatment, &c. These lectures form an excellent part of the clinical system of Edinburgh, and are too much neglected in the foreign universities in general. They are, however, too few in number. A patient may be received into the clinical ward, and pass through the whole course of an acute disease, before the professor has an opportunity of making any remarks on the case in these lectures; but even though made more frequent than they are, they never can, in ray opinion, entirely compensate for the want of remarks on the cases, in the clinical wards, such as are made in most foreign clinics. In Edinburgh, the number of patients to be examined, in the period of time to which the visit is limited, renders it impossible to make any remarks of conse quence." 11.

Abroad, the pupil is generally required to attend to clinical medicine for four sessions, or two scholastic years—at Edinburgh, only six months' attendance on the clinical course is necessary, and the same length of time at any respectable hospital. Abroad, the graduate must pass a considerable time, after obtaining his degree, before he can enter on the practice of his profession-that time being either in an hospital, or with some practical physician. After the completion of the period of probation, he again undergoes an examination, as to the progress he has made in practical medicine, before he can be admitted to the Libera Praxis of his profession. We are ashamed to compare, or rather to contrast, this with what we see done in this country.

We have only one more point to touch upon in this short article. In foreign universities, the clinical professor receives his appointment "erpressly in consequence of his qualification to teach practical medicine.” His duties, as clinical professor, are regarded as by far the most important, and in the exercise of this branch he is regularly occupied during the whole academical year. In Edinburgh, the clinical professors hold other chairs

"It is true the pupils may, I believe, visit the patients in the clinical wards in the intervals of the visits; but were many to avail themselves of this privilege, the patients labouring under acute diseases would not benefit by the practice."