miles from town (where there were, undoubtedly, glandered horses), excepting only in this, that in that case the inflammation on the face went to gangrene, which I never saw in erysipelas of that part. In this case, likewise, from the state of the general system, it is very likely that gangrene would have ensued, if the typhoid fever had not been so early fatal. The appearances on the skin were manifestly similar to those of the pustule maligne of the French authors, and of the glanders in human subjects, described by Dr Elliotson, in their early stage.

What is most deserving of notice here, is the confirmation thus given of the principle, which former observations seem indeed sufficient to establish,—that this morbific poison is not only capable of being communicated from the lower animals to man, but acts (as we have reason to believe the variolous poison does) as a more virulent poison on the human body. For although the same poison in the horse, where it is diffused over the body, in the form to which the name of "Button Farcy" is given, producing numerous hard pustules which may go to ulceration, is often much more acute in its progress, than when confined to the nostrils, and having the name of Glanders, yet by far the greater number of cases of disease in the horse, resulting from this poison, are chronic, and many of them, at least for long, seem quite local,-whereas, in the human body, bad typhoid symptoms seem always to attend the first stage of the disease thus excited, and even when they are got over, as in one of the cases given by Dr Elliotson, the pustules soon degenerate into intractable ulcers, and the general health has appeared to be irretrievably broken.

We had in the Ward No. 1, five well-marked cases of Pleurisy, with extensive effusion, besides one (a young man, Kelly) with distinct pleuro-peripneumony; and on this occasion, as during the last summer, it appeared, on examination, that no one of these had such general symptoms, particularly such firmness of pulse, or heat of skin, as seemed to me (however anxious to show the good effect of that summum remedium in the cases suited to it) to justify general bleeding; nor were any of them bled at the arm at any period of their disease. Several of them were, no doubt, admitted in an advanced stage of the disease, but two of them I had myself seen previously in the earlier stage. Kelly was admitted on the 5th day, and Flyn (the worst case), on the 9th day, after the first rigors, both with feeble pulse and cool skin, and Flyn with so much of the typhoid aspect, especially as he had a copious eruption on the skin (which, however, soon disappeared, and had probably been from fleabites) that I hesitated for two days whether his case was not to be regarded as typhus.

All these cases have, however, improved as decidedly as could have been expected in this time-several of them with the help of a little of the stimulating treatment. In the case of Flyn the effusion extended considerably for some time after his admission, as shown by the displacement of the heart, and by the extension upwards and forwards of the dull sound on percussion, and absence of respiratory murmur; and as the affected side measured at one time 14 inches more, horizontally, from the scrobiculus cordis, than the sound, we naturally began to think of the paracentesis. There has been, however, so much improvement under the use of calomel and opium-slightly affecting his mouth-that this expedient has been postponed, and may probably not be required. How far this improvement should be regarded as the result of the remedy, or how far it should be ascribed to the rest and antiphlogistic regimen, and to that influence on the inflammation, which we may reasonably suppose to have been exerted by the other remedies used when he came in-leeching, blistering, purging, and antimonials, it is very difficult to judge. Certainly we had several examples of more rapid and satisfactory absorption of the pleuritic effusion, in patients who took no mercury, and by taking none escaped a risk which I cannot but think attends the full use of mercury in many constitutions.

It is remarkable that the most rapid recovery has been in the young man Kelly, in whom pneumonia as well as pleurisy was distinctly marked-proba

bly because, being admitted on the 5th day after the first attack, he had above twenty leeches and a blister applied, besides being purged and taking the antimonial solution, within three days after admission, or within eight days from the attack. After this treatment his pulse came down from 114 to below 60, and after this he had a small allowance of wine during the remainder of his stay in the house, and all the indications of effusion, except slight dulness, disappeared within ten days.

We had, in this ward, two deaths by old Bronchitis, in men advanced in life, one of whom was admitted in the last stage of lividity, cold sweats, and delirium, and died within forty-eight hours. The other had been an inmate of the ward almost continuously since April, was much emaciated, and had repeated remissions and exacerbations of the symptoms. Both bodies were examined, and exhibited the usual appearances and the usual effects of long-continued bronchitis and habitual asthma, distinctly and nearly uncomplicated; the muco-purulent effusion in the smaller branches of the bronchi, and those two lesions of the substance of the lungs, which hardly ever fail to attend such cases, i.e., the emphysema pulmonum in some parts, and the atelectasis, or carnification, as distinguished from hepatisation, of other parts. Both these we may regard as certainly the consequence of the habitual bronchitis. As to the mechanism of their production, there is still some difficulty; but as it is fully discussed, and the latter in particular, I think very satisfactorily explained, by Dr Gairdner, in recent Numbers of this Journal, I need not dwell upon it. The enlargement of the right side of the heart and of the liver, so general in such cases, and often obvious, and causing part of the symptoms before death, were observed in those cases, but in a less degree than is common.

A more striking case than any in the men's wards, in illustration of the adynamic character now common in inflammatory diseases, was that of H. M'Gillivray, æt. 42, admitted into No. 11 on the 4th December. She was a stout woman, of the melancholic temperament, in the sixth month of pregnancy; had been formerly subject to slight disorders of the stomach and bowels, and it appeared afterwards had been so affected for a week or two prior to this attack, but thought herself in good health till the 29th November, when she was seized with rigors, followed by pain of abdomen, but especially of right hypochondrium. She was admitted, therefore, on the sixth day of febrile disease, for which nothing but rest and confinement had been prescribed; she still complained much of the pain, increased by pressure and inspiration, but there was no decided dulness on percussion in the hypochondrium, and her pulse (about 100) was so soft, feeble, and irregular, with cold clammy perspiration, that I thought it necessary to give an opiate, and wait for some degree of reaction before using any evacuant. After this there was slight reaction, and she had ten leeches to the hypochondrium, and a dose of castor-oil that night. She had little vomiting, and no diarrhoea, but had a miscarriage the second night she was in the house, attended with little hemorrhage, and by which her symptoms did not appear sensibly altered. I stated, that if she had been first seen on the second or third, instead of the sixth, day of this inflammation, affecting pretty certainly the peritoneum, and perhaps also the liver, I should have had good hopes of seeing the pulse improve in strength, as well as abate in frequency, under an alternation of local bleeding and gentle purging or evacuation, with repeated opiates-and perhaps improve so far as to justify general bleeding; but that, after the sixth day, such improvement of the pulse after evacuations was hardly to be looked for. In fact, there was no improvement as to the state of the circulation after this time, although the pain abated; she had a little wine, as well as repeated opiates, but continued to sink, without any fresh rigors or return of pain, and died on the morning of the 10th, i. e. the twelfth day after the first rigor her pulse having been very feeble, and skin colder than natural during the whole five days she was in the ward.

Now in this case it appeared, on dissection, that the liver, although hardly enlarged, was studded with abscesses, most of them very small, but two or

three nearly as large as small oranges; that there were some patches of lymph on the peritoneum, both at the liver and about the cœcum; and a number of the aggregate glands, on a limited portion of the mucous membrane of the lower end of the ileum and cæcum, were inflamed, with deposition of lymph on them, and partial ulceration, and even sloughing; and, moreover, there was a partial deposit of pus between the layers of the mesentery attached to this portion of intestine. This last appearance seems to me to make it most probable that the affection of the liver (and probably the whole of the febrile disease) had been subsequent to, and consequent upon, the disease of those aggregate glands; and different opinions may be formed, and supported by cases more or less analogous, as to the mode of connection between this affection and that of the liver. But what I wish particularly to observe is, that the inflammation, and very copious effusion of lymph and pus on the peritoneum and in the liver, must have been going on during a time when her circulation was exceedingly languid, and her surface cold and clammy-illustrating what I have often before remarked, as a leading fact regarding inflammation, that the power, whatever it be, which determines the exudation from the vessels, and the aggregation together, of inflammatory deposits, is one which often acts with the greatest force when the general circulation is preternaturally feeble; and when we know also, by experiment, that the arteries leading to the parts are weakened as to vital power, as compared with others; and illustrating, likewise, as far as a single case can do so, the proposition which I have stated as to the low form of fever usually observed at present to attend inflammatory diseases in this neighbourhood; of which I think the occurrence of seventeen cases of pneumonia and pleurisy during three months of attendance on two wards of the hospital this year-only one of which was fatal, and not one of which was bled at the arm, before or after admission-will be allowed to be sufficient evidence.

CLINICAL SURGERY-PROFESSOR SYME.

LECTURE INTRODUCTORY TO THE COURSE OF CLINICAL SURGERY, WINTER SESSION, 1850-51.

IN commencing the course of surgical instruction upon which we are about to enter, I must, in the first place, explain the objects it is proposed to attain, and the plan to be followed in their pursuit. The best way of doing this will be to consider what are the qualifications required for the practice of your profession. It is plain that you should be intimately acquainted with the structure of the machine, the derangements of which it is to be your business to remedy that you should, so far as possible, know the uses of its various parts in a state of health-the changes to which they are liable from diseased action, or the influence of external circumstances-and the effects so produced, whether on the animal economy in general, or the local condition of the part concerned; also, that you should know the uses and applications of the various medical agents which are employed for the restoration of health-and the operative manipulations practised with a similar view; and for your guidance in the application of all this knowledge, that you should understand the rules established for selecting and exercising the means of remedy in each of the cases requiring them. No arguments are required to show the absolute necessity of all that has been mentioned, namely, anatomy, physiology, morbid anatomy, pathology, materia medica, operative surgery, and the principles of surgical practice. But you may not be so well prepared for my next statement, which is, that possession to the utmost possible extent of all this varied and extensive instruction would not be sufficient to qualify you for the practice of your profession; and that, if you were to enter upon it without being qualified in another way, immediately to be explained, you would find insuperable difficulties at every step.

The obstacles to which I allude depend upon the difficulty of ascertaining in any given case the precise seat and nature of the derangement which requires to be remedied. For instance, let us suppose that the patient has been thrown down with force, that he has not been able to rise from the ground, and that he has been conveyed to bed complaining of pain in the neighbourhood of the hipjoint. In such a case, there can hardly be any doubt that one of three things has happened, namely, dislocation of the thigh bone, fracture through the trochanters or neck of the bone, or bruise of the joint from violent compression of its articulating surfaces. The appropriate treatment for each of these derangements is clearly set forth in the principles of practice which are understood to have been learnt, and the different manipulations requisite may be easily carried into effect. If the bone is displaced, it must be pulled in the direction proper for withdrawing it from its abnormal position; if fracture has occurred, the long splint should be applied to prevent motion of the broken surfaces at the seat of injury; and if the joint has been bruised, leeches, fomentation, and perfect rest of the articulation are required. It may, therefore, seem that a case of this kind should form an easy subject of treatment, and yet there are few rocks on which the patient's comfort and the surgeon's credit are more apt to suffer shipwreck. Let us take another case, and suppose that the patient labours under a tumour of the breast. In all probability, the swelling here must depend upon an abscess, a cyst, a fibrous growth, a simple enlargement of the gland, or a malignant degeneration of its texture. In the first of these conditions, the matter should be evacuated; in the second, the bag may be punctured or dissected out; in the third, the tumour may be removed with every prospect of permanent benefit; in the fourth, local treatment of a soothing kind, with what other means are requisite for correcting any derangement of the system concerned in its production; and, in the fifth, either free ablation of the breast, or, as is much more frequently the proper course, merely such palliatives as may tend to allay uneasiness and delay the morbid process. In all this there is little difficulty for either the head or hands, and yet there are few subjects of surgical practice more perplexing than tumours of the breast. Indeed, you will see to-day a young woman who has come more than two hundred miles for relief from a fibrous growth, in consequence of her medical attendant-a very experienced and intelligent practitioner-entertaining doubts as to the nature of her case. In short, gentlemen, you will find that the great difficulty of practice is not in doing what is necessary, but in discovering what the circumstances of the case require, and ascertaining, in the first place, the seat and nature of whatever derangement has taken place.

In accomplishing these grand essential steps of an accurate diagnosis, you must be guided by the signs or symptoms which result from the morbid state of each part affected. Most of them are recognised by sight and touch, but some of them also by the ear and nose. According to the facility with which they are noticed, discriminated, and appreciated, as evidence of what is wrong, does the practitioner readily and surely ascertain the assistance which it is requisite that he should afford the patient. But although the indications are present, it does not follow that they make an impression on the mind so as to attract attention. You have all, doubtless, often heard or made the reply, "I must have seen, but did not observe, the object in question," the meaning of which is, that though within the sphere of vision, it did not make an impression on the sense of sight,-and it is the same with regard to the other sources of information. How, then, you are now prepared to ask, are we to acquire the power of observing the signs which are to guide us in our progress? And here I may refer you to the invariable practice of all persons who desire to observe with nicety and precision the distinctive characters of different objects. In all pursuits, professions, and employments, which require for their successful exercise that this should be done, you will find that the power of doing it is always obtained in the same way,-namely, by careful examination of the circumstances to be distinguished, so as to fully understand and become familiar with

them. The more familiarly acquainted with any object, the more readily you recognise it; and it is this familiarity with symptoms of disease which enables an experienced practitioner to judge quickly and correctly as to the condition of his patient.

In the

You will now be able to see why hospital attendance has been enjoined as an essential part of your professional study. You may read or hear the symptoms of disease described over and over again, without being able really to know them, or to acquire the power of observing them. But you have here an opportunity of witnessing the actual existence of morbid derangements in the living body, with all the sensible characters by which they are distinguished. Surgical cases bear a small proportion to the subjects of ordinary medical treatment; and it is, therefore, of peculiar importance that you should study them when brought together in large establishments such as this. course of the ensuing six months, most, if not all, of you, will see more surgical cases than any one will have to treat in the whole duration of his private practice, however much it may be prolonged. Indeed, I have heard gentlemen of considerable standing and experience declare, that in once going round the wards which are to be your field of study, they have seen more cases of surgery than all that had ever fallen under their treatment. But it must not be supposed that you are promised an opportunity of seeing an example of every case that may occur in the practice of surgery. This would plainly be quite impossible, and fortunately is not at all necessary, since each particular disease is not distinguished by characters exclusively belonging to it alone, but rather by certain combinations of characters which it possesses in common with many others. If, therefore, you acquire the requisite familiarity with symptoms, whatever may be their source, you will be able to recognise them, though differently grouped, in connection with other morbid derangements.

The great duty imposed upon me as a teacher of clinical surgery will now also begin to appear. If left "to walk the wards" without assistance, you might be able to ascertain whether there were many operations or few, whether their performance was accomplished with ease or difficulty, and whether the patients died or recovered. But as hospital attendance, productive only of such fruits, would be of little value in your preparation for practice, it has been deemed expedient that a teacher should be provided for rendering this opportunity of observation more conducive to improvement. In discharging the duty thus confided to me, instead of merely lecturing upon the cases, and telling what may be learnt from their examination, I bring the patients before you, having them conveyed in a basket if not able to walk, and carefully point out every circumstance that seems deserving of attention. So far as possible I let you see the people who are to be under treatment at the time of their admission, so that they may be presented just as they will be to yourselves when engaged in practice; and also, that you may witness the process of investigation which is pursued, in the first instance, for the recognition of their respective ailments. In the progress of treatment, I bring them again and again into this place (the great theatre of the hospital), so that the changes which have occurred may be duly explained. On alternate days I visit the wards, when you have an opportunity of seeing the patients more closely, and obtaining further information directly from themselves. On the two remaining days of each week (Sunday being a day of rest), the operations of too great importance for extemporaneous execution are performed. There is thus a constant system of instruction; and it is pursued, I am happy to say, not only with much advantage to you, but also with great satisfaction to the patients, who, so far from feeling any unwillingness to have their cases examined in your presence, regard it as a guarantee for their careful treatment, and an expression of interest in their welfare. In pointing out to you the distinctive characters of disease, I shall be careful to avoid perplexing you with irrelevant matter, as would seem too frequently done, if any judgment as to the practice of other schools may be formed from the lucubrations with which, under the title of "Clinical Lectures," the periodical