50

tected in the right brachial, or subclavian arteries; pulse at theleft wrist 100, full; respiration twenty in the minute, and appa-rently performed with some difficulty. The chest sounds well onpercussion on both sides, except over a space somewhat less thanthe size of a crown piece at the junction of the first rib with thesternum, on the right side, where there is a marked dulness.Respiration is puerile in the left lung ; in the right it is re-markably feeble, without rale of any kind, both anteriorly andposteriorly. The sounds of the heart are natural, but near thesternal end of the right clavicle there is a distinct pulsation,gradually losing its intensity as the heart is approached. Thispulsation gives a strong impulse, is not double, nor accompaniedby any bruit de souffiet. Although no tumour can be felt aboveor behind the right clavicle, I was led at once to the conclusion,from the signs present, that the case was one of aneurism, eitherof,the arch of the aorta or the arteria innominata, but more pro-bably of the latter. The good sound elicited on percussion allover the chest, with the exception of the small space before-mentioned, corresponding with the seat of the supposed aneurism,being present with puerile respiration in the left lung, and re-markably feeble respiration without rale all over the right lung,led me to suppose that the cause of these phenomena must be atumour of some kind pressing on the right bronchus, and thusobstructing respiration, and which, from a consideration of theother signs present, I concluded to be aneurismal. To a properappreciation of this important sign, I am indebted to Dr. Stokes,who published a somewhat similar case, some years since, in thefifth volume of the Dublin Journal. In his case, however, thissign was not of such value as in the case before us, as from thecommencement he could feel the aneurismal tumour behind theclavicle; it is, therefore, where no tumour can be felt, and, con-sequently, where there may be doubt as to the nature of the case,that this sign is of most importance.

She was ordered to lose eight ounces of blood from the arm,and to confine herself to a spare diet; pills, composed of digitalisand extract of hyosciamus, were also ordered.

Oct. 20.-She was much relieved by the bleeding, but is stillharassed by the cough, which is of a laryngeal character. Pulse96, and full; respiration 20; complains that she has had uneasydreams, and occasionally a sense of suffocation; bowels actingwell Ordered to lose a small quantity of blood from the arm,and to continue the use of the digitalis and hyosciamus; restrictedto a small quantity of solid food, and to eight ounces of fluid inthe twenty-four hours.Nov.5th.-The symptoms were much relieved by the treat-

ment, but on this day the breathing is laborious and somewhatstridulous, and the patient is more troubled by cough; face andneck livid from venous engorgement; much anxiety of counte-nance ; complains of slight headache and tinnitus aurium; fearsshe has got fresh cold from sitting near an open window; somebronchitis is evidently present. These symptoms were much Irelieved by local bloodletting, and a combination of calomel,squills, and digitalis, but, I regret to say, only temporarily, for on the25th of November the state of this lady became more alarming:breathing stridulons; occasional aphonia; voice sometimes weakand shrill; anxiety increased; no change in stethoscopic pheno-mena, unless it be that respiration is more puerile in the left lung,more feeble in the right. The chest still sounds generally wellon percussion; the dulness over part corresponding to seat ofaneurism more marked; difficulty of swallowing remains thesame. The symptoms were again relieved by a repetition ofsmall bleedings and other treatment, but in the month ofJanuary, 1844, her state became, if possible, more alarming. Ihad then the valuable assistance of Dr. Corrigan, who recom-mended the continuance of small bleedings now and then, andthat the dose of digitalis should be increased; also restriction asto diet, and particularly fluid, to be insisted on. Under thistreatment she again improved for a short time; but the badsymptoms soon returned with renewed violence, and she conti-nued to suffer, notwithstanding all treatment, from the most dis-tressing attacks of dyspnoea. On one occasion, in the month ofMarch last, she complained to me that she felt as if some onewere in the act of choking her, by pressing his fingers on herwindpipe. Although no tumour has made its appearance, Ithought it right, now, to propose the operation of tying thecommon carotid artery on the distal side of the aneurism, asrecommended by Mr. Wardrop. The proposal was, however, re-jected, and she lingered until the 20th of June last, when, beingattacked by a more than usually violent paroxysm of dyspnoea,she expired, apparently suffocated. She retained her senses tothe last.

Post-mortem examination set’enteen hours after death.-The sur-face of upper part of chest, neck, and face, presented a lividappearance from venous engorgement. On opening the thorax,the lungs were found to be healthy, with the exception of slight

emphysema in the left. There were some old adhesions in bothpleurse: those in the right cavity were apparently of more recentdate than those in the left. The heart and aortic valves werefree from the disease. The arteria innominata was dilatedinto an aneurismal sac, about the size of a small apple, of irre-gular shape, and in close contact with the trachea and rightbronchus, the calibre of which was much narrowed; the aneu-rismal tumour also pressed on the oesophagus, which, as well asthe trachea, was somewhat displaced towards the left side. Thedysphagia during life seldom amounted to more than an annoy-ance. In speaking of this particular symptom, Dr. Stokes says," How far dysphagia, from a small aneurism of the innominata.,might occur, is yet to be determined; the situation of the vesselwould render this less likely than in the aorta." Now, thissymptom did occur in this lady’s case, and the postmortem ap-pearances fully justify us in attributing it to the direct pressureon this tube of the aneurismal tumour. That dysphagia may takeplace from a small aneurism of the aorta, is fully proved by casespublished by Professor Porter and others.The sac was partly filled by coagula, and its coats of very un-

equal thickness; indeed, from the thin septum which separatedthe cavity of the sac from that of the trachea, it is probable that,had she lived much longer, death would have taken place from arupture of its coats and haemorrhage into this tube. The rightsubclavian artery is healthy, but there does not appear to be anycommunication between this artery and the cavity of the sac, asthe smallest probe will not pass from one to the other. Thecommunication with the right carotid is almost obliterated.These openings are closed by firm coagula. On opening thearch of the aorta, it was found unhealthy, being rough on itsinner surface. The head was opened, but no morbid appearancefound, excepting slight congestion, and effusion of about anounce of fluid into the ventricles.The preparation was shewn by me at the last meeting of the

Surgical Society. - >>--------

THE LONDON HOSPITAL.To the Editor of THE LAJ’JC,T.

LETTER FROM MR. LUKE, ONE OF THE SURGEONS.

SIR,-A letter, which appeared in your publication of last week,(p. 415, vol. ii. 1844,) relating to the recently made appointments ofhouse-surgeons at the London Hospital, hasjust fallen under myob-servation. In that letter your correspondent seems fearful that thegreat advantages hitherto enjoyed by the dressers at this institu-tion are about to be greatly diminished, if not altogether annihi-lated, and endeavours to convey to your readers an impression oflike import. You will perhaps permit me to attempt, in yourcolumns, to soothe his fears, and disabuse the minds of others,upon this point. There are two matters of which he complains-viz., the removal of the responsibility formerly possessed by thehouse-dressers, and, their exclusion from the hospital during thenight. For brevity sake, it will be convenient to compare theduties of the house-dresser under (what may be called) the oldand new systems with each other. Under the former, there wereseven dressers annually appointed by each surgeon, who weredivided into a senior and junior class; one from each class residedin the hospital, in rotation, for one week, during which they hadthe charge of recent cases of accident brought to the instituiion,which they continued to dress and attend under the direction ofthe surgeon, or the assistant, until recovery was established. Thehospital was visited twice daily; once, in the day time, by the sur-geon, and once, in the evening, by the assistant; the responsibilityof the charge was therefore limited. During their week of re-sidence, the dressers were provided with board and lodging by theinstitution.Under the latter, or new system, the same words (lodging

omitted) will designate the numbers and duties of the presenthouse-dressers. They are still seven in number under each sur-geon ; they still reside during the day, and are provided withboard by the institution, and enter upon their duties in weeklyrotation; they still have the charge of recent cases of accident,and dress and attend them, under the direction of the surgeon, orthe assistant. They must, however, conduct the examination ofsuch cases in the presence of the house-surgeon, who is directednot to interfere further with the examination than is necessary toverify the diagnosis previously formed and expressed by the dresser,or to correct any inappropriate treatment. The actual applicationof remedial means is left in the hands of the dresser. The oppor-tunity of forming an opinion unaided, and the responsibility ofexpressing it, still remains.The exclusion from the hospital at night, I consider, with your

correspondent, to be a diminution of advantage, but unavoidablefrom the limited extent of existing building accommodations, butyet not an unmitigated evil. The necessary exclusion exists only

51between eleven P.M. and seven A.M., although the interval of dutymay be made longer by voluntary absence. A messenger to thedomicile of the dresser, when cases of importance occur, seems aneasy remedy. Yet even without this, the loss sustained is not

likely to be great, by reason of the paucity of admissions in thespecified interval of duties.With every disposition to state the case fairly, I cannot con-

sider the probable diminution of advantages to the dresser as morethan trivial. Looking, however, to the appointments of thehouse-surgeons themselves, I think in them might be perceived aprospective and considerable increase of advantages, even to thehouse-dressers. These appointments are held for six months,renewable at the discretion of the surgeon. The qualification forholding them is, the having been a dresser at the London Hospitalfor twelve months, and, I believe, will be filled wholly irrespectiveof any pecuniary consideration. If, in addition to this, they bemade the subject of competition amongst the dressers, and thedetur digniori principle be introduced, it follows that additionalopportunities of study will be offered to them, as a body, whichthey did not before possess; and although two only in each yearcan individually attain the fulfilment of their wishes, the attemptto obtain it cannot be otherwise than advantageous, even to theunsuccessful. It is worthy of notice, too, that the number capable

Iof actually attaining the appointments will form a large pro-portion of the whole number of dressers, being, by the least favour-able computation, as two to seven, but probably much greaterafter the necessary deduction from the competitors by various ’,causes. Now, as I have designated the diminution of advantagesto the dressers as trivial, I am, on the other hand, disposed toconsider the advantages as considerable, and the appointmentsthemselves as so much gain to their interests. In conclusion, Iam unwilling to compromise myself to the extent of your corre-spondent’s expression, by saying that defects in treatment haveNEVER occurred under the administrations of dressers, yet I amfully prepared to declare that the appointments were not calledfor by any dereliction of duty on their part, nor do I believe thatsuch a feeling actuated the promoters of the measure. You mustbe aware, that in a large institution, dependent upon public opinionfor pecuniary support, a necessity exists for deference to thatopinion. In this circumstance will be found the motive whichled to the appointments in question. They do not, therefore,involve auy implied censure upon former or present dressers, butsimply a concurrence with the feelings of many, if not most, ofthe best friends and supporters of the charity.

I am, Sir, your obedient servant,J. LUKE.

Jan. 4, 1845.J. LUKE.

NEWS OF THE WEEK.

A PHYSICIAN’S NOTION OF A °COOD" 1IEDICAL EDUCATIONFOR GENERAL PRACTITIONERS.- The essential thing, in regardto the education of medical men, is, that it should be good-thatis, that it should be sufficient, first, to cultivate and improve theintellect, so as to render it capable of receiving and profiting byscientific truths; and, secondly, convey a sufficient amount ofmedical knowledge to afford a fair warrant that the possessor isqualified to practise medicine with probable benefit-at leas’,without INJURY to the public. (From the review of Sir JamesGraham’s Bill in the January number of the British and ForeignMedical Quarterly Review.)SOMEWHAT FLATTERING TO GENERAL PRACTITIONERS.-

Such a college (of general practitioners) could not, for a longtime, hope to have anything like the public consideration andinfluence possessed by the College of Physicians and the Collegeof Surgeons. Without intending anything disrespectful, it maybe said, that in medical and surgical science they would have noplace, no name, and no character. (January number of the i

Edinburgh Medical and Surgical Journal.)- What think you of ’,this, GENERAL PRACTITIONERS of England and Wales?

DR. JAMES HOME, late Professor of Medicine in the NorthernUniversity, was, at his death, on the 5th December, eighty-fouryears of age. It is only two years since he relinquished thechair. He was a professor for forty years, having succeeded hisfather, Francis, in 1799. On Materia Medica, Dr. Home was verypopular in the University, particularly during the last years ofhis holding that professorship. This increase of popularity waschiefly owing to his having adopted the new views of Sir HumphreyDavy on the subject of chlorine. For while Murray, of the

Edinburgh School, keenly opposed those views, seeking to over-throw them by experiment, and Hope hesitated to adopt them,Home remodelled this part of his lectures, and so closely followedDavy’s nomenclature and explanations, that the student did notlearn from him that there ever had been any other. In the chairof Medicine, no teacher took greater pains with his lectures ; yettheir success latterly was far from proportioned to the painsbestowed upon them. In the clinical wards, he had the reputa-tion of being attached perhaps a little too much to the lancet.-Northern Jour. of Med., Jan.

THE UNIVERSITIES OF RUSSIA.-From a report of the ministerof public instruction, it appears that Russia possesses six univer-sities,-viz., St. Petersburg, 66 professors and teachers, 557 stu-dents ; Moscow, 87 professors and teachers,836 students; Charkow,75 professors and teachers, 410 students; Dorpat, 66 professorsand teachers, 484 students; Kieff, 63 professors and teachers,320 students. The number of students is therefore 2,966. The

principality of Finland is not comprised in this statistical list.The Russian empire numbers 83 gymnasia, attended by 21,000pupils, of which 10, with 4000 pupils, are in Poland.

THE APOTHECARIES’ HALL AND UNLICENSED PRACTITIONERS.- A medical gentleman having lately written to the Apotheca-ries’ Company, to apprise them that an unlicensed practitionerhad recently settled in his neighbourhood, and to request thatthey would institute proceedings against him, received the fol-lowing answer (Times):-

"Apothecaries’ Hall, Dec. 30th, 1844.

" SiR,—In reference to the representations which you havemade to this Society on the subject of a case of unqualified prac-tice as an apothecary in your neighbourhood, I beg to informyou, that a Bill having been introduced into the House of Com-mons, at the close of the last session of parliament, by her Majesty’sSecretary of State for the Home Department, by which it is pro-posed to repeal the existing penalties upon the unlicensed practiceof medicine, the Society feel considerable hesitation in institutingproceedings for the recovery of penalties after the inutility ofsuch proceedings has been asserted by a minister of the crown,and while the propriety of their institution may be taken to beunder the consideration of the legislature, the Society havingalways been of opinion, that it is of the utmost importance thatsuch proceedings, when instituted, should carry with them thesympathy and approval both of the profession and the public.

" I am, Sir, your very obedient servant," ROBERT R. UPTON, Clerk to the Society."

THE REPRESENTATIVE PRINCIPLE.-In Ireland, we suspect,there are many who think that they are not liable to be affectedby any alteration in laws or charters, and view with anger theefforts of those who are struggling to preserve the institutions ofthe country from destruction, by adapting and adjusting them toa new state of affairs; but when it is too late they will find theirmistake, and discover that they have been deceived and betrayedby those who are interested in upholding the old corporationsystem, which throws the entire management of medical affairsinto the hands of a few influential persons in the metropolitancities.-Dublin Med. Press, Jan. 1.

DEATH FROM A BLOW ON THE JUGULAR VEIN.—That deathmay occur immediately, or in the course of a few hours, from ablow on the neck over the jugular vein, is an undoubted fact.The following case, which occurred at Portsmouth in Septemberlast, is a practical illustration of the operation of this cause ofdeath :-An inquest was recently held at the Bridge Tavern,by Mr. W. Cooper, the coroner for Portsmouth, on the bodyof a woman, aged 50, named Harriet Hill, who came by herdeath under the following circumstances :-It appeared that thedeceased was a married woman, residing at a low public-house,situate in Tower-street, Portsmouth. She had of late taken upwith the prisoner, Thomas Matthew Tucker, a young man, agedabout 20. Deceased and Tucker went out on the Friday, andwere returning home in the evening down Broad-street, quar-relling. The woman was suddenly observed to be struck bysome one, and was seen to run into the road and drop, screaming.She was immediately taken up by some lookers-on, and conveyedto her lodgings, but she never spoke more, and expired on thefollowing evening. Suspicion fell upon the prisoner Tucker,who was immediately apprehended and lodged in gaol. Thein-

quiry was a very protracted one ; eventually, however, the jury,having no doubt upon their minds but that the prisoner was theman who administered the deadly stroke, delivered a verdict of" Manslaughter against Thomas Matthew Tucker.’’ The pri-soner was removed to gaol. The surgeon who examined thebody pronounced it to be that of person of very healthy constitu-tion, although so far advanced in years, none of the usual signs