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I found him suffering the most agonizing pain in the left Ilumbar region, which he had complained of, more or less, forthree or four days previously; there was a dreadful and anxious ’,change in his countenance; lips exsanguineous; pulse not per-ceptible ; extremities cold; and a cold clammy perspiration per-vading his whole body, with other signs of a moribund condition;but withal, perfectly sensible. It was suggested by his wife thatDr. Babington should be called in, to which I acquiesced, though itwas perfectly evident all the resources of our art were unavailablein his case, and the probability was, that death would terminate hissufferings before the Doctor’s arrival. In the meantime, stimu-lants were given, and bottles of hot water applied to his feet, in-side his arms, thighs, &c. but to no purpose, for he died withinabout two minutes after the worthy Dr. made his appearance,(which was within an hour after I first saw him,) in a state littleshort of madness, probably from the effects of the stimulantsthat had been administered. From the appearance of the patient,the Dr. considered that his bowels were ruptured. I suggestedthat, with the view of testing if that were the case, an enemashould be given, when, if they answered, it would, in somemeasure, settle that question; one was immediately applied, whenit was almost as instantly ejected.

Inspection of the body, tzventy-four hours after death.-Chest,lungs, and pleurae perfectly healthy. Abdomen: on removingthe stomach and intestines, the cause of death was apparent;over the left kidney was extravasated a large quantity of blood.We at once sought for the ruptured vessel, but which, after a verypatient and diligent search, we were unable to find, when we de-termined to examine the stomach and intestines, but the pan-creas, which had been removed with them, first presented itselfto my notice, and, as it appeared somewhat harder and largerthan usual, I handed it to Dr. Babington, who immediately de-tected a cavernous rupture on its anterior surface, having all theappearance of an excavated ulcer, but which contained within itscavity a substance of blood, of about the size of a walnut, in con-centric layers. We at once concluded that this was the sourceof the haemorrhage, and on making a longitudinal section of theorgan, we found several of these sanguineous deposits, varying insize from a horse-bean to a hazel-nut, in appearance like aneu-rismal deposits; all the other organs of the abdomen werehealthy.

Remarks.—During life there was not the least symptom de-noting any disease of the pericardium, though very extensivedisease, as will have been observed, was found there. With re-gard to the pancreas, he frequently complained of severe painsin the epigastric region, which I considered as rheumatic, andwas always relieved by fomentations composed of tr. opii., threeounces; and aqua bullientis, four pints. For three days previousto his death, these pains had entirely left him, and made theirappearance in the left lumbar region, though at first not so acuteas those he had experienced in the epigastric, but very trouble-some ; rheumatism also got the credit for these pains, and he wasordered to have, as a local remedy, flannel pillows, containinghot bran, placed under his loins ; but from these he only expe-rienced slight relief. On the morning of his death this pain wasmost excruciating, which he stated was beyond anything that hehad ever suffered; this was doubtless caused by the pressure ofthe blood extravasated on the seat of pain, and was the reasonfor the pains previously complained of, from the time they leftthe epigastric region. The pain in this latter part we must attri-bute entirely to the pancreas, which was relieved immediatelythat it was ruptured, by the blood slowly draining therefrom,and causing his death.

REMARKS ON MR. SYME’S LETTER TO THELORD ADVOCATE.

To the Editor of TiaE LANCET.

SIR,—The regulation of medical and surgical practice, inany country, is at all times a very important matter, both tothe public and the profession; but there are many amongst uswho, though desiring to see the establishment of wiser rules,yet shrink from launching upon the stormy waters of publicagitation, while so many opposite blasts blow from everyquarter. I am one of those persons; but seeing that so emi-nent an individual as Mr. Syme, of Edinburgh, has put forthcertain definite propositions, I feel that it is necessary forevery class of men to speak out, and declare their sentimentson the subject; and although such sentiments may in somerespects differ from those expressed by yourself, I rest assuredthat you will allow them fair scope, from the fact that youhave ever been ambitious to make THE LANCET, not merely

your own individual organ, but an exponent of the generalfeelings of the profession.

I shall consider Mr. Syme’s arguments and proposals,seriatim, as they appear in his pamphlet, before declaring myown suggestions as to medical reform. He begins by drawinga contrast between the schools of England and Scotland,obviously to the disadvantage of the former, stating that themedical schools of the north are supported and recognised byGovernment, and their professors appointed by legitimateauthority; whereas those of the south are self-constituted co-partnerships, whose lecturers move up to their posts, by meregradation of services, from the lowest offices of dressers &c.,and retain such posts only as young men, and until they obtainpractice. Now it is altogether out of the question to takepublic universities, on the one hand, and compare them withprivate schools, on the other. If such a proud seat of learningas Edinburgh is to be brought upon the stage of discussion,then certainly Oxford and Cambridge &c. should also beborne in mind. The University of Edinburgh is not a meremedical institution, though its medical department may bemore extensive than that of any other place in the kingdom;while as to Glasgow and Aberdeen, their medical faculties areonly one of a trio. It is certainly a fact, as Mr. Syme states,that too many of the English medical-school lecturers aremere self-appointed teachers, or else nominated by someprivate association of local physicians and surgeons; butsurely this observation does not apply to Oxford, or Cam-

bridge, or University or King’s Colleges, London, or toQueen’s College, Birmingham, whose charters elevate themto the rank of public institutions, and whose professors areappointed, in permanency, by high official authorities, (cer-tainly as respectable as the civic powers of Edinburgh,) towhom they are duly responsible. The assertion advanced byMr. Syme, therefore, is rather too sweeping, and his compa-rison between the two countries very incorrect.His next remark bears upon the English Colleges of Physi-

cians and Surgeons, when he says, that " the spirit of the pre-sent time is disposed rather to curtail than extend the privi-leges of such bodies." This, I think, is not the fact. Rationalpersons feel that such authorities ought not to be mere nulli-ties, but should have a vital influence in the community, andexercise their wisdom for the general welfare of society,-ofcourse, under the safe condition that they be soundly consti-tuted.He then objects to the ordinary division of the profession

into physicians, surgeons, and general practitioners, asserting,under this head, that " the two former classes only exist inmetropolitan cities," and that in Scotland there are not abovethree or four pure physicians, and " but one surgeon who de-votes his attention exclusively to surgical cases," by which heindicates himself. Now it is scarcely fair that the erroneoussystem of one small part of the empire should be forced onall the others by Act of Parliament, or by any " Governmentor distinguished men." The condition of Scotland, indeed, as-regards the confusion of titles and degrees, is far from satis-factory. From the early age at which many do take suchdegrees, they are rather grasped at as objects of puerileambition than as necessary qualifications for practising in thehighest walks of a sacred profession. Even in metropolitanEdinburgh itself, it is quite common to see " Dr. So-and-So,Surgeon," or " Dr. So-and-So, Dentist;" nay, such graduateswill even disport their high honours over shop-doors, wherethey are fain to vend horse-drugs, and patent medicines, andbrushes, and snuff-or draw teeth for one shilling: Neitherthe profession nor the public, in England, can envy such astate of things. On the contrary, there is scarcely a town ofthe south, even of but 6000 inhabitants, that does not possessits veritable physician.

It has been considered right, by the best thinkers, thatthere should be a division of labour and a difference of gradesin our profession. Such a system tends most to improvementin the respective walks; and if Mr. Syme does not think so,it is odd that his practice should belie his precept to such adegree that he should be the pure surgeon, by sole exception,in all " broad Scotland." Not that any one should be pre-cluded from obtaining honourable titles and degrees, asrewards for talents and exertions, but let them be taken andused for their legitimate end, and not with a view merely todegrade them by base misapplications-as if some savanshould take to trade, and paint over his shop-door F.R.S.,F.G.S., D.C.L., LL.D., A.S.S., &c.; for in short the matterbecomes really ludicrous.

* Plain facts.

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It may have been this sort of abuse of titles that makes Mr.Syme say, soon afterwards, that "any attempt to determine theestimation in which medical men are to be held by usheringthem upon the stage of practice in different ranks, is no lessimpracticable than irrational :’ Now, de facto, it is, and hasever been, practised, not only in the medical, but in all other

professions and pursuits, with great advantage, as in law,divinity, soldiership, &c.; and of its rationality the worldmust be, and is, the judge. We know, as matters of fact, thatthe men who take honours at universities do gain a certainadvantage thereby, and that the studious and enterprisingyoung surgeon who aspires and attains to the fellowship ofhis College, does demonstrate something to the world, whichgives him a certain prestige; all which has nothing to dowith the trite occasional fact, that other students who maynot have distinguished themselves at an earlier period, may,at a later, obtain high reputation. If Mr. Syme really thinksotherwise, he must then resolve all tests whatever into a merefarce, which is manifestly absurd-too absurd to require ananswer.

Further on, Mr. Syme has two very notable sentences-espe-cially notable, after his decided advocacy of a mixed practice.He is speaking of the proposed College of General Practitioners,and says, firstly, " The new college would have sunk, beyondrecovery, all who were unwise enough to enrol themselvesunder its charter of degradation;" and secondly, " If thenew college were ever established, its leading members couldscarcely maintain a dignified place in the profession," &c.With this view I quite agree; but that Mr. Syme should pensuch sentences,-in juxtaposition with those that go to supportthe mixed system of practice in Scotland, and the uniformityof titles and degrees, certainly seems very inconsistent andillogical. He is thus condemning the mere enrolment of in-dividuals by a new law, or charter, while he is abetting theactual existence, in fact and. in practice, of those- same personswho at present are under the wings of the Edinburgh College ofSurgeons, or the two ordinary examining boards of England-or else are mere renegade graduates, poaching on the field ofapothecary practice.The facts of the question are simply these: that in Scotland

the College of Surgeons examines into all the qualificationsnecessary for a general practice-embracing medicine, surgery,midwifery, and pharmacy; while, in England, for examina-tion as to these branches, two authorities must be resorted to-viz., Surgeons’ College, and the Apothecaries’ Company; but,from the confused use of the names surgeon, apothecary, sur-geon-apothecary,’general practitioner, with the occasional dashof doctor, or accoucheur, much misunderstanding has arisen,and the public have got puzzled as to the real status of pro-fessional men. This confusion is further increased by certainvery ordinary practitioners making insane boasts as to theirdouble and sometimes triple qualifications, as they expressthemselves. Now I think that men should study the esse

quam videri; and I do not disapprove of that propositionlately made by the College of Physicians, that no one shouldbe allowed to use the title of doctor, unless he acted up to itaccording to the ordinary expectation of the people of Eng-land ; and if Mr. Syme saw clearly, or wished our great Uni-versity well, he would not seek to employ his argumentativepowers in endeavouring to place her graduates in the sameposition as that of the licentiates of the Apothecaries’ Com-pany. The worthier sons of our illustrious Alma Mater willnot thank him for this unadvised precipitancy. They are,or ought to be, physicians, and not a species of tradesmen,"remnnerated," to use Mr. Syme’s word regarding the generalpractitioners of England, " for professional services by theprice attached to their drugs." I, for one, must repudiate Mr.Syme’s ill-judged intercession, and I know that I shall find anecho from the breasts of more than half of the physicians ofEngland, as well as from those brother graduates who, beingcompelled by circumstances to engage in general practice,have yet the good taste and policy to lay aside their titles fora more convenient season, by which they help to maintain thedignity of the degree, and themselves ultimately reap thefruits of it.

I shall now, as briefly as possible, state my own proposi-tions-viz.

1. Let all members of the Edinburgh College of Surgeonswho desire to practise in England be admitted to that privi-lege on paying the difference of fees to the College and Hallrespectively which, in total, would be-say .621.

2. Let all ordinary members be admitted to the fellowshipat any time they--choose, by undergoing an adequate examina-tion, practical as well as theoretical; or, on the other hand;

by proving that they have practised for ten years withouttrafficking in drugs, and during that time performed surgicaloperations, implying surgical accomplishment.

3. Let all graduates of British universities be eligible forthe membership of the College of Physicians, either imme.diately after graduation, by coming under certain precautionaryengagements as to future deportment, or otherwise by provingten years of private practice as physicians.

’ 4. Let all gentlemen, whether physicians or surgeons, beentitled to the above honours on receiving any hospital orother public appointment that clearly implies the highestqualifications.

I would leave the fellowship of the College of Physiciansa free election, as it is at present, of those members who haveattained professional, or literary, or scientific eminence; and Iquite coincide with Mr. Syme as to the error of repeatedelementary examinations. Not a little of the confusion oftitles above referred to is due to the pushing forward of cer-tain inferior men, with qualifications otherwise dubious, tounnecessary tests. Thus a private country physician of barelyrespectable attainments may feel his importance ratified orincreased by the membership or fellowship of the college,while the hospital physicians of the great towns are alreadyfull of honour, without such addition to their universitydegree. Hence the frequent contrast between titles andactual position. Yet this does not invalidate the efficacy ofa real and required test; for the hospital physician, as may besupposed, could pass the ordeal if he deemed it necessary,which it is not. He might cheerfully pay the inaugurationfee, and join the college as a scientific association; but hecould not unnecessarily present himself before it, to be testedfor qualification already proved before his university, and, itmay be, the whole world.

I am. &c..EDINENSIS IN ANGLIA.March, 1850.

EXTRAORDINARY CASE OF IMPOSTURE.To the Editor of THE LANCET. I

SIR,—I forward the enclosed extract from a local paper,thinking you may consider it worthy of a corner in your journal.We have been forcibly struck with the very close resemblancewhich the case bears to what Mr. Mayo ("Outlines of HumanPathology") has described as " white gangrene" of the skin; andat page 341 of Johnson’s Medico-Chirurgical Review forApril, 1836, (where this portion of Mr. Mayo’s work is copied,)the reviewer adds the history of a case which also seems identicalin character with it. So appositely, indeed, does our case answerto the descriptions above alluded to, both as regards the first ap-pearance of a patch, (i.e. on our attention being first called to it,)and in its subsequent stages, as well as in the youth and theotherwise perfect health of the patient, that although such highauthorities seem not to have entertained the slightest notion butthat all was the effect of legitimate disease, we cannot persuadeourselves otherwise than that they were as thoroughly deceivedas have been the early attendants of our patient.-I am, &e.

GEO. FRED. HODGSON, House Surgeon.Sussex County Hospital, Brighton, May 7, 1850

(From the Brighton Gazette, May 2nd, 1850.)At the weekly board of the Sussex County Hospital yesterday,

a remarkable and almost incredible case of imposture was ex-posed.A woman, named Betsy Ginn, aged 23, (received three weeks

since as an in-patient, on the recommendation of a subscriber anda surgeon’s certificate,) was charged by her surgeon with wilfullyproducing the disease for the cure of which she had applied tothe hospital.The statement made against her was, that very numerous dis-

eased patches of the skin, over nearly the whole of her body,limbs, and face, were the result of her own application to theparts of hydrochloric acid, (spirit of salt.) Several patches werenearly as large as the palm of the hand; and they were in diffe-rent stages, the recent ones being yet in a gangrenous condition,others (from which the sloughs had separated) were deep andtroublesome ulcers, and many (the majority) had healed, but withdisfiguring scars, and in some places to the injury and contractionof the adjacent sinews.The following arguments were advanced by her attendant:-

That the parts of her body (as her back, &c.) not readily acces-sible to her own hands, remain perfectly sound and free fromscars; that the affection was totally different from any diseasewhich he had ever witnessed ; that the three fresh patches which