are changed every three months-and cannot devote nearly enough of time to the clinicum. But this is not the worst of the case. The number of patients under each physician renders it absolutely impossible that he can properly examine and explain their cases to the pupils. There ought to be double or treble the number of medical officers, in consequence of which there would be fewer wards for each, and the swarm of pupils would thus be divided into smaller bands. They would then have some chance of seeing and hearing what was going forward.

The same observations apply, à fortiori, to the London hospitals, where the rush of pupils, with the surgeons at least, renders access to clinical instruction almost nugatory. The various defects above-mentioned, are proposed by Dr. Clark to be remedied in the following manner :

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1st, By increasing the period during which the candidate for a medical degree shall be required to attend to clinical medicine (as without sufficient time he cannot possibly acquire a knowledge of practical medicine, however fair the opportunities held out to him may be); 2ndly, By increasing the number of clinical professors in office at the same time; 3dly, By diminishing the number of patients under the charge of each professor; 4thly, By increasing the number of clinical lectures; 5thly, By making the office of clinical professor permanent, or fixed at least for a series of years, in the same individuals; and, lastly, by instituting a practical clinic, upon the principle of the poly-clinics of Germany." 19.

We think there cannot be a doubt, among reflecting men, that the only plan of securing the utility of the profession to the public, and the respectability of its members, is to raise the amount, and improve the mode of medical education to the highest degree, compatible with a proper supply for the demands of society. But we are not so Utopian as to imagine that this can be done by levelling all ranks to one denomination, and enforcing one measure of education for all members of the profession. The various gradations in society, and the different modes of remuneration, forbid this equalization and amalgamation. But this we do think, that the present scale of education should be raised in every class of the profession—that of the general practitioner, the operating surgeon, and the physician. Each of these classes is now overstocked, and the inevitable consequence is DISTRESS. It is an old proverb, that "where Poverty comes in at the door, Love creeps out at the window." This may, unfortunately, apply to the medical profession. The inordinate supply creates a tremendous conflict, not merely for reputation, but for bread! The consequences of this competition need not be descanted on. Now, by enhancing the amount of medical education, we place a check upon the redundancy of medical population, while we ensure to the public the very best assistance in time of need. True it is"and pity 'tis 'twas true," that this extension of education, and the expences inseparable from it, must prevent the ingress of many a potent mind into the ranks, from sheer want of means to go through the necessary forms. But provision cannot be made for such exceptions. In our, as in other professions, genius and talent must be left to their fate. From time to time they will rise triumphant, in spite of every obstacle opposed by the res angusta domi-and what is far worse-by the injustice, the jealousy, and the selfishness of mankind!

We will venture to make one more remark, though it is directly in opposition to the current of popular opinion at the present time. It is this:That the true and sole test of medical knowledge will not be found in an oral examination, however carefully conducted. Yet the universal cry is-let a man acquire his knowledge how, where, and when he pleases-but let him

prove his acquisition by the test of examination. This is very fine in theory, but will not work in practice. It is said that, "non ex aliquovis ligno fit mercurius." Be this as it may, we venture to affirm that, by the aid of a good grinder, either in Edinburgh or London, "ex aliquovis ligno fiat medicus." By medicus, we mean a member of any of the three classes of medical society. We shall adduce some facts in illustration. About 30 years ago, when the public services were in great want of medical officers, a considerable number of young men passed examinations under various constituted authorities, (and many of them passed with éclât) without ever having attended a single lecture or dissection, and without any hospital attendance. The proofs of such attendances were not then narrowly scrutinized. We knew a young man, who, having served three or four years with a country apothecary, came to London, and was employed in the shop of an extensive druggist in the city. He plied his books so well, in the evenings and mornings, that he at length ventured to present himself before the Court of Examiners, in Surgeon's Hall. He answered questions with such accuracy and precision, that the Court called him in again, and paid him a public compliment on the extent of his anatomical and surgical acquirements. Yet he had never had one particle of medical education beyond what his master's shop and library afforded him. He had an excellent appointment, in consequence of his brilliant examination, but was soon afterwards drowned in the Bay of Naples. The writer of this article was at Surgeon's Hall at the time this happened, and he knows of many instances where young men passed excellent examinations with little or no medical education. Seyeral of these have since turned out to be the most able and useful men which the public services can boast of.

We shall not say any thing of what annually takes place in Edinburgh and London, under the magic influence of the professed grinder. But to shew how imperfectly a man's attainments can be scrutinized by a verbal examination, we must take leave to refer to the recent rejection of Dr. John Mason Good, after an examination by the president and censors of the College of Physicians-all of whom, we believe, were friendly towards the candidate. Here, then, was one of the most erudite physicians of the age in which we live, after being in extensive practice for many years, and after having published numerous medical works of great merit, unable to make his acquirements patent in an examination which a tyro in the profession might undergo and ignominiously rejected! Again:-One of the most eloquent medical teachers, popular writers, and successful practitioners of the present day, was rejected, a few years ago, in a public examination. Will it be affirmed, with these and many other similar facts before our eyes, that the public examination is the proper test. We say it forms but a part of the test. The most authentic proofs should be required of a long and regular medical education, we care not where obtained. This is the sine qua non; for the verbal examination is fallacious. There are men capable of being crammed so brim full of technical learning, (it is not knowledge) that they will answer all questions in anatomy, pathology, and therapeutics, like parrots, and yet they might scarcely be able to tell one tissue or muscle from another; or distinguish, at the bed-side, between the most opposite diseases. In respect to the examination of graduates at Edinburgh, we hold the construction and defence of the thesis as a mere bauble. Every candidate for a diploma should be made to walk through the wards of the infirmary, and shew his clinical acquirements in the investigation of each complaint that presented itself-in remarks upon the nature and pathology of the disease —and, finally, in prescribing for the actual condition and stage of the malady then obtaining. Such a process as this would, at once, separate the

grinder's chaff from the wheat of clinical observation, assisted by regular study. If, on this point, the writer of this article should be considered as in any respect visionary-" it can only be, (as Dr. Clark himself has observed) in his believing that what is done in other countries, may be done in this, and done with a like benefit to the profession of physic."

9. ACUTE DUODENITIS-ENCEPHALITIS,

The following case is related by Dr. C. F. Bellingheri, of Turin. A female, of robust constitution, and previously enjoying good health, began, towards the end of July, to feel loss of appetite, and depression of spirits. On the 25th August she experienced aversion towards food, and inclination to vomit-tongue foul-pain in the head-no fever. 26th. Took two ounces of manna, which she vomited. The symptoms continued, and a physician pre scribed an emetic of ipecacuan and tartarised antimony. Vomiting followed, but nothing particular was discharged from the stomach-the bowels were then acted on. In the evening of this day Dr. B. saw the patient, and found her with fever; loaded tongue, the point of this organ being red; thirst great; inclination to vomit; no pain, even on pressure, in any part of the abdomen. At this period there prevailed an inflammatory fever in Florence, accompanied by considerable determination to the mucous membrane of the bowels; and, as it was suspected that this patient had made rather too free with strong liquors, Dr. B. did not hesitate to consider the disease as partaking of the reigning epidemic, and as consisting chiefly of inflammation of the stomach and bowels, which would soon affect the head. A copious bleeding was prescribed. The blood was not inflamed. Tamarind water; with sugar, for drink. 27th. The head-ache had disappeared-thirst conti nues, vomiting is still distressing-tongue very foul and yellow-sense of taste much depraved-great aversion to food-the food, when swallowed, produced no pain, or heat, or weight in the stomach, nor any increase of the sickness-neither was there any tenderness, on pressure, in any part of the abdomen. The motions were liquid and yellow-urine red, with a sediment. The fever continues, the pulse being quick and concentrated. Another ve nesection, to the extent of 16 ounces-blood inflamed. Vegetable acid drinks continued. 28th. Same symptoms: numerous leeches to the anus, followed by syncope. 29th. The thirst urgent-tongue thickly coated, red at the tip and sides-frequent efforts to vomit-no pain in the abdomenstools abundant, liquid, and yellow-less fever to day. Ten grains of ipecacuanha exhibited, which was soon returned, merely with the fluids drunk. Things continued in this state, till the 1st September, when the vomiting was almost incessant, and the fever became more intense than before. In the night delirium came on, but she did not complain of pain in the headcough and crude mucous expectoration. 2d. September, the venesection repeated to 16 ounces-blood buffed, and very consistent. 3d. The delirium has ceased-no pain in the head-none in the abdomen, even on pressure. In the evening, an exacerbation of the fever, and the bleeding was repeated. The blood was now natural, but thick. 4th. The vomiting less Frequent-the tongue begins to clean-dejections liquid and black-some miliary eruptions on the skin-general perspiration-urine clear and abundant-pulse rapid, but non-resisting-the patient could give no account of her feelings. These symptoms continued till the 7th, when the head evidently was much affected, and numerous leeches were applied there, while blood was taken from the jugular vein. Blisters, sinapisms, &c. were employed. 8th. Bled from the feet, and ice applied to the head. 9th. CoFOL. VI. No. 12 2 Q

matose-paralysis of the left arm, with convulsive contractions of the right. There was now pain, on pressure in the region of the duodenum, as evinced by signs, rather than words. 10th. Apoplexy closed the scene.

On Dissection, the duodenum was found highly inflamed throughout its whole extent, being of a deep brown colour, and adherent, by means of coagulable lymph, to the neighbouring parts. The stomach was also inflamed, in the vicinity of the pyloric orifice. The rest of the intestinal tube was sound, as were the liver, and other abdominal viscera. In the head, the pia mater was found to be inflamed and injected, particularly over the right hemisphere. The cortical substance of the brain was of a deep ash-colour, and softened. There were more than two ounces of water in the lateral ventricles, of a serosanguineous character. "The dissection," says Dr. B. "proves that the disease was a severe acute duodenitis, followed by encephalitis and acute hydrocephalus."

The conclusion which Dr. Bellingheri draws appears to be legitimate, and the case is curious, as shewing that so sensitive an organ as the duodenum may be inflamed, and no pain even on pressure, may be complained of. The emetics in this case, very probably aggravated the disease. The extension of the inflammation, from the intestinal canal to the brain, is here finely illustrated.-Journal Universel des Sciences Medicales.

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10. HYPERTROPHY OF THE HEART as a cause OF APOPLEXY."

The coincidence which has been for some years past, observed between hypertrophy of the left ventricle of the heart and apoplexy, is now fixing the attention of pathologists. It is reasonable to suppose, on mechanical principles at least, that if the aortic ventricle acquires a preternatural power of propelling the blood towards the brain, in common with other parts of the body, the delicate structure of the encephalic mass may, in time, suffer, and hæmorrhage may be the result. So, again, on the same principle, any obstruction to the free return of blood by the veins, from the head, in consequence of disease about the right side of the heart, should tend to the same disease as violent impulsion from the aortic system. But mechanical doctrines in pathology are always to be taken with some degree of caution, if not distrust. We must bear in mind that, in the great majority of cases of apoplexy, there is no disease of the heart; but a disease in the brain itself or its vessels. There can be little doubt, however, that where this idiopathic affection of the brain exists, the hypertrophy of the left ventricle may prove a powerful accelerator of the apoplectic attack. Be this as it may, we shall report some of the cases brought forward by Dr. Sablairolles, as facts which are independent of doctrines, and from which the reader may draw his own conclusions. This is the safest plan of proceeding, on the part of the journalist, and the most beneficial for the public.

Case 1. Jean B. aged 45 years, of small stature, and apoplectic constitution, had long been addicted to immoderate indulgence in wine. Formerly of very mild disposition and temper, he had lately become extremely irascible, and could not bear the least contradiction, without flying

* Nouvelles Observations pour servir à l'Histoire de l'Hypersarcose du Ventriell Gauche du Cœur, considerée par Rapport à la Production de l'Apoplexie. Par M. Sablairolles, M.D. de Montpellier.-Journal Generale de Medecine, Nov. 1826.

1827] Hypertrophy of the Heart as the Cause of Apoplexy. 587.

into a violent passion. He was subject to considerable nasal hæmorrhages, which always relieved intense head-aches, vertigo, palpitations, &c. He had had several acute inflammations. At nine o'clock, in the evening of the 26th January 1826, after eating and drinking pretty freely, he became suddenly senseless, and, on recovering a little, he was perceived to be unable to articulate his words. He was carried to bed, and our author found him with the following symptoms:-Coma, face of a deep red colour, lips blue, mouth drawn to one side (left,) pulse hard, contracted, and irregular, action of the heart tumultuous, great difficulty of breathing, deglutition impossible, general insensibility, involuntary discharge of urine and fæces. Cold was applied to the head, sinapisms to the legs and feet, Leeches to the temples, lavements, &c. In three quarters of an hour-or in two hours from the accession of the attack, he breathed his last.

Dissection. The membranes of the brain were extremely red, and the whole cerebral vascular system greatly distended with blood. On slicing the brain, the blood flowed at each cut of the scalpel. The most rigorous examination could not detect any trace of extravasation of blood in the head.

The heart was more than double its natural size. The parietes of the left ventricle were greatly thickened, and the cavity diminished. The origin of the aorta was enlarged. Nothing particular observable in the right chambers of the heart, except that they were gorged with blood. The mucous membrane of the stomach and small intestines was inflamed.

This is one of the cases which have been occasionally recorded by Morgagni and others since his time, where apoplexy quickly destroyed life, without any escape of the blood from its proper channels, but only from the general distention of those channels, by which the brain was universally compressed. These are the kinds of apoplexy which most rapidly destroy life, or else quickly disappear. If the universal compression is not relieved, the functions dependent on the brain must soon cease; for it is not as in cases of extravasation, where one half or more of the brain remains uninjured, and carries on the functions though imperfectly. On the other hand, these apoplexies from congestion are sometimes more speedily and more easily removed than those dependent on hæmorrhage. There is very little evidence, in the above case, that the apoplexy was induced through the instrumentality of the hypertrophia ventriculi sinistri; for, if the parietes of the ventricle were thickened, the capacity of the chamber was lessened so that although the momentum of the blood might be augmented, the quantum sent from the heart, at each systole, was diminished.

Case 2. Badollin, aged 69 years, had long been a prey to domestic chagrin and misfortunes, at the commencement of which, (18 years previously,) he had an attack of difficulty of breathing, which lasted six weeks, and was attended with violent palpitation of the heart. Since that period, these attacks have occasionally returned, but at long intervals, and not so severe in degree as at first. Towards the close of 1818, these paroxysms assumed all their pristine violence. The action of the heart was precipitate and tumultuous-the recumbent posture on the left side was impossible, and the difficulty of breathing was great. To these symptoms was added a severe pain in the right side of the chest. An eruption took place on the skin of the left side of the thorax, and quickly the symptoms abovementioned were mitigated. The patient went on rather better till September, 1819, when he was obliged to give up his occupations. The palpitation and dyspnoea were now in a most violent degree-his legs began to swell-effusion took place in the abdomen-the intellectual