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25. When the great artery of the thigh is wounded, (not tornacross,) the bone being uizi)2jui-ed, the sufferer will probablybleed to death, unless aid be afforded, by making compressionabove, and on the bleeding part. A long, but not broad stone,tied sharply on with a handkerchief, will often suffice untilassistance can be obtained, when both ends of the divided orwounded artery are to be secured by ligatures.

26. The upper end of the great artery of the thigh bleedsscarlet blood, the lower end dark venous-coloured blood; andthis is not departed from in a case of accidental injury, unlessthere have been previous disease in the limb. A knowledge ofthis fact or circumstance, which continues for several days, willprevent a mistake at the moment of injury, and at a subsequentperiod, if secondary hemorrhage should occur. In the upperextremity both ends of the principal artery bleed scarlet blood,from the free collateral circulation, and from the anastomoses)in the hand.

27. From this cause, mortification rarely takes place after awound of the principal artery of the arm, or even of the arm-pit. It frequently follows a wound of the principal artery inthe upper, middle, and even lower parts of the thigh, renderingamputation necessary.

28. It is a great question, when the bone is uninjured, where,and at what part, the amputation should be performed.Mortification of the foot and leg, from such a wound, is dis-

posed to stop a little below the knee, if it should not destroythe sufferer; and the operation, if done in the first instance, assoon as the tallowy or mottled appearance of the foot isobserved, should be done at that part; the wound of the

artery, and the operation for securing the vessel above andbelow the wound, being left unheeded. By this proceeding,when successful, the knee-joint is saved, whilst an amputationabove the middle of the thigh is always very doubtful in its",,,,,"1t.

29. When mortification has taken place from any cause, andhas been arrested below the knee, and the dead parts showsome sign of separation, it is usual to amputate above theknee. By not doing it, but by gradually separating and re-moving the dead parts, under the use of disinfecting medica-ments and fresh air, a good stump may be ultimately made,the knee-joint and life being preserved, which latter is

Ifrequently lost after amputation under such circumstances. ,30. Hospital gangrene, when it unfortunately occurs, should

be considered to be contagious and infectious, and is to betreated locally by destructive remedies, such as nitric acid,which is supplied for the purpose in case No. 5, and thebivouacing or encamping of the remainder of the wounded, ifit can be effected, or their removal to the open air.

31. Poultices have been very often applied in gun-shotwounds, from laziness, or to cover neglect, and should be usedas seldom as possible.

32. Chloroform may be administered in all cases of amputa-tion of the upper extremity and below the knee, and in allminor operations; which cases may also be deferred, withoutdisadvantage, until the more serious operations are performed.

33. Amputation at the upper and middle parts of the thighare to be done as soon as possible after the receipt of theinjury. The administration of chloroform in them, when thereis much prostration, is doubtful, and must be attended to, andobserved with great care. The question whether it should orshould3 not be administered in such cases being undecided.

34. If the young surgeon should not feel quite equal to theready performance of the various operations recommended,many of them requiring great anatomical knowledge andmanual dexterity, (and it is not to be expected that he should,)he should avail himself of every opportunity which may offerof perfecting his knowledge.The surgery of the British army should be at the height of

the surgery of the metropolis; and the medical officers of thatservice should recollect, that the elevation at which it hasarrived has been on many points principally due to the laboursof their predecessors, during the war in the Peninsula. It is

expected, then, that they will not only correct any errors intowhich their predecessors may have fallen, but excel them bythe additions their opportunities will permit them to make inthe improvement of the great art and science of surgery.

A deputation of the Medical Society of London, consist-ing of Mr. Headland, President ; Dr. Tyler Smith and Mr. I.B. Brown, Vice-Presidents ; Mr. Hancock, Treasurer ; Dr.Smiles, Chairman of Council ; Mr. Stedman ; Mr. A. Harrison,Librarian ; and Dr. E. Smith and Mr. C. H. R. Harrison,Hon. Secretaries, had an interview with Sir William Moles-worth, on Saturday last, at the Office of Works and Public

Buildings in Whitehall-place.

Correspondence.

POST-MORTEM APPEARANCES IN CHOLERA.

ISAAC PIDDUCK, M.D.

" Audi alteram partem."

To the Editor of THE LANCET.SiR,-In the year 1832, meeting Sir Astley Cooper in con-

sultation, I inquired if he had seen any cases of cholera? No,he replied, but that he had seen several interiors. His descrip-tion of the post-mortem appearances so exactly tallied withthose recorded by Dr. Robinson, of Newcastle, in the lastnumber of your valuable periodical, that the specific characterof the disease, after an interval of twenty-two years, remainsprecisely the same. The two points upon which Sir AstleyCooper remarked were, the inflammatory condition of thestomach and intestines, and the distention of the gall-bladder;and these are the prominent appearances recorded by Dr.Robinson, and which have presented themselves in almost allthe cases of cholera which have been examined. As the onlysuccessful practice is based upon correct pathology, I at oncedetermined to treat the disease according to the post-mortemappearances. In each successive irruption of cholera, this ruleof practice has been my guide, and the success which hasattended it has encouraged me to persevere.Of the nature of the poison which causes this morbid condi-

tion of the alimentary canal and distention of the gall-bladder,we are as ignorant as we are of the nature of certain ophidianpoisons, which cause pneumonia, or destroy the coagulatingquality of the blood; but the indications for the cure of choleraare clearly-

First, to empty the distended gall-bladder; and secondly, toallay the inflammatory condition of the stomach and bowels.To fulfil the first indication, the salt emetic is the safest and

most effectual. If this be followed by calomel and rhubarb,copious bilious evacuations will be procured, and with them allthe dangerous symptoms of the disease will subside. To emptythe gall-bladder is essential to the patient’s recovery; for ifreaction be established without this emptying of the gall-bladder, bilious fever sets in, and proves as fatal as the choleraitself in the stage of collapse.The second indication-to allay the inflammatory condition

of the bowels, and also to assist in evacuating the contents ofthe gall-bladder-is fulfilled by the saline treatment prescribedby Dr. Stevens, assisted by the calomel and rhubarb.

In this unwonted disease there are two strong instinctivedesires on the part of the patient-the one is for cold water,and the other is for salt, or more properly for the saline

powders. Therefore the desires of the patient may be safelygratified, and cold (iced) water allowed ad libitum. If theview I have taken of this dreadful disease be correct, it isobvious that all endeavours to promote reaction by means ofstimulants, and to stop the natural efforts to unload the gall-bladder by means of astringents, must be worse than useless;they must inevitably tend to seal the fate of the patient, bylocking up within him the casus ?Koy’&!’.The same principle should guide us in the treatment of the

premonitory diarrhoea, which is cholera undergoing a naturalcure. In innumerable cases, a small dose of calomel andrhubarb, followed by castor oil, by carrying off the redundantsecretion of bile, arrests the diarrhcea at once; whereas if it bestopped by astringents and sedatives, a simple disease becomescomplicated, and a bilious diarrhoea exchanged for a biliousfever of a grave character.

I remain, Sir, yours, &c.,, August, 1854. ISAAC PIDDUCK, M.D.

EXAMINATIONS AT THE UNIVERSITY OFLONDON.

To the Editor of THE LANCET.

SiR,-Perhaps there is nothing of which a man is moretenacious than the reputation of his Alma Mater, and hewould oftener shut his eyes to any little discrepancy in herconduct rather than bring it to light, and thus subject her tocensure, however merited it might be; but if she palpably errs,methinks it is a kindness to expose her errors, in order that

they may be rectified before her fame becomes sullied.I was one of the 240 candidates who presented themselves

for matriculation at the University of London, and one of the150 who passed in the first division. On proceeding to paymy examination fee, I found the offices of the University ofLondon consisted of a tico-pair back in an out-building of

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Marlborough House. The pass-examination was held at King’sCollege, in five or six different rooms, each room being presidedover by some unknown-certainly not the examiners, whonever appeared. A few days after the pass-list was published,I presented myself at the appointed time at King’s College,

with the intention of "going in" for honours. On inquiringin which room the examination was held, I was informed, ’’ Noexamination was held there, and I had better try MarlboroughHouse." On reaching the two-pair lack, I found no one inattendance but a little urchin, something between a printer’sdevil and an errand-boy, and half-a-dozen students in thesame quondary as myself. After pacing round the courtyardfor half an hour, an official conducted us to the examination-room, still more classic ground than the ttvo-pair back-namely, " The Thatched House Tavern" !

It is, I believe, an almost indisputable fact, that the exa-minations of the University of London are of a charactereminently calculated to raise the st,tfU8 of the profession: I,for my part, would sooner attach to my name 1’1. D. Lend. thanall the rest of the English and Scotch medical degrees puttogether. As the Marquis of Lansdowne well remarked inthe House recently, " The University of London has now un-deniably proved itself entitled to the approval of the public bythe very excellent way it has educated those men who haveresorted to it." But the arrangements and appointments, asthey at present remain, would utterly disgrace a charity school.I would ask, Where is the University of London ? It is not forme to suggest where it should be; but with such an influentialbody as the senate at its head, I should imagine a more dignifiedplace might be found for the dispatch of business than a two-pai-r hack, and a more appropriate spot for examination thanThe Thatched HOU8 2’cczvw.

I am, Sir, faithfully yours,AN UNDERGRADUATE IN HONOURS OF THE

August, 1854. UNIVERSITY OF LONDON.

THE CHOLERA.

VARIOUS, contradictory, and often violent as have been thearguments and discussions carried on relative to the mode ofpropagation and pathology of cholera, the battle-ground hasbeen still more hotly contested in respect to its th3rapeutics.As the organ representing the scientific and practical progressof medicine, our pages have necessarily been the medium fromtime to time of expressing the particular opinions and practice

I

of a great body of the profession of this country and of ourIndian possessions, and the result has been, of course, that wehave helped to make known the most opposed doctrines, eachoften most positively maintained, sometimes, we regret to sayit, upon grounds, too, which rather should have authorised theutmost amount of diffidence. To go through the list of"advised methods of procedure," "best modes of treatment,""safest plans," &c. &c., to say nothing of the specifics recom-mended, would be to pass in review a very fair share of all themore effective agents of the Pharmacopoeia. Even then manythings would be left unnoticed, such as transfusion into theveir.s, hot-air baths, the " cold sheet," and other appliances,which are not to be found printed in the College list. Shouldthe reader be curious, however, upon these points, if he willrefer to our second volume for the year 15.3, page 416, "hewill find something to his advantage. " Out of the manyplans of treatment which have been advised, there are twowhich have had more extensive trials perhaps than any other;these are the " saline plan" of Dr. Stevens, and the " smalldoses of calomel frequently repeated" of Dr. Ayre, of Hull. ’"

Both these plans have been largely and extensively put inforce, and, according to the evidence of the witnesses, bothwith the utmost benefit, and with the most complete inutility.Between these contradictory verdicts, it was necessary for cer-tain authorities on particular occasions to strike a mean, whichshould direct the current value to be allotted to the methodsunder consideration. In 1849, learning that the College of

Physicians had appointed a "commission" on cholera, Dr.Stevens requested one or two interviews with the President,after- having had a few with the " Central Board ofHealth," to inquire as to the opinion held of, and makesome further suggestions about, the saline plan" of treat-

* The sulphwric aeid p1_an" is now rivalling the passing reputation of theabove methods.

ment. The result of his inquiries and suggestions, (accordingto his own account,) in connexion with the former, may begleaned from the following extract from Dr. Stevens’ book*(reviewed by us in a former number, vol. ii. 1853, p. 58):-

" The learned president advanced towards me, &c.. - . ...’I am

very sorry,’ he said, ’very sorry indeed, sir, that you have againintruded yourself on me. I am very busy, too busy indeed, tohave my time-my precious time-was ed in any idle discus-sion about either the cholera or your saline treatment. (xxvii.p. op. cit.) )

Dr. Stevens’ application to the Central Board having alsobeen "a complete failure, (xxxiii. op. cit.,) in 1853 appearedthe voluminous " Observttions, contravening what had beensaid against the success of the " saline plan," asserting that theinvestigation made as to its results was a " shtni inquiry," andmaintaining it was "eminently successful" in practice.

Since the appearance of Dr. Stevens’ reclamation, the Collegeof Physicians have published their last Report, (reviewed in ourfirst volume for 1854, page 250,) and in connexion the " salineplan." It is stated-" We have no evidence that they [salines]possessed anv influence over the local morbid action in themucous membrane. It was not until this surface had in partrecovered its function of absorption that any good resultedfrom their employment.’’-(page 196, second part.) This sameReport of the College has, however, called up another and moretemperate reclaimer-viz., Dr. Ayre, the great advocate ofthe "calomel treatment" previously alluded to. The reportsays-" In general no appreciable effects followed the adminis-tration of calomel, even after a large amount in small andfrequently-repeated doses had been administered. For themost part it was quickly evacuated by vomiting or purging, orwhen retained for a longer period, was afterwards passed fromthe bowels unchanged. Salivation but very rarely occurred,and then only in the milder cases. We conclude that calomelwas inert when administered in collapse; that the cases ofrecovery following its employment at this period were due tothe natural course of the disease, as they did not surpass theordinary average obtained when the treatment consisted in theuse of cold water only."-(page 177, second part.)

In Dr. Ayre’s tract+ (the contents of which first appeared inTHE LANCET) now before us, the main points sought to beinculcated, are the following :-

1st.-That the inquiry of the " College Committee" into thetreatment of cholera has been badly conducted, and the cha-racter of the evidence adduced by it is defective.-(page 28.)2nd.-That Dr. Gull represents not merely the writer of the

Committee’s Report, (second part,) but was himself the com-mittee on the subject of the treatment, and is alone responsiblefor all that is contained in it.-(page 57.3rd.-That while " calomel is indeed not remedial in cholera

when given in large doses, or in small ones at wide intervals,when administered in small doses, according to prescribed con-ditions, and without any other adjuvant than cold water adlibitum, it exhibits a remedial power well nigh approaching to ,that of a specific; so that in very truth the cases which Dr.Gull has brought forward in support of his views, tell sostrongly against the conclusion which he aims to establish,that I have only to avail myself of them as arguments to provethe truth of the position, that calomel, when rightly given, illtruly a remedy in this disease."Between the College Report and Dr. Ayre we attempt no

reconciliation, leaving this for the present in the hands of thereporter of the second portion of the committee’s labours, Dr.Gull. From the same evidence, or rather the same sources ofthe evidence used by both parties, different conclusions havebeen arrived at. Some great error, therefore, must somewhereexist, and we cannot say that we think it beneath the dignityof the College committee to reply, through its reporter, to thereclamation of the physician of Hull. In the meantime, it maynot be out of place if we indicate once more the exact methodof procedure recommended by Dr. Ayre. It "consists, duringthe stage of collapse, in giving one or two grains of calomelevery five or ten minutes, with one or two drops of laudanumwith the first few doses of the drug, and in perseveringly con-tinuing the same dose at the same intervals of time, until thesymptoms of collapse become materially subdued.......... I

have never given stimulants in any form, because I found themnot to be necessary, and believed they would prove perniciouswhen, from the long duration of the collapse, and the delay in

’ commencing the treatment, consecutive fever might be feared;‘ Observations on the Nature and the Treatment of the Asiatic Cholera. By

William Stevens. M.D.. D.C.L. Oxon. &e. &c.† A Letter to the President and Fellows of the Royal College of Physicians,

in relation to the Evidence cited in their late Report on the Treatment ofEpidemic Cholera. By Joseph Ayre, M.D., &c. &c. London. 1854. pp. 71.