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tensive, amputation permits the removal of the fatality ofthe disease, and, in general, prevents the-possibility of re-lapse. Wherever the disease is advancing, and the use ofthe knife admissible, prompt and free removal ought to beresorted to; where the knife cannot be employed, and thedisease is within bounds, recourse may be had to escharotics,such as chloride of zinc, and the like, applied agreeably to theinstructions given by the author in the article " Caustics andCauterization," published in the Cyclopædia of Surgery."

NORTH LONDON MEDICAL SOCIETY.JANUARY 10TH, 1855.

MR. QUAIN, PRESIDENT, IN THE CHAIR.

Dr. NiCHOLL (Hampstead) exhibited a specimen ofFIBRINOUS CASTS OF BRONCHIAL TUBES,

which were expectorated by a lady, aged about fifty-two, ofdark complexion, and nervo-sanguineous temperament. He sawher, for the first time, on September 9th, 1854. She statedthat, as a child, her health had been delicate, and that shehad suffered most severely from hooping-cough, and some ofthe other infantile diseases; but that subsequently, her healthhad been generally good. The chief instances to the contraryhave been one or two attacks of bronchitis, which were accom-panied by severe cough and dyspnosa, and the expectorationof unusually solid sputa; so that it is not impossible thatfibrinous deposits in the bronchial tubes have occurred onprevious occasions. There has never been any haemoptysis;and none of the mucous membranes, with the exception ofthat of the lungs, have thrown out similar exudations.There is no apparent peculiarity about the patient’s consti-tution or bodily conformation. No other member of her familyhas suffered in the same way; some of her mother’s sistersdied from phthisis, and her father was afflicted with gout andasthma. The attack set in with an ordinary cold, and hadlasted some five or six days before it came under his notice.He found her labouring under a most severe paroxysmal cough,accompanied with a sense of constriction and oppression inthe chest. There was no great febrile disturbance; but con-siderable debility, with loss of appetite, and general malaise,owing, in great measure, to the want of rest at night. The

pulse was small, frequent, and soft; the tongue somewhat furred.Sibilant and sonorous ronchi were audible throughout thegreater part of the chest, but were more distinctly marked onthe left side. No local deficiency in resonance. The expec-toration was white, frothy, and glairy, and contained thelargest of the fibrinous casts he had found, but not the slightestappearance of blood. The treatment consisted in the employ-ment of free counter-irritation to the chest in the form ofturpentine stupe and sinapisms, and in the internal use oftartar emetic with hydrocyanic acid. After a few days, therewas an evident diminution in the consistence of these casts,and they soon became reduced to a few filmy shreds, whichdisappeared altogether at the end of little more than a weekfrom the commencement of the treatment. During this periodsome eight or ten of these masses were expectorated—generallyone, but sometimes two, in the twenty-four hours; they weregenerally brought up soon after rising in the morning, andtheir ejection was always followed by a temporary diminutionin the violence of the cough. Once or twice there were attacksof extreme dyspnœa. At the end of a fortnight the patientpassed from under his care. The cough still continued tomaintain its spasmodic character; but under the use of theordinary expectorants, and the occasional inhalation of smallquantities of chloroform, this gradually subsided, and thepatient has now perfectly recovered. Of the three casts beforethe Society, one is a mere semi-transparent film, with imper-fect ramifications. It was amongst the last which werecoughed up, and its appearance seems to indicate that thisprocess of deposition was proceeding less actively; the othertwo were expectorated earlier in the attack, and are distin-guished by their firm texture, and the more perfect manner inwhich they are moulded : each presents a kind of flocculenthead, which must have completely sealed up the bronchialtube in which it was formed, and fully accounts for the attackof dyspncea that occasionally occurred. The trunk which sue-ceeds this head is nearly one-fifth of an inch in diameter, andtwo-fifths of an inch long, in both specimens ; it then divides,and each branch continues to bifurcate in the same manner asthe bronchial tubes themselves: they are firm, elastic, white.distinctly luminated and tubular. Through -the trunk of OUt

of these casts I readily passed a common director. Beneaththe microscope they present an immense number of corpusclesimbedded in a granular basis-mass; the former appears to besomewhat longer than blood globules, are occasionally ulce-rated, and contains granules and molecules; the latter seemed,for the most part, to be structureless, though here and therean evident tendency to fibulation manifested itself. Theirhistological characters showed that these deposits consist ofRokitansky’s " compound variety of fibrine."

Mr. SEDGWICK read a paperON PERFORATING ULCERS Or THE STOMACH.

After briefly alluding to the labours of others in the same fieldof observation, the author stated that it was his intention torestrict his remarks to such points of interest connected withthe disease as he was enabled to illustrate by recent cases, ofwhich he exhibited five post-mortem preparations. Some ofthese would be found to contain facts which were probablynew, and might consequently interest, from their novelty; butin directing the attention of the Society to them, he (Mr.Sedgwick) was more anxious to dwell upon such points asshould be considered practically useful, rather than such asmight be thought to possess the attraction merely of beingnew. The author observed that the immediate cause of theseulcers was still involved in obscurity, and that much patientinquiry, especially by means of the microscope, would probablybe required, before we could hope to arrive at any definiteconclusions on the subject. The poor and ill-fed were moreliable to them than the rich, and more particularly that classof the idle poor who were addicted to habitual intemperance.In such, the stomach after a time was reduced to a state similarto that of a person who had been kept on food, either deficientin quantity, or of a quality insufficient to nourish the body.Under such circumstances, the stomach appeared to lose itsdigestive power, and a return to a nutritious diet often failedto restore it. He (Mr. Sedgwick) remarked, that when thishad occurred, there seemed to be a proneness in the stomachto local inflammation and ulceration, analogous to what wasknown to take place in the lower animals who had beenstarved to death. In most of the cases the author had exa-mined of perforation of the stomach, and, he might add, in allthose where he had specially looked for it, he had noticed thatpeculiar condition of the mucous membrane termedmammilla-tion, to which much attention had been directed of late yearstWith reference to its pathological importance, or whether itwas in all cases to be looked upon as a morbid condition of themucous membrane, he (Mr. Sedgwick) was not prepared tooffer a decided opinion; but from the frequency with which ithad been met with in persons who had died suddenly fromaccident, as well as from disease, he was not disposed to attachmuch importance to it, beyond being an evidence of thesuddenness of the death. After describing at some length thehistory and post-mortem appearances of the five cases of per-foration alluded to, he (Mr. Sedgwick) begged to submit to theSociety the following points for consideration: first, the sexand age most liable to the disease; second, its diagnosis; third,its seat; and lastly, its terminations by perforation. It wasgenerally stated that perforating ulcers of the stomach weremost common in young, unmarried females, especially thosebelonging to the class of domestic servants. The author re-marked that it was only in this country, however, that thegreater frequency of the disease at an early age had beenobserved. The French pathologists seemed to consider it asmore common later in life; whilst amongst the Germans,Rokitansky, who was celebrated for the great number of hispost-mortem examinations, had found it more frequent afterfifty than under thirty. He, (Mr. Sedgwick,) in calling atten-tion to the ages of the five cases under notice-one a female,aged thirty-eight, and the others men of the respective ages offifty-three, fifty-nine, sixty-six, and eighty-two-observed, thatthe last case was interesting, as being the oldest on record, and was

. useful as showing that the disease might occur at even the most ad-’ vancedperiodoflife. The author stated as the result of his observa-’ tions on diseases of the stomach, extending over a period of twelve

years, that cases of perforation occurring late in life oftenescaped notice as such, whilst many more occurred withoutbeing published, and that consequently he was of opinion that

: this alleged greater frequency of the disease with us at anearly age was more apparent than real. He thought the

i diagnosis of the disease, before perforation had occurred, might, sometimes be very doubtful; and instanced the case of an old! Chelsea pensioner, who had suffered from pain after food for, upwards of thirty years, but had never had vomiting, or appa-. rently any other symptom referring to the stomach. After

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death, which was the result of perforation, great thickeningand induration were found around the ulcer, showing that itmust have existed for several years. Mr. Sedgwick observedthat when perforation took place, he had always found thesymptoms sufficiently indicative. These were, sudden andintense pain in the epigastric region, with not unfrequently afeeling on the part of the patient that something had givenway in his inside, followed by collapse, and in some cases evensyncope; tenderness over the abdomen, with occasionallytympanitis; a disposition to vomit, generally without theability to do so; urgent thirst, and the suppression of urine.Some writers on the subject were of opinion that vomitingoccurred in most cases of perforation; but in his experience ofthe disease the recurrence of vomiting was unusual, and he hadonly noticed it in one case, which was in other respects also anexceptional one. The suppression of urine, which did not

appear to have attracted much notice, was as marked a symp-tom in these cases as in cholera, and the patient, notwith-standing the quantity of fluid so often improperly allowed tobe swallowed, either did not pass any urine after the accident,or only a few ounces, which were turbid and high-coloured,and after death no urine was found in the bladder, which, asin cholera, appeared to be always firmly contracted. Whilsthe considered that, with a due regard to these symptoms, sograve an accident as perforation of the stomach was not likelyto take place without being recognised during life, he wouldbeg to call the attention of the Society to the possibility of theopposite mistake occurring from cases simulating more or lessperforation of the stomach, and where, after death, the stomachhad been found free from disease. During the last year hehad been present, by invitation, at two post-mortem examina-tions where this was the case. As they both presented manysymptoms in common, and the sudden death was due to thesame cause in each, he would only describe the first-awoman, aged forty-three, and suffering from cancer of thewomb. There had been, as was so often observed in thesecases, great irritability of the stomach, with much nausea andoccasional vomiting after taking food. For four or five daysbefore death she had suffered much from pain in the pit of thestomach, and complained of tenderness on pressure there, forwhich turpentine fomentations had been used. The pain andtenderness increased, and after passing a night of great suffer-ing, she was suddenly seized, at nine A. M., with agonizing pain.in the epigastrium, and complained that the pressure of thebed-clothes over the abdomen distressed her. She quicklypassed into a state of collapse, and died soon after eleven A.M.the same morning. ,. The sudden death was found to be due todisease of the heart, which was in a very advanced stage offatty degeneration ; there was no evidence of peritonitis, andthe stomach, beyond some patches of well-marked mammilla-tion, appeared free from disease. After discussing at somelength the seat of the disease, and referring to one of the pre-parations on the table as an exceptional instance of a perforatingulcer, occurring, not only in the cardiac division, but also on itsposterior surface, he (Mr. Sedgwick) concluded with someremarks on the terminations of the disease by perforation. Heobserved that all the preparations on the table illustrated thistendency in ulcer of the stomach to go on to a fatal termina-tion, either by communicating with the cavity of the abdomen,and so causing death by peritonitis, or by opening into anarterial branch, and so leading to death by haemorrhage. Fourof the cases related proved fatal by peritonitis from perforation,and, as usual, in each of them one ulcer only existed in thestomach. One of these cases was remarkable from the fact ofhaemorrhage, to an almost fatal extent, having occurred fiveyears previous to death, and on no subsequent occasion. Inthe last case, that of a labourer, aged sixty-six, the immediatecause of death was doubtful. In this case, two ulcers werefound in the stomach, in both of which the perforating processhad evidently been going on up to the time of death in theposterior ulcer leading to haemorrhage, which commenced threedays before death, and was alone sufficiently profuse to accountfor it; whilst in the anterior ulcer there was a small openingcommunicating with the cavity of the abdomen, and which hadgiven rise to peritonitis, which was, however, unusually slight.After commenting upon all the particulars of this interestingcase, he (Mr. Sedgwick) was inclined to believe that the per-foration in the anterior ulcer was the result of the over-disten-sion of the stomach with blood, and that the haemorrhageshould be considered to have accelerated, rather than havecaused, the death of the patient.The paper gave rise to a protracted discussion, in which a

considerable number of the members took part. Mr. Sedgwickreplied, and the Society adjourned.

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Correspondence.

CHLOROFORM IN SURGICAL OPERATIONS.

" Audi alteram partem."

To the Editor of THE LANCET.

SIR,—I shall be obliged by your permitting me to supply adeficiency in my letter on chloroform, which appeared in THELANCET of last week, relating to the alleged saving of life by itin severe operations. As a letter from Professor Simpson wasprinted in The Times of the 5th inst., strongly insisting onthis advantage of chloroform, it is more necessary that thedefect should be remedied.

In this letter, communicated by Colonel Napier, who kindlyacts as accoucheur on the occasion, he presents the great publicwith a table, showing that there is a saving of life to the ex-traordinary amount of 11 per cent., by the use of anaestheticsin amputation of the thigh. What can be said against chloro-form after this triumphant argument-this statistical, mathe-matical proof?

Unhappily, there are other tables in existence proving thevery contrary, drawn up by parties having no personal interestin the matter, and under other circumstances better calculatedto win our confidence than those under which Dr. Simpson’swere prepared. To these I only alluded in my letter; I nowsend them. They are contained in the American Journal of theMedical Sciences for April, 1852, and are accompanied withthe necessary explanations, and with criticisms on Dr. Simpson’stables. The records of the hospitals of New York, Boston, andPhiladelphia, furnish the data on which these tables are con-structed ; and, surely, if a prejudice is to exist anywhere infavour of etherization, we should expect to find it in the landof its birth:-

These tables tell a very different tale from Dr. Simpson’s;they show that, instead of saving, chloroform kills 11 per cent.,and annexed to this is the express " conviction of Dr. Porter,of the American army, that in the cases in which he saw anæs-thetics employed during the late war with Mexico, they exer-cised a decidedly unfavourable influence upon the state of thewounds and upon the result of operations."

I do not, however, conceive that this question can as yet besettled by statistics, if, indeed, it be one admitting of such evi-dence ; but if tables on one side are published, common fairnessrequires that those on the other should not be concealed. A

priori, we could not expect advantage, under the circum-stances, from an agent possessing the properties of chloroform.All analogy is against such a supposition.

I shall take this opportunity of stating that communicationshave been made to me respecting a difficulty that has been ex- perienced in getting frigorific mixtures to act properly duringthe present cold weather. I ought to have stated in my latelypublished " minute instructions," that ice of a lower tempera-ture than 32° does not dissolve with sufficient rapidity. Con-sequently, whoever uses it for anaesthesia, must, when it is

brought to him of that temperature, do, as the lady, peevishlycomplaining of the coldness of the ice-cream which he had pre-scribed, was recommended to do by Sir Henry Halford-hemust warm it. The courtly physician may have been betteracquainted with the chemistry of confections than those whohave laughed at his polite recommendation.

I am, Sir, yours most obediently,JAMES ARNOTT.February, 1855.

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THE MEDICAL EXAMINATIONS OF THEEAST INDIA COMPANY.

To the Editor of THE LANCET.

SIR,—I think most-yea, all-practical men (and women,too) who have been in India, will agree in the soundness ofyour remarks on the impropriety of so large a number as

thirty-two, out of sixty-nine questions, having been devotedto botany and zoology in the late examinations of the twenty-eight candidates for the medical service of the East India