No. 1358.

SEPTEMBER 8, 1849.

LEAVES FROM THE CASE-BOOK OFA PRACTISING PHYSICIAN.

BY JOHN CHARLES HALL, M.D.,FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS, EDINBURGH; MEMBER

OF THE ROYAL COLLEGE OF SURGEONS, LONDON.

(Continued from p. 173.)

" Hæc denum sunt quæ non subgessit phantasiea imaginatricis teme-ritas, sed phsenomena practica edocuere."—SYDENHAM.

LEAF THE SIXTH.

Is the .Nitrale of Silver oil’ Advantage as a Local Applicatdoztin Erysipelas ?

WE remarked, in the former part of this paper, (Section e,p. 170,) that erysipelas may be communicated from oneperson to another, under circumstances favourable for itsdevelopment. I remember attending a nobleman, in consul-tation with another physician. After examining the surfacewith his finger, my friend touched a pimple on his face, andin a day or two lie had a slight attack of erysipelas of thatpart. This fact coming under my more immediate observa-tion induced me to conclude that the opinion generally ex-pressed on the continent, that erysipelas is not contagious, isnot founded on a correct basis. If the reader turn to thesecond volume of the Transactions of the Society for the Im-provement of Medical and Surgical Knowledge, he will therefind several cases related by Dr. Wells, in which there canbe no doubt of the disease resulting from contagion. Hesays:

" I visited, on the 8th of August, 1796, in Vine-street,Clerkenwell, an elderly man, named S-, who had beenattacked several days before with erysipelas of the face. Inabout a week afterwards he died. On the 19th of the fol-lowing month I saw a Mrs. D-, of about seventy years ofage, the landlady of the house in which Skelton had been alodger, and found her labouring under an erysipelas of herface. I inquired of her whether any other person in her househad been ill of the same disease since the death of Skelton;and was told that his wife had been seized with it a few daysafter his decease, and had died in about a week. During myattendance upon Mrs. D-, an old woman, her nurse, wasattacked with the same disorder, and was sent to her parishworkhouse, where she died. Mrs. D- has since informedme that a young man, the nephew of S-, was taken withthe disease of which his uncle had died shortly after visitinghim, and survived the attack only a few days; that she her-self had been several times with S- and his wife duringtheir sickness; and after their death had removed some fur-niture from their room to her own apartment."Two cases are also related by Mr. Lawrence, in which the

attack appeared in each individual to have resulted fromcontagion; the disease having arisen from their accidentalcontact with a patient suffering from a severe attack of ery-sipelas of the head and face, which had commenced after theinsertion of a seton in the neck.

In his Lectures on the Practice of Physic, Dr. Elliotsondescribes an attack of erysipelas in his own person. A patientunder his care had " erysipelas badly" of the head and face;the doctor was stooping down to examine the skin, when theman’s " breath came upon his face." Dr. Elliotson adds: " Iturned away disgusted, and said, I hope I have not caught it;’but five days afterwards, having forgotten the circumstance, Iwas seized with it."The following case is related by Dr. Watson:-"A man, residing somewhere in Westminster, fell ill of I

idiopathic erysipelas. In that state, for some reason or other,he was removed thence; and his brother, who was a servantin or near Portland-place, received him clandestinely into hismaster’s house, and allowed him (for two nights; I believe) toshare his bed. That brother was soon attacked with erysi-pelas, and in the course of his illness was visited by his master.The master also was attacked; and it is worthy of remark,that in both master and servant the disease showed itself justseven days after they had respectively come near another whowas affected with it."-(Watson on the Principles and Prac-tice of Physie, vol. ii. p. 830.)

Contagion may therefore, I think, be very fairly set downas one of the exciting causes of erysipelas; but we are all ofus called to attend many cases of this disease, in which thereis no reason to suppose they are the result of contagion. Wehave seen an example of this in the case of Mr. H-.

p. 170, where the exciting cause was evidently exposure tocold; and I have known instances in which both exciting anddepressing influences have given rise to an attack of erysi-pelas ; but in all these cases there was in all probability someprevious morbid condition of the blood. Erysipelas is alsofrequently seen to attack parts after injuries or operations.In truth, erysipelas is, if not created, at any rate promoted,by all causes which have a tendency to depress the vitalpowers-by hard drinking; by improper food; by mentalanxiety; by want of cleanliness; by breathing an atmosphereloaded with animal and vegetable exhalations-and such is toooften the case in badly-constructed hospital wards and in thebadly-ventilated abodes of the working classes; and moreespecially in common lodging-houses for tramps, which arethe most prolific sources of disease and crime.*

The Local Application of the Nitrate of Silver.It has been contended by those who are opposed to the em-

ployment of the nitrate of silver as a local application inerysipelas, that this is not a local disease; this, they say, isevidenced by the great amount of constitutional disturbancewhich is present before the appearance of the eruption, whichis only an outward and visible sign of the disease, and not thedisease itself; that it is an acknowledged fact that the suppres-sion of an eruption by local means, which depends on constitu-tional causes, is dangerous, and often productive of death.Sir B. C. Brodie never uses the nitrate of silver in erysipelas,and considers it "dangerous;" h0 was kind enough to tell methat 11 he knew of two cases in which there was reason to be-lieve that the determination of the inflammation to internalorgans, and the death of the patient, was the consequence ofthe application of the nitrate of silver to a local surfaceaffected with erysipelas." Such is the opinion of one of themost experienced surgeons in Europe-of him from whose lipsI received the first lines of our art-the opinion of one whosewell-known talents and experience entitle every opinion hemay express to the greatest possible respect and attention !* Lodging-houses for tramps would be more appropriately designated

"pest depots, "for they are the receptacles of filth, disease, and crime.Here alike all herd together—the prostitute, the thief, the filthy, and theunfortunate-men, women, and children, married and single, sleeping to-gether, irrespective of age or sex. Here are nightly collected together anindescribable mass of human beings, having no common object in view butthat of preying upon the industry, the credulity, and generosity of the com-monwealth, whose morals they contaminate, and whose health they arecontinually jeopardizing. In these dens-without ventilation or any meansfor healthful accommodation- the inmates are affected by diseases of everykind, including fever, syphilis, itch. I have visited these tolerated nuisancesmany times, both by twilight and after they have been shut up for the night.In the evening, some are smoking, some cooking, some making matches,some playing at cards. If you enter a night-room-the disgusting stenchof which can only be compared to a common sewer—you may see thirty orforty of these unfortunate creatures sleeping on the floor, most of themnaked, in order more readily to rid themselves of bugs and fleas.

I was once summoned, late at night, to a common lodging-house in EastRetford, to see a young girl suffering from a severe form of low fever, underwhich she had evidently been labouring for some days, I found her at theend of a long, dark, narrow room, upon the floor of which were sleepingindiscriminately about twenty, men, women, and children. The narrowpassage between the beds was nearly filled by the filthy clothes that hadbeen hastily cast off. Packages of various sizes were also throwing about : -.and the stench arising from an atmosphere loaded with the fumes ofmatches, clothes smelling of tobacco-smoke, ale, spirits, perspiration, andthe breath of the unfortunate beings thus huddled together in the closeand heated room, which was without a chimney, and through the windowof which it was quite impossible the smallest portion of pure air could enter,requires to be experienced in some similar dwelling, in order to form anyadequate notion of it. Only think of passing a night in such a room—anight of fever !

It may belong to the investigation of the causes tending to deprave themorals of the humbler classes, rather than to the question more imme-diately under discussion, to consider the awfully depraved and callous stateof feeling possessed by the men and women thus sleeping together in oneroom-surrounded, too, by children -children destined to follow the samecourse of deception, sin, and depravity; but the connexion between thetwo is closer than appears on a haty consideration of the matter; and it isquite impossible not to reflect witii horror on the miserable fate of those iin-happy children, who are thus exposed to all the worst possible sources ofcontamination that surround mankind. What must be the inevitable fateof children thus left without shield or protection from the cradle to thegrave ? ?

" Where shall their hope find rest ? No mother’s careProtects their infant innocence by prayer ;No father’s guardian hand their youth maintains,Calls forth their vhtues, or from vce restrains,"

The loss is equally great on the part of the parents who thus cruellyabandon their children : the lessons taught from the cradle can never befully estimated. it is lamentable to contemplate the fate of the childrenof those operatives inhabiting the miserable abodes of our larger manufac-turing towns,—abandoned all day by their parents when at work, neglectedby the state, and but for the interference of public or private benevolence,left-so far as the government of the country is concerned—without anyeducation whatever. But there is no such thing as non-education; for asArchbishop Sharpe has truly said, " If we do not educate those childrenthe devil v.-ill," and in the absence 01 proper instructors, depravity and inare ever active in supplying teachers.

254

But now arises the question,—Does this application" repelerysipelas ?"-in other words, Does, or can it " determine theinflammation to the internal organs ?" "It is said," remarksDr. Watsoi3, " that the erysipelas does, now and then, suddenlydesert the surface, and that inflammation of some internalpart, and particularly of the brain, is apt to follow such rapidsubsidence of the external malady. I presume that this me-tastasis is rare; I do not recollect to have seen it." (Principlesand Practice of Physic, p. 829.) And again, (op. cit., p. 834,)speaking of local applications, this experienced physician ob-serves : " In a few cases, and but a few, the warm applicationshave been disliked, and cold lotions preferred; and when suchis the case, there is no risk incurred by using them, no hazard,I mean, such as you may read of, of the inflammation beingrepelled from the surface, and driven in upon some vitalorgan." ,

In the year 1842, had the honour of attending the lateEarl S-, in consultation with my esteemed friend, Dr. Scho-field, of Doncaster, for a severe attack of erysipelas of the faceand head. The nitrate of silver was applied in solution(twenty-five grains to the ounce of distilled water) over thewhole of the affected surface; the result was highly satisfac-tory, the inflammation appeared checked by the remedy, andour patient recovered. Within a month of attending this case,it so happened that I was consulted by three other patientslabouring under erysipelas of the head and face, to all of whomI ordered the application of the nitrate of silver with advan-tage, and both before and since I have advised its employ-ment. I do not say I can boast of the same success as Mr.Higginbottom, of Nottingham, but it has never in my handsdone harm, and has proved quite as successful as any otherremedy with which I am acquainted, and which is prescribedfor the cure of this or any other disease.The result of my experience of the application of this

remedy leads me to the conclusion, that lunar caustic does notrepel erysipelas, but that its effects are to moderate and limitthe local affection; nor must we lose sight of the importanceof so limiting the affection of the skin, (whatever part of thebody may be attacked,) which becomes secondarily a cause ofconstitutional disturbance, in exact proportion to its extentand severity. To do this as soon as possible is, therefore, apoint of the greatest possible importance; for by so doing, wenot only remove one exciting cause of general disorder of thesystem; but as the local mischief will be increased and ren-dered more nnmanageable by severe constitutional derange-ment, by taking away this secondary cause of general disturb-ance, we very materially diminish the hazard of highly seriousand permanent local injury.We will now consider the opinions of some of those who

have written on the subject, as well as the results of their ex-perience kindly communicated to myself by other physicians.and surgeons, regarding nitrate of silver.

Mr. Nunneley observes: "The nitrate of silver was first re-commended by Mr. Higginbottom as a local remedy of greatpower in the treatment of erysipelas; it has since been muchused, and, on the whole, opinion is in favour of it. Mr. Higgin-bottom does not hesitate to apply it freely over the whole in-flamed surface, and also a short distance upon the sound skin.Though the remedy has not proved so uniformly successful inthe hands of others, as represented by Mr. Higginbottom, itcertainly in some cases acts very beneficially, and is one thatI think might be tried, if the case be seen at an early stage,and matter has not formed before having recourse to incisions."(On the Nature, Causes, and Treatment of Erysipelas. By T.Nunneley, Surgeon to the Eye Infirmary, Leeds. p. 283.)

It is the opinion of Dr. Craigie, of Edinburgh, that" amongthe measures employed to arrest the extending progress of thedisease, (erysipelas,) perhaps none is more effectual than theplan of enclosing an erysipelatous patch in a ring of nitrate ofsilver." (Practice of Physic. By Dr. Craigie. Vol. ii. p. 479.)

" The best local application, in ordinary cases, is that re-commended by Mr. Higginbottom-the lunar caustic." (Bate-man’s Synopsis. Edited by Dr. A. T. Thomson, p. 158.)

" In erythema, the skin only being affected, advantagesometimes results from the application of nitrate of silver.The pain and uneasy sensations in the part being thereby,diminished or removed; the extension of the disease seemingto be arrested. Discolouration caused by such practice is oflittle consequence, as desquamation must follow." (Elementsof Surgery. By R. Liston, F.R.S., p. 136.)

" I do not at first use the nitrate of silver in slight cases oferysipelas of the face, but resort to every active constitutionalmeans of cure; if these means have failed, I have recourse tothe nitrate of silver. It arrests, almost instantly, the spread-ing of the inflammation; its influence, besides, extends beyond I

the surface, and checks the tendency to cellular innammaMon—the symptoms (query results) most to be guarded against in

erysipelas." (Higginbottom on the Use of the Nitrate ofSilver in Cases of Inflammation, second edition, p. 28.)What I have seen of this disease leads me, as already stated,

to think highly of the powers of the nitrate of silver, not onlyin arresting erysipelas, but also in preventing those fearfulconsequences we too often see when the cellular membranebecomes to any extent involved in the disease; but I cannotagree with Mr. Higginbottom, that we ought first to resort to"constitutional means of cure," and that only "if these meanshave failed," to have, in "slight cases of erysipelas of theface, recourse to the nitrate of silver." If, as I think it does,the remedy " arrests, almost instantly, the spreading of theinflammation," why delay a moment in combining the localwith the "active constitutional means of cure" ? and if itsinfluence extend " beyond the surface," that influence will bedoubly exerted by an early application, by which I have oftenseen a case that would have, in all probability, run on to in-flammation and sloughing of the cellular membrane, cut short;the disease making no progress, from the moment the causticwas freely applied to the skin.There is one form of caustic," writes Dr. Elliotson, "which

is frequently of great use, even in certain acute inflammations,which is nitrate of silver. In certain inflammations of theskin, the application wetted and rubbed on the part., or astrong solution applied with a brush, is frequently of greatuse. There is sufficient testimony in its favour, but I havenot employed it extensively myself. In one form of violentinflammation of the skin, however, I have made a circle allround the inflamed part. I have not touched the inflamma-tion itself, but a certain portion all round, so as to blacken it;and I have seen it put a limit to inflammation which threatenedto spread to a great extent. Inflammation is thus arrested,which, in all probability, would have run on to the destructionof life." (Practice of Physic, art. Inflammation, p. 141.)

Dr. Elliotson also adds, " We may put a stop to the pro-gress of the disease (erysipelas) by the application of thenitrate of silver. If we rub the nitrate of silver on thehealthy part around the disease, or make a strong solution,and apply it all round with a brush, we may generally preventits farther progress. Some persons recommend blisters, butthe nitrate of silver answers much better. It is necessary,however, that the application should be continuous, for if weallow a small place at which the disease cau creep out, it issure to do so."I have seen cases where a portion was left unguarded, and I

have seen the affection creep through there, and spread alongthe part :’ Dr. Elliotson then gives this very important ad-vice, " It is very necessary to stop the progress of the disease,if it be near the head, because, if it should spread over thehead, or even half over it, it is ten chances to one that wehave delirium and inflammation of the membrane of the brain,and the patient will die in an apoplectic state." (Practice ofPhysic, art. Erysipelas, p. 428.)

Dr. Elliotson, in the above extracts, makes mention of theuse of blisters in the treatment of erysipelas. They havebeen, and still are, more extensively used in France than inthis country, but I cannot, from what I saw of their applica-tion when in Paris, consider them very efficacious in the treat-ment of erysipelas.Baron Larrey was the determined advocate of the actual

cautery, and speaks highly of its utility.* It is a remedy Inever saw used, and one, even admitting its utility, that wouldnot be a little difficult to introduce into private practice in thiscountry. M. Baudcns has employed it with advantage inAfrica. The application of blisters upon erysipelatous partswas first recommended by Dupuytren, and they have beenused in this country with advantage, by Duncan, (EdinburghMed. Chir. Trans. vol. i. p. 369) James, (on Inflammation, p.395,) and Copeland, (Dictionary, p. 834.) Dupuytren appearsto have been only partially sucessful in his treatment of erysi.pelas by blisters, which are " not to be used if the symptomscontinue to increase; I cannot recommend blisters; suchdifferent effects have resulted from their employment, that Icannot venture to employ them. (Lecons Orales, vol. ii. p. 158.)Velpeau has tried blisters in every possible shape and in everypossible manner; large and small; above and below; around andin the centre of the inflamed surface, and has come to the con-clusion that they " are of nousein erysipelas, properly so called:’In phlegmonous erysipelas he covers the whole inflamed sur-face with an enormous blister. Mercurial ointments have also

* The actual cautery applied to the parts which are reddest and nearestthe wound, instantly stops the progress of the inflammation. (Revue Me-

dicale, 186.)

255

been much lauded. Chomel attributes the cures ascribed tothem, to the natural march of the affection. Mr. Nunneleythinks this ointment at least of doubtful utility. Rayer tellsus (Traite des Maladies de la Peau) that he has covered onepart of the face with mercurial ointment, and with equal ad-vantage spread butter on the other, or left it altogether un-covered, and the late Mr. Liston has ridiculed in no measuredterms the use of mercurial ointment. (Clinical Lectures, THELANCET, vol. xxix. p. 330.)

But to return to the use of the nitrate of silver. The late1B11’. S. Cooper remarks that " the application of the nitrate ofsilver, in substance, or in the form of a lotion, appears to have-considerable power, as a means of checking the peculiar actionof the vessels on which erysipelatous inflammation depends.It tends to repress the effusion of serosity in the cellular tis-sue, and if applied bepond the erysipelas, will form an obstacleto its spreading in any particular direction; by forming ablack line with it, the inflammation may be kept from runningp the neck to the face and head. In the early stages of ery-sipelas, I have often used it at the North London Hospitalwith advantage; but it should not be continued too long, forwhen it fails to lessen the distention of the cellular tissue withserosity, the fluid should be discharged by puncture or inci-sion. (Cooper’s Surgical Dictionary, seventh edition, p. 506,.art. Erysipelas.)

"The nitrate of silver," says Mr. Donellan, in the paper be-fore quoted, " first recommended by Serres" (Annuaire, Med.-Chir., 1826) in variola and zona, was subsequently applied byMr. Higginbottom in the treatment of erysipelas, and Dr.Thompson employs it with success in all inflammations of the’skin. Brett, although having often used it with advantage inerysipelas,was obliged, in severe cases, to have recourse to cau-terizations, and a solution of the nitrate of mercury in an equalpart of nitric acid." (Encyclopaedia, of Practical Surgery.)"This remedy (nitrate of silver) is not to supersede active

treatment when necessary." (Dr. Tweedie, Cyclopaedia ofPractical Medicine, p. 114.)

" In idiopathic erythema," says Dr. Joy, " when the part isvery painful, and considerably inflamed, a solution of nitrateof silver affords one of the most healing, and after the momen-tary suffering immediately ensuing upon its use, one of themost soothing applications; fat persons who have been in astate of torture after a long walk, or a hard day’s shooting,liave found instant relief from this remedy." (Cyclopaedia ofPractical Medicine, p. 127, art. Erythema.)

In answer to a note requesting information as to the resultsof his experience, in Dublin, of the advantages of nitrate ofsilver as a local application in erysipelas, the late 1B1 r. Carmi-chael was kind enough to say, that " he could confidently statethat he had, both in hospital and private practice, arrested theprogress of erysipelatous inflammation, by drawing lines ofcircumvallation round the margin of the surface affected witherysipelas. Indeed it has seldom failed in doing so whenproperly applied."The following note was received from my much lamented

friend, Mr. Tyrrel, only a few days before his death deprived ourprofession of one of its brightest ornaments:" From the use Ihave seen of nitrate of silver as an appliation in erysipelas, I amam induced to believe it has some influence in checking the ex-tent of the local mischief, when applied on the healthy skinaround the affected part; but in my own practice I do not putmuch faith in local remedies, believing the disease of the skinto be promoted and maintained by the peculiar febrile dis-order:’Mr. Lawrence was also so obliging as to favour me with the

result of his extensive experience in the treatment of erysi-pelas by the nitrate of silver. "He had not employed it inerysipelas, as a sole or principal remedy, but often in conjuuc-tion with other means :’ Mr. Lawrence goes on to say, I Ihave not used it when the affection has become more general.I have sometimes used it on the boundary of the inflammation,particularly in the limbs. The complaint has sometimes beenarrested, sometimes passed on with diminished pace. My ownexperience does not lead me to attach much value to the ap-plication:’The remedy is never used by Mr. Csesar Hawkins, at St.

George’s Hospital, who " has only found it effect a boundaryin mild cases, which would have done as well without it. Inmany cases the disease spreads beyond the part to which thecaustic has been applied, and it is utterly useless when the in-flammation affects the cellular tissue as well as the skin."Mr. Csesar Hawkins, therefore, only considers it of use, if at

all, in mild cases; and this certainly confirms, in some degree,he opinion I have already ventured to express-viz., that thecaustic, when used, ought to b applied in the early stages of

the disorder; for I quite agree with him in thinking, that theremedy would be useless or even injurious, when the inflam-mation has extended to the cellular texture. It is appliedwith the view of preventing the erysipelas extending to theseparts, and its virtues are most clearly apparent when the ap-plication has been made sufficiently early, and the arrestingthe progress of the local affection is a point of the utmost im-portance. From the history and progress of erysipelas, itsacute nature appears perfectly clear; the local symptoms ex-hibit the most convircing proofs of inflammatory action-red-ness, heat, pain, and swelling:* moreover, if we trace its ter-mination in resolution, effusion, suppuration, and gangrenejthe conclusion, according to the soundest principles of patho-logy, is, that wherever erysipelas arises there is inflammationof the skin, or of the cutaneous and cellular tissues combined,and if we revert to the general and constitutional symptoms,we find they are exactly proportionate to the extent and in-tensity of the local affection.Mr. Lane is not, he tells me, "disposed to speak highly of

the nitrate of silver as a local remedy in erysipelas," he adds," I have seen it decidedly fail. My opinion is, that it succeedsbetter in the erratic form, and that it acts by producing achange in the capillary circulation of the skin; in otherwords, that it indisposes to erysipelas, by engaging the vesselsin another kind of inflammation."

I have often seen the nitrate of silver employed at St.George’s Hospital by Mr. Keate, and have heard him declarehe has used it constantly for the last thirty years, a prettygood proof that one of the oldest of our hospital surgeons isfully convinced of the beneficial results arising from its em-ployment, and he still continues to make use of it, not onlyin the hospital, but also in private practice, in certain formsand states of erysipelas. The cases in which I have seen Mr.Keate employ it, and certainly with very great success, werethose where inflammation is running up along the course ofthe absorbents, above the chief seat of the erysipelatous in-flammation.From what has now been placed before our readers, it will

appear, that even with regard to the advantages of a singleremedy for the treatment of erysipelas, the greatest possibledifference of opinion still exists. Well might a modernwriter (Mr. Nunneley) say, when speaking of the treatmentof erysipelas, "so confidently are the most opposite remediesenforced, and so contradictory are the results said to followthe application of the same means, in the hands of differentpersons equally worthy of credit, that the impugner ofmedical skill may fairly point with confidence to this part ofour field, and demand if such contradictions are worthy thename of a science or of trust ?"

It is much to be regretted that the opinion of the professionis not more unanimous on a point of so much importance asthe one we have endeavoured to investigate; this only showsus that a simple record of facts, in a concise and accessibleform, unencumbered by hypothesis, is the most useful con-tribution a medical man can make to the archives of his pro-fession. The author of such a record contributes that whichhas a fixed and certain value, provided it be a correct, clear,and truthful description of what he has seen; for he thus sup-plies a number of important facts which every physician andsurgeon can study at his leisure, and reflect on for himself;and from which lie may acquire a knowledge of phenomena,and of their relation to each other, almost in the samemanner as if he had, at the bedside of each patient, observedthe symptoms, and noted the res-alts for himself. It is clearthat our practice, to be successful, must be grounded upon anextensive and correct knowledge of the natural history andpathology of diseases; the experience of any individual, how-ever extensive his private and public practice, however pro-longed his facilities for observation, is, after all, but limitedand insufficient; and, therefore, it is only upon a large numberof facts, contributed by many observers, that legitimate prin-ciples in medical science can be founded. In my own prac-tice I have used the nitrate of silver with advantage as a localremedy, and I shall certainly continue to do so, combinedwith constitutional remedies, in certain forms of erysipelas,and at certain stages of the disease. Many physicians andsurgeons of established reputation order it ; among othersMr. Keate, senior surgeon to St. George’s Hospital, London-a truly practical man, and one not very likely to be carriedaway by fanciful theories, distinguished for nothing but theirnovelty-used to-day and abandoned to-morrow. I first sawit used by him at St. George’s, and during a period of morethan five years, when a student at this hospital, I had proof

* Notee vero inilammationis sunt quatuor, mbor et tumor, cum calore etdolore.-Celsus, book iii. chap 10.

256

almost every week of the value of the remedy in his hands;this induced the application of the caustic in private practice,and the results have been sufficiently satisfactory, in myhands, to warrant my continuing to prescribe the remedy,under the limitations already pointed out. At the same time,be it remembered, many practitioners of the highest standingconsider it not only useless, but dangerous. I cannot helpthinking a more extensive trial would lead to a different con-clusion, for the nitrate of silver does not repel erysipelas, butdoes, in many cases, when properly applied, at a sufficientlyearly period, so diminish the peculiar local affection as toprevent the fatal destruction of parts already described. As,however, it is our wish to elicit truth, and not to establish aparticular theory, both sides of the question have been stated,and the reader must decide for himself as to the utility or in-utility of using the nitrate of silver as a local application in ery-sipelas. At present the treatment varies, not only in our metro-politan hospitals, but even in the same hospital. If A. B. beadmitted for an attack of erysipelas in the " taking-in week"of Mr. C., the caustic will not be used; because Mr. C.considers it not only of no use, but even dangerous. Butshould A. B. go to the same hospital in the " taking-in week"of Mr. D., the nitrate of silver will be at once applied, be -cause Mr. D. has used it for a great many years, and is con-vinced of the beneficial results attending its employment.

In conclusion, it may be added, that the general principleswhich ought to guide us in the treatment of erysipelas occur-ring in a previously healthy subject should be, to remove what-ever may be considered the exciting cause of the disease, toenjoin, in the first instance, repose and abstinence, and tokeep the patient strictly confined to his bed.With regard to bleeding, I have seen few cases where the

local or general abstraction of blood has been required. Suchcases have occurred in the country in young plethoric persons; inLondon and our larger manufacturing towns such a remedyrequires to be employed with the greatest possible caution,and in the majority of cases will not be required. Wherethere is much headach, great febrile distress, and a hard pulse,a few leeches are often of use. It is good practice, whenthe ease is seen sufficiently early, to unload the stomach by anemetic, and to clear out the alimentary canal. After this, thetartar-emetic should be administered in small doses in a salinedraught, as prescribed for Mr. H——.’* Having done this, itwill be better not to be too anxious about administeringremedies. If the pulse become weaker and more frequent,with tremors, and a dry, dark.brown tongue, five or six grainsof the sesquicarbonate of ammonia must be given in excess,in an effervescing draught, and repeated every four or sixhours, as the symptoms indicate. The bowels must be keptopen, but any powerful purgative will do harm. Two or threegrains of calomel mixed in a little table-salt can be put uponthe tongue at bedtime, and a draught of rhubarb and magnesia,or decoction of aloes and peppermint-water, given the nextmorning. The diet should consist of chicken-broth or beef-tea, and the patient 1.Jay drink freely of soda-water, or soda-water and milk.Every case of erysipelas will require the most anxious care

on the part of the medical attendants; and should, as is oftenthe case, the powers of life appear to wane, wine or brandymust be given early and freely, but cautiously, and the disul-phate of quina should be given also in as large doses as thepatient will bear.As a local application, when called sufficiently early, I re-

commend the nitrate of silver to be fairly and freely used;not only would I apply it to the sound skin on the part beyond Ithe disease, so as to surround it in a black band, but I wouldalso either rub a stick of caustic wetted with water over thcpartalready involved in the disease, or brush it over with a strongsolution of nitrate of silver. When sore throat is complainedof, and the. question ought always to be particularly askedwhen erysipelas of the head and face is present, the whole ofthe back of the throat should be washed over with a solutionof the nitrate of silver; and this must be repeated as often asrequired. -

The skin may be fomented with water as hot as is agreeableto the patient, to which tincture of opium may be added, orsome poppy-heads may be boiled in it; milk-and-water as hot ascan be borne affords considerable relief in many cases; it iswell to add something of this kind to the water, for although iwe gain from the heat and moisture all that can be expected Ifrom the remedy, still a sick patient is apt to think somethingmore than hot water is required in his condition, and he willnot always think it worth while to permit the employment of

* See the former part of this paper, p. 170.

the fomentation for a sufficiently long period, and to be ofuse it should be continued for a considerable time; linen rags,covered with an ointment composed of equal parts of leadointment and spermaceti ointment, and placed upon the in-flamed surface, will prove a soothing and agreeable applicationafter the caustic has been used. When, however, the cellulartissue is becoming distended by serosity, no time should belost in procuring its evacuation by puncture or incision.There are certain seasons when erysipelas appears to depend

on some epidemic influence, when attacks are very numerous,and appear to increase by a sort of atmospheric contagion. Atsuch periods, our hospital surgeons very properly avoid per-forming any operation, if possible, as the slightest injury tothe skin is almost certain to be followed by an attack of ery-sipelas. At such times patients will die under any plan oftreatment we may adopt, but by the early and prompt em-ployment of appropriate remedies many may be saved.

(To be continued.)Sheffield, September, 1849.

An EssayON

GREEK ELEPHANTIASIS,AS OCCURRING IN

TRACADIE AND ITS VICINITIES.

BY ROBERT BAYARD, M.D. (Edin.), D.C.L.,ST. JOHN’S, NEW BRUNSWICK.

FORMERLY PROFESSOR OF OBSTETRICS IN THE MEDICAL INSTITUTION OFNEW YORK; LATELY APPOINTED BY THE COLONIAL GOVERNMENT TOEXAMINE INTO, AND REPORT UPON, THE TRACADIE LEPROSY.

<7<MM of Greek Elephantiasis in the Lazaretto upon SheldrakeIsland, and in Tracadie and its vicinities.

CASE I.-Peter Savoy, aged forty-one, married; has had ele-phantiasis for eight years ; he complained of great weakness andoppression, and pain in the stomach for three or four yearsprior to the appearance of the eruption, which showed itself pri-marily in spots of a dark yellowish colour upon the face and fore-head, accompanied with great depression of physical strengthand spirits. The disease, after its outwardappearance,advancedrapidly, and the skin assumed a dirty-yellow hue throughoutits whole surface. In the course of a few weeks the spots be-came livid, slightly elevated, and oleaginous; but there wasnot any remarkable change of sensibility in these elevations,which were not large, and soon assumed the tuberculous cha-racter. The tubercles appeared first upon the nose and otherparts of the face, and afterwards upon the arms, legs, andbody; the face is slightly puffed, but there are no deep furrowsseparating the tubercles either upon the cheek or forehead.The cheeks are thickened, puffy, and greasy in appearance;the nostrils are swollen, and greatly dilated; the ears arethickened, elongated, puffy, and tuberculous. Some of thetubercles have disappeared without medical treatment, butothers again shortly afterwards succeeded them upon the face.The tubercles continued indolent for several years, after whichulceration commenced. He does not recollect whether ulce-ration was preceded or accompanied by any febrile symptomsor pain when the process commenced. Scabs formed on someof the sores, and others of them healed, but there was not anypain, neither in the scabby tubercle, nor in the cicatrices ofthose which sometimes healed spontaneously. The tuberclesupon the arm appeared first upon the outside of the humeralportion of it. The hands are swollen, discoloured, and tuber-culous ; the palms are puffed out, and the tubercles upon themare fattened. The feet arc swollen, tuberculous, and ulce-rated, and the soles of them resemble the palms of the hands ;the tubercles upon them are smaller than those upon otherparts of the body. The knee has been tuberculous, and severalof the ulcerated spots have healed, leaving a smooth shiningcicatrix, with irregular margins. Ulceration has attacked theends of the toes, and has degenerated into sphacelus; he com-plains of debility in the legs, which he describes as being tooheavy for him. The hair has fallen from his whiskers, eye-brows, breast, and axilla, and from the other parts of the sur-face attacked with tubercles. The inside of the mouth is filledwith tubercles corresponding with the drawings in Rayer’splates; the sublingual veins are enlarged. The trunk of thebody is tuberculous, but the indurations are not elevated. Inmany places, these indurations resemble psoriasis: the voiceis impaired, and conversation is a tiresome exertion to him;the nose discharges a small quantity of an irritating puriform

fluid. He complains of general debility, and of pain in the