No.1355.

AUGUST 18, 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. 88, vol. ii. 1849.)

10 Heec denum sunt quae non subgesset phattasiae ]maginatricis teme-retas, sed phsenomena practice edocuere."—SYDNNHAM.

LEAF THE FIFTH.

2s th Nitrate-of Silver of Advantage as a Local Applicationin Erysipelas ? ?

THE term " erysipelas" has perhaps been applied in a morevague and indefinite manner than any other we employ inthe medical vocabulary. It would be foreign to the objectwith which these papers are written to enter at length intodisputations as to what constitutes the distinction betweenerysipelas and erythema. Dr. Watson has proposed, with aview to the formation of more settled opinions in respect to’erysipelas, that the term should be restricted to " that dis-ease in which the integuments of the face and head becomediffusely inflamed, the term ’ erysipelatous inflammation’ mayproperly enough be applied to other cases similar to this, in sofar as the condition of the skin is concerned; but in what- Ishould consider true erysipelas, in the medical sense of theword, there are other characters belonging to the disorderquite as important as, and more distinctive than, the cuta-neous affection:" Dr. Willow mentions four kinds of erysi-pelas:*—

1. E. P7ùegmonides. 3. E. Gangrenosum.2. E. (JJ]dematodes. 4. E. Erraticum,

each too well known to require notice here. In the firsteditions of Dr. Bateman’s work, erysipelas was classedamongst the "$ullae;" in the last edition it is regarded asone of the exanthematathe editor concluding, that "althoughvesications certainly occur in severe and aggravated- cases,yet in the great majority of cases this symptom is absent;"and unless it be an invariable attendant on the disease thereis more propriety in placing the disease in its present class(Exanthemata) than where it formerly stood in Dr. Bateman’swork.In the first species (phlegmonous erysipelas) the eruption -is

accompanied with great pain and a severe burning-sensation;the tingling-and excessive heat of the part is <:onstantly-com-plained of; the colour is more of a dull, livid scarlet than therosy tint peculiar to the other kinds; the swelling generallyappears on the- second night or third day of the fever; andextends to the cranium from the face; the cutis only isaffected, and in the line of its progress is elevated, and shows-a-well-defined edge, the diseased parts appearing upon thehealthy almost like embossed work."t Vesications, whenthey are present, arise on the fourth or fifth day, and subsideor burst on the sixth; the redness melts into a yellow tint,the fever declines, and the swelling diminishes. Whengangrene takes place there is disorganization of the cellulartissue, which comes away in shreds, bathed in pus; the inte-guments are livid, deprived of their vitality, and if the suffererrecover, an agglutination of muscle, fascia, and skin havingtaken place, the motion of the affected part is more or lessimpeded.

Happily, phlegmonous erysipelas, excepting when the lowerextremities are attacked, very frequently, under appropriatetreatment, terminates in resolution; in the legs and feet thisresult cannot so often be hoped for; suppuration takes place,the cellular tissue in these parts having as great a tendency tosuppurate, or nearly so, as the eyelids and scrotum. This re-sult is always attended with a great deal of mischief; the puscollects, not into one large cavity, but in innumerable small

points, and large portions of the cellular structure come away.Nor is the mischief confined to this part only; the skin becomesaltered in colour, assuming a dark, dingy hue, and perishes, notso much from inflammation as from want of nourishment. Thiswas clearly pointed out by Dupuytren, who observed, that* EpV<T’’1I’e^a, from epvw, 2reas, indicative of its tendency to wander;

according to others, from epc8por, expressive of redness. Celsns speaks ofit as " ignis sacer ;" and Lucretius writes-

Et simul ulcerimus quasi inustis omne rubore,Corpus, ut est, per membra sacer quom diditnr ignis."

t Bateman’s Synopsis, eighth edition, p. 148.l Clin. Chir. t. ii. P. 29.

"mortification of the skin is very common in the leg, wherethe nutrient arteries, being deeply placed, communicate withthe integuments by small branches only, and the destructionof the cellular substance destroys at the same time all theseslender branches."This kind of erysipelas is very common on the face and head,

but here the disease very seldom ends in mortification, whichBateman and Dupuytren both justly ascribe to the distribu-tion of the temporal, frontal, and occipital arteries.In oadematous erysipelas, (which is attended with consider-

able danger when it invades the head-and face, and whichcommonly attacks persons of debilitated and impaired consti-tutions, the inflammation is sub-acute, and the swelling pits asin common osdema. The vesications are small=and numerous,rise on the third or fourth day after the appearance of theswelling, and in two or three days more the parts are coveredwith thin, dark-coloured -seabs. Dr. A. T. Thomson has re-marked, that this species is often accompanied-with an affee-tion of the throat and fauces, evidently erysipelatous: the-symptoms-are, a red blush over the velum palati and uvula;slight tumefaction, and considerable pain on deglutition; aftera few days, excoriation and superficial ulceration sometimesextend to the larynx, affecting speech and respiration, some-times to the pharynx and cesophagus.*Gangrenous erysipelas commences "sometimes," says Dr.

Willan, "like one and sometimes like the other of the fore-going species, and most commonly occurs in the face, neck,or shoulders; it is not improbable that this is only an in-creased degree of the first species. It is accompaniedwith symptoms of low fever, and with delirium, which issoon followed by coma, which remains through the sub-sequent course of the disease; the colour of the affectedpart is dark red; and scattered phlyotense, with a lividbase appear upon the surface, and frequently run into-gangrenous ulcerations. Even when it terminates favourably,suppuration and gangrene of the muscles, tendons, and cel-lular tissue, often take place, producing little caverns andsinuses, which contain an ill-conditioned pus, together with.sloughs of the parts destroyed by mortification, which areevacuated at length from the ulcers; -it is always a slow-andprecarious disease, and irregular in the period of its termina-tion. A peculiar form of gangrenous erysipelas, often fatal,.occasionally occurs in infants a few-days after birth, especiallyin lying-in hospitals, and the noisome, dark, unventilated,badly-drained, and confined dwellings of the poor, in the backcourts of London and our larger towns. Here, too, is the-abode of fever and cholera; indeed, from such localities, howcan fever ever be absent? a In London, and every large city,the chief localities of disease and premature death are thenarrow courts and lanes inhabited by the poor, and themajority of victims are supplied from the working dasses.The districts thus unhealthy are well known to all who havepaid the slightest possible attention. to the subject of. life,health, and disease, as influenced by locality; and to them itis known, as certainly as the large red cross on the door, andover it, " Lord, have mercy upon us," in the days of the plague,denoted that house to be visited by the pestilence, that in alldensely populated neighbourhoods, where the by-lanes areclosed at one end, dirty, narrow, and badly drained-the housesill-constructed, and without the means for ventilation, eleanii-ness, or. decency, there will most assuredly be found those dis-eases which spread from such abodes to the more favouredhabitations of the wealthy. Here, too, are the congenialabodes of drunkenness, idleness, profligacy, crime; here re-cruits are daily trained, not only for the workhouse and thehospital, but for the prison and the gallows-for filth, destitu-tion, and crime herd together-sisters of our neglect, they arenaturally congenial and inseparable companions. It is there--fore manifest that the time must come when a wise govern--ment will feel that it is necessary to consider this question.more seriously than it ever has been regarded yet, for humanityand justice in the safety of the commonwealth, our duty toour neighbour and our God, alike demand that our energiesshould be devoted to the removal of those causes which atpresent so fearfully increase the bills of mortality, and veryseriously affect the health of towns.In these unhealthy districts, not only does this form of the

disease (gangrenous erysipelas) appear a few days after birth,but even at birth vesication and incipient gangrene mayoccasionally be observed. In such young patients the attackgenerally commences at the umbilicus or genitals, and extends* A very interesting paper on this affection of the throat appeared in the

Medico-Chirurgical Transactions of Edinburgh, vol. ii., from the pen ofDr. Stevenson, descriptive of the disease as it appeared at Arbroath.

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upwards or downwards, affecting the parts which it reacheswith a slight puffiness, which feels hard; then the skin be-comes of a dark-red cast, and is covered with vesications; thebase of each vesication becomes gradually more livid; theserun on to sphacelus, and if the child be not quickly destroyed.the parts, particularly the genitals, are most seriously injured.In milder cases, in which the attack is confined to the ex-tremities, suppuration is rapidly established about the jointson the hands or feet. The complaint sometimes continuestwelve or fourteen days, and then terminates favourably.*In the last, or wandering form of erysipelas (erysipelas erra-

ticum.) the disease attacks first one part of the body, and thenanother, and generally a favourable termination may be ex-pected in a week or ten days. After an operation for fistula Iin an6, performed at the Palace, Kensington, on Mr. B-, byMr. Keate, many years ago, I saw this species of erysipelascontinue for more than three weeks. The case terminatedfavourably, and although the disease at ’one time extendedfrom the anus to the neck, covering the whole of the back, theconstitutional symptoms were never at any time severe, withthe exception of two days, in which the bounds of prudence,in both eating and drinking, had been sadly transgressed.This shows how very requisite it is to watch most attentivelythe condition of the internal organs, more particularly if thereversion of the erysipelatous inflammation should be followedby symptoms indicative of visceral disease. Frank- has sup-plied the history of the case of a woman in whom erysipelasmigrated from the face to the feet, thence to the hips, thenback again to the face. After it disappeared from the face,the intestines became affected, "and she was seized with dis-ease, first in the chest, and afterwards in the brain." Accord-ing to Dr. Willan, erratic erysipelas seldom terminates fatally;he " never knew but one fatal case !"A. B-, a labouring man, aged forty-four, after being for

some days overworked, and exposed to wet and cold, wasattacked with febrile symptoms, attended by cough and short-ness of breath.In five days a patch of erysipelas was observed on the left

leg, and another on the left shoulder; similar patches appearedabove or below the knees on the seventh day. On the eighththe eyelids became tumid and red. About this time the otherswelling assumed a livid hue, the febrile symptoms becamemore severe; then deafness and coma came on. On the ninthday, the- tumour of the right eye extended to the temple, uponwhich small phlyctenae soon after formed; the man becamequite insensible on the twelfth day. On the thirteenth, he- died.

In speaking of erysipelas, I have adopted the classificationof Dr. Willan. Mr. Nunneley, in his very clear and excellenttreatise, speaks of-1, the cellulo-cutaneous variety; 2, thecutaneous variety; 3, the cellular variety; 4, the erysipelas ofinfants. The division adopted by Mr. Lawrence is into-1,erythema; 2, simple e e 3, de erysipelas;

4, phlegmonous erysipelas. Burserius founded his division onthe supposed causes of the disease, and divided erysipelas intothree classes-1, primary or idiopathic, (arising spontaneouslyfrom some internal cause;) 2, symptomatic or secondary,(supervening on an active disease, by which its progress isinfluenced;) 3, accidental, when it arises from some externalcause.t

There is yet another division to which our attention mustbe directed, and which is, perhaps, the best. Mr. Donelan-l-has adopted it.

Varieties of Erysipelas.-Section 1: Apyretic erysipelas,simple erysipelatous fever, inflammatory erysipelas, biliouserysipelas, adynamic erysipelas, ataric erysipelas. Section 2:<Edematous erysipelas, phlegmonous erysipelas, traumatic ery-sipelas. Section 3: Erysipelas of the head, erysipelas of theextremities, erysipelas of the trunk. Section 4: Erratic ery-sipelas, periodic erysipelas. Section 5: Infantile erysipelas,senile erysipelas.

Mr. Nunneley remarks,&sect; " So confidently are the most oppo-site remedies enforced, and so contradictory are the resultssaid to follow the application of the same means, in the handsof different persons equally worthy of credit, that the impugnerof medical science may fairly point to this part of our field,and demand if such contradictions are worthy the name of ascience or of trust."

* The works of Dr. Willan, Dr. Thompson, Dr. West. Underwood onthe Diseases of Children, fifth edition, vol. i. p. 31. A paper by Dr. Garthshore,in vol. ii. of the Medical Communications, (art. v., 1790,) and a case relatedby Dr. Broomfield, art. iv. of the same work, will supply a large amount ofuseful and highly important information relating to this form of erysipelas.

t Instit. Prac. Med., t. ii. c. 2, Leipsic, 1798.t Cyclopaedia of Practical Surgery, vol. i., art., Erysipelas.

&sect; On the Nature, Causes, and Treatment of Erysipelas.

The complete antithesis of opinion which exists even tothis day, has led us to extend these observations on the nature,causes, and varieties, of erysipelas previous to the considera-tion of the utility of the nitrate of silver as a local remedy,for we find one class of surgeons considering erysipelas to bepurely inflammatory, and another refusing it any inflammatorynature, &c.With regard to the inflammatory nature of erysipelas,

according to Blandin, it varies with its anatomical nature," cutitis prevailing in spontaneous erysipelas, while in thetraumatic kind, lymphitis is the first and chief element of thedisease," Dr. Ribes considers " erysipelas to be capillaryphlebitis," and Frank, that " the nature of erysipelas wouldseem to partake of inflammation and exanthema." To Dr.Willan we are indebted for first pointing out its dependanceupon the agency of a morbid poison, its analogy with otherdiseases of specific origin, and for establishing its infectiousnature, as demonstrated by inoculation.

If we look at erysipelas solely with reference to its localcharacteristics, we simply recognise the fundamental signs ofinflammation-the inflammatory action being of course modi-fied by the nature of the causes whence it has arisen, and theconstitution of the patient in whom the disease is present. If,however, we look at it, and this is the proper view to be taken,in relation to the entire organism, we find its scope enlarged,and its special genus proclaims itself; " and it would be," saysMr. Donellan, " highly erroneous to see in erysipelas a pure in-flammation-a disease circumscribed in the limits of its topicalmanifestations;" and, as we. observed at the commencement ofthis paper, there are other characteristics belonging to the dis-order quite as important as, and more distinctive than theaffection of the skin.

In simple erysipelas of the head and face, we have,a. Inflammation of the integuments attended by heat, pain,

and redness; or, in other words, by an eruption.b. A disorder affecting more or less the constitution, and

which may be included correctly within that class of exan-thematous diseases, in which we rank continued fever. Theplague, measles, scarlet-fever, and small-pox.

c. It runs under ordinary circumstances nearly the samecourse.

d. It often prevails epidemically.e. It may be communicated from one person to another,

under circumstances favourable for its development.*f. It does not, like small-pox and measles, protect the con-

stitution from its own recurrence; on the contrary, it veryfrequently returns in the same individual.The following case wiil probably best explain the ordinary

symptoms of erysipelas as attacking the face and head:-. CAsE.-Mr. R. H-, aged thirty-two, had been for some

time generally out of health, previously to the month of De-cember, 1848. One day during that month, he went out shoot-ing, and remained out some hours, exposed to a heavy rain andcold. He afterwards walked five miles in his wet clothes, tothe house of a gentleman, where he had promised to meetsome friends at dinner. On the road he felt very unwell, andvomited; he afterwards felt better, and after changing hisclothes, partook of a hearty dinner. Shortly after dinner, heagain felt cold and shivering, and immediately drank a glassof warm brandy-and-water, and went to bed. The next day,he had a somewhat severe attack of English cholera, and forsome weeks afterwards he felt very unwell, drowsy, shivery,feeble, and languid, particularly in an evening, and after the

’ slightest exertion. The bowels were constipated, and therewere evident symptoms of derangement of the alimentarycanal.On the evening of the 23rd, he was seized with distinct

rigors; he put his feet into warm water, took a dose of aperientmedicine, and went to bed.

’ 24th.-This morning, when I saw him, the pulse was 20;he had had two rigors in the night; and the right side of thenose was stiff; and on it, and the cheek next to it, was a slightblush of redness. The tongue was coated, but not dry; the

, urine scanty and high-coloured; and the skin hot and harsh.The bowels are confined. Powdered ipecacuanha, one scruple;

’ tartar-emetic, one grain; water, two ounces. To be made into,

a draught, and taken immediately. The emetic having actedfreely, three hours afterwards, five grains of calomel, mixed

l with a little table salt, were put upon the tongue; and he was

, ordered to take, five hours after the powder, the followingl draught:-Powdered rhubarb, one scruple; carbonate of mag-f nesia, ten grains; spirit of nutmeg, two drachms ; syrup of

A nurse was twice under the care of Dr. Watson, and another patientthree or four times, for attacks of erysipelas.

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.ginger, one drachm; cinnamon water, nine drachms. Mix for.a draught. The diet to consist of a little toast and tea, or- barley-water. There is, however, little inclination to take-food of any kind; the patient lying perfectly still; towardsthe evening there was some slight wandering of the mind;the bowels have been freely opened; pulse 120; urine still

scanty; skin hot, and without moisture. Ordered, emetic-tartar, one grain; nitrate of potash, one drachm; cinnamon-water, eight ounces. Two tablespoonfuls to be taken everysix hours.

25th.-He has had one rigor during the night. He com-plains of sore-throat. Pulse 120. The right side of the face.and nose are described as feeling hot and stiff; they areswelled and hard, and the disease is extending towards theeyelids; the lips are also much enlarged. A stick of nitrateof silver was drawn over each eyelid, and over the right sideof the nose and face, so as to blacken the surface; after which,linen covered with the following ointment was spread uponthe face and forehead. A solution of nitrate of silver (five.grains to the ounce) to be painted over the throat. Orderedof unguentum cetaceum, one part; of unguentum plumbi com-positum, one part. Mix for an ointment, to be applied to theface. To continue the mixture, and to take chicken broththree times during the day. When thirsty, soda water andjmilk.&mdash;Evening: The nitrate of silver appears to have ar-rested the spreading of the erysipelas. The ointment is fre-quently applied, as the patient derives much comfort from it,- and also from fomenting the parts well with milk and wateras warm as is pleasant. As the bowels have not acted to-day,five grains of calomel are to be taken at bed-time, and a.draught of rhubarb and magnesia to-morrow morning.26th.-Much the same.27th.-The erysipelas has extended along the centre of the

nose, between the eyes, and is creeping up towards the head;the right eye is quite closed, the lips are enormously dis--tended. The redness is marked by an irregular, hard, elevatedmargin. Yesterday evening he had a rigor. The bowelslave acted freely; pulse 110; the skin is moist; the urinestill scanty. The throat is still sore. He is perfectly ra-tiona.1, and complains of a good deal of pain in the head, and,general soreness over the whole of the scalp.A stick of nitrate of silver was dipped in distilled water,

and applied slightly over both eyelids, and more freely abovethe red margin of the eruption, over the whole of the fore-head, so as to form a black and vesicated arched border, of aquarter of an inch in width, upon that portion of the skin as ’,yet free from the attack. The whole of the inflamed surface Iwas also rubbed with the caustic. The part where it hadbeen used most freely was very painful, and, to relieve which,a bread and water poultice was applied, after which the oint-ment was continued as before. Five grains of sesquicarbonateof ammonia, in excess, in an effervescing draught, with lemonjuice and water every six hours. Ordered, compound rhu-barb pill, five grains; extract of henbane, five grains. To be-made into two pills, and taken at night. Diet, beef tea, milk,and soda water.28th.-The erysipelas is not extending; in other respects

much the same.29th.-Much better. Pulse 108; skin moist; tongue dry.

The erysipelas has not extended. The countenance is soaltered, that it is difficult to recognise a single feature; almost.every trace of the natural expression being effaced.

30th.-The improvement is more marked to-day; pulse 100,.feeble; there is great prostration of strength; skin moist;urine more copious. The nose is covered with patches of-shrivelled and dead cuticle; the lips are coated with thick <- crusts. The throat is less sore. Ordered, disulphate of quina,one grain; syrup of lemons, one drachm; tincture of orangepeel, one drachm; rose water, ten drachms. Mix for a draught,to be taken three times a-day.-Mercury pill, two grains; ex-tract of henbane, five grains; extract of aloes, one grain and ahalf; powdered ipecacuanha, half a grain. To be made into-two pills, and taken at bed-time. ’

The patient was some weeks before he was quite well, butTio symptoms presented themselves after this date worthy ofrecord. INow in all these cases there is considerable variety in the

symptoms; one patient, as was the case with this gentleman, I,IDay have a severe attack of erysipelas, the head and face ’

being much affected externally, without the brain being af- ’fected at all; another will have much wandering of the mind,IDore particularly in an evening, and during the night, the deli-rium is followed by coma, and death takes place in a very fewdays. In some, too, delirium is caused by the febrile derange-inent of the circulation disturbing the functions of the brain;

in others, the inflammation appears to have extendedfrom the integuments to the brain; after death, serous

fluid is found beneath the arachnoid, and in the ven-

tricles ; the veins of the pia mater are also turbid; some-times no morbid appearances sufficient to account for thesymptoms during life, can be discovered. It has been said,(and when we consider more directly the effect of the nitrateof silver as a local remedy, this point must be considered) thaterysipelas sometimes leaves the skin, and that such an event isfollowed by inflammation of some internal part, more parti-cularly the brain. I never saw a case of this kind, and at onetime the wards of St. George’s Hospital presented a verywide field for inquiry; but although I have never seen thismetastatis, I have seen many cases in which an increase in theseverity of the local symptoms has been attended by severedelirium ending in coma and death, and the examination ofthe body after death, has shown extensive effusion on the brain.In erysipelas, then, we may have death, ’

a. From effusion on the brain-delirium, coma, and death.b. From asthenia. There is no wandering worthy of notice,

no shortness of breath, no coma. But hour after hour thepulse becomes weaker, the legs and feet are cold; there isgradually a failing of the powers of life; the heart ceases topulsate; and the patient dies.

c. The soreness of the throat, was mentioned as present inthe case of Mr. H-; in erysipelas of the head and face, sorethroat is always more or less present, although, perhaps, it isnot complained of, nor mentioned, unless the question be asked.Sometimes death takes place suddenly, and when not at allexpected. A post-mortem examination will frequently bringthe cause of death to light. The sub-mucous tissues of theglottis and epiglottis, are loaded with serum; sometimes withpus, the chink of the larynx is altogether, or in part, closed.The picture presented internally is exactly a copy of what wehave sketched, as seen upon the face, and the enormous swell-ing and puffy distension of the eye-lids, lips, and face, is the re-sult of serous fluid occupying the sub-cutaneous areolar mem-brane. In these patients, where the throat is attacked, deatharises from suffocation; or, as it is termed, death from apncea.

This affection of the throat is a point of considerable import-ance, and one that ought never to be overlooked in a case oferysipelas of the head and face. I have been in the habit, forsome years, of ordering the throat and fauces to be well washedwith a solution of the nitrate of silver, and this should be donear soon as possible. Five to ten grains of the nitrate of silvershould be dissolved in an ounce of distilled water, and the backof the throat well painted over with a brush or sponge dippedinto the solution; this must be repeated as often as required.The patient should be seated on a chair or on the edge of thebed, the head supported by an assistant, and the mouth opened,and every care taken that the whole of the inflamed surface ispainted over with the lotion. I have often used it, and withthe most satisfactory results, and would therefore stronglyrecommend its adoption in that affection of the throat by whicherysipelas of the head and face is so frequently accompanied.

It will be observed that calomel was ordered with a littlecommon salt, and uncombined with any other purgative, forby such combination its useful effects are often obscured orimpaired, the full advantages of the remedy being best ob-tained by the addition of a little salt only; by putting it dryupon the tongue and abstaining for some time from takingwater or other fluids. This is a point of practical importance,and well worthy the attention of the practising physician andsurgeon. It is a well known fact, that the inhabitants ofmaritime localities, and sailors after a long voyage, in whichthey have been deprived of the use of fresh provisions andkept upon salt meat, are more liable than others not so cir-cumstanced to the influence of mercurial preparations, whicharises, in the opinion of Mialhe,* from the bodies of suchpersons containing large quantities of the alkaline chlorides;so that there is more complete conversion of calomel into cor-rosive sublimatet than under the usual state of the body.Children, and patients confined to a milk diet, support large* Trait&eacute; de 1’Art de Formuler, ou Notions de Pharmacologie, appliquee a

de la Medecine. Par la Docteur Mialhe. Paris, 1845.t In the opinion of Dr. Mialhe, all the preparations of mercury used by us

for medicinal purposes, are, with or without the presence of atmosphericair, reacted on by the alkaline chlorides, in solution ; thus giving rise tothe formation of corrosive sublimate, the quantity so produced depending inpart on the quantity of alkaline chloride which may be present, and also onthe kind of mercurial employed. He states that he has found the dento-mercurial compounds, by means of a double decomposition, at once producetheir equivalents of the bichloride of mercury; this is not, however, the casewith the protoxide and protosalts of mercury; these are first formed intoprotochloride of mercury, and then converted, by a subsequent reaction,into the smallest possible quantity of corrosive sublimate. The conclusionsof this physician are in accordance with those of others in active practice,

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doses of calomel because the fluids in their alimentary canalsare destitute of, or contain only very small quantities of thealkaline-chlorides. Patients who have lived some time onbroth or low diet, the fluids of whose bodies are also ex-hausted of chlorides, consequently bear large doses of calomelwithout the system becoming affected.

It -will also be seen, on the perusal of the accompanyingmote,* why the purgative effects of calomel are greater if givendry upon the tongue, with the admixture of a few grains ofcommon salt, for the experiments of Dr. Mialhe have led himto the conclusion, (p. 278,) "that the action of insolubleremedies must be inversely to the quantity of water admi-nistered with them."

It has been proved, by actual chemical experiment, thatthe more a solvent is diluted with water, the less its influ-ence on the substance to be dissolved. For example, if ninegrains of calomel, nine grains of table salt, and the samequantity of muriate of ammonia, are put into seventy dropsof water, they will produce, in twenty-four hours, one-third of3r grain of the bichloride of mercury. Place the same in-’gredients, for the same space of time, in one hundred andforty drops of water, (twice the quantity,) and the result willbe one-quarter of a grain of corrosive sublimate; and if fourtimes the quantity of water be employed, the one-sixth of agrain will only be formed. This proves, if the opinion ofMialhe be correct, that the purgative effects of calomel aremuch lessened by the taking of- a large draught of water im-mediately afterwards-a fact with which I have for -someyears been practically acquainted, although, in common withother physicians, I owe my thanks to Dr. Mialhe for its solu-tion.t It may also be added, that in giving the -bichlorideof mercury, it-is best to order it in solution, with a smallquantity of common- table salt and muriate of ammonia, bywhich it will be kept in a state of solution, and its acting onthe tissues of the alimentary canal thus prevented.t In

speaking of opacities of the cornea, the advantages of givingthe bichloride in solution were fully pointed out, and theliquor hydrargyri bichloridi contains the hydrochlorate ofammonia.+The importance of phlegmonous erysipelas requires that it

should be attentively considered, and that we should makeone or two -additional observations upon it. It is quite im-possible to read, without advantage, the very practical paper,from the pen of Mr. Lawrence, in the .2tfeaHco-C7tM’M?’tcoTransactions,&sect; to which the student is referred.when inflammation seizes upon the areolar tissue, all the

events of inflammation may take place. There is, however, astrong tendency to form circumscribed abscesses, the suppu-rative process being bounded by a wall of lymph which isformed around it, the adhesive inflammation controlling theSuppurative. There is usually great pain, which is muchmore-severe when the swelling of the areolar tissue producestension. This boundary unfortunately is riot always erected,and the diffused and wide-spreading inflammation then b-e-comes a frightful malady; the areolar tissue, by a process ofsloughing and unhealthy suppuration, altogether perishingover a very large space, and the patient dies completely ex-hausted.

that all the mercurial preparations produce the same series of physiologicaleffects, differing only in degree, and depending, as Dr. Mialhe supposes, onthe quantity of the bichloride which results from the employment of thedifferent salts of mercury. It has also been shown by Lassaigne, that thebichloride of mercury forms a compound with albumen, insoluble in water,but soluble in the alkaline chlorides, and Mialhe adds, that this solublecompound, consisting of an alkaline chloride, bichloride of mercury, andalbumen, is formed when either corrosive sublimate or any other mercurialis administered internally; that mercury thus gains access to the circula-tion, and is in this form carried over the body without sustaining anymolecular change.* A writer in the last number of the British and Foreign Medico-Chirar-

gical Review- explains, in a very able and interesting article, 11 own theChemistry of Therapeutics," why the large doses of calomel administeredin Asiatic cholera produce very slight effects; and Mialhe remarks, " Itwill be evident that where by reason of disease the intestinal fluids containJess of the alkaline chlorides than usual, or even when, from a greateramount of fluid matter present, the solution becomes more diluted, thencalomel would not be freely transformed into corrosive sublimate, and itsaction would consequently be below par."-p. 143.

t The day is not, I hope, far distant, when an attempt will be made toteach the student the right use of a few remedies, and their proper mode ofexhibition, rather than to fill his head with a host of names of preparationsof questionable utility. Millon has recently proved that any soluble salinepurgative, given in a large quantity of water, is very rapidly absorbed, andpasses off quickly by the kidneys. It is thus made a diuretic, given in asmall quantity of water, thus forming a solution, the density of which isgreater than that of the blood ; the salt acts as a strong purgative, andhardly a trace of it can be detected in the urine.

t The formula of the London Pharmacopoeia is: Bichloride of mercuryand hydrochlorate of ammonia, of each ten grains; water, twenty ounces.Thus there is half a grain of the bichloride of mercury in an ounce, and theone-sixteenth of a grain in a drachm of the solution.

&sect; Vol. xiv. p. 12.

When the skin is implicated in the inflammatory process,the name of erysipelas phlegmonoides is usually employed, butwhen the skin escapes, diffused inflammation of the cellularmembrane is the term most generally employed.*Speaking of phlegmonous erysipelas, Mr. Lawrence remarks,"That the swollen part at first yields in some slight degree tothe pressure of the finger, but subsequently becomes tense andfirm." Sloughing of the cellular tissue soon comes on, withsymptoms of increased febrile excitement. These dangers arenot denoted by increased swelling, or by "’pointing" at anyparticular part, as- in an ordinary circumscribed abscess; onthe contrary, the parts feel soft, like dough, and I have heardthe disease pronounced " stationary :’ Stationary to an inex-perienced eye it may appear! but to any one who has seenthis disease, as it at one time existed in the wards of St.George’s Hospital, and who has learnt the symptoms whichdenote each phase of it, not from books, but at the bedside ofthe sick, this condition will be considered as fraught with thegreatest danger, and instead of waiting like the inexperiencedfor the arrival of this hoped-for stage of resolution, he will-atonce proceed to direct the making of timely punctures andincisions; if this be not done sufficiently early, what is the re-sult 1the skin," says Dupuytren, "separates from the subjacent

parts, and -breaks, or the phlyctenae give way; a dark-colouredserosity flows out, and white, sometimes black sloughs arevisible under the skin, which extend with rapidity." Onplacing the finger on the limb, the sensation communicated oit has been likened by Mr. Pearson to that which is excitedby a quagmire or morass, and which has also been termedboggy; the peculiar sensation given to the finger is difficult todefine; once felt it will never be forgotten."With regard to the treatment of this form of erysipelas by

incisions, as first recommended by Dr. A. C. Hutchinson, itmay be said, that by a free division of the skin, the disease isprevented from spreading, and a ready exit afforded to theeffusions as soon as formed. By free division of the skin, Imean three or four sufficiently free incisions, the longest notexceeding two - inches, at some distance from -each other.These continue to discharge freely, and this perpetual dio-charge not only immediately takes off the tension, but effec-tually prevents its return. This cannot be the case when anincision is made on one side of the limb only, as recommendedby Mr. Lawrence, nor can those long dashing cuts of thescalpel be repeated; and should the patient recover, we havena right to expect the entire healing of the wound by the firstintention, and-so long a cicatrix will be a perpetual source ofannoyance, and very materially impede the free use of- thelimb.The loss of blood caused by these long incisions is not a,

matter to escape our notice; such incisions have been followedby a loss of blood which has caused the death of the patients,as will be seen by the following cases, related with his usualcandour and truthfulness of description, by Mr.’Lawreiiee.They are copied from his paper in the Medteo-C7tirurgical3’StMtMOKS.

" CASE 27.-He has inflammation of the skin and cellularsubstance of the leg in nearly its whole length and circum-ference. I made an incision through the skin and cellulartissue the whole length of the inflamed part, and about fortyounces of blood nowed from the wound.

" CASE -28.=I saw her about eight o’clock in the evening,and made an incision through the skin and cellular membraneover the middle of the call, extending from the ham to theheel.

" CASE 32.-Mr. Lawrence made two incisions through theskin and cellular membrane of the fore-arm, extending nearlythe length of the limb. Blood flowed from them at first ratherfreely, but not more so than is desirable for procuring relief tothe inflamed and distended parts. The bleeding graduallystopped, and had ceased in about three-quarters of an hour,when the patient fainted; before any means could be adoptedfor his restoration, the patient had died."Mr. Cooper remarks, " whoever looks over the reports of

incisions of immoderate length will find that several patientstreated in this way have gone out of the world in a verysudden manner instead of being saved, sometimes from theshock of an enormous wound on the constitution in its dis-turbed state, sometimes from profuse heemorrhage2lt

It would appear, looking at this mode of treatment, thatsurgeons at times forget that their supposed remedies are in

It is the opinion of Dr. Craigie, that in cases of spreading inflammation,the adipose tissue is the part affected. t P. 508.

173

themselves frightful evils, which may produce the loss of life,and that, therefore, it may sometimes, at least, be better-- to bear the ills we have,Than fly to others that we know not of."

If there be two ways of treating the same affection equallyefficacious, differing in severity only, and not in utility, we in-flict a direct wrong on the patient by selecting the mostsevere. Early and free incisions made upon different parts ofthe surface where- the disease is most active in the casesI -have seen, and in which I have been consulted, havealways effected everything to be hoped for from the practice,and they are, in my opinion, better calculated to arrest theprogress of the disease than one large and dangerously longincision.That a sufficiently large evacuation may be obtained from

several incisions of moderate length I have had abundantproof; and in the notes of a case now before me, in which Iwas consulted (March 28th, 1844,) for an attack of phleg-monous erysipelas attacking the hand and fbrearm, from threeor four incisions, not one of which was longer than- an inchand a half, a very large quantity of blood was lost with con-siderable advantage; and in another case, related by Mr. S.Cooper, in a note to that edition of Dr. Mason Good’s "Prac-tice of Physic,"-of which he was the editor, three pints ofserous fluid flowed from the small punctures made in the partin twenty-four hours. These small incisions answer everyuseful purpose, nor is the practice open to the charge that hasbeen made against it, of doing good by " instalments."From what has already been written, it will at once be seen

by the student, that we have not only to combat varieties oferysipelas, but also that each variety of the disease is charac-terized by different symptoms, at each of its several stages.This being the case, the difference of opinion respecting thentility of the nitrate of silver as a local application, may havearisen from-its having been used at different stages of thecomplaint, by different physicians and surgeons. What maybe of advantage at the commencement of fever, will be, per-haps, the last thing the physician would think of employing,after it has continued many days. So in the treatment oferysipelas, what may be highly proper in one form, and at one i

period of the disease, may be as improper as futile at another;and we are not hastily to conclude this or that to be useless,because its employment is not successful in the first case underour care. It is only by-patient, careful, and repeated observa-tion ; by the exercise of that tact and judgment which canonly be reaped in the wide field of an extensive experience;that the proper remedy for each stage of a disease can beselected and applied; nor is any symptom too trivial to beoverlooked or disregarded, for we all of us require every pos-sible assistance to form a correct diagnosis. Points whichmay be passed over, as of no moment, by one practitioner, willbe eagerly seized upon by another; points too often regardedas of trifling import, by the hasty, careless, and inexperienced,are like the marks in the forest, by which the red-man dis-covers that friends or enemies are on his track, a brokenbranch, a torn leaf, a crushed flower, a flattened blade ofgrass, are signs which would never be read by-an inhabitant-of the plain; but to the cultivated eye of the Indian they areall-important; and, in like manner, in the treatment of dis-ease, symptoms which would be passed over by an ordinaryobserver, to the all-seeing eye of the experienced and intelli-gent practitioner, will afford the greatest possible guide to the-employment of the proper remedies.In the next ",Leaf," the effects of the nitrate of silver, as a

local application in certain forms and stages of erysipelas, sofar as they are known to me, not only in my own practice, butalso in that of many of the leading physicians and surgeons ofthe day, will be given.

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

ESSAYS ON

PETIT’S OPERATION FOR STRANGULATEDHERNIA.

BY HENRY HANCOCK, ESQ., F.R.C.S.,SURGEON TO CHARING-CROSS HOSPITAL.

(Read before the Westminster Medical Society.)

No. ii.I HAVE before observed that Sir A. Cooper was opposed to

Petit’s mode of operation, except in cases of large ruptures; itis true that in such instances he laid considerable stress uponthis method, observing, " feel convinced that- this operation

will be gradually introduced into general practice when it hasbeen fairly tried, and found, if performed early, to be freefrom danger, and attended with no unusual difficulty?’ Butin neither edition of his Surgical Lectures, neither that in THBLANCET of 1823-24, nor that edited by Tyrrell in 1827, does heallude to the division of the stricture without opening the sac,except in large ruptures.* On the contrary, in allusion to-femoral hernia, he says, 11 When the hernia is small, the prac-tice of not opening the sac becomes objectionable, on accountof the risk of gangrene ensuing in the coats of the intestine.The aperture in the femoral rupture is so narrow, that long--continued pressure is more likely to be attended with fatal.consequences to the intestine than in the inguinal species, and).moreover, Key states, notwithstanding it is so strongly recom-mended by the best surgeons during the whole period of my,attendance at the Borough hospitals since the year 1812, the-operation (Petit’s) had never been performed; whilst Southadds, that he has no remembrance of having seen Sir A-Cooper operate without opening the sac, in the many operartions for strangulated rupture which he saw him performduring- the first fourteen years of his professional life.".;My objections to Petit’s operation are, that it is not applica-.

ble to all cases, and that consequently the patient is exposed.to the danger attending error of selection. In performing-operations, it is our duty to select that method which is capa-ble of embracing, as far as may be, all difficulties and modifi-.cations which may be met with during such operation, andwhich it is impossible to ascertain before the operation is Gom-menced ; and moreover we ought to select that mode whichholds out the greatest certainty of effecting that for which it-is undertaken, and of which, in strangulated hernia, we cannever be certain, unless the sac be opened. It is of verygreat importance that we should be able to judge of the con-dition of the contents of the hernial sac; whether the intestinebe healthy, ulcerated, or gangrenous,-whether adh-esions,con-fine it to any part of the sac; the condition and disposition ofthe omentum, the number of protrusions, the condition andarrangement of the sac, whether double, single, or otherwise,and the seat of the stricture, are all matters influencing thesuccess of the operation.

Pelletan has frequently found the testicle engaged in the.ring conjointly with a hernia,&sect; and although Petit denies thepossibility of such an occurrence, still, in congenital inguinalhernia we can readily understand that such instances may be.met with. Neubeaur dissected a hernial sac, the inferior por-tion of which adhered strongly to the tunica vaginalis testis.1IZimmerman was the subject of such a complication. Meckel,who describes the case.ff says that the omentum which formedthe hernia was adherent to the testicle by means of a singleband, and free in the rest of its extent.La Moirier relates a case which he opened, thinking it was

hydrocele; he discovered it to be hernia, filled with hydatids,which he cut off, and the patient entirely recovered.** Reichelgives the account of a boy who had swelling in the right groin,about the size of a pigeon’s egg, with severe pain coming onafter a sudden attack of convulsions. As there was no testiclein the scrotum on that side, no constipation, no tension of ab-domen, and the pain subsided, nothing was done beyond a dose,of medicine. The patient, however, died. Post-mortem exa-mination: The intestines were covered with gangrenouspatches; a portion of ileum was fixed in the groin with thetesticle, and was constricted and gaogrenous.Ledran mentions an instance where a portion of omentum

adhered to the surface of the sac of a crural hernia, so as toform a bag within a bag, and producing such a narrowing ofthe neck, that the intestine could not be returned withoutopening the sac and dividing the omentum.

Parrish also relates a similar case.&sect;&sect; Richter pointed outthat the omentum sometimes formed a complete bag, includinga portion of intestine;1I11 and Mr. Key has published two some-what similar instances In 1844, Mr. Hewett*** read a paperat the Medico-Chirurgical Society, containing the account offour cases of these omental sacs. In one, the intestine wasfirmly united to the neck of the omental sac, in the threeothers the intestine was free from adhesions; he says, "Theneck of the omental sac may become the sole cause of strangil-lation. Of this, Case 3 is a well marked example. In this,

* South, Chelius, vol. ii. p. 44 t On Hernia. t Op cit.&sect; Clinique Chirurgicale, vol. iii.

H Philosophical Transactions, vol. Ivii.! ( De Morbo Hernioso-Coiaouito.’ ** Academic de Chir., vol. viii., p.451.

tt Ludwig Adversario Med. Practica, vol. iii. p. 731.** Obs. on Surgery, translated by J. S., p. 190.

Parrish on Hernia. ))![ Traitd des Hernies, p. 133.Practical Obs. pp. 211-214. *** Med-Chir. Transactions, vol. 27.