TREATMENT OF ULCERS OF THE LOWER EXTREMITY.

124 be classed with be intermittents, and that the group proceed to investigate, in a more scientific spirit, its true symptoms usually called cholera doreally constitute the nature, in the trust that it is better to have a principle which cold stage of an intermittent,-no doubt an intermittent connects some of its phenomena, than to be continually specificcharacter of its own, but having, at the same groping in the dark. Leith, 1848. time, much in common with other intermittents. Indeed,no

ought to of

having a of seeing intermittents, whocountry, hasinhadthebutopportunity be struck with the remarkable even in this of the diseases. The an

one

must

two physiognomy symptoms preceding an attack of cholera.—viz., the debility, tremors, general uneasiness, and epigastric

DESCRIPTION OF AN

similarity

oppres-

such as usher in the cold stage of an intermittent; and though the subsequent symptoms are not in all respects similar, yet we have in both the determination of the fluids to the interior, causing coldness and lividness of surface, shrunk features, and great prostration; followed, in the one instance, by shivering; in the other, by cramps. The purging and vomiting, which are the result of this determination of fluids to the interior, though not frequent symptoms in the early stage of intermittents, are sometimes, however, observed; while in some of the severer forms of cholera, they are either absent or very limited in amount. But it is not my intention to maintain that there is an absolute identity between cholera and any particular form of intermittent, but that there is such an affinity as to justify this classification, and to point to a The origin, progress, and more rational mode of treatment. present habitudes of this disease, will also tend to confirm this view of its nature. Its first appearance amidst the marshy plains of Bengal; its favourite haunts along the beds of rivers; and its selection of our damp and filthy closes and alleys-which may be regarded as the swamps of our towns, as the principal scene of its ravages,-here cholera will meet with forces acting in the same direction as itself. The malaria of these places, though insufficient of itself to produce the disease, becomes a powerful auxiliary to the cholerific virus; it is of a similar nature, and readily associates with it in action. This view may tend to dissipate, in some respects, the great obscurity which hangs over the question of contagion. It is well known that intermittents, in certain circumstances, become contagious, and no doubt cholera was so originally, but the cholerific virus, ere reaching this country, has become so weak and attenuated, as to be incapable, of itself, of producing the disease, except in circumstances of peculiar concentration ; otherwise it would extend, irrespective of place or person. It is only when it meets with agents which cooperate with it, as in our filthy alleys and swampy places, that it becomes developed, and even then principally in persons of intemperate habits, who are also the chief victims of intermittents in warm countries. It should likewise be remarked, that a lengthened exposure to the miasm is required before the disease can manifest itself. This explains why so few medical men become affected, whose visits are of so short duration; while friends and attendants, who remain longer, are frequently attacked. The only cases where its contagious nature was distinctly exhibited, occurred in individuals who had washed the clothes of cholera patients. Three well-marked instances of this came under my observation, all of whom had cholera in its most virulent form, and died within a few hours. Here the clothes must have imbibed and accumulated the virus direct from the body of the patient, and communicated it, in its most concentrated state, to these persons. Assuming these views to be correct, the course of treatment becomes obvious. Our whole efforts should be directed to push the disease into its sweating stage, and if called at an early period of the disease, ere collapse shall have occurred, little difficulty will be experienced in arriving at this desirable result. The vomiting and purging-which are the result of internal congestion, and will cease as soon as the skin is stimulated to action-ought in a great measure to be overlooked, and the most powerful sudorifics employed. Those that were found most useful I have already stated, in the earlier part of this communication. The difference of treatment in men and women, however singular, is founded on actual observation. Should cramps be present, anti-spasmodics, such as ether and chloroform, may be used to relieve these, but ought not to be relied on as a means of curing the disease. There is no safety until a warm, copious perspiration shall be produced, and maintained until every vestige of purging and vomiting have ceased. When collapse shall have taken place, this course of treatment becomes less applicable, and recourse must be had to the most powerful stimulants. In such cases, consecutive fever usually follows, and must be treated upon general principles. It is now time that medical men should abandon the em. pirical treatment they have hitherto pursued in cholera, and

sion,

IRREGULAR DISTRIBUTION OF THE VEINS OF THE NECK. BY HOLMES COOTE, ESQ., F.R.C.S. THE following account of an irregularity in the distribution

sudden

are

of the vessels of the neck-of importance with reference to the application of a ligature around the subclavian artery, in that part of its course between the outer border of the sternomastoid muscle, and the lower border of the first rib,-may be of sufficient interest to merit a place in your journal:A well-made, muscular subject, about six feet high, a negro, was received for dissection in the Medical School of St. Bartholomew’s Hospital, the last week of December, 1848. The chest was remarkably broad, and the clavicles curved prominently forwards. Upon the reflection of the integuments and the platysma myoides from the right side of the neck, a large vein, an inch and a quarter in diameter, was seen lying immediately to the outer border of the sternomastoid muscle. It received the external and the internal jugular veins, the supra and the posterior scapular veins, and a considerable trunk, which, given off from the cephalic vein, passed over the clavicle, to terminate in this large reservoir. The reflection of the sterno-mastoid muscle brought into view the internal jugular vein, which inclined obliquely outwards, to open into the reservoir in front of the omo-hyoid muscle. The carotid artery and the vagus nerve pursued their usual course, but they were unaccompanied by any vein; the nerve lay external to the artery. The other vessels of the neck presented no irregularity worthy of notice. The distance between the outer border of the sterno-mastoid muscle and the margin of the trapezius measured two inches and a quarter, the clavicles being long. Of this, one inch and a quarter was occupied by the large vein; the remaining inch by the supra-scapular vein and artery, the posterior-scapular vein, the large trunk from the cephalic vein, and the chords forming the axillary plexus of nerves. It appears to me that, in a neck so constituted, it would be impossible to cut down, with safety to the patient, upon the subclavian artery, as it emerges from between the scaleni muscles. If the irregularity were not observed before the commencement of the operation, the first incision would most probably lay open the large venous trunk, and cause death by the admission of air into the circulation. The application of a ligature to veins of such size would be inadmissible. Southampton-street, Jan. 1849. ’

I

TREATMENT

OF ULCERS OF EXTREMITY.

THE

LOWER

To the Editor of THE LANCET. SIR,—The admission to the pages of your widely-circulating journal of the accompanying brief remarks upon a notice, in the recent number of the British and Foreign Medico-Chirurgical Review, of an essay by me on the Treatment of Ulcers on the Leg, without Confinement, by Bandaging and WaterDressing," will much oblige, your obedient servant, HENRY T. CHAPMAN, F.R.C.S. &C. I

’

,

’,

The chief practical object of the publication in question is the advocacy of the treatment, not alone of indolent ulcers but of those intractable cases, confirmed irritable ulcers, by a modification of water-dressing and bandaging, in following which I have met with a greater degree of success than under any other method of treating them. Applied to the simply indolent ulcer, or to ulcers but slightly irritable, this proceeding differs from the mode of water-dressing employed with the bandage, by many surgeons, ’ in such cases, in the following particular:-After dressing the sore with a compress of wet lint, before the bandage is put on, I encircle the part of the limb on which the ulcer is ’ situated with from three to six, or more, moistened strips of linen or calico, of the same length and breadth as the straps employed by Baynton, drawn tightly, and crossed in precisely the same manner as the adhesive plaster. These wet strips adhere to the skin as closely and smoothly as the strapping; ’

127 a thin subject. The operation offered no difficulwhatever, but immediately the vessel was secured, the Hancock had stated. patient was seized with a constant and continued short cough, Mr. B. Coopurt, who had only heard a part of Mr. Hancock’s which went on until he died. On examination, the phrenic paper read, proceeded to make some observations, under nerve was found to be uninjured, but highly inflamed, as was its neurilemma. He said that unsuccessful cases were often an erroneous impression as to the meaning of the author. He more instructive than successful ones. was afterwards set right by the president as to what the paper Mr. HANCOCK took the liberty of observing that the case really intended to convey. In consequence of Mr. Cooper’s mistake, the observations did not apply, and we therefore see just related was an additional argument in favour of the position he had assumed, inasmuch as in his operation the no object in recording the greater portion of his observations. We may, however, remark, that Mr. Cooper animadverted in phrenic nerve would have been out of the way. (Laughter.) rather strong terms upon the paper, supposing that Mr. Hancock had confounded traumatic aneurism of the axilla with <-B orr SCARL 4TINAI. * AND$SHORT ’ simple wound of that vessel, and said that any surgeon would OBSERVATIONS THE SCARLATINAL TO THAT AFFECTIO1V. WITHat once cut down upon the wounded vessel, and not thinkof M.D., securing the subclavian in cases of simple wound. In aneurism, Physician to the Western General DIspensary. he said that no surgeon would resort to the difficult proceeding The writer prefaces his paper by a table, comprising 219 of tying the axillary below the clavicle, when the much more easy operation of tying the subclavian external to the scalenus cases of scarlatina observed during the summer of 1848. In. could be resorted to; for the former was not only a more fifty-nine cases the scarlatina was followed by renal anasarca, diffi-cult operation, but, in his opinion, offered no advantages while in ten cases, the latter affection occurred, unpreceded with regard to the collateral circulation, in respect to the by any of the ordinary outward signs of scarlatina, the cases of renal anasarca making- altogether somewhat more than onethyroid axis, nor as to the successful issue of the case. Mr. HANCOCK had not formed his opinion solely on his own third of the whole. Giving a brief sketch of the prominent experience, but on a number of cases collected from the features of the renal anasarca following scarlatina, as it ordivarious European journals and works on the subject. These narily occurs, and noticing the importance of cedema of the statistics were embodied in the paper. He was surprised at face as a characteristic symptom, he divides the disease into the remark of Mr. Phillips respecting the opinions of Mr. four species, according to the intensity of the general sympHodgson and other surgeons in regard to the operation in toms, the absence or presence of dropsy, &c., and points to the question. He (Mr. Hancock) had no recollection of any such relation observed to subsist between albuminuria and anasarca statement in the works of these authors. Facts proved the -namely, that the degree or intensity of the one is, as a inaccuracy of Mr. Cooper’s assertion respecting the relative general rule, in an inverse proportion to that of the other. advantages of the two modes of proceeding, for in four cases The question whether renal dropsy succeeding scarlatina. of aneurism of the axillary, the result of injury in which that should be considered a sequela or not, is then taken up. In vessel itself was ligatured, they all recovered; whereas, in accordance with the laws of the operation of the scarlatinal eighteen cases of a similar disease, from the same cause, in poison in the human economy, the notion of the kidney being involved among its primary actions, although usually second which the subclavian was tied, ten died, and eight recovered. Mr. B. COOPER questioned the validity of the statistics just or third in the order of structures affected, is considered, and alluded to, and conjectured that in the cases in which the sub- an attempt made to strengthen the supposition, by a detail of clavian had been secured, it must have been in consequence eight cases in which there was direet exposure to the scarlaof secondary hsemorrhage, for no one would surely resort to tinal miasm, but which were wholly unpreceded by eruption, throat affection, &c., a such an operation for simple wound in the axilla. rigor alone ushering it in with slight Mr. HANCOCK had expressly, as the paper showed, excluded and short preliminary fever. Such cases the author distinall cases of mere wound of the artery, and had strictly con- guishes by the name of scarlatinal renum; and he includes fined himself to cases of aneurism. The cases enumerated in also under that appellation, the cases in which the kidney exthe paper were under three heads : First, those in which the hibits an equally intense morbid action, but in which the skin subclavian artery was tied for idiopathic axillary aneurism; has previously been affected in a minor degree. He further secondly, those in which the subclavian artery was tied for supports his position by the known epidemic character of the traumatic axillary aneurism; and thirdly, those in which the complication, and its occurring in families and groups of chilaxillary itself was tied for traumatic aneurism of that vessel. dren, in accordance with the unknown law which stamps each Of the first, there were twenty cases-ten recovered, ten died; epidemic with its special character from the commencement. of the second, eighteen cases-eight recovered, and ten died; The present epidemic is noticed as one essentially of a renal of the last, there were four cases, all of which recovered. character, and the fact is remarked on, that former epidemics With respect to Mr. Cooper’s observations regarding the thy- have been distinguished by the same feature, while others roid axis, it might be merely observed that the branches of have been characterized by the partial, if not nearly complete, absence of renal symptoms. The conclusion of the paper is this axis had no influence on either operation. Mr. ERICHSEN had paid some attention to the subject under occupied by a few cases of inflammation of serous membranes discussion, and the result of his inquiries had been the forma- subsequent to, if not consequent upon, the renal disorder of tion of the very opposite opinion to that promulgated by Mr. scarlatina. Such inflammations, described as among the Hancock. He might say that he agreed with the author in secondary and tertiary direct effects of the morbid poison by his definition of aneurism, and excluded all cases which did most writers, are here viewed as more properly falling under not come under that category. Now in eight cases in which the head of sequelae, being indeed the proper sequelae of the the subclavian had been tied above the clavicle for traumatic affection in question. Dr. WEBSTER said, that as upwards of 3550 persons had died axillary aneurism, seven had recovered; and four or five cases tied below the clavicle, all had recovered. He said it was of scarlatina in London alone, since the 1st of July last, consenecessary in these inquiries to distinguish between spontaneous quently, according to the ratio of deaths reported by the and circumscribed false aneurism, as in the first the mortality author, of one in seven, about 25,000 cases of this disease was greater in an equal number of cases when the subclavian must have occurred in the metropolis, being the greatest epiwas tied. In the operation recommended by the author, it demic of the kind which had been known for many years; must not be forgotten that you run the risk of cutting off and the epidemic scarlatina, at Florence, spoken of by altogether the collateral circulation of the arm, and the pro. Bunerius, occurred in 1717, upwards of 140 years age. bable consequence would be, gangrene of the extremity-a Dr. SNOW said, he was of opinion that the kidneys were liable consequence which was not unusual. As to the relative diffi- to be affected as well as the skin, tonsils, or mucous membrane culties of the two operations, there could be no comparison in the first days of an attack of scarlet fever. In two or three between those of the former and those of the latter. cases where children died during the eruption, he had found Mr. HANCOCK denied the validity of Mr. Erichsen’s statis- the lining membrane of the pelvis of the kidney red and intics, and said that, as he had before remarked, he had drawnjected,and believed that the inflammation extended to the lining his conclusions from a much larger number of cases. With of the tubuli uriniferi. He considered that this first affecregard to the mortification, Mr. Erichsen had proved how tion of the kidney, either by causing a desquamation of the futile was such an objection, for in his own four cases they all epithelial scales, analogous to the shedding of the cuticle, or in some other way, led to secondary congestive disease of the recovered. Mr. B. COOPER would mention a case embodying a point of kidney, which was the immediate cause of the anasarca, ininterest, not that it bore strictly on the paper, but because no flammation of the serous membranes, and other results. In

recommending any novel mode of proceeding. The operation on the axilla was the rule, and not the exception, as Mr.

lenus in ties

-

NOTICEON THE SEQUELae PROPER TOJADIES MILLER,

CASES ILLUSTRATIVE orGeneral Dispensary. wnn

writer

detail.

surgery had alluded to the accident he was about to He had secured the subclavian external to the sea-

on

those

cases

related in the paper in which the albuminuria and supposed to be the first and only effects of the

anasarca were

128 scarlatinal poison, he (Dr. Snow) considered that there must have been a mild attack of the fever some three weeks previously, which had been overlooked by the parents of the children, an occurrence he had known to happen amongst dispensary patients. Dr. M:LLER replied that he had had no opportunity of examining the kidneys during the eruptive stage of the fever. When death took place at a later period, after dropsy had existed, there was no redness of the pelvis of the kidney, but great congestion of the cortical substance, as shown by the mottled condition of the exterior of the organ. Dr. WEBSTER said that the author of the paper had confined himself to the pathology of the disease. At the present time, he thought it would have been desirable to have spoken of the treatment employed. Dr. BASHAM was glad that the author of the paper had confined himself to the pathology of the disease, as he regarded it of the utmost importance at the present time. Every one must have been struck with the peculiar tendency of the late epidemic to be attended with dropsy. This sequence was so common, that he had thought it had occurred even more frequently than the author had stated. He considered that the dropsy depended on the effect of the poison of the disease itself on the kidneys. He related a case in which albumen appeared in the urine two or three days after the eruption of scarlet fever had disappeared. Dr. STEWART thought that the dropsy must depend on some Cause independent of the poison of the disease, or we should not have it more frequently in one epidemic of this complaint than another. The next meeting of the Society will be held on Tuesday, February 13th. ’

THE MEDICAL DIRECTORY FOR 1849. To the Editor of TuE LANCET. cannot but be matter of as much satisfaction tc SIR,-It every qualified practitioner, as it is of chagrin and vexation tc the unqualified, that the great desideratum of an authentic record of every medical man’s professional status is now furnished both to the profession and the public, in a form sc felicitous as that of the London and Provincial Medical Directory. The feature, however, which renders any work of this description valuable to the community at large, is precisely that which, without sufficient care, is calculated to injure individuals ; I allude to its presumed accuracy. Two months previous to the appearance of the present volume,I delivered to the publisher, in plain handwriting, an exact statement oj my qualifications, requesting, at the same time, a copy of the forthcoming book. To those who know the difference between a British and Foreign degree, it will not be surprising that J should feel somewhat annoyed at finding myself registered af a graduate of a German university, instead of that of Glasgow and when it is remembered that some extra-British degreef are to be had by forwarding a mere remittance of money without either residence or examination, I may justly complain that the present publication is not very flattering to myself I might not, perhaps, have been induced to make any unfavour able remark on a work which, on the whole, is so highly useful had the misrepresenfation been confined to my own case, but the appearance of other still more flagrant errors, convinces me that the care which is necessary to render this Directorz really efficient, has not been observed in compiling the volumE for 1849. As my object is not to depreciate the work ir question, but, on the contrary, to promote its utility, I woulc conclude these observations by suggesting, that injuture every member of the profession should receive by post a printed proq; of his commureicatioaz, which he might return approved or cor rected, as required. Such a method of revision could not fai to be attended with the best results.

1’o the L’ctitor

0/ THE LANCET.

the pages of THE LANCET are always open to the of the profession, permit me to lay before you a brief illustration of the nature of the material composing the Medical Directory for 1849, for which I had been induced ta subscribe. I simply give the result of a sparehalf-hour last

Sm,-As grievances

night. Page 1, Hastings, John, Phys. Why not M.D.? or else, why not other M.D.s designated as Pliys.-Page 2, Culverwell, Robert James, same remark; Quin, ditto; Gibbs, ditto; and so through the street-list. Let them be uniformly one way or another. I would suggest that Phys. should in future be appended to all fellows and licentiates of the College of Physicians, and to none others. In page 4, Guy and Goodfellow; in page 5, Hodgkin and Storrer; in page 6,A. S. Taylor; in page 8, Meryonand Packman; in page 9, Adey, (misspelt Adye,) Farre, Cape, and Woodfall; in page 10, Oldham; in page 12, Brewer and Barnes; in page 15, Winslow and Boisragon, Curie, Furnivall, and Downing; in page 23, Freund and John Forbes; in page 24, W. Jones; in page 26, Darling; in page 27, Kirkes, (misspelt ;) in page 28, Hurnby; in page 30, McWilliam ; in page 31, Day and Malan; and in page 33, Addison-are all physicians without that fact being indicated. I may further add, that in this street-list, in page 15, Southey is misprinted South, and Chambers is put in twice; and in page 11, Peacock, instead of being in Finsbury-circus, is put, on the Pavement. In p. 34, in the too late list, for Hairland read Haviland. I add a few miscellaneous criticisms. to know the origin of the errors.

It will be

interesting

Addison, W., 78, Wimpole-street. Did not join the College of Physicians in 1825, but in 1848, being the last licentiate but one on the list. Alexander, James, 12, North Audley-st. It should be added} that he is surgeon to the Western Ophthalmic Institution. Barnett, S. B., 17, Dorset-place. What is F.R.C. Physic and Surgery, Jamaica ? Bennett, James Risdon, 24, Finsbury-place, Fellow of the College of Physicians by election. How else are fellows made z Brown, W. H., 1, Hinde-street, Manchester-square, is not Mem. Roy. Coll. Phys., 1844." Chisholm, A. Bain. Is he M.D. of London ! Edinburgh!!t and Paris ! ! ! Clayton, Oscar, is Serj. (Sergeant ?) of Police. Cockle, James, 18, Ormond-street. No reference to the discovery of the pills. Is " matriculated at the University of Edin.," a title assumed by the eminent Dr. La’Mert, a thing to be inserted ? Collier, Charles. Is he F.R.S ? Edwards, Samuel, 7, Upper George-street. No qualification Andrew’s, and keeps an open surgery. Ellis, George Viner. If he joined the college in 1840, was he elected to the fellowship in 1843 ? We thought the junior but M.D. St.

fellow had been four years a member. Flood, Valentine, dead these two years. Gairdner, William, 12, Bolton-street, is not fellow of the College of Physicians, but a licentiate. Jones, H. Dence, ought to be put down as fellow of the College of Physicians. Also Blackall, Thomas. Rowe, George Robert, 33, Cavendish-square. Is not, as is asserted, a licentiate (but merely an extra-licentiate) of the College of Physicians. His name has been long down as intending to go up for the licence, but he has not appeared. Silver, Ebenezer Dwid, 12A, Margaret-street, is not M.D.

King’s College, Aberdeen, 1843. Simpson, William, High-street, Bloomsbury. Matriculated in Trin. Coll. Dublin, 1826. What then ? Smith, Thomas Southwood. A fellow, not a simple member, of the College of Physicians. Smyth, George, 43, Sackville-street, is not, as is stated, Lic. Col. Phys. Roy. T am qir- vnur obedient servant. Seth, isfull physician to the Middlesex Hospital. Thompson, THOMAS LIGHTFOOT. Keppel-street, Russell-square, Jan. 1849. Truman, Alatthew, lecturer on anatamy-where ? Tuson, Edward Wm., 15, Harley-street, surgeon to the *** This letter is written in a very candid spirit, and the Middlesex Hospital. Very much the reverse. suggestion which Mr. Lightfoot has made, is one of real pracR. H., Putney, is "lecturer on the nutritive Whiteman, tical value. The plan which he has suggested for the adop- functions of the human Is this an accredited body, &c." tion of the editor, is annually pursued by the proprietors of honorary title ? that admirable work, the Post-office Directory. By merely Williams, C. J. B., Holles-street. Has omitted to mention well-known letter on the cause of the death of Liston. spoiling two Directories, the use of a little paste, and a hisWitt, Charles, 30, Spring-gardens, is recorded as a member the in last year’s entry each case might be very little trouble, of the Royal College of Physicians, 1841. His name is not on forwarded in the annual circular. Such a proceeding would the College List. have the effect of increasing, to a vast extent, the accuracy Wray, Septimus. Is lie a member of the Royal College of and utility of the work.-ED. L. I-AX. Physicians, 1815 ?