IDIOPATHIC ERYSIPELAS.

69

fitted, the above described ulcer, being occasioned by the instrument. Thus the post-mortem appearances well corresponded with the symptoms induced, showing that an aneurism had formed at the arch of the aorta; that its internal eoat had given way, but that haernorrhage had been stopped for a time by deposition of coagulable lymph, probably formed during asphyxia; subsequently the sac had been opened by ulceration, commencing within the trachea ; that the pressure of the aneurism upon the windpipe, above the bronchi, had produced the suffocation which was relieved, and the life preserved weeks after apparent death, by the tube keeping the weight of the aneurism from collapsing the trachea ; that the irritation of the ulcers, and the presence of the tube, induced the vast secretion from the lining membrane. That the dysphagia experienced a day or two before death was induced by the blush of inflammation in the oesophagus, and had he livecl longer the tube probably would have passed through the side of the trachea into the oesophagus, and been lost in the stomach. The coagulum being detached by the cough, seemed to have admitted the blood contained in the aneurism and heart into the lungs, which suffocated him. It is next to certain that the several coagula seen floating after death, were lamina that had been deposited one after another to seal up that first described orifice, that would otherwise have bled the patient to death at a much earlier period, viz., at the first asphyxia.

structure, they come off from the aneurismal sac, provided

opening between the left ventricle and the sac be large enough to admit of the usual supply of blood, and so long as the semilunar valves perform their office. It proves that ulceration, opening into the aneurismal sac, the

does at times commence in the trachea. This case also shows the superior comfort with which an elastic gum tube can be worn in the trachea, compared with the metallic one sold for this purpose ; and that cases may occur in which the tube commonly made for tracheotomy must be useless, being far too short to keep the pressure of aneurism, abscess, or other tumour, from suffocating the patient, even after tracheotomy has been ably performed. And it points out, as the pressure of the end of the tube (when long used) produces ulceration, that the length of the tube should be varied every second or third day, so as to avoid constant on one spot, which would render its presence almost liarmless in that respect. I feel no apology needful for publishing this case, as I believe it to be, of its kind, unique ; and as it especially proves that this operation would, more frequently than imagined, restore life after dark blood had traversed the brain, and even when the spark of life had for some time appeared to be extinct. A very pretty preparation of the parts is in my possession, and may be seen by any member of our college who takes an interest in such cases.

practically

pressure

IDIOPATHIC ERYSIPELAS.

By

A. Larynr, Trachea, 0eM:Mg’, and 7’tibe. B. Alleurismal Sac:: 1. Innominata and carotid. 2. Second sac. 3. Arch of aorta, going out of the great aneurism. 4. Left carotid. 6. Left subclavian. 6. Aorta and valves ; passage to left ventricle.

C. Heart : 7. The ventricle. 8. The auricle. .11.. Silk threads suspending the

preparation.

Several instructive and curious hints are furnished by this case. It shows that an aneurism close to the heart does not necessarily occasion intermission of the pulse in the innominata, radials, or carotid, even if, from altered

JOHN

CHIPPENDALE, Esq., Surgeon, London.

THOUGH inclined to concur in much that has been advanced by Dr. Wilson, in his paper on the above subject, inserted in the last number of your Journal, I shall be glad to be allowed to make a few remarks thereon. I confess I was at first surprised to find Dr. Wilson inculcate the infrequency of the occurrence of this disease, which, although I felt willing to admit, as far as relates to private practice, I could by no means allow to be accurate in respect to hospital and dispensary patients ; but when I came to reflect that St. George’s Hospital is situated in the midst of open spaces and well-ventilated streets, and that even such patients as inhabit the purlieus of Westminster are exposed to no contaminated atmosphere, I readily perceived how it is that I, at the Farringdon Dispensary, which is placed in a crowded neighbourhood, with an atmosphere contaminated by almost every imaginable cause of vitiation, find the disease one of constant occurrence. Indeed, I think I may safely say that, during upwards of the last seven years, I have not passed a month without having under my care two or three cases of idiopathic erysipelas. Imay, with tolerable confidence, assert that this disease cannot be considered contagious, for I have never found a case liable to the suspicion- of having been so contracted, although the patients are, for the most part, in I may also rooms inhabited by many other individuals. mention that 1 never had a case which terminated fatally. The fever has, as Dr. Wilson justly remarks, always a tendency towards the typhoid type, and therefore, in my opinion, justifies the administration of cin-chona in a mild form, if not as a remedy, at any rate as a prophylactic, on the principle that prevention is better than cure. I have found the best treatment to consist in a good purge of calomel and aloes, in the first instance, and then in the administration, at intervals offour or five hours, of a mixture of from one to two ounces of infusion of senna, and six or seven ounces of decoction of Peruvian bark ; and under this plan the patients have recovered much more speedily than by any other which I have tried, the attack extending in such cases to four or five days at the furthest; while in those who have been treated otherwise, the course has been from eight to twelve days. I have not found any preparation of quinine nearly so efficacious as the bark in the above form. Porter or wine I believe to be absolutely pernicious. As a local application, I always employ cloths dipped in saturnine wash, and although I have read a gre at deal about such means acting as a repellent which

70 determines the disease to the cerebral meninges, I have found this to be true, but that the only effect which the patient has experienced from it has been a great addition to his comfort. In regard to applications of nitrate of silver, all I can say is, that I think such practice totally inert in arresting the progress of the disease, cruel in the extreme, and therefore highly to be reprobated. There are some arguments in Dr. Wilson’s paper which are directed to show that idiopathic erysipelas should rather be considered as coming within the domain of the physician than in the province of the surgeon, but they appear to me rather specious than convincing ; for if the presence of fever, or the real or supposed presence of a morbific poison in the blood, is to determine the claim of the physician, why, then, the formation of a whitlow, or any other abscess, or the accession of secondary syphilis, or, indeed, the presence of any surgical disease, properly so called, should be ravished from the surgeon and be adjudged to the physician. For my part I think the treatment of this disease so simple that either a physician, a surgeon, or any one, may be intrusted with it, and that the only use of a medical practitioner at all, in such cases, is to guard against the supervention of accidents. I do not see the use of altering either the name or the place in the classification of this disease, but if it must be placed in another category is not erysipelasfever an improper term ? Two substantives cannot come together without the second being placed in the genitive, therefore the qualification of the fever must be an adjective, and should be erysipelous or never

’

A long splint (on a plane anterior to the thorax) "is applied, having one extremity in juxta-position with the internal condyle of the humerus, and the other is

tion.

twirled round the palmar surface of the hand. In performing this evolution the radius is rotated on the ulna inwards, and made to cross that bone at an acute angle,.

thus destroying the interosseous space, and tending to produce permanent contraction, which renders the individual incapable of supinating the hand when the fracture is united, and thus materially interferes with its utility. Surely it might occur to a "member," that the action of the pronator quadratus would, in itself, be sufficient to produce, this malposition, without his aiding and assisting in the distortion. Notwithstanding, I find one of the 11 fellows" belonging to Bartholomew’s Hospital open to this imputation, in the case of Catherine Pretty, 27, Apollo-buildings, so far as the putting up of the fracture (?) was concerned, and my note of interrogation means nothing more or less than that when the limb was examined next day by a mere member there was no fracture at all. Having seen many instances of deformed and comparatively useless extremities, from the foregoing treatment, I am induced, in the present case, to obtrude myself on your notice; nor would I believe, if I had not witnessed it, that such gross ignorance, or grosser negligence, could exist in these days of charter notoriety. I usually, having first made extension sufficient to bring the fractured portions in situ, apply two splints, one anteriorly, the other posteriorly, to the fore-arm, so that when the arm is flexed both splints are on a plane with the horizon, and having supinated the hand as much as erysipelatous. Great Queen-street, Lincoln’s-inn-fields, possible, direct my patient to keep it in that position ; March 25, 1844. thus I rotate outwards, not inwards, and the consequence is a straight arm and useful hand. Permit me, Mr. Editor (though foreign to this subject, THE " BEST REMEDIES" FOR NEURALGIA. yet of equal interest to the community), to inquire whether it accords with the spirit, or even letter To the Editor of THE LANCET. order" issued by the poorthe of of SiR,-In your report proceedings the Medical of the 11 general medical commissioners, that the midwifery of the parish Society of London, contained in the last number of THE law should be given at 5s per case to antiquated nurses, LANCET, Mr. Pilcher is stated to have observed, that who are just as well acquainted with the anatomy of the " in neuralgia of the face, morphia and quinine, and of the breast, belladonna and liquor (?) cii-ichonoe, were the pelvis, or the process of parturition, as they are with the squaring of the circle. I am the more inclined to seek best remedies. this information, as a circular from Somerset-house was I for one should feel extremely indebted to Mr. Pilcher, addressed to the different medical officers of unions, on or any one else, if he could, by promulgating a " great 8th instant, in which the attendance of " unqualified fact," render the treatment of these most unmanageable the disorders a matter of comparative certainty, as it would assistants" is objected to, though the latter are generally be instrumental in removing a weight from the mind, and medical students of some years standing. Without enumerating cases in which death might an opprobrium from the practice, of many a hesitating and timid practitioner. But I am sorry to be compelled occur whilst a surgeon is, being sent for to repair the to protest against the validity of the assertion, if by the damage of the midwife, I can assure you the instances in this parish, of prolapsus uteri, which I term best Mr. Pilcher expresses an unqualified affirmative are numerous, in some measure, to the practice of " walking attribute, that cases of and intends to convey genuine about" in the room proposition, immediately previous to delivery, unsophisticated tic have been, or indeed can be, curecl by when the uterus, by its gravitation, has a tendency to these methods. The indiscriminate employment of tonics and narcotics protrude, the neighbouring parts being in a dilatable in neuralgia I hold to be the crying sin of this generation; state, and the muscular contractions not being sufficiently to expel the burden of the womb. and if Mr. Pilcher had seen, as I have seen, in numerous advanced This and other improprieties, which parish midwives inwretched for lifemiserable objects—rendered instances, variably encourage, might be adduced, but your time is on whom this " best of treatment" pushed to its utmost too precious for such details. Craving your notice in I full and had its effects, never-failing limits, produced these instances, for the honour of surgery, and the ina little less sanbeen really do think that he would have terests of the nnnr. I remain vour ohHe’ed Kervantguine in recommending it for universal adoption. I am, M. K. O’SHEA, M.R.C.S. Sir. vollr most obedient servant.

Parliament-street, Whitehall,

R. H. ALLNATT, M.D. March 25, 1844.

ON THE TREATMENT OF FRACTURES THE RADIUS. To the Editor

OF

Lambeth, Feb. 17, 1844.

FOREIGN DEPARTMENT. ACADEMIE DE MEDECINE,

PARIS.

of THE LANCET. FIBROUS TUMOURS OF THE MAMMAE. SIR,—The superior excellency of surgery, as practised of AT the beginning of last January M. Cruveilhier, the by the " fellows" our college, induces me to address a few observations to you on what may be deemed a simple well-known anatomist and pathologist, read before the subject, yet one of vast interest to the labouring class, academy a memoir on Fibrous Tumours of the Mammæ. and on which depends their capability of following their The statements which it contained were so contrary to usual employment ; I allude to fractures of the radius. the current opinions of the day that they roused into It is to the mode of « putting up" those fractures, as vehement opposition nearly all the surgical members of adopted in our metropolitan hospitals, and by the sur- the above institution. We have hitherto refrained from geons educated therein, that I would direct your atten- giving an account of M. Cruveilhier’s communication, as