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ON ERYSIPELAS, WITH CURSORY REMARKS ON ITS TREATMENT.
292 in the form of ointment,* smeared on a of the size of the urethra, and introduced for about three inches up its length, and there retained for about three minutes. After its application, immersion of the penis in warm water has been recommended, and I believe very
advocated-namely, bougie,
’
affected, the disease, however, subsiding in the parts first attacked. The forehead was much swollen, tense, and of a dusky-red; the pulse still 120, but decidedly weaker. He
wandered considerably, but still replied to questions with tolerable accuracy, though rambling off again immediately. properly. During the night he had been violently delirious; had got out I do not wish it to be imagined that I am empiric enough to of bed in spite of his attendants; and was with difficulty say this means of treatment can never fail; it does sometimes, restrained. His forehead was punctured by Mr. Solly in even when we expect it most to succeed; but as in by far several places with the point of a lancet, and a large breadA few drops of blood only the greater amount of cases, it has been found successful, and-water poultice applied. I think it well worthy the attention and practice of sur- exuded. He was ordered to have two ounces of port wine geons. every two hours, and to continue his mixture as before. This was at mid-day. About midnight we found him slightly imSt. Michael’s-terrace, Bristol, Aug. 1846. proved, quiet, rational, and his pulse, if anything, stronger and less frequent. The wine and bark had been given regularly, and he had taken considerable quantities of jelly and ON ERYSIPELAS, WITH CURSORY REMARKS strong beef-tea. ON ITS TREATMENT. On the ensuing day, (Friday, Feb. 6th,) at half-past four o’clock P.M., we found him again very decidedly changed, for By WILLIAM MUNK, M.D., the worse. The erysipelatous inflammation had not extended, MEMBER OF THE ROYAL COLLEGE OF PHYSICIANS; PHYSICIAN TO THE but his tongue had become dry, dark-brown, and fissured ; his TOWER HAMLETS DISPENSARY, ETC. OF the important and extensive class of zymotic diseases, pulse 130, and much weaker: the whole surface was below the there is probably none which presents more points of interest natural temperature, and the extremities were decidedly cold. and importance than erysipelas. Occurring alike in medical He laid in a heavy, semi-comatose condition, and was altogether and surgical practice, it constitutes an arena within which all incapable of replying to our inquiries. His breathing was difficult and infrequent. Two ounces of port wine may enter-a neutral ground, in which, without encroachment becoming ordered every hour. and to each dose of the mixture, on the proper and peculiar province of one another, the were which was now to be given at intervals of two hours, there was physician and the surgeon may alike exerthimself.t It is no part of my intention on the present occasion to go added, one drachm of the compound spirit of sulphuric ether. into the literary history of erysipelas, neither do I purpose A turpentine enema was also employed, at the suggestion of patient’s friend, Mr. Bristowe, of Camberwell, who, writing a compendious essay on the disease. My object is our much more humble, though, in its tendency, perhaps more throughout, watched the case with much anxiety, and favoured utilitarian. It is of a character strictly practical, for I merely us with his assistance and advice during the most alarming wish to illustrate the varied conditions of the general system stages of the disease. At six o’clock P.M., our patient was seen which may accompany the disease, and show how striking by his neighbour, Mr. Henry, of the Commercial-road. He The pulse had risen to 150 or upwas then sinking rapidly. are the modifications of treatment which are thus required. This I shall proceed to do by the narration of three cases. i wards, and had become weak and thready; the respirations In the first, depression was the main characteristic, and life ’ took place at longer intervals, and were more laborious; his legs were icy cold. Mr. Henry poured a full glass of brandy was again and again periled by symptoms of sinking. Stimulants were here indicated, and they were administered to an ex- down the throat, and repeated it at intervals of half an hour tent of which neither reading nor prior experience furnishes me or an hour; beef-tea and jelly were also given freely. By these: with a parallel instance. The second case is one where power means the symptoms of sinking were for the time arrested. and excitement of the vascular system were the prominent At half-past ten o’clock P.M., I found him perfectly rational, his tongue moist, and the dark-brown coating gone; the pulse symptoms, where stimuli were contra-indicated, and where reduced in frequency, from 150 to 112 or 118, and having, in bloodletting and other antiphlogistic remedies were freely and successfully employed. The third case is of a totally great measure, recovered its strength and volume; his breathdifferent character from the second, but presenting some ing was now natural and easy, and the body and extremities. warm. The brandy was ordered to be continued every general resemblance with the first. Here, however, excite- were ment of the nervous system interfered with the normal pro- hour. Feb. Mh.—Our patient went on well during the early portion gress of the disease, and the patient was, I believe, saved by of the night, but at four o’clock A.M., symptoms of sinking the free administration of laudanum. On Monday, Jan. 26th, 1846, a medical man, aged twenty- again appeared; his pulse became rapid and weak; the surface and the respirations laboured. Drachm-doses of sulphuric five, had a small encysted tumour dissected out from behind cold, the angle of the lower jaw. The operation was performed by ether were now given with the brandy, and under their joint Alr. Solly. Little blood was lost, and notwithstanding that influence he again rallied. Since this, he has been progressthe attachments of the cyst were much deeper than was anti- ing favourably. His pulse is now (ten o’clock P.M.) under 100; skin warm and moist; tongue clean and moist. He is now percipated, the operation was completed in one and a half or two minutes. The patient went on satisfactorily for some days; fectly rational, and has slept quietly and comfortably at but on Saturday, Jan. 31st, he felt unwell, and erysipelas intervals; the inflammation has not extended, and desquamathe bowels have not been relieved since attacked the wound, which, at that time, however, had nearly tion has commenced; last evening; but he feels an inclination to go to stool. He and The extended somewhat over healed. redness swelling this time continued, and is still to continue, the the cheek, and along the neck, and an incision was made has, up to beef-tea, &c., at short intervals. brandy, Port of the swollen decoction wine, bark, parts. through 8th.-IVToon: the swelling of the face has now much dimiand small quantities of infusion of senna, were given at innished, and desquamation is taking place over the whole of tervals. I saw the case, in consultation with Mr. Solly, on Tuesday, the affected parts; pulse below ninety, with more power, but and with a long intermission from time to time. This Feb. 3rd. The inflammation had then extended over the unequal, intermission, however, is less marked at the heart than in the whole of one side of the face, and the right eye was completely closed. The affected parts were of a dusky-red hue; the radial artery; tongue moist; feet comfortably warm: owing to the diminution of the he can now open both eyes; he pulse 120; the bowels purged; and there was some griping. has passed one healthyswelling evacuation. About four o’clock this The patient was manifestly anxious about himself, and symptoms of sinking again returned; he breathed wandered slightly at times, although answering every question morning, with much effort, and the feet and legs became cold, a state with perfect accuracy. He was ordered eight ounces of port which however, disappeared under the freer use of wine, and seven drachms of decoction of bark; one drachm of stimuli.shortly, He was now ordered to take the brandy in smaller the compound tincture of bark, and four grains of the sesquiquantities, and to have two grains of quinine in decoction of carbonate of ammonia, every four hours. bark every four hours. The following day (Wednesday, Feb. 4th) he appeared On Monday, Feb. 9th, I found him in every respect* immuch the same; the erysipelas, however, extending, now improved ; lie was quite collected and comfortable ; had slept plicated the forehead, though not encroaching upon the hairy well during the night; his pulse had more power, and was scalp. under ninety in the minute; the skin was warm and moist. On Thursday, Feb. 5th, he was, in every respect, decidedly Convalescence was from this period steadily progressive. S-,Ipworse; the left side of the face and ear had now become puration of both eyelids took place, and the pus was evacuated * Nitrate of by the lancet. He left town on the 26th of February, and. silver, one drachm; lard, one ounce. Mix. returned about the end of March perfectly well. t Read before the South London Medical Sociey, 3pril 2nd, 1846. -
293 Here is an instance of erysipelas treated by what some extension of the disease, the colour and pungent heat of the would perhaps characterize as an undue and lavish adminis- affected parts, seemed to me clearly to indicate the necessity tration of stimulants; but I feel fully convinced (and I believe of active depletory measures. I therefore ordered a vein to the conviction is equally strong in the minds of those who be opened, and twelve ounces of blood abstracted. This was watched the case,) that nothing short of the quantities given slightly buffed, but not cupped. He was ordered to take would have been competent to bring about a favourable issue. a quarter of a grain of tartar emetic every three hours, and to I am no advocate for large doses of medicines in ordinary repeat the purgativepills at night, and the purgative draught the ensuing morning. For some hours after the venesection, cases. On the contrary, I am inclined to believe that the tendency of medical opinion and practice is, at the present the patient felt much relieved; the pain and heat of the head time, in favour of larger doses than the absolute require- were much diminished; he was less restless, and got about ments of disease render necessary; and I am quite sure that half an hour’s quiet sleep. Towards evening, however, the benefit would accrue to the patient, in most cases, by a dimi- febrile symptoms increased, the pain, heat, and throbbing of nution in this respect. It must, however, be remembered, the head returned, and shortly after midnight he became dethat cases do every now and then occur of such extreme se- lirious. At two o’clock the following day, 28th,) I found verity as to render ordinary plans of treatment inefficient. In the head more swollen than at my former visit; the pulse 96, these we must step out of the beaten track, and administer and harder; tongue white; much thirst, and the skin hot. He was again bled, and upon this occasion to sixteen ounces. our remedies to an amount which, in more ordinary cases, would be injurious and culpable. The case above related is The blood was now both cupped and buffed. He experienced I know of no instance of erysipelas in which so almost immediate relief; the pulse dropped to 90, and in great one in point. large a quantity of stimulants has been necessary; and I cer- measure lost its hardness. He was to continue the mixture tainly have never met with one in which their effects were so of tartar emetic with a drachm of sulphate of magnesia in each dose. strikingly and unequivocally beneficial. On Thursday, Feb. 5th, about mid-day, the freer use of wine On the next day (Nov. 29th), the swelling of the head was was commenced. He took two ounces every two hours, and notably diminished; the affected parts were not so hot, and continued it till half-past four P.lII. of the following day. In their colour was less vivid. Pulse 88; less thirst; the tongue the four-and-twenty hours he had thus taken twenty-four continued white and furred; but the heat of surface had ounces of wine, besides jelly, beef-tea, and the bark-and-amdiminished. monia mixture. At half-past four o’clock, when Mr. Solly, 30th.—In every respect improved; the swelling has diMr. Bristowe, Mr. Henry, and I saw him, he was sinking, minished, and desquamation commenced; pulse 88; tongue and now two ounces of wine were given every hour, and a less coated; heat of surface not above the natural standard. drachm of Hoffman’s anodyne every alternate hour. Even He had slept for some hours during the night. He was now this quantity did not suffice, and at six o’clock Mr. Henry, ordered a drachm of sulphate of magnesia, with three drachms with a promptitude and decision to which our patient, I be- of liquor ammonia acetatis, in camphor mixture, twice or lieve, owes his life, commenced the administration of brandy. three times during the day. From this time he went on graA wine-glassfull was given every hour, and continued in the dually improving. same quantity, and at similar intervals, till Feb. 8th, at noon. December 2nd.-He had an ounce and a half of decoction During this period of forty-two hours, he took, at the very of bark, with ten minims of dilute sulphuric acid; and by the lowest computation, upwards of sixty ounces of brandy. Not- llth of December my attendance was no longer necessary. withstanding the quantity administered, neither the patient’s pulse nor his nervous system were at any time unduly excited.I A man, aged twenty-eight, came under my care as a patient On the contrary, the larger the quantity of brandy given, the ’, of the Farringdon Dispensary, in Jan. 1838. He had been ill stronger but less frequent became the pulse, the stupor was and confined to bed for three or four days, and during that diminished, and the delirious wandering quieted. The tongue time had been attended by a surgeon in the neighbourhood. likewise became clean and moist. The latter circumstance He had erysipelas of the left eyelid, which had from thence was strikingly illustrated on Friday, Feb. 6th. At half-past extended across the face and over the forehead and scalp. four o’clock, the tongue was dry, dark-brown, and fissured; at These parts were of a deep red, without much increase of six o’clock he appeared to be dying, and now commenced the heat, and with no very large amount of swelling. His tongue administration of brandy. A wine-glassfull was given at in- was moist, but covered with a yellowish-brown coating; his tervals of less than an hour. At ten o’clock, the tongue had pulse 118. He had been taking ammonia out of some bitter become moist, and the dark-brown coating was gone. infusion, and was now to have ammonia in decoction of bark. The next day (Jan. 7th), I could perceive but little alteration A gentleman, aged thirty-two, of full habit of body, residing in his symptoms; his pulse was, perhaps, weaker, and the on the borders of Epping Forest, was, in the month of Notongue more coated; but the appearance of the erysipelatous vember, 1842, riding, after midnight, a distance of five or six parts remained the same. He was ordered to take four miles, on the outside of a carriage. The night was cold, wet, ounces of gin, in divided doses, within the twenty-four hours, and tempestuous, and he was insufficiently clothed. Ere and to continue the mixture as before. 9th.-The back part of the neck had now become affected, reaching home, he felt shivered, but this passed off under the genial influence of a warm room, a large fire, and a tumbler the face and head remaining as before. There was no dimiof strong whisky-and-water. He retired to rest and soon nution of the swelling, and no appearance of desquamation; fell asleep, but in less than two hours was awakened by a his pulse was 124, and weaker; the tongue covered with a sharp rigor. This, after continuing for some time, gradually thick, moist, yellowish coating; there was slight floccitation, gave way to heat of skin, thirst, and throbbing pain in the and some involuntary catching of the muscles. The quantity head. He took a strong dose of aperient medicine, which of gin was doubled. 10th.-The head and face remained the same, but the inoperated freely, and during the following day restricted himself to slops. The next night he slept comfortably, and awoke flammation was creeping gradually down the back. The pulse apparently well ; but in the middle of the day was again at- was weaker and more frequent; he was delirious, and the tacked with rigors. These lasted until evening, when re- character of the wandering was that of delirium tremens. action took place. He became hot, restless, and feverish, and There was likewise considerable tremor of the extremities; experienced a good deal of heat and pain about the head. I his tongue was moist and coated, and his skin was clammy saw him in the evening of the following day, Nov. 26th ; his and perspiring. These symptoms led me to more minute inface was then somewhat swollen, hot, and painful; the skin of quiries as to his past habits and mode of life, and to further a dark red, and the eyes injected; his tongue was white; there questions as to sleep; but from his wife, who alone was in atwas much tliirst, and his pulse was 92, full, but not hard. He tendance upon him, and who was far advanced towards inwas ordered five grains of calomel, and eight of compound toxication, I could get no information of a connected chaextract of colocynth, immediately, and a dose of senna and racter-none of a kind upon which any reliance might be salts four hours afterwards. A drachm of sulphate of mag- placed. Taking all the circumstances of the case into consinesia, with twenty minims of antimonial wine, was then to be deration, and inferring (perhaps unjustly), from the present condition of his wife, what had been his own habits during given every four hours. 27th.-The whole head had now become greatly swollen,with health, I thought the case one that might be benefited by a deep red and pungent heat; the tongue white and furred; opium, and therefore ordered him twenty minims of laudanum pulse 92, full and hard. He had some thirst; but his chief immediately, and other twenty minims in four hours, if the complaint was of severe throbbing pain in the head, and of a first dose failed to produce sleep. The following day, (Jan. llth,) I could perceive no change feeling of tightness and pricking pain of the scalp. His bowels: the better. The laudanum had been twice administered, had been freely purged. The hardness of the pulse at this period, and the degree of pyrexia, together with the rapidI but it had failed to produce sleep. The delirium was greater,
(Nov.
’ for l ,
294 the tremors increased, and his skin, though warm, was sodden, has abundantly shown that it is analogous to, if not identical and perspiring profusely. I therefore ordered forty minims with, that in delirium tremens. The symptoms are similarof laudanum immediately, and a further dose of twenty the treatment identical. Of this, the third case is an exminims every two hours, until sleep was induced. The first ample. dose sufficed to produce the desired effect: he slept for six or Finsbury-place South, Aug. 1846. eight hours, and awoke quiet, collected, and refreshed. I saw him again on the morning of Jan. 12th. The inflamREMARKS ON mation had not extended; the swelling had diminished, and on OF THE BOARD CONSTITUTION was the THE PRESENT the delirium apparent cheeks; desquamation was gone, and the tremor of the extremities diminished; his OF COMMISSIONERS IN LUNACY, tongue was dry and brown. He was to take twenry minims And the inconsistency and probably mischievous effects of electing of laudanum every night, and to continue the 0gin and the to such offices who have had no practical knowledge of persons tonic mixture as before. the treatment of the Insane, and are consequently ignorant of It is unnecessary to adduce the further daily reports of this the actual management of Lunatic Asylums. case. Suffice it to say, that the man ultimately, though slowly, recovered. For two or three days more, the above-mentioned BY WILLIAM SMITH, ESQ. treatment was continued; and subsequently, he was put upon FORMERLY HOUSE-SURGEON TO THE LINCOLN LUNATIC ASYLUM, AND MEMBER OF THE ASSOCIATION OF MEDICAL OFFICERS OF HOSPITALS quinine and infusion of roses. FOR THE INSANE. The three cases above narrated are not adduced as examples ON reference to THE LANCET for 184G, vol. i. fol. 134,I find of erysipelas, such as is ordinarily presented to our notice. My object in selecting these from many others has been to show the following remarks, (probably extracted from a recent how varied are the phases under which any one disease may work by Forbes Winslow, M.D.)—" Now, there are for the present itself to our notice, and how widely different is the I administration of the law of lunacy twomasters in lunacy, treatment which such varieties require. In this, there is no i (barristers,) five honorary commissioners, (non-medical,) three novelty either of statement or of fact. It is a circumstance ’, paid commissioners, (barristers,) and three paid commiswhich we are one and all ready to admit; but it is; at the sioners, (physicians, or surgeons,) the whole of the appointments being vested in the Lord Chancellor-thirteen appointsame time, one which can never be too strongly or too prominently impressed upon us. I believe that long-continued prac- ments in a medical department, only three of which are tice tends strongly towards routine methods of treatment. This medical!" Now, let us just ask a few plain matter-of-fact is a remark I have heard made by one of the most esteemed questions relative to these same commissioners. How long and cautious practitioners of the present day; and I firmly have they been in existence ? What salutary reforms have believe, that if each of us would be but strictly honest to him- they brought about in the management of asylums, public and self, the sentiment would find an echo and a confirmation in private ? With the exception of one meagre report addressed his own breast. Now, it seems to me, that nothing is more to the Lord Chancellor, what have they done towards calculated to counteract this tendency than to dwell promi- ameliorating the condition of the insane? Does not that very nently on the different forms which any one disease may report (by pointing out numerous and very glaring abuses) assume. The three cases just related are illustrative of this virtually prove their own previous neglect of supervision and fact. incompetency? Have not all the principal improvements, Erysipelas, as it occurs in London, requires, in the immense and especially the abolition of the mischievous practice of inmajority of instances, a treatment by tonics and stimulants. strumental restraint, been brought about by the force of This I imagine to be the general experience of the profession public opinion, (the pressure from without,) and the free disat the present day in this metropolis; and of such instances, cussion of the insane practice by the medical press, and esthe case I have first narrated may be taken as an extreme pecially by that independent periodical, THE LANCET ? How are these precious appointments conducted? example. By the Lord But it would seem that, some years since, the type of the Chancellor, forsooth! What opportunities can he have of disease in London was different-that it was then more inflam- judging of their qualifications? What has Dr. John Bright matory - that bloodletting was in many instances advan- or Dr. Hume ever done towards advancing the science of metageously employed--and although bark and quinine were not dicine ?1 How did the former gentleman perform his duties unfrequently administered, that wine and spirits were, in the whilst (nominally) senior physician to the Westminster Hosmajority of cases, inadmissible. Cases of this kind do even pital ? What says THE LANCET of 1843, vol. ii. fol. 553, on this now occasionally, though rarely, present themselves to our subject?We believe we are correct in saying, that during notice: of this, the second case I have adduced is an illustra- the very many years that Dr. Bright was physician to the tion. That the inflammatory character, as marked by active hospital, he never on any one occasion gave a clinical lecture! pyrexia and strong arterial action, still pertains to erysipelas, His visits wereso few and far between,’ that many of the as the general rule in some parts of the country, I am fully perpetual pupils did not even know the person of their convinced. I have, within the last three or four years, had respected teacher." Then again, with reference to Dr. occasional opportunities of seeing cases of this kind in dif- Hume, what was he other than a sinecurist? Out upon such ferent parts of Devonshire; and I do not remember a single appointments as these! Dr. Prichard, we believe, has favoured exception to the statement, that they were marked by strong us with a compilation. But what is his practical knowledge of arterial action, and had been indubitably benefited by vene- insanity compared with such men as Dr. Conolly, of Hanwell, section. The third case I have brought forward to show the (whose lectures form a new era in the treatment of the insane;) influence of a deranged condition of the nervous system in Mr. Gaskell, of Lancaster; Dr. Hitch, of Glo’ster; Dr. Powell, of interfering with the usual course of the disease. It seldom Nottingham; Dr. Corsellis, of Wakefield, and a host of others? happens that erysipelas, fever, or any other of the zymotic Why, even our very learned friend, Mr. P. G. Hill, of Lincoln, diseases, run through their entire course, especially if severe, the supposed author of the " Lecture on the Management of without the occurrence of some symptoms directly referable Lunatic Asylums," could give them some valuable information. to the brain and nervous system. In some, such symptoms We might well take a lesson or two from our French neighbours evidently have their origin in an excited action of the vessels on these points. Let us have the concours, and then adieu to of the brain; in others,-and these are by far the more the antiquated noodles and fawning sycophants, who disnumerous,-they seem to be part and parcel of the generally grace our public institutions, and literally fatten on the spoils depressed and typhoid condition of the patient. In such of our medical charities. As a proof of the pernicious effects cases, the cerebral affection is the more or less direct conse- of unbounded funds, and the exclusion of that wholesome corquence of these conditions-it preserves a due proportion to rector of abuse-public opinion, look at the doings in the them-requires no special treatment-but is best met by those Royal Hospital of Bethlehem, olim Bedlam, that huge mass of remedies which in the one instance allay inordinate vascular wealth, indolence, and exclusiveness! How often have they action, and in the other stimulate the depressed and failing refused their printed reports and other such matters to instipowers of life. But there is another class of cases, in which tutions of a similar character? Have they not refused the the disturbance of the brain observes no proportion to, but liberty of inspection to individuals who were or had been runs very far ahead of, all the other symptoms. Here, there officially connected with other asylums?? Here we have a may be no inordinate excitement of the cerebral circulation, noble institution, situated in the metropolis, endowed with and no urgent typhoid symptoms. The cerebral symptoms ample funds, and capable of being rendered a fertile source of would seem, in such cases, to depend on some peculiar condi- improvement-in fact, an invaluable clinical school for the tion of the brain itself, and to be an accidental concomitant rising generation of medical practitioners; and yet what do rather than an essential accompaniment of the disease. What we see? Why, marry, we see it humbled into the second may be the precise condition we know not; but experience rank, giving place to a pauper asylum-the Hanwell Asylum, --
advocated-namely, bougie,
’
affected, the disease, however, subsiding in the parts first attacked. The forehead was much swollen, tense, and of a dusky-red; the pulse still 120, but decidedly weaker. He
wandered considerably, but still replied to questions with tolerable accuracy, though rambling off again immediately. properly. During the night he had been violently delirious; had got out I do not wish it to be imagined that I am empiric enough to of bed in spite of his attendants; and was with difficulty say this means of treatment can never fail; it does sometimes, restrained. His forehead was punctured by Mr. Solly in even when we expect it most to succeed; but as in by far several places with the point of a lancet, and a large breadA few drops of blood only the greater amount of cases, it has been found successful, and-water poultice applied. I think it well worthy the attention and practice of sur- exuded. He was ordered to have two ounces of port wine geons. every two hours, and to continue his mixture as before. This was at mid-day. About midnight we found him slightly imSt. Michael’s-terrace, Bristol, Aug. 1846. proved, quiet, rational, and his pulse, if anything, stronger and less frequent. The wine and bark had been given regularly, and he had taken considerable quantities of jelly and ON ERYSIPELAS, WITH CURSORY REMARKS strong beef-tea. ON ITS TREATMENT. On the ensuing day, (Friday, Feb. 6th,) at half-past four o’clock P.M., we found him again very decidedly changed, for By WILLIAM MUNK, M.D., the worse. The erysipelatous inflammation had not extended, MEMBER OF THE ROYAL COLLEGE OF PHYSICIANS; PHYSICIAN TO THE but his tongue had become dry, dark-brown, and fissured ; his TOWER HAMLETS DISPENSARY, ETC. OF the important and extensive class of zymotic diseases, pulse 130, and much weaker: the whole surface was below the there is probably none which presents more points of interest natural temperature, and the extremities were decidedly cold. and importance than erysipelas. Occurring alike in medical He laid in a heavy, semi-comatose condition, and was altogether and surgical practice, it constitutes an arena within which all incapable of replying to our inquiries. His breathing was difficult and infrequent. Two ounces of port wine may enter-a neutral ground, in which, without encroachment becoming ordered every hour. and to each dose of the mixture, on the proper and peculiar province of one another, the were which was now to be given at intervals of two hours, there was physician and the surgeon may alike exerthimself.t It is no part of my intention on the present occasion to go added, one drachm of the compound spirit of sulphuric ether. into the literary history of erysipelas, neither do I purpose A turpentine enema was also employed, at the suggestion of patient’s friend, Mr. Bristowe, of Camberwell, who, writing a compendious essay on the disease. My object is our much more humble, though, in its tendency, perhaps more throughout, watched the case with much anxiety, and favoured utilitarian. It is of a character strictly practical, for I merely us with his assistance and advice during the most alarming wish to illustrate the varied conditions of the general system stages of the disease. At six o’clock P.M., our patient was seen which may accompany the disease, and show how striking by his neighbour, Mr. Henry, of the Commercial-road. He The pulse had risen to 150 or upwas then sinking rapidly. are the modifications of treatment which are thus required. This I shall proceed to do by the narration of three cases. i wards, and had become weak and thready; the respirations In the first, depression was the main characteristic, and life ’ took place at longer intervals, and were more laborious; his legs were icy cold. Mr. Henry poured a full glass of brandy was again and again periled by symptoms of sinking. Stimulants were here indicated, and they were administered to an ex- down the throat, and repeated it at intervals of half an hour tent of which neither reading nor prior experience furnishes me or an hour; beef-tea and jelly were also given freely. By these: with a parallel instance. The second case is one where power means the symptoms of sinking were for the time arrested. and excitement of the vascular system were the prominent At half-past ten o’clock P.M., I found him perfectly rational, his tongue moist, and the dark-brown coating gone; the pulse symptoms, where stimuli were contra-indicated, and where reduced in frequency, from 150 to 112 or 118, and having, in bloodletting and other antiphlogistic remedies were freely and successfully employed. The third case is of a totally great measure, recovered its strength and volume; his breathdifferent character from the second, but presenting some ing was now natural and easy, and the body and extremities. warm. The brandy was ordered to be continued every general resemblance with the first. Here, however, excite- were ment of the nervous system interfered with the normal pro- hour. Feb. Mh.—Our patient went on well during the early portion gress of the disease, and the patient was, I believe, saved by of the night, but at four o’clock A.M., symptoms of sinking the free administration of laudanum. On Monday, Jan. 26th, 1846, a medical man, aged twenty- again appeared; his pulse became rapid and weak; the surface and the respirations laboured. Drachm-doses of sulphuric five, had a small encysted tumour dissected out from behind cold, the angle of the lower jaw. The operation was performed by ether were now given with the brandy, and under their joint Alr. Solly. Little blood was lost, and notwithstanding that influence he again rallied. Since this, he has been progressthe attachments of the cyst were much deeper than was anti- ing favourably. His pulse is now (ten o’clock P.M.) under 100; skin warm and moist; tongue clean and moist. He is now percipated, the operation was completed in one and a half or two minutes. The patient went on satisfactorily for some days; fectly rational, and has slept quietly and comfortably at but on Saturday, Jan. 31st, he felt unwell, and erysipelas intervals; the inflammation has not extended, and desquamathe bowels have not been relieved since attacked the wound, which, at that time, however, had nearly tion has commenced; last evening; but he feels an inclination to go to stool. He and The extended somewhat over healed. redness swelling this time continued, and is still to continue, the the cheek, and along the neck, and an incision was made has, up to beef-tea, &c., at short intervals. brandy, Port of the swollen decoction wine, bark, parts. through 8th.-IVToon: the swelling of the face has now much dimiand small quantities of infusion of senna, were given at innished, and desquamation is taking place over the whole of tervals. I saw the case, in consultation with Mr. Solly, on Tuesday, the affected parts; pulse below ninety, with more power, but and with a long intermission from time to time. This Feb. 3rd. The inflammation had then extended over the unequal, intermission, however, is less marked at the heart than in the whole of one side of the face, and the right eye was completely closed. The affected parts were of a dusky-red hue; the radial artery; tongue moist; feet comfortably warm: owing to the diminution of the he can now open both eyes; he pulse 120; the bowels purged; and there was some griping. has passed one healthyswelling evacuation. About four o’clock this The patient was manifestly anxious about himself, and symptoms of sinking again returned; he breathed wandered slightly at times, although answering every question morning, with much effort, and the feet and legs became cold, a state with perfect accuracy. He was ordered eight ounces of port which however, disappeared under the freer use of wine, and seven drachms of decoction of bark; one drachm of stimuli.shortly, He was now ordered to take the brandy in smaller the compound tincture of bark, and four grains of the sesquiquantities, and to have two grains of quinine in decoction of carbonate of ammonia, every four hours. bark every four hours. The following day (Wednesday, Feb. 4th) he appeared On Monday, Feb. 9th, I found him in every respect* immuch the same; the erysipelas, however, extending, now improved ; lie was quite collected and comfortable ; had slept plicated the forehead, though not encroaching upon the hairy well during the night; his pulse had more power, and was scalp. under ninety in the minute; the skin was warm and moist. On Thursday, Feb. 5th, he was, in every respect, decidedly Convalescence was from this period steadily progressive. S-,Ipworse; the left side of the face and ear had now become puration of both eyelids took place, and the pus was evacuated * Nitrate of by the lancet. He left town on the 26th of February, and. silver, one drachm; lard, one ounce. Mix. returned about the end of March perfectly well. t Read before the South London Medical Sociey, 3pril 2nd, 1846. -
293 Here is an instance of erysipelas treated by what some extension of the disease, the colour and pungent heat of the would perhaps characterize as an undue and lavish adminis- affected parts, seemed to me clearly to indicate the necessity tration of stimulants; but I feel fully convinced (and I believe of active depletory measures. I therefore ordered a vein to the conviction is equally strong in the minds of those who be opened, and twelve ounces of blood abstracted. This was watched the case,) that nothing short of the quantities given slightly buffed, but not cupped. He was ordered to take would have been competent to bring about a favourable issue. a quarter of a grain of tartar emetic every three hours, and to I am no advocate for large doses of medicines in ordinary repeat the purgativepills at night, and the purgative draught the ensuing morning. For some hours after the venesection, cases. On the contrary, I am inclined to believe that the tendency of medical opinion and practice is, at the present the patient felt much relieved; the pain and heat of the head time, in favour of larger doses than the absolute require- were much diminished; he was less restless, and got about ments of disease render necessary; and I am quite sure that half an hour’s quiet sleep. Towards evening, however, the benefit would accrue to the patient, in most cases, by a dimi- febrile symptoms increased, the pain, heat, and throbbing of nution in this respect. It must, however, be remembered, the head returned, and shortly after midnight he became dethat cases do every now and then occur of such extreme se- lirious. At two o’clock the following day, 28th,) I found verity as to render ordinary plans of treatment inefficient. In the head more swollen than at my former visit; the pulse 96, these we must step out of the beaten track, and administer and harder; tongue white; much thirst, and the skin hot. He was again bled, and upon this occasion to sixteen ounces. our remedies to an amount which, in more ordinary cases, would be injurious and culpable. The case above related is The blood was now both cupped and buffed. He experienced I know of no instance of erysipelas in which so almost immediate relief; the pulse dropped to 90, and in great one in point. large a quantity of stimulants has been necessary; and I cer- measure lost its hardness. He was to continue the mixture tainly have never met with one in which their effects were so of tartar emetic with a drachm of sulphate of magnesia in each dose. strikingly and unequivocally beneficial. On Thursday, Feb. 5th, about mid-day, the freer use of wine On the next day (Nov. 29th), the swelling of the head was was commenced. He took two ounces every two hours, and notably diminished; the affected parts were not so hot, and continued it till half-past four P.lII. of the following day. In their colour was less vivid. Pulse 88; less thirst; the tongue the four-and-twenty hours he had thus taken twenty-four continued white and furred; but the heat of surface had ounces of wine, besides jelly, beef-tea, and the bark-and-amdiminished. monia mixture. At half-past four o’clock, when Mr. Solly, 30th.—In every respect improved; the swelling has diMr. Bristowe, Mr. Henry, and I saw him, he was sinking, minished, and desquamation commenced; pulse 88; tongue and now two ounces of wine were given every hour, and a less coated; heat of surface not above the natural standard. drachm of Hoffman’s anodyne every alternate hour. Even He had slept for some hours during the night. He was now this quantity did not suffice, and at six o’clock Mr. Henry, ordered a drachm of sulphate of magnesia, with three drachms with a promptitude and decision to which our patient, I be- of liquor ammonia acetatis, in camphor mixture, twice or lieve, owes his life, commenced the administration of brandy. three times during the day. From this time he went on graA wine-glassfull was given every hour, and continued in the dually improving. same quantity, and at similar intervals, till Feb. 8th, at noon. December 2nd.-He had an ounce and a half of decoction During this period of forty-two hours, he took, at the very of bark, with ten minims of dilute sulphuric acid; and by the lowest computation, upwards of sixty ounces of brandy. Not- llth of December my attendance was no longer necessary. withstanding the quantity administered, neither the patient’s pulse nor his nervous system were at any time unduly excited.I A man, aged twenty-eight, came under my care as a patient On the contrary, the larger the quantity of brandy given, the ’, of the Farringdon Dispensary, in Jan. 1838. He had been ill stronger but less frequent became the pulse, the stupor was and confined to bed for three or four days, and during that diminished, and the delirious wandering quieted. The tongue time had been attended by a surgeon in the neighbourhood. likewise became clean and moist. The latter circumstance He had erysipelas of the left eyelid, which had from thence was strikingly illustrated on Friday, Feb. 6th. At half-past extended across the face and over the forehead and scalp. four o’clock, the tongue was dry, dark-brown, and fissured; at These parts were of a deep red, without much increase of six o’clock he appeared to be dying, and now commenced the heat, and with no very large amount of swelling. His tongue administration of brandy. A wine-glassfull was given at in- was moist, but covered with a yellowish-brown coating; his tervals of less than an hour. At ten o’clock, the tongue had pulse 118. He had been taking ammonia out of some bitter become moist, and the dark-brown coating was gone. infusion, and was now to have ammonia in decoction of bark. The next day (Jan. 7th), I could perceive but little alteration A gentleman, aged thirty-two, of full habit of body, residing in his symptoms; his pulse was, perhaps, weaker, and the on the borders of Epping Forest, was, in the month of Notongue more coated; but the appearance of the erysipelatous vember, 1842, riding, after midnight, a distance of five or six parts remained the same. He was ordered to take four miles, on the outside of a carriage. The night was cold, wet, ounces of gin, in divided doses, within the twenty-four hours, and tempestuous, and he was insufficiently clothed. Ere and to continue the mixture as before. 9th.-The back part of the neck had now become affected, reaching home, he felt shivered, but this passed off under the genial influence of a warm room, a large fire, and a tumbler the face and head remaining as before. There was no dimiof strong whisky-and-water. He retired to rest and soon nution of the swelling, and no appearance of desquamation; fell asleep, but in less than two hours was awakened by a his pulse was 124, and weaker; the tongue covered with a sharp rigor. This, after continuing for some time, gradually thick, moist, yellowish coating; there was slight floccitation, gave way to heat of skin, thirst, and throbbing pain in the and some involuntary catching of the muscles. The quantity head. He took a strong dose of aperient medicine, which of gin was doubled. 10th.-The head and face remained the same, but the inoperated freely, and during the following day restricted himself to slops. The next night he slept comfortably, and awoke flammation was creeping gradually down the back. The pulse apparently well ; but in the middle of the day was again at- was weaker and more frequent; he was delirious, and the tacked with rigors. These lasted until evening, when re- character of the wandering was that of delirium tremens. action took place. He became hot, restless, and feverish, and There was likewise considerable tremor of the extremities; experienced a good deal of heat and pain about the head. I his tongue was moist and coated, and his skin was clammy saw him in the evening of the following day, Nov. 26th ; his and perspiring. These symptoms led me to more minute inface was then somewhat swollen, hot, and painful; the skin of quiries as to his past habits and mode of life, and to further a dark red, and the eyes injected; his tongue was white; there questions as to sleep; but from his wife, who alone was in atwas much tliirst, and his pulse was 92, full, but not hard. He tendance upon him, and who was far advanced towards inwas ordered five grains of calomel, and eight of compound toxication, I could get no information of a connected chaextract of colocynth, immediately, and a dose of senna and racter-none of a kind upon which any reliance might be salts four hours afterwards. A drachm of sulphate of mag- placed. Taking all the circumstances of the case into consinesia, with twenty minims of antimonial wine, was then to be deration, and inferring (perhaps unjustly), from the present condition of his wife, what had been his own habits during given every four hours. 27th.-The whole head had now become greatly swollen,with health, I thought the case one that might be benefited by a deep red and pungent heat; the tongue white and furred; opium, and therefore ordered him twenty minims of laudanum pulse 92, full and hard. He had some thirst; but his chief immediately, and other twenty minims in four hours, if the complaint was of severe throbbing pain in the head, and of a first dose failed to produce sleep. The following day, (Jan. llth,) I could perceive no change feeling of tightness and pricking pain of the scalp. His bowels: the better. The laudanum had been twice administered, had been freely purged. The hardness of the pulse at this period, and the degree of pyrexia, together with the rapidI but it had failed to produce sleep. The delirium was greater,
(Nov.
’ for l ,
294 the tremors increased, and his skin, though warm, was sodden, has abundantly shown that it is analogous to, if not identical and perspiring profusely. I therefore ordered forty minims with, that in delirium tremens. The symptoms are similarof laudanum immediately, and a further dose of twenty the treatment identical. Of this, the third case is an exminims every two hours, until sleep was induced. The first ample. dose sufficed to produce the desired effect: he slept for six or Finsbury-place South, Aug. 1846. eight hours, and awoke quiet, collected, and refreshed. I saw him again on the morning of Jan. 12th. The inflamREMARKS ON mation had not extended; the swelling had diminished, and on OF THE BOARD CONSTITUTION was the THE PRESENT the delirium apparent cheeks; desquamation was gone, and the tremor of the extremities diminished; his OF COMMISSIONERS IN LUNACY, tongue was dry and brown. He was to take twenry minims And the inconsistency and probably mischievous effects of electing of laudanum every night, and to continue the 0gin and the to such offices who have had no practical knowledge of persons tonic mixture as before. the treatment of the Insane, and are consequently ignorant of It is unnecessary to adduce the further daily reports of this the actual management of Lunatic Asylums. case. Suffice it to say, that the man ultimately, though slowly, recovered. For two or three days more, the above-mentioned BY WILLIAM SMITH, ESQ. treatment was continued; and subsequently, he was put upon FORMERLY HOUSE-SURGEON TO THE LINCOLN LUNATIC ASYLUM, AND MEMBER OF THE ASSOCIATION OF MEDICAL OFFICERS OF HOSPITALS quinine and infusion of roses. FOR THE INSANE. The three cases above narrated are not adduced as examples ON reference to THE LANCET for 184G, vol. i. fol. 134,I find of erysipelas, such as is ordinarily presented to our notice. My object in selecting these from many others has been to show the following remarks, (probably extracted from a recent how varied are the phases under which any one disease may work by Forbes Winslow, M.D.)—" Now, there are for the present itself to our notice, and how widely different is the I administration of the law of lunacy twomasters in lunacy, treatment which such varieties require. In this, there is no i (barristers,) five honorary commissioners, (non-medical,) three novelty either of statement or of fact. It is a circumstance ’, paid commissioners, (barristers,) and three paid commiswhich we are one and all ready to admit; but it is; at the sioners, (physicians, or surgeons,) the whole of the appointments being vested in the Lord Chancellor-thirteen appointsame time, one which can never be too strongly or too prominently impressed upon us. I believe that long-continued prac- ments in a medical department, only three of which are tice tends strongly towards routine methods of treatment. This medical!" Now, let us just ask a few plain matter-of-fact is a remark I have heard made by one of the most esteemed questions relative to these same commissioners. How long and cautious practitioners of the present day; and I firmly have they been in existence ? What salutary reforms have believe, that if each of us would be but strictly honest to him- they brought about in the management of asylums, public and self, the sentiment would find an echo and a confirmation in private ? With the exception of one meagre report addressed his own breast. Now, it seems to me, that nothing is more to the Lord Chancellor, what have they done towards calculated to counteract this tendency than to dwell promi- ameliorating the condition of the insane? Does not that very nently on the different forms which any one disease may report (by pointing out numerous and very glaring abuses) assume. The three cases just related are illustrative of this virtually prove their own previous neglect of supervision and fact. incompetency? Have not all the principal improvements, Erysipelas, as it occurs in London, requires, in the immense and especially the abolition of the mischievous practice of inmajority of instances, a treatment by tonics and stimulants. strumental restraint, been brought about by the force of This I imagine to be the general experience of the profession public opinion, (the pressure from without,) and the free disat the present day in this metropolis; and of such instances, cussion of the insane practice by the medical press, and esthe case I have first narrated may be taken as an extreme pecially by that independent periodical, THE LANCET ? How are these precious appointments conducted? example. By the Lord But it would seem that, some years since, the type of the Chancellor, forsooth! What opportunities can he have of disease in London was different-that it was then more inflam- judging of their qualifications? What has Dr. John Bright matory - that bloodletting was in many instances advan- or Dr. Hume ever done towards advancing the science of metageously employed--and although bark and quinine were not dicine ?1 How did the former gentleman perform his duties unfrequently administered, that wine and spirits were, in the whilst (nominally) senior physician to the Westminster Hosmajority of cases, inadmissible. Cases of this kind do even pital ? What says THE LANCET of 1843, vol. ii. fol. 553, on this now occasionally, though rarely, present themselves to our subject?We believe we are correct in saying, that during notice: of this, the second case I have adduced is an illustra- the very many years that Dr. Bright was physician to the tion. That the inflammatory character, as marked by active hospital, he never on any one occasion gave a clinical lecture! pyrexia and strong arterial action, still pertains to erysipelas, His visits wereso few and far between,’ that many of the as the general rule in some parts of the country, I am fully perpetual pupils did not even know the person of their convinced. I have, within the last three or four years, had respected teacher." Then again, with reference to Dr. occasional opportunities of seeing cases of this kind in dif- Hume, what was he other than a sinecurist? Out upon such ferent parts of Devonshire; and I do not remember a single appointments as these! Dr. Prichard, we believe, has favoured exception to the statement, that they were marked by strong us with a compilation. But what is his practical knowledge of arterial action, and had been indubitably benefited by vene- insanity compared with such men as Dr. Conolly, of Hanwell, section. The third case I have brought forward to show the (whose lectures form a new era in the treatment of the insane;) influence of a deranged condition of the nervous system in Mr. Gaskell, of Lancaster; Dr. Hitch, of Glo’ster; Dr. Powell, of interfering with the usual course of the disease. It seldom Nottingham; Dr. Corsellis, of Wakefield, and a host of others? happens that erysipelas, fever, or any other of the zymotic Why, even our very learned friend, Mr. P. G. Hill, of Lincoln, diseases, run through their entire course, especially if severe, the supposed author of the " Lecture on the Management of without the occurrence of some symptoms directly referable Lunatic Asylums," could give them some valuable information. to the brain and nervous system. In some, such symptoms We might well take a lesson or two from our French neighbours evidently have their origin in an excited action of the vessels on these points. Let us have the concours, and then adieu to of the brain; in others,-and these are by far the more the antiquated noodles and fawning sycophants, who disnumerous,-they seem to be part and parcel of the generally grace our public institutions, and literally fatten on the spoils depressed and typhoid condition of the patient. In such of our medical charities. As a proof of the pernicious effects cases, the cerebral affection is the more or less direct conse- of unbounded funds, and the exclusion of that wholesome corquence of these conditions-it preserves a due proportion to rector of abuse-public opinion, look at the doings in the them-requires no special treatment-but is best met by those Royal Hospital of Bethlehem, olim Bedlam, that huge mass of remedies which in the one instance allay inordinate vascular wealth, indolence, and exclusiveness! How often have they action, and in the other stimulate the depressed and failing refused their printed reports and other such matters to instipowers of life. But there is another class of cases, in which tutions of a similar character? Have they not refused the the disturbance of the brain observes no proportion to, but liberty of inspection to individuals who were or had been runs very far ahead of, all the other symptoms. Here, there officially connected with other asylums?? Here we have a may be no inordinate excitement of the cerebral circulation, noble institution, situated in the metropolis, endowed with and no urgent typhoid symptoms. The cerebral symptoms ample funds, and capable of being rendered a fertile source of would seem, in such cases, to depend on some peculiar condi- improvement-in fact, an invaluable clinical school for the tion of the brain itself, and to be an accidental concomitant rising generation of medical practitioners; and yet what do rather than an essential accompaniment of the disease. What we see? Why, marry, we see it humbled into the second may be the precise condition we know not; but experience rank, giving place to a pauper asylum-the Hanwell Asylum, --