ever.

In the majority of instances, however, it induced a sense of heat and constriction in the throat and stomach-in a few instances, colicky pains. In one case of phthisis, it gave origin to severe diarrhoea, and was discontinued. In about half the subjects, the cough was notably diminished, as well as the dyspnoea and the difficulty of expectorating. The nature of the sputa, however, was not changed. The nights were less distressing under its influence, and some sleep was obtained. In one young man, the cough and fever were removed for a time; but a relapse took place, and death ensued. In these cases, other anodynes had entirely failed. Upon the whole, it appears evident to M. Recamier, and indeed to others, that the prussic acid, especially in large doses, irritates the mucous membrane of the digestive tube, and therefore should not be administered when this membrane is in a state of chronic inflammation or irritation. In other respects, it seems to exercise a considerable sedative influence on the respiratory apparatus.

5. Hæmoptysis. Several cases of recent hæmoptysis were treated with nitre, either alone, or combined with conserve of roses. The dose was, from a drachm to half an ounce in the 24 hours. It produced no inconvenience, in this quantity, in the stomach or bowels. The patients merely complained of an acrid heat in the throat, and the urine was. sensibly increased. The hæmoptysis gradually diminished, and soon ceased altogether. M. Recamier observes that the practice of giving. large doses of nitre, imported from Italy into France, is now established. beyond all doubt, as a very useful one, in the disease above-mentioned, and in some others.

6. Angina Pectoris. A supposed case of this disease is detailed by M. Recamier, of which we shall state some of the particulars.

Case. Ravier, aged 37 years, had been subject, in early youth, to fainting fits and falls, from sudden loss of power in the lower extremities. About the age of fifteen, he became affected with palpitations and sense of uneasiness in the region of the heart; but his health was otherwise undisturbed till the age of 29, when profuse hæmoptysis occurred. This was checked by bleeding, leeching, and other means. It returned the succeeding spring, but did not continue long. Four years passed without any discharge of blood from the lungs; but the pain in the præcordial region continued, bounded to a space of about six inches in extent, over the sixth rib on the left side. The year after, although Ravier was gaining in embonpoint, both his arms, but especially the left, became the seat of a painful numbness, that stretched down, occasionally, to the fingers' ends, in the direction of the median nerves. To this was added a difficulty of breathing-all these symptoms coming on periodically. In 1824, the attacks were in the habit of recurring at short intervals, and it was found necessary to have recourse to repeated bleedings to mitigate the dyspnoea, which was now rendered

very distressing on the least motion, especially of ascent. In process of time, the sufferer was unable to go to bed at all, and was afraid of going to sleep in any position. In this condition he came under the notice of M. Recamier, who made an accurate examination of the case, of which the following is a summary. The pulse is regular at both wrists, being full and not frequent. In the remissions (which were much prolonged in the hospital, by repeated bleedings) exploration of the chest by auscultation, percussion, &c. shewed nothing particular. The heart beats over a moderate space, and no unnatural noise is heard in that region. The respiration is free, and percussion elicits a natural sound in all parts. Nothing can be felt in the tract of the nerves of the arm, where the pain is sometimes so distressing. When the accession comes on, (which is not now very frequent in consequence of low diet and bleeding,) the pulsations of the heart become very violent, quick, and extended over a great space the respiration is acceleratedthe face reddens—and the præcordial and brachial pains become extremely intense, especially that of the left arm-the epigastrium is then so tender that the slightest touch cannot be borne, without convulsive motion of the diaphragm and imminence of suffocation. An accession of the paroxysm has more than once been brought on by pressure of the epigastrium. An attentive examination of the abdominal viscera could not detect any disease there.

M. Recamier does not venture to pronounce this a decided case of angina pectoris; but considers that it bears a very close resemblance to that terrible malady. We may observe, that there are essential differences in the symptoms, which induce us to place the above disease to some other account than that of angina pectoris. These are, the redness of the face and the increased strength of the heart's action during the paroxysm. It is directly the reverse in real angina pectoris. The face turns of a deadly pale colour, and the pulsations of the heart are small, quick, and confined or intermitting. We have had such repeated opportunities of watching the phenomena, and examining the bodies after death, in this fatal disease, (three exquisitely marked cases of which we have published) that we have no hesitation in separating the case of M. Recamier from those of syncope anginosa. We are inclined to look upon the present case as an instance of nervous irritation--and especially of irritation of the epigastric centre. The exceeding tenderness at the pit of the stomach, and the circumstance of pressure there bringing on an attack, are, in our minds, proof positive that the origin of the malady is in or near the solar plexus-or in the stomach or duodenum, where the nerves of this system are so profusely scattered. The case is interesting, and we hope it will be long ere the scalpel unravels its true nature. Indeed, we much question whether the knife is capable of unveiling the mystery.

7. Intestinal Ulceration. Our readers will see, in another part of this Periscope, an interesting case of intestinal hæmorrhage, during convalescence from fever, and which proved, on dissection, to be occasioned

by ulceration of the ileum, the product of the preceding fever. The following case mentioned in M. Recamier's report, is somewhat analogous.

66

Among the subjects who fell a victim to fever this quarter, we cannot pass over in silence the case of a young man who, having twice recovered from severe attacks, had a third relapse, from which also he emerged, for ten days, into a state of convalescence, and then suddenly sunk. On dissection, a chain of ulcerations was found in the ileum and cæcum. What great care should be taken, during convalescence from fever, to guard the patients against too much food! These people attribute all their debility to want of nourishment, and the consequences of repletion are too often fatal!"

In the case of a female, who died after being a week in the hospital, presenting the common symptoms of fever, some pain in the abdomen, stupor, and diarrhoea, the stomach and small intestines were found perfectly healthy; but, from the valve of the colon to the rectum there was scarcely a spot which was free from ulceration! The mucous membrare was almost entirely destroyed, and even the muscular coat, in numerous cases, was perforated. These cases may prove useful beacons to the young practitioner, when pressed by nurses and friends to allow food in early convalescence from fever.

4. CELLULAR IMFLAMMATION.

[Bartholomew's.]

In a clinical lecture delivered by Mr. Earle, at Bartholomew's hospital, and afterwards published in the January number of the Medical and Physical Journal, we find some interesting observations on the treatment of this severe disease, especially as relates to the practice of making deep incisions, first introduced by Mr. Copland Hutchison.

Mr. Earle objects to the term phlegmonous erysipelas, which is usually applied to diffuse inflammation of the cellular membrane. Erysipelas is essentially of the skin, whereas the disease under consideration" exerts its influence (a bad expression by the way) principally on the subcutaneous tissue and fascia." For some time past, cases of this kind have been occurring at St. Bartholomew's in most of which Mr. Hutchison's plan was adopted, with success. The disease, as surgeons well know, is an acute and rapidly diffused phlogosis of the cellular membrane, to which no bounds are set, and which, if not arrested quickly, terminates in suppuration and sloughing of the subcutaneous tissues and fascia, which relieves itself, if the patient survives, by a large and uncontrollable sloughing of the integuments. Mr. E. has. known, in the space of 36 hours, the whole integuments of an upper and lower extremity involved in one extensive sloughing abscess. In his experience, it has generally followed punctured wounds or severe bruises upon the elbow, and lacerations of the integuments of the hands or fingers. It has also occurred after wounds of joints, or in the neighbourhood of joints, which have been attempted to be closed. In the majority of cases, it was accompanied by well-defined inflammation of

the absorbents; but these soon became so involved in the general tumefaction of the limb, that they could not be traced. The constitution sympathises much-the secretions are deranged or suspended—the circulation hurried the pulse hard and contracted, and, after a time, irregular. The nervous system is greatly disturbed-the countenance anxious-features contracted-want of sleep. When the cellular membrane has sloughed extensively, the greatest prostration of strength takes place and bad irritative fever too often closes the scene.

The treatment which Mr. Earle has found most beneficial was, by free longitudinal incisions, if possible, before suppuration takes place, through the swollen inflamed integuments, down to the fascia or muscles. The vessels of the skin should be allowed to bleed freely, and even encouraged by warm fomentations. The limb should then be enveloped in a warm bread and water poultice. A large dose of calomel, antimony, and opium is then to be given; and, after some hours, the patient should be freely purged with salts and senna. If the incisions be sufficiently large and deep, the relief is very speedy, and it is seldom necessary to repeat them. In a few hours there will be a complete subsidence of the tension and pain-the nervous system will be tranquillized-and the secretions restored.

The objections which have been urged against this practice, on the score of the severity of the operation, are frivolous and vexatious; but they are such as will always weigh with timid practitioners, or with those who have not confidence in themselves, or the art of inspiring confidence in their patients.

Fourteen years ago the Editor of this Journal drew the attention of the profession to this mode of treatment, in a quarterly report of sick and wounded on board the flag-ship of the late Sir William Young, in the Scheldt, and published in the 7th vol. of the "New Medical and Physical Journal, p. 183–203, March, 1814." We shall give a short extract from this report, in corroboration of the practice.

H.M. S. Impregnable, in the Scheldt, Feb. 1814. "The species of erysipelas, which I have observed most prevalent in the navy, comes nearest to that which Dr. Bateman treats of under the head of Erysipelas (Edematodes.' When it attacks the face or breast, it is often dangerous. Vomiting, rigors and delirium, followed by coma, take place about the height of the disorder, and often terminate fatally on the seventh or eighth day.' Bateman, p. 127. Several instances of this kind I witnessed on board the Saturn a few years ago in Basque Roads, which proved fatal. Where it attacked the lower extremities, the inflammation soon destroyed the cellular membrane, forming the connecting medium between the integuments (including the adipose substance) and the muscles; which membrane, (attended with a quantity of ill-conditioned pus) would occasionally slough away, and come out wherever any orifices were made, either by nature or art, leaving a whole tribe of integuments surrounding, but disconnected from, the subjacent muscles. When this happens, in the thigh for instance, the patient is too often exhausted by the discharge, the mischief

spreading farther and farther up, till it even begins to separate the muscles of the abdomen from the superincumbent integuments, and thus puts an end to his miseries! To check this evil, in embryo, a medical gentleman of my acquaintance, (Mr. Hutchison, of Deal Hospital) first, I believe, made deep incisions through the skin, adipose and cellular membranes, quite down to the muscles, as early as possible, and before suppuration. The effect is, a discharge of the stagnant-looking blood, with a reduction of the tension, swelling, heat, pain, and, in short, of all the unfavourable symptoms. I have witnessed this in three or four instances; and in one case lately, where the erysipelas was spreading fast up the leg, half a dozen incisions completely arrested its progress in one day, and in a short time afterwards the man returned to his duty. I am not prepared to say how far this treatment could be adopted, where the affection appears on the face, head, or breast; my observations being confined to the disease, as it appears in the above-mentioned manner, on the extremities; but I cannot help recommending these practical facts to the serious attention of the profession, as I am well convinced, that many lives and much suffering may be saved by adopting the treatment sketched out."*

We believe the above report was published some time before Mr. Hutchison's paper appeared in the Medico-chirurgical Transactions; and the cases alluded to in the Saturn, in Basque Roads, happened in 1809 or 1810. There the disease assumed an epidemic form, and several men died with typhoid symptoms. The incisions alluded to were made, in these cases, with great benefit; but they were often too late, as the destruction of the cellular membrane goes on with inconceivable rapidity.

Seven cases, in illustration, are given by Mr. Earle, for the particulars of which we refer to the journal in which they are published."

* In corroboration of the term œdematodes, as applied by Dr. Johnson, to the disease in question, we may cite a case reported from St. Thomas's Hospital, in No. 176 of the Lancet. A sailor, 27 years of age, of sallow unhealthy aspect, was admitted under Mr. Travers, on the 12th December, 1826, with diffuse cellular inflammation of the right upper arm. He had received a contusion, while intoxicated, some days previously. There was now a dusky redness of the skin, from the shoulder to below the elbow, and spreading over the breast. The limb was immensely swelled. "At some parts it had a tense unyielding feel, whilst at other parts, there was slight dema on pressure." There was fever and other constitutional symptoms. Leeches in large numbers and lotions were applied, and he had a grain of calomel and a quarter of a grain of tartar emetic every four hours. A poultice was next day ordered. These remedies were continued for some days; but, on the 18th December, we find incisions made, which gave great relief, although only a small quantity of matter was evacuated. From the wounds, large sloughs of cellular membrane were extracted, and ill conditioned pus flowed out. The patient was now much relieved the quinine was given, with wine and nourishing diet, and the man recovered.

The above was a case where early incisions would have saved the patient much suffering, and greatly abridged, if they did not entirely prevent the extensive sloughing of the cellular membrane.

VOL VI. No. 12.

2N