727MR. LAWRENCE ON ERYSIPELAS.

tions, the rule were genera in all hospitals,that persons dying there and unclaimed,should be dissected, are you of opinion thatthe number of applicants for admission intosuch hospitals generally, would be much di-minished ?—I have no hesitation in saying,that it would be the most injurious thingthat could be to the public hospitals."Such are the answers of Mr. Harrison;

it will be seen by the following extract fromthe evidence of A. B., how much this gen-tleman is surpassed by the body-snatcher in

point of intelligence and sagacity." Do you think the dissecting of murder-

ers tends to increase the dislike of the lowerclasses to dissection?-In my opinion, the !,public think there are none fit to be dissectedbut very bad characters, through that verything.Suppose the bodies of all persons dying

in hospitals, complete strangers to this

place, with no relatives whatever near, doyou think the public would care much iftheir bodies were dissected ?-No ; I shouldthink the public would care nothing aboutit, because they would not know it.Suppose the bodies of those who die in

workhouses, and have no friends to claimthem, were given up, do you think that thepublic would be much against that prac-tice ?-There is no doubt that the inhabi-tants of the parish where the workhousewas situated, would be prejudiced a littlewhile ; but they would come round after a

time, and they would know it would be donefor the good of the public."There is a part of Sir AsTLEY COOPER’S

evidence, which is likely to have a strongerinfluence than any arguments which can be

urged in favour of an alteration of the law, I,towards inducing persons of a certain intel-lectual calibre, to support any measure

which may have the effect of putting anend to the practice of exhumation. The

worthy baronet has not hesitated to declare,that there is no person, however exalted his

rank, whose body, if he were disposed todissect it, he could not obtain.

" Does the state of the law actually pre-vent the teachers of anatomy from obtam-ing tbe body of any person which, in con-sequence of some peculiarity of structure,they may be particulary desirous of pro-curiug ?-The law does not prevent ourobtainmg the body of an individual if we ethink proper ; for there is no person, lethis situation in life be what it may, whom,

if I were disposed to dissect, I could notobtain.

" If you are willing to pay a price suffi-ciently high, you can always obtain thebody of any individual ?—The law only en-hances the price, and does not preventthe exhumation ; nobody is secured by thelaw, it only adds to the price of the sub-ject." *

This declaration is well calculated to

produce an effect on the fears of persons towhose understanding reason could find noaccess. We shall have frequent occasionto return to the Report, and to the Minutesof evidence taken before the Select Com-

mittee.

Medico-Chirugical Transactions. Vol. XIV.Part 1 and 2. Longman and Co., 1828.

(Continued from page 688.)Observations on the Nature and Treatment of

Erysipelas, illustrated by Cuses. By W.LAWRENCE, Surgeon to St. Bartholo-mew’s Hospital, &c., &c.

" ALTHOUGH erysipelas, in its various forms,is a disease of frequent occurrence, andcomes daily under the observation of thephysician and surgeon, great difference ofopinion still prevails respecting its nature

and management Regarding it as an affec-tion essentially inflammatory, some adoptthe antiphlogistic plan, including generaland local bleeding ; while others, conceiv-ing that the part, the constitution, or both,are in a state of debility, endeavour to

remove this by the free use of stimulantsand tonics, more especially by bark, ammo-nia, and wine. The former appears to me

the correct view and practice ; 1 accordinglyconsider the latter notion completely erro.neous, and the treatment founded on it, notonly inappropriate, but injurious.’ By erysipelas I understand mflammationof the skin, either alone or in conjunctionwith that of the subjacent adipous and cel-lular tissue. Like other inflammations itvaries in degree. When it affects the sur-face of the skin, which is red, not sensiblyswelled, soft, and without vesication, it is

called erythema. Simple erysipelas is a more

We have given Sir Astley credit forwhat, we presume, he meant to say ; but itis evident that the worthy Baronet has,with his wonted felicity of diction, madehis threat of dissection apply rather to theliving, than to the dead.

728

violent cutaneous inflammation, attendedwith effusion into the cellular substance,and generally with vesication ; phleg7)2onoziserysipelas is the highest degree of the affec-tion, involving the cellular and adipousmembrane as well as the skin, and causingsuppuration and mortification of the former.

Description of the Affection. Simple Erysipelas.In simple erysipelas the skin is preterna-

turally red and shining, having a light orrosy tint in the early stage and slightercases of the affection ; whence, in somelanguages, it has received the popular ap-pellation of the rose ; while in other in-stances it is of a bright scarlet, or even adeep and livid red. The colour disappears’on pressure, returning as soon as the pres-sure is removed. If the skin alone be

affected, there is hardly any perceptibleswelling, and no tension ; yet some diffe-rence is perceived between the sound andthe inflamed part by passing the finger overit. Erysipelas, however, is seldom confinedto the skin, except in the slightest cases ;effusion soon takes place into the cellulartexture, causing a soft swelling ; and thismay be considerable, together with muchtension and a shining surface, when a largepart of the body, or an entire limb, is in-volved. The inflamed part is hot and pain-ful ; at first a stinging, or itching, is felt,which soon becomes a sharp smarting andburning sensation, with acute pain on pres-sure. The pain is not so intense and un-remitting as in phlegmon, nor is it attendedwith throbbing. This kind of inflammationoften ends by resolution ; the redness andother symptoms disappearing, and the skinrecovering its natural state, with or withoutdesquamation of the cuticle. Frequentlyserous effusion takes place from the in-flamed surface, elevating the cuticle intosmaller or larger vesicles, or into bullæ,like those produced by blisters, or raisingit by a soft yellow jelly-like deposit, whichremains slightly adherent to both the cutis Iand cuticle, and exactly resembles the effectoften produced by the common blisteringplaster. The contents of the vesicles, orbtillae, are transparent, sometimes nearlycolourless, but more commonly yellowish;sometimes they consist of a thin pus ; orthey may exhibit a bloody or livid disco-louration (phlyctæenæ.) The fluid losesits clearness, becoming thicker, opake, andwhitish or yellowish. The cuticle givesway, the fluid escapes, and incrustationsform, which soon fall off, leaving the skinsound ; or they may lead to superficial ulce-rations. Erysipelas sometimes producesgangrene, but this is a comparatively rareoccurrence. So long as this inflammationis confined to the skin, it does not producesuppuration ; and the affection of the cellu-

lar structure is too slight for that terminn-tion in most cases of simple erysipelas. It

may, however, become more severe at onepoint ; and thus we occasionally see theformation of abscess under the skin towardsthe decline, or after the disappearance ofthe general erysipelatous redness.

This inflammation generally attacks a

considerable surface of the skin, the in-flamed part being irregularly circumscribedby a defined line. It spreads quickly to theneighbouring skin, declining and disappear-ing in the part first affected ; and this alter-nation is repeated until the whole surfaceof the head and face, of a limb, or of thetrunk, has been successfully inflamed. Thuswe commonly see the various stages of ery-sipelas existing together at the same timein different parts of the skin ; the portionlast affected is red and swelled ; anotherpart is vesicated, while others exhibit in.crustation and desquamation. Sometimesit leaves entirely the part first affected, toappear in a distant situation. Its origin,development, and complete termination sel.dom take place in one and the same spot.The neighbouring absorbent glands are fre-quently inflamed, and red streaks are some.times seen leading towards them.

The local symptoms, above described, arepreceded and accompanied by fever, whichvaries in its character according to the can.stitution, age, and general state of health.Shivering, followed by increased heat, ge-neral uneasiness, lassitude, headach, lossof appetite, nausea, white or foul tongue,and constipation, usher in a severe attack,and the general disturbance is of a decidedlyinflammatory character in the young, strong,and those of full habit. Blood drawn froma vein exhibits, in a greater or less degree,the inflammatory character. This circum-stance was noticed by Sydenham, Cullen,and Vogel ; it has, nevertheless, been de-nied by Callisen. Often, particularly whenthe head is the seat of erysipelas, the sen-sorium is principally affected, and the symp-toms are of the kind cabled nervous, suchas pain and oppression of the head, sleepi-ness, coma, or delirium. The tongue, insuch cases, becomes dry and brown ; butthis state of the organ is often owing, prin-cipally, to the circumstance of the patientbreathing entirely through the mouth ; thepulse is rapid and feeble, and there is greatloss of muscular strength ; in short, thesymptoms at length are those called ty-phoid. In other cases, the circulation andthe nervous system are not much affected;but there is pain in the epigastric regiun,

foul tongue, with bad taste in the mouth,nausea, and constipation ; that is, so manyindications of disordered stomach and in-

testinal canal, to which, as its cause, thelocal affection must be referred.

729

It is not to be expected that an affec-

tion, of which the obvious symptoms duringlife are merely vascular distension and red-ness, with swelling, will produce muchchange in the affected parts, recognisableafter death. In simple erysipelas, the redcolour disappears as soon as the circulationstops. The cuticle, if not already separatedby vesication, soon loses its adhesion to thecutis, and the surface of the latter, in anadvanced stage of the affection, has a lividappearance. The texture of the skin pre-senting a reddish or brownish tint, is loadedwith serum. Serous effusion is found indie cellular tissue ; and its vessels, as wellas those of the skin, are distended. Some-times we unexpectedly discover suppurationwhere the case has appeared during life tobe simple erysipelas, and no symptoms, in-dicating formation of matter, have beennoticed.

Phlegmonous Erysipelas.Phlegmonous differs from simple erysi-

pelas merely in the higher degree and deeperextent of the inflammation, which not onlyoccupies the whole thickness of the skinand subjacent adipous and cellular tissue,but soon proceeds in the latter to suppura-tion and sloughing, the skin itself beingoften involved secondarily in the mortifi-cation. Both the local and general symp-toms are more strongly maiked, and hencemore serious effects are produced than insimple erysipelas. Rigours, feverishness,and disorder of the stomach precede theinflammation of the skin, which then showsitself from the first in a violent form ; or,the local complaint begins mildly, withoutmuch general disturbance, and graduallyassumes a more serious character. Theredness is deeper than in simple erysipelas,often with a brownish or dark livid tint;the discolouration is often irregular, givingto the part a marbled appearance ; the tu-mefacticn is more considerable, the wholedepth of the adipous and cellular texturesbeing loaded with effusion, so that an armor leg appears of twice the natural size ;the sensation of heat and pain, at first

slight, is aggravated to a very severe de-gree, and may be accompanied with throb-bing. The swollen part at first yieldsslightly to the pressure of the finger, butsubsequently becomes tense and firm. Vesi-cations form on the surface, often minuteand miliary, with purulent contents ; fre-quently, however, the skin does not vesicate.Suppuration and sloughing of the cellularmembrane soon come on, the skin ,be,-coming livid and covered with phlyctænæ,ar,d tile febrile symptoms are aggravated.These changes are not attended with in-creased swelling, elevat:on, and pointing,as in phlegmon ; on the contrary, there is

rather a diminution of tension, a subsi.dence, and a feel of softness in the part.At first the cellular texture contains a whey-like or whitish serum, which I have some-times seen in the eyelids almost of milkywhiteness. The fluid gradually becomesyellow and purulent, and we often find itpresenting all the characters of good pus,and very thick. The serum is diffusedthrough the cells at an early period, and amixture of serum and pus often fills a con-

siderable portion of the cellular texturewithout any distinct boundary. Frequentlymatter is deposited in small separate por-tions, forming a kind of little abscesses,which often run irregularly in the cellulartexture. Such small collections are some-times found where lividity or phlyctmnmhave not preceded, and where no externalchanges nor any aggravation of other symp-toms have announced suppuration. Duringthis process of suppuration the cellular tex-ture turns grey, yellowish or tawny, andsometimes appears like a dirty, spongy sub-stance filled with turbid fluid ; then losingits vitality altogether, it is converted intomore or less considerable fibrous shreds,of various size and figure, which come awaysoaked with matter, like a sponge. The

integuments over a large slough of thiskind, being deprived of their vascular sup-ply, become livid, and often lose their vita-lity. The suppurating and sloughing pro-cesses go on to a great extent when anentire limb is affected, sometimes com-

pletely detaching the skin, and often se-parating it through a large space ; occa-

sionally penetrating deeper, passing be-tween the muscles, causing inflammationof them, suppuration between them, andoften sloughing of the tendons. When thesubstance of a limb is thus generally in-flamed, the joints situated in the affectedpart do not escape.Phlegmonous erysipelas spreads, like the

simple species, to new parts successively ;we notice a visible advance of the rednessand swelling every day, and thus the affec-tion is, in different stages, in the differentportions of the inflamed part. The absor-bent glands are generally more or less swol-leii, and the absorbent vessels are frequentlyinflamed in the commencement of the affec-tion.

Seat and Nature of the Affection and Diagnosis.The practice of making incisions into the

inflamed textures, enables us to see that thevessels are enlarged and more numerous inthe early part of the disease, and that thecellular texture is loaded with a yellowishserum. Portions of that texture thenassume a light yellow, or a dirty colour,which is the precursor of mortiiication.The actual occurrence of suppuration and

730

sloughing must, of course, be immediatelyObservable. The matter often extends irre-

gularly, or is diffused in the cells of the

part. Thus the skin and the cellular sub-stance are the seat of this inflammation,which, in examination after death, is gene-rally found not to extend beneath the fasciaA consideration of the origin, develop-

ment, and effects of erysipelas, of all it,

phenomena, whether local or general, lead,us irresistibly to the conclusicn, that ttnnature of the affection is inflammatory. Inits four leading characters of redness, swell.ing, heat, and pain, and in its effects o;effusion, suppuration, and sloughing, i1

agrees with what is called common oj

phlegmonous inflammation; while the gene-ral disturbance, preceding and accompany-ing the local affection, is often exactly alikein the two cases. Erysipelas then is merelya particular modification of cutaneous, oxcutaneous and cellular, inflammation. If wewere to class these according to their natu-ral affinities, we should place erysipelas be-tween the exanthemata and phlegmon. Itis less diffused than the former, not so cir-cumscribed as the latter. The exanthe-mata are coned to the skin; erysipelasaffects both skin and cellular structure ;while phlegmon has its original seat in thelatter, the skin being secondarily involved.The most striking and important distinctionbetween the two affections, is that inflam-mation is confined to one spot in phlegmon,and is distinctly circumscribed in its seat,while it is diffused in erysipelas, and

spreads without limit. This difference seemsto depend on the adhesive character of theinflammatory process in the former ; thesubstance called coagulating, coagulable, ororganisable lymph, effused around the in-flamed part, forms a boundary between itand the sound portion, which is altogetherwanting in erysipelas. In the latter, theeffusion is serous; hence, when matter is

formed, it is not confined to one spot, butbecomes extensively diffused in the cellulartissue. We cannot, at present, explain thecause of this difference ; that ’is, we do notknow how it happens that coagulatinglymph is poured out in the one case, andserum in the other.

Nosological Arrangement.Of erysipelas, which may be called spread-

ing inflammation of a considerable portionof the skin, with diffuse redness and swell-ing, sometimes preceded and generally ac-companied by fever, it would be sufficientto admit three species ; namely, ,

1. Erysipelas Simplex superficial spread-ing inflammation of the skin, with brightscarlet or rosy redness, and soft tume-faction of the part, generally with vesica- itions and fever.

2. E. Œdematodes; the swollen part darkred, and pitting on pressure.’ 3. E. Phlegmonosum; acute inflamma-tion of the skin and cellular texture, with

firm, general, and deep-red swelling of theaffected part, ending quickly in suppuration. and sloughing.

Causes-There is really no difference, inthis respect, between erysipelas and otherinflammations. The habitual excitement of! the vascular system, or the long-continuedt disturbance of the stomach, alimentary ca.. nal, and liver, consequent on intemperancef and excess, lay the foundation of inflamma-tion generally, and it depends on individualpeculiarity, or on local causes, whetherthe skin or other parts shall be the seat ofdisease.

When it arises from internal causes, thatis, when its appearance depends on the

previous existence of disorder in anotherorgan, it is called sympathetic or symptomatic.But, in a large proportion of cases, it is

directly excited by external causes imme-diately acting on the part, and it is then

called idiopathic.Simple erysipelas, and those cases more

especially, winch some writers have de-nominated the exanthematous, true, or

genuine species of the complaint, are usuallyof the sympathetic kind, arising from inter-nal causes, particularly from disorder of theprimas vis or liver : hence the epithetsbilious and d gastric. As these causes are

more or less permanent, they may producerepeated attacks of the disease, or render itof long duration : hence the expressions ofperiodic, chronic, and habitual erysipelas.The occurrence of erysipelas of the face,may be traced, in some instances, to con-

tagion.Phlegmonous erysipelas is more com.

monly idiopathic ; it supervenes on thewound of venesection, on injuries of the

superficial bursse, as those of the patella andolecranon, on incised and lacerated wounds,and compound fractures. An inflamed stateof ulcers, especially in the lower extremi.ties, is a common cause of it. This fre-

quently comes on when large ulcers or ex-tensive wounds are healed rapidly, in per-sons confined to bed, and allowed a full dietof meat and beer. It has often been pro-duced by wounds received in dissection.

Treatment.-As this affection resemblesother inflammations in its causes, symp-toms, and effects, so it must be treated onthe same principles; that is, on the anti-

plilogistic plan. Venesection, local bleed-ing, purging, and low diet, are the firstmeasures, to which saline and diaplioreticmedicines may be afterwards added. Theearlier these means are employed the better:vigorous treatment in the beginning willoften cut the attack short, and prevent the

731

disease from spreading beyond its originalseat.

In contending for the inflammatory natureof erysipelas, and for the propriety of treat-ing it antiphlogistically, I do not mean torecommend that measures equally active,and, in particular, that bleeding, whethergeneral or local, are to be employed in allcases.

The treatment of erysipelas, like that ofany other inflammation, must be modified

according to the age, constitution, previoushealth and habits of the patient, and the

period of the complaint. In asserting gene-rally that the antiphlogistic treatment is

proper, I speak of the beginning of the dis-ease, when the original and proper charac-ter of the affection is apparent ; and I amdecidedly of opinion that, in some shape ordegree, such treatment will always be bene-ficial in that stage.When the affection occurs in old and

debilitated subjects, the powers of life aresoon seriously impaired, and our effortsmust be directed rather towards supportingthem, than combating the local affection. 1have often seen such patients labouringunder erysipelas of the face in its advanced

stage, with rapid and feeble pulse, dry andbrown tongue, recovered, under circum-stances apparently desperate, by the freeuse of bark and wine.The cases of erysipelas which I have

seen in young persons, have almost all pro-ceeded from external causes, and requiredantiphlogistic treatment. The tonic and

stimulating’ plan has been injurious to suchpatients under all circumstances.Local bleeding is sufficient in the milder

cases of erysipelas, and is often necessaryin the more severe ones, as an auxiliarymeasure. It may be accomplished eitherby cupping’ or leeches. The former, wherepracticable, is the most efficacious : a greatobjection to it arises from the painful stateof the inflamed skin. Although leeches,when applied to the sound skin of some. in-dividuals, produce an effect analogous to

erysipelas, they exert no similar influenceover the inflamed skin, to which they maybe applied freely and safely.General experience has determined that

local applications possess but little efficacy ;they rel;eve the patient’s feelings, however,if they do not contribute greatly to stopthe disease. In the commencement, andbefore the inflammation is fully developed,cold applications are very agreeable by les-sening the sharp burning heat of the skin.It their use is preceded and accompanied bya proper plan of general treatment, there isno fear that the diminution of the externalaffection will cause inflammation of any in-ternal part. Warm applications, more espe-Mitity fomentations, are very soothing when

the inflammation is developed. To derivethe full benefit from them, they should beused steadily four hours together, and thepart may be covered with a warm breadand water poultice in the intervals of fo-menting.

Treatment of Phlebmonous Erysipelas.Venesection, and the application of

leeches in large numbers to the inflamedpart, together with the antiphlogistic treat-ment generally, may be advantageously em-ployed in the early stage of phlegmonouserysipelas, in order to prevent the full de-velopment of the affection. The bleedingof the leech-bites should be encouraged bywarm fomentations, and cold lotions nanybeafterwards applied to the part; when, how.ever, the inflammation is more advanced,the latter must be exchanged for fomenta-tions and poultices. After the bowels havebeen evacuated, calomel and antimony maybe freely administered, accompanied withsaline medicines. The local abstraction ofblood is more serviceable than venesection ;the latter therefore may be reserved for theinstances in which the patient is young andplethoric, the pulse full and strong, or thehead much affected.The most powerful means of arresting the

complaint, is by making incisions throughthe inflamed skin and the subjacent adipousand cellular textufes, which are the seat ofdisease. These incisions are followed veryquickly, and sometimes almost instanta-

neously, by relief and cessation of the painand tension; and this alleviation of thelocal suffering is accompanied by a corre-sponding interruption of the inflammation,whether it be in the stage of effusion, or inthe more advanced period of suppurationand sloughing. The redness of the skin is

visibly diminished during the flow of bloodfrom the incisions ; in twenty-four hours ithas usually disappeared, and the skin itselfis found wrinkled from the diminution ofthe general inflammatory tension. The im-mediate relief, although very desirable tothe patient, is, however, of less conse-

quence than the decided influence of the

practice in preventing the further progressof the disorder ; and this important resulthas never failed to occur, within my expe-rience, when the case has been a properone for the practice, and the state of the

patient has admitted of its being fairlytried.The treatment by incisions is suited to

various stages of the complaint ; but it is

, ! employed to greatest advantage at the be-’ ginning, since it prevents the further ex-

tension of inflammation, and the occurrenceof suppuration and sloughing. The rednessand swelling gradually subside ; the sur-

732

face of the cut granulates, and it heals ra-pidly. At a more advanced period, theincisions limit the extent of suppurationand gangrene ; and at a still later time,they afford the readiest outlet for matterand sloughs, and facilitate the commence-ment and progress of granulation and cica-trization.To preclude the possibility of misconcep-

tion on a practical point of so much import-ance, I beg to observe, that I do not adviseincisions in erysipelas generally, but confinetheir employment to cases of the phlegmo-nous kind.When erysipelas attacks the face, it is

not attended with that serious inflammationof the subcutaneous structures which re-

,quires incisions. However, the abundantcellular structure of the eye-lids not unfre-quently becomes the seat of more severe ’,inflammation, proceeding to suppurationand sloughing, and even causing partial,mortification of the skin. Here incision maybe advantageously resorted to. ’

We may have in the scalp either simpleerysipelas affecting the skin, and the tex-ture exterior to the aponeurosis, or a formof the complaint which may be called

phlegmonous, in which the cellular tissueunder the aponeurosis is inflamed. Theformer is to be treated by the ordinary an.tiphlogistic means. In the latter by havingrecourse to incisions at-an early period weprevent the progress of this very seriousaffection, and the same proceeding is neces-sary at a more advanced stage, either tolimit the suppurative and sloughing pro-cesses, or to provide a discharge for mat-ter and large masses of dead cellular mem-brane.

After the incisions have been made, thepart may be covered with warm fomenta-tion cloths until the bleeding has ceased,when a warm bread poultice may be ap-plied. If discharge does not soon take

place from the wound, it should be dressed,under the poultice, with lint thickly spreadwith the yellow basilicon ointment, or withsome other stimulant. When suppurationhas already occurred, the matter finds afree discharge at the incision ; large por-tions of the cellular membrane often slough,and come away with copious discharges ofmatter, and it is sometimes necessary toextend the incision, in order to promotetheir separation. When this is at an end,and more particularly when the skin has beenextensively detached by sloughing of thecellular membrane, pressure by bandage isvery serviceable in promoting the healingprocess."

In giving this summary of Mr. Lawrence’spaper, we have carefully embraced all the

leading points; so that our readers mayconsider themselves in possession of a con.cise statement of the talented author’s views

and practice in Erysipelas ; want of spacehas compelled us to omit the various quota-tions and references which the erudition of

the writer has supplied; and, from the samecause, we have not inserted the numerous

cases which he has related ;-the greater parthave indeed appeared in this Journal at dif.ferent times in the repo.’ts from St. Bar-tholomew’s. The cases tend fully to con.

firm the correctness of Mr. Lawrence’s

opinions respecting the inflammatory natureof Erysipelas, and they exhibit in a strikingmanner the beneficial results of the antiphlo-gistic mode of practice-pursued, be it reomembered, not blindly, but in reference tocertain conditions of the system.

We cannot avoid expressing our surprisethat Mr. Lawrence should have devoted

(sacrificed, we should say) several pages, tothe refutation of the opinions of Mr. HenryEarle, and Mr. Arnold (Surgeon of the

Grampus !), on inflammation of the fascia.

We smile, indeed, at placing such names in

juxtaposition with that of Lawrence;—how-ever, it has been truly said that there is

but one step between the sublime and the

ridiculous, and here is a case in point. Mr.

Lawrence has adopted a process closelyanalogous to that of 11 breaking a fly on a

wheel." To be sure, we had somethingequally ludicrous, in Da. JAMES JOHN-

STONE’S "literary collision!"On the subject of incisions in cases of

phlegmonous erysipelas, we must say a fewwords in conclusion. There are, doubtless,

many cases in which this practice is of the

highest advantage ; there are other cases

in which it is unnecessary, and manyin which circumstances prohibit its adop-tion. If the whole cellular tissue of a

limb be in a state of high inflammation, en.

gorged with fluids producing immense swell-ing, and threatening a destructive suppura.tion-this is a case in which free incisions

733

afford the greatest possible relief; the dis-tended vessels get rid of their superfluousblood, the serum already effused, and pro-dncing excessive tension, escapes ; suppu-ration is prevented, and, in a word, the

disease is cut short.

A less degree of disease, of course re-

quires a less active treatment; and we

would not adopt the full extent of practiceapplicable to the robust and vigorous, in thecase of a debilitated old man. But it is not

only in preventing suppuration that in-

cisions are useful ; when matter has alreadyformed, and there is great destruction of

cellular membrane, then free incisions areimperatively necessary, to allow of the exitof pus and dead cellular tissue ; for want of

ample incisions, we have witnessed the bur-

rowing of pus, suppuration of the wholelimb, and destruction’ of the patient. If

we could reduce the thing to a mere dryquestion of arithmetic, and compute the

quantum of pain in a given number of

quarter of an inch incisions, as contrastedwith the pain experienced in making an in-cision of eight or ten inches in length, thebalance would be decidedly in favour of thelatter practice. It is not, however, withthis childish view, that we must regard thematter; let us look at the results of the

separate modes; let those who hold out thedelusive bugbear-debility, and adopt the

phlùgistic plan of treatment, bring forward amass of evidence equal to that Mr. Law-rence has adduced ; and then, we say

again, look to the results. As the questionnow stands, the evidence is all in support ofMr. Lawrence’s opinions and practice.

LONDON UNIVERSITY.

V’E can state, on the authority of theWarden, Mr. Horner, that the MedicalCertificates of the Professors of this Insti-tution, will not be 7-eceived for the Diplomaby the Scotch Universities. We shall offerMme remarks on this subject at an earlyperiod.

ST. THOMAS’S HOSPITAL.

CASE OF CHOREA SUCCESSFULLY TREATED

WITH CARBONATE OF IRON.

JANE CRESEY, a spare little girl, mt. 14,was admitted into Queen’s Ward on the14th of August, under the care of Dr. Roots.She stated, that she had been ill threemonths previous to her admission, havingsuffered a great deal from pain in her head,and also from violent motions in her rightarm and leg, which were more severe onfirst waking, and over which she had nocontrol. She had a very severe attackfive years ago, when both sides of the bodywere affected, and she was then ill for fivemonths. For some time previous to heradmission, she had frequently complaineda pain in her head, although she has had noreturn of it since she has been in the Hos-pital. When admitted, the surface wascold, and she complained of chilliness ; thebowels have generally been constipated ;the pulse small and weak, 88. She wasordered to take fifteen grains of the pow-der of scammony, with calomel, immedi-ately, and two drachms of the carbonate ofiron every six hours.

22. The symptoms are much more slightin every respect ; the bowels were freelyopened by the cathartic powder, but haveagain become constipated. Ordered to re-

peat the powder and the carbonate of ironas before.

26. She continues to improve. Orderedto take the medicines, with an increase ofhalf a drachm to each dose, and to have acathartic powder every other morning.

29. The symptoms of chorea have entirelyceased ; she has had no return of pain ; thebowels are regular, appetite good, and sheonly feels weak. Ordered to continue themedicines, with an addition of half a drachmof the carbonate of iron to each dose ; thecathartic powders as before.

She continues to take three drachms ofthe carbonate of iron every six hours, butmay be considered as quite well.

PROLAPSUS UTERI, OCCURRING SUDDENLY

IN A YOUNG WOMAN, FKOM VIOLENT EX-

ERTION, AND FOLLOWED BY PROFUSE

HEMORRHAGE.

E. R., of spare habit and cachectic appear-ance, was admitted into Queen’s Ward, onthe 31st of July, under the care of Dr.Elliotson. She stated, that about six monthsback, she was lifting a person out of acoach, when she suddenly felt intense painin her back, and the uterus descended,and protruded beyond the os externum ;its descent was accompanied by profusehemorrhage. She was immediately placed