stances. took place. He would therefore be dis- have been the case in the foregoing inposed to adopt the same remedy, under similar circumstances-but not otherwise. The combination of melæna with the hæmatemesis would induce him to expect a morbid state, or, at all events, a morhid action in the mucous membrane of the intestines as well as stomach, and consequently a condition not proper for the emetic practice. Dr. Barry drew the attention of the Society to the superiority of local over general bleeding, in cases of vicarious hæmorrhages. Thus, when hæmatemesis, from suppressed or interrupted men. struation, occurs in this country, we seldom think of attempting to restore the natural or original discharge, by leeching the labia, the hip-bath, &c.—or of applying leeches to the anus, where there has been suppression of the hæmorrhoidal discharge. Yet such is the practice all over the Continent and such practice is rational. The doctrine of derivation (it was observed by Dr. Barry) was now much in disgrace-but perhaps unmeritedly so, as there were few points of ancient pathology better founded in nature or fact. Upon the whole, it appears to us that there was not sufficient distinction made, by several of the members, between simple vicarious hæmatemesis and that dangerous disease melæna. Although Dr. Ayre did not admit that the disease for which he prescribed calomel was true melæna, (at least so we understood him,) yet we apprehend that it is in this last affection, rather than in simple hæmatemesis, that the above-mentioned medicine is efficacious. At all events, the cases brought forward by Mr. North and others, will render medical men more circumspect in their prognosis, than appears to 2. ERYSIPELAS. The local treatment of erysipelas by in- Mr. Earle observed that, however beneficial might be these local means in erysipelas, as adjuvants to constitutional the disease was, in a majority of intreatment, yet still, in his experience, stances, connected with, or dependant on, derangement of the general health. On this account, he had found smart purgation, especially with calomel and tartaremetic, conduce to recovery, in a very remarkable manner. Local means were, of course, to be used at the same time. Dr. Johnson followed on the same side, and contended that, in the majority of cases, erysipelas on the surface was merely a symptom of constitutional disorder. If patients were attentively watched, there would be found preceding phenomena that indicated a derangement of the whole system, as manifested by the tongue, the sensations, the secretions, and the excretions. This being the case, it is pretty certain that cases of erysipelas would, in most instances, get well, by attention to diet and the bowels, with very common local applications. Mr. Lloyd, since the recent discussions on erysipelas, had had several opportunities of testing the efficacy of the method recommended by Dr. Dobsonsmall incisions with the lancet-and had experienced the most beneficial results. In one or two cases, where the local inHammation had resisted the enormous venesection of 70 or 80 ounces of blood, at one bleeding, the erysipelas gave way to a series of punctares by the lancet. This treatment had been employed by him in erysipelas of the scalp-the abdomen-and the extremeties. Mr. Lovd never, of course, neglected the constitutional treatment, and always paid great Mr. L. conattention to the bowels. firmed the statements of the author of the paper (Dr. Dobson) as to the good effects of local incisions in the neighbourhood of old and obstinate ulcers. By this auxiliary, he had recently cured an ulcer of the lower extremities, which had reMr. sisted all other modes of treatment. Alcock observed, that this practice was as old as the days of Ambrose Paré, and that Lisfranc always employed it in LA PITIE. Mr. Lawrence made some observations ou the local treatment of erysipelas, as recommended by Dr. Dobson; and then stated the particulars of a case that had recently occurred, of dissection-wound, in the person of the present very intelligent house-physician of the Fever-Hospital-Dr. Dill. This gentleman, while opening the abdomen of a female who had died of puerperal peritonitis, received a scratch on the back of his hand, from the extremity of a sawn rib. The consequences were, some uneasiness at the time, and a pustule or vesicle the next day, with tense and shining inflammation of the back of the hand, accompanied by great pain. An incision, of about an inch in length, from which a great quantity of blood issued, gave great relief and this was promoted by the application of leeches, and the immersion of the hand in warm water, Dr. Dill rapidly recovered. Drs. Tweedie and Gregory corroborated this statement. is probable that, as far as the instrumental treatment of erysipelas is concerned, the mode of Dr. Dobson will supersede the long and short incisions by the scalpel. We have reason to know that the lancet cuts heal generally by the first intention, and consequently leave no scar, which It were might not be the case with scalpel inci- 3. MEDICAL JURISPRUDENCE. The following is the recent curriculum "Regulations of the Council relating to the "1. The only schools of anatomy, and physiology, recognized, are London, Dublin, Edinburgh, Glasgow, and Aberdeen. "II. Attendance upon the surgical practice of an Hospital will be recognized, provided such Hospital contain at least one hundred patients. "III. No person under twenty-two years of age shall be admitted a member of the college. "IV. The following certificates will be required of candidates for the diploma of this college: "1. Of having been engaged six years, at least, in the acquisition of professional knowledge: "2. Of having regularly attended three or more winter-courses of anatomy and physiology; and two or more winter-courses of dissections and demonstrations; delivered at subsequent periods. "Two courses of anatomy and physiology in Edinburgh or Dublin, which are of six month's duration, and the accompanying courses of dissections and demonstrations will be considered as equivalent to the foregoing attendance. "3. Of having regularly attended two or more courses of lectures on the principles and practice of surgery; one of which shall have been delivered in a recognized school of anatomy. "4. Of having also attended the following lectures, viz. "Two courses on the theory and practice of physic of three months each, or one of six months. "One course on materia medica, and botany. "Two courses on chemistry, of three months each, or one of six months. "Two courses on midwifery, of three months each, or one of six months. "5. And of having attended, during the term of at least one year, the surgical practice of one or more of the following Hospitals; viz. ST. BARTHOLOMEW's, ST THOMAS's, the WESTMINSTER, GUY'S, ST. GEORGE's, the LONDON and the MIDDLESEX, in London; the RICHMOND, STEVEN'S and the MEATH, in Dublin; and the ROYAL INFIRMARIES, in Edinburgh, Glasgow, and Aberdeen; or during four years the surgical practice of a recognized provincial Hospital, and six months, at least, the practice of one of the above named Hospitals in the schools of anatomy. "V. Candidates under the following circumstances, of the required age, and who have been engaged five years in the acquisition of professional knowledge, will be admissible to examination, viz. "Members, or licentiates in surgery, of any of the legally constituted colleges of surgeons in the united kingdom. "And graduates in medicine of any of the universities in the united kingdom, provided they have attended lectures, the practice of an Hospital, and performed dissections, as required in regulation IV. "VI. The required certificates shall express the dates of the commencement and of the termination of attendance on each course of lectures, and dissections; and also of attendance on hospital-practice. "VII. The required certificates shall be delivered at the college ten days before candidates can be admitted to examination. "By order, "EDMUND BELFOUR, Secretary. "5th day of January, 1828." It is not here necessary to make any comments on the new curriculum, since the whole system is in need of re-construction. But we may observe, that the College is beginning to act on those principles, which we have so long endeav oured to inculcate-the union of medical with surgical knowledge. We have shown, on many occasions, the impossibility and the absurdity, of separating the study of surgery from that of physic, and vice versa. The College of Surgeons have now broken the ice, and driven their crow-bar through the paper partition that divided them from their brethren in Pall-mall East! They have planted their colours (and very properly too) in the very camp of their rivals. They have only to extend a little the medical flank of their curriculum, in the next edition, and enforce their standing orders by proper musters and inspections (examinations) and then the surgeons of this country, will be, bona fide, physiciansor rather they will be, what Hippocrates himself was-GENERAL PRACTITIONERS! The College of Physicians has only to persevere for a few years more in riding on stilts, and the whole practice of the profession will be in the hands of surgeons. Let them carefully avoid all attempts to follow the dictates of reason and common sense-let them continue to prescribe Greek, Latin, and Mathematics, instead of anatomy, surgery, and pathology, and the public, as well as the profession, will soon see the absurdity of consulting those, whose education fits them better for a cloister or a monastery than for clinical practice. It would be useless for us to offer their high mightinesses any counsel on this occasion. Cardinal Wolsey is their pillar of light-and his PRIESTCRAFT is their favourite physic. *We shall comment on some items of this curriculum in our next fasciculus. HOSPITAL PRACTICE. 1. ROYAL INFIRMARY OF EDIN BURGH. ANGRENOUS ERYSIPELAS. AMPUTATION -DEATH.* "Case We were somewhat startled, on looking at the table of contents of the Lancet, to find the following heading. of gangrenous erysipelas, in which amputation was performed with success." On turning to the case in question, however, all our pleasing anticipations vanished into "air-thin air," for we found that, though the amputation might have been performed with success, the patient had most certainly died. Case. D. H. aged seventy-two, addicted to drink, was admitted, Jan. 10th, under the care of Dr. Hunter, with gangrenous erysipelas of the arm. The patient appeared to be moribund-the whole limb, up to near the axilla, was enormously swelled, of a dusky red colour, and quite livid over the wrist and metacarpal bones, whilst here and there were several large vesications. He stated that, ten days previously, he had received a bite on the forefinger from a boy, and that nothing had been applied but poultices. Five or six incisions, about two inches in length each, were made by Dr. Hunter in the arm, and he was ordered wine in small doses, until the pulse rose, with a fermenting poultice to the limb. On the next day, the pulse was stronger, but irregular-tongue coated-bowels confined. Wine to be continued. Quin. Sulph gr. ij. Mist. camph. Zj. 4tis horis 12th. Pulse rather fuller-bowels not yet openedwounds gaping, and filled with a beercoloured fluid. Ol. ricini, 3iij. statim. Camphor emulsion to be omitted-winequinine fermenting poultice. We shall not pursue the diurnal details of this case, which "drag their slow length along," with the most tiresome verbosity. On the 13th, the inflammation had extended on the posterior aspect of the arm, but, on the 14th, it was diminishing, and three of the wounds had begun to suppuOn the 15th, he was no better, rate. but the report states that a line of separation was beginning to form above the elbow, though it was not a very decided one. On the 16th, it was determined, in consultation, to amputate the arm, which was done, "a little above the middle of cles of the fore-arm were flaccid, but not the humerus," by Dr. Hunter. The musdisorganized, and the cellular membrane over the carpus and metacarpus was destroyed, some matter being thrown out amongst the sheaths of the extensor tendons. No mention whatever is made of the state of the stump, or whether the operation was performed in sound or unsound parts! Next day the patient was more comfortable, but somewhat incoherent; tongue moist and cleaner. Quinine to be discontinued, and three ounces of white wine in whey, to be given with barley water and beef tea. We shall not bore our readers with the prosy details which Scorus has given de die in diem; suffice it to say, that no attempt at union took place upon the stump, and that the patient never rallied from the operation. The pulse was never below one hundred-the tongue coated with yellow mucus-the mind more or less affected. On the 20th, he became affected with diarrhea, which, however, was checked by infusion of roses, with sulphuric acid, and chalk mixture. On the 21st, the pulse was feeble and intermitting, he became affected progressively with rigors, hiccup, &c. and on the 24th, he died. In the account of the dissection, it is merely stated that the heart was "slightly diseased," and the left lung covered with an old false membrane. REMARKS. Of this case, reported as it is, we can make, to use a vulgar phrase, "neither top nor tail." First of all we are told that the whole limb was enormously swelled, and of a dusky red colour "from near the axilla to the ends of the fingers." On the 13th, the inflammation had “extended on the posterior aspect of the arm,” and yet, on the 15th, a line of separation was forming, just above the elbow!! Now in our younger days, some twenty years ago, or more, we well remember being taught, that the line of separation was a boundary, formed by a sloughing process, between sound and unsound parts, between the living matter and the dead. How, then, we would ask ScoTUS, or any body else, could a line of separation form above the elbow, when his own report affirms, that the disease had extended to near the axilla. It would be an odd kind of separation, indeed, which divided the dead matter from the dead! Secondly, we would ask Dr. Hunter, upon what principle, or for what reason, he made six incisions into the limb upon the patient's admission? Did he expect to find matter, or did he expect to prevent its formation? If he did either, we think he did wrong. This was not a case of phlegmonous erysipelas, or of erysipelas phlegmonodes The tint, we are told, was not bright, but dusky red; the skin was not tense and glistening, but covered with gangrenous phlyctenæ; the pulse did not indicate action, but was "frequent, feeble, and irregular." Was this a case for incisions? We should say it was a case for bark and opium, and that with no sparing hand. Thirdly, we cannot conceive why the operation was performed about the middle of the arm. Surely the object of the surgeon must have been to get fairly above the disease, and how this was to be accomplished by amputating in the arm, whilst the erysipelas had extended almost to the axilla, we declare we cannot, for the life of us, comprehend. Fourthly and lastly, we doubt the pro priety of performing the operation at all; for, as far as we can judge, a man of seventy two, who had drunk freely, who was labouring under the most terrible form of erysipelas, and who was in the very worst condition imaginable, either to originate or maintain the reparative process, was no subject for the amputating knife, however, or wherever, applied. We know not, for we have no means of knowing, whether this report of Scotus be correct or otherwise; but we will say, that whilst the exact quantities of wine taken, and stools voided, are doled out by the yard, the most important particulars, as the state of the parts in which the operation was performed, the appearance of the face of the stump, &c. are passed over in silence. The consequence of all this, is, that the reader gets up from the perusal of the case, just as wise as when he sat down to it. 2. MIDDLESEX HOSPITAL. MR. BELL ON THE QUESTION of AMPUTAL TION.* The question of primary and secondary amputation, in cases of gun-shot wound or compound fracture, one would imagine to be pretty well set at rest. Mr. Bell, however, has dedicated two clinical lectures to the subject, and, what is more, contrived to make them exceedingly interesting. We notice these observations more for the purpose of commenting on one or two points, than with any intention of detailing them at length. compress the Case. A soldier, æt. 27, whilst drunk, fell in the street, and the wheel of a loaded waggon passed over his leg. He was admitted soon afterwards into the Middlesex Hospital with compound fracture of the leg, the tibia protruding, and simple fracture of the femur in two places, viz. at its centre, and near the trochanter minor. The operation was deferred till next morning, to allow of his recovering from the intoxication, when it was performed high in the thigh. Mr. bell, being one of those gentlemen who believe it impossible effectually to artery at the groin, every precaution was taken against hæmorrhage. First, there was the tourniquet applied; secondly, there was a gentleman with his thumb on the femoral artery; and, thirdly, to keep out the blood from below, there was "a fillet tied firmly round the thigh, below where it was intended to make the incision." No doubt these were proper precautions, and must have been excellent lessons for the pupils of the Middlesex Hospital; but, probably, if the ampu tation had been performed in the cockpit, or, as Mr. Bell once expressed it, "on a pack-saddle at the top of the Pyrennees," the surgeon would have con trived to do without two of them, at any rate. An incision was then made on the fore part of the thigh, cutting across the main artery, which bled freely. It was accordingly taken up by the tenaculum and tied, as was the profunda. The oper ation was concluded by making two semicircular flaps, one on the inner, the other on the outer side of the thigh, and removing the bone. The patient bitherto *Med. Gazette, Nos. 8-10. |